Patient Diagnosed With Clear Cell Renal Cell Carcinoma

History of Present Illness

Mr. X  is a 38-year-old man who has been recently diagnosed with clear cell renal cell carcinoma (ccRCC). The patient presented to medical oncology for treatment options.

Initially, he presented with gross hematuria around June 2023. His computed tomography (CT) scan on July 18, 2023, showed a 12-cm large inferolateral renal mass on the left side, along with ipsilateral retroperitoneal adenopathy. A CT-guided biopsy of the left kidney showed ccRCC, grade 2/3. Therefore, he was referred to surgery in August of 2023 and underwent radical nephrectomy with retroperitoneal lymph node dissection on August 22. Pathology was consistent with ccRCC, grade 3, pT3apN0 (extraprostatic extension or microscopic invasion of bladder neck, no regional lymph node metastasis). Therefore, he was referred to the medical oncology department for consideration of adjuvant treatment.

Social History

Mr. X is married. He is employed, working full time as an accountant.

Past Medical History

There are no comorbidities.

Current Medications: None

Review of systems is negative.

Physical exam is negative.

Labs

Pathology

On August 22, 2023, patient had a left nephrectomy for the L renal mass  with supra hilar para-aortic rection resection and retroperitoneal regional resection

Pathology showed:

• Clear cell renal cell carcinoma (9.1 cm), WHO grade 3, with associated necrosis
• Areas of hyalinization with focal ossification
• The tumor extending into segmental vessels
• Ureteral and vascular margins of resection were negative for carcinoma
• Tumor focality unifocal
• Tumor size greatest dimension: 9.1 cm
• Non-neoplastic renal parenchyma showed no significant pathological changes
• Tumor extent extended into major vein (renal vein or its segmental branches, inferior vena cava)
• Tumor necrosis present
• All margins were negative for invasive carcinoma. Thirteen regional lymph nodes were examined, and all were negative for tumor.
• Sarcomatoid features not identified
• Rhabdoid features not identified
• Tumor necrosis present
• Left retroperitoneal, regional resection:
  • 12 lymph nodes, negative for carcinoma
• Supra hilar para-aortic, regional resection:
  • Neural tissue and small focus of paraganglia, negative for carcinoma
  • 1 lymph node, negative for carcinoma
• Primary tumor pT3a
• Regional Lymph nodes (total examined – 13) pN0

On September 22, 2023, the patient underwent a CT of the abdomen and pelvis with contrast which showed:

• Expected postoperative changes related to interval left nephrectomy without evidence of complication
• Enlarged portocaval lymph node measuring 10 mm in short axis, which is nonspecific
• Hepatomegaly and hepatic steatosis

As the patient is under 46 years old, his tissue will be referred for genomic testing.

Staging: Stage III (pT3a, pN0, M0)

Treatment

Adjuvant treatment, surveillance or a clinical trial would all be appropriate for this patient. The patient and care team considers multiple factors when deciding on the treatment plan. Some of these factors include the risk of recurrence,  common long- and short-term side effects of the potential treatment, how much the treatments would cost, and the clinic time involved, especially since Mr. X is working full time. Another factor to consider are genomic results in this patient. For patients who have a confirmed hereditary renal cell cancer there are specific surgical and systemic therapy recommendations (NCCN, 2024). With a stage III tumor, the risk of recurrence is also considered. Mr X could be considered for a clinical trial, such as a phase 3, double-blind study to compare belzutifan (MK-6482) plus pembrolizumab (MK-3475) vs placebo plus pembrolizumab in participants with clear cell renal cell carcinoma post-nephrectomy (MK-6482-022). Belzutifan is an orally administered agent with a reasonable safety profile. It is indicated for advanced renal cell carcinoma and for treatment for adult patient with von Hippel-Lindau disease, not requiring immediate surgery. The clinical trial premise is based on data demonstrating that belzutifan has efficacy in advanced renal cell carcinoma and the possibility that it may also delay cancer recurrence.

Reference:

National Comprehensive Cancer Network. NCCN Guidelines Version 1.2024. Accessed December 21, 2023. https://www.nccn.org/guidelines/guidelines-process/transparency-process-and-recommendations/GetFileFromFileManagerGuid?FileManagerGuidId=8cf963d5-151c-4bb0-bbbf-c057046d13db