Treatment of patients with metastatic renal cell cancer: a RAND Appropriateness Panel

Gln223Arg polymorphism in the Caucasian population and Pro1019Pro polymorphism in the Chinese population are risk factors for OSAS: An updated meta-analysis of 1159 subjects

BACKGROUND

We conducted a meta-analysis of published literature to identify the correlation between leptin receptor gene polymorphisms and the risk of obstructive sleep apnea syndrome (OSAS).

METHODS

Five different single nucleotide polymorphisms (SNPs) were studied. Only Gln223Arg and Pro1019Pro had multiple studies. Nine studies focused on the correlation between Gln223Arg and Pro1019Pro polymorphisms and OSAS risk. Fixed-effects model or random-effects model was used to calculate the pooled odds ratio (ORs) and its corresponding 95% confidence interval (95% CI). The Begg's, Egger's, Perter's and Harbord tests were used to measure publication bias. Sensitivity analysis was also performed to ensure the robustness of the findings.

RESULTS

Six studies on Gln223Arg polymorphisms (661 cases and 498 controls) and three studies on Pro1019Pro polymorphisms (561 cases and 561 controls) were extracted. There was no correlation between the leptin receptor Gln223Arg polymorphism and the risk of OSAS (odd ratio=0.86, 95% CI=0.68-1.10, P=0.23). However, Caucasian OSAS patients had a higher Arg allele frequency; whereas Chinese population with G genotype were more susceptible to OSAS (odd ratio=1.28, 95% CI=1.04-1.57, P=0.02) in the studies on Pro1019Pro polymorphisms.

CONCLUSION

The Gln223Arg polymorphisms in the Caucasian population and the Pro1019Pro polymorphisms in the Chinese population are risk factors for OSAS.

Surgical considerations for patients with metastatic renal cell carcinoma

Among patients with renal cell carcinoma (RCC), 25-30% present with metastatic disease at the time of initial diagnosis. Despite the ever-increasing array of treatment options available for these patients, surgery remains one of the cornerstones of therapy. Proper patient selection for cytoreductive surgery is paramount to its effective use in the management of patients with metastatic RCC despite the decrease in reported morbidity rates. We explore the evolving role cytoreductive surgery in metastatic RCC spanning the immunotherapy era to the targeted therapy era. Despite significant advances in the management of patients with metastatic RCC, further evidence on the definitive role of cytoreductive surgery in the targeted therapy era is awaited through large randomized trials.

Assessment of survival of patients with metastatic clear cell renal cell carcinoma after radical cytoreductive nephrectomy versus no surgery: a seer analysis

PURPOSES

To examine the factors related to the choice of cytoreductive nephrectomy (CN) for patients with metastatic clear cell renal cell carcinoma (mCCRCC), and compare the population-based survival rates of patients treated with or without surgery in the modern targeted therapy era.

MATERIALS AND METHODS

From 2006 to 2009, patients with mCCRCC were identified from SEER database. The factors that affected patients to be submitted to CN were examined and propensity scores for each patient were calculated. Then patients were matched based upon propensity scores. Univariable and multivariable cox regression models were used to compare survival rates of patients treated with or without surgery. Finally, sensitivity analysis for the cox model on a hazard ratio scale was performed.

RESULTS

Age, race, tumor size, T stage and N stage were associated with nephrectomy univariablely. After the match based upon propensity scores, the 1-, 2-, and 3-year cancer-specific survival rate estimates were 45.1%, 27.9%, and 21.7% for the no-surgery group vs 70.6%, 52.2%, and 41.7% for the surgery group, respectively (hazard ratio 0.42, 95%CI: 0.35-0.52, log-rank P<0.001). In multivariable Cox proportional hazard regression model, race, T stage, N stage and median household income were significantly associated with survival. Sensitivity analysis on a hazard ratio scale indicated that the hazard ratio might be above 1.00 only when the unknown factor had an opposite effect on survival which was 3-fold than CN.

CONCLUSION

The results of our study showed that CN significantly improves the survival of patients with metastatic CCRCC even in the targeted therapy era.

