Investigator Perspectives on Emerging Concepts in the Management of Genitourinary CancersCase discussion: A 60-year-old man with metastatic non-clear cell RCC treated with everolimus
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TRANSCRIPTION:
DR GOMELLA: So this is actually somewhat of a little bit of a sad case, because this is a man whose wife had actually recently died just a few months earlier with breast cancer. And he was a retired police officer. He was 60 years old and had an episode of gross hematuria about 3 or 4 years ago and, as many men do, sort of ignored it. And he had an episode of DVT, and it was thought to be ascribed to the anticoagulation. And if you want to talk about a pearl, a take-home message, you shouldn’t ascribe gross hematuria to any type of anticoagulation. And that’s something we stress to our residents, to our primary care colleagues. It’s very easy to say it’s due to the anticoagulant, but you’ve really got to work the patient up with any episode of gross hematuria. DR LOVE: That was in 2010, so 5 years earlier. DR GOMELLA: Yes. No. It is. And whether or not it was related, we don’t know. But I think when we finally got in there and he’s got a 6- to 7-cm mass, we know that these tumors grow about a half a centimeter/three quarters of a centimeter a year. It’s certainly possible that that was the earliest manifestations of his renal tumor. DR LOVE: Wow! DR GOMELLA: So he did have a workup and, unfortunately, had about an 8 x 7 x 7 large right renal mass with extensive lymphadenopathy and a tumor thrombus extending partway into the vena cava. He did have further staging studies. There were some very small nodules in his chest, but again, in the concept of debulking these tumors and getting the primary out and seeing exactly what’s going on, he went ahead and he had a radical nephrectomy and partial vena cava resection, but he unfortunately had a pathologic T3N1 papillary renal cell carcinoma. The nodes right around the hilum were involved. And, of course, he had invasion of the vena cava wall, which means we had to resect a small component of the vena cava. He recovered from the surgery and again had some follow-up scans and did show that the pulmonary lesions were, in fact, getting larger. So what’s interesting about a lot of the stuff being done right now at cancer centers is trying to do genomic analysis. And again, we don’t have clear pharmacogenomics right now to figure out what’s the best treatment for patients with renal cell carcinoma, but again, we’re all trying to learn. All this information is going to very large databases. So based on his report, where he had a PIK3CA abnormality, our medical oncologists thought that perhaps his initial therapy should be with an mTOR inhibitor. So they chose everolimus to treat him for his pulmonary metastases. And he did have a reasonable response. He’s still doing well. He’s functioning. He has good performance status. But this is an example of the direction — I chose this case because it’s showing us the direction that we’re moving in. This is a nonclear cell renal cell carcinoma, which is not the common ones. The more common is the clear cell. We have a little bit better, longer track record in some of these systemic agents that are used in the clear cell population. We don’t have as much track record, but we’re learning more and more about for this gentleman’s papillary renal cell carcinoma, the type of agents that are probably best used in his particular setting. |