Phase II presurgical feasibility study of bevacizumab in untreated patients with metastatic renal cell carcinoma

Use of RENAL nephrometry scores for predicting tumor upgrading between core biopsies and surgical specimens: a prospective ex vivo study

Determination of Fuhrman grade (FG) on biopsies of renal masses is relatively inaccurate, being prone to underestimating the true grade as ascertained from surgical specimens. This study evaluated whether anatomical features of tumors could predict tumor upgrading between core biopsies and surgical specimens. We prospectively enrolled 249 patients undergoing surgical resection of solid renal masses at our institution from 2012 to 2013. Tumor anatomical features were defined using RENAL nephrometry scores. Two peripheral and 1 central ex vivo core biopsies were taken from surgical specimens with an F18-gauge needle. Logistic regression was used to assess associations between covariates and FG upgrading. A comprehensive nomogram was constructed to quantitate the probability of tumor upgrading. The median tumor size was 4.75 cm and FG upgrading occurred in 43.6% of cases. In tumors of low, intermediate, and high complexity, the risk of FG upgrading was 22.0%, 47.6%, and 50.6%, respectively. According to multivariate analyses, anatomical features R (radius) and L (location) scores correlated significantly with FG upgrading. A combination of anatomical features and core biopsy findings predicted tumor upgrading with an accuracy of 0.884. With a threshold of 30%, our nomogram identified 92.4% of cases with upgrading; however, it overrated 26.8% of patients without upgrading. This ex vivo prospective study demonstrated that RENAL nephrometry score can aid prediction of FG upgrading between core biopsies and surgical specimens. Our nomogram uses anatomical features to predict true FG from renal biopsies.

Renal cell carcinoma

The treatment of renal cell carcinoma (RCC) has changed greatly over the past 15 years. Progress in the surgical management of the primary tumor and increased understanding of the molecular biology and genomics of the disease have led to the development of new therapeutic agents. The management of the primary tumor has changed owing to the realization that clean margins around the primary lesion are sufficient to prevent local recurrence, as well as the development of more sophisticated tools and techniques that increase the safety of partial nephrectomy. The management of advanced disease has altered even more dramatically as a result of new agents that target the tumor vasculature or that attenuate the activation of intracellular oncogenic pathways. This review summarizes data from prospective randomized phase III studies on the surgical management and systemic treatment of RCC, and provides an up to date summary of the histology, genomics, staging, and prognosis of RCC. It describes the management of the primary tumor and offers an overview of systemic agents that form the mainstay of treatment for advanced disease. The review concludes with an introduction to the exciting new class of immunomodulatory agents that are currently in clinical trials and may form the basis of a new therapeutic approach for patients with advanced RCC.

Bevacizumab and wound-healing complications: mechanisms of action, clinical evidence, and management recommendations for the plastic surgeon

Reflecting the growing understanding of vascular endothelial growth factor (VEGF) in cancer survival and growth, the anti-VEGF antibody bevacizumab (Avastin) is increasingly used to treat advanced malignancy. However, because VEGF also mediates proper wound healing, bevacizumab may lead to potentially severe wound-healing complications (WHCs). Because bevacizumab expands in use, the plastic surgeon will increasingly be entrusted to manage such WHCs successfully. Therefore, this review summarizes the pathophysiological evidence, systematically reviews the available clinical evidence, and provides management guidelines for bevacizumab-related WHCs. Bevacizumab produces WHCs by disrupting vasodilation, increased vascular permeability, and angiogenesis. Current clinical evidence suggests that bevacizumab may increase WHC risk. This risk seems higher with neoadjuvant than adjuvant bevacizumab use and may be decreased by extending the bevacizumab-surgery interval. Further research is required to quantify the exact bevacizumab-related WHC incidence and optimize the bevacizumab-surgery interval. We propose management guidelines for bevacizumab-related WHCs by indication that should be integrated with clinical judgment, input from the oncology team, and patient wishes when making therapeutic decisions.

Surgical management of metastatic renal cell carcinoma in the era of targeted therapies

BACKGROUND

Cytoreductive nephrectomy (CN) has been considered standard management for patients with metastatic renal cell carcinoma (mRCC) for over a decade. This practice, based on evidence from the immunotherapy era, has now come into question with the dramatic shift in management of mRCC patients due to the development and approval of several targeted molecular therapies (TMT).

METHODS

A comprehensive English language literature review was performed using MEDLINE/PubMed to identify articles and guidelines pertinent to CN in mRCC.

RESULTS

Retrospective studies have demonstrated improved survival for patients who underwent CN compared to those that did not; however, these studies suffer from heavy selection bias. Furthermore, the optimal timing of TMT, before or after surgery is not known. Pre-surgical TMT has the advantage of early treatment of metastases, downsizing of the primary, and may be an effective 'litmus test' for the selection of patients for CN based on response to TMT. The results of two ongoing phase III trials (CARMENA and SURTIME) will address much of the controversy on the role of CN and the timing of systemic therapy in the TMT era. In this review, we aim to present the evidence that lead to adoption of CN in the era of immunotherapies as well as the available data about the oncologic benefit of CN in patients with mRCC who receive TMT as their primary systemic therapy.

