Case Overview: 58-Year-Old Man With Advanced RCC

Robert Alter, MD: Today we’re going to discuss a case involving a 58-year-old gentleman who presented to his primary care physician complaining of anorexia and fatigue for several months. The patient had a moderate weight loss of 15 pounds. After the patient was seen by his primary care physician, the appropriate work-up was performed. The patient underwent laboratory assessments, including a CBC [complete blood count] and chemistry panel that included calcium and LDH [lactate dehydrogenase], a chest x-ray, and a CT scan of the abdomen and pelvis. It was discovered that the patient had a renal mass measuring 10.3 cm in size. After ruling out any evidence of metastatic disease, the patient underwent a left total nephrectomy. Surgical and pathology findings were all consistent with stage IIIA disease. The pathology findings included a 10.2-cm renal mass and renal vein invasion. Otherwise, all margins were negative, with 2 lymph nodes resected negative for metastatic disease.

The patient then underwent active surveillance. The concerns of risk for recurrence were initially discussed with the patient, as well as considerations for adjuvant therapy. Active surveillance was recommended. The patient underwent surveillance testing with scans performed at 6-month intervals. And then, in March of 2019, the patient, who was asymptomatic, was noted to have, on a chest x-ray and a subsequent CT scan of the chest, development of pulmonary nodules, the largest nodule measuring 3.5 x 3 cm. Soft tissue disease was noted, as well as mediastinal adenopathy. In analyzing the patient’s case, the patient was considered to be intermediate risk, with an ECOG performance status of 1.

The patient was started on axitinib given at a dose of at 5 mg orally, twice a day, as well as pembrolizumab given at 200 mg IV [intravenously] every 3 weeks.

The patient had an excellent tolerance to therapy. Initial scans performed 3 months after initiation of therapy noted a 60% reduction in disease. This was considered to be a partial response. The patient had nominal toxicities requiring no dose adjustments with axitinib therapy.

Subsequent scans performed in September of 2019 revealed disease progression. Pulmonary lesions had increased to 5.0 x 4.5 cm. There was an increase in size and development of new mediastinal adenopathy, and hilar adenopathy, with the patient still having an excellent functional performance status. At that time, the patient’s therapy was changed to lenvatinib, which was dosed at 18 mg by mouth daily, along with everolimus dosed at 5 mg by mouth daily.

At first assessment at 4 weeks after evaluation, the patient was noted to have grade 1 diarrhea. The dose of lenvatinib was decreased to 14 mg daily, but the dose of everolimus remained the same. The patient had scans performed in December of 2019 that revealed pulmonary lesions decreasing by 2 cm in size. This indicated a partial response. The patient remained on therapy. This patient was last seen in January of 2020, and continued on lenvatinib at 14 mg orally daily along with everolimus dosed at 5 mg daily.

Transcript edited for clarity.

Case: A 58-Year-Old Man With Advanced Renal Cell Carcinoma

• August 2018: A 58-year-old man complained of fatigue and anorexia; after appropriate workup the patient was diagnosed with clear cell renal cell carcinoma
  • He underwent left total nephrectomy
• March 2019: He developed metastatic disease to the lungs bilaterally (30 x 35 mm), mediastinum and soft tissue metastatic deposits
  • MSKCC risk status: intermediate
  • ECOG 1
  • He was started on pembrolizumab 200 mg IV every 21 days + axitinib 5 mg PO q2Days
• September 2019: He developed progressive disease (45 x 50 mm); pulmonary lymph nodes increased in size and new mediastinal and hilar lymphadenopathy was noted
  • He was started on lenvatinib 18 mg PO qDay + everolimus 5 mg PO qDay
• October 2019: Due to grade 1 diarrhea, reduced dose of lenvatinib to 14 mg PO qDay + everolimus 5 mg PO qDay
• December 2019: Lesions reduced to 20 x 20 mm from September 2019; achieved partial response
• January 2020: He remained on therapy with lenvatinib + everolimus