Frontiers in clinical and molecular diagnostics and staging of metastatic clear cell renal cell carcinoma

The last few years have brought advances in the understanding of the molecular biology of metastatic clear cell renal cell carcinoma (RCC). Both preclinical research and clinical trials brought together results from the latest advancements in RCC diagnostic and staging. Understanding of the complex molecular alterations involved in the development and progression of RCC enables development of immunohistochemical and genetic diagnostic tools and is also opening the doors for experimental targeted therapies. At the same time, improvements of medical and molecular imaging improves the sensitivity and specificity of metastatic disease diagnosis. Moreover, independent validation of molecular profiles across high-throughput platforms, methods, laboratories and cancer populations has recently been successfully performed in RCC. Generation of informative, clinical diagnostic tools is likely to contribute to development of novel personalized diagnostic and treatment protocols and ensure prolonged survival of RCC patient in the near future.

Assessing the impact of evolving evidence in renal cell carcinoma treatment: an update of the Renal Cell Carcinoma Appropriateness-based Treatment Toolkit (ReCATT)

The appropriateness of the numerous therapeutic options available for patients with advanced or metastatic renal cell carcinoma (RCC) was evaluated in 2011, using the RAND/University of California, Los Angeles (UCLA) appropriateness methodology to match treatment suitability to a range of patient scenarios. However, the RCC therapeutic area evolves rapidly and a body of new clinical data has accrued in the intervening years; as a result the exercise was repeated in 2013 using the same methodology, expert panel and patient scenarios. The aim of the updated assessment was to update the guidance to clinicians and use it to develop an interactive web-based application, the Renal Cell Carcinoma Appropriateness-based Treatment Toolkit (ReCATT). This round of assessment achieved greater concordance concerning the appropriateness of treatments/interventions for the clinical scenarios tested; this higher level of agreement is likely to reflect the body of scientific evidence accrued since the previous assessment exercise. Many of the areas of disagreement in 2011 related to the suitability of pazopanib or sunitinib treatment; in the 2013 assessment both agents were considered appropriate treatment options for many of the clinical scenarios assessed. Uncertain scenarios often are related to the optimal management of metastatic RCC with clear cell histology. The use of the RAND/UCLA RCC assessment findings to develop the ReCATT support tool will help to disseminate expert opinion concerning best treatment practice and guide the clinical management of RCC patients treated in the community setting.

Management of metastatic renal cell carcinoma patients with poor-risk features: current status and future perspectives

With seven agents approved for renal cell carcinoma within the past few years, there has undoubtedly been progress in treating this disease. However, patients with poor-risk features remain a challenging and difficult-to-treat population, with the mTOR inhibitor, temsirolimus, the only agent approved in the first-line setting. Phase III trial data are still lacking VEGF-pathway inhibitors in patients with poor prognostic features. Poor-risk patients need to be considered as a heterogeneous population. Further understanding of biomarkers can lead to a better selection of patients who may benefit the most from treatment and improvements in prognosis. The presence of poor Karnofsky scores and liver or CNS disease may affect the outcome of these patients much more than other identified factors. This consideration may provide the rationale to further stratify poor-risk patients further subgroups destined to receive either cure or palliation.

Using the Delphi technique to improve clinical outcomes through the development of quality indicators in renal cell carcinoma

PURPOSE

Optimal quality of care is needed for ideal outcomes. In renal cell carcinoma (RCC), there is a lack of information defining optimal care. This is particularly important in RCC, with increased complexity of care and a need for coordination among providers. The goal of this study was to identify quality indicators (QIs) and measures of quality care across the RCC disease spectrum.

MATERIALS AND METHODS

A modified Delphi technique was used to select QIs that are relevant and practical to RCC care. This technique involved an expert panel of 13 urologic and medical oncologists who participated in two e-mail questionnaires and an in-person meeting to review and prioritize potential QIs. These potential QIs were identified from a systematic literature review or were suggested by panel members.

RESULTS

From 233 literature citations, 34 possible QIs were identified; 24 additional potential QIs were suggested. A final set of 23 QIs was established. These are distributed across the RCC disease spectrum as follows (number of QIs in parentheses): screening (n=1), diagnosis/prognosis (n=3), surgical for localized disease (n=6), surgery for advanced disease (n=3), systemic therapy (n=6), and follow-up (n=2). In addition, two QIs related to survival outcomes (overall and progression-free survival) were selected.

CONCLUSION

A systematic, consensus-based approach was used to determine relevant QIs in RCC care. These 23 QIs will provide a means of evaluating the quality of RCC care in an effort to improve outcomes in patients. The next step will be to establish a means of measuring each QI based on defined or yet-to-be-defined benchmarks.

