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Staehler M, Battle D, Pal SK, Bergerot CD. Counterbalancing COVID-19 with Cancer Surveillance and Therapy: A Survey of Patients with Renal Cell Carcinoma. Eur Urol Focus 2020; 7:1355-1362. [PMID: 32943372 PMCID: PMC7486070 DOI: 10.1016/j.euf.2020.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/27/2020] [Accepted: 09/07/2020] [Indexed: 12/20/2022]
Abstract
Background While providers are challenged with treatment decisions during the coronavirus disease 2019 (COVID-19) crisis, decision making ultimately falls in the hands of patients—at present, their perspective is poorly understood. Objective To ascertain renal cell carcinoma (RCC) patients’ perspectives on COVID-19 and understand the associated implications for treatment. Design, setting, and participants An online survey of RCC patients was conducted from March 22 to March 25, 2020, disseminated through social media and patient networking platforms. The survey comprised 45 items, including baseline demographic, clinicopathologic, and treatment-related information. Patients were additionally queried regarding their anxiety level related to COVID-19 and associated implications for their cancer diagnosis. Intervention An online survey study. Outcome measurements and statistical analysis Descriptive statistics with graphical outputs were used to characterize survey results. Results and limitations A total of 539 patients (male:female 39%:58%) from 14 countries responded. Of them, 71% felt that their risk of COVID-19 infection was higher than the general population, and 27% contacted their physician to establish this. Among patients with localized disease (40%), most (42%) had scheduled surveillance scans within 6 wk–65% were unwilling to delay scans. Among patients with metastatic disease, 76% were receiving active therapy. While most patients preferred not to defer therapy (51%), patients receiving immune therapy regimens were less amenable to deferring therapy than those receiving targeted treatment (20% vs 47%). Conclusions Despite high levels of anxiety surrounding COVID-19, many patients with RCC were inclined to adhere to existing schedules of surveillance (localized disease) and systemic treatment (metastatic disease). Patient summary The coronavirus disease 2019 (COVID-19) pandemic has prompted many doctors to develop different treatment strategies for cancer and other chronic conditions. Given the importance of the patient voice in these strategies, we conducted a survey of patients with kidney cancer to determine their treatment preferences. Our survey highlighted that most patients prefer to continue their current strategies of kidney cancer treatment and monitoring.
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Procopio G, Hamberg P, Bigot P, Suarez C, Barthélémy P, Eymard JC, Masini C, Gajate Borau P, Dutailly P, Perrot V, Staehler M. 730P Interim analysis of CASSIOPE: A real-world study of cabozantinib for the treatment of advanced renal cell carcinoma (aRCC) after VEGF-targeted therapy in Europe. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Staehler M, Panic A, Goebell PJ, Merling M, Potthoff K, Herrmann E, de Geeter P, Vannier C, Hogrefe C, Marschner N, Grünwald V. First-line pazopanib in intermediate- and poor-risk patients with metastatic renal cell carcinoma: Final results of the FLIPPER trial. Int J Cancer 2020; 148:950-960. [PMID: 32738823 DOI: 10.1002/ijc.33238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 11/10/2022]
Abstract
Temsirolimus has long been the only approved first-line standard of care (SOC) with overall survival (OS) benefit in poor-risk patients with advanced or metastatic renal cell cancer (mRCC). However, tyrosine kinase inhibitors are also commonly used in clinical practice. Pazopanib is an SOC for first-line mRCC treatment, but for poor-risk patients data are scarce. The FLIPPER (First-Line Pazopanib in Poor-Risk Patients with Metastatic Renal Cell Carcinoma) study aimed to assess efficacy and safety of first-line pazopanib in poor-risk mRCC patients. FLIPPER was a single-arm, multicenter, Phase IV trial. Key inclusion criteria were treatment-naive clear cell, inoperable advanced or mRCC, poor-risk according to MSKCC with slight modification, Karnofsky performance status (KPS) ≥60% and adequate organ function. Oral pazopanib 800 mg was given daily. Primary endpoint was the 6-month progression-free survival rate (PFS6). Secondary endpoints included PFS, OS, overall response rate (ORR), duration of response (DOR) and safety. For analysis, descriptive statistics were used. Between 2012 and 2016, 60 patients had been included. Forty-three patients qualified for safety analyses, 34 for efficacy. Median age was 66 years, 64.7% of patients were poor-risk, 82.4% had a KPS ≤70%. PFS6 was 35.3% (95% CI, 19.7-53.5). Median PFS and OS were 4.5 months (95% CI, 3.6-7.8) and 9.3 months (95% CI, 6.6-22.2), respectively. ORR was 32.4% (95% CI, 17.4-50.5), median DOR 9.7 months (95% CI, 1.8-12.4). The most common treatment-related grade 3/4 adverse event reported in 4.7% of patients was hypertension. No treatment-related death occurred. Since pazopanib is active and well tolerated in poor-risk patients with clear cell mRCC, our results support its use as first-line treatment in this setting.
