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Collinson F, Royle KL, Swain J, Ralph C, Maraveyas A, Eisen T, Nathan P, Jones R, Meads D, Min Wah T, Martin A, Bestall J, Kelly-Morland C, Linsley C, Oughton J, Chan K, Theodoulou E, Arias-Pinilla G, Kwan A, Daverede L, Handforth C, Trainor S, Salawu A, McCabe C, Goh V, Buckley D, Hewison J, Gregory W, Selby P, Brown J, Brown J. Temporary treatment cessation compared with continuation of tyrosine kinase inhibitors for adults with renal cancer: the STAR non-inferiority RCT. Health Technol Assess 2024; 28:1-171. [PMID: 39250424 PMCID: PMC11403377 DOI: 10.3310/jwtr4127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
Background There is interest in using treatment breaks in oncology, to reduce toxicity without compromising efficacy. Trial design A Phase II/III multicentre, open-label, parallel-group, randomised controlled non-inferiority trial assessing treatment breaks in patients with renal cell carcinoma. Methods Patients with locally advanced or metastatic renal cell carcinoma, starting tyrosine kinase inhibitor as first-line treatment at United Kingdom National Health Service hospitals. Interventions At trial entry, patients were randomised (1 : 1) to a drug-free interval strategy or a conventional continuation strategy. After 24 weeks of treatment with sunitinib/pazopanib, drug-free interval strategy patients took up a treatment break until disease progression with additional breaks dependent on disease response and patient choice. Conventional continuation strategy patients continued on treatment. Both trial strategies continued until treatment intolerance, disease progression on treatment, withdrawal or death. Objective To determine if a drug-free interval strategy is non-inferior to a conventional continuation strategy in terms of the co-primary outcomes of overall survival and quality-adjusted life-years. Co-primary outcomes For non-inferiority to be concluded, a margin of ≤ 7.5% in overall survival and ≤ 10% in quality-adjusted life-years was required in both intention-to-treat and per-protocol analyses. This equated to the 95% confidence interval of the estimates being above 0.812 and -0.156, respectively. Quality-adjusted life-years were calculated using the utility index of the EuroQol-5 Dimensions questionnaire. Results Nine hundred and twenty patients were randomised (461 conventional continuation strategy vs. 459 drug-free interval strategy) from 13 January 2012 to 12 September 2017. Trial treatment and follow-up stopped on 31 December 2020. Four hundred and eighty-eight (53.0%) patients [240 (52.1%) vs. 248 (54.0%)] continued on trial post week 24. The median treatment-break length was 87 days. Nine hundred and nineteen patients were included in the intention-to-treat analysis (461 vs. 458) and 871 patients in the per-protocol analysis (453 vs. 418). For overall survival, non-inferiority was concluded in the intention-to-treat analysis but not in the per-protocol analysis [hazard ratio (95% confidence interval) intention to treat 0.97 (0.83 to 1.12); per-protocol 0.94 (0.80 to 1.09) non-inferiority margin: 95% confidence interval ≥ 0.812, intention to treat: 0.83 > 0.812 non-inferior, per-protocol: 0.80 < 0.812 not non-inferior]. Therefore, a drug-free interval strategy was not concluded to be non-inferior to a conventional continuation strategy in terms of overall survival. For quality-adjusted life-years, non-inferiority was concluded in both the intention-to-treat and per-protocol analyses [marginal effect (95% confidence interval) intention to treat -0.05 (-0.15 to 0.05); per-protocol 0.04 (-0.14 to 0.21) non-inferiority margin: 95% confidence interval ≥ -0.156]. Therefore, a drug-free interval strategy was concluded to be non-inferior to a conventional continuation strategy in terms of quality-adjusted life-years. Limitations The main limitation of the study is the fewer than expected overall survival events, resulting in lower power for the non-inferiority comparison. Future work Future studies should investigate treatment breaks with more contemporary treatments for renal cell carcinoma. Conclusions Non-inferiority was shown for the quality-adjusted life-year end point but not for overall survival as pre-defined. Nevertheless, despite not meeting the primary end point of non-inferiority as per protocol, the study suggested that a treatment-break strategy may not meaningfully reduce life expectancy, does not reduce quality of life and has economic benefits. Although the treating clinicians' perspectives were not formally collected, the fact that clinicians recruited a large number of patients over a long period suggests support for the study and provides clear evidence that a treatment-break strategy for patients with renal cell carcinoma receiving tyrosine kinase inhibitor therapy is feasible. Trial registration This trial is registered as ISRCTN06473203. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme (NIHR award ref: 09/91/21) and is published in full in Health Technology Assessment; Vol. 28, No. 45. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Fiona Collinson
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kara-Louise Royle
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jayne Swain
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Christy Ralph
- Leeds Institute of Medical Research, St James's University Hospital, University of Leeds, Leeds, UK
| | - Anthony Maraveyas
- Academic Oncology, Faculty of Health Sciences, Hull York Medical School, Queens Centre Oncology and Haematology, Hull, UK
| | - Tim Eisen
- Department of Oncology, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Paul Nathan
- Department of Oncology, Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Robert Jones
- School of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - David Meads
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Tze Min Wah
- Department of Diagnostic and Interventional Radiology, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Adam Martin
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Janine Bestall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - Jamie Oughton
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kevin Chan
- Medical Oncology, Weston Park Cancer Hospital, Sheffield, UK
| | - Elisavet Theodoulou
- Division of Clinical Medicine, University of Sheffield, Weston Park Hospital, Sheffield, UK
| | - Gustavo Arias-Pinilla
- Division of Clinical Medicine, University of Sheffield, Weston Park Hospital, Sheffield, UK
| | - Amy Kwan
- Academic Unit of Clinical Oncology, University of Sheffield, Sheffield, UK
| | - Luis Daverede
- Department of Clinical Oncology, Austral University Hospital, Buenos Aires, Argentina
| | - Catherine Handforth
- Division of Clinical Medicine, University of Sheffield, Weston Park Hospital, Sheffield, UK
| | - Sebastian Trainor
- St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Abdulazeez Salawu
- Academic Unit of Clinical Oncology, University of Sheffield, Sheffield, UK
| | | | - Vicky Goh
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - David Buckley
- Faculty of Medicine and Health, School of Medicine, University of Leeds, Leeds, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Walter Gregory
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Peter Selby
- Leeds Institute of Medical Research, St James's University Hospital, University of Leeds, Leeds, UK
| | - Julia Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Janet Brown
- Division of Clinical Medicine, University of Sheffield, Weston Park Hospital, Sheffield, UK
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2
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Yokota T, Hamauchi S, Kawakami T, Fushiki K. Lenvatinib rechallenge after failure of lenvatinib and sorafenib in metastatic thyroid cancer. Invest New Drugs 2024; 42:361-368. [PMID: 38809355 DOI: 10.1007/s10637-024-01449-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/22/2024] [Indexed: 05/30/2024]
Abstract
The oral multikinase inhibitors sorafenib and lenvatinib are currently available as first-line treatment for patients with unresectable or metastatic thyroid cancer. However, treatment options for patients who are refractory to these multikinase inhibitors are limited. This study aimed to evaluate the safety and efficacy of rechallenged lenvatinib after failure of both lenvatinib and sorafenib in patients with metastatic thyroid cancer in the real-world clinical practice. We retrospectively reviewed the data of consecutive 16 patients with metastatic thyroid cancer who received lenvatinib as a rechallenge after failure of initial lenvatinib and sorafenib treatment at Shizuoka Cancer Center between 2016 and 2023. Of these, the initial lenvatinib was discontinued in 12 patients owing to progressive disease, in 3 patients owing to adverse events, and in 1 patient owing to both. The overall response rate was 6.7%, and disease control was achieved by rechallenge with lenvatinib in all patients with the target lesions. The median progression free survival after rechallenging with lenvatinib was 15.0 months. No new signs of toxicity were observed after rechallenging with lenvatinib. Our findings suggest that rechallenge with lenvatinib after failure of both lenvatinib and sorafenib showed manageable safety and modest efficacy in patients with metastatic thyroid cancer in clinical practice. The strategy of lenvatinib rechallenge may provide an alternative option for patients with no targetable driver genes or when selective kinase inhibitors are not indicated.
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Affiliation(s)
- Tomoya Yokota
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Satoshi Hamauchi
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Takeshi Kawakami
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kunihiro Fushiki
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
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3
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Van Not OJ, van den Eertwegh AJM, Haanen JB, van Rijn RS, Aarts MJB, van den Berkmortel FWPJ, Blank CU, Boers-Sonderen MJ, de Groot JWWB, Hospers GAP, Kapiteijn E, Bloem M, Piersma D, Stevense-den Boer M, Verheijden RJ, van der Veldt AAM, Wouters MWJM, Blokx WAM, Suijkerbuijk KPM. BRAF/MEK inhibitor rechallenge in advanced melanoma patients. Cancer 2024; 130:1673-1683. [PMID: 38198485 DOI: 10.1002/cncr.35178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Effectivity of BRAF(/MEK) inhibitor rechallenge has been described in prior studies. However, structured data are largely lacking. METHODS Data from all advanced melanoma patients treated with BRAFi(/MEKi) rechallenge were retrieved from the Dutch Melanoma Treatment Registry. The authors analyzed objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) for both first treatment and rechallenge. They performed a multivariable logistic regression and a multivariable Cox proportional hazards model to assess factors associated with response and survival. RESULTS The authors included 468 patients in the largest cohort to date who underwent at least two treatment episodes of BRAFi(/MEKi). Following rechallenge, ORR was 43%, median PFS was 4.6 months (95% confidence interval [CI], 4.1-5.2), and median OS was 8.2 months (95% CI, 7.2-9.4). Median PFS after rechallenge for patients who discontinued first BRAFi(/MEKi) treatment due to progression was 3.1 months (95% CI, 2.7-4.0) versus 5.2 months (95% CI, 4.5-5.9) for patients who discontinued treatment for other reasons. Discontinuing first treatment due to progression and lactate dehydrogenase (LDH) levels greater than two times the upper limit of normal were associated with lower odds of response and worse PFS and OS. Symptomatic brain metastases were associated with worse survival, whereas a longer treatment interval between first treatment and rechallenge was associated with better survival. Responding to the first BRAFi(/MEKi) treatment was not associated with response or survival. CONCLUSIONS This study confirms that patients benefit from rechallenge. Elevated LDH levels, symptomatic brain metastases, and discontinuing first BRAFi(/MEKi) treatment due to progression are associated with less benefit from rechallenge. A prolonged treatment interval is associated with more benefit from rechallenge.
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Affiliation(s)
- Olivier J Van Not
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alfons J M van den Eertwegh
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - John B Haanen
- Department of Molecular Oncology & Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Rozemarijn S van Rijn
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Maureen J B Aarts
- Department of Medical Oncology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Christian U Blank
- Department of Molecular Oncology & Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology & Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marye J Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Geke A P Hospers
- Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Manja Bloem
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Djura Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Rik J Verheijden
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Astrid A M van der Veldt
- Department of Medical Oncology and Radiology & Nuclear Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Michel W J M Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Willeke A M Blokx
- Department of Pathology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karijn P M Suijkerbuijk
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Baudry E, Naoun N, Auclin E, Saldana C, Barthelemy P, Geoffrois L, Thibault C, de Vries-Brilland M, Borchiellini D, Maillet D, Hirsch L, Vauchier C, Carril-Ajuria L, Colomba E, Bernard-Tessier A, Escudier B, Flippot R, Albigès L. Efficacy and safety of cabozantinib rechallenge in metastatic renal cell carcinoma: A retrospective multicentric study. Eur J Cancer 2023; 193:113292. [PMID: 37717282 DOI: 10.1016/j.ejca.2023.113292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Despite metastatic renal cell carcinoma (mRCC) expanded treatment options, disease progression ultimately occurs for most patients. Rechallenge may be a compelling strategy in a refractory setting. Cabozantinib is the standard of care in first and later lines of therapy, but its activity in rechallenge is unknown. METHODS This retrospective study assessed the efficacy and safety of cabozantinib rechallenge, as defined by a second exposure after an interval of ≥3 months without treatment or ≥1 other treatment line, in patients with mRCC. The primary endpoint was median progression-free survival (PFS) at rechallenge. Secondary endpoints included overall survival, objective response rate, and safety at rechallenge. RESULTS We included 51 mRCC patients who received cabozantinib in a rechallenge setting between 2017 and 2022. Median age at diagnosis was 54 years, 78% were male, 90% had clear cell mRCC, and 92% had prior nephrectomy. 15 patients (29%) were rechallenged after a pause in treatment, whereas 36 (70.6%) had ≥1 other treatment lines between first cabozantinib exposure (CABO-1) and rechallenge (CABO-2). Median PFS was 15.1 months (mo, 95% Confidence interval 11.2-22.1) at CABO-1 and 14.4mo (95%CI 9.8-NR) at CABO-2. Median overall survival was 67.6mo for CABO-1 (95% CI 52.2-NR) and 27.4mo for CABO-2 (95%CI 17.2-NR); objective response rate was 70.6% for CABO-1 and 60% for CABO-2. CABO-2 PFS was higher for patients with CABO-1 PFS > 12 months, and for those who discontinued CABO-1 because of toxicity, without statistical significance. There were no unexpected adverse events. CONCLUSIONS Cabozantinib rechallenge is a feasible treatment option with potential clinical benefit for mRCC patients.
