Spontaneous regression of renal cell carcinoma metastases after preoperative embolization of primary tumor and subsequent nephrectomy

Combinations of Anti-Angiogenic Agents and Immune Checkpoint Inhibitors in Renal Cell Carcinoma: Best Option?

Over the past decade, major advances have been made in the treatment of advanced and metastatic renal cell carcinomas, specifically clear cell carcinomas. For many years the optimal approach was sequential; thus, monotherapies [principally tyrosine kinase inhibitors (TKIs)] targeting angiogenesis until toxicity or progressive disease developed. The rationale was the common mechanisms of action of the targeting agents and avoidance of the risk of overlapping toxicities. Immune checkpoint inhibitors (ICIs) are effective monotherapies, and combinations thereof with anti-angiogenic agents were thus later considered. Synergistic interactions were reported in vitro. Clinical efficacy was evident in three pivotal phase III trials with axitinib-pembrolizumab, cabozantinib-nivolumab, and lenvatinib-pembrolizumab combinations. Two other combinations showed interesting results but did not improve overall survival. However, the data aided our understanding of the new therapeutic approaches. A combination of the ICIs nivolumab and ipilimumab was the first to evidence better progression-free and overall survival compared to sunitinib in patients with intermediate or unfavourable prognoses as evaluated by the International mRCC Database Consortium (IMDC). Here we focus on the TKI-ICI combinations, emphasising the rationale of their use and the clinical results. To date, no biomarker facilitating the selection of an optimal treatment by disease and patient status has been reported.

Tumour devascularisation as a potential immunotherapeutic strategy

Complete tumour devascularisation (CTD) is a surgical technique which entails the complete disruption by ligation or cutting of afferent and efferent tumour vasculature which remains in situ. In some animal models, CTD induces immune responses that lead to regression of distant metastases and protective immunity.

Preoperative Renal Tumor Embolization

The medical reports of 113 patients operated upon for renal tumors were retrospectively reviewed to assess the value of preoperative embolization. Coils or ethanol were used preoperatively in 55 patients while 58 patients underwent nephrectomy without embolization. The tumors were staged according to the TNM and the Robson staging classification. T1 and T2 tumors as well as T3 and T4 tumors were grouped together for statistical evaluation. There was no significant difference in intraoperative blood loss, operation time and survival rate between patients undergoing preoperative embolization and those who had only nephrectomy. Duration of hospital stay was always longer in the preoperatively embolized group. Preoperative embolization of renal tumors neither improved the patients' outcome nor reduced the surgical risk. Robson's classification, stage III/IV, did not show any significant differences for embolized patients or for those nephrectomized without embolization.

Spontaneous regression of renal cell carcinoma: Reality or myth?

Spontaneous regression of a malignant tumor is a very rare phenomenon. Renal cell carcinoma (RCC) is an aggressive malignancy with an often unpredictable behaviour. The incidence of spontaneous regression in metastatic RCC has been estimated to lie between < 1% and 7%. The spontaneous regression of a primary RCC has been reported much less commonly. Our literature review assesses the published literature concerning spontaneous regression of either primary or metastatic RCC. In order to examine this phenomenon in more detail we performed a literature search in the PubMed Database using the Keywords “renal cell carcinoma”, “metastatic disease”, and “spontaneous regression” and included reports from the last 100 years. The incidence of spontaneous regressions in RCC has always been considered a special feature of RCC compared to other solid malignancies. The majority of case reports of spontaneously regressed RCC describe the regression of metastases after nephrectomy rather than the spontaneous regression of a primary tumor. In cases of reported regression of metastatic RCC, this mostly applied to pulmonary lesions. As possible reasons for spontaneous regressions host immune defense mechanisms against metastatic RCC tissue following nephrectomy are discussed as important factor. RCC is known to be highly immunogenic and the possible existence of cytotoxic serum factors and tumor-specific surface antigens may trigger a cell-mediated cytotoxicity as an immunological basis for regression. Histological verification of supposed regression of a primary tumor may cause diagnostic difficulties, since large central areas of necrosis and cystic lesions of the tumor can occur simultaneously. The well-known phenomenon of necrosis in a fast growing RCC at the time of nephrectomy must not be confused with true spontaneous regression. Therefore, in our opinion such reported cases of supposed partial spontaneous regressions of primary RCCs are highly questionable. Most cases of spontaneous regression of RCC metastases have been reported after nephrectomy as the only treatment. Debulking by tumor nephrectomy then gives the immune system the chance to cope effectively with the remaining much lower quantity of tumour antigens. However, the mechanisms leading to spontaneous regression of metastatic lesions after cytoreductive nephrectomy are still poorly understood.

