Abstract
BackgroundRenal cell carcinoma (RCC) may involve both kidneys. When bilateral nephrectomy is necessary renal replacement therapy is mandatory. Treating such patients with sequential therapy based on cytokines, antiangiogenic factors and mammalian target of rapamycin (mTOR) inhibitors is challenging.Case presentationThe first case, a 50-year-old Caucasian female, underwent a radical right nephrectomy for RCC. Twelve years later she underwent a radical left nephrectomy along with total hysterectomy including bilateral salpingo-oophorectomy for RCC involving the right kidney and ovary. Hemodialysis was necessary because of bilateral nephrectomy. She relapsed with pulmonary metastases and enlarged mediastinal lymph nodes and received cytokine based therapy along with bevacizumab. Therapy was discontinued despite the partial response because of hemorrhagic gastritis. Therapy was switched to an antiangiogenic factor but the patient manifested a parietal brain hematoma and stopped therapy. Subsequently disease relapsed with malignant pleural effusion and pulmonary nodules and a mammalian target of rapamycin inhibitor was administered which was withdrawn only at patient’s deteriorating performance status. The patient died of the disease 13 years after the initial diagnosis of RCC.The second case, a 51-year-old, Caucasian male, underwent a radical right nephrectomy for a chromophobe RCC. Six months later he underwent a radical left nephrectomy for RCC that proved to be a clear cell RCC. Due to bilateral nephrectomy hemodialysis was obligatory. Following disease recurrence at the anatomical bed of the right kidney therapy with antiangiogenic factor was administered which led to disease regression. However the patient experienced a left temporal-occipital brain hematoma. A radical excision of the recurrence which histologically proved to be a chromophobe RCC was not achieved and the patient received mTOR inhibitor which led to disease complete response. Nine years after the initial diagnosis of RCC he is disease free and leads an active life.ConclusionPatients with RCC are in significant risk to manifest bilateral disease. Renal insufficiency requiring hemodialysis poses therapeutic challenges. Clinicians must be aware of the antiangiogenic factors’ adverse effects, especially bleeding, that may manifest in higher frequency and more severe in this setting.
Highlights
Renal cell carcinoma (RCC) may involve both kidneys
Clinicians must be aware of the antiangiogenic factors’ adverse effects, especially bleeding, that may manifest in higher frequency and more severe in this setting
There are no established guidelines about the management of chemotherapy administration and toxicity in patients undergoing dialysis [11,12]; albeit both tyrosine kinase inhibitors (TKI’s) and mTOR inhibitors have mainly hepatic metabolism and only a minor renal excretion [13,14,15,16]. In this case report and short literature review we present 2 patients with bilateral RCC who underwent bilateral nephrectomy and received therapy based on cytokines, antiangiogenic factors, inhibitors of tyrosine kinases receptors and inhibitors of the mammalian target of rapamycin while on hemodialysis
Summary
In patients diagnosed with RCC, especially those with young age at diagnosis, the risk to develop a secondary lesion to the contralateral kidney is relatively high. Patients undergoing hemodialysis because of bilateral nephrectomy pertain to a group that poses therapeutic challenges to clinicians. Since there are no established guidelines on management of therapy administration and toxicity in mRCC patients undergoing dialysis, therapy should be given with caution and increased vigilance for adverse effects. Medical oncologists must be aware of the higher incidence of bleeding disorders in patients undergoing hemodialysis. More studies on mRCC patients treated with agents targeting molecular pathways under hemodialysis are needed. Consent Written informed consent was obtained from the of kin of the first patient and from the second patient for publication of this case report. A copy of the written consent is available for review by the Series Editor of this journal. NT was the treating physician, coordinated and supervised drafting the manuscript. All authors read and approved the final manuscript
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