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Affiliation(s)
- Edwige Baudry
- Gustave Roussy, Department of Cancer Medicine, Université Paris-Saclay, Villejuif, France; Institut de Cancérologie de Lorraine, Department of Medical Oncology, Université de Lorraine, Nancy 54000, France
| | - Natacha Naoun
- Gustave Roussy, Department of Cancer Medicine, Université Paris-Saclay, Villejuif, France
| | - Edouard Auclin
- Hôpital Européen Georges Pompidou, Institut du Cancer Paris CARPEM, AP-HP Centre, Department of Medical Oncology, Université Paris Cité, Paris 75015, France
| | - Carolina Saldana
- Hôpital Henri Mondor, AP-HP, Department of Medical Oncology, Université de Paris, Créteil 94000, France
| | - Philippe Barthelemy
- Institut de Cancérologie Strasbourg Europe, Department of Medical Oncology, Strasbourg 67200, France
| | - Lionnel Geoffrois
- Institut de Cancérologie de Lorraine, Department of Medical Oncology, Université de Lorraine, Nancy 54000, France
| | - Constance Thibault
- Hôpital Européen Georges Pompidou, Institut du Cancer Paris CARPEM, AP-HP Centre, Department of Medical Oncology, Université Paris Cité, Paris 75015, France
| | - Manon de Vries-Brilland
- Institut de Cancérologie de l'Ouest, Department of Medical Oncology, Université d'Angers, Angers 49055, France
| | - Delphine Borchiellini
- Centre Antoine-Lacassagne, Department of Medical Oncology, Université Côte d'Azur, Nice 06100, France
| | - Denis Maillet
- Hôpital Lyon-Sud, Université de Lyon, Department of Medical Oncology, Pierre-Bénite 69495, France; Faculté de médecine Jacques Lisfranc, Saint Etienne 42270, France
| | - Laure Hirsch
- Hôpital Cochin-Port Royal, Department of Medical Oncology, AP-HP, Paris 75014, France
| | - Charles Vauchier
- Hôpital Bichat, AP-HP, Department of Thoracic Oncology, Université de Paris, Paris 75018, France
| | - Lucia Carril-Ajuria
- Gustave Roussy, Department of Cancer Medicine, Université Paris-Saclay, Villejuif, France; CHU Saint Pierre/CHU Brugmann, Brussels, Belgium
| | - Emeline Colomba
- Gustave Roussy, Department of Cancer Medicine, Université Paris-Saclay, Villejuif, France
| | - Alice Bernard-Tessier
- Gustave Roussy, Department of Cancer Medicine, Université Paris-Saclay, Villejuif, France
| | - Bernard Escudier
- Gustave Roussy, Department of Cancer Medicine, Université Paris-Saclay, Villejuif, France
| | - Ronan Flippot
- Gustave Roussy, Department of Cancer Medicine, Université Paris-Saclay, Villejuif, France
| | - Laurence Albigès
- Gustave Roussy, Department of Cancer Medicine, Université Paris-Saclay, Villejuif, France.
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Astore S, Baciarello G, Cerbone L, Calabrò F. Primary and acquired resistance to first-line therapy for clear cell renal cell carcinoma. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2023; 6:517-546. [PMID: 37842234 PMCID: PMC10571064 DOI: 10.20517/cdr.2023.33] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/26/2023] [Accepted: 07/11/2023] [Indexed: 10/17/2023]
Abstract
The introduction of first-line combinations had improved the outcomes for metastatic renal cell carcinoma (mRCC) compared to sunitinib. However, some patients either have inherent resistance or develop resistance as a result of the treatment. Depending on the kind of therapy employed, many factors underlie resistance to systemic therapy. Angiogenesis and the tumor immune microenvironment (TIME), nevertheless, are inextricably linked. Although angiogenesis and the manipulation of the tumor microenvironment are linked to hypoxia, which emerges as a hallmark of renal cell carcinoma (RCC) pathogenesis, it is only one of the potential elements involved in the distinctive intra- and inter-tumor heterogeneity of RCC that is still dynamic. We may be able to more correctly predict therapy response and comprehend the mechanisms underlying primary or acquired resistance by integrating tumor genetic and immunological markers. In order to provide tools for patient selection and to generate hypotheses for the development of new strategies to overcome resistance, we reviewed the most recent research on the mechanisms of primary and acquired resistance to immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) that target the vascular endothelial growth factor receptor (VEGFR).We can choose patients' treatments and cancer preventive strategies using an evolutionary approach thanks to the few evolutionary trajectories that characterize ccRCC.
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Affiliation(s)
- Serena Astore
- Medical Oncology, San Camillo Forlanini Hospital, Rome 00152, Italy
| | | | - Linda Cerbone
- Medical Oncology, San Camillo Forlanini Hospital, Rome 00152, Italy
| | - Fabio Calabrò
- Medical Oncology, San Camillo Forlanini Hospital, Rome 00152, Italy
- Medical Oncology, IRCSS, National Cancer Institute Regina Elena, Rome 00128, Italy
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6
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Brown JE, Royle KL, Gregory W, Ralph C, Maraveyas A, Din O, Eisen T, Nathan P, Powles T, Griffiths R, Jones R, Vasudev N, Wheater M, Hamid A, Waddell T, McMenemin R, Patel P, Larkin J, Faust G, Martin A, Swain J, Bestall J, McCabe C, Meads D, Goh V, Min Wah T, Brown J, Hewison J, Selby P, Collinson F. Temporary treatment cessation versus continuation of first-line tyrosine kinase inhibitor in patients with advanced clear cell renal cell carcinoma (STAR): an open-label, non-inferiority, randomised, controlled, phase 2/3 trial. Lancet Oncol 2023; 24:213-227. [PMID: 36796394 DOI: 10.1016/s1470-2045(22)00793-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Temporary drug treatment cessation might alleviate toxicity without substantially compromising efficacy in patients with cancer. We aimed to determine if a tyrosine kinase inhibitor drug-free interval strategy was non-inferior to a conventional continuation strategy for first-line treatment of advanced clear cell renal cell carcinoma. METHODS This open-label, non-inferiority, randomised, controlled, phase 2/3 trial was done at 60 hospital sites in the UK. Eligible patients (aged ≥18 years) had histologically confirmed clear cell renal cell carcinoma, inoperable loco-regional or metastatic disease, no previous systemic therapy for advanced disease, uni-dimensionally assessed Response Evaluation Criteria in Solid Tumours-defined measurable disease, and an Eastern Cooperative Oncology Group performance status of 0-1. Patients were randomly assigned (1:1) at baseline to a conventional continuation strategy or drug-free interval strategy using a central computer-generated minimisation programme incorporating a random element. Stratification factors were Memorial Sloan Kettering Cancer Center prognostic group risk factor, sex, trial site, age, disease status, tyrosine kinase inhibitor, and previous nephrectomy. All patients received standard dosing schedules of oral sunitinib (50 mg per day) or oral pazopanib (800 mg per day) for 24 weeks before moving into their randomly allocated group. Patients allocated to the drug-free interval strategy group then had a treatment break until disease progression, when treatment was re-instated. Patients in the conventional continuation strategy group continued treatment. Patients, treating clinicians, and the study team were aware of treatment allocation. The co-primary endpoints were overall survival and quality-adjusted life-years (QALYs); non-inferiority was shown if the lower limit of the two-sided 95% CI for the overall survival hazard ratio (HR) was 0·812 or higher and if the lower limit of the two-sided 95% CI of the marginal difference in mean QALYs was -0·156 or higher. The co-primary endpoints were assessed in the intention-to-treat (ITT) population, which included all randomly assigned patients, and the per-protocol population, which excluded patients in the ITT population with major protocol violations and who did not begin their randomisation allocation as per the protocol. Non-inferiority was to be concluded if it was met for both endpoints in both analysis populations. Safety was assessed in all participants who received a tyrosine kinase inhibitor. The trial was registered with ISRCTN, 06473203, and EudraCT, 2011-001098-16. FINDINGS Between Jan 13, 2012, and Sept 12, 2017, 2197 patients were screened for eligibility, of whom 920 were randomly assigned to the conventional continuation strategy (n=461) or the drug-free interval strategy (n=459; 668 [73%] male and 251 [27%] female; 885 [96%] White and 23 [3%] non-White). The median follow-up time was 58 months (IQR 46-73 months) in the ITT population and 58 months (46-72) in the per-protocol population. 488 patients continued on the trial after week 24. For overall survival, non-inferiority was demonstrated in the ITT population only (adjusted HR 0·97 [95% CI 0·83 to 1·12] in the ITT population; 0·94 [0·80 to 1·09] in the per-protocol population). Non-inferiority was demonstrated for QALYs in the ITT population (n=919) and per-protocol (n=871) population (marginal effect difference 0·06 [95% CI -0·11 to 0·23] for the ITT population; 0·04 [-0·14 to 0·21] for the per-protocol population). The most common grade 3 or worse adverse events were hypertension (124 [26%] of 485 patients in the conventional continuation strategy group vs 127 [29%] of 431 patients in the drug-free interval strategy group); hepatotoxicity (55 [11%] vs 48 [11%]); and fatigue (39 [8%] vs 63 [15%]). 192 (21%) of 920 participants had a serious adverse reaction. 12 treatment-related deaths were reported (three patients in the conventional continuation strategy group; nine patients in the drug-free interval strategy group) due to vascular (n=3), cardiac (n=3), hepatobiliary (n=3), gastrointestinal (n=1), or nervous system (n=1) disorders, and from infections and infestations (n=1). INTERPRETATION Overall, non-inferiority between groups could not be concluded. However, there seemed to be no clinically meaningful reduction in life expectancy between the drug-free interval strategy and conventional continuation strategy groups and treatment breaks might be a feasible and cost-effective option with lifestyle benefits for patients during tyrosine kinase inhibitor therapy in patients with renal cell carcinoma. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Janet E Brown
- Department of Oncology and Metabolism, University of Sheffield, Weston Park Hospital, Sheffield.
| | - Kara-Louise Royle
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Walter Gregory
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Christy Ralph
- Leeds Institute of Medical Research at St James's, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Anthony Maraveyas
- Queens Centre for Oncology and Haematology, Faculty of Health Sciences, Hull York Medical School, Hull, UK
| | - Omar Din
- Department of Clinical Oncology, Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Timothy Eisen
- Department of Oncology, University of Cambridge, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul Nathan
- Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, Northwood, UK
| | - Tom Powles
- Barts Cancer Institute, Queen Mary University, London, UK
| | | | - Robert Jones
- University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Naveen Vasudev
- Leeds Institute of Medical Research at St James's, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Matthew Wheater
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Abdel Hamid
- Broomfield Hospital, Mid and South Essex NHS Foundation Trust, Chelmsford, UK
| | - Tom Waddell
- Christie NHS Foundation Trust, Manchester, UK
| | - Rhona McMenemin
- Northern Centre for Cancer Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Poulam Patel
- Academic Unit of Translational Medical Sciences, University of Nottingham, Nottingham, UK
| | | | - Guy Faust
- Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Adam Martin
- Academic Unit of Health Economics, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Jayne Swain
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Janine Bestall
- Leeds Institute of Health Sciences, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | | | - David Meads
- Academic Unit of Health Economics, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Vicky Goh
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Tze Min Wah
- Department of Radiology, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Julia Brown
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Peter Selby
- Leeds Institute of Medical Research at St James's, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Fiona Collinson
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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7
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Jin J, Xie Y, Zhang JS, Wang JQ, Dai SJ, He WF, Li SY, Ashby CR, Chen ZS, He Q. Sunitinib resistance in renal cell carcinoma: From molecular mechanisms to predictive biomarkers. Drug Resist Updat 2023; 67:100929. [PMID: 36739809 DOI: 10.1016/j.drup.2023.100929] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/19/2023]
Abstract
Currently, renal cell carcinoma (RCC) is the most prevalent type of kidney cancer. Targeted therapy has replaced radiation therapy and chemotherapy as the main treatment option for RCC due to the lack of significant efficacy with these conventional therapeutic regimens. Sunitinib, a drug used to treat gastrointestinal tumors and renal cell carcinoma, inhibits the tyrosine kinase activity of a number of receptor tyrosine kinases, including vascular endothelial growth factor receptor (VEGFR), platelet-derived growth factor receptor (PDGFR), c-Kit, rearranged during transfection (RET) and fms-related receptor tyrosine kinase 3 (Flt3). Although sunitinib has been shown to be efficacious in the treatment of patients with advanced RCC, a significant number of patients have primary resistance to sunitinib or acquired drug resistance within the 6-15 months of therapy. Thus, in order to develop more efficacious and long-lasting treatment strategies for patients with advanced RCC, it will be crucial to ascertain how to overcome sunitinib resistance that is produced by various drug resistance mechanisms. In this review, we discuss: 1) molecular mechanisms of sunitinib resistance; 2) strategies to overcome sunitinib resistance and 3) potential predictive biomarkers of sunitinib resistance.