Integration of surgery and systemic therapy for renal cell carcinoma

Proper integration of surgery and systemic therapy is essential for improving outcomes in renal cell carcinoma (RCC). There is no current role for adjuvant therapy after nephrectomy for clinically localized disease. The potential benefits of neoadjuvant therapy for locally advanced nonmetastatic disease are in need of further study. In metastatic disease, the proper integration of cytoreductive surgery and systemic therapy remains to be elucidated. Presurgical targeted therapy is feasible and may be beneficial. Pending the results of randomized controlled trials, upfront cytoreductive nephrectomy in appropriate patients will likely continue as the paradigm of choice in metastatic RCC.

Spontaneous regression of thoracic malignancies

BACKGROUND

Clinicians are frequently questioned by patients about the possibility of spontaneous regression of tumors. Although there are many reports and a few case series documenting spontaneous regression, there is concern that these cases may not represent true regression. Using specific criteria, we attempted to determine the incidence and types of thoracic malignancy most likely to regress spontaneously.

METHODS

We used a PubMed search of the phrase "spontaneous regression of thoracic lesions" reported from 1951 to December 2008. Using a modified Everson and Cole criterion we developed to define spontaneous regression, this search was refined for true spontaneous regression of primary and metastatic thoracic malignancies.

RESULTS

Only 5 cases in the literature involved spontaneous regression of a primary thoracic malignancy. These include pleural mesothelioma, primary lung cancer and adenoid cystic carcinoma. 71 cases involved true spontaneous regression of metastatic thoracic neoplasms, of which 5 cases showed regression of the primary extrapulmonary tumors along with the pulmonary metastasis. Thoracic metastasis from renal cell carcinoma was the most common malignancy found to regress spontaneously.

CONCLUSION

Spontaneous regression of primary thoracic malignancy is rare. Renal cell carcinoma accounts for most reported cases.

Rapid improvement in pain and functional level in a patient with metastatic renal cell carcinoma: a case report and review of the literature

Renal cell carcinoma (RCC) represents approximately 3% of all adult cancers and is more common in males. Systemic treatment for RCC has improved following the introduction of sunitinib. Bone metastases are present in up to 50% of RCC patients. We report a case of rapid improvement in metastatic bone lesions, recorded by nuclear bone scan, in a male patient receiving localized palliative radiotherapy in addition to systemic sunitinib and zoledronic acid. Concurrently, quality of life and performance status improved dramatically. Although we are unsure of the exact mechanism for such rapid improvement in metastatic bone lesions, the swiftness this improvement deserves reporting.

Spontaneous regression of metastatic renal cancer. Case report and literature review

A case of spontaneous regression of pleural and intrapulmonary metastases from renal cell cancer is reported with more than 60 cases reported since the original review of this clinical phenomenon in 1964. The metastatic disease sites are most often pulmonary, but extrapulmonary sites include liver, bone, and CNS regressions. The role of nephrectomy in "spontaneous regression" continues to be obscure, accounting for < 50% of documented cases. Immunologic mechanisms, although intellectually attractive, have not been identified.

