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KEY CONCEPTS

KEY CONCEPTS

  • imageRenal cell carcinoma (RCC) predominantly occurs later in life, with about 70% of all cases diagnosed between the ages of 55 and 84 years.

  • imageEstablished risk factors for RCC include smoking, obesity, hypertension, and inherited susceptibility.

  • imageInactivation of the von Hippel-Lindau tumor suppressor gene (VHL) is the hallmark of the most common type of RCC, the clear cell histologic subtype.

  • imageMore than 50% of RCC cases are diagnosed by incidental findings on routine imaging for unrelated reasons.

  • imageThe International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) Criteria classifies patients into favorable-, intermediate-, and poor-risk groups based on five clinical factors, and can predict survival among both untreated patients and those treated with immunotherapy and/or targeted agents.

  • imageSurgical excision of the primary tumor, either by radical or partial nephrectomy, is the preferred treatment modality for patients with stage I-III RCC, but some patients with stage IV disease may also benefit from surgery.

  • imageHistorically, immunotherapy (interleukin [IL]-2 and interferon [IFN]-α) were considered preferred first-line therapies for metastatic RCC (mRCC), but have largely been replaced by immune checkpoint inhibitors and targeted agents because of their improved efficacy and tolerability.

  • imageFirst-line treatment options for mRCC are chosen based on patient-specific factors and include small molecule tyrosine kinase inhibitors (sunitinib, pazopanib, axitinib, cabozantinib), an mTOR inhibitor (temsirolimus) and immune checkpoint inhibitors (ipilimumab plus nivolumab and pembrolizumab plus axitinib).

  • imageIn patients who progress after first-line treatment, the multikinase inhibitors sorafenib, cabozantinib, axitinib, and lenvatinib (in combination with everolimus) are the preferred options. Immunotherapy with nivolumab has also demonstrated clinical efficacy in the second-line setting, and combination immunotherapy with a multikinase inhibitor (eg, pembrolizumab plus axitinib) is an option.

PATIENT CARE PROCESS

Patient Care Process for Renal Cell Carcinoma

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Collect

  • Patient characteristics (age, weight, height, sex, race) and past medical history

  • Laboratory assessment with a complete blood count (CBC), comprehensive metabolic panel, liver function tests (LFTs), and lactate dehydrogenase (LDH). Calculate the corrected calcium.

  • Social history (including tobacco and alcohol use) and family history (including cancer history)

  • A comprehensive medication list that includes prescribed and OTC medications, herbal remedies, dietary supplements, and vitamins

  • Additional information pertinent to patient prognosis (see Table e155-3)

Assess

  • Tumor staging based on TNM criteria and histology (see Tables e155-1 and e155-2)

  • Performance status to evaluate the ability to undergo treatment

  • Patient prognostic risk score by International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) (see Table e155-3)

  • Potential moderate and serious drug-drug interactions (see Table e155-4)

Plan*

  • Treatment selection, which includes dose, route, frequency, and duration

  • Establish monitoring parameters, frequency of monitoring, and plan for follow-up in clinic

  • Coordination of medication acquisition with insurance, specialty pharmacy, and in certain situations with the pharmaceutical industry (eg, free drug for indigent patients)

  • Medication administration education and determine barriers to adherence for orally administered targeted therapies

Implement

  • Patient education on all facets of the treatment plan, including management of ...

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