Nivolumab plus Ipilimumab versus Sunitinib in Advanced Renal-Cell Carcinoma

Spontaneous Dramatic Regression of Clear Cell Renal Cell Carcinoma After Pazopanib-Induced Severe Systemic Inflammatory Syndrome: A Case Report and Literature Review

Renal cell carcinoma (RCC) is the most common type of kidney cancer, accounting for a significant proportion of all cancer cases in Korea. This case report presents a unique instance of spontaneous dramatic tumor regression in a 42-year-old Korean male diagnosed with clear cell RCC. The patient initially presented with right lower back pain, weight loss, and a loss of appetite. Following systemic immunotherapy with nivolumab and ipilimumab, and right radical nephrectomy, the patient was diagnosed with metastatic clear cell RCC, with new metastatic lesions detected in the liver, and on the chest wall on follow-up imaging. Second-line systemic treatment with pazopanib was initiated. Shortly thereafter, the patient developed severe systemic inflammatory syndrome, resulting in a mental stupor and acute kidney failure. Intensive care, including continuous renal replacement therapy and high-dose immunosuppressants, was administered. The patient's condition improved significantly with the intensive care regimen, leading to unintended tumor regression. These potentially fatal side effects occurred without infection, as confirmed by negative blood and urine cultures, and were attributed to the recent introduction of pazopanib. Follow-up imaging showed a significant reduction in hepatic metastatic lesions and the disappearance of chest wall nodules. This is the first reported case of RCC tumor regression following the side effects of pazopanib, underscoring the need for further studies into the immune mechanisms involved in RCC treatment and highlighting potential therapeutic strategies that leverage innate immune responses.

Revealing the mechanisms and therapeutic potential of immune checkpoint proteins across diverse protein families

Host immune responses to antigens are tightly regulated through the activation and inhibition of synergistic signaling networks that maintain homeostasis. Stimulatory checkpoint molecules initiate attacks on infected or tumor cells, while inhibitory molecules halt the immune response to prevent overreaction and self-injury. Multiple immune checkpoint proteins are grouped into families based on common structural domains or origins, yet the variability within and between these families remains largely unexplored. In this review, we discuss the current understanding of the mechanisms underlying the co-suppressive functions of CTLA-4, PD-1, and other prominent immune checkpoint pathways. Additionally, we examine the IgSF, PVR, TIM, SIRP, and TNF families, including key members such as TIGIT, LAG-3, VISTA, TIM-3, SIRPα, and OX40. We also highlight the unique dual role of VISTA and SIRPα in modulating immune responses under specific conditions, and explore potential immunotherapeutic pathways tailored to the distinct characteristics of different immune checkpoint proteins. These insights into the unique advantages of checkpoint proteins provide new directions for drug discovery, emphasizing that emerging immune checkpoint molecules could serve as targets for novel therapies in cancer, autoimmune diseases, infectious diseases, and transplant rejection.

The prognostic value of the haemoglobin/red cell distribution width ratio in a cohort of pre-treated patients with renal cell carcinoma receiving nivolumab

BACKGROUND

Metastatic renal cell carcinoma (mRCC) has a dismal prognosis. Effective prognostic and predictive factors are needed. A higher haemoglobin (Hb) / red cell distribution width (RDW) ratio is known to be related to better outcomes. Here we evaluated the prognostic value of the Hb/RDW ratio in pre-treated mRCC patients receiving nivolumab.

MATERIAL AND METHODS

This is a sub-analysis of the retrospective Meet-URO 15 study, on pre-treated patients with mRCC, receiving nivolumab. The first objective was to investigate the prognostic role of Hb/RDW ratio, in terms of overall survival (OS) and progression-free survival (PFS).

RESULTS

356 were included in the present analysis. Patients were mainly males with a median age of 63 years. We classified patients in high and low Hb/RDW ratio, according to two different cut-offs: 0.9frequently used in literature, and 0.7, result of the time-dependent AUC analysis.. Median OS and PFS were 22.3 months (95 %CI 19.4-29.0) and 5.6 months (95 %CI 4.74.-7.53), respectively. At univariable analysis, higher Hb/RDW ratio was related to longer OS (p < 0.001) and PFS (p = 0.011); the multivariable model confirmed only the association between a Hb/RDW ratio ≥ 0.7 and better OS.

CONCLUSIONS

The Hb/RDW ratio is a manageable and practical prognostic tool in patients with cancer; its prognostic value for OS was confirmed in pre-treated mRCC patients, receiving nivolumab, only using a cut-off value derived from a time-dependent AUC.

Validation of five prognostic models treated with axitinib beyond first-line nivolumab plus ipilimumab therapy for metastatic renal cell carcinoma: a Japanese multicenter retrospective study

OBJECTIVE

To validate multiple prognostic models in metastatic renal cell carcinoma patients who received second-line axitinib following first-line nivolumab plus ipilimumab therapy.

METHODS

Five prognostic models (ACL, albumin, C-reactive protein, and lactate dehydrogenase; IMDC, International Metastatic Renal Cell Carcinoma Database Consortium; MSKCC, Memorial Sloan Kettering Cancer Center; ATP, axitinib treatment prediction; JMRC, Japanese metastatic renal cancer) to predict overall survival (OS) were validated and compared using data from 86 metastatic renal cell carcinoma patients who received second-line axitinib therapy following first-line nivolumab plus ipilimumab therapy at 34 hospitals affiliated with the Japan Urologic Oncology Group.

RESULTS

The Karnofsky performance status, time from initial diagnosis to first-line therapy, and hemoglobin, platelet, albumin, and C-reactive protein levels correlated with OS in univariate Cox regression analyses. Among these factors, only albumin had a significant impact on OS in the multivariate analysis. The integrated area under the curve (AUC) of the ACL, IMDC, MSKCC, ATP, and JMRC models were 0.78, 0.76, 0.76, 0.69, and 0.70, respectively. The ACL model showed a higher value than the others in the time-dependent AUC.

CONCLUSIONS

The accuracy of the five prognostic models (ACL, IMDC, MSKCC, ATP, and JMRC) created in the pre-immuno-oncology (IO) treatment cohort was maintained in the second-line axitinib group after nivolumab plus ipilimumab therapy. The ACL model demonstrated moderate accuracy in predicting OS with the fewest number of clinical variables.

Pathologic Response to Immunotherapy is Associated with Survival in Patients Undergoing Delayed Nephrectomy for Metastatic Renal Cell Carcinoma

Introduction

The role of consolidative nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) patients treated with immune checkpoint inhibitors (ICIs) remains unknown. As patients derive variable benefit from immunotherapy (IO), understanding how treatment response correlates with long-term outcomes could inform patient surgical selection. We thus conducted a retrospective study to evaluate whether radiographic and pathologic tumor responses after immunotherapy are associated with survival in patients undergoing CN at a high-volume academic center.

Methods

We identified mRCC patients treated with at least one IO-containing regimen followed by CN between 2015 and 2024. Radiographic response was assessed using RECIST. Pathologic response was measured using percent residual viable tumor (RVT), with major pathologic response (MPR) defined as RVT <10%. Outcomes included progression-free (PFS) and overall survival (OS), analyzed using Cox proportional hazards models.

Results

Sixty patients underwent CN after immunotherapy. Median time to nephrectomy was 9 months (IQR: 7, 14) and 2-year OS was 75% (95% CI: 60-85). Fifteen patients (26%) had an MPR and 21 patients (35%) had a radiographic response of the primary tumor. Radiographic response was moderately correlated with RVT (Spearman correlation 0.51, p <0.001) and was protective but not significantly associated with PFS or OS. MPR was significantly associated with PFS (HR: 0.05, 95% CI: 0.01-0.41; p=0.005) and OS (HR: 0.07, 95% CI: 0.01-0.88; p=0.04).

Conclusion

Patients with MPR at nephrectomy had longer PFS and OS. Pathologic response may help guide post-nephrectomy treatment timing and sequencing, though future efforts should further validate the utility of post-IO pathologic endpoints.

First-Line Ipilimumab with Nivolumab versus Immune Checkpoint Inhibitors with Tyrosine Kinase Inhibitors in Patients with Intermediate- or Poor-Risk Metastatic Clear Cell Renal Cell Carcinoma

Ipilimumab with nivolumab (Ipi + Nivo) and immune checkpoint inhibitors with tyrosine kinase inhibitors (ICI + TKI) are the first-line approved treatments for intermediate- and poor-risk metastatic clear cell renal cell carcinoma (mccRCC); however, they have not been compared head-to-head in prospective trials to guide treatment selection. Thereupon, we sought to compare survival outcomes of patients receiving first-line Ipi + Nivo versus ICI + TKI, using a large, real-world database among patients with intermediate- and poor-risk mccRCC. This retrospective cohort study used a nationwide electronic health record-derived deidentified database, where patients with mccRCC with intermediate- or poor-risk who received first-line Ipi + Nivo or ICI + TKI between 20 June, 2016, and 26 January, 2023, were included. Primary outcomes were real-world time to next therapy (rwTTNT) and real-world overall survival (rwOS), summarized via Kaplan-Meier survival estimates with 95% confidence intervals (CIs) and compared in the context of propensity score (PS) matching weighted analysis. Of the 12,707 patients in the dataset, 1,438 with mccRCC met eligibility and were included. After PS matching weighted analysis, no significant difference in rwOS was noted between both groups (HR 1.01, 95% CI 0.86-1.19; p = 0.91); however, rwTTNT was significantly shorter with Ipi + Nivo than with ICI + TKI (HR 0.78, 95% CI 0.68-0.89; p < 0.001). In this large real-world study, there was evidence that rwOS was comparable, while rwTTNT was superior in patients receiving ICI + TKI compared to those receiving Ipi + Nivo. These real-world data offer important guidance for clinicians in choosing between Ipi + Nivo and ICI + TKI as frontline treatment.

