Question

My dad has a tumor in the upper and middle pole of the right kidney measuring 14 *6.9*10.5 CMS as per latest USG. 2. Likewise prostrate is also enlarged at 5 CMS. 3. The Impressions mentioned in the report include Mild Hepatocellular splenomegaly, small cyst measuring 1.7 CMS in the left lobe of liver, mass lesion in the right kidney, enlarged prostate.
4.The latest chest ray states, well defined rounded opacities in right mid zone and bilateral lower zone with a possibility of lungs metastasis.
5. He has lost 10 kgs in the last 1 year.
6. His left and right foot especially appear to be swelling now. Not sure why.
7. He wakes up 6-7 times at night to pass urine and as a result has a disturbed sleep.
8.He has been constantly having cough and pain along the lower back and spinal cord.
How do you suggest I go about?

Dr.Nikhilesh Borkar · Accepted Answer

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.

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