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Case history

image A 76-year-old man presented to his GP with haematuria. Investigations demonstrated a 5 cm primary renal tumour in the upper pole of the kidney. Biopsy of the primary revealed a clear cell renal cell carcinoma, grade 3. Prior to his cancer diagnosis he had lived alone and managed his activities of daily living (ADL) with the help of his family, who visited once weekly to assist with shopping and cleaning. He left the house on a daily basis and liked to attend the local social club to catch up with friends. His past medical history included high cholesterol and hypertension controlled with atorvastatin and ramipril, respectively, and marginal chronic renal failure (glomerular filtration rate 58 ml/min). The discussion at the multidisciplinary team (MDT) meeting proposed that a radical nephrectomy was not appropriate because of his impaired renal function, but that alternative methods of controlling the tumour locally should be considered. The interventional radiologist felt that the tumour was too large for radiofrequency ablation (RFA), and the urological surgeon recommended partial nephrectomy. This was carried out laparoscopically 1 week later and, after an overnight stay in the HDU for meticulous attention to fluid balance and BP, he mobilized and went home 5 days later.

Eighteen months later he re-presented with cough, weight loss and fatigue, and a CT scan showed multiple bilateral lung metastases. He was seen in the oncology outpatient clinic and discussed the options of a tyrosine kinase inhibitor (TKI) or best supportive care. He chose a TKI and commenced sunitinib. He did not require changes to medications prior to commencing sunitinib, as his BP was normal (125/75 mmHg) on ramipril.

Eight weeks into treatment he presented with a significant decline in function secondary to painful hands and feet. His daughter had called the renal clinical nurse specialist to express her concerns regarding her father. Over the last week his hands and feet had become increasingly painful and he was struggling to mobilize around the house. He had not been seen in the social club for 5 days and his oral intake had declined, as he was finding it easier to stay in bed due to the pain and feeling generally unwell. His daughter stated that her father had not wanted to bother anyone and she felt he was becoming low in mood. A recent CT scan had shown stable disease.

He was reviewed on the oncology assessment unit and found to have erythematous swollen areas on the pressure points of his hands and feet, consistent with sunitinib-induced hand-foot syndrome. His BP was 115/60 mmHg. Routine blood tests showed a mild acute kidney injury, urea 14 mmol/l, creatinine 120 µmol/l.

What are the options for the treatment of a renal primary in patients with reduced renal function?

What is the place of sunitinib in metastatic disease in older patients?

What is the side effect profile of sunitinib in older patients?

What is hand-foot syndrome?

How should this patient be ...

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