Thread by @brian_rini

@TumorBoardTues 1/15 #TumorBoardTuesday #RenalCellCancer #OncTwitter

63 👩🏻 with 1 month hematuria

h/o HTN

Inflammatory Bowel Disease #IBD

Type 2 DM

🩻CT scan: 7 cm hyper enhancing L renal mass; no enlarged LN; no other distant abnormalities

✂️Patient undergoes L radical nephrectomy

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims 2/15 #TumorBoardTuesday #RenalCellCancer #OncTwitter

🔬: clear cell RCC, grade 2, pT3aNx (perinephric fat invasion), no sarcomatoid features

👩🏻uneventful recovery

📆F/u 6 weeks

🩻CT c/a/p NED 🎉

🔮Pt asks about future needs

🤨What would you offer patient next?

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims 3/15 #TumorBoardTuesday

👨🏻‍🏫Mini tweetorial 1

✨Risk of recurrence of resected renal cancer✨

📍Tumor stage

📍grade

📍presence of necrosis or sarcomatoid features

📍performance status

📍symptoms on presentation

Patient would have ≈ 30% risk of recurrence at 5yrs.

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims 4/15 #TumorBoardTuesday

👨🏻‍🏫Mini tweetorial 2

Adjuvant sunitinib: FDA approved 👉🏽

✨S-TRAC trial✨

🔺Randomized high-risk resected ccRCC to 1yr adjuvant sunitinib vs placebo

🔺Demonstrated significant ⬇️ risk of recurrence w/o prolongation of survival

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims pubmed.ncbi.nlm.nih.gov/27718781/

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims 5/15 #TumorBoardTuesday

👨🏻‍🏫Mini tweetorial 3

However, several other similar trials of VEGF-targeted 🎯 agents in the same setting were negative.

☀️These other data, plus the toxicity of sunitinib, has led to LIMITED use of this agent in the adjuvant RCC setting.

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims 6/15 #TumorBoardTuesday

👨🏻‍🏫Mini tweetorial 4

IO used in advanced RCC 👉🏽 several trials ofIO in resected high-risk ccRCC.

✨KEYNOTE-564✨

👉🏽randomized patients with pT2/grade 4 or higher risk (including resected M1 patients) to 1 year of adjuvant pembrolizumab vs placebo.

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims 7/15 #TumorBoardTuesday

👨🏻‍🏫Mini tweetorial 5

✨KEYNOTE-564✨

👉🏽 Pembrolizumab reduced the risk of recurrence of #RenalCellCancer with an HR of 0.63 in the updated analysis.

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims @RaviBarodUrol @mlazqui @kwinkunks @PignotG @gautiermarcq @PGrivasMDPhD @MichaelRink_MD 8/15 #TumorBoardTuesday

👨🏻‍🏫Mini tweetorial 6

DFS benefit

✅generally consistent across subgroups

✅more pronounced in patients at higher recurrence risk including M1 NED & patients with sarcomatoid features.
OS HR was below 1, & didn’t meet pre-specified sig p value

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims @RaviBarodUrol @mlazqui @kwinkunks @PignotG @gautiermarcq @PGrivasMDPhD @MichaelRink_MD @ReisLO @Leglesszebra @FatihKose_prof @FSchlurmann @RodlerSeverin @KFKowalewski @onkowissen @High5Md @E_Laukhtina @evacomperat 9/15 #TumorBoardTuesday

👨🏻‍🏫Mini tweetorial 7

Toxicity is noted in the table including approx 8% of patients with high-grade irAEs and need for high-dose steroids.

📚 dailynews.ascopubs.org/do/10.1200/ADN…

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims @RaviBarodUrol @mlazqui @kwinkunks @PignotG @gautiermarcq @PGrivasMDPhD @MichaelRink_MD @ReisLO @Leglesszebra @FatihKose_prof @FSchlurmann @RodlerSeverin @KFKowalewski @onkowissen @High5Md @E_Laukhtina @evacomperat @RicBertolo @grimm_mo @OraianthiF @HitenDPatel @ZineEddineKhene @CHURennes @AkgulMd @MedUni_Wien 10/15 #TumorBoardTuesday #RenalCancer #OncTwitter

What factors:

🤨 Would influence your use of pembrolizumab in a patient on high dose corticosteroids for another disease condition?

