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Fallah J, Gittleman H, Weinstock C, Chang E, Agrawal S, Tang S, Pazdur R, Kluetz PG, Suzman DL, Amiri-Kordestani L. Cytoreductive nephrectomy in the era of immune checkpoint inhibitors: a US Food and Drug Administration pooled analysis. J Natl Cancer Inst 2024; 116:1043-1050. [PMID: 38486364 DOI: 10.1093/jnci/djae066] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/12/2024] [Accepted: 03/04/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND This pooled analysis of patient-level data from trials evaluated the clinical outcomes of patients with metastatic renal cell carcinoma with or without cytoreductive nephrectomy before a combination of immune checkpoint inhibitor and antiangiogenic therapy. METHODS Data from 5 trials of immune checkpoint inhibitors plus antiangiogenic therapy were pooled. Only patients with stage 4 disease at initial diagnosis were included to ensure that nephrectomy was performed for cytoreductive purposes and not to previously treat an earlier stage of disease. The effect of cytoreductive nephrectomy before immune checkpoint inhibitor therapy on outcomes was evaluated using the Kaplan-Meier method and a Cox proportional hazards regression model, adjusted for age, sex, risk group, performance status, and the presence of sarcomatoid differentiation. RESULTS A total of 981 patients were included. The estimated median progression-free survival with and without nephrectomy was 15 and 11 months, respectively; the adjusted hazard ratio was 0.71 (95% confidence interval = 0.59 to 0.85). The estimated median overall survival with and without nephrectomy was 46 and 28 months, respectively; the adjusted hazard ratio was 0.63 (95% confidence interval = 0.51 to 0.77). Objective response was 60% of patients with vs 46% of patients without cytoreductive nephrectomy. CONCLUSIONS Patients with metastatic renal cell carcinoma who undergo cytoreductive nephrectomy before immune checkpoint inhibitor plus antiangiogenic therapy had improved outcomes compared with patients without cytoreductive nephrectomy. Selection factors for cytoreductive nephrectomy may be prognostic and could not be fully controlled for in this retrospective analysis. Prospective determination of and stratification by prior cytoreductive nephrectomy may be considered when designing clinical trials to assess the impact of this factor on prognosis.
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Affiliation(s)
- Jaleh Fallah
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Haley Gittleman
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Chana Weinstock
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Elaine Chang
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Sundeep Agrawal
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Shenghui Tang
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Richard Pazdur
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, MD, USA
| | - Paul G Kluetz
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, MD, USA
| | - Daniel L Suzman
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Laleh Amiri-Kordestani
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, MD, USA
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Schmeusser BN, Master VA. The 5-factor frailty index for radical nephrectomy: Simplifying personalized preoperative risk-stratification. Urol Oncol 2023; 41:329.e9-329.e10. [PMID: 37258372 DOI: 10.1016/j.urolonc.2023.05.007] [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: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 06/02/2023]
Abstract
Radical nephrectomy is the gold standard treatment for large renal cell carcinoma. Given the rising incidence of renal cell carcinoma and higher prevalence of geriatric patients in the population, readily identifying patients preoperatively that are at risk for a more complicated postoperative course is critical. The 5-factor modified frailty index (5-IFi) is a scoring system that assigns 1 point for each of the following comorbidities: dependent functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients with higher 5-IFi scores have been shown to be at significant risk for increased postoperative morbidity and mortality in many cohorts, including patients that undergo radical nephrectomy. This simplified comorbidity index with only 5 components is much more clinically pragmatic than its predecessors. As we encounter an increasing volume of patients with renal cell carcinoma and geriatric surgical candidates, readily risk stratifying patients on a personalized basis may be informative for shared clinical and surgical-decision making.
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Affiliation(s)
| | - Viraj A Master
- Department of Urology, Emory University School of Medicine, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA.
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3
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Drăgan A, Sinescu I. The Role of the Cardiac Biomarkers in the Renal Cell Carcinoma Multidisciplinary Management. Diagnostics (Basel) 2023; 13:1912. [PMID: 37296764 PMCID: PMC10253077 DOI: 10.3390/diagnostics13111912] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/27/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Renal cell carcinoma, an aggressive malignancy, is often incidentally diagnosed. The patient remains asymptomatic to the late stage of the disease, when the local or distant metastases are already present. Surgical treatment remains the choice for these patients, although the plan must adapt to the characteristics of the patients and the extension of the neoplasm. Systemic therapy is sometimes needed. It includes immunotherapy, target therapy, or both, with a high level of toxicity. Cardiac biomarkers have prognosis and monitoring values in this setting. Their role in postoperative identification of myocardial injury and heart failure already have been demonstrated, as well as their importance in preoperative evaluation from the cardiac point of view and the progression of renal cancer. The cardiac biomarkers are also part of the new cardio-oncologic approach to establishing and monitoring systemic therapy. They are complementary tests for assessment of the baseline toxicity risk and tools to guide therapy. The goal must be to continue the treatment as long as possible with the initiation and optimisation of the cardiological treatment. Cardiac atrial biomarkers are reported to have also antitumoral and anti-inflammatory properties. This review aims to present the role of cardiac biomarkers in the multidisciplinary management of renal cell carcinoma patients.
