ESMO Preceptorship Programme
METASTATIC RENAL CELL CARCINOMA
(Case Study)
ENG JIE YI
ONCOLOGY TRAINEE UNIVERSITY MALAYA MEDICAL CENTER
MALAYSIA (MD)
Metastatic Bladder and Kidney Cancer 2018– Singapore– 19 till 20 September 2018
ESMO PRECEPTORSHIP PROGRAMME
Disclosures
� No disclosures
History of Madam PA
� 57 years old lady
� Complaining of non specific symptoms (loss of appetite and
loss of weight) for few months in 2012
� CT Abdomen Pelvis September 2012 showed large right
upper lobe renal mass with lung nodules (largest
1.4x1.5cm)
� Background
- Works as lecturer
- No co-morbidity
� Right nephrectomy was done in Oct 2012
� HPE: renal cell carcinoma with tumor size of 10x8x6cm. It
was infiltrating the capsule but not involving perinephric
fat and Gerota fascia (pT2N0Mx)
� Repeated CT restaging on 31/12/2012 showed multiple
lung nodules and L2 vertebra metastasis.
� Bone scan: L2 vertebra metastasis
� Referred to oncologist for further management
� Fit, ECOG 0, asymptomatic
� Blood parameters: Hypercalcemia with corrected calcium
2.8 mmol/L
Treatment History
� Surgery
� Oncology
Heng’s criteria: Intermediate risk
Treatment History
o Sunitinib 50mg OD 4/2 on 16/1/2013 with monthly
Zoledronic acid
o G1 HFS, tiredness, gastritis, mucositis and grade 2
diarrhea
o CT restaging 3 months after Sunitinib: PR
o Switch to denosumab in Nov 2013 as patient preferred for
subcutaneous instead of intravenous injection
o 1 year later, CT assessment on 15/1/2014 showed new
mediastinal LN, 3cm with new lytic lesion at T1 and T10
vertebra.
� 1st line
Sunitinib
~ 1 year
o Everolimus 10mg OD started on 29/1/2014 and
continue with monthly denosumab
o CT reassessment 3 months after everolimus:
mediastinal LN did reduce in size but overall still SD
o The disease was progressing after 6 months of
everolimus with local recurrence and enlarging right
hilar and paraoartic lymph node
o CT scan on 29/9/2014: disease progression with bigger
renal bed lesion and larger mediastinal LN and lung
nodule.
�2nd line
Everolimus
~ 8 months
Treatment History
Treatment History
� 3rd line
Axitinib
~ 4 months
o Axitinib 5mg BD started on 9/10/2014. Disease was
progressed 2 months later, axitinib dose increased to
7mg BD but patient only took 7mg OM, 5mg ON due to
asthenia
o Unfortunately in June 2015, disease progressed again in
lung, hilar LN and bone metastasis at T10,11 with
extradural extension at T10-11 level
o She had back pain at that area as well
o She was re-challenged with Sunitinib on 17/6/2015,
started with 25mg OD 2/1 then increased the dose to
37.5mg OD 2/1
o Palliative RT 40Gy/15# was given to T9 to T12 for
bone metastasis in August 2015
Treatment History
� 4th line
Sunitinib
(re-challenged on
17/6/2015 till
1/2017)
~ 1 and a ½ years
� Patient complaint of intermittent
toothache then noted to have
osteonecrosis of jaw in January 2016
� Denosumab was stopped since then
(was on denosumab for 2 years)
Treatment History
� Patient had more side effects from
Sunitinib this time
- More lethargy
- Grade 2 mucositis
- Hypertension (Amlodipine 10mg OD)
- Hypothyroidism (L-thyrosine 100mcg
OD)
Osteonecrosis of jaw
� The disease was progressed in Feb 2016 with enlarging
right renal bed lesion and worsening lung metastasis
� Patient stopped the sunitinib in Jan 2017 as suffered from
G3 lethargy and no appetite. ECOG was 3 at that time
� CT reassessment in March 2017 showed disease
progressed
� In early of May 2017, she was admitted to ward for
symptomatic hypercalcemia and anemia. Her condition
deteriorating and succumbed to death
Treatment History
� 4th line
Sunitinib
(re-challenged
on 17/6/2015
till 1/2017)
~ 1 and a ½
years
ESMO PRECEPTORSHIP PROGRAMME
Summary (Oct 2012-May 2017)
mRCC in Oct 2012
-post cytoreductive
nephrectomy
1 year
Everolimus 10mg OD
1/2014
- Grade 1 mucositis
and lethargy
8 months
Axitinib 5mg BD
-2 months later disease
progressed and increase
dose to 7mg BD
-Very bad asthenia
4 months
Sunitinib 25mg OD 2/1
Then 37.5mg OD 2/1
- Developed HFS, mucositis,
hypertension, hypothyroidism
- Palliative RT to T9-T11
Developed ONJ
- Stop denosumab
1 & ½ years
Death
Sunitinib 50mg OD 4/2
1/2013 + zometa
-Grade 2 diarrhea with
grade 1 HFS, lethargy,
mucositis
-Switched to Denosumab
ESMO Preceptorship Programme
Thank you