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Affiliation(s)
- Juan Jin
- Department of Nephrology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang 310003, China
| | - Yuhao Xie
- Institute for Biotechnology, St. John's University, Queens, NY 11439, USA; Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, USA
| | - Jin-Shi Zhang
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Jing-Quan Wang
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, USA
| | - Shi-Jie Dai
- Zhejiang Eyoung Pharmaceutical Research and Development Center, Hangzhou, Zhejiang 311258, China
| | - Wen-Fang He
- Department of Nephrology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang 310003, China
| | - Shou-Ye Li
- Zhejiang Eyoung Pharmaceutical Research and Development Center, Hangzhou, Zhejiang 311258, China
| | - Charles R Ashby
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, USA
| | - Zhe-Sheng Chen
- Institute for Biotechnology, St. John's University, Queens, NY 11439, USA; Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, USA.
| | - Qiang He
- Department of Nephrology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang 310003, China.
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8
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Terashima Y, Hakozaki T, Takeuchi S, Hosomi Y. Lenvatinib rechallenge in a patient with advanced thymic carcinoma: A case report. Thorac Cancer 2022; 13:3408-3411. [PMID: 36251511 PMCID: PMC9715831 DOI: 10.1111/1759-7714.14699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 01/09/2023] Open
Abstract
Advanced thymic carcinomas have limited treatment options. Recently, lenvatinib was approved for advanced thymic carcinoma treatment. However, the clinical benefit of lenvatinib re-administration in patients with advanced thymic carcinoma who developed prior lenvatinib treatment resistance (lenvatinib rechallenge) remains unclear. Here, we present a case treated with lenvatinib rechallenge for advanced thymic carcinoma who was previously treated with lenvatinib as the second-line treatment followed by multiple cytotoxic agents. Disease control rapidly deteriorated after the eighth line of treatment because of uncontrollable right pleural and pericardial effusion, which required repeated thoracic and pericardial drainage. Shortly after lenvatinib re-administration, rapid pleural and pericardial effusion reduction was observed. Thereafter, the patient achieved sustained clinical response with good pleural and pericardial effusion control for approximately 7 months. Our case might suggest lenvatinib rechallenge as a treatment option for patients with advanced thymic carcinoma, especially those with poor pleural and pericardial effusion control.
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Affiliation(s)
- Yuto Terashima
- Department of Thoracic Oncology and Respiratory MedicineTokyo Metropolitan Cancer and Infectious Diseases Center Komagome HospitalTokyoJapan,Department of Pulmonary Medicine and OncologyGraduate School of Medicine, Nippon Medical SchoolTokyoJapan
| | - Taiki Hakozaki
- Department of Thoracic Oncology and Respiratory MedicineTokyo Metropolitan Cancer and Infectious Diseases Center Komagome HospitalTokyoJapan,Graduate School of Advanced Science and Engineering, Faculty of Science and EngineeringWaseda UniversityTokyoJapan
| | - Susumu Takeuchi
- Department of Pulmonary Medicine and OncologyGraduate School of Medicine, Nippon Medical SchoolTokyoJapan
| | - Yukio Hosomi
- Department of Thoracic Oncology and Respiratory MedicineTokyo Metropolitan Cancer and Infectious Diseases Center Komagome HospitalTokyoJapan
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9
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Bouchalova P, Beranek J, Lapcik P, Potesil D, Podhorec J, Poprach A, Bouchal P. Transgelin Contributes to a Poor Response of Metastatic Renal Cell Carcinoma to Sunitinib Treatment. Biomedicines 2021; 9:biomedicines9091145. [PMID: 34572331 PMCID: PMC8467952 DOI: 10.3390/biomedicines9091145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 12/24/2022] Open
Abstract
Renal cell carcinoma (RCC) represents about 2-3% of all cancers with over 400,000 new cases per year. Sunitinib, a vascular endothelial growth factor tyrosine kinase receptor inhibitor, has been used mainly for first-line treatment of metastatic clear-cell RCC with good or intermediate prognosis. However, about one-third of metastatic RCC patients do not respond to sunitinib, leading to disease progression. Here, we aim to find and characterize proteins associated with poor sunitinib response in a pilot proteomics study. Sixteen RCC tumors from patients responding (8) vs. non-responding (8) to sunitinib 3 months after treatment initiation were analyzed using data-independent acquisition mass spectrometry, together with their adjacent non-cancerous tissues. Proteomics analysis quantified 1996 protein groups (FDR = 0.01) and revealed 27 proteins deregulated between tumors non-responding vs. responding to sunitinib, representing a pattern of deregulated proteins potentially contributing to sunitinib resistance. Gene set enrichment analysis showed an up-regulation of epithelial-to-mesenchymal transition with transgelin as one of the most significantly abundant proteins. Transgelin expression was silenced by CRISPR/Cas9 and RNA interference, and the cells with reduced transgelin level exhibited significantly slower proliferation. Our data indicate that transgelin is an essential protein supporting RCC cell proliferation, which could contribute to intrinsic sunitinib resistance.
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Affiliation(s)
- Pavla Bouchalova
- Department of Biochemistry, Faculty of Science, Masaryk University, 625 00 Brno, Czech Republic; (P.B.); (J.B.); (P.L.)
| | - Jindrich Beranek
- Department of Biochemistry, Faculty of Science, Masaryk University, 625 00 Brno, Czech Republic; (P.B.); (J.B.); (P.L.)
| | - Petr Lapcik
- Department of Biochemistry, Faculty of Science, Masaryk University, 625 00 Brno, Czech Republic; (P.B.); (J.B.); (P.L.)
| | - David Potesil
- Proteomics Core Facility, Central European Institute of Technology, Masaryk University, 625 00 Brno, Czech Republic;
| | - Jan Podhorec
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, 656 53 Brno, Czech Republic; (J.P.); (A.P.)
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, 656 53 Brno, Czech Republic
| | - Alexandr Poprach
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, 656 53 Brno, Czech Republic; (J.P.); (A.P.)
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, 656 53 Brno, Czech Republic
| | - Pavel Bouchal
- Department of Biochemistry, Faculty of Science, Masaryk University, 625 00 Brno, Czech Republic; (P.B.); (J.B.); (P.L.)
- Correspondence: ; Tel.: +420-549-493-251
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10
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de Velasco G, Ruiz-Granados Á, Reig O, Massari F, Climent Duran MA, Verzoni E, Graham J, Llarena R, De Tursi M, Donskov F, Iglesias C, Pandha HS, Garcia Del Muro X, Procopio G, Oudard S, Castellano D, Albiges L. Outcomes of systemic targeted therapy in recurrent renal cell carcinoma treated with adjuvant sunitinib. BJU Int 2021; 128:254-261. [PMID: 33547860 DOI: 10.1111/bju.15356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the efficacy and tolerability of rechallenge with sunitinib and other targeted therapies (TTs) in patitents with relapsed recurrent renal cell carcinoma (RCC) in the advanced setting. METHODS In this multi-institutional retrospective study, patients with relapsed RCC were rechallenged with sunitinib or other systemic TTs as a first-line therapeutic approach after failed adjuvant sunitinib treatment. Patient characteristics, treatments and clinical outcomes were recorded. The primary endpoint was progression-free survival (PFS). Secondary endpoints were objective response rate (ORR) and overall survival (OS). RESULTS A total of 34 patients with relapses were recorded, and 25 of these (73.5%) were men. Twenty-five patients were treated with systemic TT: 65% of patients received TT against the vascular endothelial growth factor pathway (including sunitinib), 21.7% received mammalian target of rapamycin inhibitors and 13% received immunotherapy. The median (interquartile range) time to relapse was 20.3 (5.2-20.4) months from diagnosis, and 7.5 months (1.0-8.5) from the end of adjuvant suntinib treatment. At a median follow-up of 23.5 months, 24 of the 25 patients had progressed on first-line systemic therapy. The median PFS was 12.0 months (95% confidence interval [CI] 5.78-18.2). There were no statistical differences in PFS between different treatments or sunitinib rechallenge. PFS was not statistically different in patients relapsing on or after adjuvant suntinib treatment (≤ 6 or >6 months after adjuvant suntinib ending). The ORR was 20.5%. The median OS was 29.1 months (95% CI 16.4-41.8). CONCLUSIONS Rechallenge with sunitinib or other systemic therapies is still a feasible therapeutic option that provides patients with advanced or metastastic RCC with additional clinical benefits with regard to PFS and OS after failed response to adjuvant sunitinib.
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Affiliation(s)
- Guillermo de Velasco
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Álvaro Ruiz-Granados
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Oscar Reig
- Translational Genomics and Targeted Therapeutics in Solid Tumours Lab, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesco Massari
- Oncologia Medica, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia.,Division of Oncology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Elena Verzoni
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | | | | | - Michele De Tursi
- Department of Oncology and Neurosciences, Consorzio Interuniversitario Nazionale per la Bio-Oncologia, University G. d'Annunzio, Chieti, Italy
| | - Frede Donskov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Clara Iglesias
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Xavier Garcia Del Muro
- Department of Medical Oncology, Institut Català d'Oncologia L'Hospitalet, Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Giuseppe Procopio
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stephane Oudard
- Medical Oncology Department, Georges Pompidou Hospital, University of Paris, Paris, France
| | - Daniel Castellano
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Laurence Albiges
- Medical Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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11
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Clinical Implications of Acquired BRAF Inhibitors Resistance in Melanoma. Int J Mol Sci 2020; 21:ijms21249730. [PMID: 33419275 PMCID: PMC7766699 DOI: 10.3390/ijms21249730] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 12/13/2022] Open
Abstract
Understanding the role of mitogen-activated protein kinase (MAPK) pathway-activating mutations in the development and progression of melanoma and their possible use as therapeutic targets has substantially changed the management of this neoplasm, which, until a few years ago, was burdened by severe mortality. However, the presence of numerous intrinsic and extrinsic mechanisms of resistance to BRAF inhibitors compromises the treatment responses’ effectiveness and durability. The strategy of overcoming these resistances by combination therapy has proved successful, with the additional benefit of reducing side effects derived from paradoxical activation of the MAPK pathway. Furthermore, the use of other highly specific inhibitors, intermittent dosing schedules and the association of combination therapy with immune checkpoint inhibitors are promising new therapeutic strategies. However, numerous issues related to dose, tolerability and administration sequence still need to be clarified, as is to be expected from currently ongoing trials. In this review, we describe the clinical results of using BRAF inhibitors in advanced melanoma, with a keen interest in strategies aimed at overcoming resistance.
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12
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Krchniakova M, Skoda J, Neradil J, Chlapek P, Veselska R. Repurposing Tyrosine Kinase Inhibitors to Overcome Multidrug Resistance in Cancer: A Focus on Transporters and Lysosomal Sequestration. Int J Mol Sci 2020; 21:ijms21093157. [PMID: 32365759 PMCID: PMC7247577 DOI: 10.3390/ijms21093157] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 12/22/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) are being increasingly used to treat various malignancies. Although they were designed to target aberrant tyrosine kinases, they are also intimately linked with the mechanisms of multidrug resistance (MDR) in cancer cells. MDR-related solute carrier (SLC) and ATB-binding cassette (ABC) transporters are responsible for TKI uptake and efflux, respectively. However, the role of TKIs appears to be dual because they can act as substrates and/or inhibitors of these transporters. In addition, several TKIs have been identified to be sequestered into lysosomes either due to their physiochemical properties or via ABC transporters expressed on the lysosomal membrane. Since the development of MDR represents a great concern in anticancer treatment, it is important to elucidate the interactions of TKIs with MDR-related transporters as well as to improve the properties that would prevent TKIs from diffusing into lysosomes. These findings not only help to avoid MDR, but also help to define the possible impact of combining TKIs with other anticancer drugs, leading to more efficient therapy and fewer adverse effects in patients.
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Affiliation(s)
- Maria Krchniakova
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, 61137 Brno, Czech Republic; (M.K.); (J.S.); (J.N.); (P.C.)
- International Clinical Research Center, St. Anne’s University Hospital, 65691 Brno, Czech Republic
| | - Jan Skoda
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, 61137 Brno, Czech Republic; (M.K.); (J.S.); (J.N.); (P.C.)
- International Clinical Research Center, St. Anne’s University Hospital, 65691 Brno, Czech Republic
| | - Jakub Neradil
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, 61137 Brno, Czech Republic; (M.K.); (J.S.); (J.N.); (P.C.)
- International Clinical Research Center, St. Anne’s University Hospital, 65691 Brno, Czech Republic
| | - Petr Chlapek
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, 61137 Brno, Czech Republic; (M.K.); (J.S.); (J.N.); (P.C.)
- International Clinical Research Center, St. Anne’s University Hospital, 65691 Brno, Czech Republic
| | - Renata Veselska
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, 61137 Brno, Czech Republic; (M.K.); (J.S.); (J.N.); (P.C.)
