How do you treat clear cell renal cell carcinoma with metastatic recurrence while on adjuvant pembrolizumab?

My colleagues and I recently tried to address this question in a review paper in the Kidney Cancer Journal which is worth a read.

In the absence of prospective data in this space, we provide recommendations for clinicians based on existing evidence and constructed a potential algorithm to consider....

In general, I have given very little adjuvant pembro. There have been other adjuvant IO studies in RCC which have been negative for DFS. I am eagerly awaiting the OS signal before committing to the routine use of adjuvant pembro. With respect to this question, I think the kind of progression matters...