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McLoughlin DE, Chevalier N, Choy E, Cote GM, Gao X, Juric D, Reynolds KL. A Rare Presentation of Aggressive Renal Cell Carcinoma and the Utility of Early Molecular Testing in Rapidly Progressing Malignancies: A Case Report. Oncologist 2023; 28:1094-1099. [PMID: 37844295 PMCID: PMC10712707 DOI: 10.1093/oncolo/oyad280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/11/2023] [Indexed: 10/18/2023] Open
Abstract
In rapidly progressing cancers, appropriate selection of first-line therapy is essential in prolonging survival. Alongside immunohistochemistry (IHC), comprehensive genomics, including whole exome and transcriptome sequencing (WES/WTS), can improve diagnostic accuracy and guide therapeutic management. Here, we report a young patient with rapidly progressing malignancy and unexpected post-mortem results, a scenario that may have been altered by early, comprehensive genomic sequencing. A 43-year-old man with no relevant medical history presented to the emergency department with progressive cough and dyspnea despite treatment for pneumonia. Radiology revealed enlarged subcarinal, hilar, retroperitoneal, and mesenteric lymph nodes, suspicious for metastasis, and a right kidney mass. Pathologic analysis of a retroperitoneal lymph node was felt to be most consistent with metastatic epithelioid angiomyolipoma (mEAML). Three weeks later, he was urgently treated with an mTOR inhibitor for presumed mEAML due to rapid clinical decline, and a subsequent 4R lymph node biopsy was performed to confirm the diagnosis and identify genomic targets via IHC and WES/WTS. Unfortunately, he developed hypoxic respiratory failure, and only posthumously did WES/WTS reveal pathogenic variants in BAP1 and VHL, consistent with clear cell renal cell carcinoma (ccRCC). With an earlier ccRCC diagnosis, he would have received combination immunotherapy/tyrosine kinase inhibition, which has significantly greater activity than mTOR inhibition in ccRCC. He could have received systemic treatment earlier, with optimal therapy, while potentially carrying lower tumor burden and greater clinical stability. In cases of rapidly progressing malignancies with complex histopathological presentations, early comprehensive molecular-based testing can aid in diagnosis and critical therapeutic decision-making.
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Affiliation(s)
- Daniel E McLoughlin
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Termeer Center for Targeted Therapies, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Nicholas Chevalier
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Termeer Center for Targeted Therapies, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Edwin Choy
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Gregory M Cote
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Termeer Center for Targeted Therapies, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Xin Gao
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Termeer Center for Targeted Therapies, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Dejan Juric
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Termeer Center for Targeted Therapies, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, MA, USA
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Guo G, Gu L, Zhang X. Everolimus in Invasive Malignant Renal Epithelioid Angiomyolipoma. Front Oncol 2021; 10:610858. [PMID: 33575217 PMCID: PMC7870865 DOI: 10.3389/fonc.2020.610858] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/30/2020] [Indexed: 01/12/2023] Open
Abstract
Background To evaluate the efficacy and safety of everolimus, a mTOR inhibitor, on invasive malignant renal epithelioid angiomyolipoma (EAML). Materials and Methods From Oct 2014 to May 2019, we collected data from seven patients with a definite (clinical and pathological) diagnosis of EAML received everolimus in our hospital. Targeted sequence capture array technique with next-generation of high throughput sequencing (NGS) were performed to detect mutations of TSC1/2 genes. All patients had received surgery and everolimus. The clinical efficacy and safety of the therapy were evaluated. Results Mutations of TSC1 and TSC2 were detected in two and three patients though targeted sequence capture array technique with NGS, respectively. Among seven patients, three had missense mutations, one had nonsense mutation, and one had the large fragment deletion mutation. Five patients accompanied with tuberous sclerosis complex (TSC) were identified. All patients were administered 10mg everolimus once daily, the treatment duration lasted for 3 to 28 months. The objective response was assessed 3 months later, five partial response, two stable disease (SD), the mean greatest tumor diameter of all patients decreased from 9.6 to 5.2cm. Six patients stayed SD and one patient died during follow up. Patients accompanying with TSC had better responses to everolimus compared with non-TSC. Conclusion The mTOR inhibitor can be an effective treatment for patients with invasive malignant renal EAML. Patients with TSC may benefit more from the therapy.
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Affiliation(s)
- Gang Guo
- Department of Urology, The Third Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Liangyou Gu
- Department of Urology, The Third Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xu Zhang
- Department of Urology, The Third Medical Centre, Chinese PLA General Hospital, Beijing, China
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Guo B, Song H, Yue J, Li G. Malignant renal epithelioid angiomyolipoma: A case report and review of the literature. Oncol Lett 2015; 11:95-98. [PMID: 26870174 PMCID: PMC4727053 DOI: 10.3892/ol.2015.3846] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 09/28/2015] [Indexed: 12/17/2022] Open
Abstract
Malignant renal epithelioid angiomyolipoma (EAML) is rare, and currently there is no malignant criteria for its pathological diagnosis. In the present study, the case of a patient who suffered malignant renal EAML and underwent nephrectomy is reported. The histological patterns of the tumor were composed of sheets or nests of large polygonal epithelioid cells and thick-walled blood vessels, with clear mitoses. Immunohistochemistry demonstrated that the epithelioid and smooth muscle cells characteristically expressed human melanoma black-45, epithelial membrane antigen and actin. Pathological evaluation revealed malignant EAML with regional lymph node metastases. Magnetic resonance imaging and X-ray examination identified multiple liver and lung nodules at 16 months post-surgery. Since the patient did not respond to the initial treatment with doxorubicin and cisplatin, sorafenib was subsequently administered. However, the treatment was not effective, and the patient succumbed to multiple metastases six months later.
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Affiliation(s)
- Baoyin Guo
- Department of Urology, Tianjin Baodi Hospital of Tianjin Medical University, Tianjin 300321, P.R. China
| | - Hualin Song
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin 300211, P.R. China
| | - Jiuling Yue
- Department of Head and Neck Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, P.R. China
| | - Gang Li
- Department of Urology, The Second Hospital of Tianjin Medical University, Tianjin Institute of Urology, Tianjin 300211, P.R. China
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