The role of delayed cytoreductive nephrectomy following axitinib–toripalimab for the mRCC patient in current immunotherapy era: a case report and literature review

The global incidence of renal cell carcinoma (RCC) has shown a significant upward trend in recent years, with growing health inequities related to its incidence. RCC remains the most lethal urological cancer. Although with the gradual popularization of physical examination screening, an increasing number of RCC patients have been detected and treated at an early stage, approximately 30% of patients are still diagnosed with locally advanced or metastatic RCC at the time of initial diagnosis. The treatment landscape for advanced or metastatic RCC has evolved substantially with the introduction of immune checkpoint inhibitors (ICIs) combined with tyrosine kinase inhibitors (TKIs). Neoadjuvant ICI-TKI combinations may downstage primary tumors and enable deferred cytoreductive nephrectomy (CN), but evidence regarding feasibility, efficacy, and safety remains limited. We present the case of a 50-year-old man with advanced clear-cell RCC and pulmonary metastases who received three cycles of neoadjuvant axitinib plus toripalimab. The regimen resulted in marked tumor shrinkage and necrosis, allowing safe robotic-assisted deferred CN. Pathology revealed extensive necrosis with minimal viable tumor. The treatment was overall well tolerated, and the patient recovered without recurrence. This case supports the feasibility and potential efficacy of neoadjuvant axitinib plus toripalimab followed by delayed CN in selected patients. Further studies are warranted to validate this sequential strategy and optimize perioperative safety management.