Frontline IO-TKI Therapy for Symptomatic, Bulky Metastatic RCC

A patient case anchors this discussion of frontline management for de novo metastatic RCC with bulky, symptomatic disease. The patient is an otherwise healthy man with an intact primary tumor, sizable lung nodules, painful retroperitoneal lymphadenopathy, and marked fatigue. Faculty stress reviewing imaging personally and watching for obstructive complications such as hydronephrosis. They warn that hospitalization for uncontrolled disease or hypercalcemia can prompt early hospice referral, forfeiting the long survival that modern combinations can deliver. For this presentation, the panel favors an immunotherapy-TKI regimen such as cabozantinib plus nivolumab for its balance of efficacy, quality of life, and safety. The discussion then covers baseline and ongoing monitoring of blood pressure, proteinuria, and cardiac function, along with supportive care for hand-foot syndrome, mucositis, and diarrhea. Faculty also explain how lenvatinib’s greater tendency to cause hypertension and proteinuria shapes their regimen choice.