Patient C is a 68-year-old white man who was diagnosed with metastatic RCC, clear cell type in July 2008 discovered as part of an evaluation for new onset atrial fibrillation. He had a 7.1 × 9.7 cm left renal mass, enlarged retroperitoneal and mediastinal lymph nodes and multiple lung nodules. Mediastinal lymph node was positive for metastatic RCC on biopsy. He underwent debulking nephrectomy in August 2008 and then had a trial of high-dose IL-2 (600,000 IU/kg) which failed with progressive disease. He began sunitinib 50 mg daily for 4 weeks of a 6 week cycle, and had initially stable disease, but progressed after 36 weeks. He then began everolimus 10 mg daily but developed symptomatic mTOR-inhibitor-associated pneumonitis which resolved with steroids and discontinuation of everolimus. He then began bevacizumab 10 mg/m2 given every 2 weeks and had an initial minor response then prolonged stable disease. He remains on therapy at 24 weeks to date. He continues to be very active, golfing regularly and traveling.
Patient A was a 73-year-old white male who was diagnosed with RCC in 2000 and subsequently underwent a left radical nephrectomy. He went on to have multiple locoregional recurrences in the nephrectomy bed and in the lower pole of the right kidney. By January of 2007, he had involvement of the pancreatic tail and the left adrenal gland as well. He was evaluated at our medical center in March of 2007. He was restaged at that point and it was confirmed that he had no disease outside of the abdomen, so he was offered radical resection of his disease with curative intent by surgical oncology, but the patient declined. Therefore, he was started on sunitinib 50 mg daily for 4 weeks of a 6 week cycle, and an MRI in July 2007 showed decrease in the size of the tumor in the left renal bed and the pancreatic mass and right renal pole mass remained stable. Imaging after 24 weeks of sunitinib showed stable disease in known sites. His disease remained stable until imaging performed in April of 2008, after 36 weeks of treatment, showed clear enlargement of the renal fossa mass. The patient was then started on temsirolimus 25 mg IV weekly for second-line therapy. The patient had thrombocytopenia, worsening of lipid profile, and elevated blood glucose levels on temsirolimus that required a 20% dose reduction. After 12 weeks, CT scan showed pneumonitis consistent with mTOR inhibitor induced pneumonitis, a possible new lung metastasis, and progression of disease in the liver and renal fossa. Single agent bevacizumab 10 mg/m2 given every 2 weeks was started for third-line therapy and restaging every 3 months showed continued stable disease. The patient enjoyed 12 months of stable disease on single agent bevacizumab. It was stopped despite stable disease due to development of osteonecrosis of the jaw and patient request. The patient subsequently progressed rapidly and expired while off therapy.