CONCLUSION

There seems to be an important role for CN in the era of TMT, mostly in patients with favorable risk and where a high percentage of tumor burden can be removed by cytoreductive surgery.

Transcription factor binding site analysis identifies FOXO transcription factors as regulators of the cutaneous wound healing process

The search for significantly overrepresented and co-occurring transcription factor binding sites in the promoter regions of the most differentially expressed genes in microarray data sets could be a powerful approach for finding key regulators of complex biological processes. To test this concept, two previously published independent data sets on wounded human epidermis were re-analyzed. The presence of co-occurring transcription factor binding sites for FOXO1, FOXO3 and FOXO4 in the majority of the promoter regions of the most significantly differentially expressed genes between non-wounded and wounded epidermis implied an important role for FOXO transcription factors during wound healing. Expression levels of FOXO transcription factors during wound healing in vivo in both human and mouse skin were analyzed and a decrease for all FOXOs in human wounded skin was observed, with FOXO3 having the highest expression level in non wounded skin. Impaired re-epithelialization was found in cultures of primary human keratinocytes expressing a constitutively active variant of FOXO3. Conversely knockdown of FOXO3 in keratinocytes had the opposite effect and in an in vivo mouse model with FOXO3 knockout mice we detected significantly accelerated wound healing. This article illustrates that the proposed approach is a viable method for identifying important regulators of complex biological processes using in vivo samples. FOXO3 has not previously been implicated as an important regulator of wound healing and its exact function in this process calls for further investigation.

Recommendations from the Spanish Oncology Genitourinary Group for the treatment of patients with renal cell carcinoma

Clear-cell renal cell carcinoma (RCC) is the most common kidney cancer. New treatment options of localized RCC recently incorporated include laparoscopic surgery, nephron-sparing surgery, ablative techniques and active surveillance. But 50 % of patients may develop disease recurrence attributable to subclinical metastases. In these cases, and considering the low benefits of chemotherapy, new targeted therapies such as tyrosine kinase inhibitors (TKIs) and mammalian target of rapamycin (mTOR) inhibitors have been developed as first- and second-line treatment. Both sunitinib and pazopanib are TKIs that constitute the first-line treatment option in patients with metastatic RCC. As second-line treatment, sequential therapy with a second TKI or a mTOR inhibitor is recommended. This review has collected together a series of recommendations issued by the Spanish Oncology Genitourinary Group with the aim of facilitating the treatment of these patients. Each recommendation is accompanied by the level of evidence and grade of recommendation on the basis of the available data.

Phase 2 trial of neoadjuvant axitinib in patients with locally advanced nonmetastatic clear cell renal cell carcinoma

BACKGROUND

Previous studies have shown a modest impact of tyrosine kinase inhibitors on primary renal tumors. Those studies were mostly retrospective or heterogeneous in their eligibility criteria with regard to histology, disease stage, duration of therapy, and time off therapy prior to surgery.

OBJECTIVE

To prospectively investigate the safety and efficacy of axitinib in downsizing tumors in patients with nonmetastatic biopsy-proven clear cell renal cell carcinoma (ccRCC).

DESIGN, SETTING, AND PARTICIPANTS

This was a single-institution, single-arm phase 2 clinical trial. Patients with locally advanced nonmetastatic biopsy-proven ccRCC were eligible.

INTERVENTION

Patients received axitinib 5mg for up to 12 wk. Axitinib was continued until 36h prior to surgery. Patients underwent partial or radical nephrectomy after axitinib therapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was objective response rate prior to surgery. Secondary outcomes included safety, tolerability, and quality of life. A dedicated radiologist independently reviewed all computed tomography scans to evaluate for response using Response Evaluation Criteria in Solid Tumors (RECIST).

RESULTS AND LIMITATIONS

A total of 24 patients were treated. Twenty-two patients continued axitinib for 12 wk; 1 patient continued axitinib for 11 wk and underwent surgery as planned. One patient stopped treatment at 7 wk due to adverse events (AEs). Median reduction of primary renal tumor diameter was 28.3%. Eleven patients experienced a partial response per RECIST; 13 had stable disease. There was no progression of disease while on axitinib. The most common AEs were hypertension, fatigue, oral mucositis, hypothyroidism, and hand-foot syndrome. Postoperatively, 2 grade 3 and 13 grade 2 complications were noted. No grade 4 or 5 complications occurred. Functional Assessment of Cancer Therapy-Kidney Specific Index-15 changed over time, with quality of life worsening while on therapy, but by week 19, it was not statistically different from screening. Limitations include single-arm design and small patient numbers.

CONCLUSIONS

Axitinib was clinically active and reasonably well tolerated in the neoadjuvant setting in patients with locally advanced nonmetastatic ccRCC.

PATIENT SUMMARY

In this prospective clinical trial, we found that axitinib, when given prior to surgery, results in significant shrinking of kidney cancers. Larger studies are needed prior to further clinical use.

