As a tumor with a high degree of malignancy, kidney cancer often appears metastatic foci in other parts of the body except for the primary lesion, becoming metastatic kidney cancer (mRCC). The data show that the most common metastatic organs of kidney cancer are the lungs, bones, liver, and adrenal glands, and once metastasis occurs, it indicates that it is advanced. At this time, it is particularly important to control the further development of the disease and improve the survival period.
For metastatic kidney cancer, scientific research has made more progress in recent years. Currently, K-drug (pambolizumab) in combination with acytinib is recommended for first-line treatment of metastatic kidney cancer. Unlike other tumors, in patients with kidney cancer, the destruction of kidney cells is very likely to cause deterioration of renal function, and dialysis treatment is often required in end-stage renal disease (ESRD).
Dialysis may affect the concentration of drugs in the body, too low a concentration of drugs will reduce the efficacy, and too high concentrations will aggravate the occurrence of toxic side effects. So, for metastatic kidney cancer with end-stage renal disease, can it be treated with K drug combined with acytinib? The following case, cancer take you to see.
Case stories
Mr. Wang was admitted to the hospital 15 years ago for hematuria. CT showed that his right kidney lesion was 8.5 cm in diameter (Figure 1) and had infiltration of surrounding adipose tissue, but fortunately there were no lymph nodes or distant metastases. Subsequently, he underwent laparoscopic right nephrectomy and was diagnosed with "right RCC (clear cell carcinoma), stage pT3".
Figure 1. The right renal tumor shown by CT was enhanced at the first follow-up
After the operation, Mr. Wang followed up after the operation according to the doctor's request. After 7 years, a small area of high absorption is seen on CT showing the left inferior renal pole (Figure 2). Further MRI tests suggest that the mass is 2.4 cm in diameter, and it is considered that the kidney cancer has recurred and requires clinical treatment. At this time, through routine renal function examination, the doctor also noticed that Mr. Wang's serum creatinine level gradually increased. Because it was a local recurrence, the doctor recommended stereotactic radiation therapy for Mr. Wang for a new lesion of the left kidney.
Figure 2. Left renal tumor shown by flat SCAN ct at first recurrence
After treatment, the new lesion of Mr. Wang's left kidney gradually narrowed. Unfortunately, however, Mr. Wang's kidney function deteriorated sharply, and serum creatinine rose to 9 mg/dL and required hemodialysis treatment. After dialysis treatment began, doctors continued to follow up on Mr. Wang's left kidney and other parts. It was found that Mr. Wang's left renal pole and lung had a new metastase, and the disease progressed again (Figures 3 and 4). In response to these two new lesions, the doctors carried out radiation therapy separately, and the lesions were controlled and did not increase further.
Figure 3. Pulmonary metastases shown by a flat scan CT at the second recurrence
Figure 4. Left kidney tumor shown by flat scan CT at the second recurrence
Unexpectedly, the degree of malignancy of metastatic kidney cancer was too high, and in a routine evaluation two years after the end of radiotherapy, the doctor found that a new soft tissue mass appeared in Mr. Wang's right shoulder blade through CT, accompanied by bone destruction, and through PET-CT, the doctor confirmed that this was a bone metastase lesion (Figures 5 and 6).
Figure 5. A flat scan CT shows a metastase of the right shoulder blade
Figure 6. Bone scan suggests right shoulder blade metastases
Bone metastases suggest more severe distant metastases, in which case systemic therapy is required. Since Mr. Wang is a hemodialysis patient, the use of systemic anti-tumor must be extremely cautious. After the doctor's evaluation, it was recommended that Mr. Wang try to treat with first-line K drug (200 mg, once every 3 weeks) combined with acytinib (10 mg per day) and monitor closely.
Within two months of the initial treatment, Mr. Wang experienced increased blood pressure and occasional fatigue during dialysis, as well as an increase in C-reactive protein, and the doctor adjusted the dose of axitinib to 4 mg per day. During the six months of follow-up, Mr. Wang was treated with the K drug plus acytinib during dialysis treatment, and there were no obvious immune-related adverse events (Figure 7).
Figure 7. Papolizumab application, acytinib dose adjustment, and timeline of adverse events
Summary and Revelation
The K-drug combined with reduced acytinib treatment regimen was effective and safe for Mr. Wang, and no significant immune-related toxicity was observed for at least 6 months of follow-up. Although it is an isolated case, it is a clinical case worth referring to for the clinical diagnosis and treatment of metastatic kidney cancer in end-stage renal disease.
Individualized diagnosis and treatment is an important principle of the treatment of tumor patients, according to the drug application indications obtained from rigorous large-scale clinical research, in the case of complex and changeable clinical situations, it is necessary to determine the treatment strategy according to the specific situation of the patient. For patients with metastatic kidney cancer with end-stage renal disease, under the premise of close monitoring of the patient's general condition, multidisciplinary opinions should be followed, and the medication regimen and dosage should be gradually adjusted to achieve a trade-off between efficacy and safety.
参考文献：Yuki Katsumata, et al. Combination Therapy of Pembrolizumab plus Axitinib for a Patient on Hemodialysis with Metastatic Renal Cell Carcinoma: A Case Report. Case Rep Oncol 2021;14:1522-1529.