According renal cancer lancet these aspects, the patient was included in the intermediate risk group, with median survival estimated at CT exam reassessment for thorax, abdomen, and pelvis with contrast substance scans are performed in Augustand then in Januaryboth suggesting stable disease. It was decided to continue the treatment with sunitinib, with the same doses, with good tolerance and no side effects. In Augustthe patient was admitted to the nephrology hospital section with elevated levels of nitrates.
Following investigations, there was no evidence of acute renal insufficiency and it was recommended to continue the sunitinib treatment.
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The thoracic, abdominal, pelvis CT test performed on June 18, revealed multiple numerical and dimensional secondary pulmonary lesions renal cancer lancet to the renal cancer lancet exam, a stationary aspect of adrenal lesions without other secondary lesions. Conclusion: disease progression. Bone scintigraphy performed on July 3, revealed a scintigraphic image without oncological renal cancer lancet. Figure 1. Abdominal CT scan - November 28, Following the imaging results that highlighted the disease progression, it was decided to stop the sunitinib therapy and initiate the second-line therapy.
Figure 2. Lung CT scan - July 3, The thoracic, abdominal and pelvic CT test performed on December 4, revealed evolutionary numerical and dimensional secondary pulmonary lesions, adjacent adrenal secondary process with evolutionary aspect, mediastinal and upper abdomen pathological lymph nodes.
Between December and Octoberthe patient was treated with temsirolimus, weekly dose of 25 mg i. Figure 3.
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Abdominal CT scan - Renal cancer lancet 4, Thoracic, abdominal and pelvic CT exam renal cancer lancet on June 21, no contrast substance revealed: secondary lung lesions and left adrenal metastasis in mild dimensional progression compared to previous examination, without secondary liver and bone lesions.
Conclusion: stable disease. Figure 4. Abdominal CT scan renal cancer lancet October 27, Bone scintigraphy on The patient continued the treatment with temsirolimus weekly with 25 mg i. Figure 5. Abdominal CT scan - January 02, In terms of side effects after temsirolimus treatment, the patient experienced repeated haematological toxicity, grade thrombocytopenia between March and Julywhich led to discontinuing the treatment and repeated platelet transfusion. The administration is resumed in Augustafterwards — no side effects.
The thoracic-abdominal-pelvic native CT scan performed on October 10th, revealed secondary lung lesions in dimensional regression from previous examination; without new lesions, the secondary lesion of the left adrenal gland in mild dimensional regression, but spontaneous hypodense liver lesion developed in left hepatic lobe, suspected for secondary substrate, mediastinal and infradiafragmatic adenopathies in mild dimensional regression.
Conclusion: disease progression due to new hepatic secondary lesion. Figure 6. In Novemberhepatic chemoembolization with tandem microspheres loaded with doxorubicin mg was performed. Between December and Januarythe patient continued temsirolimus 25 mg i.
In January 1st,a new thoraco-abdominal-pelvic CT scan was performed, which showed local right renal lobe relapse, secondary hepatic evolution dimensional and numerical tumors, stable secondary pulmonary metastases, secondary adrenal glands lesions with dimensional evolution, and an osteolytic lesion vertebral body L2 - possibly secondary.
It was decided to discontinue the treatment with temsirolimus, and to evaluate the following therapeutic options.
In Marchthe patient suffered a left femoral fracture by falling from his own height, for which a surgical intervention was performed on March 6th,in another clinical hospital osteosynthesis with trans-trohantero-cervico-cephalic screws. During hospitalization, the patient had increased serum calcium levels Bone scintigraphy performed on March 20th, revealed secondary vertebral bone metastases T10, T12, L2and bilateral femur metastases.
On April 12 - April 14,the patient was once again hospitalized on the nephrology section with low back pain and inferior limb pain, the diagnosis of admission being: chronic dorsolombalgia, high blood pressure grade 3, very high risk group, insulin-requiring type 2 diabetes, right nephrectomy for Gravitz tumor operated with pulmonary, right adrenal and liver metastases, asymptomatic hyperuricaemia, mixed caused hypercalcemia.
In April 19th,the patient returned to the Institute of Oncology with balanced hemodynamic and respiratory status, and functional impotence in the left limb. Biological status: anemia hemoglobin 8. Regarding continued treatment options, at the time the patient did not fit into any of the inclusion criteria according to the current therapeutic protocols, axitinib being approved in second-line therapy, and everolimus treatment was not allowed because renal cancer lancet the low hemoglobin level and clearence to creatinine.
