1. Clinical Case Ricardo Leão
Serviço de Urologia – Centro Hospitalar de Coimbra EPE
Director: Dr. Fernando Sobral

2. Case Report Men 68 years old Healthy Outpatient Clinic
Right Scrotal Discomfort
2 months evolution
No Fever
No urethral discharge
No other constitucional symptoms
Physical Examination:
Hard nodule at right spermatic cord (independent from testis), no painfull, no local inflamatory signs

3. Inguino-Scrotal Ultrassonography
Radiologic Evaluation
Inguino-Scrotal Ultrassonography
“Solid nodule, heterogeneous; 2 cm´s…”
“…difuse hyper-reflectivity, with no evidence of collections…”
Right Side

4. ? Question 1 Next Step… Radiologic Evaluation – X-Ray; CT; MRI
Percutaneous Biopsy
Excisional Biopsy – Inguinal Approach
Testicular Tumor Biomarkers
Other...

5. Radiologic Evaluation
Chest X-Ray

6. ? Question 2 Diagnosis Hypothesis Testicular Cancer
Liposarcoma Spermatic Cord
Leiomiosarcoma Spermatic Cord
Infectious Disease
Pulmonary Neoplasm
Other

7. ? Question 3 Next Step… Radiologic Evaluation – CT; MRI
Percutaneous Biopsy
Excision Biopsy – Inguinal Approach
Radical Orquidectomy
Other...

8. Right Radical Orquidectomy
Surgery
Right Radical Orquidectomy
28th May 2009

9. Spermatic cord metastasis from
Pathology
Hematoxylin + Eosin
200x
“…tumor 1.9 cm in diameter… irregular but clear boundaries, fibroelastic consistency. Not observed any relation to the testicle. Testis with 7x3, 5x3, 5 cm in size without changes in the macroscopic study ...” ”
“… neoplasm of large cells, clear cytoplasm, small oval nuclei, some with monotonous prominent nucleoli, a pattern of solid growth…”
CD10
400x
“…Immunohistochemical study: immunoreactivity for cytokeratin CAM 5.2, vimentin, and CD10”
Spermatic cord metastasis from
renal cell carcinoma

10. Imagiologic Staging
“…pulmonary nodular formations observed numerous solid pericentimetrics dimensions of metastatic nature. ... right kidney shows nodule with approximately 55 mm, heterogeneous, infiltrating the renal sinus. ... "

11. ?

12. ? Question 4 Next Step… Neo Adjuvant Therapy + RN
Radical Nephrectomy + Adjuvant Therapy
Radical Nephrectomy
Embolization
Other...

13. Right Radical Nephrectomy
Surgery
Right Radical Nephrectomy
right spermatic vein drained directly into the renal vein
6th August 2009

14. nuclear grade 3/4 with invasion of perinephric fat and renal vein
Pathology
Hematoxylin + Eosin
200x
Clear cell carcinoma with 5,5 cm x 4,5 cm x 3,5 cm in the middle third of the right kidney,
nuclear grade 3/4 with invasion of perinephric fat and renal vein

15. Staging and Prognosis
International TNM/ American Joint Commitee on Cancer 2002
pT3NxM1
Performance Status ECOG
Grade 0 – active, normal life, without restrictions
Performance Status Karnofsky
> 90 % – Normal activity, some signs of disease

16. Paliative/Adjuvant Treatment?
Question 4
Paliative/Adjuvant Treatment
Sunitinib – 50 mg id
IL-2 High Dose
Temsirolimus
Sorafenib
Other...

17. Sunitinib; 50 mg; id; oral – 4 weeks + 2 weeks off
Paliatve Therapy
Sunitinib; 50 mg; id; oral – 4 weeks + 2 weeks off

18. Clinical Evaluation Before treatment… Clinical Evaluation
No Hypertension
No Cardiac Problems or Congestive Heart Failure
No Vascular Pathology – including transient cerebral vascular attack
No Seizures
No Kidney problems
No Liver problems
No Depression History
No Hypothyroidism
No Anemia
No dermatologic lesions (including keratosis)
No Medication (ocasionally or dietary supplements)

19. Laboratory Evaluation
Before treatment…

20. Laboratory Evaluation
Before treatment…

21. Laboratory Evaluation
Before treatment…

22. Cardiologic Evaluation
Before treatment…

23. Staging and Prognosis MSKCC Model *
* “Validation and Extension of the Memorial Sloan- Kettering Prognostic Factors Model
for Survival in Patients With Previously Untreated Metastatic Renal Cell Carcinoma “

24. Intermedium Risk – 58% (1st Year)
Staging and Prognosis
MSKCC Model *
Intermedium Risk – 58% (1st Year)
* “Validation and Extension of the Memorial Sloan- Kettering Prognostic Factors Model
for Survival in Patients With Previously Untreated Metastatic RenalCell Carcinoma “

25. Hematologic Alterations
Adjuvant/Paliative Therapy
Sunitinib ; 50 mg; id; oral – 4 weeks + 2 weeks off
Initiated 4 weeks after surgery
Adverse Effects
Fatigue/Asthenia
Yes; Grade I-II 1
Diarrhoea
Yes; Grade I-II
Nausea
Vomiting
Stomatitis
Yes: Grade I 2
Hypertension No
Hand-Foot Syndrome
Hematologic Alterations
Yes; Leucopenia; G I
1 2nd week after initiation
2 2nd week; alleviated at 2 weeks off

26. Evaluation and Follow-Up
After 6 Cycles of therapy with Sunitinib
No Grade III-IV adverse effects
PS > 80%
Grade I-II adverse effects
Diarrhoea
Vomiting
Nausea
Astenia
Tolerable without
discontinuation

27. Evaluation and Follow-Up
Response Evaluation Criteria in Solid Tumors
(RECIST) version 1.1 Criteria
Evaluation of Target Lesions
Complete Response Disappearance of all target lesions
Redution in all pathologic LN to <10 mm
Parcial Response »30% decrease in the sum of the longest diameter of target lesions
Progressive Disease »20% increase in the sum of target lesions and
5 mm´s absolute increase of target lesions
We achieved Stable Disease after 3 cycles of Sunitinib

28. Evaluation and Follow-Up
Response Evaluation Criteria in Solid Tumors
(RECIST) version 1.1 Criteria
Begin
After 6 cycles - Sunitinib

29. Evaluation and Follow-Up
Response Evaluation Criteria in Solid Tumors
(RECIST) version 1.1 Criteria
We achieved Parcial Response after 6 cycles of Sunitinib
Begin
After 6 cycles - Sunitinib

30. Therapeutics
Duration ?
When to stop?

31. Obrigado