Tailoring Immunotherapy Treatment of Synchronous Renal Cell Carcinoma (RCC) and Triple-Negative Breast Cancer (TNBC)

Case Reports in Oncological Medicine
12 Jun, 2019 ,

This is a case of a 67-year-old woman who is a K/C/O metastatic Triple-Negative Breast Cancer (TNBC). Three cycles of chemotherapy showed no response in distant sites. She developed two new pulmonary nodules, enlarging renal mass, new retroperitoneal lymphadenopathy, and worsening osteosclerotic metastasis; capecitabine was discontinued. Renal biopsy showed clear cell RCC.  Ipilimumab and nivolumab were started. After 4 cycles of ipilimumab/nivolumab, CT showed partial response with a resolution of lung nodules and shrinkage of the RCC primary tumor, enlarging adenopathy and worsening bony metastasis. Then, nivolumab maintenance was implemented and nab-paclitaxel was added which was given a mixed response. A later CT showed partial response with improved adenopathy, stable renal lesion, and stable bony lesions.

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A 67-year-old woman presented (10/2017) with right side breast discomfort. Ultrasound demonstrated a  mass with no adenopathy, and biopsy showed an ER-negative, PR-negative, HER2-negative IDC. Staging computerized tomography (CT) showed bilateral pulmonary nodules (), a 5 cm lower pole left kidney mass, renal vein thrombus, and innumerable sclerotic bone lesions. Bone marrow biopsy confirmed metastatic breast cancer. In 12/2017, she started taking capecitabine. While follow-up evaluations revealed breast softening, CT after 3 cycles of capecitabine showed no response in distant sites. She developed two new pulmonary nodules, enlarging renal mass, new retroperitoneal lymphadenopathy, and worsening osteosclerotic metastasis; capecitabine was discontinued.

For a clinical trial, breast tissue underwent genomic testing and an activating SQSTM1-RET fusion mutation was revealed. Renal biopsy (to exclude a second primary malignancy) showed clear cell RCC. The genomic analysis of the renal biopsy did not yield mutations. Ipilimumab and nivolumab were started in 5/2018. She developed a treatment-related rash, which was resolved with steroids. After 4 cycles of ipilimumab/nivolumab (7/2018), CT showed partial response with a resolution of lung nodules and shrinkage of the RCC primary tumor, enlarging adenopathy and worsening bony metastasis. A clinical breast exam was normal. Given the mixed response, nivolumab maintenance was implemented and nab-paclitaxel was added. CT (10/2018) showed partial response with improved adenopathy, stable renal lesion, and stable bony lesions. The patient currently remains on this combination of nivolumab and nab-paclitaxel with her last CT showing stable disease (current duration of therapy: 10 months).