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It appears that this patient is likely in the favorable prognostic risk group unless there are any surprises on his labs. It is over 10 years from nephrectomy. He has resected stage 4 disease and has never seen systemic therapy. So assuming that is the case, in this category, one standard of care option would be to give targeted therapy with a VEGF inhibitor. The options in this front line healthy patient include sunitinib and pazopinib. It would enable long term disease control, and certainly if he is symptomatic from any of the disease, this is a reasonable option.
It was brought up at our tumor board that in light of his disease being good risk and the patient being young and fit, high dose IL-2 is an option. The consideration is based on long term data showing a survival “tail”, albeit still quite low numbers. It was pointed out that the toxicity is clearly more substantial, and with modern day therapy, there is no way to know at this point that there isn’t a “tail” with current options.
However, a very reasonable option for this patient would include active surveillance which this might be the right patient for in that it is in the lungs and is progressing extremely slowly. Prospective ph 2 trial showed that subsets like these can undergo active surveillance with initiation of systemic therapy upon progression. https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(16)30196-6/abstract. This is a very reasonable approach.
In light of his contralateral renal masses, and young age of initial presentation, we recommended seeing genetic counselor and possible germline testing.
NCCN guideline utilized: Yes.
Clinical Trial: No.
Systemic therapy upon progression
Pending Moderator approval.
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