Regression of metastatic renal cell carcinoma after cytoreductive nephrectomy

Fewer than 1% of patients with renal cell carcinoma are reported to experience spontaneous regression of metastatic lesions after nephrectomy. We report on 4 of 91 patients (4.4%) with metastatic renal cell carcinoma who had spontaneous regression of all metastatic lesions after cytoreductive nephrectomy. These patients were carefully selected before surgery for the ability to receive high dose interleukin-2. One patient had recurrence at 2 months, 1 had recurrence at 11 months, and 2 had no evidence of disease at 3 and 4.5 years.

Arterial embolization in patients with renal carcinoma

The literature concerning embolization of the renal artery in patients with renal cell carcinoma is reviewed. Based on this review it is concluded that the method is useful in this patient group as it will facilitate the surgical procedure if nephrectomy is performed afterwards. Used as a palliative method, embolization reduces haematuria. It was not possible to draw conclusions concerning survival rates or eventual immuno-stimulating effects of embolization.

Preoperative devascularization of advanced renal adenocarcinoma using a sclerosing agent

Sodium tetradecyl sulfate is a sclerosing agent used currently as therapy for varicose veins. Animal experiments have demonstrated this drug to be a useful agent for renal tissue destruction. We have used sodium tetradecyl sulfate with or without steel coils for preoperative renal devascularization in 6 patients with advanced renal adenocarcinoma. In all patients sodium tetradecyl sulfate effectively caused renal infarction and was tolerated well. No complications were associated with the use of this agent. Sodium tetradecyl sulfate is an efficient fluid embolic agent that can be a useful adjunct to nephrectomy in selected cases.

Regression of metastatic renal cell carcinoma: a case report and literature review

The literature provides few examples of regression of documented metastatic renal cell carcinoma. We report a case of cytologically documented pulmonary metastases from a renal cell carcinoma, which resolved following nephrectomy and hormonal therapy. The patient has been followed for 6 years without evidence of recurrence.

Infarction-nephrectomy for metastatic renal carcinoma. Southwest oncology group study

Thirty patients with metastatic renal cell cancer were treated by renal infarction, followed by delayed nephrectomy. All cases were collected over an eighteen-month period, with a minimum follow-up of one year. There were no complete remissions and only one partial remission, which lasted twenty-one months before progression of disease. Three patients had stable disease for at least six months, but eventually all patients showed evidence of progression. After tumor progression was documented patients were treated with intramuscular medroxyprogesterone acetate (Depo-Provera) 800 mg per week. No patient responded to this therapy. Overall, a 28 per cent one-year survival and a seven-month median survival were realized, which is similar to other series in which no therapy or palliative nephrectomy was performed. We conclude that infarction and nephrectomy is not an effective modality in the treatment of metastatic renal cell carcinoma. In addition, medroxyprogesterone was not shown to be significantly active against renal cancer in this study.

Enhancement of mouse natural killer cell activity after dearterialization of experimental renal tumors

Dearterialization of intrarenally transplanted syngeneic or allogeneic tumors in C57Bl/6 mice resulted in a pronounced enhancement of spontaneous cell mediated cytotoxicity of spleen lymphocytes. The augmentation was evident 48 hours after occlusion of the renal artery and persisted for at least 1 week. Dearterialization of non-tumor bearing kidneys had no effect on spontaneous cell mediated cytotoxicity. The effector cells responsible for the increased cytotoxicity were identified as natural killer cells based on their lack of adherence to nylon-wool, resistance to treatment with Thy 1.2 antibodies and complement and complete elimination by antibodies to asialo-GM1 and complement. The increase in natural killer cell activity reported here is in close parallel to that observed after embolization of human renal tumors. The present murine system may provide a valuable tool for evaluation of immunobiological effects of tumor dearterialization.

Culture of peripheral monocytes in vitro in patients with renal cell carcinoma: a possible prognostic indicator

An in vitro assay has been applied in 23 patients with renal cell carcinoma. A mononuclear cell-rich fraction was cultured from peripheral blood of patients with renal cell carcinoma. The number of monocytes maturing into macrophages was quantitated over a period of 7 days. Monocyte maturation was significantly lower in patients with renal cell carcinoma than in normal individuals. Of 10 patients tested both pre- and post-nephrectomy, 8 patients showed clinical improvement after surgery. In all 8, the posttreatment macrophage yield improved significantly from the pretreatment values to approach normal values. In 2 patients found to have metastasis postoperatively, the macrophage yield continued below normal levels. Our results suggest that the in vitro maturation of macrophages from mononuclear cells may parallel clinical events.

