Association between tyrosine-kinase inhibitor induced hypertension and treatment outcomes in metastatic renal cancer

Reviewing the path to balance: mechanisms and management of hypertension associated with targeting vascular endothelium in cancer therapy

Contemporary anticancer drugs are often accompanied by varying degrees of cardiovascular toxicity, with hypertension emerging as one of the most prevalent side effects, particularly linked to inhibitors of vascular endothelial growth factor receptor (VEGFR) and tyrosine kinase inhibitors (TKIs). Hypertension induced by cancer therapies contributes to increased cardiovascular mortality in cancer patients and survivors. Given the shared common risk factors and overlapping pathophysiological mechanisms, hypertension is also a prevalent comorbidity in this patient population. The mechanisms underlying hypertension induced by therapies targeting the vascular endothelial growth factor (VEGF) signaling pathway primarily involve reduced nitric oxide (NO) synthesis, increased endothelin-1 (ET-1) production, oxidative stress, microvascular rarefaction and dysfunction, decreased natriuresis, activation of the renin-angiotensin system (RAS), and partial endothelial cell death. Research into hypertension associated with therapies targeting the VEGF signaling pathway (VSP) could facilitate the optimization of cancer treatments, improve the evaluation and management of hypertension during targeted therapy, and help to reduce cardiovascular event rates and overall patient mortality. This review aims to provide a comprehensive summary of the current advancements in this area.

A Phase II study of neoadjuvant axitinib for reducing the extent of venous tumour thrombus in clear cell renal cell cancer with venous invasion (NAXIVA)

BACKGROUND

Surgery for renal cell carcinoma (RCC) with venous tumour thrombus (VTT) extension into the renal vein (RV) and/or inferior vena cava (IVC) has high peri-surgical morbidity/mortality. NAXIVA assessed the response of VTT to axitinib, a potent tyrosine kinase inhibitor.

METHODS

NAXIVA was a single-arm, multi-centre, Phase 2 study. In total, 20 patients with resectable clear cell RCC and VTT received upto 8 weeks of pre-surgical axitinib. The primary endpoint was percentage of evaluable patients with VTT improvement by Mayo level on MRI. Secondary endpoints were percentage change in surgical approach and VTT length, response rate (RECISTv1.1) and surgical morbidity.

RESULTS

In all, 35% (7/20) patients with VTT had a reduction in Mayo level with axitinib: 37.5% (6/16) with IVC VTT and 25% (1/4) with RV-only VTT. No patients had an increase in Mayo level. In total, 75% (15/20) of patients had a reduction in VTT length. Overall, 41.2% (7/17) of patients who underwent surgery had less invasive surgery than originally planned. Non-responders exhibited lower baseline microvessel density (CD31), higher Ki67 and exhausted or regulatory T-cell phenotype.

CONCLUSIONS

NAXIVA provides the first Level II evidence that axitinib downstages VTT in a significant proportion of patients leading to reduction in the extent of surgery.

CLINICAL TRIAL REGISTRATION

NCT03494816.

Combination Therapy in Renal Cell Carcinoma: the Best Choice for Every Patient?

PURPOSE OF REVIEW

Therapeutic alternatives to treat metastatic renal cell carcinoma (mRCC) are increasing, and combination therapies, including antiangiogenic agents and tyrosine kinase/mTOR/immune checkpoint inhibitors, are identified as the gold standard driven by the results of recent clinical studies. Nevertheless, the real-world RCC population is very heterogeneous, with categories of patients not represented in the enrolled trial population who may not benefit more from these treatments. The purpose of this expert review is to assess the rationale on which tyrosine kinase alone may still be a viable first-line treatment option for some subgroups of patients with mRCC.