TRIAL REGISTRATION

This clinical trial was registered with clinicaltrials.gov (NCT01263769).

Targeted therapy of kidney cancer: keeping the art around the algorithms

BACKGROUND

Therapy for metastatic kidney cancer is actively evolving, particularly in the results of registration drug trials that have led to the approval of vascular endothelial growth factor pathway drugs such as sorafenib, sunitinib, pazopanib, bevacizumab, and axitinib, with focus on patients with good- or intermediate-risk criteria and clear cell histology. Mammalian target of rapamycin (mTOR) drugs such as everolimus and temsirolimus pivotal trials emphasize experiences in the setting of prior treatment or high-risk features. Interferon and interleukin 2 also are part of the treatment algorithms.

METHODS

The results of pivotal trials and the underlying context for the development of a cogent, cohesive treatment plan for an individual are reviewed, touching on decision points such as nephrectomy, metastasectomy, and medical initiation and discontinuation time points.

RESULTS

To the extent that these drug therapies are essential for achieving best outcomes for patients, these pivotal trial results and associated guidelines exist within a multidimensional, multidisciplinary context of many other disease features, comorbid features, and non-drug treatment decisions. Other dimensions include investigational targeted therapies, patient selection strategies, surgical strategies, and immunotherapies, some of which are in active development.

CONCLUSIONS

Clinicians should work toward the best use of drug sequencing and selection strategies based on core data derived from prospective randomized trials. To address individual patient needs, they should also recognize and emphasize individualized goals, to the extent that these are different from issues that were directly addressed in the trials.

Cytoreductive nephrectomy for metastatic renal cell carcinoma: a review of the historical literature and its role in the era of targeted molecular therapy

Renal cell carcinoma presents with metastatic disease in approximately 30% cases. While surgical intervention remains the standard of care for organ confined disease, its role is limited in the management of metastatic disease. Over the last decade, cytoreductive nephrectomy prior to immunotherapy has demonstrated significant improvement in overall survival for appropriately selected patients. This review summarizes the evidence for the role of cytoreductive nephrectomy in combination with immunotherapy and discusses its potential role in the current era of targeted molecular therapy.

Cytoreductive nephrectomy: past, present and future

Cytoreductive nephrectomy (CN) is an integral part of the treatment of patients with metastatic renal cell carcinoma. Improved survival has been shown with CN and IFN-α. The introduction of targeted therapy for metastatic renal cell carcinoma has raised important questions regarding the role of CN. The majority of patients who were enrolled in the Phase III studies of targeted therapies had undergone prior nephrectomy. Thus, the benefit of these agents has largely been demonstrated in a nephrectomized population. CARMENA and SURTIME, important Phase III studies examining the role and timing of CN, are ongoing. Until new evidence is available, CN is a reasonable approach in selected patients with a resectable primary tumor and good performance status.

Presurgical therapy with axitinib for advanced renal cell carcinoma: a case report

Background

Targeted therapy with tyrosine kinase inhibitors has been shown to reduce tumor volumes and prolong the survival of patients with metastatic renal cell carcinoma. Tyrosine kinase inhibitors, particularly sunitinib, have recently been used in neoadjuvant and presurgical settings. Axitinib is a promising second-line therapy option for advanced or metastatic renal cell carcinoma. Herein, we report a patient with advanced renal cell carcinoma who received presurgical treatment with axitinib.

Case presentation

A 73-year-old man was transported by ambulance to a community hospital with chief complaints of high fever and a gait disorder. Computed tomography screening revealed a hypervascular tumor (size, 9 × 8.5 cm) in the lower pole of the left kidney. Upon admission to our hospital, his general condition was poor and his performance status was judged as 3, based on the Eastern Cooperative Oncology Group performance status criteria. After biopsy for the renal tumor, he received 5 mg of axitinib twice daily for 3 months. No serious adverse events were reported during this treatment. The tumor diameter shrank by 56%. Left radical nephrectomy was performed, and there were no intraoperative or postoperative complications. Pathological examination indicated a pT3aN0M0, Furman grade 3, clear cell renal cell carcinoma with necrosis, hyaline degeneration, and hemosiderosis. The patient was asymptomatic and disease-free at 1 year post-diagnosis.

Conclusion

This case study demonstrate that presurgical therapy with axitinib is feasible and might have several potential advantages for patients with advanced renal cell carcinoma.

Molecular markers to predict response to therapy

Currently approved treatments for metastatic renal cell carcinoma (RCC) include vascular endothelial growth factor (VEGF)-blocking agents, mammalian target of rapamycin (mTOR) inhibitors, and cytokine therapy. In the near future, we are likely to add immune checkpoint blocking agents to this list. As we develop treatment platforms around each therapeutic class, determining which drug is best for a particular patient becomes increasingly important. At this point, we do not have validated predictive biomarkers for patients with RCC. Here, we discuss the logistical challenges surrounding biomarker development, summarize the current crop of biomarker candidates, and explore potential avenues for the development of more effective predictive tools for patients with advanced RCC.

