METASTATIC RENAL CELL CARCINOMA (Case Study) Disclosures

ESMO Preceptorship Programme Metastatic Bladder and Kidney Cancer 2018– Singapore– 19 till 20 September 2018

ENG JIE YI ONCOLOGY TRAINEE UNIVERSITY MALAYA MEDICAL CENTER MALAYSIA (MD) METASTATIC RENAL CELL CARCINOMA (Case Study) Disclosures

ú No disclosures

ESMO PRECEPTORSHIP PROGRAMME History of Madam PA

ú 57 years old lady ß Background ú Complaining of non specific symptoms (loss of appetite and loss of weight) for few months in 2012 - Works as lecturer

ú CT Abdomen Pelvis September 2012 showed large right - No co-morbidity upper lobe renal mass with lung nodules (largest 1.4x1.5cm) Heng’s criteria: Intermediate risk Treatment History

ß Surgery ú Right nephrectomy was done in Oct 2012 ú HPE: renal cell carcinoma with tumor size of 10x8x6cm. It was infiltrating the capsule but not involving perinephric fat and Gerota fascia (pT2N0Mx) ú Repeated CT restaging on 31/12/2012 showed multiple lung nodules and L2 vertebra metastasis. ú Bone scan: L2 vertebra metastasis

ß Oncology ú Referred to oncologist for further management ú Fit, ECOG 0, asymptomatic ú Blood parameters: Hypercalcemia with corrected calcium 2.8 mmol/L Treatment History

ß 1st line o Sunitinib 50mg OD 4/2 on 16/1/2013 with monthly Zoledronic acid Sunitinib o G1 HFS, tiredness, gastritis, mucositis and grade 2 ~ 1 year diarrhea

o CT restaging 3 months after Sunitinib: PR o Switch to denosumab in Nov 2013 as patient preferred for subcutaneous instead of intravenous injection o 1 year later, CT assessment on 15/1/2014 showed new mediastinal LN, 3cm with new lytic lesion at T1 and T10 vertebra. Treatment History

o Everolimus 10mg OD started on 29/1/2014 and continue with monthly denosumab ß2nd line Everolimus o CT reassessment 3 months after everolimus: mediastinal LN did reduce in size but overall still SD ~ 8 months o The disease was progressing after 6 months of everolimus with local recurrence and enlarging right hilar and paraoartic lymph node

o CT scan on 29/9/2014: disease progression with bigger renal bed lesion and larger mediastinal LN and lung nodule. Treatment History

o Axitinib 5mg BD started on 9/10/2014. Disease was progressed 2 months later, axitinib dose increased to ß 3rd line 7mg BD but patient only took 7mg OM, 5mg ON due to asthenia Axitinib

~ 4 months o Unfortunately in June 2015, disease progressed again in lung, hilar LN and bone metastasis at T10,11 with extradural extension at T10-11 level

o She had back pain at that area as well Treatment History

ß 4th line Sunitinib

(re-challenged on 17/6/2015 till 1/2017) o She was re-challenged with Sunitinib on 17/6/2015, started with 25mg OD 2/1 then increased the dose to 37.5mg OD 2/1 ~ 1 and a ½ years o Palliative RT 40Gy/15# was given to T9 to T12 for bone metastasis in August 2015 Treatment History

ú Patient had more side effects from ú Patient complaint of intermittent Sunitinib this time toothache then noted to have osteonecrosis of jaw in January 2016

- More lethargy - Grade 2 mucositis ú Denosumab was stopped since then (was on denosumab for 2 years) - Hypertension (Amlodipine 10mg OD) - Hypothyroidism (L-thyrosine 100mcg OD)

Osteonecrosis of jaw Treatment History

ß 4th line ú The disease was progressed in Feb 2016 with enlarging right renal bed lesion and worsening lung metastasis Sunitinib (re-challenged ú Patient stopped the sunitinib in Jan 2017 as suffered from G3 lethargy and no appetite. ECOG was 3 at that time on 17/6/2015

till 1/2017) ú CT reassessment in March 2017 showed disease progressed

~ 1 and a ½ ú In early of May 2017, she was admitted to ward for years symptomatic hypercalcemia and anemia. Her condition deteriorating and succumbed to death Summary (Oct 2012-May 2017)

Sunitinib 25mg OD 2/1 Then 37.5mg OD 2/1 - Developed HFS, mucositis, Everolimus 10mg OD hypertension, hypothyroidism mRCC in Oct 2012 1/2014 - Palliative RT to T9-T11 -post cytoreductive - Grade 1 mucositis Death nephrectomy and lethargy

8 months 1 & ½ years

1 year 4 months

Sunitinib 50mg OD 4/2 Axitinib 5mg BD 1/2013 + zometa -2 months later disease Developed ONJ -Grade 2 diarrhea with progressed and increase grade 1 HFS, lethargy, dose to 7mg BD - Stop denosumab mucositis -Very bad asthenia -Switched to Denosumab

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