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Uptodate Reference Title
Approach to initial systemic therapy in patients with metastatic clear cell RCC
Approach to initial systemic therapy in patients with metastatic clear cell RCC
Patients with advanced or metastatic clear cell RCC are typically treated with systemic therapy as initial treatment. The decision to start systemic therapy and the selection of agent(s) depend on disease-related symptoms, patient comorbidities, and tumor risk stratification. Listed treatments are preferred options, although alternative agents that are not listed may also be effective. Clinical trials are encouraged if available. Select patients may be candidates for cytoreductive nephrectomy prior to initiation of immunotherapy. Refer to UpToDate content on surgical management of RCC.
RCC: renal cell carcinoma; IMDC: International Metastatic Renal Cell Carcinoma Database Consortium; KPS: Karnofsky performance status; LLN: lower limit of normal; ULN: upper limit of normal; VEGFR: vascular endothelial growth factor receptor. * Patients with limited disease on imaging are usually asymptomatic. However, the decision to treat must take into account multiple factors, including rate of growth, location of tumor (eg, proximity to vital organs with potential for damage), and symptoms. ¶ For patients with limited burden, favorable-risk disease who desire a more aggressive management approach, options include sunitinib or pazopanib. Refer to UpToDate content on targeted therapy for RCC. Δ For patients who are ineligible for or decline initial treatment with immunotherapy combinations, we offer antiangiogenic therapy that incorporates a VEGFR inhibitor. For patients with substantial burden, favorable-risk disease, options include lenvatinib plus everolimus, sunitinib, pazopanib, and cabozantinib. For those with intermediate- or poor-risk disease, options include lenvatinib plus everolimus or cabozantinib. Refer to UpToDate content on systemic therapy for advanced clear cell RCC and targeted therapy for RCC. ◊ All of these combinations improve overall survival, and the choice between these agents is based on toxicity profile, patient performance status, age, comorbidities and preferences, and the potential for a treatment-free interval (with nivolumab plus ipilimumab). Refer to UpToDate content on systemic therapy for advanced clear cell RCC.
