Thread by @shilpaonc

@TumorBoardTues @MPishvaian 1/18 #TumorBoardTuesday #RenalCancer #OncTwitter

60yo 👴🏽#RenalCell dx in 2022 tx with right radical nephrectomy
6mo f/u
Uses WC d/t DM2 - limited mobility & homebound

🤨 What would be your next step?

@TumorBoardTues @MPishvaian 2/18 #TumorBoardTuesday
🩻Lung nodules, mediastinal lymphadenopathy🫁
🔬: Bx returns as metastatic clear cell #RCC
➡️1st relapse at 6mo f/u

👴🏽 limited mobility and difficult time leaving the house.

🤨 What treatment would you select for this patient?

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri 3/18 #TumorBoardTuesday #RenalCell

🤨 What factors do you take into account to decide between VEGF-TKI or IO-IO as treatment option at 1st relapse?

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri 4/18 #TumorBoardTuesday
👩🏽‍🏫 Mini Tweetorial 1

Risk criteria used for #RCC are MSKCC prognostic model or Internat’l Met RCC Database Consortium.
Important to determine risk to guide Tx.
Ipi/Nivo ONLY approved for Int/poor risk pts while VEGF-TKI combos are approved for any risk

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👩🏽‍🏫 Mini Tweetorial 2

💊@NCCN guidelines, all options are category 1 recommendations.

Axitinib-pembro
Cabozantinib-nivo
Lenvatinib-pembro
Ipilimumab-nivolumab

VEGF TKI -IO or IO-IO for poor risk mRCC. If contraindication to IO, only cabo can be used

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN 6/18 #TumorBoardTuesday
👩🏽‍🏫Mini Tweetorial 3

👍🏽Advantages of IO-IO (Ipi/Nivo) include durable long-term responses & avoiding TKI related tox & maintenance nivo an easy to tolerate regimen.

👎🏽Disadvantages include higher risk of irAEs & hospitalization risk due to Ipilimumab.

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👩🏽‍🏫Mini Tweetorial 4

Salvage ipi 🚫as effective as using front-line.

👍🏽Advantages of IO-VEGF TKI combo:⬆️ ORR & ⬇️risk of irAE

BUT

👎🏽risk of overlapping tox (GI, liver) with VEGF TKI &IO & challenging to attribute to 1 or both agents.

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN 8/18 #TumorBoardTuesday
👩🏽‍🏫Mini Tweetorial 5

👎🏽Combo continues long-term & can become burdensome.
📚nccn.org/professionals/…

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN 9/18 #TumorBoardTuesday
👩🏽‍🏫Mini Tweetorial 6
✨Combo Trials
✅CHECKMATE-9ER: Cab-niv @DrChoueiri nejm.org/doi/full/10.10…
🗝️KEYNOTE-426:Axi-pemb @brian_rini nejm.org/doi/10.1056/NE…
🪟CLEAR: Len-pemb @motzermd nejm.org/doi/full/10.10…
✅CHECKMATE-214:ipi/nivo https://t.co/DHBqThHAb6

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @AmandaNizamMD
@YuWeiChenMD @minaseconomides
@UROncDoc @koshkin85 @tompowles1 @PBarataMD @TomJayram @arnabguonc @KidneyCancerDoc

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc 10/18 #TumorBoardTuesday
Back to case🔎

👴🏽starts Cabo-nivo & asks about f/u

1) H/P,🩸, CT/MRI q3 mo
2) H/P,🩸at tx visits (4 wks), 🩻(CT/MRI) 2-3 mos or sooner if indicated

📌Assess often
🤕symptoms🩸
🤕irAEs
⚠️tox from VEGF TKI 👉🏽dose interrupt/mods/dc may be needed for IO

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc 11/18 #TumorBoardTuesday #RenalCell #RCC

📌irAE

During regular symptom and side effect monitoring

👴🏽BP 150/94 mm/Hg

🤨What will you do?

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc 12/18 #TumorBoardTuesday #RCC
📌HTN

Class effect of VEGF-TKI

📍Risk factors
🔸Pre-existing HTN
🔸age >60y
🔸BMI >/=25 kg/m2

‼️Control HTN well before starting TKI‼️

☑️ BP regularly at home
☑️ add anti hypertensives
☑️ Dose reduce VEGF TKI if BP uncontrolled despite meds

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc 13/18 #TumorBoardTuesday

👴🏽diarrhea: 2-3 loose 🚽 1 day after 2 cycles

🤨What’s your next step?

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc 14/18 #TumorBoardTuesday
📌Diarrhea

VEGF TKI and IO can have overlapping AE of diarrhea.

📍Important to distinguish etiology (dose reduce TKI vs start steroids).

➡️mild diarrhea
🟢loperamide
🍽️modification
Hold VEGF TKI few days. If no improvement, hold IO.

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc 15/18 #TumorBoardTuesday

📌Diarrhea

➡️severe symptoms
🟢hydration
hold VEGF TKI and IO
🟢steroids (prednisone 1-2 mg/kg/d or equivalent). No response in 2-3 days, consider adding IFX or vedo within 2 weeks.

‼️GI referral‼️Consider tofa or uste

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📌Diarrhea

➡️severe symptoms

📍VEGF TKI related
⬇️dose reduction recommended.

📍IO related
📖Society guidelines for mgmt
No consensus on Io re-challenge

📍grade 4 irAE, permanently discontinue IO.

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Back to our case🔎

👴🏽diarrhea initially improved with loperamide
📆6 months, has a significant response on 🩻scans BUT develops 5-6 loose stools/day
👩🏽‍⚕️Diagnosed grade 3 irAE colitis on colonoscopy/biopsy
🏥Requires admission

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc 18/18 #TumorBoardTuesday #RenalCell
Back to our case🔎

👴🏽Starts high dose steroids
🙌🏽improving
👩🏽‍⚕️OV, after steroid taper ➡️👴🏽doesn’t want nivo anymore

🤝only cabo & dc nivo d/t severe colitis
🩻scans & f/u 6-8 wks

📚sitcancer.org/research/cance…
📚ascopubs.org/action/showCit…

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc #PostTest Q1️⃣ #TumorBoardTuesday
👉🏽#CME Eval 🔗 integrityce.com/tbtEval
👉🏽ALL CME🔗 integrityce.com/tbt

🤔@shilpaonc taught us tx clear cell #RCC, test your 🧠 with 2 quick Q’s

75yo🎅🏼
S2 #RenalCell
1st relapse
Clear cell
Risk: Poor
limited mobility
What tx would you pick?

@TumorBoardTues @MPishvaian @montypal @brian_rini @DrYukselUrun @TiansterZhang @KidneyCancer @HHammersMD @arihakimi @RCCadvocate @AmandaNizamMD @QingZhangLab @DrRanaMcKay @DrScottHaake @DrDavidNanus @PavlosMsaouel @OAlhalabiMD @kcCURE @motzermd @MosheOrnsteinMD @neerajaiims @RenoHemonc @DrChoueiri @NCCN @dawood_findakly @mtsiatas @sonpavde @nataliagandur @LauraEsfeller @DrJeffreyGraham @BourlonMaite @PBarataMD @TomJayram @drenriquegrande @YuWeiChenMD @minaseconomides @UROncDoc @koshkin85 @tompowles1 @arnabguonc @KidneyCancerDoc #PostTest Q2️⃣ #TumorBoardTuesday
👉🏽Free #CME🔗 integrityce.com/tbt

🧐 How many prognostic factors constitute a POOR risk group according to the @MSKCancerCenter (MSKCC) Prognostic Model?