- International Clinical Research Center, St. Anne’s University Hospital, 65691 Brno, Czech Republic
- Correspondence: ; Tel.: +420-549-49-7905
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13
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Nachbargauer S, Bruchbacher A, Fajkovic H, Remzi M, Schmidinger M. Sunitinib Rechallenge in Patients With Metastatic Renal Cell Carcinoma. Clin Genitourin Cancer 2019; 18:e277-e283. [PMID: 31902715 DOI: 10.1016/j.clgc.2019.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/02/2019] [Accepted: 11/27/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Sunitinib has been the standard of care for patients with metastatic renal cell carcinoma (mRCC). However, nearly all patients will eventually develop resistance. Before the introduction of novel agents, few treatment options remained after sunitinib failure. Sunitinib rechallenge is a strategy based on the presumption that resistance might be only temporary. The aim of this analysis was to evaluate the efficacy and safety of sunitinib rechallenge in patients with mRCC. PATIENTS AND METHODS Patients who had undergone sunitinib rechallenge (SU2) at the Medical University of Vienna from 2010 to 2017 were identified for the present retrospective study. The primary endpoint was the treatment duration with rechallenge (TDSU2). The secondary endpoints included the treatment duration with upfront sunitinib (TDSU1), progression-free survival (PFSSU1 and PFSSU2), overall survival (OSSU1 and OSSU2), the objective response rate in both settings (ORRSU1 and ORRSU2), and toxicity. RESULTS A total of 31 patients were eligible. The median TDSU2 was 7.2 months, and the median TDSU1 was 17.8 months. The median OSSU1 and OSSU2 was 57.9 months and 14.7 months, respectively. The median PFSSU1 and PFSSU2 was 14.2 months and 5.6 months, respectively. The ORRSU1 and ORRSU2 was 34% and 16%, and another 48% and 42% achieved stable disease (SD), respectively. Fatigue and hypertension were the most common adverse events. CONCLUSIONS Sunitinib rechallenge appears to benefit patients in later treatment lines. With the abundance of novel treatment options available, this approach might appear less relevant. However, novel agents are not yet available everywhere. Thus, sunitinib rechallenge could be an additional strategy to improve the outcomes of patients with mRCC.
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Affiliation(s)
- Sebastian Nachbargauer
- Clinical Division of Oncology and Comprehensive Cancer Center, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
| | - Andreas Bruchbacher
- Clinical Division of Oncology and Comprehensive Cancer Center, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Harun Fajkovic
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Mesut Remzi
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Manuela Schmidinger
- Clinical Division of Oncology and Comprehensive Cancer Center, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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14
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Muto H, Kuzuya T, Ito T, Ishizu Y, Honda T, Ishikawa T, Ishigami M, Fujishiro M. Complete response of advanced hepatocellular carcinoma achieved by sorafenib dose re-escalation after failure of long-term low-dose-sorafenib treatment combined with transcatheter arterial chemoembolization: a case report. Clin J Gastroenterol 2019; 13:397-402. [PMID: 31709503 DOI: 10.1007/s12328-019-01066-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/28/2019] [Indexed: 12/14/2022]
Abstract
Few reports have described dose re-escalation after long-term low-dose sorafenib leading to good outcomes. Here, we report the case of an 80-year-old woman with advanced hepatocellular carcinoma who achieved complete response from sorafenib dose re-escalation after the failure of long-term low-dose sorafenib treatment combined with transcatheter arterial chemoembolization. Sorafenib therapy was initiated at 400 mg once daily due to old age and low platelet count. 5 months later, this dose was reduced to 200 mg once daily because of adverse events. Best radiological antitumor response by sorafenib treatment alone was judged as stable disease according to the modified Response Evaluation Criteria in Solid Tumors. 1 year later, she showed progressive disease owing to the progression of intrahepatic lesions. She received combination therapy with low-dose sorafenib (200 mg every other day) and transcatheter arterial chemoembolization, which proved relatively effective for three and a half years. Antitumor response by the fourth transcatheter arterial chemoembolization and subsequent low-dose sorafenib was clearly progressive disease. At that time, sorafenib-related adverse events were well-controlled. Sorafenib dose was re-escalated to 200 mg once daily. After this re-escalation, tumor markers declined rapidly, and adverse events remained tolerable. 4 months later, complete response was achieved.
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Affiliation(s)
- Hisanori Muto
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Teiji Kuzuya
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takanori Ito
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoji Ishizu
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tetsuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
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15
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Sunitinib rechallenge in advanced renal cell carcinoma: outcomes of a multicenter retrospective study. Cancer Chemother Pharmacol 2019; 84:781-789. [PMID: 31367791 DOI: 10.1007/s00280-019-03913-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 07/25/2019] [Indexed: 01/26/2023]
Abstract
PURPOSE The aim of this multicenter study was to evaluate the clinical outcomes of patients with metastatic renal cell carcinoma (mRCC) who received sunitinib retreatment. METHODS Clinical data from patients treated with sunitinib rechallenge in nine Spanish centers were retrospectively analyzed. All patients received first-line sunitinib until progression or intolerance, followed by one or more successive drugs and rechallenge with sunitinib thereafter. RESULTS Thirty-seven patients were included. At first-line treatment, objective response rate (ORR) was 69.4% and median progression-free survival (PFS) was 19.4 months. At rechallenge, ORR was 27.2% and 39.4% of patients obtained stabilization of disease. Median PFS was 6.2 months. Clinical benefit was obtained by 21 patients (75%) with > 6-month interval between sunitinib treatments and by 1 patient (20%) among those with ≤ 6-month interval (P = 0.016). Hemoglobin levels ≥ lower level of normal were associated with clinical benefit (P = 0.019) and with PFS (P = 0.004). Median overall survival from start of first-line sunitinib was 52.7 months. No new adverse events were observed at rechallenge. CONCLUSIONS Sunitinib rechallenge is a feasible treatment option for selected patients with mRCC.
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16
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Nagyiványi K, Budai B, Gyergyay F, Küronya Z, Bíró K, Géczi L. Sunitinib Rechallenge After Other Targeted Therapies in Metastatic Renal Cell Carcinoma Patients: A Single-Center, Retrospective Study. Clin Drug Investig 2019; 39:577-583. [PMID: 30915661 PMCID: PMC6555772 DOI: 10.1007/s40261-019-00778-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Sunitinib is still one of the standard therapies in metastatic renal cell carcinoma (mRCC). Despite the benefit of sunitinib resistance will develop in the majority of patients. Most of them receive multiple sequential therapies during the course of disease. OBJECTIVES To retrospectively investigate the efficacy and safety of rechallenged sunitinib in third or later line settings. PATIENTS AND METHODS Twenty-one mRCC patients were identified who received rechallenged sunitinib between March 2010 and April 2018. Patients received sunitinib in first or second line, then other tyrosine kinase and/or mTOR inhibitors were applied, then sunitinib was rechallenged. Patients' characteristics, tolerability, treatment modalities, and treatment outcomes were recorded. The primary end-point was progression-free survival (PFS) of rechallenged sunitinib. RESULTS Median age of patients was 62 years at the start of sunitinib rechallenge. Sixty-seven percent of patients were male. All patients had prior nephrectomy. Upon rechallenge 4 patients achieved partial response and 12 stable disease. The median PFS of first sunitinib treatment was 22 (95% CI 17-26) months and for rechallenged sunitinib 14 (95% CI 6-20) months. No increased severity of prior toxicity or new adverse events was reported during rechallenged sunitinib. The median overall survival (OS) from the start of first sunitinib was 67 (95% CI 46-76) months. Multivariate Cox regression analysis revealed that younger age (< 57 years) at start of first sunitinib (HR = 0.24; 95% CI 0.07-0.79; p = 0.019) and longer (> 2 years) first sunitinib treatment (HR = 0.28; 95% CI 0.09-0.93; p = 0.038) were independent markers of longer OS. CONCLUSION Sunitinib rechallenge is a feasible and tolerable option with clinical benefit in selected mRCC patients.
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Affiliation(s)
| | - Barna Budai
- National Institute of Oncology, Rath Gy. u. 7-9, 1122, Budapest, Hungary.
| | - Fruzsina Gyergyay
- National Institute of Oncology, Rath Gy. u. 7-9, 1122, Budapest, Hungary
| | - Zsófia Küronya
- National Institute of Oncology, Rath Gy. u. 7-9, 1122, Budapest, Hungary
| | - Krisztina Bíró
- National Institute of Oncology, Rath Gy. u. 7-9, 1122, Budapest, Hungary
| | - Lajos Géczi
- National Institute of Oncology, Rath Gy. u. 7-9, 1122, Budapest, Hungary
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Afzal MZ, Shirai K. Response to the Rechallenge With Talimogene Laherparepvec (T-VEC) After Ipilimumab/Nivolumab Treatment in Patient With Cutaneous Malignant Melanoma Who Initially Had a Progression on T-VEC With Pembrolizumab. J Immunother 2019; 42:136-141. [PMID: 30933044 DOI: 10.1097/cji.0000000000000265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Talimogene laherparepvec (T-VEC) is approved for unresected stage III-IV malignant melanoma. T-VEC has a direct cytotoxic effect and enhances the antitumor immunity of host cells. Immune checkpoints inhibitors also enhance the immunity of host cells by increasing the recruitment of antigen-presenting cells or activation and restoration of T-cell functions. Both type of therapies can potentiate the effect of the other therapy. We are reporting a case of T-VEC rechallenge who initially progressed on T-VEC with pembrolizumab but then responded to T-VEC rechallenge after intervening ipilimumab/nivolumab. An 83-year-old man developed a subungual lesion of the left thumb and found to have AJCC V. 7 stage IIIb melanoma. Few months later, he developed axillary lymphadenopathy and multiple subcutaneous nodules (AJCC V. 7 stage IIIc). The patient was started on intralesional rose Bengal and pembrolizumab. After 4 cycles of pembrolizumab with rose Bengal, a positron-emission tomography/computerized tomography scan showed the progression of disease. He was started on T-VEC intralesional injections with concurrent pembrolizumab, however, after 3 T-VEC injections and 2 more cycles of pembrolizumab, there was the progression of disease. Subsequently, ipilimumab/nivolumab was started and patient responded partially. Ipilimumab/nivolumab was held due to toxicity. Eight weeks from the last dose of ipilimumab/nivolumab, he experienced locoregional progression and was rechallenged with T-VEC monotherapy. The patient showed a significant response after second T-VEC injection and continued to show response 6 months since rechallenge. After, initial progression on T-VEC with pembrolizumab, intervening immune checkpoints inhibitors may favorably modify the antitumor immunity and potentiate antitumor effect of T-VEC rechallenge.
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Affiliation(s)
- Muhammad Z Afzal
- Department of Hospital Medicine, Dartmouth-Hitchcock Medical Center
| | - Keisuke Shirai
- Department of Hematology-Oncology, Norris Cotton Cancer Center, Lebanon, NH
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18
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Viñal D, Martinez D, Espinosa E. Efficacy of rechallenge with BRAF inhibition therapy in patients with advanced BRAFV600 mutant melanoma. Clin Transl Oncol 2019; 21:1061-1066. [DOI: 10.1007/s12094-018-02028-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/21/2018] [Indexed: 02/06/2023]
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19
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Zhang X, Shen P, Yao J, Chen N, Liu J, Zeng H. Sunitinib rechallenge with dose escalation in progressive metastatic renal cell carcinoma: A case report and literature review. Medicine (Baltimore) 2018; 97:e11565. [PMID: 30075524 PMCID: PMC6081141 DOI: 10.1097/md.0000000000011565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE We aimed to present a case of sunitinib rechallenge with dosage escalation after disease progression, hopefully, providing an optional approach to the personalized medication management of progressive metastatic renal cell carcinoma (mRCC). PATIENT CONCERNS The patient was admitted to hospital due to right kidney mass, with merged enlargement of retroperitoneal lymph nodes. Subsequent surgery and sunitinib treatment was administered. DIAGNOSES Postoperative pathologic diagnosis was type II papillary renal cell carcinoma (pRCC) (Fuhrman grade 3) with metastases of retroperitoneal lymph nodes (T1aN1M0). INTERVENTIONS The patient underwent cytoreductive nephrectomy followed by treatment of sunitinib standard therapy (4/2 schedule) and alternative schedules according to different disease status. The patient received alternative 2/1 schedule while experiencing grade 3/4 adverse events. Re-challenge with sunitinib upon disease progression and metastasectomy were given. After second disease progression, sunitinib rechallenge with dose escalation was administered. Around 2/1 schedule showed desirable efficacy and better tolerance. OUTCOMES After 4 months of sunitinib individualized treatment, a complete response with retroperitoneal metastases was achieved. Rechallenge with sunitinib after disease progression and also rechallenge with dose escalation after second disease progression were effective. LESSONS Cessation of sunitinib in patients with complete response is not suggested. Also, strategy of subsequently administered sunitinib after metastasectomy is seemed to be effective. What is more, sunitinib rechallenge with escalation to 62.5 mg probably possess value in progressive mRCC and has a well tolerance when sunitinib is rechallenged. Based on this case, we probe a feasible alternative strategy in personalized therapy of sunitinib, hoping for providing referable insights into the detailed strategies of individual treatment for patients with mRCC.