Development of accurate models for individualized prediction of survival after cytoreductive nephrectomy for metastatic renal cell carcinoma

BACKGROUND

There is limited evidence to guide patient selection for cytoreductive nephrectomy (CN) following the diagnosis of metastatic renal cell carcinoma (mRCC).

OBJECTIVE

Given the significant variability in oncologic outcomes following surgery, we sought to develop clinically relevant, individualized, multivariable models for the prediction of cancer-specific survival at 6 and 12 mo after CN. The development of this nomogram will better help clinicians select patients for cytoreductive surgery.

DESIGN, SETTING, AND PARTICIPANTS

We identified 601 consecutive patients who underwent CN for kidney cancer at a single tertiary cancer center.

INTERVENTION

CN for mRCC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The development cohort was used to select predictive variables from a large group of candidate predictors. The discrimination, calibration, and decision curves were corrected for overfit using 10-fold crossvalidation that included stepwise variable selection.

RESULTS AND LIMITATIONS

With a median follow-up of 65 mo (range: 6-199) for the entire cohort, 110 and 215 patients died from kidney cancer at 6 and 12 mo after surgery, respectively. For the preoperative model, serum albumin and serum lactate dehydrogenase were included. Final pathologic primary tumor stage, nodal stage, and receipt of blood transfusion were added to the previously mentioned parameters for the postoperative model. Preoperative and postoperative nomograms demonstrated good discrimination of 0.76 and 0.74, respectively, when applied to the validation data set. Both models demonstrated excellent calibration and a good net benefit over large ranges of threshold probabilities. The retrospective study design is the major limitation of this study.

CONCLUSIONS

We have developed models for accurate prediction of cancer-specific survival after CN, using either preoperative or postoperative variables. While these tools need validation in independent cohorts, our results suggest that the models are informative and can be used to aid in clinical decision making.

Defining an individualized treatment strategy for metastatic renal cancer

Treatment of metastatic renal cell carcinoma (mRCC) has evolved dramatically within the past 10 years with the advent of therapy targeting the angiogenesis and mammalian target of rapamycin (mTOR) pathways. These therapies rapidly supplanted immunotherapy as a first-line systemic treatment option. Response rates, however, continue to vary, largely due to mRCC's clinical and molecular heterogeneity. This article reviews current understanding of mRCC biology and available treatments, discusses novel biomarkers that improve prognostication and may be able to predict response, and integrates available literature on surgical and systemic therapies into an individualized strategy.

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.

Interferon-α-based immunotherapy in metastatic renal cell carcinoma patients with the primary tumor in situ

OBJECTIVE

We reviewed the outcomes of metastatic renal cell carcinoma patients with the primary tumor in situ who initially underwent interferon-α-based immunotherapy to evaluate the effect of this therapy on metastatic sites as well as primary kidney tumor and survival.

METHODS

Thirty-one patients, for whom upfront cytoreductive nephrectomy was considered to be inappropriate because of poor performance status and far-advanced disease, were the subject of the present study. Tumor response and reduction in the size of metastatic sites and primary kidney tumor were assessed. Overall survival distributions were estimated using the Kaplan-Meier method with the significance determined using the log-rank test.

RESULTS

Partial response was observed in 11 patients, yielding an overall response rate of 35%. Seventeen patients had regression or stabilization of metastatic sites, while progression of metastatic sites was observed in the remaining 14 patients. Regarding the maximum response of primary kidney tumor, a reduction in kidney primary tumor size was observed in 42% of the patients and the mean reduction rate in these patients was 18.2% (range: 3-36%). Furthermore, the reduction in the size of metastatic sites was significantly associated with that in the size of primary kidney tumor (R(2)= 0.432, P< 0.0001). The median survival for the 31 patients was 17 months. The median survival was 42 months in patients with regression or stabilization of metastatic sites and 7 months in those without (P< 0.001).

CONCLUSIONS

The present study suggests that metastatic sites as well as primary kidney tumor respond to interferon-α-based immunotherapy in metastatic renal cell carcinoma patients with primary tumor in situ.

