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Integrative Tumor Board: Metastatic Renal Cell Carcinoma

Dendritic cells are loaded with tumor antigens and induce T-cell lymphocytes to target tumor cells after host vaccination. RCC is highly vascular and theoretically an ideal target for angiogenesis inhibitors. There is also some promise with stem cell transplantation in patients with metastatic RCC that is refractory to other treatments, although this treatment can be associated with high toxicity. The patient in our clinical scenario has developed multiple metastatic sites of disease including the lungs and adrenal gland. In addition, the back pain she is experiencing and the skin nodules on her shoulder likely can be attributed to RCC. This patient, although experiencing pain, has an overall good performance status and is active. High-dose intravenous recombinant IL-2 alone seems to be superior to other regimens and has a higher incidence of complete remission and more durable response time when compared to INF-α. This patient is a good candidate for highdose IL-2 in that she has a good performance status, little comorbidity, good cardiopulmonary and renal function, and no liver metastasis. Although high-dose IL-2 should be offered, the rapid progression to metastatic disease after nephrectomy (1 year) and the presence of multiple metastatic sites have been associated with poorer outcome with this therapy. Due to the high toxicity of high-dose IL-2 therapy, other options should be offered and include phase I or phase II clinical trials with novel investigational drugs (such as the VEGF inhibitor phase I trial offered) alone or in combination with immunotherapy. Our therapeutic approach would depend on patient factors, outcome expectation, and patient acceptance. Palliative measures alone and/or observation alone are options and would be considered if the patient prefers this approach; however, because selected patients have shown complete and durable regression of tumors with immunotherapy, this modality of treatment should be strongly considered alone or in combination with new investigational approaches. In addition to systemic therapy considerations, symptom control and palliation of symptoms are necessary. This patient has developed pain in the left scapula that could be due to bony metastasis. Pain control with medication is important to maintain activity levels and allow the patient to continue to perform her daily activities. A bone scan would help with the diagnosis of bony metastasis. If bony metastases are indeed present, there is evidence to support the use of monthly intravenous bisphosphonate use (eg, zolendronate) to help with symptoms and prevent further bony disease. In addition, our patient is experiencing weight loss. This has been associated with poorer prognosis, and efforts to promote proper nutrition and weight stabilization should be undertaken. Our patient is very anxious and may be depressed; both of these factors could contribute to her weight loss and insomnia. Psychological counseling and/or introduction to support groups may help. This patient should also be offered an antidepressant with anxiolytic properties to help with symptoms. Immunotherapy, if chosen, has been found to worsen fatigue, anxiety, and depression, and these symptoms should be addressed prior to starting any systemic therapy.