The Effectiveness and Safety Profile of Nivolumab-Plus-Ipilimumab in Previously Untreated Japanese Patients With Advanced or Metastatic Renal Cell Carcinoma (J-ENCORE Study)

OBJECTIVES

Combination therapy of nivolumab-plus-ipilimumab has been approved for advanced or metastatic renal cell carcinoma in Japan, but large-scale clinical data targeting Japanese patients is limited. To evaluate the early outcomes and factors related to early progression and response.

METHODS

J-ENCORE is an ongoing multicenter, prospective, observational study of the effectiveness and safety of nivolumab-plus-ipilimumab for patients in Japan with advanced or metastatic renal cell carcinoma. The objective response rate, duration of response, progression-free survival, overall survival, incidence of adverse events, and factors related to early progression within 3 months, and response were assessed.

RESULTS

We included 274 patients (median age: 68 years, 24.8% aged ≥ 75 years, 78.8% male). The median follow-up was 23.4 months. The objective response rate was 36.8%. Among responders, 63.3% had progression-free survival > 12 months. The median progression-free survival was 9.9 months; the 12-month overall survival was 76.3%. Of the patients, 77.0% experienced treatment-related adverse events, 42.3% experienced grade 3-4 events, and 1.1% experienced treatment-related death. Early progression was associated with female sex, poor risk status, liver metastasis, high baseline C-reactive protein levels, and high neutrophil-to-lymphocyte ratios. Responders were less likely to have bone metastases. Limitations include the observational nature of the study and a relatively short follow-up period.

CONCLUSIONS

This is the first prospective, real-world study to demonstrate the effectiveness and safety of nivolumab-plus-ipilimumab in Japan, with the results comparable to those of CheckMate 214. These findings support the use of nivolumab-plus-ipilimumab, although further studies with longer follow-up on nivolumab-plus-ipilimumab are needed.

TRAIL REGISTRATION

ClinicalTrials.gov identifier: NCT04043975; University Hospital Medical Information Network-Clinical Trial Registration: UMIN000036772.

Combinational therapeutic strategies to overcome resistance to immune checkpoint inhibitors

Over the past few years, immune checkpoint inhibitors resulted in magnificent and durable successes in treating cancer; however, only a minority of patients respond favorably to the treatment due to a broad-spectrum of tumor-intrinsic and tumor-extrinsic factors. With the recent insights gained into the mechanisms of resistance, combination treatment strategies to overcome the resistance and enhance the therapeutic potential of immune checkpoint inhibitors are emerging and showing promising results in both pre-clinical and clinical settings. This has been derived through multiple interconnected mechanisms such as enhancing tumor immunogenicity, improving neoantigen processing and presentation in addition to augmenting T cell infiltration and cytotoxic potentials. In the clinical settings, several avenues of combination treatments involving immune checkpoint inhibitors were associated with considerable improvement in the therapeutic outcome in terms of patient's survival and tumor growth control. This, in turn, increased the spectrum of cancer patients benefiting from the unprecedented and durable effects of immune checkpoint inhibitors leading to their adoption as a first-line treatment for certain cancers. Moreover, the significance of precision medicine in cancer immunotherapy and the unmet demand to develop more personalized predictive biomarkers and treatment strategies are also highlighted in this review.

Loss of VHL-mediated pRb regulation promotes clear cell renal cell carcinoma

The von Hippel-Lindau (VHL) tumor suppressor is a substrate-defining component of E3 ubiquitin ligase complexes that target cellular substrates for proteasome-mediated degradation. VHL inactivation by mutation or transcriptional silencing is observed in most sporadic cases of clear cell renal cell carcinoma (ccRCC). VHL loss in ccRCC leads to constitutive stabilization of E3 ligase substrates, including hypoxia inducible factor α (HIFα). HIFα stabilization upon VHL loss is known to contribute to ccRCC development through transactivation of hypoxia-responsive genes. HIF-independent VHL targets have been implicated in oncogenesis, although those mechanisms are less well-defined than for HIFα. Using proximity labeling to identify proteasomal-sensitive VHL interactors, we identified retinoblastoma protein (pRb) as a novel substrate of VHL. Mechanistically, VHL interacts with pRb in a proteasomal-sensitive manner, promoting its ubiquitin-mediated degradation. Concordantly, VHL-inactivation results in pRb hyperstabilization. Functionally, loss of pRb in ccRCC led to increased cell death, transcriptional changes, and loss of oncogenic properties in vitro and in vivo. We also show that downstream transcriptional changes induced by pRb hyperstabilization may contribute to ccRCC tumor development. Together, our findings reveal a novel VHL-related pathway which can be therapeutically targeted to inhibit ccRCC tumor development.

Impact of Renal Function Eligibility Criteria on Clinical Trials and Real-World Survival Outcomes Among Patients With Metastatic Renal Cell Carcinoma

BACKGROUND

Registration trials of first-line (1L) therapies in metastatic renal cell carcinoma (mRCC) employed strict renal function criteria, which may not reflect real-world patients. We evaluated the impact of trial-based renal function eligibility criteria on real-world outcomes.

METHODS

Using a nationwide, deidentified electronic health record-derived database, we included patients diagnosed with mRCC between January 2011 and April 2023 who received 1L systemic therapy. Renal function criteria were based on trial protocols and included serum creatinine (≤1.5 vs >1.5 x upper limit of normal), estimated glomerular filtration rate (≥30 vs <30 mL/min/1.73 m2), and calculated creatinine clearance (≥40 vs <40 mL/min). Outcomes were real-world progression-free survival (rwPFS) and overall survival (rwOS) from 1L. Statistical analyses included inverse probability of treatment weighted Kaplan-Meier methods and Cox proportional hazard models with multiple imputation.

RESULTS

Among 6896 patients, 4647 (67.4%) met all renal function criteria (Included), 586 (8.5%) met at least one (Relaxed), 174 (2.5%) met none (Excluded), and 1489 (21.6%) had unknown renal function (Unknown). In adjusted analyses, patients in the Relaxed and Excluded groups combined had a lower median rwPFS (hazard ratio [HR], 1.12; 95% CI, 1.00-1.25) and rwOS (HR, 1.23, 95% CI, 1.08-1.39) than those in the Included group.

CONCLUSION

Patients who met all renal function criteria had better survival outcomes than those who did not, suggesting that clinical trial results for mRCC may not be fully generalizable to real-world patients.

Targeting KIT With Antibody-Drug Conjugates in Chromophobe Renal Cell Carcinoma

INTRODUCTION

Chromophobe renal cell carcinoma (ChRCC) is the third most common type of RCC. There are no proven therapies for patients with metastatic ChRCC, with a median survival of 27 months. KIT (CD117) is a membrane-associated tyrosine kinase receptor. Antibody-drug conjugates (ADC) targeting KIT were previously found to be safe and effective in preclinical models of KIT-positive cancers but have not been tested in ChRCC.

RESULTS

In The Cancer Genome Atlas, KIT mRNA expression is higher in ChRCC than any other tumor type with the mean expression 12 times higher than matched normal kidney. Of the 15 metastatic ChRCC specimens stained for KIT at our institution, 87% were positive. In single-cell RNA sequencing data, KIT and SCF, the KIT ligand, are co-expressed in ChRCC tumor cells. We found that KIT mRNA expression is significantly higher in ChRCC-derived cells compared to clear cell renal cell carcinoma (ccRCC)-derived cells and normal kidney cells. Western blot analysis confirmed KIT expression in 5 ChRCC cell lines. Despite high KIT expression, knockdown of KIT or treatment with KIT targeting tyrosine kinase inhibitors did not decrease ChRCC cell proliferation. LOP628, a KIT ADC, decreased the viability of the ChRCC-derived cells by ∼60% with no effect on ccRCC cells.

CONCLUSION

Together, these data demonstrate that KIT is a viable therapeutic target for antibody-drug conjugates in ChRCC, providing a foundation for further investigation into KIT-targeted therapies.

Neoadjuvant immune checkpoint therapy: Enabling insights into fundamental human immunology and clinical benefit

While immune checkpoint therapy (ICT) has revolutionized cancer treatment, most patients with advanced disease fail to achieve durable benefit. To address this challenge, it is essential to integrate mechanistic research with clinical studies to: (1) understand response mechanisms, (2) identify patient-specific resistance pathways, (3) develop biomarkers for patient selection, and (4) design novel therapies to overcome resistance. We propose that incorporating "direct-in-patient" studies into clinical trials is crucial for bridging the gap between fundamental science and clinical oncology. In this review, we first highlight recent clinical success of ICT in the neoadjuvant setting, where treatment is given in earlier disease stages to improve outcomes. We then explore how neoadjuvant clinical trials could be utilized to drive mechanistic laboratory-based investigations. Finally, we discuss novel scientific concepts that will potentially aid in overcoming resistance to ICT, which will require future clinical trials to understand their impact on human immune responses.

Stereotactic Body Radiation Therapy Alone or in Combination with Immunotherapy in Kidney Cancer: A Systematic Review

BACKGROUND AND OBJECTIVE

Despite its radioresistant reputation, renal cell carcinoma (RCC) is sensitive to high dose per fraction stereotactic ablative body radiotherapy (SABR). As SABR also triggers immunomodulatory effects, a combination of SABR and immunotherapy for RCC might improve patient outcomes. The current systematic review will discuss all prospective studies on SABR alone or combined with immunotherapy.

METHODS

A systematic review was conducted in January 2025 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement on the PubMed and Cochrane databases. Thirty-eight studies were included in this review.

