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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Evaluate first-line pharmacotherapeutic options for patients with metastatic kidney cancer.

  • Formulate a monitoring plan for a patient receiving treatment for metastatic kidney cancer based on patient-specific factors and the prescribed regimen.

  • Recommend alternative pharmacotherapeutic treatment options for patients with relapsed or progressive metastatic kidney cancer.

  • Provide appropriate and detailed educational information to patients about the targeted therapies for metastatic kidney cancer.

PATIENT PRESENTATION

Chief Complaint

“What treatment options do I have for my metastatic kidney cancer?”

HPI

Melanie Simmons is a 65-year-old woman who presented 3.5 years ago to her primary care physician with complaints of back pain, cough, and weight loss. She did not respond to an initial course of antibiotics for assumed pyelonephritis and developed gross hematuria a few days later. She was subsequently referred to a urologist, who detected a left kidney mass on renal ultrasound. CT scan of chest, abdomen, and pelvis revealed a 7-cm left upper-pole left kidney tumor and several bilateral small, subcentimeter lung nodules. Additional imaging found no evidence of metastatic disease in her brain, bones, or liver. She was referred to a nearby cancer center for further evaluation. A core needle biopsy of the kidney mass revealed neoplastic cells, but the sample was too small and heterogeneous to definitively determine a specific histology. In order to relieve worsening symptoms and further elucidate a specific histopathology of the mass, she underwent radical nephrectomy of her left kidney. Pathologic examination revealed kidney cancer with clear-cell histology. The patient recovered from surgery with resolution of back pain and hematuria. She received no treatment for the pulmonary nodules because interventional radiology determined that they were not cancerous; she agreed to undergo active surveillance of the nodules over time to identify changes or progression.

Now, more than 3 years later the patient presents to the outpatient oncology clinic for an appointment with the medical oncologist. Recently, a routine CT scan revealed lung metastases (which have increased in number and size since her initial scans and decision to pursue active surveillance). Imaging found no evidence of metastatic disease in her brain, bones, or liver. The patient has an estimated Karnofsky score of 90% and is interested in pursuing systemic treatment for her metastatic kidney cancer and would like to discuss appropriate and available treatment options.

PMH

Hypertension

Dyslipidemia

FH

Her mother died at age 75 due to complications related to MI, and her father died at age 73 due to PE. The patient has one brother, age 58, who is alive and living with asthma, ...

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