Two cases- RCC stage 4, early upper tract urothelial

Cases

1. Renal cell ca

 68 yo M with T1b left renal mass s/p partial nephrectomy.

Pathology: Clear cell without sarcomatoid features

Fuhrman 3. Final stage pT1b Nx

11 months later with peritoneal nodules.

KPS90

IMDC intermediate risk

Started on ipi+nivo--> progression

What are the factors to consider:

a. Progression versus pseudoprogression

b. The pace of progression slow ie > 18 months, quick < 6 months, or something in between

c. How symptomatic

d. Brain mets- yes or no

Choice of agent: second line, consider cabozantinib

If slow progression, consider axitinib pembro, otherwise lenvatinib with everolimus

2. Upper urinary tract cancer

70 yo M with right renal pelvis urothelial tract tumor presented with hematuria.

Undergoes stent placement.

What is the role of adjuvant treatment?

POUT trial showed 3 yr DFS benefit with adjuvant chemo ( platinum with gem) for pT2 or higher, or node-positive upper tract high grade urothelial.

LN dissection must be performed in high-grade urothelial cancer.

Intravesical post-op and adjuvant ( i.e 3-4 weeks after) for those not candidates for nephroureterectomy. Typical agents mitomycin, gemcitabine for both post-op and adjuvant.

BCG can be done adjuvant weekly for 6 weeks, then SWOG protocol for up to 2 yr.

A note about adjuvant nivolumab for 1 yr---> benefit in bladder but not upper tract cancer if no path CR after NACT or ineligible for cisplatin  based adjuvant for high risk early tumors.

https://ascopost.com/issues/digital-supplement-genitourinary-cancer-almanac-2020-2021/nivolumab-first-adjuvant-immunotherapy-to-show-survival-benefit-in-high-risk-muscle-invasive-urothelial-cancer/

Most patients had bladder tumors (79%), with the remaining having tumors of the upper tract; 40% had PD-L1–positive disease, and 43% had previously received neoadjuvant therapy.

Minimum follow-up was 5.9 months; median follow-up of both the nivolumab and the placebo groups was around 21 months. Treatment discontinuations were reported in 53.3% of the nivolumab group and 56.3% of the placebo group, most commonly due to recurrent disease.

Subgroup analyses of the intent-to-treat group showed that the disease-free survival benefit was driven by patients with tumors of the urinary bladder, with a 38% improvement with nivolumab, and no benefit was observed for those with tumors of the renal pelvis or ureter.