KEY FINDINGS AND LIMITATIONS

In the primary setting, 15 prospective studies have proved SABR to be a valuable alternative for (partial) nephrectomy for high-risk or medically inoperable patients, with good tolerability and excellent local control. No prospective studies have reported on SABR combined with immunotherapy in nonmetastatic patients. In the oligometastatic setting, two phase 2 trials have investigated SABR in lieu of systemic treatment. This showed encouraging results, with the majority of patients being free from systemic therapy at 1 yr. SABR combined with immunotherapy in the metastatic setting has been investigated in multiple phase 1 and 2 trials, where the most promising option seems to be SABR to multiple-preferentially all-lesions. Cytoreductive SABR and SABR to oligoprogressive lesions combined with immunotherapy are attractive future strategies.

CONCLUSIONS AND CLINICAL IMPLICATIONS

SABR is a valid alternative in localised RCC when (partial) nephrectomy is not an option. In the metastatic setting, several early-phase trials have investigated SABR alone and in combination with immunotherapy, warranting future large, randomised trials.

Efficacy and safety of nivolumab plus cabozantinib in octogenarian patients with advanced renal cell carcinoma

PURPOSE

To clarify the efficacy and safety profile of nivolumab plus cabozantinib combination therapy in advanced renal cell carcinoma patients older than 80 years.

METHODS

We retrospectively evaluated 42 patients with advanced renal cell carcinoma treated with nivolumab plus cabozantinib as the first-line therapy at our institution. The patients were categorized according to age as those aged ≥ 80 years and those aged < 80 years. Efficacy was analysed by comparing the progression-free survival, overall survival, objective response rate, and disease control rate between the two groups. Safety was assessed by comparing the incidence of adverse events.

RESULTS

Ten patients (31%) were classified as age ≥ 80 group. No significant differences were observed in the progression-free survival (p = 0.682), the overall survival (p = 0.627), objective response rate (p = 0.195), and disease control rate (p = 0.070) between the two groups. There was no significant difference in the incidence of all grades of adverse events(p = 1.000), but there was a trend toward a higher incidence of grade 3 or higher adverse events in the group of patients aged < 80 years (p = 0.066).

CONCLUSIONS

The efficacy and safety of nivolumab plus cabozantinib combination therapy were comparable between the patients aged ≥ 80 years and those aged < 80 years. Thus, chronological age alone is not a contraindication for nivolumab plus cabozantinib combination therapy for advanced renal cell carcinoma.

Identifying predictors of overall survival among patients with TMB-low metastatic cancer treated with immune checkpoint inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICIs) have significantly advanced cancer therapy, yet their efficacy in tumors with low tumor mutational burden (TMB) remains suboptimal. In this study, we aimed to elucidate the impact of somatic mutations on overall survival (OS) in TMB-low patients treated with ICIs and to explore the potential for personalized treatment selection through machine learning.

METHODS

We conducted a comprehensive analysis of 1172 TMB-low (TMB < 10 mutations per megabase) patients with cancer receiving ICIs, examining the association between specific gene mutations and OS. Additionally, we developed a decision tree model (DTM) to predict OS based on clinical features and tumor mutational profiles.

RESULTS

Our findings reveal that mutations in DAXX, HLA-A, H3C2, IGF1R, CTNNB1, SMARCA4, KMT2D, and TP53 are significantly associated with poorer survival outcomes in the multivariate analysis. Remarkably, for renal cell carcinoma (RCC) patients, VHL mutations predicted improved OS following ICI even when adjusted for age, sex, and microsatellite instability (MSI) status in both multivariate analysis and the DTM model.

CONCLUSIONS

These results reinforce the prevailing notion that TMB alone does not predict ICI response, highlighting the critical role of individual gene mutations in TMB-low tumors under ICI therapy. Furthermore, our study demonstrates the promise of machine learning models in optimizing ICI treatment decisions, paving the way for more precise and effective therapeutic strategies in this patient population.

Impact of tumor-infiltrating immune cells expressing PD-1 and those expressing PD-L1 on recurrence and prognosis in pathological T1b clear cell renal cell carcinoma

BACKGROUND

The numbers of tumor-infiltrating immune cells (TIICs) expressing programmed death (PD)-1 or PD-ligand 1 (PD-L1) reportedly predict prognosis and resistance to targeted drugs in clear cell renal cell carcinoma (ccRCC). The impact of local tumor microenvironment based on immunosuppressive TIICs on recurrence and prognosis has not been fully investigated in localized ccRCC.

METHODS

A total of 105 patients with pT1b ccRCC were included. Immunostaining for PD-1 and PD-L1 were performed. PD-1-positive TIICs and PD-L1-positive TIICs were counted in the tumor periphery (TP) and the tumor nest (TN).

RESULTS

Patients with elevated PD-1-positive TIIC scores and those with elevated PD-L1-positive TIIC scores had significantly lower recurrence-free survival (RFS) rates than their counterparts (3-year RFS rates; patients with high vs. low PD-1-positive TIIC score of TN = 73.9% vs. 95.0%, those with high vs. low PD-1-positive TIIC score of TP = 73.8% vs. 93.8%, those with high vs. low PD-L1-positive TIIC score of TN = 70.9% vs. 93.0%, and those with high vs. low PD-L1-positive TIIC score of TP = 80.3% vs. 92.6%). Univariate analysis showed that high PD-1-positive scores, high PD-L1-positive scores, high PD-L1-positive tumor cell score, high-grade tumor, tumor necrosis, and lymphovascular invasion were significantly associated with RFS. Multivariate analysis revealed that tumor necrosis [hazard ratio (HR) = 2.841, P = .0269] and PD-1-positive TIIC score of TN (HR = 6.135, P = .0023) were independent risk factors for RFS. Risk stratification using the two factors efficiently predicts recurrence (3-year RFS rates: 96.4% with 0 factor, 83.8% with 1 factor, and 61.4% with 2 factors).

CONCLUSION

PD-1-positive TIIC score of TN and tumor necrosis may efficiently predict recurrence in pT1b ccRCC.

The paths toward immunotherapy of esophageal cancer: An overview of clinical trials

As the seventh-leading contributor to global cancer-related deaths, esophageal cancer (EC) is one of the most challenging types of cancer. Despite advancements in conventional therapies, including surgery, chemotherapy, and radiotherapy, the five-year survival rate remains low, underscoring the need for the development of more efficacious treatment approaches. Immunotherapy has emerged as a promising treatment approach, offering new hope for EC patients. This review provides an in-depth examination of the latest immunotherapeutic strategies for EC, focusing on immune checkpoint inhibitors, adoptive cell therapy, cancer vaccines, and oncolytic virotherapy. We critically analyze the current clinical data to highlight the progress and pitfalls of each immunotherapeutic approach for EC. Additionally, we explore the potential for combination therapies, which could overcome the resistance often seen with monotherapies. Finally, we discuss the limitations of current treatments and outline key areas for future research to improve patient outcomes and survival.

Patient Perspective on Medical Conditions Post Immune Checkpoint Therapy in Advanced Renal Carcinoma

Immune checkpoint therapy (ICI) has enabled induction of remission in advanced renal cell carcinoma RCC. ICI toxicities can persist as chronic health conditions. We developed a patient survey to assess changes in medical comorbidities after ICI. The survey was developed by the Kidney Cancer Research Alliance (KCCure), with multidisciplinary representation from urologic surgeons, medical oncologists, and patient advocates. The survey was broadcast between July 2022 and September 2022 to patients via website, mailing lists, and social media platforms. Patient perspective on changes to any medical conditions were evaluated in the survey questionnaire. Of 1062 patients that responded, 399 were self-identified as being metastatic and 289 reported to be treated with ICI. Eighty-five percent of respondents were from the United States. The most common conditions noted were thyroid dysfunction in 80 patients, hypertension in 50 patients, chronic kidney disease in 23 patients, heart disease in 10 patients, and diabetes mellitus (DM) in 13 patients. Immune disorders developed in 26 (9%) patients. The limitations are the survey had minimal participation from minority populations. Multiple medical conditions were noted to either emerge or worsen as a result of ICI-based therapies in RCC. Awareness of this information as a starting point should stimulate the development of survivorship programs for renal cancer. A survey of patients with advanced kidney cancer showed that some medical conditions such as thyroid dysfunction, hypertension, heart and kidney disease, DM, and immune conditions were newly diagnosed and/or persisted after immune therapy.

Shared Decision-Making for Advanced Renal Cell Carcinoma: Focus on Adverse Event Management of Axitinib Plus IO: A Vodcast

Shared decision-making is essential to the care of patients with advanced renal carcinoma which can empower patients and help the healthcare team understand the patient's goals of care. An important topic during the shared-decision making process is identification and management of treatment-related adverse events. A patient author and two healthcare professionals with real-world experience provide insight into the importance of shared decision-making and its utility in the management of treatment-related adverse events in patients with renal cell carcinoma who are receiving axitinib in combination with an immunotherapy agent.

Prognostic significance of body mass index in patients with metastatic renal cell carcinoma receiving first-line therapies

OBJECTIVES

Higher body mass index (BMI) is reportedly associated with improved prognosis of patients with various cancers. However, it is unclear whether this phenomenon, also known as the obesity paradox, applies to metastatic renal cell carcinoma (mRCC). We aimed to determine the prognostic significance of BMI in patients with mRCC receiving first-line therapies.

MATERIALS AND METHODS

We retrospectively reviewed patients with mRCC receiving first-line immune checkpoint inhibitor (ICI)-based combination therapy or tyrosine kinase inhibitor monotherapy. Overall survival (OS) was defined as the time from systemic therapy initiation to death from any cause or last follow-up. Baseline patient characteristics were compared by Mann-Whitney U test or Fisher's exact test. OS curves were constructed by Kaplan-Meier estimates and were compared by log-rank test. Multivariable analysis was performed via Cox proportional-hazards regression.

