Patient D is a 58-year-old white female who was diagnosed with a T2, N0, M0 right sided RCC of clear cell histology in 2001. She underwent radical nephrectomy and was followed by her urologist who found a small enlarging left adrenal mass and numerous pulmonary nodules concerning for metastatic disease in 2005. Metastatic disease was confirmed via biopsy of a lung lesion and the patient was started on high-dose IL-2 (600,000 IU/kg). After 8 weeks, she had disease progression on CT scan in both the lung and adrenal gland. She was then treated with sunitinib 50 mg daily for 4 weeks of a 6 week cycle, in the context of a clinical trial. She required a dose reduction because of pancytopenia. Imaging after 30 weeks showed stable pulmonary disease and improvement of the adrenal lesion and retroperitoneal lymphadenopathy. She remained on sunitinib with stable disease until September 2007 when CT scan showed disease progression in aortocaval lymph nodes. Her treatment was then changed to sorafenib 400 mg BID. She achieved 54 weeks of stable disease until July 2008 when her disease progressed on CT scan. The patient was then put on temsirolimus 25 mg IV weekly until October of 2008 when, once again, she had disease progression on CT scan. She was placed on bevacizumab 10 mg/m2 every 2 weeks and completed 48 weeks of treatment. She then progressed on bevacizumab at all sites and began 6th-line treatment with pazopanib 800 mg daily. She continues to be active and well.
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.