案例報告: 晚期腎透明細胞癌於三重免疫治療後，接受減積性腎臟切除與下腔靜脈重建之顯著治療成果

葉星佐、羅浩倫

高雄長庚紀念醫院泌尿科

Case Report: Remarkable Response of Advanced Clear Cell Renal Cell Carcinoma to Triplet Immunotherapy Followed by Cytoreductive Nephrectomy and IVC Reconstruction

Hsing-Tsuo, Yeh, Hao-Lun Luo

Kaohsiung Chang Gung Memorial Hospital, Department of Urology

Introduction: The treatment landscape of advanced renal cell carcinoma (aRCC) has evolved with the integration of immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs). Landmark trials such as CheckMate 214 (Nivolumab + Ipilimumab) and CheckMate 9ER (Nivolumab + Cabozantinib) have demonstrated significant survival benefits over Sunitinib, establishing ICI-based combinations as standard first-line therapy. More recently, triplet regimens incorporating a TKI with dual ICIs have shown encouraging efficacy, particularly in patients with intermediate- or poor-risk disease. Here, we present a case of advanced poor-risk clear cell renal cell carcinoma that responded well to triplet therapy and subsequently underwent cytoreductive radical nephrectomy with IVC reconstruction, with pathology revealing only minimal residual tumor.

Case Report:  This 68-year-old male has a history of hypertension, cardiovascular disease status post percutaneous transluminal angioplasty, and right-sided hearing impairment. He presented with dull left abdominal pain for several months, accompanied by significant body weight loss since February 2024. He sought medical attention at Kaohsiung Veterans General Hospital, where a CT scan revealed a large right renal tumor measuring 16 cm, invading the right renal vein and extending beyond Gerota’s fascia to the right psoas muscle (T4). Metastatic lymph nodes in the aortocaval region were also identified (N1).

               An ultrasound-guided biopsy confirmed clear cell renal cell carcinoma (ccRCC), after which he visited our hospital for further management. Physical examination was unremarkable. Laboratory studies showed anemia (Hb 9.7 g/dL), impaired renal function (eGFR 55 mL/min), and elevated LDH (1092 U/L). According to the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) criteria, he was classified as poor risk. After discussion with the patient, combination therapy with cabozantinib, nivolumab, and ipilimumab (triplet therapy) was initiated on May 27, 2024.

               After seven courses of triplet therapy, follow-up CT on September 13, 2024 demonstrated significant regression of the primary tumor and metastatic lymph nodes. Consolidative radiotherapy was subsequently arranged. The patient then received maintenance therapy with nivolumab and cabozantinib for eight additional courses. MRI on June 25, 2025 showed further mild regression of the residual tumor.

               Following multidisciplinary discussion with the patient and the cardiovascular surgery team, cytoreductive radical nephrectomy with IVC reconstruction was performed on August 14, 2025. Pathology revealed clear cell renal cell carcinoma, pathological stage III (ypT3aNx), and papillary renal cell carcinoma, pathological stage I (pT1aNx). The specimen showed extensive necrosis with only minimal residual tumor (maximum 0.3 cm at the renal sinus microscopically). Surgical margins were clear, and no lymphovascular invasion was noted.

               The patient recovered uneventfully and was discharged on August 29, 2025. He continues regular follow-up at our outpatient department.