Nephrectomy is necessary in the treatment of metastatic renal cell carcinoma

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Clinical experience and critical evaluation of the role of sorafenib in renal cell carcinoma

Renal cell carcinoma (RCC) is a common malignancy worldwide with approximately 95,000 new cases per year and ranks as the sixth cause of cancer deaths. Until recently, the slightly active and very toxic cytokines were available for patients with advanced RCC. Advances have been made in understanding the molecular biology of renal cancer. The introduction of targeted agents has led to promising possibilities for treating these highly vascularized tumors. Angiogenesis inhibition is likely to represent the main potential therapeutic target. Sorafenib is an oral multikinase inhibitor with activity against tyrosine kinase receptors that are responsible for blood vessel development and has shown to be active in treating advanced RCC. In this review, we summarize the pharmacology, mode of action, pharmacokinetics, and safety of sorafenib use in therapy for advanced RCC.

Is there a role for partial nephrectomy in patients with metastatic renal cell carcinoma?

OBJECTIVES

The incidence of metastatic disease in patients with renal cell carcinoma (RCC) correlates with tumor size. We sought to determine the incidence of metastatic disease by tumor size, and the utilization and impact of nephron-sparing surgery on survival in those with metastatic disease.

MATERIALS AND METHODS

Utilizing the Surveillance, Epidemiology, and End Results (SEER) database, we identified 56,011 patients between 1988 and 2005 diagnosed with RCC. Patients were initially separated into two groups--those with and without metastatic disease--and stratified by tumor size. Cox proportional hazard modeling and Kaplan-Meier analyses were then utilized to evaluate the role of gender, age, grade, histology, tumor size, and type of surgery (radical vs. partial nephrectomy) on overall- and cancer-specific survival in patients with metastatic disease.

RESULTS

Eight thousand four hundred ninety-eight patients (15%) had metastatic disease. Four percent of patients with tumors less than 2 cm and 5% of patients with tumors between 2 and 3 cm presented with metastatic disease. Two thousand nine hundred fifty patients (35%) with metastatic disease underwent surgery (radical or partial nephrectomy). Seventy patients (2% of those undergoing surgery) had a partial nephrectomy. Those who underwent partial nephrectomy were 0.49 times less likely to die of RCC than those who underwent radical nephrectomy (95% CI 0.35-0.69, P < 0.001).

CONCLUSIONS

Albeit small, the risk of metastases in patients with small kidney tumors is distinct and should be considered in management discussions. Partial nephrectomy, when able to be done, should be utilized in the setting of metastatic disease.

Primary tumor response to targeted agents in patients with metastatic renal cell carcinoma

BACKGROUND

The recent development of multiple targeted agents for metastatic renal cell carcinoma (mRCC) has changed the treatment paradigm; hence the benefit and optimal timing of cytoreductive nephrectomy is being reevaluated.

OBJECTIVE

To determine primary tumor response to treatment with targeted agents in patients with mRCC.

DESIGN, SETTING, AND PARTICIPANTS

We reviewed the clinical and radiographic data of all mRCC patients seen at our institution between November 2004 and December 2009 without prior systemic treatment who received targeted therapy with their primary tumor in situ.

MEASUREMENTS

Two independent reviewers measured the diameter of primary and metastatic tumors at baseline and subsequent scans, using Response Evaluation Criteria Solid Tumors (RECIST) v.1.1 to assess disease response.

RESULTS AND LIMITATIONS

We identified 168 consecutive patients with a median 15 mo of follow-up and a median maximum tumor diameter of 9.6 cm. Median maximum primary tumor response was -7.1% (interquartile range: -14.0 to -0.1). A total of 61 patients had multiple studies available for evaluation. In 43 patients with <10% decrease in primary tumor within in the first 60 d, median maximum response was -7.2% at 154 d versus -24.5% maximum response at 174.5 d for 18 patients with ≥10% decrease in primary tumor during the initial 60 d.

CONCLUSIONS

Decrease in primary tumor diameter >30% while on targeted therapy for mRCC is rare, with most patients demonstrating minimal or no decrease in primary tumor diameter. Early response predicts a better overall primary tumor response.

