He would need a CT thorax to confirm the size and number of metastasis. Also a bone scan would be advisable if bone pain
or raised alkaline
phosphate level in blood. PET CT scan can be done instead of both the above investigations. MRI brain if symptomatic.
If he is asymptomatic for the lung mets and his general condition is good and tumor is resectable and not poor prognosis on IMDC criteria (based on some blood reports and contition of Patient), then I prefer to to a cytoreductive nephrectomy to decrease the tumor burden. If lung mets are the only site of mets and resectable (depending on site and number) then we prefer to resect those too in the same setting. And we keep the patient on post op surveillance.
If metastasis are unresectable then only cytoreductive nephrectomy is done. Later the patient is started on targeted therapy. If mets become amenable to metastatectomy after targeted therapy then metastatectomy can be considered at that stage. If not a candidate for cytoreductive nephrectomy then we consider targeted therapy (sunitinib
) upfront in those with good prognosis on IMDC criteria. Those who are intermediate or poor prognosis, immunotherapy with nivolumab and ipilimumab or single agent nivolumab, but it is a costly treatment (2-3 lac per month) and if non affording then we consider targeted therapy in these patients too.
Prostate symptomsof nocturia may be due to benign enlargement of prostate, which may need medication (alpha blockers with or without an androgen blocker like finasteride
) or surgical intervention like TURP. Let a urologist
evaluate the same.
The weight loss
may be related to the metastatic cancer
& the same can lead to low albumin
levels which can lead to the edema
of both feet. The cough
could be related to the lung mets. The back pain
may be a sign of bone mets, hence a bone scan or a PET CT would be useful.
If you have any doubts or need further explanation then you can contact me directly.