Debate 1

First Line Treatment of Metastatic RCC –

“Immunotherapy + TKI” is the New Standard
of Care
 Case Details
» 69 Male, HTN on treatment for & 30 yrs

» 1.5 Month history - Loss of appetite and weight loss (10-12 kg)
and Low grade fever at night, weakness.

» PS-1, Pallor ++, No palpable Lymph nodes

» P/A: Soft, Firm globular mass RUQ, 10 x 8 cm, non-tender,

ballotable.

» Hb 9.0 gm/dl, TLC- 13,400, ANC- 9,300, Platelets – 5.5 lakh,

Creat – 1.2, Calcium – 9.8 mg/dl, LDH - 242
 Case Details
» USG: Right Kidney Mass
» CECT abdomen:
– Large heterogenous mass involving almost the entire (R)
kidney 10.1 x 9.5 x 8.7 cm.
– Thrombus in the renal vein not extending to the IVC.
– Nodular lesion (L) lung lingular lobe.

» In view of highly suspicious nodular lesion in lung patient

underwent PET CT scan.
» PET CT s/o Right kidney mass, FDG avid multiple RP nodes
and Multiple Lung nodules.
» Radiological Impression: RCC (R) with lung and nodal
mets, IMDC 4/6 poor risk
Imaging
 Treatment

» In view of IMDC poor risk disease with significant

constitutional symptoms patient was advised Image
guided biopsy followed by systemic treatment.

» CT guided biopsy from renal mass - Clear cell RCC.

 Final Diagnosis

Metastatic Clear Cell RCC (Right) with

multiple Lymph Node and Lung
metastasis.
IMDC – poor risk
Significant Constitutional symptoms
 Audience Voting

» What would be your strategy for treating

this patient ?

A. TKI alone
B. IO+TKI
C. IO+IO
PLEASE VOTE NOW…...
 Debate

For - Dr Amit Joshi Against - Dr Amish Vora

 Audience Voting

» What would be your strategy for treating

this patient ?

A. TKI alone
B. IO+TKI
C. IO+IO
PLEASE VOTE NOW…...
THANK YOU
 Potential Panel Questions
» What is your current practice with regards to
cytoreductive nephrectomy in poor risk IMDC mRCC
patients?
» IO+TKI for all?
» Any sub-group which can do away with TKI alone?
» IO + IO versus IO + TKI for poor & intermediate risk?
» IMDC does not prognosticate for OS in patients treated
with IO+IO. What are the new prognostic indicators in
Immunotherapy era in mRCC?