Risk Stratification in Advanced Renal Cell Cancer

Robert J. Motzer, MD:The risk stratification models were originally developed at MSKCC to help prognosticate patients for counseling, in terms of patients’ individual prognosis, but also to be used in clinical trials both for eligibility and in comparing results. The 2 groupings that are widely used are the MSKCC system, and a modification of the MSKCC system, the international consensus criteria. They’re both very similar. They use 5 and 6 different pretreatment clinical features to help stratify patients into favorable, intermediate, and poor-risk features, both at initial diagnosis or at time of treatment with second- or third-line therapy.

Originally when this patient presented with metastatic disease, he fell into the intermediate-risk group based on the fact that he was anemic, and the median survival for patients with intermediate-risk RCC is approximately 20 to 25 months in a modern-day therapy. At time of progression on sunitinib he also fell into the intermediate-risk group. The intermediate-risk group is the group that most patients with metastatic kidney cancer fall into. In both systems between 40% and 50% of patients are intermediate-risk at initial diagnosis, and more than that at relapse for second- or third-line therapy.

Transcript edited for clarity.

A Japanese-American Male With Recurrent RCC

November 2015

• At the age of 49, a Japanese-American man presented to the ER with abdominal pains
• CT of the abdomen and pelvis revealed diverticulitis with an incidental left renal mass (4.2 cm × 8.6 cm × 2.8 cm)
• SH: Marathon runner; nonsmoker; social drinker
• He underwent sigmoid colon resection; left radical nephrectomy
• Pathology; sigmoid colon pathology revealed diverticulitis; renal pathology revealed RCC, clear cell type
• Diagnosis: RCC stage PT2a
• KPS: 90
• Fuhrman Grade: 3/4

September 2017

• Follow-up CT showed residual soft tissue in the left nephrectomy bed, pulmonary lung metastasis, and an expansile lucent osseous lesion in the right pubic ramus
• Biopsy of one of the osseous lesions confirmed mRCC
• He began systemic therapy with sunitinib for 20 weeks and achieved stable disease and some shrinkage of the bone lesion
• KPS: 90
• MSKCC risk score: Intermediate

July 2018

• The patient now complains of left pelvic pain
• Imaging shows marked progression in retroperitoneal mass; new lung metastasis
• Laboratory values:
  • CBC: WBC - 7; Hgb - 12.6; Platelet - 190; ANC — 5.2;
  • CMP; Creatinine - 1.82 mg/dL; LFTs - WNL; Calcium - 9.2 mg/dL; LDH — WNL
• MSKCC risk score: Intermediate
• KPS: 80
• The patient was treated with palliative radiation therapy to bone metastasis
• He was then started on treatment with lenvatinib/everolimus