RESULTS

Of the 183 patients included, 130 (71 %) were overweight (≥22 and 18 kg/m2 in men and women, respectively), and 63 (34 %) received ICI-based combination therapy. There was a significantly higher proportion of men in the overweight subgroup (87 % versus 64 %; P = 0.002). During the study period, 97 patients died, and median (95 % confidence interval) OS was 39.0 months (31.5-66.3 months) and 28.1 months (17.6-39.7 months) in overweight and normoweight patients, respectively (P = 0.015). On multivariable analysis, overweight was independently associated with longer OS (HR 0.57; P = 0.014). Subgroup analyses of patients receiving ICI-based combination therapy yielded similar results.

CONCLUSION

Overweight is associated with favorable outcomes in patients with mRCC receiving first-line therapies.

Biomarker-informed care for patients with renal cell carcinoma

Kidney cancer is a commonly diagnosed cancer in adults, and clear cell renal cell carcinoma (ccRCC) is the most common histological subtype. Immune checkpoint inhibitors have revolutionized care for patients with ccRCC, either as adjuvant therapy or combined with other agents in advanced disease. However, biomarkers to predict therapeutic benefits are lacking. Here, we explore biomarkers that predict therapeutic response in other tumor types and discuss the reasons for their ineffectiveness in ccRCC. We also review emerging predictive and prognostic biomarkers to prioritize in ccRCC, including gene expression signatures.

Prognostic value of IMDC score in non-small cell lung cancer receiving immunotherapy: old dog, new tricks? : IMDC in lung cancer immunotherapy

BACKGROUND

Although there are multiple treatment options, oncologists lack appropriate biomarkers for determining the efficacy and toxicity of immunotherapy. In this study, we aimed to use a combination of the clinical parameters of IMDC risk groups at the time of diagnosis to predict the effectiveness of immunotherapy.

METHODS

This multicenter cross-sectional study retrospectively analyzed non-small cell lung cancer (NSCLC) patients receiving nivolumab for the prognostic effects of clinical factors, including the IMDC score.

RESULTS

Two hundred and five patients were enrolled in this study. There was no favorable group because the TTI was less than 1 year in the entire study group in the IMDC. The IMDC score and IMDC groups showed significant differences in PFS (p < 0.001; p < 0.001, respectively). Intermediate and poor-risk groups had PFS of 8 and 3 months PFS, respectively. The IMDC group showed a significant effect on OS (p = 0.002). The intermediate- and poor-risk groups had 12- and 4-month OS, respectively. The TTI risk factor excluded patient numbers in the favorable, intermediate, and poor risk groups were 47, 129, and 29, respectively, in the revised IMDC group (rIMDC). The prognostic effect of the rIMDC score and groups remained significant (p < 0.001 and p < 0.001, respectively). The classical IMDC had a significant effect on PFS in the multivariate analysis (p = 0.016). Also, rIMDC score in multivariate analysis resulted with significant effect on OS (p = 0.035).

CONCLUSION

To date, this is the first study to prove that the IMDC may be a valuable option for predicting both prognosis and treatment efficacy in NSCLC patients receiving especially second or further lines nivolumab treatment.

Comparison of Outcomes Between African American and European American Patients With Metastatic Clear Cell Renal Cell Carcinoma Receiving Immune Checkpoint Inhibitors

BACKGROUND AND OBJECTIVE

Immune checkpoint inhibitors (ICIs) and ICI/tyrosine kinase inhibitor (TKI) (ICI-based) combinations are standard first-line treatment (tx) options for patients with metastatic clear cell renal cell carcinoma (mRCC). However, only 1% of patients enrolled in trials studying these agents were Blacks.

METHODS

Patients with mRCC who received front-line ICI-based tx or sunitinib after 2011 were included from the Flatiron Health electronic record-derived database. We analyzed progression-free survival in African American (Black) and European American (White) patients and tested the interaction between treatment type and race. Multivariable Cox proportional hazards models were used to assess associations with outcomes.

KEY FINDINGS AND LIMITATIONS

Of 2,592 eligible pts, 2,379 (91.8%) were White, and 213 (8.2%) were Black. Of these, 1453 (56%) received ICI-based tx and 1139 (44%) received sunitinib. IMDC favorable, intermediate/poor and unknown risk was noted among 6%, 77.5% and 16.4% of White patients and 3.3%, 86.8% and 9.9% of Black patients. Median age was 64 years. There was no significant difference in PFS between Black and White patients receiving ICI-based treatment compared to sunitinib [hazard ratio (HR) for interaction between treatment type and race was 1.063 (0.78-1.45, P = .7)]. The interaction term between race and treatment type showed that there was no evidence of a differential treatment effect by race in the first 10 months (HR = 0.931 (0.79-1.10); P = .40), however significantly improved after 10 months (HR = 0.697 (0.56-0.87); P = .001). The retrospective nature of the study is a limitation CONCLUSIONS AND CLINICAL IMPLICATIONS: The study found no significant difference in treatment effects between White and Black patients receiving ICI-based first-line treatment and should be the standard of care for both Black and White patients.

PATIENT SUMMARY

We reviewed Flatiron databases of patients with mRCC from both Black and White populations, finding that ICI-based therapy should be considered the standard of care for patients from both racial backgrounds.

Optimization of immunotherapy-based combinations for metastatic renal cell carcinoma: A network meta-analysis

BACKGROUND

Despite numerous meta-analyses comparing the efficacy and safety of immunotherapy-based combination therapies, the optimal therapeutic combinations remain unclear. This study aims to evaluate the optimal application of all immunotherapy-based combination therapy for advanced/metastatic renal cell carcinoma, focusing on efficacy and safety.

METHODS

We systemically searched the Web of Science, Cochrane Library, and PubMed for studies regarding the first-line immunotherapy-based combination therapy in patients with advanced or metastatic renal cell carcinoma until April 15, 2024. We used network meta-analysis using a random effect model to facilitate direct and indirect treatment comparisons across outcomes.

RESULTS

Seven clinical studies, including 5542 patients with metastatic renal cell carcinoma, were included in the network meta-analysis analysis. Regarding progression-free survival and overall survival, combined Toripalimab + Axitinib significantly outperformed other immunotherapy-based combination therapies. This regimen significantly improved progression-free survival in the intermediate/poor risk group when stratified by prognosis prediction risks compared to sunitinib alone. For the objective response rate, Avelumab + Axitinib was the most preferred strategy in the favorable-risk group, while Nivolumab + Cabozantinib was favored in the intermediate/poor-risk group compared to other immunotherapy-based combinations. The combinations of Nivolumab + Ipilimumab and Atezolizumab + Bevacizumab had favorable safety profiles.

CONCLUSIONS

Immunotherapy-based combination therapies significantly improved progression-free survival, overall survival and objective response rate in patients with metastatic renal cell carcinoma compared to sunitinib monotherapy. However, careful monitoring and personalized treatment strategies are required to balance efficacy and safety in patients with underlying conditions. Future research should focus on optimizing treatment protocols and elucidating the mechanisms of adverse events.

A machine learning-based analysis for the definition of an optimal renal biopsy for kidney cancer

OBJECTIVE

Renal Tumor biopsy (RTB) can assist clinicians in determining the most suitable approach for treatment of renal cancer. However, RTB's limitations in accurately determining histology and grading have hindered its broader adoption and data on the concordance rate between RTB results and final pathology after surgery are unavailable. Therefore, we aimed to develop a machine learning algorithm to optimize RTB technique and to investigate the degree of concordance between RTB and surgical pathology reports.

MATERIALS AND METHODS

Within a prospectively maintained database, patients with indeterminate renal masses who underwent RTB at a single tertiary center were identified. We recorded and analyzed the approach (US vs. CT), the number of biopsy cores (NoC), and total core tissue length (LoC) to evaluate their impact on diagnostic outcomes. The K-Nearest Neighbors (KNN), a non-parametric supervised machine learning model, predicted the probability of obtaining pathological characterization and grading. In surgical patients, final pathology reports were compared with RTB results.

RESULTS

Overall, 197 patients underwent RTB. Overall, 89.8% (n=177) and 44.7% (n=88) of biopsies were informative in terms of histology and grading, respectively. The discrepancy rate between the pathology results from renal tissue biopsy (RTB) and the final pathology report following surgery was 3.6% (n=7) for histology and 5.0% (n=10) for grading. According to the machine learning model, a minimum of 2 cores providing at least 0.8 cm of total tissue should be obtained to achieve the best accuracy in characterizing the cancer. Alternatively, in cases of RTB with more than two cores, no specific minimum tissue threshold is required.

CONCLUSIONS

The discordance rates between RTB pathology and final surgical pathology are notably minimal. We defined an optimal renal biopsy strategy based on at least 2 cores and at least 0.8 cm of tissue or at least 3 cores and no minimum tissue threshold.

PATIENTS SUMMARY

RTB is a useful test for kidney cancer, but it's not always perfect. Our study shows that it usually matches up well with what doctors find during surgery. Using machine learning can make RTB even better by helping doctors know how many samples to take. This helps doctors treat kidney cancer more accurately.