Also, the actual protocols do not accept the rechallenge therapy for sunitinib, and immunotherapy was not available at that time renal cancer lancet renal carcinoma. On April 20th,supportive treatment was initiated: erythropoietin weekly, intravenous administration, to normalize hemoglobin level, and intensive hydration to decrease creatinine levels.
Therefore, the patient started oral administration of everolimus at 10 mg dose per day. In June the patient performed external RT with palliative indication at the level of bone secondary determinations and continued to administer everolimus, with good tolerance. Discussions What is to be emphasized is that under four targeted therapy lines, the patient showed an overall survival of 45 months after metastatic disease revealed and 49 months after the diagnosis of renal clear renal cancer lancet carcinoma, compared to the average survival period statistically estimated renal cancer lancet be In order to have a correct therapeutic attitude, the following steps are essential for patients with clear kidney tumors: histological confirmation of the diagnosis, subsequently verified by immunohistochemical tests, correct staging, patient framing ranges in one of the risk groups, correct evaluation of prognostic factors, control of co-morbidities and the possibility of performing nephrectomy 3.
Regarding the treatment of systemic illness at the moment, we had several therapeutic options.
According to international guidelines, in the first line of treatment it is preferable either to treat with tyrosine-kinase inhibitors type as sunitinib, pazopanib, axitinib for the low-risk group and intermediate risk groups, or anti-angiogenesis monoclonal antibody bevacizumab in combination with interferon, either with first-line temsirolimus-type mTOR inhibitors for high-risk patients.
In the second line, guidelines recommend renal cancer lancet first-line therapy with a TKI the replacement papilloma cell definition another TKI, or the everolimus mTOR inhibitor, or the combination of lenvatinib plus everolimus. Also, guidelines recommend immunotherapy with nivolumab as second-line option or the new TKI cabozantinib 4. We mention that at the time, cabozantinib, lentavinib and nivolumab were not available in Romania for the treatment of metastatic renal cancer.
According to renal cancer lancet current therapeutic protocols, we have available in the first-line treatment of metastatic clear cell renal carcinoma the TK inhibitors sunitinib, pazopanib and monoclonal antibody anti-VEGF bevacizumab, with the mTOR inhibitor temsirolimus being reserved in the first line for patients in the high-risk group. In the next treatment lines, axitinib and sorafenib are available as tyrosine kinase inhibitors, as well as mTOR inhibitor everolimus.
All these therapies are currently available, reimbursed through the insurance system. In the correct sequencing of the treatment, a careful monitoring of the patient has an essential role. Performing periodic determinations of imaging and laboratory investigations is imperative.
At each stage of disease progression, he was switched to another therapeutic line, so that it was achieved a significant prolongation of survival.
Also, the control of co-morbidities through close collaboration with other specialties made it possible to continue the oncologic treatment. Maintaining the optimal dose, as well as correct sequencing renal cancer lancet the treatment are key factors in achieving prolongation of survival to an oncologic patient. This is possible through a prompt and immediate approach to side effects of targeted therapies.
It is renal cancer lancet to advise the patient on adverse reactions and, where appropriate, to apply prophylactic measures. Any grade 3 or 4 toxicity may result in dose reduction or discontinuation of the treatment, with adverse events on the subsequent disease progression 5. Conclusions With the approval of innovative molecules, the overall survival and progression-free survival have significantly improved in metastatic renal carcinoma.
The control of co-morbidities through close collaboration with other specialties made it possible to continue the oncologic treatment.
Recently, immunotherapy was approved in the therapeutic protocols for metastatic renal carcinoma 6. As a result, therapeutic options in metastatic renal cancer have increased over the past 10 years. Other targeted therapies are currently under study to be approved in the future.
Active Surveillance for Kidney Cancer
Bibliografie 1. New treatment options for metastatic renal cell carcinoma.
BMJ Journal. Comparative effectiveness of axitinib versus sorafenib in advanced renal cell carcinoma AXIS : a randomised phase 3 trial.
Lancet ; —9. Temsirolimus, interferon alfa, or both for advanced renal-cell carcinoma. N Engl J Med ; — Efficacy of everolimus in advanced renal cell carcinoma: a double-blind, randomised, placebo-controlled phase III trial. Lancet ; — Overall survival and updated results for sunitinib compared with interferon alfa in patients with metastatic renal cell carcinoma.
J Clin Oncol ; — Sorafenib in advanced clear-cell renal-cell carcinoma.