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Affiliation(s)
| | | | | | | | - Jiyan Liu
- Department of Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Zeng
- Department of Urology, Institute of Urology
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20
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Reguera-Nuñez E, Man S, Xu P, Kerbel RS. Preclinical impact of high dose intermittent antiangiogenic tyrosine kinase inhibitor pazopanib in intrinsically resistant tumor models. Angiogenesis 2018; 21:793-804. [PMID: 29786782 DOI: 10.1007/s10456-018-9623-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/09/2018] [Indexed: 12/16/2022]
Abstract
Antiangiogenic tyrosine kinase inhibitors (TKIs) target vascular endothelial growth factor receptors and other receptor tyrosine kinases. As a result of toxicity, the clinical failures or the modest benefits associated with antiangiogenic TKI therapy may be related in some cases to suboptimal drug dosing and scheduling, thereby facilitating resistance. Most antiangiogenic TKIs, including pazopanib, are administered on a continuous daily basis. Here, instead, we evaluated the impact of increasing the dose and administering the drug intermittently. The rationale is that using such protocols, antitumor efficacy could be enhanced by direct tumor cell targeting effects in addition to inhibiting tumor angiogenesis. To test this, we employed two human tumor xenograft models, both of which manifest intrinsic resistance to pazopanib when it is administered continuously: the VHL-wildtype SN12-PM6-1 renal cell carcinoma (RCC) and the metastatic MDA-MB-231/LM2-4 variant breast cancer cell line, when treated as distant metastases. We evaluated four different doses and schedules of pazopanib in the context of primary tumors and advanced metastatic disease, in both models. The RCC model was not converted to drug sensitivity using the intermittent protocol. Using these protocols did not enhance the efficacy when treating primary LM2-4 tumors. However, one of the high-dose intermittent pazopanib protocols increased median survival when treating advanced metastatic disease. In conclusion, these results overall suggest that primary tumors showing sensitivity to continuous pazopanib treatment may predict response to this drug when given at high doses intermittently in the context of advanced metastatic disease, that are otherwise resistant to the conventional protocol.
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Affiliation(s)
- Elaine Reguera-Nuñez
- Department of Medical Biophysics, University of Toronto, Toronto, ON, M5S 2J7, Canada
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Shan Man
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Ping Xu
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada
| | - Robert S Kerbel
- Department of Medical Biophysics, University of Toronto, Toronto, ON, M5S 2J7, Canada.
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON, M4N 3M5, Canada.
- Biological Sciences Platform, Sunnybrook Research Institute, 2075 Bayview Ave, Room S-217, Toronto, ON, M4N 3M5, Canada.
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21
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Maráz A, Cserháti A, Uhercsák G, Szilágyi É, Varga Z, Révész J, Kószó R, Varga L, Kahán Z. Dose escalation can maximize therapeutic potential of sunitinib in patients with metastatic renal cell carcinoma. BMC Cancer 2018; 18:296. [PMID: 29544452 PMCID: PMC5856318 DOI: 10.1186/s12885-018-4209-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 03/09/2018] [Indexed: 12/24/2022] Open
Abstract
Background In patients with metastatic renal cell cancer, based on limited evidence, increased sunitinib exposure is associated with better outcome. The survival and toxicity data of patients receiving individualized dose escalated sunitinib therapy as compared to standard management were analyzed in this study. Methods From July 2013, the data of metastatic renal cell cancer patients with slight progression but still a stable disease according to RECIST 1.1 criteria treated with an escalated dose of sunitinib (first level: 62.5 mg/day in 4/2 or 2 × 2/1 scheme, second level: 75 mg/day in 4/2 or 2 × 2/1 scheme) were collected prospectively. Regarding characteristics, outcome, and toxicity data, an explorative retrospective analysis of the register was carried out, comparing treatments after and before July 1, 2013 in the study (selected patients for escalated dose) and control (standard dose) groups, respectively. Results The study involved 103 patients receiving sunitinib therapy with a median overall and progression free survival of 25.36 ± 2.62 and 14.2 ± 3.22 months, respectively. Slight progression was detected in 48.5% of them. First and second-level dose escalation were indicated in 18.2% and 4.1% of patients, respectively. The dosing scheme was modified in 22.2%. The median progression free survival (39.7 ± 5.1 vs 14.2 ± 1.3 months (p = 0.037)) and the overall survival (57.5 ± 10.7 vs 27.9 ± 2.5 months (p = 0.044)) were significantly better in the study group (with dose escalation) than in the control group. Patients with nephrectomy and lower Memorial Sloan Kettering Cancer Center (MSKCC) scores showed more favorable outcomes. After dose escalation, the most common adverse events were worsening or development of fatigue, hypertension, stomatitis, and weight loss of over 10%. Conclusions Escalation of sunitinib dosing in selected patients with metastatic renal cell cancer, especially in case of slight progression, based on tolerable toxicity is safe and improves outcome. Dose escalation in 12.5 mg steps may be recommended for properly educated patients.
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Affiliation(s)
- Anikó Maráz
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary.
| | - Adrienn Cserháti
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Gabriella Uhercsák
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Éva Szilágyi
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Zoltán Varga
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - János Révész
- Institute of Radiotherapy and Clinical Oncology, Borsod County Hospital and University Academic Hospital, Szentpéteri Kapu 72-76, Miskolc, H-3526, Hungary
| | - Renáta Kószó
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Linda Varga
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
| | - Zsuzsanna Kahán
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, H-6720, Hungary
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22
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Rechallenge with BRAF-directed treatment in metastatic melanoma: A multi-institutional retrospective study. Eur J Cancer 2018; 91:116-124. [DOI: 10.1016/j.ejca.2017.12.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/02/2017] [Indexed: 12/11/2022]
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23
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Miyake H, Harada KI, Fujisawa M. Promising response to axitinib rechallenge for metastatic renal cell carcinoma after progression on prior axitinib: report of two cases. Int Cancer Conf J 2017; 7:30-34. [PMID: 31149509 DOI: 10.1007/s13691-017-0313-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/02/2017] [Indexed: 11/29/2022] Open
Abstract
With the marked improvement in the prognosis of patients with metastatic renal cell carcinoma (mRCC) in the era of molecularly targeted therapy, sequential therapies using multiple targeted agents have been intensively performed for these patients. Despite being conducted targeting small cohorts, several studies showed efficacious findings on rechallenge with some targeted agents, such as sunitinib and sorafenib; however, there has not been any report describing axitinib rechallenge for patients with mRCC. Here, we report two cases of mRCC showing a significant response to axitinib rechallenge after progression on prior systemic treatment with multiple agents, including axitinib. These findings suggest that mRCC, once refractory to axitinib, can still show favorable disease control on rechallenge with this agent during sequential treatment with targeted agents.
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Affiliation(s)
- Hideaki Miyake
- 1Division of Urology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017 Japan.,2Department of Urology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, 431-3192 Japan
| | - Ken-Ichi Harada
- 1Division of Urology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017 Japan
| | - Masato Fujisawa
- 1Division of Urology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017 Japan
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24
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Felicetti F, Nervo A, Piovesan A, Berardelli R, Marchisio F, Gallo M, Arvat E. Tyrosine kinase inhibitors rechallenge in solid tumors: a review of literature and a case description with lenvatinib in thyroid cancer. Expert Rev Anticancer Ther 2017; 17:1093-1098. [PMID: 28988510 DOI: 10.1080/14737140.2017.1390432] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION In the last decade tyrosine kinase inhibitors (TKIs) have been employed for a wide range of hematological and solid tumors and today they represent a valid therapeutic option for different neoplasms. Among them, both sorafenib and lenvatinib were approved for the treatment of radioactive iodine (RAI) refractory differentiated thyroid carcinoma (DTC). Unfortunately, in some cases the efficacy of TKIs is limited by the onset of drug resistance after the initial response. Areas covered: We report the case of a patient with a RAI refractory advanced DTC, treated with lenvatinib after surgery, multiple RAI administrations, traditional chemotherapy, and sorafenib. During treatment with lenvatinib, a noticeable response was detected by sequential computed tomography scans but, after 27 months, tumor progression became evident and led to lenvatinib interruption. In absence of any active treatment, a further disease progression was documented, and lenvatinib was re-administered obtaining a new objective response. Starting from this case report, we review available reports about the rechallenge with TKIs in solid tumors, discussing the possible mechanisms underlying the efficacy of this approach. Expert commentary: Rechallenge with TKIs in solid tumors could be a therapeutic option in subjects with advanced and metastatic DTC who experience a progressive disease after initial response to lenvatinib.
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Affiliation(s)
| | - Alice Nervo
- a Department of Medical Sciences , University of Turin , Turin , Italy.,b Oncological Endocrinology Unit , Città della Salute e della Scienza Hospital , Turin , Italy
| | - Alessandro Piovesan
- b Oncological Endocrinology Unit , Città della Salute e della Scienza Hospital , Turin , Italy
| | - Rita Berardelli
- b Oncological Endocrinology Unit , Città della Salute e della Scienza Hospital , Turin , Italy
| | - Filippo Marchisio
- c Diagnostic and Interventional Radiology Unit , Città della Salute e della Scienza Hospital, University of Turin , Turin , Italy
| | - Marco Gallo
- b Oncological Endocrinology Unit , Città della Salute e della Scienza Hospital , Turin , Italy
| | - Emanuela Arvat
- a Department of Medical Sciences , University of Turin , Turin , Italy.,b Oncological Endocrinology Unit , Città della Salute e della Scienza Hospital , Turin , Italy
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25
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Dizman N, Bergerot P, Bergerot C, Lanman RB, Raymond VM, Banks KC, Jones J, Pal SK. Exceptional Response to Nivolumab Rechallenge in Metastatic Renal Cell Carcinoma with Parallel Changes in Genomic Profile. Eur Urol 2017; 73:308-310. [PMID: 28844598 DOI: 10.1016/j.eururo.2017.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/02/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Nazli Dizman
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Paulo Bergerot
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Cristiane Bergerot
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | | | | | | | - Jeremy Jones
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sumanta K Pal
- Department of Medical Oncology & Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
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26
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Davis ID, Xie W, Pezaro C, Donskov F, Wells JC, Agarwal N, Srinivas S, Yuasa T, Beuselinck B, Wood LA, Ernst DS, Kanesvaran R, Knox JJ, Pantuck A, Saleem S, Alva A, Rini BI, Lee JL, Choueiri TK, Heng DY. Efficacy of Second-line Targeted Therapy for Renal Cell Carcinoma According to Change from Baseline in International Metastatic Renal Cell Carcinoma Database Consortium Prognostic Category. Eur Urol 2017; 71:970-978. [DOI: 10.1016/j.eururo.2016.09.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/30/2016] [Indexed: 11/30/2022]
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27
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Aggarwal R, Thomas S, Pawlowska N, Bartelink I, Grabowsky J, Jahan T, Cripps A, Harb A, Leng J, Reinert A, Mastroserio I, Truong TG, Ryan CJ, Munster PN. Inhibiting Histone Deacetylase as a Means to Reverse Resistance to Angiogenesis Inhibitors: Phase I Study of Abexinostat Plus Pazopanib in Advanced Solid Tumor Malignancies. J Clin Oncol 2017; 35:1231-1239. [PMID: 28221861 DOI: 10.1200/jco.2016.70.5350] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose This phase I trial evaluated epigenetic modulation of vascular endothelial growth factor (VEGF) and hypoxia-inducible factor by using a histone deacetylase abexinostat in combination with pazopanib to enhance response and reverse resistance. Patients and Methods Pazopanib was administered once a day on days 1 to 28 and abexinostat was administered orally twice a day on days 1 to 5, 8 to 12, and 15 to 19 (schedule A) or on days 1 to 4, 8 to 11, and 15 to 18 (schedule B). Dose escalation (3 + 3 design) in all solid tumors was followed by dose expansion in renal cell carcinoma (RCC). Results Fifty-one patients with RCC (N = 22) were enrolled, including 30 (59%) with one or more lines of prior VEGF-targeting therapy. Five dose-limiting toxicities, including fatigue (n = 2), thrombocytopenia (n = 2), and elevated AST/ALT (n = 1), were observed with schedule A; one dose-limiting toxicity was observed (elevated AST/ALT) was observed with schedule B. Grade ≥ 3 related adverse events included fatigue (16%), thrombocytopenia (16%), and neutropenia (10%). The recommended phase II dose was established as abexinostat 45 mg/m2 twice a day administered per schedule B plus pazopanib 800 mg/d. Objective response rate was 21% overall and 27% in the RCC subset. Median duration of response was 9.1 months (1.2 to > 49 months). Eight patients (16%) had durable control of disease for > 12 months. Durable tumor regressions were observed in seven (70%) of 10 patients with pazopanib-refractory disease, including one patients with RCC with ongoing response > 3.5 years. Peripheral blood histone acetylation and HDAC2 gene expression were associated with durable response to treatment. Conclusion Abexinostat is well tolerated in combination with pazopanib, allowing prolonged exposure and promising durable responses in pazopanib- and other VEGF inhibitor-refractory tumors, which supports epigenetically mediated reversal of treatment resistance.