Trend of cardiovascular mortality among metastatic renal cell cancer patients in the US from 2005 to 2020

Recent advances in treating advanced renal cell carcinoma (RCC) with distant metastasis have significantly enhanced cancer-specific outcomes. However, these patients are at increased risk for cardiovascular disease (CVD) and events. This study aims to investigate the trend of incidence-based mortality specific to CVD in patients with metastatic RCC. We examined data from 26,501 adult patients aged 18 and older diagnosed with metastatic RCC between 2005 and 2020 in the Surveillance, Epidemiology, and End Results (SEER) 17 registry. We used a linear regression model to examine trends in metastatic RCC incidence and mortality rates among the US general population stratified by gender using R statistical software version 4.3.2. Among 26,501 adult patients diagnosed with metastatic RCC, RCC-specific mortality accounted for 18,258 (81.1 %) deaths, while mortality due to cardiovascular (CV) events was 737 (3.3 %). The overall incidence rate of metastatic RCC increased over time (p-value < 0.001). A significant interaction between time and sex was found, indicating greater increase in metastatic RCC incidence rates in males than females over time (p < 0.001 for interaction). There was no statistically significant difference in metastatic RCC-specific mortality rate between sexes (p = 0.25) or over time (p = 0.89). The combined CV mortality rate (in both sexes) increased from 0.02 to 0.04 during the years 2005-2020 and was statistically significant (p = 0.001) with no significant difference in mortality between sexes (p = 0.13). The trend of increasing metastatic RCC incidence with no change in all cause and metastatic RCC specific mortality would suggest benefit of advances in therapy. However, the slow but gradual rise in CV mortality needs to be further studied. Keywords: advanced renal cell carcinoma, cardiovascular mortality, sex.

Novel Combination Immunotherapy and Clinical Activity in Patients With HPV-Associated Cancers: A Nonrandomized Clinical Trial

IMPORTANCE

Patients who experience progression of advanced human papillomavirus (HPV)-associated cancers and who have previously received first-line systemic treatment have a poor prognosis and limited therapeutic options.

OBJECTIVE

To assess the clinical activity of the combination of the HPV type 16 therapeutic vaccine PDS0101, the tumor-targeting interleukin 12 antibody-drug conjugate PDS01ADC, and the bifunctional anti-programmed cell death ligand 1 (PD-L1)/transforming growth factor β (TGF-β) bintrafusp alfa in advanced HPV-associated cancers.

DESIGN, Setting, and Participants

This nonrandomized clinical trial was phase 1/2 and investigator initiated, and was conducted at a single US cancer research center between June 2020 and July 2022. Patients with advanced or metastatic HPV-associated cancers were eligible, including patients who were both immune checkpoint blockade (ICB) naive and ICB resistant. The cutoff date for data analysis was May 13, 2024.

INTERVENTION

Patients received 1 mL of PDS0101 subcutaneously every 4 weeks for 6 doses then every 12 weeks for 2 additional doses, PDS01ADC, 16.8 µg/kg, subcutaneously every 4 weeks or PDS01ADC, 8 µg/kg, subcutaneously every 2 weeks, and bintrafusp alfa, 1200 mg, intravenously every 2 weeks.

MAIN OUTCOMES AND MEASURES

Objective response rate (ORR) by Response Evaluation Criteria in Solid Tumors version 1.1 in ICB-naive patients.

RESULTS

Of the 50 eligible patients, 26 (52%) were men and the median age was 56 years (range, 28-80 years). The median (IQR) follow-up was 37.7 (30.6-42.0) months. Fourteen patients (28%) were ICB naive, with an ORR of 35.7% (95% CI, 12.8%-64.9%), and median overall survival (OS) 42.4 months (95% CI, 8.3 months-not estimable); in ICB-resistant patients, the ORR was 16.7% (6 of 36 patients; 95% CI, 6.4%-32.8%) and median OS was 15.8 months (95% CI, 9.0-21.3 months). Among patients with HPV-16-positive tumors (37 patients [74%]), in the ICB-naive group (8 patients [21.6%]) the ORR was 62.5% (95% CI, 24.5%-91.5%) and a median OS measure was not reached. Grade 3 and 4 treatment-related adverse events occurred in 26 of 50 patients (52%). There were no treatment-related deaths.

CONCLUSIONS AND RELEVANCE

In this trial, the combination of PDS0101, PDS01ADC, and bintrafusp alfa showed an acceptable safety profile and promising antitumor activity and improved OS in patients with HPV-16-positive cancers, in both ICB-naive and ICB-resistant patients, warranting further evaluation of the combination of PDS0101 and PDS01ADC with simultaneous PD-L1/TGF-β inhibition in these populations.

Trial Registration

ClinicalTrials.gov Identifier: NCT04287868.

Clinical benefit of immune checkpoint inhibitors in elderly cancer patients: Current evidence from immunosenescence pathophysiology to clinical trial results

The age-related decline in immunity appears to be associated not only with cancer development but also with differential responses to immune checkpoint inhibitors (ICIs). Despite their increasing utility across various malignancies and therapeutic settings, limited data -derived primarily from subgroup analyses of randomized controlled trials (RCTs), pooled meta-analyses, and retrospective studies- are available on the effects of aging on their efficacy and toxicity. Immunosenescence, characterized by the progressive decline of the function of the immune system, and inflammaging, a state of persistent low-grade sterile inflammation, may influence ICI outcomes. Additionally, the incidence, severity, and subtypes of immune-related adverse events (irAEs) may differ between older and younger individuals due to loss of immunotolerance. In the current review, starting from a a comprehensive discussion of the pathophysiology of immunosenescence, we proceed to critically review age-related retrospective and randomized evidence supporting FDA-approved ICIs. We highlight similarities or differences across age groups and the clinical benefit of ICIs in elderly versus younger cancer patients. The optimal integration of ICIs in geriatric oncology necessitates greater inclusion of this patient demographic in RCTs along with real-world data in order to acquire robust data which will guide evidence-based treatment decisions for this population.

[Gender-/Sex-Specific Differences in Clinical Trials in Uro-Oncology]

Subgroup analyses in clinical trials sometimes reveal gender-/sex-dependent differences in cancer outcomes. However, drug approvals are rarely restricted to a specific sex or gender, and recommendations regarding dosage are rarely tailored accordingly. Furthermore, discrepancies exist between the gender-/sex-dependent enrollment rates in clinical trials and real-world incidence or mortality rates. This article highlights gender-/sex differences in clinical trials in uro-oncology.

Incidence and management of hepatic immune‑related adverse events in advanced urologic cancers treated with immune checkpoint inhibitors: A multicenter retrospective study

The present study aimed to evaluate the incidence, characteristics and management of hepatic immune-related adverse events (irAEs) in patients with advanced or metastatic urothelial carcinoma (UC) and renal cell carcinoma (RCC) receiving immune checkpoint inhibitors (ICIs). Data regarding the demographics, ICI regimens and hepatic irAEs from 213 patients with metastatic UC or metastatic RCC receiving ICIs between February 2018 and September 2023 at three tertiary medical centers (Inje University Busan Paik Hospital, Busan, South Korea; Dongnam Institute of Radiological and Medical Sciences Cancer Center, Busan, South Korea; Pusan National University Hospital, Busan, South Korea) in South Korea were collected and retrospectively analyzed. Hepatic irAEs were graded using the Common Terminology Criteria for Adverse Events version 5.0 and classified based on R value patterns. Among the 213 patients evaluated, 76 (35.6%) experienced at least one irAE, whereas 48 (22.5%) developed hepatic irAEs. The median onset time for hepatic irAEs was 6.5 weeks, with incidence rates being higher with combination therapies than with monotherapies (31.8 vs. 18.3%; P=0.014). Furthermore, 72.9 and 27.1% of the patients had grade 1-2 and 3-4 hepatic irAEs, respectively. The patterns of liver toxicity included cholestatic (35.4%), mixed (35.4%) and hepatocellular (29.2%). All patients with grade 1-2 hepatic irAE recovered with supportive treatment without ICI discontinuation or corticosteroids use. Among the 13 patients with grade ≥3 hepatic irAEs, 12 recovered with high-dose corticosteroids, while 1 died due to fulminant hepatitis. Hepatic irAEs are common in patients with advanced and metastatic urologic cancers who are treated with ICIs, particularly with combination therapies. Most cases have low-grade irAE that are manageable without ICI discontinuation; however, severe cases require prompt recognition and treatment with corticosteroids. These findings emphasize the importance of regular liver function monitoring and appropriate management strategies for hepatic irAEs in patients with urologic cancer receiving ICI therapy.

The selection of targeted therapies for relapsed or refractory advanced renal cell carcinoma

INTRODUCTION

Advancements in immunotherapy and angiogenesis-targeted therapies have transformed the upfront treatment of renal cell carcinoma (RCC). However, long-term prognoses for patients with unresectable and metastatic disease often remain limited, with the majority experiencing progression after exposure to front-line therapy. In most cases of relapsed or refractory (R/R) disease after prior exposure to an immune checkpoint inhibitor (ICI), there is no role for ICI-rechallenge. Therefore, treatment of R/R RCC relies on the appropriate selection of therapies targeting growth pathways dependent on vascular endothelial growth factor (VEGF) or hypoxia-inducible factor (HIF).

AREAS COVERED

This review article summarizes the current landscape of targeted therapies for use in second-line or later-line settings for the treatment of clear cell and non-clear cell RCC. Novel therapeutic strategies currently in development are also discussed.

EXPERT OPINION

The treatment of R/R RCC primarily consists of inhibition of VEGF, HIF, and mTOR pathways, and the selection of a specific agent depends on the histologic subtype of the tumor, the prior lines of therapy chosen, and patient co-morbidities. Future tumor-based and circulating biomarker research might one day enable the identification of transcriptional signatures that could predict a response to immune, angiogenesis, or HIF-based therapies.

