clinical cases

[GUoncologist]

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ctDNA 2-4w after surgery. If positive, CapeOx x4. If negative, monitor.

May I ask why not cape monotherapy for 6 months?

 

[gutonc]

May I ask why not cape monotherapy for 6 months?

Mostly extrapolating from the IDEA collaborative data. If someone can't tolerate oxali, I'll just do cape.

 

[Royster33]

ctDNA 2-4w after surgery. If positive, CapeOx x4. If negative, monitor.

Did you mean 3 months? I am not familiar with x 4. Either way I think this is a good middle ground in these borderline cases.

 

[gutonc]

Did you mean 3 months? I am not familiar with x 4. Either way I think this is a good middle ground in these borderline cases.

4 cycles = 3 months

 

[ONC2023]

42 year old.

Bilateral renal masses, biopsy proven ccRCC (called low grade on path).

The left mass is so large it needs radical nephrectomy. The right mass is borderline.

She’s seeing me for neoadjuvant treatment to shrink them before urology goes in.

I like the idea of dual IO in young people because it’s the best chance of a durable response, but the response rate is lower than IO/TKI.

Would anyone do “neoadjuvant” dual IO, or do you prioritize the ORR of TKI’s in this setting? I’m leaning toward IO/TKI - either Cabo/nivo or if the patient is ok with the toxicity, Len/pembro.

 

[HemeOncHopeful19]

42 year old.

Bilateral renal masses, biopsy proven ccRCC (called low grade on path).

The left mass is so large it needs radical nephrectomy. The right mass is borderline.

She’s seeing me for neoadjuvant treatment to shrink them before urology goes in.

I like the idea of dual IO in young people because it’s the best chance of a durable response, but the response rate is lower than IO/TKI.

Would anyone do “neoadjuvant” dual IO, or do you prioritize the ORR of TKI’s in this setting? I’m leaning toward IO/TKI - either Cabo/nivo or if the patient is ok with the toxicity, Len/pembro.

I would probably do what you’re doing. We love the idea of those sustained CRs with dual IO but in reality it’s like… 10-15%?

If it is the chance or staying off dialysis I’d probably lean toward IO/TKI. Response rates are higher and you’re still getting exposure to IO anyway.

 

[GUoncologist]

I would probably do what you’re doing. We love the idea of those sustained CRs with dual IO but in reality it’s like… 10-15%?

If it is the chance or staying off dialysis I’d probably lean toward IO/TKI. Response rates are higher and you’re still getting exposure to IO anyway.

I agree, while in the metastatic setting there is a good argument for io/io, I would do pembro lenva for cytoreduction prior to surgery, especially if there is no sarcomatoid differentiation.

I'm sure you are planning this, but would make sure he has genetic testing. Likelihood >10% you'll find something.

 

[ONC2023]

Just a brief Lenvatinib update regarding my earlier question on len-pembro for ccRCC: I hate this drug.

1) A CLL case (mal heme is my weak area, and I'm covering for a partner - so pardon how simple of a question this is)
- 80 year old. CLL treated with obinutuzumab and venetoclax 4 years ago with excellent response. Counts normalized for 4 years. Earlier in 2026, WBC starting rising, almost entirely lymphocytosis. 40K --> 100K. Platelets now down to 50K. ANC is now < 1. New anemia. LDH 550 and uric acid 12. No blasts on smear. Flow pending.

CT CAP with new upper abdominal nodes.

The question here is Richter's Transformation vs just relapsed CLL, right? The textbook right answer is PET him and then get excisional biopsy I believe but this is inpatient and can't get a PET. Also, he's too sick to get an abdominal surgery to go after the abdominal nodes - I don't think they're accessible percutaneously.

Would a bone marrow be an appropriate replacement?

2) ccRCC case. Good performance status 55 year.
--- Nephrectomy 2024 with 1 year adjuvant pembro ending July 2025.
-- Oct 2025, developed small thigh mas on PET with her previous oncologist.
-- PET with me 3/2026: growing thigh mass and small hip lytic lesion --> very small volume of disease.
-- Thigh mass removed, confirmed as ccRCC.

