Patient B is a 76-year-old white male who presented with microscopic hematuria in 1986 on a routine urinalysis and a diagnosis of left RCC was made by imaging. He then underwent nephrectomy for a 7 × 6 × 5.5 cm tumor extending though the fascia into the perinephric fat. He did well until March of 2006 when he had a routine chest X-ray that showed new lung nodules and a CT scan was ordered. A large retroperitoneal mass posterior to the stomach measuring 10 × 9 × 8 cm was also found along with bilateral lung nodules, with the largest lung lesion measuring 2 cm. Biopsy of the retroperitoneal mass confirmed RCC. MRI of the brain and bone scan was negative. He was seen for the first time at our institution in April of 2006. He was determined to be a candidate for high-dose IL-2 (600,000 IU/kg). After 8 weeks, he did show some response, but was only able to tolerate half of cycle 2 and he declined further IL-2. He was then started on sorafenib and had a minor response at all disease sites until CT scan in January 2007 after 24 weeks showed progression. He was then switched to sunitinib 50 mg daily for 4 weeks of a 6 weeks cycles, and after 12 weeks on therapy had a significant response which he enjoyed until week 54 when CT scanning showed marked disease progression. Sunitinib was discontinued and in January of 2008 he was started on temsirolimus 25 mg IV weekly. He required a 20% dose reduction for thrombocytopenia and oral ulcers. He remained on temsirolimus until April of 2008 when he developed symptomatic mTOR interstitial pneumonitis, so temsirolimus was discontinued. His disease continued to progress off therapy and in October of 2008, bevacizumab 10 mg/m2 given every 2 weeks was started as fifth line therapy. After 24 weeks of treatment the patient was found to have a pulmonary embolus. Lovenox was started and bevacizumab was continued without incident. At the time of submission, the patient's disease has remained stable after 72 weeks of bevacizumab. He has continued to work full time as a maintenance man.
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.