[New anti-angiogenic strategies in the management of kidney cancer]

INTRODUCTION

The aim of this study was to clarify the current role of adjuvant and neo-adjuvant in the treatment of kidney cancer.

MATERIALS AND METHODS

The data were explored in Medline (http://www.ncbi.nlm.nih.gov) using the following MeSH terms or combinations of these keywords: "cancer", "rein", "kidney", "adjuvant", "neoadjuvant", "antiangiogenique", "antiangiogenic" and selecting the items produced in their methodology, their relevance to the theme explored and their date of publication.

RESULTS

Thirty-two English and French items published between 2001 and 2011 were selected: five studies of evidence level 1, nine level 2 studies, nine level 4 studies, five studies at level 5 and four literature reviews. The cytoreductive nephrectomy as first-line treatment of locally advanced or metastatic kidney cancer is now controversial with the advent of new targeted anti-angiogenic therapies. In neoadjuvant setting, these treatments showed a moderate decrease in tumor volume and rarely improved resectability. In adjuvant setting, their place has yet to be specified and several trials are currently underway.

CONCLUSION

Recent years have seen the anti-angiogenic therapeutic strategies upset in locally advanced and metastatic renal cancer. The development of clinical trials and research protocols will allow us to determine in the near future the optimal therapeutic sequences.

Differential microRNA expression in renal cell carcinoma

The present study aimed to detect microRNA expression levels in the tissues and sera of patients with clear cell renal cell carcinoma (ccRCC). The association of microRNA expression with ccRCC clinical pathology was analyzed, and the potential of the microRNAs as ccRCC serum markers and the significance of their expression in the clinical diagnosis, staging, prognosis and selection of new therapeutic targets for ccRCC were discussed. Specific microRNAs were selected according to the associated literature. TaqMan quantitative polymerase chain reaction (qPCR) technology was used to determine the expression levels of selected microRNAs. miR-34a, miR-224 and miR-21 were upregulated, whereas miR-141, miR-149 and miR-429 were downregulated in the ccRCC tissues (P<0.01). The expression of miR-221 and miR-211 was not significant in the ccRCC tissues (P>0.05). miR-34a, miR-21 and miR-224 were upregulated and miR-141 was downregulated in the sera of patients with ccRCC (P<0.01), while the expression of miR-149 and miR-429 was not significant (P>0.05). The serum miR-21 expression levels were significantly correlated with the clinical staging of the patients with ccRCC (P<0.05). miR-34a, miR-21 and miR-224 are upregulated in the tissues and sera of patients with ccRCC, whereas miR-141 is downregulated. miR-21 and miR-141 are associated with ccRCC and are, thus, potential ccRCC serum markers.

Cytoreductive radiofrequency ablation in patients with metastatic renal cell carcinoma (RCC) with small primary tumours treated with sunitinib or interferon-α

OBJECTIVES

To evaluate the role of cytoreductive radiofrequency ablation (cRFA) in patients with metastatic renal cell carcinoma (RCC) with small primary tumours treated with immuno- or targeted therapy. To assess the efficacy of sunitinib in patients with metastatic RCC with unresected small primary tumours.

PATIENTS AND METHODS

Three parallel single-arm prospective studies were conducted. Eligibility criteria were nearly identical for all trials and included: histopathologically confirmed RCC; metastatic measurable disease; size of primary tumour <5 cm; good or intermediate prognosis according to the Memorial Sloan-Kettering Cancer Center model; and no previous therapy. Study 1: Patients were treated with percutaneous cRFA under computed tomography guidance followed by interferon (IFN)-α, 9 MIU, s.c., three times per week. Study 2: Patients received cRFA followed by sunitinib in repeated 6-week cycles of 50 mg/day orally for 4 weeks, then 2 weeks off treatment. Study 3: Patients with unresected primary RCC received sunitinib alone. The primary endpoint was progression-free survival (PFS).

RESULTS

Baseline patient characteristics (age, gender, histology, Eastern Cooperative Oncology Group performance status, metastatic sites, primary tumour size) were similar in all three studies. Efficacy data for 114 evaluable patients showed an objective response rate of 8% (95% confidence interval [CI] 4.5, 10.5) for study 1, 28.9% (95% CI 15.2, 34) for study 2, and 31.6% (95% CI 20.3, 38.9) for study 3. The median (95% CI) PFS times were 9.1 (6.9, 10.2), 13.4 (9.8, 14.4) and 12.7 (11.3, 13.5) months for studies 1, 2 and 3, respectively. Objective response rate was significantly higher and PFS significantly longer in the sunitinib trials than in study 1 (P < 0.01 all differences); no differences were found between studies 2 and 3 (objective response rate, P = 0.1; PFS, P = 0.6). Study 1 met its primary endpoint, showing that PFS was significantly longer than the expected 5 months (P = 0.02). The median (95% CI) objective survival (OS) times were greater in study 2 (cRFA/sunitinib) and study 3 (sunitinib-alone) than in study 1 (IFN-α) at 27.2 (22.6, 31.8) and 22.5 (20.7, 24.3) vs 19.5 (16.3, 22.7) months, respectively. Differences were significant (study 1 vs 2, hazard ratio [HR] = 0.55; P = 0.003; study 1 vs study 3 HR = 0.6, P = 0.01). OS was significantly longer in the cRFA/sunitinib group compared with the sunitinib-alone group (HR = 0.71; P = 0.04). There were no unexpected toxicities of medical treatment or complications of cRFA.

