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Case history

image An 84-year-old woman presented with a 6 month history of fatigue and haematuria. She had a background history of hypertension, type 2 diabetes, chronic kidney disease stage 3a (glomerular filtration rate 45-59 ml/min) and heart failure New York Heart Association class II. Her medications were metformin, gliclazide, amlodipine, ramipril, simvastatin, bendroflumethiazide and aspirin. Physical examination revealed a left-sided flank mass but was otherwise unremarkable. Her Karnofsky performance status (PS) was 80%. A staging CT scan showed an 8 cm renal mass with multiple metastases throughout both lung fields. Image-guided biopsy confirmed clear cell metastatic renal cell carcinoma (mRCC).

She was referred to a geriatrician for optimization of medical comorbidities and for oncology assessment. After discussion with the patient and family, the decision was made to commence pazopanib. After 2 weeks of pazopanib she described grade 1 fatigue, grade 1 diarrhoea, grade 1 hand-foot syndrome and grade 3 hypertension. A treatment break was initiated, her ACE inhibitor and calcium channel blocker were escalated to maximum dose and loperamide was recommended. Repeat BP monitoring after 7 days showed adequate control, and pazopanib was reintroduced with a dose reduction.

Is systemic anticancer treatment indicated in this case?

What are the first-line treatment options for mRCC and what is the evidence for their use?

What impact do the patient's age and comorbidities have on treatment decision making?

How could the patient's comorbidities be optimized prior to tyrosine kinase inhibitor (TKI) therapy?

How can toxicities be pre-emptively managed in this patient?

Is systemic anticancer treatment indicated in this case?

The incidence of renal cell cancer has risen by almost a third in the last 10 years and predominantly affects an older population: three-quarters of new cases in the UK are diagnosed in those aged over 60 and a third in those aged over 75.1 The clinical course of mRCC is known to be variable and at times it can behave in an indolent manner. Several retrospective and one prospective series have demonstrated that selected patients with intermediate- or favourable-risk mRCC and low-volume disease can safely be observed with a surveillance strategy for a period of time with no detriment to their outcome.2 Therefore, the first consideration in an older patient is whether to commence systemic treatment or whether an observation strategy is appropriate. This decision should be made with understanding of the patient's expected prognosis. The International Metastatic Renal Cell Carcinoma Database Consortium criteria form the most commonly used prognostic model for mRCC and have been validated for the current era of targeted TKI therapies.3 Patients are stratified according to the presence of six risk factors, as shown in Table 13.1.

Table 13.1Prognostic factors for OS in patients with mRCC treated with VEGF-targeted agents (adapted from Heng et al.3).

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