AUA 2018: Complex Cases: Locally Advanced and Metastatic Kidney Cancer

San Francisco, CA ( Christopher Wood, MD from the University of Texas MD Anderson Cancer Center begins the session by presenting complex kidney cancer patients and discussing their management amongst the panelists. The first case is of a 62-year-old patient that presented with decreased appetite, weight loss and a central 6 cm right renal mass found on CT scan by her PCP.

The consensus of the panelists is to proceed to a radical nephrectomy based on the size and location of the renal mass without performing a biopsy or any adjuvant therapy. An open radical nephrectomy was performed, and the final pathology was T1bNxM0 clear cell renal cell carcinoma, nuclear grade 2 with negative margins. No tumor is found on the adrenal gland. The patient inquired about adjuvant therapy, but all panelists agreed there was no role for it. However, after 5 years of follow up, the patient now presented with a growing retroperitoneal nodule.

Jose Karam, MD suggested at this point to take the patient for a complete, bilateral retroperitoneal lymph node dissection, and Jason Abel, MD concurred. On the other hand, Primo Lara, MD who is a medical oncologist would like to do a biopsy first. A biopsy was chosen for this patient which showed metastatic renal cell carcinoma, an RPLND was performed and pathology confirmed metastatic disease. Wood questions the utility of adjuvant therapy at this point. Abel said no for adjuvant therapy as did Lara, however, there is a possibility to enroll the patient in a clinical trial.

Observation was chosen for this patient but 2 years later a new lesion arose on the posterior aspect of the remaining kidney. At this point, the panelist agreed to perform a biopsy followed by ablative therapy. The patient underwent ablative therapy and a biopsy which showed normal renal parenchyma. Three years later the patient returns, but now with two growing lesions on the healthy kidney. Abel now recommended either open or robotic partial nephrectomy to help dissect the tumor off the collecting system along with cryoablation of the secondary lesion as its position was in a bad location for a resection, Karam agreed. The case concluded after the patient underwent an open partial nephrectomy and an ultrasound-guided cryoablation.

The second case was a 65-year-old, obese (BMI=52) patient with gross hematuria and a large renal mass in the central part of the kidney. Karam suggested to perform a robotic or laparoscopic radical nephrectomy due to the location and size of the mass, and Abel agreed. An open radical nephrectomy was performed, and a level one tumor thrombus was identified during the surgery. The final pathology was a T3bN0M0 clear cell renal cell carcinoma with 20% sarcomatoid and 70% rhabdoid features with negative margins. The panelists discussed the role of adjuvant therapy for this patient as the sarcomatoid features were concerning and Karam suggested that a discussion of data with the patient regarding adjuvant therapy was warranted. The patient on 6th week of follow up was recovering nicely with a negative bone scan, negative brain MRI but with mediastinal adenopathy and local recurrence of disease in the renal fossa with psoas muscle invasion. Lara said the patient needs to be risk stratified and would be put in the intermediate category, qualifying for immune therapy and perhaps TKI therapy if there are contradictions to the former, the other panelists concurred.

The third case was a 71-year-old patient with shortness of breath, chest pain and a large saddle embolus found on chest CT. Further workup identified tumor thrombus extending from the kidney to the right atrium with evidence of pulmonary metastasis. There was a discussion between the panelist for the role of biopsy, need for immediate surgery or 1 month of Lovenox then restaging. Karam stated that he would not do a biopsy as it takes too long for the turn around (1 month),  Abel said the risk of surgery was significant due to the pulmonary embolus, the patient needed the 1 month of Lovenox. Lara recommended to wait 1 month with Lovenox treatment and then perform cytoreductive therapy followed by a biopsy to guide possible systemic therapy treatment. The patient was taken for a radical nephrectomy and IVC thrombectomy with cardiopulmonary bypass, final pathology shown to be T3cN0Mx Type 2 papillary renal cell carcinoma with negative margins, grade 3. On 6th week of follow up, the patient continued to have shortness of breath and weakness. Bone scan, brain MRI, abdomen CT scan were negative, but now the saddle embolus appeared vascularized and interpreted by radiologists as a tumor thrombus, and the pulmonary nodules were enlarging which suggested metastatic disease from the Type 2 RCC. Lara suggested that the patient at this point could qualify for the SWAP clinical trial.

The fourth case was a 59-year-old patient presenting with a left varicocele, a palpable left abdominal mass and on imaging was found to have a large renal mass. The patient underwent radical nephrectomy with RPLND, final pathology was T3aN0M0 clear cell renal cell carcinoma with negative margins, grade 2. The patient followed up with serial imaging and at 22 months a pulmonary nodule was discovered. At 28 months, the nodule had increased in size, but no other metastatic disease evident. Karam suggested at this point to perform VATS surgery, and while observing the patient making sure no other nodules appear, Lara agreed. Abel added that there is a role of biopsy if one was to perform localized ablative therapy. The patient underwent VATS which showed 6 nodules and only 2 demonstrated metastatic RCC. At 11 months follow up a new nodule appeared. At this point, Karam suggested that the patient undergo systemic therapy at this point. 

The final case was a 32-year-old patient presenting with back pain and a history of left renal cell carcinoma (T2aN0M0) treated with a radical nephrectomy with RPLND. On imaging, a large mass was identified be involving the left retro-peritoneum, psoas muscle, posterior wall of the stomach, and in between the liver and spleen. Abel suggested doing presurgical therapy to reduce the number of organs that would need to be surgically taken out. Karam said there was no need to perform a biopsy and agreed with Abel. Lara also agreed with the surgeons. The patient was treated with sunitinib however due complications this was changed to pazopanib and eventually taken to surgery for mass resection en bloc of the affected organs.

Moderator: Christopher Wood, MD, The University of Texas MD Anderson Cancer Center
Panelists: Primo Lara, MD, University of California Davis Comprehensive Cancer Center, Jason Abel, MD, University of Wisconsin School of Medicine and Public Health, Jose Karam, MD, The University of Texas MD Anderson Cancer Center

Written by: Egor Parkhomenko Department of Urology, University of California-Irvine, medical writer for at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA