title: Metastatic Renal Cell Carcinoma Presenting as Painful Chewing Successfully Treated with Combined Nivolumab and Sunitinib.
abstract: Metastatic renal cell carcinoma (RCC) to the head and neck is rare. It is the third-most common cause of distant metastasis to the head and neck, after breast cancer and lung cancer. Several drugs are available to treat metastatic RCC including high-dose interleukin and targeted therapy. Immunotherapy with nivolumab was recently approved by the US Food and Drug Administration (FDA) as a second-line treatment for patients with metastatic RCC.
  
  
  
  We present a case of metastatic RCC in a 71-year-old man with a single complaint of a 1-year history of pain while chewing food. Positron emission tomography-computed tomography showed diffuse metastatic disease. Nivolumab, off-label use before its recent FDA approval, was combined with sunitinib and resulted in an excellent and ongoing response.
  
  
  
  RCC is the third-most common cause of distant metastasis to the head and neck. The patient described in this case did not have any symptoms commonly seen in RCC, such as painless hematuria, weight loss, anorexia, fatigue, or anemia, despite the bulk of his disease. The other important aspect of this case is the almost complete response of his metastatic disease to the combination of nivolumab and sunitinib that was used off label before the FDA issued the approval. Future clinical trials should look at combining immunotherapy with targeted therapy in metastatic RCC.
authors.affiliation: Assistant Professor of Medicine in the Department of Hematology and Oncology at the University of Arkansas for Medical Sciences in Little Rock. fmahmoud@uams.edu.
authors.forename: Fade
authors.initials: F
authors.lastname: Mahmoud
authors.affiliation: Fellow in the Department of Hematology and Oncology at the University of Arkansas for Medical Sciences in Little Rock. aaabdallah@uams.edu.
authors.forename: Al-Ola
authors.initials: AO
authors.lastname: Abdallah
authors.affiliation: Associate Professor of Medicine in the Department of Hematology and Oncology at the University of Arkansas for Medical Sciences in Little Rock. karnaoutakis@uams.edu.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Arnaoutakis
authors.affiliation: Associate Professor of Medicine in the Department of Hematology and Oncology at the University of Arkansas for Medical Sciences in Little Rock. imakhoul@uams.edu.
authors.forename: Issam
authors.initials: I
authors.lastname: Makhoul
mesh_terms: D000368:Aged; D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000494:pharmacology*; D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000494:pharmacology*; D000971:Antineoplastic Combined Chemotherapy Protocols; D002292:Carcinoma, Renal Cell / Q000209:etiology*; D006801:Humans; D007211:Indoles / Q000008:administration & dosage / Q000494:pharmacology*; D007680:Kidney Neoplasms / Q000473:pathology*; D008297:Male; D008409:Mastication / Q000502:physiology*; D009362:Neoplasm Metastasis / Q000188:drug therapy; D000077594:Nivolumab; D010146:Pain; D011758:Pyrroles / Q000008:administration & dosage / Q000494:pharmacology*; D000077210:Sunitinib; D016896:Treatment Outcome; D014481:United States
chemical_list: D000911:Antibodies, Monoclonal; D000970:Antineoplastic Agents; D007211:Indoles; D011758:Pyrroles; D000077594:Nivolumab; D000077210:Sunitinib