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Erlmeier F, Steffens S, Stöhr C, Herrmann E, Polifka I, Agaimy A, Trojan L, Ströbel P, Becker F, Wülfing C, Barth P, Stöckle M, Staehler M, Stief C, Haferkamp A, Hohenfellner M, Macher-Göppinger S, Wullich B, Noldus J, Brenner W, Roos FC, Walter B, Otto W, Burger M, Schrader AJ, Hartmann A, Ivanyi P. Characterization of PD-1 and PD-L1 Expression in Papillary Renal Cell Carcinoma: Results of a Large Multicenter Study. Clin Genitourin Cancer 2020; 19:53-59.e1. [PMID: 32778505 DOI: 10.1016/j.clgc.2020.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/27/2020] [Accepted: 07/06/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) play a decisive role as prognostic markers in clear-cell renal cell carcinoma (RCC). To date, the role of PD-1/PD-L1 as a prognostic marker in papillary RCC (pRCC) remains scarce. PATIENTS AND METHODS Patients' sample collection was a joint collaboration of the nationwide PANZAR consortium - a multicenter study. Medical history and tumor specimens were collected from 245 and 129 patients with pRCC types 1 and 2, respectively. Expression of PD-1 and PD-L1 was determined by immunohistochemistry in pRCC and tumor-infiltrating mononuclear cells. RESULTS Of 374 pRCC specimens, 204 type 1 and 97 type 2 were evaluable for PD-1 and PD-L1 expression analysis. In total, PD-1 and PD-L1 expression were found in 8 (4.9%) of 162 and 12 (7.2%) of 166 evaluable pRCC type 1 specimens. Comparably, PD-1 and PD-L1 expression were found in 2 (2.4%) of 83 and 5 (6.2%) of 81 evaluable pRCC type 2 specimens. Hardly any clinically relevant associations between PD-1 and PD-L1 positivity and clinicopathologic or clinical courses were observed, neither in pRCC type 1 nor type 2. CONCLUSION The analysis of a large pRCC cohort from a multicenter consortium revealed no impact of PD-1/PD-L1 expression on prognosis in patients with pRCC with predominantly limited disease status, neither for type 1 nor type 2. However, the impact of PD-1 and PD-L1 in more advanced pRCC disease needs further elucidation.
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Rodler S, Schott M, Tamalunas A, Marcon J, Graser A, Casuscelli J, Stief C, Fürweger C, Muacevic A, Staehler M. Safety and efficacy of Cyberknife radiosurgery for visceral and lymph node metastases of renal cell carcinoma – a retrospective, single center analysis. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abu-Ghanem Y, Fernández-Pello S, Bex A, Ljungberg B, Albiges L, Dabestani S, Giles R, Hofmann F, Hora M, Kuczyk M, Kuusk T, Marconi L, Merseburger A, Tahbaz R, Staehler M, Volpe A, Powles T, Lam T, Bensalah K. Bias of available data makes it unreliable to compare outcomes of thermo-ablation versus surgery for the treatment of T1 renal tumours: A systematic review from the European Association of Urology Renal Cell Cancer Guideline Panel. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33805-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Siva S, Correa RJM, Warner A, Staehler M, Ellis RJ, Ponsky L, Kaplan ID, Mahadevan A, Chu W, Gandhidasan S, Swaminath A, Onishi H, Teh BS, Lo SS, Muacevic A, Louie AV. Stereotactic Ablative Radiotherapy for ≥T1b Primary Renal Cell Carcinoma: A Report From the International Radiosurgery Oncology Consortium for Kidney (IROCK). Int J Radiat Oncol Biol Phys 2020; 108:941-949. [PMID: 32562838 DOI: 10.1016/j.ijrobp.2020.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Patients with larger (T1b, >4 cm) renal cell carcinoma (RCC) not suitable for surgery have few treatment options because thermal ablation is less effective in this setting. We hypothesize that SABR represents an effective, safe, and nephron-sparing alternative for large RCC. METHODS AND MATERIALS Individual patient data from 9 institutions in Germany, Australia, USA, Canada, and Japan were pooled. Patients with T1a tumors, M1 disease, and/or upper tract urothelial carcinoma were excluded. Demographics, treatment, oncologic, and renal function outcomes were assessed using descriptive statistics. Kaplan-Meier estimates and univariable and multivariable Cox proportional hazards regression were generated for oncologic outcomes. RESULTS Ninety-five patients were included. Median follow-up was 2.7 years. Median age was 76 years, median tumor diameter was 4.9 cm, and 81.1% had Eastern Cooperative Oncology Group performance status of 0 to 1 (or Karnofsky performance status ≥70%). In patients for whom operability details were reported, 77.6% were defined as inoperable as determined by the referring urologist. Mean baseline estimated glomerular filtration rate (eGFR) was 57.2 mL/min (mild-to-moderate dysfunction), with 30% of the cohort having moderate-to-severe dysfunction (eGFR <45mL/min). After SABR, eGFR decreased by 7.9 mL/min. Three patients (3.2%) required dialysis. Thirty-eight patients (40%) had a grade 1 to 2 toxicity. No grade 3 to 5 toxicities were reported. Cancer-specific survival, overall survival, and progression-free survival were 96.1%, 83.7%, and 81.0% at 2 years and 91.4%, 69.2%, 64.9% at 4 years, respectively. Local, distant, and any failure at 4 years were 2.9%, 11.1%, and 12.1% (cumulative incidence function with death as competing event). On multivariable analysis, increasing tumor size was associated with inferior cancer-specific survival (hazard ratio per 1 cm increase: 1.30; P < .001). CONCLUSIONS SABR for larger RCC in this older, largely medically inoperable cohort, demonstrated efficacy and tolerability and had modest impact on renal function. SABR appears to be a viable treatment option in this patient population.
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Patel A, Ravaud A, Motzer RJ, Pantuck AJ, Staehler M, Escudier B, Martini JF, Lechuga M, Lin X, George DJ. Neutrophil-to-Lymphocyte Ratio as a Prognostic Factor of Disease-free Survival in Postnephrectomy High-risk Locoregional Renal Cell Carcinoma: Analysis of the S-TRAC Trial. Clin Cancer Res 2020; 26:4863-4868. [PMID: 32546645 DOI: 10.1158/1078-0432.ccr-20-0704] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/28/2020] [Accepted: 06/09/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE In the S-TRAC trial, adjuvant sunitinib improved disease-free survival (DFS) compared with placebo in patients with locoregional renal cell carcinoma (RCC) at high risk of recurrence. This post hoc exploratory analysis investigated the neutrophil-to-lymphocyte ratio (NLR) for predictive and prognostic significance in the RCC adjuvant setting. EXPERIMENTAL DESIGN Kaplan-Meier estimates and Cox proportional analyses were performed on baseline NLR and change from baseline at week 4 to assess their association with DFS. Univariate P values were two-sided and based on an unstratified log-rank test. RESULTS 609 of 615 patients had baseline NLR values; 574 patients had baseline and week 4 values. Sunitinib-treated patients with baseline NLR <3 had longer DFS versus placebo (7.1 vs. 4.7; HR, 0.71; P = 0.02). For baseline NLR ≥3, DFS was similar regardless of treatment (sunitinib 6.8 vs. placebo not reached; HR, 1.03; P = 0.91). A ≥25% NLR decrease at week 4 was associated with longer DFS versus no change (6.8 vs. 5.3 years; HR, 0.71; P = 0.01). A greater proportion of sunitinib-treated patients had ≥25% NLR decrease at week 4 (71.2%) versus placebo (17.4%). Patients with ≥25% NLR decrease at week 4 received a higher median cumulative sunitinib dose (10,137.5 mg) versus no change (8,168.8 mg) or ≥25% increase (6,712.5 mg). CONCLUSIONS In the postnephrectomy high-risk RCC patient cohort, low baseline NLR may help identify those most suitable for adjuvant sunitinib. A ≥25% NLR decrease at week 4 may be an early indicator of those most likely to tolerate treatment and derive DFS benefit.
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Rodler S, Apfelbeck M, Schulz GB, Ivanova T, Buchner A, Staehler M, Heinemann V, Stief C, Casuscelli J. Telehealth in Uro-oncology Beyond the Pandemic: Toll or Lifesaver? Eur Urol Focus 2020; 6:1097-1103. [PMID: 32534969 PMCID: PMC7286644 DOI: 10.1016/j.euf.2020.05.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/26/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Telehealth services are rapidly embraced in uro-oncology due to the current coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE To determine patients' perspective on adoption of telehealth as a response to the pandemic and its sustainability in the future. DESIGN, SETTING, AND PARTICIPANTS Following a COVID-19 outbreak, 101 patients with advanced genitourinary cancers are currently managed "virtually" for therapy administration at our tertiary care unit. They were surveyed about the current situation, and current and long-term employment of telehealth. INTERVENTION Rapid implementation of virtual patient management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Patients' perception of anxiety of COVID-19 and cancer, perspective on telehealth measures as a reaction to the current COVID-19 pandemic, and long-term acceptance were used as outcomes. Wilcoxon matched-pair signed rank test, chi-square test, and Mann-Whitney U test were performed. RESULTS AND LIMITATIONS Of 101 patients, 92 answered the questionnaire, with 71 (77.2%) responding virtually by e-mail or phone call. Anxiety of cancer (6/10, interquartile range [IQR] 3-8) superseded that of COVID-19 (four/10, IQR 2-5.25, p<0.001), and patients oppose temporary treatment interruption. Of the patients, 66.0% perceive their susceptibility to COVID-19 as equal to or lower than the general population and 52.2% believe that COVID-19 will not affect their therapy. In future, patients (62.6%) prefer to maintain in-person appointments as opposed to complete remote care, but accept remote care during the pandemic (eight/10, IQR 5-9). Beyond the crisis, maintaining telehealth has low preference rates (four/10, IQR 2-7), with high acceptance for external laboratory controls (60.9%) and online visit management (48.9%), but lower acceptance for remote treatment planning including staging discussions (44.6%) and for referral to secondary care oncologists (17.4%). CONCLUSIONS Despite the pandemic, cancer remains the key concern and patients are not willing to compromise on their treatment. Rapid implementation of telehealth is tolerated well during the need of social distancing, with a clear "red line" concerning changes in existing patient-physician relationships. Balancing future implementation of telehealth while considering patients' demand for personal relationships will ensure human dignity in uro-oncology. PATIENT SUMMARY We queried patients with genitourinary cancers treated in an almost virtual setting following a local coronavirus outbreak. Acceptance of telehealth during the current situation is high; however, long-term implementation of the adapted services is less favored. We deduce that patient-physician relationship is crucial for cancer patients and needs to be balanced against measures for social distancing to forge the future management.
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Mumm JN, Osterman A, Ruzicka M, Stihl C, Vilsmaier T, Munker D, Khatamzas E, Giessen-Jung C, Stief C, Staehler M, Rodler S. Urinary Frequency as a Possibly Overlooked Symptom in COVID-19 Patients: Does SARS-CoV-2 Cause Viral Cystitis? Eur Urol 2020; 78:624-628. [PMID: 32475747 PMCID: PMC7236674 DOI: 10.1016/j.eururo.2020.05.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/12/2020] [Indexed: 01/21/2023]
Abstract
The current coronavirus disease 2019 (COVID-19) pandemic is a challenge for physicians in triaging patients in emergency rooms. We found a potentially dangerous overlap of classical urinary symptoms and the as yet not fully described symptoms of COVID-19. After a patient was primarily triaged as a urosepsis case and then subsequently diagnosed with COVID-19, we focused on an increase in urinary frequency as a symptom of COVID-19 and identified this in seven males out of 57 patients currently being treated in our COVID-19 wards. In the absence of any other causes, urinary frequency may be secondary to viral cystitis due to underlying COVID-19 disease. We propose consideration of urinary frequency as an anamnestic tool in patients with infective symptoms to increase awareness among urologists during the current COVID-19 pandemic to prevent fatal implications of misinterpreting urological symptoms.
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Mittlmeier LM, Unterrainer M, Todica A, Clevert DA, Cyran CC, Schmoeckel E, Rodler S, Bartenstein P, Stief CG, Ilhan H, Staehler M. Advanced Molecular Imaging in Histologically Verified Metanephric Adenoma. Urology 2020; 140:e10-e11. [PMID: 32171695 DOI: 10.1016/j.urology.2020.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/22/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
Metanephric adenoma (MA) describes a rare renal tumor and is generally considered a benign lesion. However, there are cases with regional lymphogenic and distant metastases. Noninvasive diagnosis of MA using conventional imaging remains challenging. Here, we describe a case of histologically verified MA with additional advanced molecular imaging consisting of 18F-PSMA-1007 PET/CT, 99mTc-Sestamibi SPECT and contrast-enhanced ultrasound.
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Abu-Ghanem Y, Fernández-Pello S, Bex A, Ljungberg B, Albiges L, Dabestani S, Giles RH, Hofmann F, Hora M, Kuczyk MA, Kuusk T, Marconi L, Merseburger AS, Tahbaz R, Staehler M, Volpe A, Powles T, Lam TB, Bensalah K. Limitations of Available Studies Prevent Reliable Comparison Between Tumour Ablation and Partial Nephrectomy for Patients with Localised Renal Masses: A Systematic Review from the European Association of Urology Renal Cell Cancer Guideline Panel. Eur Urol Oncol 2020; 3:433-452. [PMID: 32245655 DOI: 10.1016/j.euo.2020.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/03/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023]
Abstract
The European Association of Urology (EAU) Renal Cell Carcinoma (RCC) Guideline Panel performed a protocol-driven systematic review (SR) on thermal ablation (TA) compared with partial nephrectomy (PN) for T1N0M0 renal masses, in order to provide evidence to support its recommendations. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed, and only comparative studies published between 2000 and 2019 were included. Twenty-six nonrandomised comparative studies were included, recruiting a total of 167 80 patients. Risk of bias (RoB) assessment revealed high or uncertain RoB across all studies, with the vast majority being retrospective, observational studies with poorly matched controls and short follow-up. Limited data showed TA to be safe, but its long-term oncological effectiveness compared with PN remains uncertain. A quality assessment of pre-existing SRs (n=11) on the topic, using AMSTAR, revealed that all SRs had low confidence rating, with all but two SRs being rated critically low. In conclusion, the current data are inadequate to make any strong and clear conclusions regarding the clinical effectiveness of TA for treating T1N0M0 renal masses compared with PN. Therefore, TA may be cautiously considered an alternative to PN for T1N0M0 renal masses, but patients must be counselled carefully regarding the prevailing uncertainties. We recommend specific steps to improve the evidence base based on robust primary and secondary studies. PATIENT SUMMARY: In this report, we looked at the literature to determine the effectiveness of thermoablation (TA) in the treatment of small kidney tumours compared with surgical removal. We found that TA could cautiously be offered as an option due to many remaining uncertainties regarding its effectiveness.
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de Bruijn R, Wimalasingham A, Szabados B, Stewart GD, Welsh SJ, Kuusk T, Blank C, Haanen J, Klatte T, Staehler M, Powles T, Bex A. Deferred Cytoreductive Nephrectomy Following Presurgical Vascular Endothelial Growth Factor Receptor-targeted Therapy in Patients with Primary Metastatic Clear Cell Renal Cell Carcinoma: A Pooled Analysis of Prospective Trial Data. Eur Urol Oncol 2020; 3:168-173. [PMID: 31956080 DOI: 10.1016/j.euo.2019.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/29/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cancer du Rein Métastatique Nephrectomie et Antiangiogéniques (CARMENA) concluded that sunitinib alone is not inferior to cytoreductive nephrectomy (CN) followed by vascular endothelial growth factor receptor tyrosine kinase inhibitors (VEGFR-TKIs) in patients with metastatic renal cell carcinoma. It remains uncertain whether deferred CN is beneficial in this setting. OBJECTIVE The aim of this study was to compare outcome in patients treated with presurgical VEGFR-TKI followed by CN (deferred CN) with that in patients receiving CN followed by VEGFR-TKI (upfront CN). DESIGN, SETTING, AND PARTICIPANTS Pooled data from prospective trials in which a strategy of deferred CN in the absence of disease progression was investigated were compared with a retrospective dataset of upfront CN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Overall survival (OS) in the Memorial Sloan-Kettering Cancer Center (MSKCC) intermediate-risk group. RESULTS AND LIMITATIONS Patients were treated between 2006 and 2016. In the MSKCC intermediate-risk group, 144 patients with a strategy of deferred CN after systemic therapy were compared with 131 patients treated with upfront CN. OS in the deferred cohort was 33.0 mo (95% confidence interval [CI] 25.0-51.0) compared with 22.8 mo (95% CI 17.9-30.6) after upfront CN (hazard ratio 0.72 [95% CI 0.52-0.996], p = 0.047). This study is limited by retrospective comparison of data, subgroup analysis, and a lack of intention-to-treat data for the upfront CN cohort. CONCLUSIONS In MSKCC intermediate-risk patients, a strategy of deferred CN in the absence of progression yields OS, which compares favourably with upfront CN and published trial data from CARMENA. This warrants a formal individual patient data analysis of CARMENA, SURTIME, and single-arm prospective studies to define the role and timing of deferred CN in intermediate-risk patients. PATIENT SUMMARY In this study, we report outcomes in patients with metastatic renal cell cancer treated with targeted therapy followed by nephrectomy, which compared favourably with nephrectomy followed by targeted therapy and results from published studies.
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Staehler M, Spek AK, Rodler S, Schott M, Casuscelli J, Mittelmeier L, Schlemmer M. Real-World Results from One Year of Therapy with Tivozanib. KIDNEY CANCER 2019. [DOI: 10.3233/kca-190073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Staehler M, Motzer RJ, George DJ, Pandha HS, Donskov F, Escudier B, Pantuck AJ, Patel A, DeAnnuntis L, Bhattacharyya H, Ramaswamy K, Zanotti G, Lin X, Lechuga M, Serfass L, Paty J, Ravaud A. Adjuvant sunitinib in patients with high-risk renal cell carcinoma: safety, therapy management, and patient-reported outcomes in the S-TRAC trial. Ann Oncol 2019; 29:2098-2104. [PMID: 30412222 PMCID: PMC6247664 DOI: 10.1093/annonc/mdy329] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Adjuvant sunitinib has significantly improved disease-free survival versus placebo in patients with renal cell carcinoma at high risk of recurrence post-nephrectomy (hazard ratio 0.76; 95% confidence interval, 0.59–0.98; two-sided P = 0.03). We report safety, therapy management, and patient-reported outcomes for patients receiving sunitinib and placebo in the S-TRAC trial. Patients and methods Patients were stratified by the University of California, Los Angeles Integrated Staging System and Eastern Cooperative Oncology Group performance status score, and randomized (1 : 1) to receive sunitinib (50 mg/day) or placebo. Single dose reductions to 37.5 mg, dose delays, and dose interruptions were used to manage adverse events (AEs). Patients’ health-related quality of life, including key symptoms typically associated with sunitinib, were evaluated with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). Results Patients maintained treatment for 9.5 (mean, SD 4.4) and 10.3 (mean, SD 3.7) months in the sunitinib and placebo arms, respectively. In the sunitinib arm, key AEs occurred ∼1 month (median) after start of treatment and resolved within ∼3.5 weeks (median). Many (40.6%) AEs leading to permanent discontinuation were grade 1/2, and most (87.2%) resolved or were resolving by 28 days after last treatment. Patients taking sunitinib showed a significantly lower EORTC QLQ-C30 overall health status score versus placebo, although this reduction was not clinically meaningful. Patients reported symptoms typically related to sunitinib treatment with diarrhea and loss of appetite showing clinically meaningful increases. Conclusions In S-TRAC, AEs were predictable, manageable, and reversible via dose interruptions, dose reductions, and/or standard supportive medical therapy. Patients on sunitinib did report increased symptoms and reduced HRQoL, but these changes were generally not clinically meaningful, apart from appetite loss and diarrhea, and were expected in the context of known sunitinib effects. Clinical trial registration ClinicalTrials.gov, NCT00375674.
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Staehler M, Goebell PJ, Müller L, Emde TO, Wetzel N, Kruggel L, Jänicke M, Marschner N. Rare patients in routine care: Treatment and outcome in advanced papillary renal cell carcinoma in the prospective German clinical RCC-Registry. Int J Cancer 2019; 146:1307-1315. [PMID: 31498894 PMCID: PMC7003963 DOI: 10.1002/ijc.32671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/15/2019] [Accepted: 07/30/2019] [Indexed: 12/27/2022]
Abstract
Non‐clear cell renal cell carcinoma is a very rare malignancy that includes several histological subtypes. Each subtype may need to be addressed separately regarding prognosis and treatment; however, no Phase III clinical trial data exist. Thus, treatment recommendations for patients with non‐clear cell metastatic RCC (mRCC) remain unclear. We present first prospective data on choice of first‐ and second‐line treatment in routine practice and outcome of patients with papillary mRCC. From the prospective German clinical cohort study (RCC‐Registry), 99 patients with papillary mRCC treated with systemic first‐line therapy between December 2007 and May 2017 were included. Prospectively enrolled patients who had started first‐line treatment until May 15, 2016, were included into the outcome analyses (n = 82). Treatment was similar to therapies used for clear cell mRCC and consisted of tyrosine kinase inhibitors, mechanistic target of rapamycin inhibitors and recently checkpoint inhibitors. Median progression‐free survival from start of first‐line treatment was 5.4 months (95% confidence interval [CI], 4.1–9.2) and median overall survival was 12.0 months (95% CI, 8.1–20.0). At data cutoff, 73% of the patients died, 6% were still observed, 12% were lost to follow‐up, and 9% were alive at the end of the individual 3‐year observation period. Despite the lack of prospective Phase III evidence in patients with papillary mRCC, our real‐world data reveal effectiveness of systemic clear cell mRCC therapy in papillary mRCC. The prognosis seems to be inferior for papillary compared to clear cell mRCC. Further studies are needed to identify drivers of effectiveness of systemic therapy for papillary mRCC. What's new? Over the past decade, the treatment landscape for locally advanced or metastatic renal cell carcinoma (mRCC) has dramatically changed. To date, however, guideline recommendations mainly address patients with clear cell mRCC, due to a lack of prospective Phase III evidence for the rarer, non‐clear cell mRCC subtypes. This is the first longitudinal, prospective cohort study evaluating treatment and survival of patients with papillary mRCC outside a prospective clinical trial setting. The presented real‐world data help bridge the evidence gap by revealing the frequent use and effectiveness of systemic clear cell mRCC therapy in papillary mRCC, with a seemingly inferior prognosis.
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Correa RJM, Louie AV, Zaorsky NG, Lehrer EJ, Ellis R, Ponsky L, Kaplan I, Mahadevan A, Chu W, Swaminath A, Hannan R, Onishi H, Teh BS, Muacevic A, Lo SS, Staehler M, Siva S. Reply to Francesco Montorsi, Alessandro Larcher, and Umberto Capitanio's Letter to the Editor re: Rohann J.M. Correa, Alexander V. Louie, Nicholas G. Zaorsky, et al. The Emerging Role of Stereotactic Ablative Radiotherapy for Primary Renal Cell Carcinoma: A Systematic Review and Meta-Analysis. Eur Urol Focus. 2019 Jun 24. pii: S2405-4569(19)30157-9. https://doi.org/10.1016/j.euf.2019.06.002. [Epub ahead of print]. Eur Urol Focus 2019; 7:404-405. [PMID: 31679868 DOI: 10.1016/j.euf.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
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Ravaud A, Martini JF, Ching K, Staehler M, Magheli A, Escudier B, Mu X, Valota O, Lin X, Motzer R. Phase III trial of adjuvant sunitinib in patients with high-risk renal cell carcinoma: Comprehensive tumour genomic and transcriptomic analyses. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz249.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Correa RJ, Siva S, Warner A, Staehler M, Gandhihassan S, Ponsky L, Ellis R, Kaplan I, Mahadevan A, Chu W, Swaminath A, Onishi H, Teh BS, Lo SS, Muacevic A, Louie AV. 19 Stereotactic Body Radiotherapy for Large Primary Large Renal Cell Carcinoma: A Report from the International Radiosurgery Oncology Consortium for Kidney (IROCK). Radiother Oncol 2019. [DOI: 10.1016/s0167-8140(19)33248-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rodler S, Buchner A, Schott M, Schulz G, Stief C, Staehler M, Casuscelli J. Patient’s perspective on digital biomarkers in advanced urologic malignancies. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz239.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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71
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Goebell P, Mueller L, Grüllich C, Reichert D, Bögemann M, Dörfel S, von der Heyde E, Binninger A, Jänicke M, Merling M, Marschner N, Staehler M, Grünwald V. Advanced renal cell carcinoma: First results from the prospective research platform CARAT for patients with mRCC in Germany. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz249.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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72
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Ziegelmueller BK, Spek A, Szabados B, Casuscelli J, Buchner A, Stief C, Staehler M. Partial Nephrectomy in pT3a Tumors Less Than 7 cm in Diameter Has a Superior Overall Survival Compared to Radical Nephrectomy. Cureus 2019; 11:e5781. [PMID: 31723540 PMCID: PMC6825485 DOI: 10.7759/cureus.5781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/27/2019] [Indexed: 12/30/2022] Open
Abstract
Objectives We conducted this study to analyze the survival rates of patients with advanced renal tumors <7 cm in diameter treated surgically by partial nephrectomy (PN) compared to those who received radical nephrectomy (RN). Material and methods We retrospectively analyzed clinical data from 55 consecutive patients from our institutional database with T3a renal cell carcinoma of <7 cm treated surgically either by PN (n = 38) or RN (n = 17) in the Department of Urology of Ludwig Maximilians University from January 2006 to August 2014. The overall survival (OS) rates were calculated according to Kaplan-Meier estimation. Results The median age of the population was 67.9 years (range: 39.4 to 87.9 years). The median blood loss was 164.1 ml (range: 0 to 1200 ml), and the median clamping time was 8.85 minutes (range: 0 to 38 minutes). On average, the surgery lasted for 118 minutes (range: 40 to 210 minutes). The median serum creatinine level measured was 1.2 mg/dl (range: 0.7 to 2.3 mg/dl) preoperatively, and 1.4 mg/dl (range: 0.7 to 4.3 mg/dl) postoperatively. The median creatinine serum level measured during follow up was 1.4 ng/ml in individuals with a PN (range: 0.7 to 3.2 ng/ml), and 1.5 ng/ml in those with an RN (range: 0.9 to 4.3 ng/ml). Patients with an RN had a median OS of 38.6 months (range: 0 to 63.3 months). The median OS for patients with a PN was not reached after a follow-up of 80 months. The difference in OS in patients with PN and RN was statistically significant (P < 0.005). Conclusion Performing a PN in T3a tumors leads to better survival rates compared to an RN. In tumors <7cm, cT3a does not seem to be a contraindication for a PN. Further data should be analyzed to prove this survival benefit in a larger, multi-institutional cohort.
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Rodler S, Weig T, Finkenzeller C, Stief C, Staehler M. Fournier´s Gangrene Under Sodium-Glucose Cotransporter 2 Inhibitor Therapy as a Life-Threatening Adverse Event: A Case Report and Review of the Literature. Cureus 2019; 11:e5778. [PMID: 31723537 PMCID: PMC6825492 DOI: 10.7759/cureus.5778] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/26/2019] [Indexed: 12/21/2022] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a relatively new class of oral antidiabetic drugs. The US FDA has recently published a new warning about the safety of SGLT2 inhibitor administration in type 2 diabetes mellitus patients. There is an emerging evidence of an increased risk for developing Fournier´s gangrene (FG; a life-threatening complication) while under SGLT2 therapy. However, there are only three case reports and a total of 55 patients reported by the FDA to date. Therefore, there is a lack of evidence-based treatment algorithms for clinicians. We present the case of a 39-year-old male patient with diabetes on oral dapagliflozin, metformin, and sitagliptin therapy who was admitted with FG to our hospital. Following emergency scrotal surgery, he had to be transferred to the intensive care unit due to respiratory and circulatory insufficiency. After a prolonged 27-day hospital stay with delirium, blood glucose imbalance, and five further surgical interventions, the patient was stabilized and discharged. Dapagliflozin was discontinued permanently. This case demonstrates the risks of SGLT2 inhibitor therapy and the importance of early discontinuation after the occurrence of severe adverse events such as FG. According to the evidence in the literature, deranged glucose levels before admission are a common risk factor. However, further studies are required to identify patients at risks for FG and to investigate a direct connection with SGLT2 inhibitors.
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Ziegelmüller BK, Spek A, Szabados B, Casuscelli J, Clevert DA, Staehler M. [Epidemiology and diagnostic assessment of small renal masses]. Urologe A 2019; 57:274-279. [PMID: 29460170 DOI: 10.1007/s00120-018-0585-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The incidence of small renal masses has been rising over the last few decades. At the same time, mortality of renal cell carcinoma (RCC) is decreasing. These trends can be explained by the availability of improved therapeutic measures and the good prognosis of small renal masses (SRM) turning out to be histopathologically benign or of low malignancy in many cases. OBJECTIVES The aim of this article is to present epidemiology and diagnostic assessment of SRM. MATERIALS AND METHODS Statistics, basic research, guidelines. RESULTS The incidence of SRM is rising due to the widespread use of imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and contrast-enhanced ultrasound (CEUS). Sensitivity is excellent for CEUS and for CECT in the characterization of SRM, while good specificity values can be reached by MRI. For characterization of complex cystic renal masses, CEUS has good diagnostic accuracy. CONCLUSIONS Due to improved diagnostic possibilities, SRMs can be diagnosed in early asymptomatic stages. As SRM have a good prognosis and often are of low malignancy therapy, options should be carefully considered; especially in older patients, active surveillance should considered.
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Marcon J, Graser A, Horst D, Casuscelli J, Spek A, Stief CG, Reiser MF, Rübenthaler J, Buchner A, Staehler M. Papillary vs clear cell renal cell carcinoma. Differentiation and grading by iodine concentration using DECT—correlation with microvascular density. Eur Radiol 2019; 30:1-10. [DOI: 10.1007/s00330-019-06298-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/12/2019] [Accepted: 06/03/2019] [Indexed: 10/26/2022]
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