In this third tumor board case, Dr. Mark Ball of the National Cancer Institute moderates a multidisciplinary discussion of a 51-year-old man presenting with new right-sided testicular swelling, ultimately found to have a large right renal mass with extensive IVC tumor thrombus. He is joined by Dr. Brandon Manley (urologic oncology, Moffitt Cancer Center), Dr. Raki Hannan (radiation oncology, UT Southwestern), and Dr. Rena McKay (GU medical oncology, UC San Diego).
The panel begins by reviewing why a right-sided varicocele is clinically concerning and often prompts evaluation for retroperitoneal pathology. Imaging revealed a bulky right kidney tumor with intracaval extension extending toward the liver. The team discusses the role of biopsy, the need for multidisciplinary coordination, and indications for neoadjuvant systemic therapy to reduce tumor burden before attempting a complex resection.
The group examines the rationale for initiating TKI–IO combination therapy (e.g., axitinib + pembrolizumab) to achieve more rapid tumor shrinkage compared to IO–IO regimens. They also address the investigational role of radiation therapy in cases of major vascular invasion, potential risks, and emerging data. After several months of therapy, the patient experienced meaningful tumor reduction but also clinical complications, prompting reevaluation for surgery.
Dr. Manley describes the surgical decision-making process following systemic therapy, including the unpredictability of desmoplastic reaction, variability in pathologic response, and technical challenges of operating after prolonged immunotherapy. The episode highlights how combining multidisciplinary expertise can optimize outcomes in patients with locally advanced clear cell RCC and IVC involvement.
Contributors:
Dr. Mark Ball is an attending surgeon at the Urologic Oncology Branch of the National Cancer Institute and Associate Program Director of the Urologic Oncology Fellowship Program in Bethesda, Maryland.
Dr. Raquibul Hannan is the chief of the genitourinary radiation oncology service at UT Southwestern in Dallas, Texas.
Dr. Brandon Manley is a urologic oncologist at Moffitt Cancer Center in Tampa, Florida.
Dr. Rana McKay is a medical oncologist and associate professor at UC San Diego Health in California.
