Factors Influencing Treatment Selection and Sequencing in Advanced Renal Cell Carcinoma

Case Overview: A 71-Year-Old Woman with R/R Metastatic Clear Cell RCC

Initial Clinical Presentation and Diagnosis:

• SW is a 71 y/o woman who visited her oncologist for annual follow up.
  • Hx: Diagnosed in 2018 with metastatic renal cell carcinoma (mRCC) with metastases in her adrenal gland; post-left nephrectomy and adrenalectomy
  • Patient was observed based on low-volume and indolent behavior of disease and patient preference.
  • PMH: T2DM (well managed with medication)
  • SMH: Does not smoke and occasionally drinks alcohol

Disease Progression, Clinical Workup, and Treatments:

• SW was initiated on systemic therapy of pembrolizumab + axitinib; stable disease on follow up
  • Moderate diarrhea and fatigue were reported by SW
• 14 months later, the patient reported increased back pain, weight loss, and new onset of persistent rib pain
  • Imaging confirmed disease progression – growth of paratracheal LN, new mediastinal nodal involvement, and new lytic osseous lesions
  • Patient was then initiated on cabozantinib 60 mg QD
• 6 months later, further disease progression is documented
  • Shared decision was made to initiate treatment with tivozanib 1.34 mg QD x 21 days, followed by 7 days off (28-day cycle) until disease progression or undesirable toxicity