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Renal Cell Carcinoma Relapsing in Brain 12 Years After Surgery

Alok Gupta

Consultant Medical Oncologist

Max Super Specialty Hospital

Saket, New Delhi, India

Metastatic Bladder and Kidney Cancer 2018: Singapore

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Disclosures

� No disclosures

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Presentation

� Mr. RP, 76/Male

� Comorbidities: HTN x 27 years, CAD (CABG 23 years back)

� 2005: Left renal mass detected. Underwent nephrectomy

� HPR- Clear cell RCC pT2N0

� Asymptomatic for 12 years.

� December 2017 : Presented with Seizures

� MRI brain Three Rim and nodular enhancing lesions in left cerebral hemisphere with variable perilesional edema.

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MRI Brain

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FDG PET CT scan

FDG avid spiculated soft

tissue lesion, 3.0x2.9x3.2

cm in left lung lower lobe

with other FDG avid

confluent nodular lesions

infero-medial to it.

Mildly FDG avid

subcentimeter sized

superior mesenteric and

aortocaval lymph nodes.

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Diagnosis

Biopsy from left lung mass: Metastatic clear cell carcinoma.

Recurrent Clear Cell RCC (Brain and Lung and Nodal mets)

IMDC risk - good risk

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Treatment

� Received SRS for brain mets on 11.1.18.

� 2 D echo: EF - 56%, Basal lateral wall is scarred, thinned

out and akinetic.

� Started on Sutent 37.5 mg OD 2/1 regimen wef 30.1.18.

� After 3rd cycle reported neurological worsening with

increasing imbalance, drowsiness and weakness + weight

loss.

� PS deteriorated from 2 to 3.

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MRI Brain (April 2018)

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FDG PET CT scan (05.04.2018)

� Lung lesion decreased in avidity. New Liver and skeletal lesions

(skeletal lesion in B/L scapula, left 7th and 9th rib, D2 , B/L pelvic

bones, proximal left femur).

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� Received External Beam Radiotherapy by 3 Dimensional Conformal Radiotherapy (3D CRT) technique to whole brain to a dose of 35 Gyin 17 fractions till 10.05.2018.

� Axitinib 5 mg BD started from 20.5.18

� After 1 month – No further improvement in general condition, no improvement in neurological condition.

� Poor Tolerance to Axitinib (Severe Fatigue and loss of appetite). Patient stopped Axitinib.

� As a desperate measure, started Nivolumab on 3rd July 2018.

� General condition/ neurological condition worsened. Patient got admitted for extreme weakness, loss of appetite, drowsiness and fever. Diagnosed with UTI and pneumonia. Died of Sepsis on 24th

July 2018.

Rapid progression in brain, liver and

bones after first line TKI

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Discussion Points

1. Which 1st line systemic therapy should be preferred, if any, in patients with symptomatic brain metastasis?

2. Which 2nd line systemic therapy should be preferred, if any, in patients with rapid progression after first line TKI?

3. How safe it is to initiate immunotherapy after whole brain RT? Is there any specified safe time interval between RT completion and immunotherapy?

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Thank You For Your Attention