Clinical Scenario 1: Renal Cell Carcinoma Diagnosis and Staging

Centering discussion on a clinical scenario of metastatic renal cell carcinoma, expert panelists reflect on optimal diagnosis and stratification methods in this setting.


Chung-Han Lee, MD, PhD: Welcome to this Cancer Network® presentation, “Morning Rounds: Metastatic Renal Cell Carcinoma Decision Making.” I’m your host, Dr Chung-Han Lee. I’m a medical oncologist at Memorial Sloan Kettering Cancer Center [MSKCC, New York, New York], focused on renal cell carcinoma [RCC], running not only clinical trials, but also clinical biomarker development. Here today I have members of my care team, Christine Anderson.

Christine Anderson, NP: Hi, I’m Christine Anderson. I’m a nurse practitioner at Memorial Sloan Kettering [Cancer Center]. I started as a nurse practitioner on the inpatient team caring for GU [genitourinary] patients, and then transitioned to the outpatient role about 5 years ago with continuing care of GU patients with a focus on kidney cancer.

Chung-Han Lee, MD, PhD: And Patricia Fischer.

Patricia Fischer, Research Nurse: Hi, I am Patricia Fischer. I’m a clinical trials nurse at Memorial Sloan Kettering Cancer Center. Part of my role is to educate patients about the therapy that they’re receiving and potential side effects, as well as management.

Chung-Han Lee, MD, PhD: Today we’re going to be discussing the testing and treatment of patients with metastatic clear cell renal cell carcinoma, and we’ll look through some clinical scenarios and review some best practices. Let’s begin.

Chung-Han Lee, MD, PhD: For our first clinical scenario, we have a 75-year-old man who presented the emergency [department] with shortness of breath, fatigue, and pain in his left flank. He’s described these symptoms going on for a relatively long period of time for probably a few months and he’s really noticed that the symptoms have gotten a little bit worse over the last couple weeks or so. He got some initial labs and demonstrated that he had a hemoglobin of 9.8, a corrected calcium of 10.1, an elevated neutrophil count of 9, and a platelet count that was normal in the 200-type of range. His chest x-ray at that time ended up demonstrating multiple masses within his left kidney and within his left lung. This is certainly not an uncommon scenario for us to see [with] the absence of any screening measures that we have for RCC. A good portion of our patients are just kind of showing up to the ED [emergency department] in this sort of setting in which they presented for something else, and in this workup it reveals kidney cancer. Christine, how often do you see these patients present and what are the signs and symptoms that you have seen from kidney cancer?

Christine Anderson, NP: I think this is a pretty typical presentation. A lot of times this pain has been going on for a while and then ultimately gets so acute that brings them to the emergency [department]. The workup reveals these rather sometimes large kidney masses. I think also when you get to speaking with them and kind of talking to them when we first meet them is that they say that they’ve been just tired for a long period of time. Certainly, sometimes there’s weight loss that plays a factor. Depending on the location too of the mass, we see hematuria quite frequently with these patients. This is not an uncommon event.

Chung-Han Lee, MD, PhD: Definitely. In thinking about next steps for the patients, what sort of imaging do you think that the patient needs?

Christine Anderson, NP: In this setting, I think certainly a CT scan of the chest, the abdomen, and of [the] pelvis would be helpful just to get the overall extent of his disease.

Chung-Han Lee, MD, PhD: Then, in terms of thinking about diagnosis, how do you guys go ahead and think about how to confirm this diagnosis based on the suspicion?

Christine Anderson, NP: Certainly, a biopsy I think would also be helpful [not] just to have tissue, but to confirm the diagnosis. The labs here are also very helpful at kind of seeing where he falls in risk factors and things like that.

Chung-Han Lee, MD, PhD: I mean biopsies are certainly incredibly important, especially of the metastatic site, because that gives us both staging and of course histologic classification. Certainly, there are a lot of different kidney cancer histologies in which sometimes there are send outs in order to figure out the appropriate subtypes with the most common type being clear cell.

Christine Anderson, NP: Yes. Definitely.

Chung-Han Lee, MD, PhD: Now, as you mentioned the labs a little bit earlier, clearly one of the things that’s very important from a treatment planning type of perspective is thinking about the different risk stratification schemes. Both MSKCC risk and IBC risk being commonly used stratification schemes. IMDC [International mRCC Database Consortium] is a kind of a 6-factor risk stratification scheme, which it takes into account time from diagnosis to time to need to start treatment. Also, looking at the patient performance status. Certainly, sicker patients do worse. Then also lab abnormalities including looking at the calcium, looking at elevated platelets, looking at elevated neutrophils, and looking at whether or not they’re anemic.

Christine Anderson: Yes. Definitely.

Transcript edited for clarity.

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