So I have a lady with oligorecurrent disease -- one of which has been surgically excised. The other area is amenable to SBRT.

My options are:
1) IO-IO ---> I am a bit concerned about IO/IO rechallenge since she relapsed so soon after end of pembro, though it's low volume recurrence
2) IO-TKI --> this is not curative (at least likely than IO/IO)
3) SBRT perhaps then "adjuvant" IO/TKI?

 

[GUoncologist]

Just a brief Lenvatinib update regarding my earlier question on len-pembro for ccRCC: I hate this drug.

1) A CLL case (mal heme is my weak area, and I'm covering for a partner - so pardon how simple of a question this is)
- 80 year old. CLL treated with obinutuzumab and venetoclax 4 years ago with excellent response. Counts normalized for 4 years. Earlier in 2026, WBC starting rising, almost entirely lymphocytosis. 40K --> 100K. Platelets now down to 50K. ANC is now < 1. New anemia. LDH 550 and uric acid 12. No blasts on smear. Flow pending.

CT CAP with new upper abdominal nodes.

The question here is Richter's Transformation vs just relapsed CLL, right? The textbook right answer is PET him and then get excisional biopsy I believe but this is inpatient and can't get a PET. Also, he's too sick to get an abdominal surgery to go after the abdominal nodes - I don't think they're accessible percutaneously.

Would a bone marrow be an appropriate replacement?

2) ccRCC case. Good performance status 55 year.
--- Nephrectomy 2024 with 1 year adjuvant pembro ending July 2025.
-- Oct 2025, developed small thigh mas on PET with her previous oncologist.
-- PET with me 3/2026: growing thigh mass and small hip lytic lesion --> very small volume of disease.
-- Thigh mass removed, confirmed as ccRCC.

So I have a lady with oligorecurrent disease -- one of which has been surgically excised. The other area is amenable to SBRT.

My options are:
1) IO-IO ---> I am a bit concerned about IO/IO rechallenge since she relapsed so soon after end of pembro, though it's low volume recurrence
2) IO-TKI --> this is not curative (at least likely than IO/IO)
3) SBRT perhaps then "adjuvant" IO/TKI?

Really tough case and an area where there is not much data. Just thinking out loud:
1. Is this imdc favorable risk (assuming the rest of the lab values are normal)? Who knows... recurrence was relatively quick after adjuvant IO, but did the pembro change the natural history of this disease (i.e. how do we measure time to systemic therapy - from diagnosis or from end of adj therapy)? Who knows...
2. After sbrt, you have no measurable disease. What are you treating and how do we measure efficacy/overtreatment? Is active surveillance a reasonable option? (For the record I agree with SBRT)
3. Real world data post adjuvant pembro followed by io combination - looked like we may be converging on 6 months as a reasonable target for rechallenge. However, this person recurred 3 months post but is now >6 months when they will receive treatment. Where does this patient's benefit lie in rechallenging with IO/tki or io/io? (Im guessing towards less benefit)
3. Low volume disease - as you point out, is this the type of patient where you have the luxury of a trial of io/io whether it works or not? But the risk of life altering toxicity is not negligible...
4. I think the biology of this disease is aggressive and I would advocate for treatment rather than active surveillance.

If it were my patient, I would explain the above and get a feel for what they want. We have time as they will get SBRT and then come back with repeat CT. If truly nothing, the convo will be long. If tiny lung nodules start appearing, I would guide towards 1L IO/IO -> 2L cabozantinib in a 55 yo who tolerated pembro well.

Would love to hear others' thoughts!

 

[whoknows2012]

Just a brief Lenvatinib update regarding my earlier question on len-pembro for ccRCC: I hate this drug.

1) A CLL case (mal heme is my weak area, and I'm covering for a partner - so pardon how simple of a question this is)
- 80 year old. CLL treated with obinutuzumab and venetoclax 4 years ago with excellent response. Counts normalized for 4 years. Earlier in 2026, WBC starting rising, almost entirely lymphocytosis. 40K --> 100K. Platelets now down to 50K. ANC is now < 1. New anemia. LDH 550 and uric acid 12. No blasts on smear. Flow pending.