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Affiliation(s)
- Rahul Aggarwal
- All authors: University of California, San Francisco, San Francisco, CA
| | - Scott Thomas
- All authors: University of California, San Francisco, San Francisco, CA
| | - Nela Pawlowska
- All authors: University of California, San Francisco, San Francisco, CA
| | - Imke Bartelink
- All authors: University of California, San Francisco, San Francisco, CA
| | | | - Thierry Jahan
- All authors: University of California, San Francisco, San Francisco, CA
| | - Amy Cripps
- All authors: University of California, San Francisco, San Francisco, CA
| | - Armand Harb
- All authors: University of California, San Francisco, San Francisco, CA
| | - Jim Leng
- All authors: University of California, San Francisco, San Francisco, CA
| | - Anne Reinert
- All authors: University of California, San Francisco, San Francisco, CA
| | | | - Thach-Giao Truong
- All authors: University of California, San Francisco, San Francisco, CA
| | - Charles J Ryan
- All authors: University of California, San Francisco, San Francisco, CA
| | - Pamela N Munster
- All authors: University of California, San Francisco, San Francisco, CA
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28
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Russo M, Bardelli A. Lesion-Directed Therapies and Monitoring Tumor Evolution Using Liquid Biopsies. Cold Spring Harb Perspect Med 2017; 7:a029587. [PMID: 28003276 PMCID: PMC5287059 DOI: 10.1101/cshperspect.a029587] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Precision oncology relies on targeted drugs, such as kinase inhibitors, that are presently administered based on molecular profiles obtained from surgical or bioptic tissue samples. The inherent ability of human tumors to molecularly evolve in response to drug pressures represents a daunting diagnostic challenge. Circulating free DNA (cfDNA) released from primary and metastatic lesions can be used to draw molecular maps that can be continuously updated to match each tumor's evolution. We will present evidence that liquid biopsies can effectively interrogate how targeted therapies drive lesion-specific drug-resistance mechanisms. The impact of drug-induced molecular heterogeneity on subsequent lines of treatment will also be discussed.
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Affiliation(s)
- Mariangela Russo
- Department of Oncology, University of Torino, 10060 Candiolo (TO), Italy
- Candiolo Cancer Institute-FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Alberto Bardelli
- Department of Oncology, University of Torino, 10060 Candiolo (TO), Italy
- Candiolo Cancer Institute-FPO, IRCCS, 10060 Candiolo, Torino, Italy
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29
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Nassif E, Thibault C, Vano Y, Fournier L, Mauge L, Verkarre V, Timsit MO, Mejean A, Tartour E, Oudard S. Sunitinib in kidney cancer: 10 years of experience and development. Expert Rev Anticancer Ther 2016; 17:129-142. [PMID: 27967249 DOI: 10.1080/14737140.2017.1272415] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Sunitinib is a multi-target, anti-angiogenic tyrosine kinase inhibitor and a key molecule in the treatment of metastatic renal cell carcinoma (mRCC). Since it first demonstrated its efficacy ten years ago, overall survival of mRCC has more than doubled, in part due to sunitinib. In most recent years, progress has been made in the comprehension of its mechanism of action and resistance. Areas Covered: In this article, clinical trials involving sunitinib in kidney cancer have been reviewed, defining its different indications in metastatic and localized RCC. The rationale of sunitinib's efficacy, preclinical trials, past-clinical trials and ongoing clinical trials are summarized. Dose and scheme base are discussed, as the recommended dosage is frequently not well tolerated. Combination therapies appear to be toxic. Novel immunotherapies are changing the landscape of mRCC treatment and challenging sunitinib. Special attention has been paid towards cancer cell biology and immunity involved in treatment response. Expert Commentary: Sunitinib's place in the therapeutic arsenal is being redefined with the arrival of major challengers. Dosage and scheduling of sunitinib remains a major challenge.
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Affiliation(s)
- Elise Nassif
- a Oncology Department , Georges Pompidou European Hospital , Paris , France
| | - Constance Thibault
- a Oncology Department , Georges Pompidou European Hospital , Paris , France.,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
| | - Yann Vano
- a Oncology Department , Georges Pompidou European Hospital , Paris , France.,b Cordeliers Research Center, UMRS1138 Team 13 Cancer, Immune Control and Escape , Paris , France .,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
| | - Laure Fournier
- c Radiology Department , Georges Pompidou European Hospital , Paris , France.,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
| | - Laetitia Mauge
- d Biological Hematology Department , Georges Pompidou European Hospital , Paris , France.,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
| | - Virginie Verkarre
- d Biological Hematology Department , Georges Pompidou European Hospital , Paris , France.,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
| | - Marc-Olivier Timsit
- e Urology Department , Georges Pompidou European Hospital , Paris , France.,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
| | - Arnaud Mejean
- e Urology Department , Georges Pompidou European Hospital , Paris , France.,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
| | - Eric Tartour
- f Immunology Department , Georges Pompidou European Hospital , Paris , France.,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
| | - Stéphane Oudard
- a Oncology Department , Georges Pompidou European Hospital , Paris , France.,g Université Paris Descartes Sorbonne Paris-Cité , Paris 5 , France
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30
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Abstract
Sunitinib is an oral multi-targeted tyrosine kinase inhibitor (TKI) that targets various receptors, including vascular endothelial growth factor receptors (VEGFRs). Sunitinib received approval in 2006 and became a standard treatment option in the first-line treatment of metastatic renal cell cancer (mRCC) after a phase III trial showed superiority compared with interferon alpha (IFN-α). Sunitinib has also shown activity in second-line treatment in several trials. Most of the combination trials with sunitinib with various agents have led to considerable toxicity without improving efficacy. Sunitinib alone causes significant side effects and has a distinct profile with diarrhoea, hypertension, skin effects hypothyroidism, fatigue and nausea of special interest. The recommended dose of sunitinib in mRCC is 50 mg orally daily for 4 weeks, followed by 2 weeks off treatment (4/2 schedule). An alternative 2 weeks on, 1 week off schedule (2/1 schedule) seems to be of similar efficacy and better tolerability and could be more widely used in the future. An intermittent treatment strategy with a stop in remission and re-induction after progression showed efficacy in smaller trials and is currently being evaluated in a phase III trial. Direct comparison of sunitinib with pazopanib in first-line treatment showed a similar efficacy for both TKIs with a distinct toxicity profile. Data from two phase II trials showed that sunitinib has also activity in non-clear cell cancer and is an option due to a lack of better alternatives. Currently, after immune checkpoint inhibitors have shown very promising results in the second-line treatment of RCC, they are being tested in a number of phase III trials in the first-line setting. The future will show the position of sunitinib in the first-line treatment of RCC in the era of the immune checkpoint inhibitors.
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Affiliation(s)
- Thomas A. Schmid
- Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
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Gao Y, Li J, Qiao N, Meng Q, Zhang M, Wang X, Jia J, Yang S, Qu C, Li W, Wang D. Adrenomedullin blockade suppresses sunitinib-resistant renal cell carcinoma growth by targeting the ERK/MAPK pathway. Oncotarget 2016; 7:63374-63387. [PMID: 27556517 PMCID: PMC5325371 DOI: 10.18632/oncotarget.11463] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/13/2016] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To evaluate the mechanisms underlying sunitinib resistance in RCC and to identify targets that may be used to overcome this resistance. RESULTS Reanalysis of transcriptome microarray datasets (GSE64052 and GSE76068) showed that adrenomedullin expression was increased in sunitinib-resistant tumors. And adrenomedullin expression was increased in sunitinib-resistant tumor xenografts, accompanied by upregulation of phospho-ERK levels. However, blocking adrenomedullin inhibited sunitinib-resistant tumor growth. Treatment of RCC cells with sunitinib and ADM22-52 was superior to monotherapy with either agent. Additionally, adrenomedullin upregulated cAMP and activated the ERK/MAPK pathway, promoting cell proliferation, while knockdown of adrenomedullin inhibited RCC cell growth and invasion in vitro. MATERIALS AND METHODS We searched the Gene Expression Omnibus (GEO) database to find data regarding sunitinib-resistant RCC. These data were subsequently reanalyzed to identify targets that contribute to sunitinib resistance, and adrenomedullin upregulation was found to mediate sunitinib resistance in RCC. Then, we created an RCC mouse xenograft model. Mice were treated with sunitinib, an adrenomedullin receptor antagonist (ADM22-52), a MEK inhibitor (PD98059) and different combinations of these three drugs to investigate their effects on tumor growth. RCC cells (786-0) were cultured in vitro and treated with an ADM22-52 or PD98059 to determine whether adrenomedullin activates the ERK/MAPK pathway. Adrenomedullin was knocked down in 786-0 cells via siRNA, and the effects of this knockdown on cell were subsequently investigated. CONCLUSIONS Adrenomedullin plays an important role in RCC resistance to sunitinib treatment. The combination of sunitinib and an adrenomedullin receptor antagonist may result in better outcomes in advanced RCC patients.
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Affiliation(s)
- Yongqian Gao
- Department of Interventional Radiology, Tangshan Gongren Hospital, Hebei Medical University, Tangshan 063000, P.R. China
| | - Jinyi Li
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, 10029, USA
| | - Na Qiao
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Qingsong Meng
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Ming Zhang
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Xin Wang
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Jianghua Jia
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Shuwen Yang
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Changbao Qu
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Wei Li
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Dongbin Wang
- Department of Urologic Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
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Abstract
As a multitargeted kinase inhibitor, sunitinib has carved its way into demonstrating itself as a most effective tyrosine kinase inhibitor in the treatment of metastatic renal cell carcinoma. Mechanistically, sunitinib inhibits multiple receptor tyrosine kinases, especially those involved in angiogenesis, that is, vascular endothelial growth factor receptor, platelet-derived growth factor receptor, and proto-oncogene cKIT. Sunitinib has also been implicated in enhancing cancer invasiveness and metastasis. Mechanisms of resistance are poorly understood, but both intrinsic and acquired mechanisms are thought to be involved. While the side effects are manageable, sunitinib, like many other tyrosine kinase inhibitors, can be associated with serious toxicities that require careful management including frequent dose reductions. Although still in the early stage, emerging evidence points to an immunomodulatory role for sunitinib. It is also likely to contribute to the overall outcomes, especially those seen in metastatic renal cell carcinoma, and such effects are thought to be mediated by the proto-oncogene cKIT receptor. Combination with other modalities such as stereotactic body radiation therapy, therapeutic vaccines, and checkpoint inhibitors is being pursued for improved efficacy.
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Affiliation(s)
- Zhonglin Hao
- Department of Medicine, Section of Hematology and Oncology, Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Ibrahim Sadek
- Department of Medicine, Section of Hematology and Oncology, Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Oudard S, Geoffrois L, Guillot A, Chevreau C, Deville JL, Falkowski S, Boyle H, Baciuchka M, Gimel P, Laguerre B, Laramas M, Pfister C, Topart D, Rolland F, Legouffe E, Denechere G, Amela EY, Abadie-Lacourtoisie S, Gross-Goupil M. Clinical activity of sunitinib rechallenge in metastatic renal cell carcinoma—Results of the REchallenge with SUnitinib in MEtastatic RCC (RESUME) Study. Eur J Cancer 2016; 62:28-35. [DOI: 10.1016/j.ejca.2016.04.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/30/2016] [Accepted: 04/04/2016] [Indexed: 01/31/2023]
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Ueda K, Suekane S, Ogasawara N, Chikui K, Suyama S, Nakiri M, Nishihara K, Matsuo M, Igawa T. Long-term response of over ten years with sorafenib monotherapy in metastatic renal cell carcinoma: a case report. J Med Case Rep 2016; 10:177. [PMID: 27312478 PMCID: PMC4911686 DOI: 10.1186/s13256-016-0961-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/30/2016] [Indexed: 01/14/2023] Open
Abstract
Background Molecular targeted therapies have dramatically improved the prognosis of metastatic renal cell carcinoma. However, patients in whom the treatment could initially be effective will experience disease progression later. Case presentation A 74-year-old Japanese man who was diagnosed with renal cell carcinoma with no evidence of metastasis presented to our hospital. He initially underwent radical nephrectomy, and subsequently the disease metastasized to the lung. Sorafenib was started for the lung metastases 1 year after the operation. The dose of sorafenib was reduced and temporarily discontinued because adverse events, including fatigue and cardiac infarction, occurred. The patient has continued sorafenib monotherapy for over 10 years without disease progression and severe adverse events. Conclusions We present a rare case of a patient with metastatic renal cell carcinoma who has survived for over 10 years while receiving sorafenib monotherapy.
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Affiliation(s)
- Kosuke Ueda
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan.
| | - Shigetaka Suekane
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Naoyuki Ogasawara
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Katsuaki Chikui
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Shunsuke Suyama
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Makoto Nakiri
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Kiyoaki Nishihara
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Mitsunori Matsuo
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Tsukasa Igawa
- Department of Urology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 830-0011, Japan
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Abstract
PURPOSE OF REVIEW To explore the accumulating evidence and feasibility of rechallenge with agents targeting the vascular endothelial growth factor (VEGF) and mammalian target of rapamycin (mTOR) pathways for incorporation into the evolving management algorithm for metastatic renal-cell carcinoma (mRCC). RECENT FINDINGS The current standard of care after the development of resistance to first-line targeted therapies in mRCC is sequential treatment with subsequent lines of alternative anti-VEGF agents or mTOR inhibitors, with optimal sequencing being the focus of ongoing research. Recent evidence from case study and retrospective reports suggests that mRCC patients can achieve important clinical benefits from rechallenge at later lines of therapy with the same targeted therapy used for previous line treatment. Further, the results of REchallenge with SUnitinib in MEtastatic, the first study of sunitinib rechallenge to include a prospective component, reinforce the potential for prolonged survival with this treatment approach for mRCC patients. SUMMARY Rechallenge represents an important and feasible therapeutic option for the future treatment of mRCC patients. The results of ongoing prospective studies are expected to further evaluate the benefits of rechallenge and better inform wherein this approach fits in the treatment algorithm for mRCC.
