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 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.