OR

🤨 Your decision to observe this patient without any systemic therapy?

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims @RaviBarodUrol @mlazqui @kwinkunks @PignotG @gautiermarcq @PGrivasMDPhD @MichaelRink_MD @ReisLO @Leglesszebra @FatihKose_prof @FSchlurmann @RodlerSeverin @KFKowalewski @onkowissen @High5Md @E_Laukhtina @evacomperat @RicBertolo @grimm_mo @OraianthiF @HitenDPatel @ZineEddineKhene @CHURennes @AkgulMd @MedUni_Wien 11/15 #TumorBoardTuesday

👩🏻Patient receives pembrolizumab x4 after risk vs benefit discussion.

😥5th dose 👉🏼 watery diarrhea

🫧diagnosed as grade 3 immune-mediated colitis on colonoscopy & biopsy #IBD

Well-appearing & doesn’t require inpatient admission 🙏🏼 Next step?

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims @RaviBarodUrol @mlazqui @kwinkunks @PignotG @gautiermarcq @PGrivasMDPhD @MichaelRink_MD @ReisLO @Leglesszebra @FatihKose_prof @FSchlurmann @RodlerSeverin @KFKowalewski @onkowissen @High5Md @E_Laukhtina @evacomperat @RicBertolo @grimm_mo @OraianthiF @HitenDPatel @ZineEddineKhene @CHURennes @AkgulMd @MedUni_Wien 12/15 #TumorBoardTuesday

📍Immune-mediated tox generally needs steroids, especially high-grade / critical organs

📍Start/taper dose schedule NOT defined ➡️ generally 1mg/kg

✅Society guides for irAEs mgmt

🤷NO consensus on re-treat after irAE & individual benefit/risk

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims @RaviBarodUrol @mlazqui @kwinkunks @PignotG @gautiermarcq @PGrivasMDPhD @MichaelRink_MD @ReisLO @Leglesszebra @FatihKose_prof @FSchlurmann @RodlerSeverin @KFKowalewski @onkowissen @High5Md @E_Laukhtina @evacomperat @RicBertolo @grimm_mo @OraianthiF @HitenDPatel @ZineEddineKhene @CHURennes @AkgulMd @MedUni_Wien 13/15 #TumorBoardTuesday

Adjuvant pembrolizumab 👉🏼 SOC in resected high-risk RCC

Consider:

✅individual risk of recurrence

✅ability to tolerate toxicity

✅current lack of proven survival must be considered

👉🏼Adjuvant IO in ccRCC trials conducted & results 🤞🏽

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims @RaviBarodUrol @mlazqui @kwinkunks @PignotG @gautiermarcq @PGrivasMDPhD @MichaelRink_MD @ReisLO @Leglesszebra @FatihKose_prof @FSchlurmann @RodlerSeverin @KFKowalewski @onkowissen @High5Md @E_Laukhtina @evacomperat @RicBertolo @grimm_mo @OraianthiF @HitenDPatel @ZineEddineKhene @CHURennes @AkgulMd @MedUni_Wien 14/15 #TumorBoardTuesday Back to our case🔎

👩🏻 Patient recovers from colitis and tapers off steroids over 4 weeks.

🤨 Would you re-treat this patient with pembrolizumab?

@TumorBoardTues @CParkMD @declangmurphy @TiansterZhang @Uromigos @montypal @DrChoueiri @AlbigesL @neerajaiims @RaviBarodUrol @mlazqui @kwinkunks @PignotG @gautiermarcq @PGrivasMDPhD @MichaelRink_MD @ReisLO @Leglesszebra @FatihKose_prof @FSchlurmann @RodlerSeverin @KFKowalewski @onkowissen @High5Md @E_Laukhtina @evacomperat @RicBertolo @grimm_mo @OraianthiF @HitenDPatel @ZineEddineKhene @CHURennes @AkgulMd @MedUni_Wien 15/15 #TumorBoardTuesday

👩🏻 Patient chooses not to receive further pembrolizumab given risk/benefit profile

➡️surveillance protocol

🔺H&P & CMP every 3-6 mo for 3 years

🩻Chest & abdominal (CT or MRI) every six months for 3 years

🔦 annual surveillance until year five