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Abstract

Introduction

The management of renal cell carcinoma has undergone major transformation in recent years. With the onset of innovative surgical treatments and systemic medications – there has been an overall decrease in mortality.1 The systemic medications that target the vascular endothelial growth factor (VEGF) protein have created the most potent effects, especially when treating metastatic renal cell carcinoma. These prove to be important treatments since renal cell carcinoma has become the seventh most common cancer in men, with a general prevalence of 2-3%.2 With more advancement in knowledge about renal cell carcinoma, research has shown the utility of pazopanib (Votrient), a specific tyrosine kinase inhibitor, targeting multiple receptors; its action is primarily to block angiogenesis and tumor growth, such as VEGFR-1, VEGFR-2, VEGFR-3, PDGFR-A, PDGFR-B, FGFR-1, and FGFR-3.3 Targeting these specific receptors helps pazopanib to achieve an overall clinical benefit rate of greater than 90%, creating long-lasting disease control for patients 4

CASE PRESENTATION

A 63 year old Caucasian female with a past medical history of migraine headaches, dyslipidemia and depression was diagnosed with clear cell type Renal Cell Cancer, in late 2004. She underwent a laparoscopic nephrectomy in 2005 and a kidney mass measuring 9 x 7 x 4 cm was removed, revealing T2 disease with Furman Grade 2 disease. The patient was followed for years and had a CT scan of her Chest in June of 2012 - where multiple bilateral pulmonary nodules were identified, the largest nodule was a 1.5 x 1.2 cm nodule at the right middle lobe. CT-guided biopsy was attempted, however was not diagnostic. Therefore, the patient underwent a right upper lobe wedge resection in October of 2012, which confirmed metastatic renal cell cancer to the lung. A PET/CT scan was also performed, and ruled out any evidence of abdominal or bone metastatic disease.

Additional therapeutic options were discussed with the patient, such as high-dose interleukin-2 infusion to achieve durable remission and then potentially start targeted therapy when needed. At the time when she was diagnosed with metastatic disease, the patient was in optimal health and was an excellent candidate for high-dose interleukin-2 treatment because she only had pulmonary nodules, without evidence of metastatic disease elsewhere in her body. She was agreeable and finished three cycles of high-dose interleukin-2 treatment along with Stereotactic Body Radiation Therapy. The patient was finally started on targeted therapy with a multi-tyrosine kinase inhibitor in June of 2013. Pazopanib 400mg daily was started and titrated up to 600mg daily, which is considered optimal therapy. However, this patient began to have significant diarrhea without relief from Lomotil and other antidiarrheal medication regimens. Her dose was decreased to 400mg daily which resulted in a decreased amount of diarrhea - one to two times a day which was tolerable. Additionally, a few months after the onset of pazopanib treatment, the patient began having blurry vision, a symptom which was very worrisome.

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