PSMA-Guided Metastasis-Directed Therapy for Oligometastatic Renal Cell Carcinoma: The Proof-of-Concept PEDESTAL Study

Metastasis-directed therapy (MDT) in oligometastatic renal cell carcinoma (RCC) is typically based on conventional imaging. Prostate-specific membrane antigen (PSMA) PET/CT has shown superiority over conventional imaging. Our objective was to perform a proof-of-concept study to evaluate the efficacy of PSMA-guided MDT in oligometastatic RCC. Methods: A PSMA PET/CT database was queried for oligometastatic RCC patients undergoing MDT from 2014 to 2020. The primary endpoint was progression-free survival. Secondary endpoints included freedom from local progression, freedom from change in systemic therapy strategy, and overall survival. Results: A search of 3,095 PSMA PET/CT scans identified 83 RCC patients and 34 receiving MDT to 60 sites. The median follow-up was 4.1 y. Six patients (18%) had synchronous metastatic disease. The median number of metastases was 1 (interquartile range, 1-2). Common sites included bone (19, 32%) and lung (19, 32%). Radiation therapy was delivered to 56 metastases (93%), including stereotactic ablative body and conventional radiotherapy (38 and 18 metastases, respectively), and 4 (7%) underwent surgery. One-, 3-, and 5-y freedom from local progression was 94% (95% CI, 85%-98%), 85% (95% CI, 69%-94%), and 85% (95% CI, 69%-94%), respectively. One-, 3-, and 5-y overall survival was 88% (95% CI, 71%-95%), 71% (95% CI, 52%-84%), and 64% (95% CI, 45%-79%), respectively. One-, 3-, and 5-y progression-free survival was 47% (95% CI, 30%-63%), 26% (95% CI, 13%-42%), and 8% (95% CI, 2%-22%), respectively. One-, 3-, and 5-y freedom from change in systemic therapy strategy was 76% (95% CI, 57%-87%), 65% (95% CI, 45%-79%), and 43% (95% CI, 19%-65%), respectively. Conclusion: In this proof-of-concept study, PSMA-guided MDT provided durable oncologic outcomes for oligometastatic RCC, even at 5 y. To our knowledge, this study had the first cohort uniformly undergoing PSMA-guided MDT and one of the longest follow-ups of MDT for oligometastatic RCC. With increasing availability, PSMA PET/CT can be rapidly instituted to select patients for MDT and improve outcomes for patients with oligometastatic RCC.

First-line cadonilimab plus chemotherapy in HER2-negative advanced gastric or gastroesophageal junction adenocarcinoma: a randomized, double-blind, phase 3 trial

Programmed cell death protein-1 (PD-1) inhibitors plus chemotherapy have been the standard of care in the first-line treatment of advanced gastric or gastroesophageal junction (G/GEJ) adenocarcinoma; however, the survival benefits are modest in patients with low programmed death ligand 1 (PD-L1) expression. Here we investigated the efficacy and safety of cadonilimab (PD-1/cytotoxic T lymphocyte antigen-4 (CTLA-4) bispecific antibody) plus chemotherapy as first-line treatment in G/GEJ adenocarcinoma. The prespecified interim analysis is reported here. This was a randomized, double-blind, placebo-controlled phase 3 study. Eligible patients were adults with untreated, unresectable, locally advanced or metastatic G/GEJ adenocarcinoma. Patients were randomized 1:1 to receive cadonilimab (10 mg kg-1 every 3 weeks) or placebo plus chemotherapy (every 3 weeks). The primary endpoint was overall survival (OS) in the intention-to-treat population (one-sided significance level, P = 0.025). Secondary endpoints included OS in patients with a PD-L1 combined positive score ≥5, progression-free survival, objective response rate, duration of response and safety. As of 18 August 2023, 610 patients from 75 study centers were randomized to cadonilimab (n = 305) or placebo (n = 305). With a median follow-up of 18.7 months, the cadonilimab group had a significantly longer median OS (14.1 versus 11.1 months; hazard ratio (HR) 0.66; 95% confidence interval (CI) 0.54-0.81; P < 0.001) than the placebo group. The primary endpoint was met. The median progression-free survival was 7.0 months versus 5.3 months (HR 0.53, 95% CI 0.44-0.65). The median OS in patients with a PD-L1 combined positive score ≥5 was 15.3 months versus 10.9 months (HR 0.58, 95% CI 0.41-0.82). The objective response rate was 65.2% versus 48.9% with a median duration of response of 8.8 months versus 4.4 months. Grade ≥3 treatment-related adverse events occurred in 65.9% of the cadonilimab group and 53.6% of the placebo group, and the most common were decreased platelet count, decreased neutrophil count and anemia. Most of the immune-related adverse events were grade 1 or 2. No new safety signals were observed. Cadonilimab plus chemotherapy significantly improved OS with a manageable safety profile in patients with advanced G/GEJ adenocarcinoma. ClinicalTrials.gov registration: NCT05008783 .

Renal Cell Carcinoma With Venous Tumor Thrombus Has a Predilection for the Lungs

OBJECTIVE

To investigate the association between venous tumor thrombus (VTT) and the risk of pulmonary metastases in patients with clear cell renal cell carcinoma (ccRCC).

METHODS

We queried our institutional registry for ccRCC patients undergoing radical nephrectomy (1970-2019). Cox proportional hazards regression models, adjusting for factors associated with ccRCC progression, were used to determine whether VTT was associated with pulmonary metastases.

RESULTS

Of 3410 patients studied, 1025 (30%) had VTT. Patients with VTT were more likely to present with synchronous pulmonary metastasis (20% vs 7%, P<.001). Within the VTT subset, level of VTT was not significantly associated with synchronous pulmonary metastasis (P=.3). Moreover, among patients with metastatic disease at nephrectomy (n=643), pulmonary metastases were more common in those with VTT versus those without VTT (68% vs 51%, P<.001). Further, excluding patients with synchronous pulmonary metastases, on multivariable analysis, VTT remained associated with an increased risk of developing metachronous pulmonary metastases (hazard ratio (HR) 1.31, P<.001). Interestingly, the presence of PE in the setting of VTT was also identified to be associated with an increased pulmonary metastases post-nephrectomy (HR 2.31, P<.001).

CONCLUSION

VTT is associated with disproportionately increased pulmonary metastases at presentation and post-nephrectomy in ccRCC. Further, the presence of PE at nephrectomy for VTT was associated with increased pulmonary metastases post-nephrectomy. These results support a metastatic predilection of ccRCC with VTT in the lungs.

Clinical outcomes by baseline metastases in patients with renal cell carcinoma treated with lenvatinib plus pembrolizumab versus sunitinib: Post hoc analysis of the CLEAR trial

Lenvatinib plus pembrolizumab significantly improved efficacy versus sunitinib in treatment of advanced renal cell carcinoma (aRCC) in the phase 3 CLEAR study. We report results of an exploratory post hoc analysis of tumor response data based on baseline metastatic characteristics of patients who received lenvatinib plus pembrolizumab versus sunitinib, at the final overall survival analysis time point of CLEAR (cutoff: July 31, 2022). Treatment-naïve adults with aRCC were randomized to: lenvatinib (20 mg PO QD in 21-day cycles) plus pembrolizumab (n = 355; 200 mg IV Q3W); lenvatinib plus everolimus (not reported here); or sunitinib (n = 357; 50 mg PO QD; 4 weeks on/2 weeks off). The most common (lenvatinib plus pembrolizumab; sunitinib, respectively) metastatic site was lung (71.0%; 63.9%), followed by lymph node (45.6%; 43.7%), bone (22.5%; 24.9%), and liver (17.7%; 19.6%). Across treatment arms, ≥65% had two or more metastatic organs/sites involved, >80% of patients had nontarget lesions, and ~45% had baseline sums of diameters of target lesions ≥60 mm. Lenvatinib plus pembrolizumab demonstrated greater progression-free survival, objective response rate, and duration of response versus sunitinib across evaluable subgroups regardless of site or size of baseline metastasis or number of metastatic sites at baseline. Overall survival generally trended to favor lenvatinib plus pembrolizumab versus sunitinib; and tumor shrinkage was greater across sites (lung, lymph node, liver, and bone) for patients in the lenvatinib-plus-pembrolizumab arm versus the sunitinib arm. These results further support lenvatinib plus pembrolizumab as a standard-of-care in patients with aRCC regardless of site or size of baseline metastasis or the number of metastatic sites.

Predictive Factors for Oligometastatic Renal Cell Carcinoma Treated with Stereotactic Radiation: A Retrospective Study

BACKGROUND AND OBJECTIVE

Stereotactic ablative radiotherapy (SAbR) has shown promise in controlling oligometastatic renal cell carcinoma (omRCC). Careful patient selection is critical, and yet the selection criteria remain unknown for patients who will not be harmed by delayed systemic therapy using SAbR. Here, we analyzed long-term follow-up of omRCC patients treated with SAbR to derive the predictors of survival benefit.

METHODS

We retrospectively reviewed patients with up to five omRCC sites treated with sequential SAbR from November 2007 to July 2022. Overall survival (OS), progression-free survival (PFS), local control (LC), and toxicity were analyzed. The predictors of PFS were analyzed using a univariate analysis and a Cox proportional hazard (CPH) model-based machine learning approach.

KEY FINDINGS AND LIMITATIONS

We analyzed 153 patients who underwent SAbR to 337 metastases with a median follow-up of 27 mo. The median OS and PFS were 61.3 and 32 mo, respectively. The rate of grade ≥3 toxicity was 1.3%, and the 3-yr rate of LC was 98%. Patients with bone and brain metastases had lower PFS on the univariate analysis. When compared with historical controls, the delayed-onset PFS with first-line systemic therapy in this cohort was not compromised. The CPH model found bone, brain, and number of metastases at diagnosis to be the predictors of PFS, with a C-index of 0.66 and 1-yr area under the curve of 0.68.