CONCLUSIONS

cRFA is a safe and effective approach for select patients with metastatic RCC treated with immunotherapy. The cRFA technique did not improve PFS in patients treated with sunitinib; cRFA probably has impact on OS in these patients. This needs to be tested in a larger trial. Sunitinib was effective in patients with metastatic RCC with unresected small primary tumours.

Probability of downsizing primary tumors of renal cell carcinoma by targeted therapies is related to size at presentation

OBJECTIVE

To evaluate the probability of downsizing primary renal tumors by targeted therapy in correlation to size.

METHODS

A literature search was conducted and our own data were pooled with data of retrospective series and prospective trials in which patients were treated with tyrosine kinase inhibitors (TKIs) and in which tumor sizes before and after treatment were reported. Included were 89 primary clear cell renal tumors, including 34 from our institutes. The longest diameter of the primary tumors before and after treatment was obtained. Primary tumor size at presentation was divided in 4 categories: <5 cm (n=10), 5 to 7 cm (n=21), 7 to 10 cm (n=31), and >10 cm (n=27). Pearson correlation and t test were used for statistical analysis.

RESULTS

The TKI was sorafenib in 21 tumors and sunitinib in the remaining 68. Smaller tumor size was related to more effective downsizing (P=0.01). Median downsizing was 32% (-46% to 11%) in the first group (<5 cm) and 11% (-55% to 16%) in the second group (5-7 cm); however, 8 of 21 (38%) in this group reduced to a range of 2.3 to 4.7 cm in which ablative techniques are feasible and nephron-sparing surgery may benefit from the reduced size. Median downsizing was 18% (-39% to 2%) in tumors of 7 to 10 cm and 10% (-31% to 0%) in those>10 cm.

CONCLUSION

The smaller the primary tumor, the greater the likelihood and the more effective the downsizing. A potential benefit of neoadjuvant treatment to downsize the primary tumor for ablative techniques or nephron-sparing surgery may exist, particularly in tumors sized 5 to 7 cm.

Selecting patients for cytoreductive nephrectomy in advanced renal cell carcinoma: who and when

Renal cell carcinoma presents with metastatic disease in approximately 30% of patients at the time of diagnosis. Cytoreductive nephrectomy (CN) of the primary tumor in the face of metastatic disease is part of a multimodality approach including systemic therapy that is based on evidence from randomized trials in the cytokine era. Data from the pretargeted therapy era showed that CN had a clear role in metastatic renal cell carcinoma, increasing life expectancy by approximately 6 months. The substantial improvement in outcomes reported for targeted therapy has challenged the previous role of CN. However, despite the absence of data from Phase III trials, available evidence suggests that some patients may benefit substantially from CN in the era of targeted therapy. This review summarizes current arguments for CN and how to best select patients for surgery. Ongoing trials are key in generating evidence towards a personalized approach to debulking nephrectomy.

Bevacizumab: overview of the literature

Inhibiting the angiogenic process is a clever method of cancer care. Over the last decade, some antiangiogenic compounds have been developed and approved for cancer treatment. Bevacizumab is a humanized monoclonal antibody that inhibits VEGF activity. When used in combination with chemotherapy, it has an important role for treating many types of advanced cancer, including colorectal cancer, renal cell carcinoma, non-small-cell lung cancer, breast cancer, ovarian cancer and glioblastoma multiforme. In this paper we review the basic science behind this molecule's development, as well the major clinical trials in which bevacizumab was involved in oncology.

Biomarkers: the next therapeutic hurdle in metastatic renal cell carcinoma

Despite recent advances, metastatic renal cell carcinoma remains largely an incurable disease. Vascular endothelial growth factor and mammalian target of rapamycin inhibitors have provided improvements in clinical outcomes. High-dose interleukin 2 remains an option for highly selected patients and is associated with durable remissions in a small minority of patients. The toxicity profiles of specific agents and patient characteristics and comorbidities and costs have an important role in the current choice of therapy. Major challenges encountered in developing molecular biomarkers to guide therapy are tumour heterogeneity and standardisation of tissue collection and analysis. Although biomarkers are in their infancy of development, they should be a priority in early preclinical and clinical development in order to guide rational tailored development of emerging agents.

Is there a role for neoadjuvant targeted therapy to downsize primary tumors for organ sparing strategies in renal cell carcinoma?

With an increasing number of small renal masses being diagnosed organ-preserving treatment strategies such as nephron-sparing surgery (NSS) or radiofrequency and cryoablation are gaining importance. There is evidence that preserving renal function reduces the risk of death of any cause, cardiovascular events, and hospitalization. Some patients have unfavourable tumor locations or large tumors unsuitable for NSS or ablation which is a clinical problem especially in those with imperative indications to preserve renal function. These patients may benefit from downsizing primary tumors by targeted therapy. This paper provides an overview of the current evidence, safety, controversies, and ongoing trials.

