Case – Long-term remission after repeated courses of palliative radiotherapy in a patient with metastatic MiT family translocation renal cell carcinoma

AssoCIAtIon resIdents' roomCase -Long-term remission after repeated courses of palliative radiotherapy in a patient with metastatic MiT family translocation renal cell carcinoma CASE REPORT A previously healthy woman in her fourth decade presented with left flank pain and gross hematuria in the late 1990s.Computed tomographic (Ct) imaging revealed a 7x7 cm renal mass involving the upper pole of the left kidney and a 3x8 cm paraaortic lymph node without other evidence of metastases.she underwent a left nephrectomy and lymphadenectomy.pathology reported clear-cell renal cell carcinoma (rCC), Fuhrman grade 3, and the final stage was pt3bn1m0 (stage III).two years later, her cancer relapsed with nodal masses in the posterior mediastinum, retroperitoneum, and pelvis (Figure 1).Interferon-α was initiated but was discontinued after three months due to disease progression.she received palliative radiotherapy 20 gy/5 fractions (F) directed towards the recurrent disease, which had filled the entire renal bed/left flank and extended to the lower thoracic and lumbar spine.she tolerated radiotherapy well and had excellent radiological response; however, within three months, there was further progression in the left flank, and she again received radiation 20 gy/5F.she received oral Ae941 for nearly one year in a clinical trial and then her tumor progressed with bilateral t12 paravertebral masses.As this required retreatment of a previously irradiated area, she received 20gy/13F to these areas as an oblique pair going through the left flank, spine, and contralateral right sided tumor.Again, she tolerated radiotherapy well and imaging demonstrated partial regression of the left paravertebral mass and stability of a large mediastinal mass.she received gd-0039 in a phase 2 trial, which was discontinued after two months due to disease progression.Her chronic cancer pain reached crisis levels, and a pain specialist was consulted and initiated methadone and dexamethasone.restaging abdominal Ct scan reported increase in a left retroperitoneal mass, a large left paraspinal mass measuring 8 x 6 cm at level of t12, and metastases to bone with tumor infiltration into t11, t12 vertebral body and ribs, and t11/t12 foramina, encasing the aorta and extending into posterior mediastinum and left psoas muscle.she received two courses of concurrent simplified intensity-modulated arc therapy: 30 gy/10F above the diaphragm and 20 gy/10F below the diaphragm.Her pain improved, and imaging showed regression of masses in both locations.eight months later, she presented with pain in the right shoulder and imaging identified a 2x1 cm lesion in the right paravertebral area near the posterior thoracic inlet.she was treated with 40 gy/16F to the right supraclavicular area (Figure 2A).two months afterwards, she started treatment on a phase 1 clinical trial with an agonist monoclonal antibody to the trAIl receptor 2 (tr2J).After receiving one dose, she developed signs and symptoms of spinal cord compression confirmed by magnetic resonance imaging (mrI) at the t3-5 level.study therapy was discontinued, and she was treated with radiotherapy to a total dose of 21 gy/11F.symptoms resolved, and with the sponsor's permission, treatment with tr2J resumed and continued for 20 months.she developed symptoms of t12 radiculopathy, and mrI confirmed progression of disease with destruction of left side of t12 vertebral body, expansion of proximal left 12 th rib, and a new t12 paraspinal soft tissue deposit.drug therapy was stopped, and she received radiotherapy 30 gy/10F to

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