Below is a concise synopsis of their discussion points and thoughts on each case.
Case 1: 49yo male with gross hematuria, history of CAD. Right 6.5cm renal mass abutting sinus
Dr. Haber – Renal mass biopsy is probably unnecessary for this young gentleman. He would proceed to robotic partial Nx given the age and health of the patient.
Dr. Kavoussi – Radical Nx should be considered because of high rate of T3 disease found after excising cT1b lesions. “5 years ago I would have done a partial nephrectomy, but now would do a radical.”
Dr. Uzzo – Imaging looks like ccRCC with necrosis. He made a pitch for renal mass biopsy (RMB). The sensitivity of core biopsy, specificity, and PPV are all >95%. He pointed out that the metrics for prostate biopsy are much lower, yet we rely on biopsy results prior to treatment in prostate!
Outcome 1: Surgical pathology: pT3a, high grade
Dr. Srinivas: Would recommend checkpoint inhibition (IO) adjuvant trials given the lack of effectiveness of adjuvant TKIs so far.
Dr. Pal: He was encouraged by adjuvant results of IO in melanoma and feels that kidney cancer will likely have success in this space as well.
Outcome 2: 2 years later – 5mm pulmonary nodule; 3 years later – 11mm and 5mm pulmonary nodules
Dr. Srinivas: surgical resection is reasonable; but with IO therapy available, the likelihood of achieving a complete response is higher and curative treatment possible. Hence a multimodal approach should be taken.
Outcome 3: VATS – 3 nodules excised metastatic ccRCC, R0 – favorable metastatic disease
Dr. Pal: This is a perfect patient for the adjuvant atezolizumab trial (for patients who have undergone metastasectomy) – Dr. Uzzo also pointed out this is a SUO-CTC trial and is hopeful this will give meaningful results for these patients with favorable metastatic disease.
Case 2: 72M R 2.8cm incidental renal mass with history of multiple myeloma (MM), GFR 45
Dr. Uzzo: AUA guidelines are helpful here – in this gentleman a biopsy may be helpful given the great PPV and diagnosis metrics of core biopsy.
Dr. Kavoussi – In the community, the availability of good interventional radiologists, etc.., may be quite variable. Hence, it is very reasonable to consider active surveillance as a good option – it doesn’t hurt to at least follow for 6 months and see what the mass does/how it grows.
Case 3: 53M bilateral renal masses – genetic testing negative, healthy, GFR 78
Right 5.8cm central, Left 3.6cm central
Right Papillary Type 1 RCC on RMB
Dr. Kavoussi – Take care of easier side (left) to make sure you have good renal function before approaching the harder side. Would consider doing both sides simultaneously off clamp if amenable.
Dr. Haber – Approach the harder side first (right) and let patient recover for 3 months before staging the other side.
Dr. Uzzo – Also agrees that doing the easy side first may be optimal.
Outcome: Both sides are Papillary Type 1; 10yrs after surgery, multiple large left retroperitoneal masses (LNs) are seen abutting the left renal hilum
Dr. Uzzo – The TCGA gave us good information on biology of these Papillary Type 1 lesions (met mutations). This is a very late recurrence, so it is reasonable to offer surgery via a templated retroperitoneal node dissection.
Dr. Kavoussi – This case highlights how inadequate our follow-up guidelines are in terms of length of follow-up. This patient recurred well outside of the 5-yr window that is normally recommended. Renal US would also miss lesions like this.
Dr. Pal: There is an ongoing trial for metastatic Type 1 papillary RCC comparing sunitinib against met-inhibitors, which should be considered for this patient.
Case 4: 43yo F with grow hematuria and back pain – metastatic RCC, GFR 96; 7cm left Type II Papillary RCC; liver and retroperitoneal metastases
Dr. Srinivas: There is no clear role for cytoreductive Nx, especially for non-ccRCC tumors. Patients with liver metastases and Type II papillary RCC would probably benefit from treatment with systemic therapy first to assess for response prior to subjecting them to surgery.
Dr. Uzzo: This patient likely has HLRCC (FH mutation later confirmed by moderator) – A phase II bevacizumab/erlotinib study is currently underway that would be ideal.
Outcome: A cytoreductive Nx was performed and patient was placed on the bevacizumab/erlotinib study. Reassuringly, her metastatic disease has been responding radiographically.
These cases highlight some of the complexities involved in the management of even index patients that present with kidney cancer. Many of the experts disagree on exact approaches, but they all agree on the idea that precisely targeting treatment to individual pathological types is the way of the future. Enrollment into ongoing clinical trials that are leveraging our growing biological knowledge is key to improving outcomes for these patients in the future.
Presenter(s): Georges Haber (CCF), Robert Uzzo (FCCC), Sandy Srinivas (Stanford), Sumanta Pal (City of Hope), Louis Kavoussi (Hofstra)
Written by: Shreyas Joshi, MD, Fox Chase Cancer Center, Twitter: @ssjoshimd at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA