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In light of this patient having a calculated at least intermediate IMDC risk disease, Ipilumumab + Nivolumab would be an ideal option for the patient once the local issues are dealt with or in conjunction with dealing with the local issues. This is based on the Checkmate 214 data showing an OS benefit (18 month OS increased from 60 to 75%), and better gr 3 / 4 SAEs over Sunitinib. https://www.nejm.org/doi/full/10.1056/NEJMoa1712126
If no specific contraindications, this was tumor board recommendation. Other options would include Cabozatinib based on CABOSUN showing a DFS benefit in a randomized ph 2 study over Sunitinib. There is subset analysis data from METEOR trial that Cabozatinib ten to work particularly well in patients with bone metastases, so that would be an advantage here, however, the size, strength and results of the CHECKMATE 214 data is very compelling.
If they are determined to have poor risk disease when get the labs, then Temserolimus had historically been an option, however, as noted above, Ipilumumab/Nivolumab combination for those without contraindications would be optimal.
NCCN guideline utilized: Yes.
Clinical Trial: No
Pending Moderator approval.
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