Multi-modal treatment for metastatic renal cancer: the role of surgery

Surgical intervention in the patients with metastatic renal cancer can occur in two settings: (1) to render a patient clinically free of all sites of primary disease and metastases, termed nephrectomy/metastasectomy, or (2) to resect the primary tumor in the face of unresectable metastatic disease prior to the initiation of systemic therapy, termed cytoreductive nephrectomy. Carefully selected patients with good performance status undergoing nephrectomy and subsequent metastasectomy may experience prolonged survival in the range of 30 months, which could be attributed to a combination of patient selection factors and the surgical resections. Randomized clinical trials from the United States and Europe have demonstrated a small but significant survival benefit to cytoreductive nephrectomy and cytokine therapy versus cytokine therapy alone which is measured in the range of 3-6 months and associated with overall survival of approximately 12 months. The precise mechanism by which cytoreductive nephrectomy improves survival is not known but may relate to reduction in the large primary immunosuppressive burden. Patient selection factors including performance status and serum factors (Hgb, corrected Ca++, LDH) stratify metastatic patients into risk groups, which are strongly associated with survival time in both medically and surgically treated patients with metastatic renal cancer. The development of multi-kinase and mTOR inhibitors has markedly improved survival in treatment naïve and previously treated patients with metastatic renal cancer , and these agents are currently under active clinical investigation in the neo-adjuvant and adjuvant setting.

Role of cytoreductive nephrectomy in renal cell carcinoma

Cytoreductive nephrectomy prior to cytokine therapy has a well-established role in the treatment of appropriately selected patients with metastatic renal cell carcinoma (RCC). Recent use of novel molecular targeted agents in the management of metastatic RCC has challenged the current dogma of treatment with regards to the necessity, patient selection for and timing of cytoreductive nephrectomy. Current evidence suggests that cytoreductive nephrectomy still plays an integral part in the multimodal paradigm of management for metastatic RCC. This review highlights the role of cytoreductive nephrectomy, and discusses controversial issues surrounding cytoreductive nephrectomy in the treatment of metastatic RCC, in the context of immunotherapy and also in the new era of targeted therapy. It also gives updates on the changing concepts of surgical approaches to cytoreductive nephrectomy in metastatic RCC.

Cytoreductive nephrectomy for metastatic RCC in the era of targeted therapy

Metastatic renal cell carcinoma (RCC) has traditionally been associated with a poor prognosis with few effective treatments. In the multimodal treatment of metastatic RCC, cytoreductive nephrectomy (CN) became the standard of care after two randomized trials demonstrated a benefit in overall survival in patients who received CN prior to treatment with interferon. More recently, several agents (sunitinib, sorafenib, temsirolimus, everolimus and bevacizumab) have been developed that target angiogenesis and the cellular growth pathways involved in metastatic RCC. These targeted agents have demonstrated improved outcomes compared to cytokine therapy, and have transformed metastatic RCC treatment. Targeted agents are being used as a first-line systemic treatment in patients with metastatic RCC with unprecedented success, and many studies are now focusing on the role of CN in combination with these agents for patients with metastatic RCC.

Sensitivity analysis to investigate the impact of a missing covariate on survival analyses using cancer registry data

Having substantial missing data is a common problem in administrative and cancer registry data. We propose a sensitivity analysis to evaluate the impact of a covariate that is potentially missing not at random in survival analyses using Weibull proportional hazards regressions. We apply the method to an investigation of the impact of missing grade on post-surgical mortality outcomes in individuals with metastatic kidney cancer. Data came from the Surveillance Epidemiology and End Results (SEER) registry which provides population-based information on those undergoing cytoreductive nephrectomy. Tumor grade is an important component of risk stratification for patients with both localized and metastatic kidney cancer. Many individuals in SEER with metastatic kidney cancer are missing tumor grade information. We found that surgery was protective, but that the magnitude of the effect depended on assumptions about the relationship of grade with missingness.

Vaccination of renal cell cancer patients with modified vaccinia ankara delivering tumor antigen 5T4 (TroVax) administered with interleukin 2: a phase II trial

PURPOSE

The attenuated vaccinia virus modified vaccinia ankara (MVA) has been engineered to deliver the tumor antigen 5T4 (TroVax). TroVax has been evaluated in an open-label phase II trial in metastatic renal cell cancer patients in which the vaccine was administered in combination with interleukin-2 (IL-2). The safety, immunologic, and clinical efficacy of TroVax in combination with IL-2 was determined.