CONCLUSIONS AND CLINICAL IMPLICATIONS

For selected patients, SAbR is effective in controlling omRCC for >2 yr and can delay systemic therapy without compromising patient outcome. Bone and brain metastases, as well as an increasing number of metastases are poor predictive factors for omRCC patients treated with sequential SAbR who may benefit from upfront systemic therapy. Prospective studies are required to verify these findings.

Germline prediction of immune checkpoint inhibitor discontinuation for immune-related adverse events

INTRODUCTION

Immune checkpoint inhibitors (ICIs) can yield remarkable clinical responses in subsets of patients with solid tumors, but they also commonly cause immune-related adverse events (irAEs). The predictive features of clinically severe irAEs leading to cessation of ICIs have yet to be established. Given the similarities between irAEs and autoimmune diseases, we sought to investigate the association of a germline polygenic risk score for autoimmune disease and discontinuation of ICIs due to irAEs.

METHODS

The Genetics of immune-related adverse events and Response to Immunotherapy (GeRI) cohort comprises 1302 patients with non-small cell lung cancer (NSCLC) who received ICI therapy between 2009 and 2022 at four academic medical centers. We used a published polygenic risk score for autoimmune diseases (PRSAD) in the general population and validated it in the All of Us. We then assessed the association between PRSAD and cessation of ICI therapy due to irAEs in the GeRI cohort, using cause-specific and Fine-Gray subdistribution hazard models. To further understand the differential effects of type of therapy on the association between PRSAD and cessation of ICI due to irAEs, we conducted a stratified analysis by type of ICI therapy.

RESULTS

Using a competing risk model, we found an association between PRSAD and ICI cessation due to irAEs (HR per SD=1.24, p=0.004). This association was particularly strong in patients who had ICI cessation due to irAEs within 3 months of therapy initiation (HR per SD=1.40, p=0.005). Individuals in the top quintile of PRSAD had 4.8% ICI discontinuation for irAEs by 3 months, compared with 2% discontinuation by 3 months among patients in the bottom quintile (log-rank p=0.03). In addition, among patients who received combination programmed cell death protein-1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors and cytotoxic T-lymphocyte associated protein 4 (CTLA4) inhibitors, ICI discontinuation for irAEs by 3 months occurred in 4 of the 13 patients (30.8%) with high PRSAD genetic risk (top quintile) versus 3 of 21 patients (14.3%) with low PRSAD genetic risk (bottom quintile).

CONCLUSIONS

We demonstrate an association between a polygenic risk score for autoimmune disease and early ICI discontinuation for irAEs. Our results suggest that germline genetics may be used as an adjunctive tool for risk stratification around ICI clinical decision-making in solid tumor oncology.

Exploring the efficacy of nivolumab and ipilimumab in renal cell carcinoma: insights from a district hospital cohort study

Background

Nivolumab and ipilimumab combination is recommended as a first-line treatment for metastatic renal cell carcinoma (mRCC) in patients without life-threatening symptoms. This study aims to assess the efficacy and safety of this treatment regimen administered in the one-day chemotherapy unit of a district hospital.

Materials and methods

We conducted a retrospective study involving 36 patients diagnosed with mRCC who had received combined immunotherapy at the Department of Chemotherapy, District Hospital in Sucha Beskidzka, Poland. We evaluated treatment response and adverse events (AEs). Laboratory parameters were recorded, and we calculated neutrophil-lymphocyte ratios (NLR), platelet-lymphocyte ratios (PLR), and lymphocyte-monocyte ratios (LMR) at baseline, after 3 months of treatment, and prior to disease progression.

Results

After a median follow-up of 11 months (7.5-17.5 months), the median overall survival was not reached (NR, 6.7-NR), while the median progression-free survival was 11.5 months (6.7-NR). The objective response rate was 30.6% (n = 11), and the disease-control rate was 66.7% (n = 24). Hemoglobin and eosinophil levels varied at three checkpoints, without differences in NLR, PLR, and LMR. AEs of any grade were observed in 23 patients (63.9%) with a median onset time of 3 months (2-4 months), and serious AEs in 13.8% of patients (n = 5).

Conclusions

Our analysis suggests that the combination of nivolumab and ipilimumab for mRCC has an acceptable toxicity profile and can be effectively managed in a district hospital's outpatient clinic. This approach requires close patient monitoring and collaboration with other hospital departments to ensure patient safety and treatment efficacy.

Real-world comparison of the efficacy of first-line therapies and the influence of risk factors in advanced renal cell carcinoma

INTRODUCTION

Systemic therapy for advanced renal cell carcinoma (aRCC) has become increasingly diverse. In the 1st-line setting, various combination therapies are available, with little comparative data on the efficacy of the therapies. The aim of this study was to compare the current 1st-line combination therapies under real-life conditions and to investigate risk factors in the patient population.

METHODS

Patients with aRCC who started 1st-line IO/IO or IO/TKI combination  therapy between 03/2019 and 10/2023 were included. The primary endpoints were progression-free survival (PFS) and overall survival (OS). Secondary endpoints were time on treatment (ToT), duration of response (DoR), subsequent therapies, the evaluation of risk factors and their influence on PFS and OS. Survival data were analysed using Kaplan-Meier estimates with log-rank tests, risk factors for PFS and OS using Cox regression analysis.

RESULTS

A total of 59 patients, mainly men (79.7%) with a median age of 64.8 years were included. The median follow-up was 21 months. The comparison of IO/IO vs. IO/TKI demonstrated a median PFS of 6 (2.08-9.92) vs. 14 (9.06-18.94) months (47 events; HR IO/TKI vs. IO/IO: 0.53 (0.29-0.99); p = 0.039) and a median OS of 20 (15.07-24.94) vs. 33 (21.68-44.32) months (32 deaths; HR IO/TKI vs. IO/IO: 0.74 (0.36-1.51); p = 0.403). Off all risk factors analysed only synchronous metastases proved to be of independent predictive value for PFS (HR 2.38; 95% CI 1.11-5.11; p = 0.026) and OS (HR 3.47; 95% CI 1.15-10.44; p = 0.027).

CONCLUSION

An IO/TKI therapy showed a significantly improved PFS in the real-world setting compared to an IO/IO combination. In terms of OS, the improved treatment response of the IO/TKI group did not prevail.

Pyrotinib monotherapy for advanced HER2-positive esophageal adenocarcinoma with trastuzumab resistance and chemotherapy intolerance: a case report and literature review

HER2-positive advanced esophageal adenocarcinoma (EAC) cases demonstrate a poor prognosis because of drug resistance that develops after standard first-line trastuzumab therapy. The patient was initially diagnosed with stage cT2N1M0 III EAC. He underwent neoadjuvant chemotherapy, radical esophageal resection, and postoperative adjuvant radiotherapy. However, four months after treatment, the lesion relapsed and progressed to the right back, rendering the case inoperable. Pathological analysis revealed HER2 amplification. Given a poor tolerance to chemotherapy, the patient was administered cadonilimab and trastuzumab for three months. Subsequently, the second-line therapy was switched to pyrotinib monotherapy as a salvage treatment. Remarkably, after one month of treatment, the tumor showed significant reduction, with mild toxic side effects. Pyrotinib can be used for salvage later-line therapy in HER2-positive advanced EAC with trastuzumab resistance or poor chemotherapy tolerance, which deserves further promotion.

Histopathology based AI model predicts anti-angiogenic therapy response in renal cancer clinical trial

Anti-angiogenic (AA) therapy is a cornerstone of metastatic clear cell renal cell carcinoma (ccRCC) treatment, but not everyone responds, and predictive biomarkers are lacking. CD31, a marker of vasculature, is insufficient, and the Angioscore, an RNA-based angiogenesis quantification method, is costly, associated with delays, difficult to standardize, and does not account for tumor heterogeneity. Here, we developed an interpretable deep learning (DL) model that predicts the Angioscore directly from ubiquitous histopathology slides yielding a visual vascular network (H&E DL Angio). H&E DL Angio achieves a strong correlation with the Angioscore across multiple cohorts (spearman correlations of 0.77 and 0.73). Using this approach, we found that angiogenesis inversely correlates with grade and stage and is associated with driver mutation status. Importantly, DL Angio expediently predicts AA response in both a real-world and IMmotion150 trial cohorts, out-performing CD31, and closely approximating the Angioscore (c-index 0.66 vs 0.67) at a fraction of the cost.

ZEB1 promotes the immune escape of ovarian cancer through the MCSF-CCL18 axis

This study aimed to determine the molecular mechanisms underlying immune escape in ovarian cancer. Samples of ovarian cancer were used to explore the regulatory pathways involved in the malignant phenotype. Tumor cell models with different levels of factor expression were constructed via transfection, and their regulation was determined through investigation of protein expressions. Moreover, our study aimed to investigate the effects of M2 polarization and TAMs aggregation on the apoptosis of CD8 + T-cells, and determine their regulatory axis. Results revealed ZEB1 may promote CCL18 expression via upregulation of MCSF concentration. Notably, high CCL18 expression levels were associated with the aggregation of M2-TAMs and the apoptosis of CD8 + T-cells. In addition, results of the present study demonstrated that the proliferation and invasion of ovarian cancer cells with high expression levels of proteins associated with ZEB1 signal pathway were increased. At the same time the growth rate of tumors in mice was reduced following ZEB1 knockdown, and the volume/weight of tumors were markedly decreased both in vitro and in vivo. Moreover, our results revealed that the aggregation of M2-TAMs and the apoptosis of CD8 + T-cells were significantly decreased in tumor cells following ZEB1 knockdown. Thus, these results verified that ZEB1 may promote the M2 polarization of TAMs via the MCSF axis, leading to the increased secretion of CCL18. Moreover, the MCSF axis may mediate immune escape through the induction of CD8 + T-cell apoptosis, ultimately promoting the malignant phenotype in ovarian cancer cells.