Current and future systemic treatments for renal cell carcinoma

Systemic treatment of renal cell carcinoma has changed dramatically since 2007, with the development and approval of six new agents, which target complex molecular pathways regulating tumour angiogenesis and cell proliferation and survival. These treatments have significantly improved survival times in metastatic renal cell carcinoma, but remain palliative. A number of newer agents are in clinical development, which offer theoretical advantages over existing treatments, and research methodologies are adapting with the aim of defining an individualised approach to therapy which exploits the underlying tumour biology. This review will provide an overview of current and emerging systemic treatments and how they might be integrated with surgical therapy, with a particular focus on advanced, clear cell metastatic renal cell carcinoma.

Neo adjuvant treatment with targeted molecules for renal cell cancer in current clinical practise

Target molecule Treatment (TMT) have emerged as the primary treatment in metastatic renal cell carcinoma. Majority of the patients in pivot trials were post nephrectomy cases. The benefit of cytoreductive nephrectomy in the era of TMT is debated. The role of these molecules in the adjuvant settings and in neo adjuvant/pre surgical role has evoked interest. In this review the different molecules used in the treatment of metastatic renal cancer and its effect on the primary renal tumour is discussed. Information available in the public domain about the presurgical/neoadjuvant targeted molecular treatment (TMT) is reviewed to understand the benefits and adverse effects of this modality of treatment. Sunitinib and sorafenib are the most commonly used and effective molecules in the neo adjuvant/re surgical treatment of renal cell carcinoma . Bevacizumab is less effective and has more chance of surgical complications in these settings mainly due to poor wound healing secondary to prolonged wash off period . The patent and the surgeon should be aware of the unpredictability and possible adverse effects before advising these molecule pre operatively. The response of the primary renal tumour to the target molecule is different from that of the metastatic tumour. The side effects of the molecules and its effect on the peri operative morbidity and mortality should also be considered when we advise these molecules as pre surgical/neo adjuvant treatment.

Integration of surgery and systemic therapy for renal cell carcinoma

Proper integration of surgery and systemic therapy is essential for improving outcomes in renal cell carcinoma (RCC). There is no current role for adjuvant therapy after nephrectomy for clinically localized disease. The potential benefits of neoadjuvant therapy for locally advanced nonmetastatic disease are in need of further study. In metastatic disease, the proper integration of cytoreductive surgery and systemic therapy remains to be elucidated. Presurgical targeted therapy is feasible and may be beneficial. Pending the results of randomized controlled trials, upfront cytoreductive nephrectomy in appropriate patients will likely continue as the paradigm of choice in metastatic RCC.

Neoadjuvant therapy of renal cell carcinoma: a novel treatment option in the era of targeted therapy?

The study was carried out to evaluate the effectiveness, toxicity and optimal duration of neoadjuvant therapy for patients with organ-confined or locally advanced renal cell carcinoma in the era of targeted agents. A literature review was carried out using Medline/Pubmed articles, as well as congress reports from the last five American Society of Clinical Oncology, American Urological Association and European Association of Urology Annual Meetings. Neoadjuvant targeted therapy is feasible and shows toxicity similar to that seen in a palliative setting. Most studies recommend an application for 2-4 months. The current data situation is best for sunitinib. Surgery can apparently be carried out the day right after discontinuing the drug. However, even sunitinib leads to only a mean 10% decrease in primary tumor size, and one-quarter to one-fifth of all patients show local tumor progression during treatment. Few patients (approximately 12%) with a vena cava tumor thrombus achieve a significant decrease in its level under neoadjuvant therapy; here too, progression is observed in a significant number of cases. Even the new targeted agents show limited effectiveness in achieving relevant remissions of the primary tumor. Furthermore, tumor progression is seen in a significant percentage of patients during neoadjuvant therapy. Thus, even today in the era of targeted agents, a neoadjuvant approach should only be made in patients with localized or locally advanced renal cell carcinoma, which primarily seem to be absolutely inaccessible by (partial) nephrectomy.

Rapid angiogenesis onset after discontinuation of sunitinib treatment of renal cell carcinoma patients

PURPOSE

To investigate the angiogenic changes in primary tumor tissue of renal cell carcinoma (RCC) patients treated with VEGF-targeted therapy.

EXPERIMENTAL DESIGN

Phase II trials of VEGF pathway-targeted therapy given before cytoreductive surgery were carried out with metastatic RCC patients with the primary tumor in situ to investigate the necessity of nephrectomy. Primary tumor tissues were obtained and assessed for angiogenesis parameters. Results were compared with similar analyses on untreated tumors.