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Daste A, Gross-Goupil M, Quivy A, François L, Bernhard JC, Ravaud A. Efficacy of Rechallenge of Metastatic Renal Cell Carcinoma Patient With Sunitinib After Prior Resistance to Axitinib: Case Report and Review of the Literature. Clin Genitourin Cancer 2016; 14:e525-e527. [PMID: 27185091 DOI: 10.1016/j.clgc.2016.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 04/11/2016] [Indexed: 01/15/2023]
Affiliation(s)
- Amaury Daste
- Department of Medical Oncology, Hôpital Saint-André, University of Bordeaux-CHU Bordeaux, France; University of Bordeaux, Bordeaux, France.
| | - Marine Gross-Goupil
- Department of Medical Oncology, Hôpital Saint-André, University of Bordeaux-CHU Bordeaux, France
| | - Amandine Quivy
- Department of Medical Oncology, Hôpital Saint-André, University of Bordeaux-CHU Bordeaux, France
| | - Louis François
- Department of Medical Oncology, Hôpital Saint-André, University of Bordeaux-CHU Bordeaux, France; University of Bordeaux, Bordeaux, France
| | | | - Alain Ravaud
- Department of Medical Oncology, Hôpital Saint-André, University of Bordeaux-CHU Bordeaux, France; University of Bordeaux, Bordeaux, France
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Incorvaia L, Bronte G, Bazan V, Badalamenti G, Rizzo S, Pantuso G, Natoli C, Russo A. Beyond evidence-based data: scientific rationale and tumor behavior to drive sequential and personalized therapeutic strategies for the treatment of metastatic renal cell carcinoma. Oncotarget 2016; 7:21259-71. [PMID: 26872372 PMCID: PMC5008283 DOI: 10.18632/oncotarget.7267] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
The recent advances in identification of the molecular mechanisms related to tumorigenesis and angiogenesis, along with the understanding of molecular alterations involved in renal cell carcinoma (RCC) pathogenesis, has allowed the development of several new drugs which have revolutionized the treatment of metastatic renal cell carcinoma (mRCC).This process has resulted in clinically significant improvements in median overall survival and an increasing number of patients undergoes two or even three lines of therapy. Therefore, it is necessary a long-term perspective of the treatment: planning a sequential and personalized therapeutic strategy to improve clinical outcome, the potential to achieve long-term response, and to preserve quality of life (QOL), minimizing treatment-related toxicity and transforming mRCC into a chronically treatable condition.Because of the challenges still encountered to draw an optimal therapeutic sequence, the main focus of this article will be to propose the optimal sequencing of existing, approved, oral targeted agents for the treatment of mRCC using evidence-based data along with the knowledge available on the tumor behavior and mechanisms of resistance to anti-angiogenic treatment to provide complementary information and to help the clinicians to maximize the effectiveness of targeted agents in the treatment of mRCC.
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Affiliation(s)
- Lorena Incorvaia
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Giuseppe Bronte
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Viviana Bazan
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Giuseppe Badalamenti
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Sergio Rizzo
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Gianni Pantuso
- Department of Surgical, Oncological and Oral Sciences, Section of Surgical Oncology, University of Palermo, Palermo, Italy
| | - Clara Natoli
- Department of Medical, Oral and Biotechnological Sciences, University “G. D'Annunzio”, Chieti, Italy
| | - Antonio Russo
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
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Narayan V, Haas NB. Axitinib in the treatment of renal cell carcinoma: patient selection and perspectives. Int J Nephrol Renovasc Dis 2016; 9:65-72. [PMID: 27099525 PMCID: PMC4822864 DOI: 10.2147/ijnrd.s83874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Axitinib is a next-generation, selective tyrosine kinase inhibitor targeting the vascular endothelial growth factor receptors. It is approved for the treatment of metastatic renal cell carcinoma (mRCC) based on a demonstrated progression-free survival advantage over sorafenib in the second-line treatment setting. However, given the variety of available targeted therapies for mRCC, appropriate patient selection for the available therapies remains a significant clinical challenge. PURPOSE This review summarizes the available evidence on the clinical, toxicity, and pharmacologic considerations for determining appropriate patient selection for axitinib therapy. In addition, it describes recent data on the use of predictive biomarkers to guide clinical management. This paper consists of material obtained via PubMed and Medline literature searches through October 2015. CONCLUSION Axitinib has a well-established role in the management of mRCC. Consistent clinical efficacy has been demonstrated across prognostic risk groups and prior therapeutic exposures. Although axitinib is generally well tolerated, appropriate toxicity management is critical to maximizing drug delivery and optimizing treatment outcomes. Although incident hypertension has been associated with improved clinical outcomes on axitinib, there are currently no validated clinical or genetic predictive biomarkers to guide patient selection.
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Affiliation(s)
- Vivek Narayan
- Division of Hematology/Medical Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Naomi Balzer Haas
- Division of Hematology/Medical Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Nozawa M, Uemura H. Proposal of "cyclic therapy", a novel treatment strategy with targeted agents for advanced renal cell carcinoma. Transl Androl Urol 2016; 2:324-7. [PMID: 26816747 PMCID: PMC4708111 DOI: 10.3978/j.issn.2223-4683.2013.12.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The number of molecular targeted agents for advanced renal cell carcinoma (RCC) has gradually increased, but evidence on the optimal order of selection for such agents has not yet caught up with this trend. In addition, timing of switching molecular targeted drugs may also become an important issue for controlling the disease as types of these drugs grow in number. Based on the fact that the efficacy of a rechallenge of the drug previously used suggests the recovery of the sensitivity, a cyclic therapy in which drugs are changed before exacerbation to repeatedly administer several drugs in a rotated manner, may also be an effective sequential therapy.
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Affiliation(s)
- Masahiro Nozawa
- Department of Urology, Kinki University Faculty of Medicine,377-2 Ohno-higashi, Osaka-sayama, 589-8511, Japan
| | - Hirotsugu Uemura
- Department of Urology, Kinki University Faculty of Medicine,377-2 Ohno-higashi, Osaka-sayama, 589-8511, Japan
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Fischer S, Gillessen S, Rothermundt C. Sequence of treatment in locally advanced and metastatic renal cell carcinoma. Transl Androl Urol 2016; 4:310-25. [PMID: 26816832 PMCID: PMC4708238 DOI: 10.3978/j.issn.2223-4683.2015.04.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The spectrum of drugs that have shown activity in advanced or metastatic renal cell carcinoma (RCC) has led to a debate on the optimal sequence of treatments. There is agreement on recommending targeted agents as the standard of care in this disease. Uncertainty, however, remains on the best first-line drug choice. Physicians and patients may select sunitinib, bevacizumab in combination with interferon-alpha (IFN-α), pazopanib, or-in poor risk patients-temsirolimus. There are also a variety of therapies with proven efficacy on hand in the second-line setting: sorafenib, pazopanib, axitinib, and everolimus. While most randomized RCC trials assessed progression free survival (PFS) as primary endpoint, some agents were shown to improve median overall survival (OS), and given in sequence they have extended the life expectancy of RCC patients from 13 months in the cytokine era to over 30 months. Despite the progress made, there are sobering aspects to the oncologic success story in RCC, as the new treatments do not obtain an objective response or disease stabilization (SD) in all patients. There are also as yet no predictors to select patients who might benefit and those who are primary resistant to specific drugs, and ultimately almost all patients will experience disease progression. Bearing inevitable treatment failure in mind, availability of further drugs and switching therapy while the patient is in a condition to continue pharmacotherapy is essential. Of note, depending on the setting, only 33-59% of patients receive second-line treatment. In this review we present data on first-, second-, and third-line treatment in RCC, and discuss the difficulties in their interpretation in the context of treatment sequence. We summarize biological aspects and discuss mechanisms of resistance to anti-angiogenic therapy and their implications for treatment selection.
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Affiliation(s)
- Stefanie Fischer
- Division of Oncology/Haematology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland
| | - Silke Gillessen
- Division of Oncology/Haematology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland
| | - Christian Rothermundt
- Division of Oncology/Haematology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland
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Porta C, Giglione P, Paglino C. Targeted therapy for renal cell carcinoma: focus on 2nd and 3rd line. Expert Opin Pharmacother 2016; 17:643-55. [PMID: 26630127 DOI: 10.1517/14656566.2016.1127353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Second- and third-line treatments are more and more frequently administered to metastatic renal cell carcinoma (mRCC) patients. AREAS COVERED Here we discuss the various levels of evidence supporting presently available recommendations, trying to address a number of as yet unanswered issues, and also to take a glowing glance at the future. To do this, we interrogated the Medline database, as well as the proceedings of the main Oncological and Urological conferences for relevant studies. EXPERT OPINION Until recently, with regard to choosing the second line treatment after the failure of therapy with vascular endothelial growth factor receptors-tyrosine kinase inhibitors (VEGFR-TKIs), the continued inhibition of the VEGF/VEGR pathway, or else the switch to an mTOR inhibitor, is recommended. These two options are characterized by partly different targets, completely different toxicity profiles, but a comparable efficacy. This scenario will change soon, after the publication of two randomized, controlled, phase III trials in which cabozantinib and nivolumab proved to be superior as compared to everolimus. As regards third line treatment, where a sequence of two VEGFR-TKIs has been used beforehand, the choice is represented by the mTOR inhibitor everolimus, whilst if a VEGFR-TKI followed by everolimus has been chosen, a return to VEGF pathway inhibition is suggested.
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Affiliation(s)
- Camillo Porta
- a Medical Oncology , I.R.C.C.S. San Matteo University Hospital Foundation , Pavia , Italy.,b Italian Group of Nephro-Oncology/Gruppo Italiano di Oncologia Nefrologica (G.I.O.N.)
| | - Palma Giglione
- a Medical Oncology , I.R.C.C.S. San Matteo University Hospital Foundation , Pavia , Italy
| | - Chiara Paglino
- a Medical Oncology , I.R.C.C.S. San Matteo University Hospital Foundation , Pavia , Italy.,b Italian Group of Nephro-Oncology/Gruppo Italiano di Oncologia Nefrologica (G.I.O.N.)
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Vrdoljak E, Torday L, Szczylik C, Kharkevich G, Bavbek S, Sella A. Pharmacoeconomic and clinical implications of sequential therapy for metastatic renal cell carcinoma patients in Central and Eastern Europe. Expert Opin Pharmacother 2015; 17:93-104. [PMID: 26619144 DOI: 10.1517/14656566.2016.1107043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The incidence and mortality rates of kidney cancer in the Central and Eastern European (CEE) region are among the highest in the world. Access to second and subsequent lines of metastatic renal cell carcinoma (mRCC) therapies is highly varied in the region. Despite the increasing body of evidence supporting the clinical benefit of multiple lines of treatment, access to treatment beyond first line is restricted in many of these countries. AREAS COVERED The adoption of targeted therapies for the first-line treatment of mRCC in the region was slow and faced many obstacles. In order to evaluate the current status of treatment beyond the first-line setting in the CEE region, this review examines the availability and reimbursement of mRCC drugs and clinical practice in institutions that treat patients with mRCC. EXPERT OPINION This review highlights the need to raise awareness among physicians, payers and regulators on clinical trial and cost-effectiveness data regarding the treatment of mRCC beyond the first line. The obstacles to mRCC drug access highlighted in this review need to be overcome to ensure that patients are receiving the best treatment available.
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Affiliation(s)
- E Vrdoljak
- a University Hospital Split , Department of Oncology , Split , Croatia
| | - L Torday
- b University of Szeged , Department of Oncotherapy , Szeged , Hungary
| | - C Szczylik
- c Central Clinical Hospital , Department of Oncology, Military Institute of Medicine , Warsaw , Poland
| | - G Kharkevich
- d NN Blokhin Russian Cancer Research Center , Biotherapy Department , Moscow , Russia
| | - S Bavbek
- e VKV American Hospital , Div. Medical Oncology , Istanbul , Turkey
| | - A Sella
- f Assaf Harofeh Centre Zerifin, Department of Oncology , Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
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Schmidinger M. Improving outcomes in metastatic clear cell renal cell carcinoma by sequencing therapy. Am Soc Clin Oncol Educ Book 2015:e228-38. [PMID: 24857107 DOI: 10.14694/edbook_am.2014.34.e228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Targeted agents have substantially improved outcomes in metastatic clear cell renal cell carcinoma. However, due to multiple mechanisms of evasive resistance, almost all patients progress at some point and may require subsequent therapies. Various agents have been explored after failure of first-line treatment in randomized clinical trials. However, so far few questions about the optimal sequence have been answered. Both everolimus and axitinib have been considered standard of care after failure of first-line VEGF-TKI; sorafenib has been proposed as an additional option. In clinical practice, several factors may influence the choice of subsequent treatment: these include considerations on appropriate drug exposure in first-line, gained insights on prognostic and predictive factors as well as mechanisms of resistance. Once the decision in second-line has been made and treatment has been initiated, treating physicians may already be challenged by the question of what to offer in third- and later lines. Treatment beyond second-line treatment isn't supported by strong evidence, and at this stage of disease, retrospective reports on rechallenge may help to guide decisions. In addition, local treatment approaches including metastasectomy and stereotactic radiosurgery may help to optimize outcomes in all treatment lines.