RECENT FINDINGS

The first-line treatment with tyrosine kinase inhibitor monotherapy can still be considered an effective tool for addressing selected mRCCs, as highlighted by the successful outcome in a range of subjects such as favorable-risk patients, the ones suffering from autoimmune diseases, those with pancreatic or lung metastases, or previously undergoing organ transplantation and elderly subjects. Some selected categories of patients may still benefit from monotherapy with TKI, and smart sequential therapies can also be considered instead of a combination strategy. Tyrosine kinase inhibitors can also act as immune modulator agents, boosting the immune response to facilitate and potentiate the therapeutic effectiveness of subsequent immunotherapy.

Anlotinib-Induced Hypertension: Current Concepts and Future Prospects

BACKGROUND

Anlotinib is a new tyrosine kinase inhibitor developed in China that targets the receptors for vascular endothelial growth factor, platelet-derived growth factor, fibroblast growth factor, and stem cell factor. Therefore, anlotinib inhibits tumor angiogenesis, representing a new therapeutic alternative for lung cancer. Hypertension is one of its most common adverse effects, leading to discontinuation of the drug and limited clinical usefulness.

OBJECTIVE

The present review aims to summarize the evidence on the prevalence, physiopathology, and management of anlotinib-induced hypertension, as well as its effect on the cancer prognosis.

METHOD

Searches in Medline, Cochrane Central Library, and Embase were performed using the following terms: anlotinib, adverse effect, hypertension, clinical trial, vascular endothelial growth factor, and antiangiogenic drugs. Citations were also identified by checking the reference sections of selected papers.

RESULTS

Except for a phase I clinical trial with a small sample size (n = 6), almost all the clinical trials on anlotinib have reported the development of anlotinib-induced hypertension. In these trials, the incidence of hypertension ranged from 13% to 67.7%, and that of grade 3/4 hypertension ranged from4.8% to 16%. Alterations in nitric oxide, endothelin-1, microvascular rarefaction, selective vasoconstrictions, and renal injury have been cited as potential mechanisms leading to anlotinib-induced hypertension. When needed, treatment may include general hygienic measures and pharmacotherapy in some cases.

CONCLUSIONS

To effectively manage anlotinib-induced hypertension, early prevention, a reasonable dosage regimen, and appropriate treatment are critical to effectively manage anlotinib-induced hypertension. Additionally, anlotinib-induced hypertension may be considered a marker for predicting efficacy.

Association between tyrosine-kinase inhibitor induced hypertension and treatment outcomes in metastatic renal cancer

BACKGROUND

Tyrosine-kinase inhibitor (TKI) drugs have been considered first line treatment for metastatic renal cell cancer (RCC) for over a decade. TKI-induced hypertension is a common adverse-event in patients treated for metastatic RCC.

AIM

This study was aimed at investigating an association between TKI-induced hypertension and treatment outcomes for metastatic RCC patients.

METHODS AND RESULTS

Retrospective data pertaining to patients with histologically or radiologically confirmed metastatic RCC treated with sunitinib, pazopanib, sorafenib, axitinib or cabozantinib between June 2012 and May 2019 were evaluated. Clinical information and serial blood pressure measurements were extracted from medical records for each patient. We compared objective response rate, progression-free survival (PFS), and 12-month survival between TKI-induced hypertension (TIH) and non-TIH groups using χ² and Mann-Whitney tests. Out of 72 patients screened, 52 met study eligibility criteria. The median age at diagnosis was 61 years (range: 42-85 years) with a clear male predominance. The majority of patients had a history of nephrectomy with clear cell pathology. Almost all patients were on first-line TKI therapy with sunitinib or pazopanib. Median follow-up was 11 months. About half of patients developed TKI-induced hypertension (grade 2-3). In the TIH group 82% were commenced on an antihypertensive agent. Median PFS measured 30.5 weeks for TIH group compared to 22.2 weeks for non-TIH (P = .05). The 6 month and 12 month survival rates for TIH were 82% and 56%, respectively, as compared to 76% and 44% for non-TIH.

CONCLUSION

The occurrence of TKI-induced hypertension was found to be a positive prognostic factor for progression in patients with metastatic RCC.