EXPERIMENTAL DESIGN

Twenty-five patients with metastatic renal cell cancer were treated with TroVax plus IL-2. 5T4-specific cellular and humoral responses were monitored throughout the study. Clinical responses were assessed by measuring changes in tumor burden by computed tomography or magnetic resonance imaging scan.

RESULTS

TroVax was well tolerated with no serious adverse event attributed to vaccination. Of 25 intention-to-treat patients, 21 mounted 5T4-specific antibody responses. Two patients showed a complete response for > 24 months and one a partial response for > 12 months. Six patients had disease stabilization from 6 to > 21 months. Median progression-free survival (PFS) and overall survival (OS) were > 3.37 months (range, 1.50- > 24.76) and > 12.87 months (range, 1.90- > 24.76), respectively. A statistically significant relationship was detected between the magnitude of 5T4-specific antibody responses and PFS and OS.

CONCLUSION

TroVax in combination with IL-2 was safe and well tolerated in all patients. The high frequency of 5T4-specific immune responses and good clinical response rate are encouraging and warrant further investigation.

Cytoreductive nephrectomy in metastatic renal cell carcinoma

PURPOSE OF REVIEW

Cytoreductive nephrectomy has an established role in management of metastatic renal cell carcinoma when performed in properly selected patients prior to administration of systemic cytokine therapy. Within the past several years, novel molecular targeted agents have not only revolutionized management of metastatic renal cell carcinoma but also created controversy regarding the necessity, patient selection for and timing of cytoreductive nephrectomy.

RECENT FINDINGS

Benefits of targeted molecular therapeutics have largely been observed in the context of prior cytoreductive nephrectomy, and limited available evidence supports cytoreductive nephrectomy in appropriately selected patients with metastatic renal cell carcinoma who are candidates for targeted systemic therapy. Presurgical systemic therapy with targeted molecular agents is an attractive paradigm, which not only offers a rational approach to select patients who are most likely to benefit from cytoreductive nephrectomy but also allows access to treated tumor tissue to study molecular mechanisms of response and resistance. Surgical approaches increasingly utilized in patients with localized kidney cancer, such as nephron-sparing and minimally invasive techniques are similarly relevant and should be utilized, when appropriate, in patients with metastatic renal cell carcinoma.

SUMMARY

Cytoreductive nephrectomy should be considered to provide a survival benefit for patients with metastatic renal cell carcinoma and should be used in patients who are candidates for systemic therapy before or after surgery.

Gene microarray analysis of human renal cell carcinoma: the effects of HDAC inhibition and retinoid treatment

Histone deacetylase (HDAC) inhibitor treatments can augment the anti-tumor effects of retinoids in renal cancer cells. We studied the effects of the HDAC inhibitor suberoylanilide hydroxamic acid (SAHA) and 13-cis retinoic acid (cRA) on two human renal cell carcinoma (RCC) lines. Cells were cultured in the presence of each drug for six days to determine the responses to monotherapy and to combination therapy. The proliferation of SKRC06 was inhibited with cRA treatment; the proliferation of SKRC39 was not. However, both RCC lines were sensitive to growth inhibition by dibutyryl cyclic AMP, with or without 13-cis RA. SAHA alone also reduced cell proliferation in both cell lines. To identify the alterations in gene expression that correlate with the responsiveness to treatment, gene microarray analyses were performed. Several retinoid-regulated genes exhibited much higher mRNA levels in SKRC06 than in SKRC39, even in the absence of drugs; these included crabp2, rargamma and cyp26A1. Combination treatment of cells with both SAHA and cRA induced several transcripts with known anti-cancer/immunomodulatory effects, including dhrs9, gata3, il1beta, phlda1, txk and vhl. Immunostaining confirmed the decreased expression of gata3 in human RCC specimens compared to normal kidney. Together, our results show that treatment of RCC with cRA and/or SAHA increases the expression of several genes and gene families that result in reduced cell proliferation.

