AUA 2019: Tumor Board: Kidney Cancer

Chicago, IL (UroToday.com) In a plenary session at the American Urologic Association Annual Meeting, Dr. Marston Linehan moderated a Tumor Board session focusing on kidney cancer. Along with panelists Dr. Rana McKay, Dr. Suzanne Merrill, Dr. Andrew Wagner, Dr. Ithaar Derweesh, and Dr. Guliz Barkan.  Dr. Linehan discussed the cases of four patients who presented to the National Cancer Institute in the past few months.

The first patient was an otherwise healthy 47-year-old woman presenting with weight loss and night sweats. Axial abdominal imaging demonstrated an 8 centimeter left renal mass on magnetic resonance imaging. While bone scan and brain CT did not demonstrate any evidence of disease, chest CT scan demonstrated at least 5 small pulmonary nodules in the right chest, with the largest measuring 9mm.

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Dr. Linehan then asked Dr. McKay, a medical oncologist, her thoughts on management options. Dr. McKay described this patient as “barely” intermediate risk de novo metastatic kidney cancer and suggested that the results of CARMENA may not be generalizable to this patient due to the significant proportion of patients with poor-risk disease accrued to the trial. Further, she highlighted that this particular patient had a high volume of disease within the kidney and a low burden of metastatic disease. As a result, she recommended cytoreductive nephrectomy. Dr. Wagner, a uro-oncologist, concurred opining that she passed the “Eyeball test” as young with good performance status. Dr. Linehan went on to say that this lady underwent a robotic-assisted left radical nephrectomy with pathology demonstrated Fuhrmann Grade 4 clear cell renal cell carcinoma with 5% sarcomatoid histology and no nodal involvement. Dr. Barkan, a pathologist, weighed in to highlight that the sarcomatoid component portended a poor prognosis. Dr. Linehan showed evidence that this patient had no germline mutations. Post-operative chest imaging showed stable nodules. Dr. McKay then considered options including surveillance, surgical resection, and systemic therapy. Given the sarcomatoid differentiation, she favored treatment in this young patient, even though she doesn’t technically fulfill criteria as having measurable disease (largest lesion <1cm). She recommended nivolumab and ipilimumab after considering pembrolizumab and axitinib. Dr. Linehan then went on to say that this patient received nivolumab monotherapy with good tumor response.

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The second patient was a 53-year-old man who underwent imaging for mild abdominal pain. Abdominal imaging demonstrated multifocal, bilateral tumors, the largest measuring 5.1cm in the right kidney.

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The patient then went on to undergo bilateral renal mass biopsy, demonstrating type 1 papillary RCC bilaterally. Interestingly, this patient had no relevant family history of RCC and germline mutation testing was negative, including for MET abnormalities. Dr. Merrill, a uro-oncologist, was then asked her opinion on management. She highlighted that, in this patient, her goal was renal preservation. Thus, as the tumor was larger than 3cm, she advocated a right partial nephrectomy with the goal to resect all tumors. She said that she would open for an open, flank approach in this patient. Dr. Linehan then showed that this patient did indeed undergoing open right partial nephrectomy with resection of 6 tumors, the largest measuring 6cm, all of which were consistent with type 1 papillary RCC. He then asked about the management of the contralateral tumors. Dr. Linehan asked Dr. McKay to discuss the role of neoadjuvant therapy in this patient. She discussed the role of MET inhibitors, including Savolitinib which was investigated in the SAVIOUR trial which has been stopped. Axitinib and cabozantinib were also discussed through the lack of level 1 evidence for their role was highlighted. In particularly, Dr. McKay pointed out that, due to its long half-life, cabozantinib may remain for weeks following the last administration and this may affect surgical timing. Left partial nephrectomy was advocated by Dr. Darweesh and this patient underwent left robotic-assisted partial nephrectomy with resection of 8 tumors, the largest of which measured 6cm, again demonstrating type 1 papillary RCC. With a good post-operative outcome,

Third, Dr. Linehan presented the case of a 60 year old lady who “looked older than stated age” who presented with a four week history of abdominal pain and malaise. Her history was remarkable for many prior abdominal surgeries including appendectomy, hysterectomy, splenectomy, and cholecystectomy. Abdominal imaging demonstrated a large, 16cm left renal mass with renal vein thrombus and local lymphadenopathy.

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Staging imaging, including FDG-PET scan, was negative for metastatic disease beyond the retroperitoneum. Dr. Wagner provided his perspective on this patient’s care. He deemed the mass resectable based on the imaging available and advocated an open, chevron approach to radical nephrectomy with retroperitoneal lymphadenectomy. In reality, this patient also required a left hemicolectomy for clinical T4 disease into the left colon. Pathology demonstrated poorly differentiated, high grade chromophobe with diffuse sarcomatoid differentiation with full thickness colonic invasion, lymph node invasion and negative surgical margins. Dr. McKay then discussed the role of adjuvant therapy in this patient and concluded that it was not warranted. On a subsequent post-operative visit, Dr. Linehan demonstrated evidence of diffuse spread including L2 metastasis, multiple hepatic metastases, and retroperitoneal recurrence.

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Dr. McKay then discussed the role of systemic therapy in treatment of this relapse. Highlighting that tumors with sarcomatoid differentiation tend to respond to checkpoint inhibition, she recommended nivolumab and ipilimumab despite the fact that there are limited data in patients with non-clear histology. Dr. Linehan then showed that this patient did receive nivo/ipi with good response and was subsequently transitioned to nivolumab monotherapy.

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After three months, she had disease progression and dual therapy was resumed.

The final case was of a 47 year old woman with multiple renal masses in a solitary left kidney as a result of right renal agenesis.

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She underwent left robotic partial nephrectomy with resection of 8 tumors off-clamp and 200cc blood loss. Dr. Linehan described the case as “textbook”. The patient had an “uncomplicated” post-operative course until postoperative day 7 when she became pale, diaphoretic and tachycardic with a hemoglobin of 6.3. She was resuscitated and transferred to ICU. Dr. Linehan asked Dr. Merrill as to her next steps: she recommends CT angiography with angioembolization which this patient received. The angiography demonstrated bleeding from the resection site of a small tumor that was successfully embolized. The patient went on to recover well.

This concluded the Kidney Cancer Tumor Board. After three months, she had disease progression and dual therapy was resumed.

The final case was of a 47-year-old woman with multiple renal masses in a solitary left kidney as a result of right renal agenesis.


Presented by: W. Marston Linehan, MD, Chief, Urologic Oncology Branch, Senior Investigator, National Cancer Institute, Center for Cancer Research, Rana McKay, MD, UC San Diego Health, Suzanne Merrill, MD, Penn State Health Milton S. Hershey Medical Center, Andrew Wagner, MD, Beth Israel Deaconess Medical Center in Boston. Ithaar Derweesh, MD, UC San Diego Health, and Guliz Akdas Barkan, MD, FIAC, FABP, Loyola Medicine

Written by: Christopher J.D. Wallis, Urology Resident, University of Toronto, @WallisCJD on Twitter  at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois