Doxorubicin and ifosfamide in patients with metastatic sarcomatoid renal cell carcinoma: a phase II study of the Genitourinary Group of the French Federation of Cancer Centers

Complete Response to Adriamycin and Ifosfamide in a Patient With Sarcomatoid Renal Cell Carcinoma

Sarcomatoid renal cell carcinoma (SRCC) is a heterogeneous disease with generally unreliable response to various therapies in clinical studies. We illustrate a case report in which a woman with metastatic SRCC had a complete and durable response to adriamycin and ifosfamide chemotherapy. We find this to be incongruous with expectations from some recently published data. It underscores the fact that the biology of SRCC needs to be studied in more detail for further subcataloging of the disease into diverse prognostic categories.

Active chemotherapy for sarcomatoid and rapidly progressing renal cell carcinoma

BACKGROUND

Immunotherapy is generally ineffective in patients with sarcomatoid renal cell carcinoma (RCC) and in patients with rapidly progressive metastatic or locally recurrent disease, with a median time to progression of approximately 2 months and a median survival of 4-7 months. Gemcitabine-based regimens have modest antitumor activity, whereas doxorubicin is often used to treat sarcomatoid RCC. Based on the antitumor activity of doxorubicin and gemcitabine in collecting duct carcinoma of the kidney, the authors used this combination to treat selected patients with sarcomatoid or rapidly progressing RCC.

METHODS

Eighteen patients (11 males and 7 females; median age, 53 years; range, 31-81 years) with RCC (56% sarcomatoid; 44% other) were treated at 2 institutions in a collaborative study that was not institutional review board reviewed. Seven patients received previous treatment with interferon or interleukin-2. Sites of metastases included the lung, soft tissue, bone, liver, and brain with 88% of patients having > or = 3 sites of disease. Treatment consisted of doxorubicin (50 mg/m2) and gemcitabine (1500 or 2000 mg/m2) every 2-3 weeks with granulocyte-colony-stimulating factor support.

RESULTS

A median of 5 courses was administered (range, 2-12 cycles). Therapy was well tolerated with no Grade 4 toxicities. Two patients had a complete response, five had a partial response, three had a mixed response, and one had stable disease. The median duration of response was 5 months (range, 2-21+ months).

CONCLUSIONS

These data suggested that the combination of doxorubicin and gemcitabine has antitumor activity in patients with sarcomatoid RCC or with rapidly progressing RCC. A prospective investigation of this combination in RCC is warranted.

C-KIT EXPRESSION IN SARCOMATOID RENAL CELL CARCINOMA: POTENTIAL THERAPY WITH IMATINIB

PURPOSE

Sarcomatoid (S) renal cell carcinoma (RCC) is an uncommon subtype of RCC with a poor prognosis because of its local aggressiveness and high metastatic rate. Currently, there is no specific, effective treatment for it. A relatively nontoxic tyrosine kinase inhibitor, imatinib (STI-571) has been approved as a target therapy in neoplasms that express c-Kit. We investigated c-Kit expression in this type of tumor, which to our knowledge has not been previously described.

MATERIALS AND METHODS

We reviewed 215 cases of RCC diagnosed at our department from 1995 to 2002. Of the cases 20 (9.3%) were SRCC. Formalin fixed, paraffin embedded material was available in 19 cases. We performed immunohistochemical staining against c-Kit using rabbit polyclonal antihuman antibody (CD117, Dako Corp., Carpinteria, California), diluted 1:100. Its expression was evaluated in the epithelial and the spindle components.

RESULTS

Two of the 20 SRCC cases (10%) showed no epithelial differentiation. The epithelial component was conventional RCC in 10 cases (50%), papillary RCC in 5 (25%) and chromophobe RCC in 3 (15%). A total of 16 cases (80%) presented at an advanced stage at diagnosis, namely T3 or T4 and/or metastatic disease. Immunohistochemical study showed positivity in the epithelial component only in the 3 chromophobe SRCCs. The sarcomatoid component was positive for c-Kit in 18 cases (94.7%).

CONCLUSIONS

High c-Kit expression in SRCC in our series and the existence of a target therapy, imatinib (STI-571), against cells that express this receptor open the possibility of using this treatment for these tumors, especially in cases of advanced disease.