Remarkable effect of presurgical nivolumab on originally inoperable papillary renal cell carcinoma with tumor thrombus in inferior vena cava

Neoadjuvant therapy in renal cell carcinoma with tumor thrombus: A systematic review and meta-analysis

To evaluate the efficacy, feasibility and safety of neoadjuvant therapy (NAT) for renal cell carcinoma with tumor thrombus (RCC-TT) in terms of response, perioperative and oncological outcomes, and compare the results between neoadjuvant and non-neoadjuvant groups. Overall, 29 single-arm studies and 5 cohort studies were included. Of the 204 patients undergoing NAT, 16.2% were level I, 35.3% level II, 24.0% level III and 18.6% level IV thrombus. Most of patients underwent preoperative targeted therapy, immunotherapy-based combination therapy was applied in 5.4% patients. The total reduction rate of thrombus level was 29.4%. NAT is associated with a shorter operative time, less blood loss (p<0.05 for both). Rate of complications and oncological outcomes were similar between two groups. Overall, 32.1% (34/106) ≥ grade 3 adverse events occurred in patients undergoing NAT. Neoadjuvant therapy is safe and feasible with acceptable perioperative outcomes in RCC-TT.

The role of cytoreductive nephrectomy and systemic therapy in the management of tumour thrombus in patients with metastatic renal cell carcinoma

BACKGROUND

Outcomes for patients with metastatic renal cell carcinoma (mRCC) and tumour thrombus remain poor. Recent data suggest limited role for cytoreductive nephrectomy (CN) and data on thrombus response to systemic therapy (ST) is scarce. Here, we describe response and survival of patients with de novo mRCC and thrombi treated with ST with or without CN.

METHODS

Demographics, disease characteristics and survival of patients with de novo mRCC were collected. Progression-free survival (PFS) and overall survival (OS) in months (m) was calculated using the Kaplan-Meier method (log-rank).

RESULTS

Between 2002 and 2019, 226 patients with mRCC were identified, 64 (28.3%) had tumour thrombus out of which 18 (28.1%) received only ST. Among 12 evaluable patients, thrombus response, stability and progression were seen in 3 (25%), 6 (50%) and 3 (25%) patients, respectively. Median OS was similar for patients with and without tumour thrombus treated with systemic therapy alone [OS: 12.1 m (8.8-27.7) vs. 13.9 m (7.9-21.5), p = 0.87]. CN predicted for better OS in patients with tumour thrombus [OS: 29.4 m (17.4-48.9) vs. 12.1 m (8.8-27.7), p = 0.01].

CONCLUSION

In this retrospective series of patients with mRCC and tumour thrombus, addition of CN to ST improved outcomes. Validation of these findings with contemporary regimens is needed.

Clinicopathological Features of Papillary Renal Cell Carcinoma With Venous Tumor Thrombus: Case Series from a Large Chinese Center

Background:

Few studies have reported the influence of the histological classification of type-2 papillary renal cell carcinoma (PRCC), which may differ from that of clear cell renal carcinoma (ccRCC), on the prognosis of renal cell carcinoma with tumor thrombus. We investigated the clinicopathological features and prognosis of type-2 PRCC associated with venous tumor thrombi (PRCC-TT).

Methods:

We retrospectively analyzed 163 patients with renal cell carcinoma with venous tumor thrombus (RCC-TT) admitted to Peking University Third Hospital between June 2016 and June 2020. Twenty-five patients had type-2 PRCC-TT and 138 had ccRCC combined with tumor thrombus; there were 125 males and 38 females. All the included patients underwent radical nephrectomy and thrombectomy under either complete laparoscopic surgery or open surgery. Univariate and multivariate Cox regression analysis were performed to evaluate the prognostic significance of each variable on cancer-specific survival (CSS). Cancer-specific survival was calculated from the date of surgery to death or the last follow-up using the Kaplan–Meier method.

Results:

The blood vessels of type-2 PRCC-TT presented on CT images were not as abundant as those of ccRCC-TT. Slight enhancement was observed in the corticomedullary phase. While wash-out symptoms were observed, contrast agent extinction was not obvious in the nephrographic and excretory phases. We compared the macroscopic and microscopic appearances of the 2 cohorts. Compared to the ccRCC-TT cohort, lymph node invasion was more prevalent in the PRCC-TT cohort (88.0% vs. 60.9%, P = .009). Multivariate analysis revealed that sarcomatoid differentiation, distant metastasis, and pathological type were the independent predictors of poor CSS. The Kaplan–Meier analysis showed that the CSS of type-2 PRCC-TT and ccRCC-TT were 23.5 and 38.4 months, respectively, with statistical significance (P = .002).

Conclusion:

Type-2 PRCC-TT varies with common ccRCC-TT in imaging manifestation and pathological characteristics. The prognosis of type-2 PRCC-TT patients was worse than that of ccRCC-TT patients.

Sequential immune-targeted surgical therapy resulted in disease-free survival in a case with advanced renal cell carcinoma

Background

Currently, immunotherapy is indicated for patients with metastatic RCC or unresectable RCC, but there is no indication for immunotherapy in the neoadjuvant setting. We report a case in which the combined use of nivolumab and ipilimumab and sequential TKI therapy enabled surgical treatment.

Case presentation

A 71-year-old female was diagnosed with a metastatic clear-cell renal cell carcinoma with a level IV tumor thrombus. She was started on nivolumab-ipilimumab therapy, and was switched to pazopanib monotherapy because the tumor thrombus progressed within the right atrium. The tumor shrank to resectable status with sequential therapy. She then underwent right nephrectomy and thrombectomy. Pathological analysis showed 10–20% residual tumor in the primary tumor, but no viable cells in tumor thrombus. She remains clinically disease-free 1 year after surgery.

Conclusion

This case suggests the utility of sequential immune-targeted therapy as neoadjuvant therapy in advanced renal cell carcinoma.

Only three cycles of nivolumab showed remarkable durable response and reversible myeloradiculoneuropathy in a patient with metastatic papillary renal cell carcinoma type 2

Introduction

The efficacy of nivolumab for non-clear cell renal cell carcinoma is still unclear. We present a rare case of metastatic papillary renal cell carcinoma remarkably responded to nivolumab but developed myeloradiculoneuropathy as immune-related adverse event.

Case presentation

The patient had previously undergone radical nephrectomy for right renal mass and was diagnosed as papillary renal cell carcinoma type 2, pT3bN0M0. Three years after the first surgery, he received 3 mg/kg of nivolumab as a second-line drug for mediastinum lymph nodes and lung metastases. With three cycles of nivolumab, the patient felt progressive weakness of the legs and received two cycles of steroid-pulse therapy based on the diagnosis of myeloradiculoneuropathy. Although nivolumab therapy has been discontinued, the metastases show radiographic complete response at 2 years after the last nivolumab administration without any additional therapy.

Conclusion

Nivolumab may be a promising treatment option for non-clear cell renal cell carcinoma such as papillary renal cell carcinoma.