Treatment of patients with metastatic renal cell carcinoma undergoing hemodialysis: case report of two patients and short literature review

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pleural effusion and pulmonary nodules and a mammalian target of rapamycin inhibitor was administered which was withdrawn only at patient’s deteriorating performance status.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.

IL-8 induces the epithelial-mesenchymal transition of renal cell carcinoma cells through the activation of AKT signaling

“…Recently, patients with RCC are being diagnosed at increasingly younger ages (7). Approximately 20% of patients with RCC lose the possibility of radical treatment approaches due to metastasis (3,8). Furthermore, 40-50% of those patients with localized advanced disease will ultimately progress to metastatic disease (9).…”

The use of everolimus in a patient with metastatic atypical bronchial carcinoid undergoing haemodialysis: a single-centre experience with one case

“…On the basis of the experience of our department and case reports described so far, the conclusion was reached that everolimus can be safely used in patients with end-stage renal disease requiring haemodialysis in the treatment for solid tumours and make it possible to achieve the stabilisation of the disease [10][11][12].…”

“…Furthermore, it should be emphasised that the other side effects manifested by the patient were not connected with the necessity for discontinuation of everolimus administration. Given the literature re-view, the significantly higher incidence of side effects in patients undergoing haemodialysis and treated with everolimus has not been documented, except adverse effects associated with antiangiogenic activity (especially bleeding, which may occur with higher frequency and more severely in this setting) [12].…”

Second-Line Treatment Landscape for Renal Cell Carcinoma: A Comprehensive Review

“…Everolimus may also be considered in patients requiring dialysis. Bleeding disorders in dialysis patients may preclude the use of VEGFR TKIs, although limited data are available for dialysis patients .…”