Interferon-alpha in combination with either imatinib (Gleevec) or gefitinib (Iressa) in metastatic renal cell carcinoma: a phase II trial

Treatments for metastatic renal cell carcinoma (MRCC) are limited. RCCs frequently overexpress epithelial growth factor receptor and express c-Kit and platelet-derived growth factor receptor-beta. Combination of interferon with tyrosine kinase inhibitors of epithelial growth factor receptor [gefitinib (Iressa)] or c-Kit and platelet-derived growth factor receptor-beta [imatinib (Gleevec)] was evaluated for efficacy and safety. Patients with MRCC received 12-week cycles of interferon [3 million units (MU) subcutaneously thrice in week 1 and 6 MU thrice weekly thereafter] and either gefitinib (500 mg daily) or imatinib (600 mg daily). The gefitinib/imatinib dose was reduced as needed owing to toxicity. The primary endpoint was objective tumor response. Secondary endpoints were time to tumor progression, overall survival, and safety. Seventeen patients were enrolled. Most had clear cell [36% (6/17)] or papillary [36% (6/17)] tumors. Most (n=14) were treated on the gefitinib arm, including two patients who crossed over from the imatinib arm after experiencing disease progression. Objective tumor responses were evaluable in 14 patients (82%). Of these 14, partial responses occurred in three (21%), stable disease in seven (50%), and progressive disease in four (29%). The most frequent treatment-related adverse events were skin rash, flu-like symptoms, and fatigue (both treatment arms); diarrhea (gefitinib arm only); and thrombocytopenia and leukopenia (imatinib arm only). Median time to tumor progression (range) for patients on the gefitinib arm only was 4.27 (1.13-15.97) months and median overall survival (range) was 11.42+ (1.13-29.07+) months. Combination of gefitinib with interferon safely delays progression of refractory MRCC. Further studies in this setting are warranted.

Changing indications for surgery in patients with stage IV breast cancer: a current perspective

BACKGROUND

Evolving concepts of cancer biology and emerging evidence of a potential survival benefit from local surgery have raised the question of an expanded role for surgery in select patients with metastatic breast cancer (MBC). To determine whether such developments have influenced clinical practice, the authors evaluated surgical practice patterns in the study institution over the last 15 years.

METHODS

Two institutional databases were screened to identify patients with MBC who underwent breast surgery (1990-2005). Retrospective review was conducted to assess trends over time and to evaluate the role of surgery in the more modern era (1995-2005).

RESULTS

The overall frequency of mastectomy remained stable over time (1.7%); however, between early (1990-1995) and late (2000-2005) periods the rate of 'symptom control' mastectomy decreased (41% to 25%), whereas the rate of 'local control' mastectomy increased (34% to 66%). Conversely, the overall frequency of wide-local excision (WLE) increased over time (1995-2001), from 1% to 9% (P< .001) with no differences noted between rates of symptom control or local control procedures. In the modern era (1995-2005), 256 of 12,529 patients (2%) with MBC underwent breast surgery (33% mastectomy, 52% WLE); most frequently to 'optimize local control' (50%) and primarily in the setting of limited/stable distant disease. Surgery was performed for palliation in only 19% of patients. At a median follow-up of 33.9 months (range, 0-198.7 months), 136 of 256 patients (53%) in this cohort remained alive; 88% were free of local disease.

CONCLUSIONS

Although surgery in MBC has historically been reserved for palliation, the authors observed a decreasing rate of traditional 'toilet mastectomy' and a broadened surgical approach to the asymptomatic patient. When viewed in parallel with evolving concepts in cancer biology, these data reflect a change in the traditional approach to patients with MBC and warrant further investigation.

Current immunotherapeutic strategies in renal cell carcinoma

Advanced renal cell carcinoma remains resistant to drug-, hormone-, and cytokine-based therapies. Promising new immunotherapeutic approaches include monoclonal antibodies, kinase inhibitors, mammalian target of rapamycin inhibition, dendritic cell, and tumor antigen vaccines. Most of these approaches have yet to produce clinical responses significantly superior to those of previous standard therapies, although most are well tolerated and elicit relatively high rates of stable disease. Two recently approved agents, a kinase inhibitor and a mTOR inhibitor, are recommended for use as first-line therapies against renal cell carcinoma. An additional approved tyrosine kinase inhibitor, sorafenib, is recommended as second-line therapy. More clinical research on these agents and their use in combination, especially sequentially, is warranted.

