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Renal Cell Carcinoma
Center of Excellence
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George Yaghmour
Jul 08, 2015
Medullary carcinoma of the kidney is rare, aggressive with poor prognosis, Given the aggressive, highly proliferative nature, platinum- or taxane-based chemotherapy is generally tried first; however, VEGF-targeted agents can be considered as second-line options.
We have limited data from few small series and case reports supporting the use VEGF inhibitors; in one report, two patients received sunitinib after progression on chemotherapy, and neither of them responded. And 1 report with partial response or stable disease was observed in 23% of the patients, and median OS was 4 months. Clinical trial should be offered, with genetics tumor profiling which might help guiding to rational therapies testing the role of combinations of the targeted therapies with cytotoxic chemotherapy in this subgroup of patients
Overexpression of PD-L1 has been linked to poor prognosis in various tumor types, including RCC. Antibodies targeting PD-1 or PD-L1 have achieved clinical benefit in several small studies evaluating RCC, albeit mostly in clear cell disease. Trials evaluating the PD-L1 antibody observed an ORR of 17% and a 24-week PFS of 20% non–clear cell RCC patients. This activity suggests that targeting the PD-1 pathway in non–clear cell RCC could be effective.
Andrew Fintel
Jul 14, 2015
This patient was not eligible for a Clinical Trial that was open in her area using PD-1 inhibitors as it was only being used for clear cell histology. There was a possibility for a new clinical trial opening she may be eligible for, but she was having rapid progression and could not wait for this. We decided to us MVAC chemotherapy to help bridge her to a clinical trial. There has been success with this regimen with PFS averaging 8.3mo according to a literature review by Rathmell and Monk. We have also sent her tumor for next generation sequencing to see if there is an actionable mutation for more targeted therapy. We held off on using typical VEGF or mTOR inhibitors used for Clear Cell RCC as there is very sparse data for using them in renal medullary carcinoma.
Eric Wiedower
Jul 14, 2015
Unfortunate situation for this patient. Medullary carcinoma of the kidney comprises 2% of all kidney cancers in young patients, exclusively affecting individuals who carry at least one sickle hemoglobin allele and 95% of which will have metatstatic disease. Clinical trial should be pursued. If immunetherapy or clinical trial not available could consider MVAC, however data with is not favorable with this prognosis. Rathmell et al published a report in Urology in 2008. Three patients were treated and were able to tolerate multiple cycles of therapy and achieved at least a partial response and longer survival than predicted from the historical precedent according to their report.
Apr 30, 2024
Pending Moderator approval.
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Andrew
Fintel
DO
George Yaghmour
Jul 08, 2015
Andrew Fintel
Jul 14, 2015
Eric Wiedower
Jul 14, 2015
Apr 30, 2024
Pending Moderator approval.