Case 1: A 75-year-old man presented with gastrointestinal bleeding 23 years after a nephrectomy for clear-cell kidney cancer (4 cm, Fuhrman grade 1/4). A CT scan showed a pancreatic head mass. An endoscopic ultrasound–guided biopsy was performed, which diagnosed metastatic renal cell carcinoma (RCC). The patient was evaluated for surgical resection, but was considered a poor candidate given his cardiovascular comorbidities and overall clinical picture. Additionally, retroperitoneal lymph nodes suspicious for metastatic disease were identified. He then started pazopanib and was initially found to have stable disease. After 11 months, he developed colonic pneumatosis and discontinued treatment because of possible drug-related bowel perforation. He then received second-line therapy with everolimus, but this agent was discontinued after 2 months due to angioedema. He was then started on sunitinib, and again needed dose reduction, this time because of increasing abdominal pain.
His pancreatic metastases had decreased from 3.8 × 7.2 cm at the start of pazopanib therapy to 2.7 × 7.1 cm at the time of pazopanib discontinuation. He had no clear evidence of active metastatic disease at that time, and because of his poor tolerance of systemic therapy, he was evaluated for stereotactic body radiation therapy (SBRT) to the pancreatic tumor. He was treated with SBRT to the head of the pancreas, 2,500 cGy in 5 fractions, 500 cGy per fraction, given daily (Figure 1A). He tolerated the SBRT well, without any adverse events. Systemic therapy was not restarted.
Seventeen months after the SBRT was completed, his pancreatic lesion had decreased in size to 1.1 × 2.3 cm, with decreased enhancement (Figure 2). The patient had minor intermittent back pain, mainly due to exercise; the pain was not believed to be related to the SBRT. Thus, with 17 months of follow-up, the treated pancreatic lesion had not progressed, and the patient was without symptoms.
Case 2: A 64-year-old woman underwent right nephrectomy of an 11.5-cm clear-cell RCC, Fuhrman grade 3, with invasion of the perinephric adipose tissue. Initial staging scans were negative for metastatic disease; however, 6 months later, metastases were found in the abdominal wall, the nephrectomy bed, and the mediastinum. The patient was started on sorafenib but experienced a significant rash that led to treatment interruption shortly after initiation. She tolerated sorafenib reintroduction, but follow-up assessments showed rapidly progressive disease. She was switched to bevacizumab but experienced bleeding from her abdominal wall tumors; therapy was discontinued soon after starting.
In light of her poor tolerance of systemic therapy, she underwent metastasectomies: open tumorectomy excision of the abdominal wall/skin tumor recurrence, tumorectomy of the renal fossa, and cryoablation of the RCC and perihilar lymphadenopathy. Shortly after these, restaging scans demonstrated innumerable bilateral lung nodules, and she was once again started on systemic therapy, this time with the experimental combination of sirolimus and erlotinib. After 2 months of therapy, imaging revealed lung and lymph node disease progression. She was then started on sunitinib therapy but had an enlarging lymph node in the aortopulmonary window. A left video-assisted thoracoscopic surgery for resection of the left aortopulmonary window metastases was performed, and the specimens obtained were consistent with RCC metastases. She resumed therapy until disease progression.
A growing subcarinal lesion and a 2.4-cm pancreatic lesion were noted on restaging CT scans. She underwent fine-needle aspiration biopsy of the pancreatic lesion and the specimen obtained was consistent with metastatic RCC. The pancreatic disease was first noted 5.5 years after the initial diagnosis. She underwent SBRT to the subcarinal lymph node and the pancreatic lesion; both were treated with 4,000 cGy in 10 fractions, at 400 cGy per fraction, given daily (Figure 1B). She had no symptoms subsequent to the SBRT treatment, and her pancreatic enzymes remained within normal limits.
After SBRT, and in light of her progressive disease, she was started on everolimus, but she developed drug-induced pneumonitis and the drug was discontinued. Pazopanib was administered, followed by axitinib, until she developed painful bone progression in the right humerus; on follow-up scans, the pancreatic lesion appeared atrophic, with a decrease in size to 10 × 6 mm and associated reduction in enhancement (Figure 3). She subsequently had a right proximal humerus resection of a 3.5-cm focus of metastatic RCC involving cancellous bone, and a prosthesis was placed. She was started on a phase I bevacizumab and programmed death ligand 1 (PD-L1) inhibitor protocol.
She later developed extensive pelvic bone disease, stopped systemic treatment, and underwent orthopedic surgery for disease stabilization before entering hospice care. With 3 years of follow-up after SBRT for her pancreatic lesion, there was no progression or development of any symptoms from this malignant deposit.
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