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Affiliation(s)
- Anca Drăgan
- Department of Cardiovascular Anaesthesiology and Intensive Care, Prof. C.C. Iliescu Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania
| | - Ioanel Sinescu
- Department of Urological Surgery, Dialysis and Kidney Transplantation, Fundeni Clinical Institute, 258 Fundeni Road, 022328 Bucharest, Romania;
- Department of Uronephrology, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
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5
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Troschel FM, Jin Q, Eichhorn F, Muley T, Best TD, Leppelmann KS, Yang CFJ, Troschel AS, Winter H, Heußel CP, Gaissert HA, Fintelmann FJ. Sarcopenia on preoperative chest computed tomography predicts cancer-specific and all-cause mortality following pneumonectomy for lung cancer: A multicenter analysis. Cancer Med 2021; 10:6677-6686. [PMID: 34409756 PMCID: PMC8495285 DOI: 10.1002/cam4.4207] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/30/2021] [Indexed: 12/20/2022] Open
Abstract
Background Mortality risk prediction in patients undergoing pneumonectomy for non‐small cell lung cancer (NSCLC) remains imperfect. Here, we aimed to assess whether sarcopenia on routine chest computed tomography (CT) independently predicts worse cancer‐specific (CSS) and overall survival (OS) following pneumonectomy for NSCLC. Methods We included consecutive adults undergoing standard or carinal pneumonectomy for NSCLC at Massachusetts General Hospital and Heidelberg University from 2010 to 2018. We measured muscle cross‐sectional area (CSA) on CT at thoracic vertebral levels T8, T10, and T12 within 90 days prior to surgery. Sarcopenia was defined as T10 muscle CSA less than two standard deviations below the mean in healthy controls. We adjusted time‐to‐event analyses for age, body mass index, Charlson Comorbidity Index, forced expiratory volume in 1 second in % predicted, induction therapy, sex, smoking status, tumor stage, side of pneumonectomy, and institution. Results Three hundred and sixty‐seven patients (67.4% male, median age 62 years, 16.9% early‐stage) underwent predominantly standard pneumonectomy (89.6%) for stage IIIA NSCLC (45.5%) and squamous cell histology (58%). Sarcopenia was present in 104 of 367 patients (28.3%). Ninety‐day all‐cause mortality was 7.1% (26/367). After a median follow‐up of 20.5 months (IQR, 9.2–46.9), 183 of 367 patients (49.9%) had died. One hundred and thirty‐three (72.7%) of these deaths were due to lung cancer. Sarcopenia was associated with shorter CSS (HR 1.7, p = 0.008) and OS (HR 1.7, p = 0.003). Conclusions This transatlantic multicenter study confirms that sarcopenia on preoperative chest CT is an independent risk factor for CSS and OS following pneumonectomy for NSCLC.
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Affiliation(s)
- Fabian M Troschel
- Department of Radiation Oncology, Münster University Hospital, Münster, Germany.,Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Qianna Jin
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany.,Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.,Translational Lung Research Centre (TLRC) Heidelberg, German Centre for Lung Research, Heidelberg, Germany.,Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Florian Eichhorn
- Translational Lung Research Centre (TLRC) Heidelberg, German Centre for Lung Research, Heidelberg, Germany.,Department of Surgery, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Muley
- Translational Lung Research Centre (TLRC) Heidelberg, German Centre for Lung Research, Heidelberg, Germany.,Department of Surgery, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany
| | - Till D Best
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Konstantin S Leppelmann
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Chi-Fu Jeffrey Yang
- Department of Surgery, Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amelie S Troschel
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hauke Winter
- Translational Lung Research Centre (TLRC) Heidelberg, German Centre for Lung Research, Heidelberg, Germany.,Department of Surgery, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany
| | - Claus P Heußel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany.,Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.,Translational Lung Research Centre (TLRC) Heidelberg, German Centre for Lung Research, Heidelberg, Germany
| | - Henning A Gaissert
- Department of Surgery, Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Florian J Fintelmann
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
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Tabakin AL, Stein MN, Anderson CB, Drake CG, Singer EA. Cytoreductive nephrectomy for metastatic renal cell carcinoma, the ultimate urologic 'Choosing Wisely' campaign: a narrative review. Transl Cancer Res 2020; 9:7337-7349. [PMID: 33354523 PMCID: PMC7751973 DOI: 10.21037/tcr-20-2343] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/21/2020] [Indexed: 01/04/2023]
Abstract
In the early 2000s, cytoreductive nephrectomy in addition to systemic cytokines became standard of care for treating metastatic renal cell carcinoma. Since that time, the development of novel systemic targeted therapies and immuno-oncologic agents have challenged the utility of cytoreductive nephrectomy in clinical practice. In 2019, the controversial CARMENA study was published, providing the first level one evidence suggesting that cytoreductive nephrectomy combined with targeted therapy yielded no survival advantage over targeted therapy alone in intermediate and poor risk metastatic renal cell carcinoma patients. Later that year, the SURTIME trial demonstrated that patients undergoing targeted therapy with delayed nephrectomy maintained a survival advantage over those that underwent upfront cytoreductive nephrectomy followed by targeted therapy. Both of these studies underscored the importance of patient selection and timing of cytoreductive nephrectomy and systemic therapy. As new immuno-oncologic agents are trialed, particularly in combination, the role of cytoreductive nephrectomy will continue to be questioned. In this narrative review, we discuss the evolution of the role of cytoreductive nephrectomy in treating metastatic renal cell carcinoma through the context of the ever-changing landscape of targeted therapies and immuno-oncologic agents. We assess the evidence for cytoreductive nephrectomy with respect to patient factors, timing of surgery, and combination with other therapies.
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Affiliation(s)
- Alexandra L. Tabakin
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
| | - Mark N. Stein
- Division of Medical Oncology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Christopher B. Anderson
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Charles G. Drake
- Division of Medical Oncology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Eric A. Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
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