CUA 2019 Management of Advanced Kidney Cancer

Question 1

what is the most lethal genitourinary malignancy?

Answer 1

Renal

Question 2

What is the systemic therapy for patients with intermediate/ppr risk per IMDC criteriae with clear cell RCC metastatic?

Answer 2

Pembro-axitinib/ ipilimumab-nivolimumab.

Avelumab/axitinib and sunitinib, pazopanib remain options too, also Cabozantinib( CABOSUN)

Question 3

What are options for Good risk patients with metastatic ccRCC?

Answer 3

Pembrolizumab+axitinib

options: avelumab/axitinib, sunitinib, pazopanib

Question 4

What if someone has metastatic ccRCC but favorable or intermediate with only one risk factor or slow growing disease?

Answer 4

Can do active surveillance. Sounds like someone who potentially is a candidate for cytoreductive nephrectomy

Question 5

What study identified the role of Pembro+ axitinib in management of metastatic ccRCC? describe it and findings

Answer 5

KEYNOTE-426, metastatic RCC. Pembro+axi vs sunitinib RCT. OS and PFS improved in pembro+axi in all IMDC risk groups vs sunitinib

Question 6

What study identified the role of Ipi+nivo in management of metastatic ccRCC? describe it and findings

Answer 6

CHECKMATE 214, IPI+Nivo then Nivo vs sunitinib. Intermediate/poor risk patients imprved OS, PFS, complete response rate of 11%! vs 1% in sunitinib. No difference in OS or PFS for favorable risk patient

Question 7

What are options if someone progresses or is intolerant of IO therapy?

Answer 7

sunitinib, pazopanib, axitinib(PREFERRED) , cabozantinib(Preferred) , lenvatinib/everlimus

Question 8

What happens if someone progresses or is intolerant of first line sunitinib or pazopanib?

Answer 8

try another TKI, also consider Nivolumab, , cabozantinib, axitinib or lenvatinib/everlimus

Question 9

what if someone progresses or is intolerant of both IO and TKIs>

Answer 9

Try something you have not before ( sunitinib, pazopanib, axitinib, cabozantinib, Lenvatinib/everlimus)

Question 10

Any special recommendations for non-clear cell RCC?

Answer 10

no, treat them like clear cell RCC. (Ipi+nivo and Pembro+axi are preferred)

Question 11

Is RCC radioresistant?

Answer 11

NO, Not if you use SBRT, response rates to SBRT are high(90%) this refutes the idea it is radioresistant, just need to give a larger dose

Question 12

Is there a role for bone modifying agents in metastatic RCC?

Answer 12

Yes, if there are bone mets (zoladronic acid)