RESULTS

Sunitinib or bevacizumab pretreatment resulted in a significant reduction of microvessel density in the primary tumor. Also, an increase in vascular pericyte coverage was found in sunitinib-pretreated tumors, consistent with efficient angiogenesis inhibition. Expression of several key regulators of angiogenesis was found to be suppressed in pretreated tissues, among which VEGFR-1 and VEGFR-2, angiopoietin-1 and angiopoietin-2 and platelet-derived growth factor-B. In addition, apoptosis in tumor and endothelial cells was induced. Interestingly, in sunitinib-pretreated tissues a dramatic increase of the number of proliferating endothelial cells was observed, which was not the case in bevacizumab-pretreated tumors. A positive correlation with the interval between halting the therapy and surgery was found, suggesting a compensatory angiogenic response caused by the discontinuation of sunitinib treatment.

CONCLUSION

This study describes, for the first time, the angiostatic response in human primary renal cancers at the tissue level upon treatment with VEGF-targeted therapy. Discontinuation of treatment with tyrosine kinase inhibitors leads to accelerated endothelial cell proliferation. The results of this study contribute important data to the ongoing discussion on the discontinuation of treatment with kinase inhibitors.

Current status of targeted therapy for advanced renal cell carcinoma

The treatment of metastatic renal cell carcinoma (mRCC) has recently evolved from being predominantly cytokine-based treatment to the use of targeted agents, which include sorafenib, sunitinib, bevacizumab (plus interferon alpha [IFN-α]), temsirolimus, everolimus, pazopanib, and most recently, axitinib. Improved understanding of the molecular pathways implicated in the pathogenesis of RCC has led to the development of specific targeted therapies for treating the disease. In Korea, it has been 5 years since targeted therapy became available for mRCC. Thus, we now have broader and better therapeutic options at hand, leading to a significantly improved prognosis for patients with mRCC. However, the treatment of mRCC remains a challenge and a major health problem. Many questions remain on the efficacy of combination treatments and on the best methods for achieving complete remission. Additional studies are needed to optimize the use of these agents by identifying those patients who would most benefit and by elucidating the best means of delivering these agents, either in combination or as sequential single agents. Furthermore, numerous ongoing research activities aim at improving the benefits of the new compounds in the metastatic situation or their application in the early phase of the disease. This review introduces what is currently known regarding the fundamental biology that underlies clear cell RCC, summarizes the clinical evidence supporting the benefits of targeted agents in mRCC treatment, discusses survival endpoints used in pivotal clinical trials, and outlines future research directions.

Adjuvant and neoadjuvant therapies in high-risk renal cell carcinoma

The standard of care for renal cell carcinoma (RCC) is surgical resection as a monotherapy or as part of a multimodal approach. A significant number of patients undergoing surgery for localized RCC experience recurrence, suggesting that there are some individuals in whom surgical excision is necessary but insufficient because of the presence of micrometastatic disease at diagnosis. This review summarizes current algorithms used to identify patients at high risk for disease recurrence following the surgical resection of RCC, the outcomes of contemporary adjuvant systemic therapy trials, and the rationale supporting the use of neoadjuvant therapy.

Vascular endothelial growth factor-targeted therapies in advanced renal cell carcinoma

Vascular endothelial growth factor (VEGF) is, to date, the key element in the pathogenesis of renal cell carcinoma (RCC). VEGF pathway activation is responsible for the recruitment, migration, and expansion of endothelial cells, with this angiogenesis tumor model being characteristic of RCC. Different strategies have been developed for almost a decade to block the VEGF pathway in this setting. Four different compounds were approved for metastatic RCC (mRCC) in the past 6 years: bevacizumab, sunitinib, sorafenib, and pazopanib. Axitinib and tivozanib are also promising compounds under evaluation. The revolution in the management and prognosis of patients with mRCC is ongoing.

Consolidative surgery after targeted therapy for renal cell carcinoma

Renal cell carcinoma is the most lethal of the common genitourinary neoplasms, with 30% to 40% of patients eventually dying from disease progression. Although the recent development of targeted therapies against kidney cancer has yielded substantially improved tumor response rates and progression-free survival, these agents are still not curative. The integration of systemic therapies with surgery still represents the best management for select patients with advanced disease. Specifically, consolidative surgery may play a vital role in the management of this challenging patient population. However, concerns remain regarding the potential for increased surgical morbidity complicating the integration of surgery after targeted therapy. Careful patient selection and specific precautions to increase surgical safety should be implemented.

Early primary tumor size reduction is an independent predictor of improved overall survival in metastatic renal cell carcinoma patients treated with sunitinib

BACKGROUND

In metastatic renal cell carcinoma (mRCC) patients treated with targeted agents and their primary tumor (PT) in situ, early PT decrease in size correlates with improved overall PT response, but the effect on overall survival (OS) is unknown.

OBJECTIVE

To evaluate whether early PT size reduction is associated with improved OS in patients with mRCC undergoing treatment with sunitinib.

DESIGN, SETTING, AND PARTICIPANTS

We reviewed the clinical and radiographic data of all mRCC patients seen at our institution between January 2004 and December 2009 without prior systemic treatment who received sunitinib with their PT in situ.

MEASUREMENTS

Two independent reviewers measured the diameter of the PT and metastatic disease at baseline and subsequent scans to assess response. Early minor response was defined as ≥10% decrease within 60 d of treatment initiation. Univariate and multivariate analyses were used to calculate a hazard ratio (HR) corresponding to the risk of death based on clinical and pathologic factors as well as PT response.

