Case 36

Published on 18/02/2015 by admin

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Last modified 18/02/2015

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CASE 36

You are looking after a 60-year-old male patient with renal carcinoma. The patient is due for surgery in 2 days, and you are investigating follow-up immunotherapies you might offer this patient, besides conventional chemotherapy. Discuss some of the options.

QUESTIONS FOR GROUP DISCUSSION

1. Explain the differences between sporadic and inherited renal cell carcinoma.

2. Describe the clinical presentation of renal cell cancer and general approach leading to diagnosis.

3. Describe the general procedure for tumor-infiltrating lymphocyte (TIL) therapy. What is the rationale for this approach?

4. TIL therapy has met with limited success. List at least two reasons why this approach may not work.

5. Attempts to enhance the efficacy of TIL therapy have led to changes in the protocol to include exogenous cytokines. Discuss the negative side effects associated with this modification. Describe an alternative approach to overcome this side effect and yet still benefit from intervention of cytokines.

6. Provide a rationale for introduction of each of the following cytokines in the TIL protocol: interleukin (IL)-2, interferon gamma (IFNγ), and granulocyte-macrophage colony-stimulating factor (GM-CSF).

7. Discuss the pros and cons (regarding tumor killing) of enhanced class I MHC on the tumor cells.

8. Discuss the general approach for treatment of tumors using antigen-pulsed dendritic cells.

9. What is the advantage of this approach compared with the tumor-infiltrating cell approach? What is the potential problem to this approach? How might this be addressed?

10. Describe, in general terms, the tetramer biology approach. Explain why this approach holds out more hope for treatment than the other two approaches (TILs, or pulsed dendritic cells).

RECOMMENDED APPROACH

Implications/Analysis of Family History

Renal cell carcinoma may be sporadic or inherited. Sporadic renal cancer typically develops in the elderly and is much more frequent in males. In contrast, hereditary renal cancers may develop much earlier in life, even in teenagers, and occur in equal frequency in females and males. There are a number of different hereditary renal cell cancers, the most common being von Hippel-Lindau (VHL) disease, a familial multiple cancer syndrome that includes renal cell cancer. The von Hippel-Lindau gene is now known to be a tumor suppressor gene.

Given that our patient is a 60-year-old man, it is likely that this patient has sporadic renal cell cancer.

Implications/Analysis of Clinical History

Clinical presentations generally include hematuria (blood in urine), abdominal pain, and mass in the abdomen. Some patients will also experience weight loss, night sweats, and a general listless feeling. However, incidental detection often occurs before these clinical symptoms appear when patients receive ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI) for other reasons.

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