CME INFORMATION

FACULTY AFFILIATIONS AND DISCLOSURES

Case Studies

Case 1 from the practice of David M Dresdner, MD: An otherwise healthy 70-year-old man presented with back and rib pain and was found to have a 6-cm renal mass with some enlarged nodes, multiple pulmonary nodules and multiple rib and spine lesions. He underwent right nephrectomy, revealing a moderately differentiated clear cell renal cell carcinoma (RCC). His postoperative creatinine was 2.1 mg/dL, and he was started on sunitinib and zoledronic acid. After three months of therapy, his pain improved and scans demonstrated stable disease in the bone and lungs. His condition remained stable for 12 months, at which time he began experiencing headaches. An MRI of the brain revealed a solitary frontal metastasis, which was surgically removed and confirmed to be clear cell carcinoma. He received whole brain irradiation, and he was started on sorafenib. His condition is now clinically stable after 14 months.

Case 2 from the practice of Daniel J Moriarty, MD: A 72-year-old man underwent resection of the left kidney for a T3, clear cell RCC with papillary features three years ago. Two years postresection, he developed left supraclavicular adenopathy, and biopsy results were histologically consistent with the original RCC. Multiple pulmonary nodules were present on CT scan. He received interferon but elected to discontinue treatment after two and a half months due to side effects. He experienced a dramatic response to his first dose of bevacizumab, with a reduction in the size of the supraclavicular nodes and stabilization of the pulmonary nodules. He has been receiving bevacizumab for 16 months, and his condition remains stable.

Case 3 from the practice of John C Leighton Jr, MD: A 72-year-old woman with a history of osteoporosis, controlled hypertension and myocardial infarction presented with vaginal bleeding and left upper quadrant pain. She was found to have a 10-cm clear cell RCC with metastasis to the vaginal wall. Her PS was 2, and her baseline creatinine was 2 mg/dL. She was treated with sunitinib at 37.5 milligrams per day, and the vaginal bleeding ceased and her pain improved. As a result of significant fatigue, the daily dose of sunitinib was decreased to 25 milligrams. After three weeks, the vaginal bleeding returned. The sunitinib was discontinued, and she received palliative radiation therapy, which helped control the vaginal bleeding. The RCC was recently restaged, and the patient was found to have extensive hepatic metastases. Treatment was changed to temsirolimus.

Case 4 from the practice of Gracy Joshua, MD: A 65-year-old man with a history of a nephrectomy for renal cell cancer five years earlier presented with a pathologic fracture of the humerus. A rod was inserted, and pathology revealed clear cell cancer. The patient had well-controlled hypertension and diabetes, a PS of 0 and no other metastatic lesions. He was treated with radiation therapy and sorafenib. He has been receiving sorafenib for two and a half years without any evidence of disease progression.

Case 5 from the practice of Matthew A Taub, MD, PA: A 54-year-old obese man presented with a large renal mass, liver and numerous bilateral pulmonary metastases and nonspecific findings on a bone scan. He underwent a nephrectomy and a liver biopsy, which revealed an RCC with high-grade sarcomatoid features (Fuhrman Stage IV), positive renal margins, prominent lymphatic invasion and three negative nodes. After surgery, his creatinine was 2.1 mg/dL, his PS was 1 and his Memorial Sloan-Kettering Cancer Center risk status was poor. After eight months of temsirolimus, scans showed no evidence of disease in the liver. Subsequently, he developed liver and brain metastases and underwent gamma knife surgery for a lesion in the brain.