CT CAP with new upper abdominal nodes.

The question here is Richter's Transformation vs just relapsed CLL, right? The textbook right answer is PET him and then get excisional biopsy I believe but this is inpatient and can't get a PET. Also, he's too sick to get an abdominal surgery to go after the abdominal nodes - I don't think they're accessible percutaneously.

Would a bone marrow be an appropriate replacement?

2) ccRCC case. Good performance status 55 year.
--- Nephrectomy 2024 with 1 year adjuvant pembro ending July 2025.
-- Oct 2025, developed small thigh mas on PET with her previous oncologist.
-- PET with me 3/2026: growing thigh mass and small hip lytic lesion --> very small volume of disease.
-- Thigh mass removed, confirmed as ccRCC.

So I have a lady with oligorecurrent disease -- one of which has been surgically excised. The other area is amenable to SBRT.

My options are:
1) IO-IO ---> I am a bit concerned about IO/IO rechallenge since she relapsed so soon after end of pembro, though it's low volume recurrence
2) IO-TKI --> this is not curative (at least likely than IO/IO)
3) SBRT perhaps then "adjuvant" IO/TKI?

Def want to r/o richters. PET with excisional as you mentioned is gold standard. Sure go for marrow but it’s subject to sampling error just like a random nodal bx is (without pet)

 

[Medonc_fellow]

When giving FOLFOX/FOLFIRI and skipping 5-FU bolus, do you guys still give leucovorin?

 

[gutonc]

When giving FOLFOX/FOLFIRI and skipping 5-FU bolus, do you guys still give leucovorin?

No.

 

[gutonc]

Just a brief Lenvatinib update regarding my earlier question on len-pembro for ccRCC: I hate this drug.

I told you.

1) A CLL case (mal heme is my weak area, and I'm covering for a partner - so pardon how simple of a question this is)
- 80 year old. CLL treated with obinutuzumab and venetoclax 4 years ago with excellent response. Counts normalized for 4 years. Earlier in 2026, WBC starting rising, almost entirely lymphocytosis. 40K --> 100K. Platelets now down to 50K. ANC is now < 1. New anemia. LDH 550 and uric acid 12. No blasts on smear. Flow pending.

CT CAP with new upper abdominal nodes.

The question here is Richter's Transformation vs just relapsed CLL, right? The textbook right answer is PET him and then get excisional biopsy I believe but this is inpatient and can't get a PET. Also, he's too sick to get an abdominal surgery to go after the abdominal nodes - I don't think they're accessible percutaneously.

Would a bone marrow be an appropriate replacement?

Too sick for an excisional biopsy and hospitalized? Probably too sick for aggressive treatment too. Marrow is an answer, but I don't think it's a good one. If I could get rituximab as an inpatient (which I can't), I'd give a dose of that, maybe some steroids and hope to temporize him enough to get discharged and the appropriate workup done.

2) ccRCC case. Good performance status 55 year.
--- Nephrectomy 2024 with 1 year adjuvant pembro ending July 2025.
-- Oct 2025, developed small thigh mas on PET with her previous oncologist.
-- PET with me 3/2026: growing thigh mass and small hip lytic lesion --> very small volume of disease.
-- Thigh mass removed, confirmed as ccRCC.

So I have a lady with oligorecurrent disease -- one of which has been surgically excised. The other area is amenable to SBRT.

My options are:
1) IO-IO ---> I am a bit concerned about IO/IO rechallenge since she relapsed so soon after end of pembro, though it's low volume recurrence
2) IO-TKI --> this is not curative (at least likely than IO/IO)
3) SBRT perhaps then "adjuvant" IO/TKI?

SBRT and observe? That's probably where I'd go, especially since you know she's going to get more systemic therapy relatively soon. Save it for when local therapy isn't an option anymore.