In this metastatic-focused tumor board case, Dr. Mark Ball of the National Cancer Institute moderates a discussion on the evaluation and management of a 62-year-old man presenting with gross hematuria, weight loss, and imaging revealing a large right renal mass with bilateral adrenal metastases and pulmonary metastases. Joining him are 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 explores how contemporary trials such as CARMENA and SURTIME have reshaped the sequencing of cytoreductive nephrectomy and systemic therapy. For this patient, the group walks through the rationale for initiating TKI–IO therapy (e.g., lenvatinib + pembrolizumab) as first-line treatment, and how disease burden and symptomatology influence the decision to defer surgery.
They also discuss scenarios where upfront nephrectomy may still be considered—including select patients with low-volume metastases, favorable histology, or those requiring palliation. The team evaluates the evolving role of SBRT to the primary tumor and metastatic sites, including its potential synergy with immunotherapy and emerging data around the abscopal effect.
Over several years of treatment, the patient’s disease stabilized except for two residual lesions—a left kidney mass and a right adrenal metastasis—prompting conversation about next steps. Options considered include additional systemic therapy, metastasis-directed SBRT, surgical removal of remaining sites of disease, and the need for biopsy confirmation before radiation.
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.
