mTOR Inhibition for Poor-Risk RCC

Treatment can be tailored for patients with poor risk metastatic renal cell carcinoma based on whether they have a poor or a good performance status, notes Bernard Escudier, MD. For those with poor performance status, Escudier prefers temsirolimus. For patients with a good performance status, he prefers to use a tyrosine kinase inhibitor (TKI) in frontline setting.

In the absence of head-to-head studies, a question that often arises, is whether temsirolimus and everolimus are interchangeable. The side effects differ, and the kinetics are different, says Susanne Osanto, MD. Although most of the data in this group of patients are with temsirolimus, in daily practice, many poor-risk patients will receive everolimus. Some will receive upfront TKIs, she adds. Upon progression, patients may be switched to an alternate class of drugs.

If a patient has several bone metastases, systemic treatment will be needed, states Osanto. If a patient has one or two bone metastases, irradiation may be appropriate. TKI therapy can be resumed following irradiation, she adds. Patients with multiple brain metastases have a poor prognosis, and there are not a lot of data in this population, says Escudier. Stereotactic radiotherapy is feasible, if a patient has up to five brain metastases. Another option to consider for these patients is neurosurgery followed by irradiation.