Emerging innovative treatment strategies for advanced clear cell renal cell carcinoma

Dramatic advances in biological discoveries, since the 1990s, have continued to reshape the treatment paradigm of metastatic renal cell carcinoma (RCC). Von Hippel Lindau (VHL) gene alterations are associated with pro-angiogenic activity and are central to the pathogenesis of clear cell RCC (ccRCC), the most predominant histologic subtype of RCC. Antiangiogenic strategies revolving around this VHL/HIF/VEGF axis have been shown to improve survival in metastatic ccRCC. The discovery of immune checkpoints and agents that target their inhibition introduced a new treatment paradigm for patients with RCC. While initially approved as monotherapy, studies investigating immune checkpoint inhibitor combinations have led to their approval as the new standard of care, providing durable responses and unprecedented improvements in clinical outcome. Despite these advances, the projected 14 390 deaths in 2024 from RCC underscore the need to continue efforts in expanding and optimizing treatment options for patients with metastatic RCC. This article reviews key findings that have transformed the way we understand and treat metastatic RCC, in addition to highlighting novel treatment strategies that are currently under development.

Targeting Immune Checkpoint Inhibitors for Non-Small-Cell Lung Cancer: Beyond PD-1/PD-L1 Monoclonal Antibodies

Non-small-cell lung cancer (NSCLC) remains a leading cause of cancer-related mortality worldwide. Immunotherapy targeting the PD-1/PD-L1 axis has revolutionized treatment, providing durable responses in a subset of patients. However, with fewer than 50% of patients achieving significant benefits, there is a critical need to expand therapeutic strategies. This review explores emerging targets in immune checkpoint inhibition beyond PD-1/PD-L1, including CTLA-4, TIGIT, LAG-3, TIM-3, NKG2A, and CD39/CD73. We highlight the biological basis of CD8 T cell exhaustion in shaping the antitumor immune response. Novel therapeutic approaches targeting additional inhibitory receptors (IR) are discussed, with a focus on their distinct mechanisms of action and combinatory potential with existing therapies. Despite significant advancements, challenges remain in overcoming resistance mechanisms and optimizing patient selection. This review underscores the importance of dual checkpoint blockade and innovative bispecific antibody engineering to maximize therapeutic outcomes for NSCLC patients.

Prognostic Significance of the Combined Albumin-To-Alkaline Phosphatase Ratio (AAPR) and Haemoglobin-Albumin-Lymphocyte-Platelet (HALP) Score in Patients with Metastatic Renal Cell Carcinoma Treated by Targeted Therapy: A New Prognostic Combined Risk Scoring

Background/Objectives: Renal cell carcinoma (RCC) accounts for 2-3% of all cancers, with approximately 25% of patients being detected at the metastatic stage. This study aimed to determine the prognostic significance of co-evaluating two risk parameters: one, the HALP score based on haemoglobin, albumin, lymphocyte, and platelet counts, and the other, albumin-to-alkaline phosphatase ratio (AAPR) in patients with metastatic RCC treated with targeted therapy. Methods: This retrospective cohort study included 147 patients with metastatic RCC. The HALP score and AAPR values were calculated from pre-treatment blood test results, and followingly, the cut-off value was determined by using ROC analysis. Patients were categorised into three groups with a low, moderate or high combined risk score based on this cut-off value. The effect of these risk groups on survival was evaluated. Results: The mean age of patients was 64.1 ± 11.9. The median follow-up time was 38.3 months, and the mortality rate was 53.7% in all groups. Kaplan-Meier survival analysis showed a statistically significant difference between the combined scores of the risk groups: the median survival time was 51.6 months in the low-risk group, 20.7 months in the medium-risk group, and 10.4 months in the high-risk group (p < 0.001), with 5-year survival rates being 38.8% in the low-risk group, 30% in the intermediate-risk group, and 19% in the high-risk group. When compared to the low-risk group, Cox regression analysis revealed that the mortality risk, i.e., HR (hazard ratio), was 2.42 times higher in the intermediate-risk group and 3.76 times higher in the high-risk group. A nephrectomy operation decreased the mortality risk (HR = 0.24) by 4.16 times. Conclusions: This new combined risk scoring, obtained from co-evaluating the HALP score and AAPR, was found to be an independent prognostic factor in metastatic RCC patients. This combined risk scoring is expected to help clinicians in treatment decisions.

Treatment and Attrition Trends for Metastatic Clear Cell Renal Cell Carcinoma in the US

Importance

The treatment landscape of metastatic clear cell renal cell carcinoma (ccRCC) has rapidly evolved with the approval of multiple immune checkpoint inhibitor (ICI)-based combinations. However, clinical data on changes in treatment patterns and attrition before and after ICI-based combinations approval are lacking.

Objective

To assess treatment patterns and attrition rates in patients with metastatic ccRCC before and after the approval of ICI-based combinations.

Design, Setting, and Participants

This cohort study used patient-level data from a nationwide deidentified electronic health record-derived database, originating from around 280 cancer clinics in the US. Patients diagnosed with metastatic ccRCC who received first-line therapy between January 1, 2011, and January 20, 2023, were included. Those treated for 2 or more malignant neoplasms or enrolled in clinical trials were excluded.

Exposures

Line of therapy initiation before and after April 16, 2018.

Main Outcomes Measures

Treatments received in each line of therapy and attrition rate were summarized using frequencies and percentages.

Results

Of 12 707 patients with metastatic ccRCC within the database, 8534 were eligible and included (median [IQR] age, 66 [59-74] years; 6032 male [70.7%]; 629 Black [8.1%], 697 Hispanic [9.0%], 5493 White [71.0%]). Before April 16, 2018, the most common first-line therapy was tyrosine kinase inhibitor (TKI) monotherapy (3595 of 4561 patients [78.8%]). Following the approval of ICI-based combinations in 2018, most patients (2392 of 3973 patients [60.2%]) received ICI-based combinations as first-line therapy for metastatic ccRCC. TKI monotherapy remained the most common second- and third-line therapy in patients treated before and after April 16, 2018. Before 2018, 2639 patients (57.9%) and 1458 patients (31.9%) received second-line and third-line therapies, respectively, compared with 1494 (37.6%) and 562 (14.1%) after 2018.

Conclusions and Relevance

In this cohort study of 8534 patients with metastatic ccRCC, although ICI-based combinations are the preferred first-line therapy due to their proven superiority over TKI monotherapy, many patients were not receiving them; high attrition rates were observed in subsequent lines. These findings highlight the need to optimize treatment selection by implementing current guidelines in clinical practice.

The genomic landscape of metastatic clear-cell renal cell carcinoma and its prognostic value: a comprehensive analysis of a large real-world clinico-genomic database

BACKGROUND

Translating findings on the genomic landscape of metastatic clear-cell renal cell carcinoma (mccRCC) into clinical practice remains challenging. A better understanding of the molecular features of mccRCC could identify a prognostic and/or predictive role for ccRCC genomic alterations.

PATIENTS AND METHODS

In this real-world observational study based on the nationwide (US-based) de-identified Flatiron Health-Foundation Medicine, Inc. clinico-genomic database (FH-FMI-CGDB), we investigate the frequency and co-occurrence of genomic alterations in mccRCC patients and assess their prognostic role. Patients (n = 858) were adults diagnosed with mccRCC, with FH electronic health records between 2011 and 2022.

RESULTS

The top 10 mutated genes were VHL (73.9%), PBRM1 (42.4%), SETD2 (25.3%), CDKN2A (20.0%), BAP1 (16.4%), CDKN2B (16.0%), KDM5C (14.5%), TP53 (12.9%), PTEN (11.7%), and TERT (9.2%). Eight genes showed prognostic value: CDKN2A, CDKN2B, TP53, PTEN, NF2, PIK3CA, and MTAP were linked to worse prognosis, whereas PBRM1 was associated with better overall survival (OS). Two of the three identified gene clusters had prognostic value: cluster 1 (VHL, SETD2, PBRM1, KDM5C, NFE2L2) correlated with better OS [adjusted hazard ratio (aHR) 0.63, P < 0.001], whereas cluster 3 (CDKN2A, CDKN2B, BAP1, NF2, MTAP) correlated with shorter OS (aHR 1.36, P = 0.023).

CONCLUSION

We identified eight genes and two gene clusters with prognostic significance for mccRCC. Future research will explore the predictive value of gene clusters in various treatments.

Cancer stem-like cells stay in a plastic state ready for tumor evolution

Cell plasticity emerges as a novel cancer hallmark and is pivotal in driving tumor heterogeneity and adaptive resistance to different therapies. Cancer stem-like cells (CSCs) are considered the root of cancer. While first defined as tumor-initiating cells with the potential to develop a heterogeneous tumor, CSCs further demonstrate their roles in cancer metastasis and adaptive therapeutic resistance. Generally, CSCs come from the malignant transformation of somatic stem cells or the de-differentiation of other cancer cells. The resultant cells gain more plasticity and are ready to differentiate into different cell states, enabling them to adapt to therapies and metastatic ecosystems. Therefore, CSCs are likely the nature of tumor cells that gain cell plasticity. However, the phenotypic plasticity of CSCs has never been systematically discussed. Here, we review the distinct intrinsic signaling pathways and unique microenvironmental niches that endow CSC plasticity in solid tumors to adapt to stressful conditions, as well as emerging opportunities for CSC-targeted therapy.

Challenges and Considerations in Modern Adjuvant Therapy Trials in Renal Cell Carcinoma: A Call to Power

Identification of effective adjuvant therapies for renal cell carcinoma remains challenging despite the development of immune checkpoint inhibitors. Enhancement of the design of trials of adjuvant therapy by focusing on populations with the highest risk and increasing the sample size is essential for reliable assessments of therapeutic efficacy.