Tyrosine kinase inhibitors and anti-angiogenic therapies in kidney cancer

Renal cell carcinoma (RCC) is a heterogeneous disease as reflected in its presentation and clinical course, pathological subtypes, nuclear grades and molecular biology. Emerging data indicate that renal tumors express a variety of molecular tumor markers and unique patterns of gene expression. Clinically the disease behaves quite heterogeneously, with courses ranging from indolent to highly aggressive. Surgical monotherapy or as part of a multimodal approach remains the standard of care for most cases of RCC. Radical or partial nephrectomy is associated with a 5-year cancer specific survival (CSS) of 85-97% for pT1 tumors. Unfortunately, 20% of patients have either locally advanced or node positive (N+) RCC while another 22% have metastatic RCC (mRCC) at presentation. Unlike the outcomes in early localized disease, survival rates for N+ patients are poor and patients with mRCC are rarely cured despite aggressive multimodal therapy. Classic cytotoxic chemotherapy has repeatedly been shown to have little effect and only 5-20% of patients with mRCC respond to immunologic agents such as interferon and/or interleukin. Cytoreductive nephrectomy with systemic immunotherapy is associated with few cures with median survivals of 12-24 months. Recent advances in our understanding of the molecular origins and pathways of RCC have led to the development of more effective targeted therapies. Here we review the molecular pathways that define the pertinent therapeutic targets in RCC and the clinical data for these new and promising agents.

Sorafenib and sunitinib: novel targeted therapies for renal cell cancer

Renal cell cancer (RCC) is a relatively uncommon malignancy, with 51,190 cases expected to be diagnosed in 2007. Localized disease is curable by surgery; however, locally advanced or metastatic disease is not curable in most cases and, until recently, had a limited response to drug treatment. Historically, biologic response modifiers or immunomodulating agents were tested in clinical trials based on observations that some cases of RCC can spontaneously regress. High-dose aldesleukin is approved by the United States Food and Drug Administration as a treatment for advanced RCC; however, the drug is associated with a high frequency of severe adverse effects. Responses have been observed with low-dose aldesleukin and interferon alfa, but with little effect on overall survival. Sorafenib and sunitinib are novel therapies that target growth factor receptors known to be activated by the hypoxia-inducible factor and the Ras-Raf/MEK/ERK pathways. These pathways are important in the pathophysiology of RCC. Sorafenib and sunitinib have shown antitumor activity as first- and second-line therapy in patients with cytokine-refractory metastatic RCC who have clear-cell histology. Although complete responses are not common, both drugs promote disease stabilization and increase progression-free survival. This information suggests that disease stabilization may be an important determinant for response in RCC and possibly other cancers. Sorafenib and sunitinib are generally well tolerated and are considered first- and second-line treatment options for patients with advanced clear cell RCC. In addition, sorafenib and sunitinib have shown promising results in initial clinical trials evaluating antitumor activity in patients who are refractory to other antiangiogenic therapy. The most common toxicities with both sorafenib and sunitinib are hand-foot syndrome, rash, fatigue, hypertension, and diarrhea. Research is directed toward defining the optimal use of these new agents.

Recent advances in targeted therapy for renal cell carcinoma

PURPOSE OF REVIEW

To provide an overview and summary of the recent developments in the use of targeted therapy in the management of advanced kidney cancer. The focus is on publications within the last year.

RECENT FINDINGS

The last year has seen several exciting developments in the targeted approach to managing advanced renal cell carcinoma. The benefits of small-molecule tyrosine kinase inhibitors have been demonstrated in two large-scale, phase III prospective, randomized controlled trials. There is growing evidence, some not yet published, that mammalian target of rapamycin inhibitors are effective in this disease and the roles of therapies directed at the receptor for vascular endothelial growth factor continue to be refined.

SUMMARY

Recent published trials offer substantial hope for those patients with advanced kidney cancer, where before the outlook was often bleak. There is an expanding menu of potential agents in this disease, so-called targeted therapies, that are grounded in a growing understanding of the biology of kidney cancer. Many challenges and questions still remain, but there are encouraging signs of progress and hope for the future.

Targeted therapies for kidney cancer in urologic practice

Renal cell carcinoma (RCC) is the most lethal of all genitourinary malignancies with nearly half of all patients presenting with locally advanced or metastatic disease. Systemic treatments such as chemo- or immunotherapy have historically been associated with overall response rates of 5-15% with very few durable responses. The basis of newly approved, more effective targeted therapies for metastatic RCC are based on a fundamental knowledge of the molecular mechanisms that give rise to RCC. We review the clinical data for targeted therapies in RCC and discuss the pertinent biology, side effects, and targets important to the practicing clinician.