Chung-Han Lee, MD: In our second case, we have a 68-year-old nonsmoking woman with a history of hyperlipidemia who presented with an incidental kidney mass in July 2015 after scans were done for a motor vehicle accident. When she returned to follow up, she was noted to have an enlarged kidney lesion of up to 10 cm and underwent a radical nephrectomy for a 10-cm mass that was from a grade 2 with renal vein invasion and no necrosis. She was followed subsequently with interval imaging and was noted to have bilateral pulmonary nodules in July 2021. The largest lesion on the left side was 2.5 cm, and the largest from the right was 1.5 cm, with the remainder of the lung showing some smaller lesions and some perihepatic lymph nodes that were available. Her labs were completely normal. And she remained asymptomatic from her disease. A CT-guided biopsy was done, which confirmed that the lung masses were clear cell renal cell carcinoma.

Here, we can see some representative baseline imaging. On the left-hand side, you can see the 2.5-cm left-lung nodule. On the right side, you can see the 2.2-cm lung nodule right next to 1 of the airways scattered throughout the lungs. Of course, you can see some of the smaller lung lesions that were there.

A decision was made to start the patient on a combination of lenvatinib and pembrolizumab. The patient was treated at the FDA-approved dosage of lenvatinib 20 mg daily and pembrolizumab 200 mg every 3 weeks.

The patient developed some early toxicity and required dose reduction from the 20-mg daily of lenvatinib to 14 mg daily at the 8-week mark for fatigue and diarrhea but then was able to remain on the 14-mg doses with good tolerability subsequently. The best response seen was a partial response at 3 months with 52.3% reduction in tumor size. In the images above, you can see some representative imaging demonstrating shrinkage to some of the lesions in her lungs.

Robert J. Motzer, MD: That’s a great illustration of a patient with favorable-risk features, according to the risk group we reviewed. Maria, this patient was treated with lenvatinib-pembrolizumab, but do all patients need to be treated with systemic therapy? Do you ever sit tight and watch some patients with metastatic kidney cancer.

Maria I. Carlo, MD: Yes, I definitely sit tight. I wonder: if we didn’t see her images right after her nephrectomy or 1 year into her nephrectomy, how long did she have these long nodules? For some patients, it depends obviously how worried I am but also how worried the patient is. Some patients prefer to stay off systemic treatment and be absurd as long as they’re asymptomatic. I agree that at that point, I would have favored systemic therapy. But if the patient had said, “Can we please hold off longer?” I would have been completely fine with that.

Robert J. Motzer, MD: Surveillance is an important tool in terms of managing patients with RCC [renal cell carcinoma] because of the variable behavior we see with these patients. With some patients, we can hold off on chronic therapy with its toxicities for a considerable time by following patients with scans over time. That’s an important tool that we use in many patients. It’s been studied prospectively by [Brian] Rini, et al, who reported that in many instances, therapy can be delayed without harmful benefit to the patient in a select population of patients.

Transcript edited for clarity.