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Affiliation(s)
- Manuela Schmidinger
- From the Department of Medicine I, Clinical Division of Oncology and Comprehensive Cancer Center, Medical University of Vienna, Austria
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Wang HK, Zhang HL, Zhu Y, Yao XD, Zhang SL, Dai B, Shen YJ, Zhu YP, Shi GH, Qin XJ, Ma CG, Lin GW, Xiao WJ, Ye DW. A Phase II trial of dosage escalation of sorafenib in Asian patients with metastatic renal cell carcinoma. Future Oncol 2015; 10:1941-51. [PMID: 25386811 DOI: 10.2217/fon.14.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To investigate the role of sorafenib dosage escalation in Asian patients with metastatic renal cell carcinoma that had progressed after routine dosages. PATIENTS & METHODS Sorafenib dosage escalation to 600 or 800 mg twice a day was offered to 41 patients with metastatic renal cell carcinoma who had progressed on normal dosages. Clinical outcome, toxicity and favorable clinical covariables for progression-free survival (PFS) were evaluated. RESULTS The median PFS with dosage-escalated therapy was 7 months. Drug-related adverse events were tolerable. The pre-escalation Karnofsky performance status, serum calcium concentration, neutrophil/lymphocyte ratio, PFS and the highest toxicity grade at the routine dosage were associated with a longer PFS in the dosage-escalation period. CONCLUSION Sorafenib dosage escalation was efficacious and tolerable in Asian patients. TRIAL REGISTRATION Chinese Clinical Trial Registry (no. ChiCTR-ONRC-12002088).
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Affiliation(s)
- Hong-kai Wang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
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Randall JM, Millard F, Kurzrock R. Molecular aberrations, targeted therapy, and renal cell carcinoma: current state-of-the-art. Cancer Metastasis Rev 2015; 33:1109-24. [PMID: 25365943 DOI: 10.1007/s10555-014-9533-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Renal cell carcinoma (RCC) is among the most prevalent malignancies in the USA. Most RCCs are sporadic, but hereditary syndromes associated with RCC account for 2-3 % of cases and include von Hippel-Lindau, hereditary leiomyomatosis, Birt-Hogg-Dube, tuberous sclerosis, hereditary papillary RCC, and familial renal carcinoma. In the past decade, our understanding of the genetic mutations associated with sporadic forms of RCC has increased considerably, with the most common mutations in clear cell RCC seen in the VHL, PBRM1, BAP1, and SETD2 genes. Among these, BAP1 mutations are associated with aggressive disease and decreased survival. Several targeted therapies for advanced RCC have been approved and include sunitinib, sorafenib, pazopanib, axitinib (tyrosine kinase inhibitors (TKIs) with anti-vascular endothelial growth factor (VEGFR) activity), everolimus, and temsirolimus (TKIs that inhibit mTORC1, the downstream part of the PI3K/AKT/mTOR pathway). High-dose interleukin 2 (IL-2) immunotherapy and the combination of bevacizumab plus interferon-α are also approved treatments. At present, there are no predictive genetic markers to direct therapy for RCC, perhaps because the vast majority of trials have been evaluated in unselected patient populations, with advanced metastatic disease. This review will focus on our current understanding of the molecular genetics of RCC, and how this may inform therapeutics.
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Affiliation(s)
- J Michael Randall
- Department of Medicine, Division of Hematology/Oncology, UCSD Moores Cancer Center, University of California, San Diego, 3855 Health Sciences Drive, #0987, La Jolla, CA, 92093-0987, USA,
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Davis ID, Long A, Yip S, Espinoza D, Thompson JF, Kichenadasse G, Harrison M, Lowenthal RM, Pavlakis N, Azad A, Kannourakis G, Steer C, Goldstein D, Shapiro J, Harvie R, Jovanovic L, Hudson AL, Nelson CC, Stockler MR, Martin A. EVERSUN: a phase 2 trial of alternating sunitinib and everolimus as first-line therapy for advanced renal cell carcinoma. Ann Oncol 2015; 26:1118-1123. [PMID: 25701452 DOI: 10.1093/annonc/mdv078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/09/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We hypothesised that alternating inhibitors of the vascular endothelial growth factor receptor (VEGFR) and mammalian target of rapamycin pathways would delay the development of resistance in advanced renal cell carcinoma (aRCC). PATIENTS AND METHODS A single-arm, two-stage, multicentre, phase 2 trial to determine the activity, feasibility, and safety of 12-week cycles of sunitinib 50 mg daily 4 weeks on / 2 weeks off, alternating with everolimus 10 mg daily for 5 weeks on / 1 week off, until disease progression or prohibitive toxicity in favourable or intermediate-risk aRCC. The primary end point was proportion alive and progression-free at 6 months (PFS6m). The secondary end points were feasibility, tumour response, overall survival (OS), and adverse events (AEs). The correlative objective was to assess biomarkers and correlate with clinical outcome. RESULTS We recruited 55 eligible participants from September 2010 to August 2012. DEMOGRAPHICS mean age 61, 71% male, favourable risk 16%, intermediate risk 84%. Cycle 2 commenced within 14 weeks for 80% of participants; 64% received ≥22 weeks of alternating therapy; 78% received ≥22 weeks of any treatment. PFS6m was 29/55 (53%; 95% confidence interval [CI] 40% to 66%). Tumour response rate was 7/55 (13%; 95% CI 4% to 22%, all partial responses). After median follow-up of 20 months, 47 of 55 (86%) had progressed with a median progression-free survival of 8 months (95% CI 5-10), and 30 of 55 (55%) had died with a median OS of 17 months (95% CI 12-undefined). AEs were consistent with those expected for each single agent. No convincing prognostic biomarkers were identified. CONCLUSIONS The EVERSUN regimen was feasible and safe, but its activity did not meet pre-specified values to warrant further research. This supports the current approach of continuing anti-VEGF therapy until progression or prohibitive toxicity before changing treatment. AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY ACTRN12609000643279.
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Affiliation(s)
- I D Davis
- Monash University Eastern Health Clinical School, Melbourne; ANZUP Cancer Trials Group, Sydney.
| | - A Long
- ANZUP Cancer Trials Group, Sydney; NHMRC Clinical Trials Centre, University of Sydney, Sydney; Sydney Catalyst Translational Cancer Research Centre, University of Sydney, Sydney
| | - S Yip
- ANZUP Cancer Trials Group, Sydney; NHMRC Clinical Trials Centre, University of Sydney, Sydney; Sydney Catalyst Translational Cancer Research Centre, University of Sydney, Sydney
| | - D Espinoza
- ANZUP Cancer Trials Group, Sydney; NHMRC Clinical Trials Centre, University of Sydney, Sydney; Sydney Catalyst Translational Cancer Research Centre, University of Sydney, Sydney
| | - J F Thompson
- ANZUP Cancer Trials Group, Sydney; NHMRC Clinical Trials Centre, University of Sydney, Sydney
| | - G Kichenadasse
- ANZUP Cancer Trials Group, Sydney; Flinders Centre for Innovation in Cancer, Flinders University, Adelaide
| | - M Harrison
- ANZUP Cancer Trials Group, Sydney; Chris O'Brien Lifehouse, Royal Prince Alfred Hospital, Sydney; Liverpool Hospital, Liverpool
| | - R M Lowenthal
- ANZUP Cancer Trials Group, Sydney; Royal Hobart Hospital and Menzies Institute for Medical Research, University of Tasmania, Hobart
| | - N Pavlakis
- ANZUP Cancer Trials Group, Sydney; Royal North Shore Hospital, University of Sydney, Sydney
| | - A Azad
- ANZUP Cancer Trials Group, Sydney; Austin Health, Melbourne
| | - G Kannourakis
- ANZUP Cancer Trials Group, Sydney; Ballarat Oncology & Haematology Services and Fiona Elsey Cancer Research Institute, Ballarat; Federation University, Ballarat
| | - C Steer
- ANZUP Cancer Trials Group, Sydney; Border Medical Oncology, Wodonga
| | - D Goldstein
- ANZUP Cancer Trials Group, Sydney; Prince of Wales Clinical School and Prince of Wales Hospital, University of New South Wales, Sydney
| | - J Shapiro
- ANZUP Cancer Trials Group, Sydney; Cabrini Hospital, Melbourne
| | - R Harvie
- ANZUP Cancer Trials Group, Sydney; Bill Walsh Translational Cancer Research Laboratories, Kolling Institute, Sydney
| | - L Jovanovic
- Australian Prostate Cancer Research Centre-Queensland, Institute of Health and Biomedical Innovation, Queensland University of Technology, Princess Alexandra Hospital, Translational Research Institute, Brisbane
| | - A L Hudson
- Bill Walsh Translational Cancer Research Laboratories, Kolling Institute, Sydney
| | - C C Nelson
- ANZUP Cancer Trials Group, Sydney; Australian Prostate Cancer Research Centre-Queensland, Institute of Health and Biomedical Innovation, Queensland University of Technology, Princess Alexandra Hospital, Translational Research Institute, Brisbane
| | - M R Stockler
- ANZUP Cancer Trials Group, Sydney; NHMRC Clinical Trials Centre, University of Sydney, Sydney; Sydney Catalyst Translational Cancer Research Centre, University of Sydney, Sydney; Chris O'Brien Lifehouse, Royal Prince Alfred Hospital, Sydney; Concord Cancer Centre, Concord, Australia
| | - A Martin
- ANZUP Cancer Trials Group, Sydney; NHMRC Clinical Trials Centre, University of Sydney, Sydney; Sydney Catalyst Translational Cancer Research Centre, University of Sydney, Sydney
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Kuczynski EA, Lee CR, Man S, Chen E, Kerbel RS. Effects of Sorafenib Dose on Acquired Reversible Resistance and Toxicity in Hepatocellular Carcinoma. Cancer Res 2015; 75:2510-9. [PMID: 25908587 DOI: 10.1158/0008-5472.can-14-3687] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/23/2015] [Indexed: 12/31/2022]
Abstract
Acquired evasive resistance is a major limitation of hepatocellular carcinoma (HCC) treatment with the tyrosine kinase inhibitor (TKI) sorafenib. Recent findings suggest that resistance to sorafenib may have a reversible phenotype. In addition, loss of responsiveness has been proposed to be due to a gradual decrease in sorafenib plasma levels in patients. Here, the possible mechanisms underlying reversible sorafenib resistance were investigated using a Hep3B-hCG orthotopic human xenograft model of locally advanced HCC. Tissue and plasma sorafenib and metabolite levels, downstream antitumor targets, and toxicity were assessed during standard and dose-escalated sorafenib treatment. Drug levels were found to decline significantly over time in mice treated with 30 mg/kg sorafenib, coinciding with the onset of resistance but a greater magnitude of change was observed in tissues compared with plasma. Skin rash also correlated with drug levels and tended to decrease in severity over time. Drug level changes appeared to be partially tumor dependent involving induction of tumoral CYP3A4 metabolism, with host pretreatment alone unable to generate resistance. Escalation from 30 to 60 mg/kg sorafenib improved antitumor efficacy but worsened survival due to excessive body weight loss. Microvessel density was inhibited by sorafenib treatment but remained suppressed over time and dose increase. In conclusion, tumor CYP3A4 induction by sorafenib is a novel mechanism to account for variability in systemic drug levels; however, declining systemic sorafenib levels may only be a minor resistance mechanism. Escalating the dose may be an effective treatment strategy, provided toxicity can be controlled.
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Affiliation(s)
| | - Christina R Lee
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Shan Man
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Eric Chen
- Department of Medical Oncology, Princess Margaret Hospital, Toronto, Canada
| | - Robert S Kerbel
- Department of Medical Biophysics, University of Toronto, Toronto, Canada. Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada.
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Bjarnason GA, Khalil B, Hudson JM, Williams R, Milot LM, Atri M, Kiss A, Burns PN. Reprint of: Outcomes in patients with metastatic renal cell cancer treated with individualized sunitinib therapy: Correlation with dynamic microbubble ultrasound data and review of the literature. Urol Oncol 2015; 33:171-8. [DOI: 10.1016/j.urolonc.2015.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/16/2013] [Accepted: 10/05/2013] [Indexed: 10/23/2022]
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Park I, Lee JL, Ahn JH, Lee DH, Lee KH, You D, Jeong IG, Song C, Hong B, Hong JH, Ahn H. Vascular endothelial growth factor receptor tyrosine kinase inhibitor (VEGFR-TKI) rechallenge for patients with metastatic renal cell carcinoma after treatment failure using both VEGFR-TKI and mTOR inhibitor. Cancer Chemother Pharmacol 2015; 75:1025-35. [DOI: 10.1007/s00280-015-2725-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
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50
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Combinatorial and Sequential Targeted Therapy in Metastatic Renal Cell Carcinoma. KIDNEY CANCER 2015. [DOI: 10.1007/978-3-319-17903-2_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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