RESULTS AND LIMITATIONS

We identified 75 consecutive patients with a median follow-up of 15 mo. All patients were intermediate or poor risk by common risk stratification systems. Median initial PT diameter was 9.7cm. Median maximum PT size reduction was -10.2% overall and -36.4% in patients who had early minor PT response. Median OS for patients without minor PT response, with minor PT response after 60 d, and with early minor PT response was 10.3, 16.5, and 30.2 mo, respectively. On multivariate analysis, early minor response was an independent predictor of improved OS (HR: 0.26; p=0.031). Other significant predictors included venous thrombus, multiple bone metastases, lactate dehydrogenase above the upper limit of normal, symptoms at presentation, and more than two metastatic sites.

CONCLUSIONS

Early minor PT response is associated with improved OS. Future studies should evaluate this prognostic factor to identify patients with prolonged OS.

Surgical management of large renal tumors

The surgical management of patients with renal cell carcinoma has undergone many changes. With equivalent oncologic outcomes and appreciation of the importance of renal functional preservation, the utilization of nephron-sparing partial nephrectomy has increased in recent years. Nevertheless, tumors of larger size continue to be preferentially treated with radical nephrectomy. Here, we present evidence that improvements in techniques and durability of oncologic outcomes has justified the use of nephron sparing to accomplish renal functional preservation even in patients with large renal tumors. In addition, surgical technical considerations when managing such tumors are discussed. Finally, we discuss cytoreductive surgery and the evolving role of systemic targeted therapies in the management of advanced metastatic disease.

Chromosome 14q loss defines a molecular subtype of clear-cell renal cell carcinoma associated with poor prognosis

Loss of chromosome 14 has been associated with poor outcomes in clear-cell renal cell carcinoma. Expression of HIFα isoforms has been linked to distinct molecular phenotypes of clear-cell renal cell carcinoma. We hypothesized that chromosome 14 loss could lead to a decrease in HIF1α levels, as its gene (HIF1A) resides in this chromosome. We analyzed 112 archival clear-cell renal cell carcinoma tumor specimens with 250K SNP microarrays. We also evaluated expression of HIFα isoforms by qPCR and immunohistochemistry in a subset of 30 patients. Loss of chromosome 14q was associated with high stage (III-IV, P=0.001), high risk for recurrence (P=0.002, RR 2.78 (1.506-5.153)) and with decreased overall survival (P=0.030) in non-metastatic clear-cell renal cell carcinoma. HIF1α mRNA and protein expression was reduced in specimens with loss of 14q (P=0.014) whereas HIF2α was not. Gain of 8q was associated with decreased overall survival (P<0.0001). Our studies confirm an association between 14q loss and clinical outcome in non-metastatic clear-cell renal cell carcinoma patients and that 8q gain is a candidate prognostic marker for decreased overall survival and appears to further decrease survival in patients with 14q loss. We have also identified that differential expression of HIF1α is associated with 14q loss. Further exploration of 8q gain, 14q loss, MYC, HIF1A and EPAS1 (HIF2α) as molecular markers of tumor behavior and prognosis could aid in personalizing medicine for patients with clear-cell renal cell carcinoma.

Safety of presurgical targeted therapy in the setting of metastatic renal cell carcinoma

BACKGROUND

In patients with metastatic renal cell carcinoma (mRCC), the timing of systemic targeted therapy in relation to cytoreductive nephrectomy (CN) is under investigation.

OBJECTIVE

To evaluate postoperative complications after the use of presurgical targeted therapy prior to CN.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of all patients who underwent a CN at The University of Texas M.D. Anderson Cancer Center from 2004 to 2010 was performed. Inclusion in this study required documented evidence of mRCC, with treatment incorporating CN.

INTERVENTIONS

Patients receiving presurgical systemic targeted therapy prior to CN were compared to those undergoing immediate CN.

MEASUREMENTS

Complications were assessed using the modified Clavien system for a period of 12 mo postoperatively.

RESULTS AND LIMITATIONS

Presurgical therapy was administered to 70 patients prior to CN (presurgical), while 103 patients had an immediate CN (immediate). A total of 232 complications occurred in 57% of patients (99 of 173). Use of presurgical systemic targeted therapy was predictive of having a complication>90 d postoperatively (p=0.002) and having multiple complications (p=0.013), and it was predictive of having a wound complication (p<0.001). Despite these specific complications, presurgical systemic targeted therapy was not associated with an increased overall complication risk on univariable or multivariate analysis (p=0.064 and p=0.237) and was not predictive for severe (Clavien ≥3) complications (p=0.625). This study is limited by its retrospective nature. As is inherent to any retrospective study reporting on complications, we are limited by reporting bias and the potential for misclassification of specific complications.

CONCLUSIONS

Despite an increased risk for specific wound-related complications, overall surgical complications and the risk of severe complications (Clavien ≥3) are not greater after presurgical targeted therapy in comparison to upfront cytoreductive surgery.