Intolerance to Sunitinib Treatment in Hemodialysis Patients With Metastatic Renal Cell Carcinoma
A 57-year-old man underwent right radical and left partial nephrectomy to treat stage III (pT3N0M0) and stage II papillary RCC (pT2N0M0), respectively, in January 2007. Thereafter, his renal function became impaired; his blood urea nitrogen level was 88 mg/mL and his creatinine level was 8.5 mg/mL. Hemodialysis was commenced, three times a week, in May 2007. Three years later, multiple metastatic lesions appeared in the lungs. He also developed additional lymph node metastases in the retroperitoneum and multiple lesions in the liver. Biopsies of the liver masses revealed the presence of mRCC. His prognostic risk category was high, as defined by the Memorial Sloan-Kettering Cancer Center (MSKCC) risk model, with a Karnofsky performance status of 70%, a serum hemoglobin level of 12.1 mg/mL, a serum-corrected calcium level of 10.7 mg/mL, and a serum lactate dehydrogenase (LDH) concentration of 568 U/L. Twenty-five milligrams of sunitinib was administered orally, on a daily basis, for 4 weeks of every 6, commencing in July 2010. Several toxicities, including facial edema, yellowish skin pigmentation, mucositis, hypertension, and general weakness, were manageable (grades 1-2). However, no attempt was made to increase the dose because of a gradual increase in anemia (from grades 1-4) associated with a requirement for frequent packed red blood cell infusion and increasingly problematic chronic fatigue and general weakness. There was no evidence of hypothyroidism. Computed tomography conducted after two cycles of treatment showed that his disease was progressive. Sunitinib was discontinued in November 2010.