Hypertension with renal carcinoma. An effect of arterial embolization

A patient presented with mediastinal metastases from renal adenocarcinoma. Palliative therapy included Gelfoam and steel coil embolization of the right renal artery. Six weeks later he was found to have developed severe hypertension. Arteriogram revealed collateral vessels which supplied the tumor; the renal vein renin activity was four times higher on the right than on the left. We suspect that infarction of the kidney was not complete because of collateral arterial supply, and renin-dependent hypertension was the result. Thus, it may be hazardous to embolize large hypernephromas without subsequent nephrectomy.

Percutaneous vaso-occlusion for nonmalignant renal lesions

Transarterial renal embolization has been used in the management of renal cancer. We report on 9 patients who underwent selective and superselective renal arterial embolization for nonmalignant renal lesions. Embolization was done in 5 patients for hemorrhage owing to renal angiomas, renal artery, pseudoaneurysm, percutaneous renal biopsy and adult polycystic kidney disease, and in 2 patients with end stage renal disease because of massive proteinuria. Another chronic renal failure patient with severe hypertension was treated successfully with bilateral renal embolization. A postoperative renal arteriovenous fistula was treated successfully by catheter vaso-occlusion. Renal embolization may be a suitable alternative to surgery in poor operative risk patients and for technically difficult benign lesions. Renal infection is a contraindication to embolization.

Renal cell carcinoma in children

Data from four pediatric hospitals concerning 20 children treated for renal cell carcinoma (RCC) from 1964-1978 were reviewed. Median age of the patients (pts) was 11.8 years (range, 14 months-19 years). Twelve were male and eight female; 17 were white and three black. Most patients presented with pain and hematuria with or without a palpable mass. An intrarenal tumor was detected at IV urography (17 pts), arteriography (2 pts), or at surgery (1 pt). Treatment consisted of nephrectomy in 15 pts, renal biopsy (4 pts), or no surgery (1 pt), followed by chemotherapy (5 pts), radiation therapy (1 pt), or both (7 pts). Ten pts died of distant metastases at a median of one year (range, 0.2 to two years) after diagnosis. The other 10 pts (50%) survive free of relapse at a median of 4 years (range, two to ten years) from diagnosis. Proportions surviving free of recurrent disease two or more years by National Wilms' Tumor Study (NWTS) Group were 5/5 in Group I, 3/7 in Group II, 1/3 in Group III, and 1/5 in Group IV; by age at diagnosis, 6/6 in those under 11 years old and 4/14 in those 11 or older; and by type of surgery, 10/15 who had nephrectomy and 0/5 with limited or no surgery. The data indicate that radiation and chemotherapy had only minor if any influences on relapse-free survival. We conclude that (1) RCC in children is similar to its counterpart in adults; (2) RCC has a worse prognosis than Wilms' tumor except for the earliest stage; (3) nephrectomy alone is adequate treatment for Group I RCC, and (4) young age (less than 11 years old) may be prognostically favorable.

Renal devitalization using 95 per cent ethyl alcohol

Preoperative embolization of renal arteries with solid material before nephrectomy is a standard procedure for the treatment of renal cell carcinoma. However, it often is difficult to use these materials and sometimes special equipment is required. We have used 95 per cent ethyl alcohol in 3 patients to devitalize kidneys with tumors. Our results show 95 per cent ethyl alcohol to be safe, effective and easy to use. When combined with epidural anesthesia alcohol embolization is well tolerated by the patient, and its destructive effect is complete and limited to the selected organ.

Spontaneous regression of metastases of renal cancer: A report of two cases including the first recorded regression following irradiation of a dominant metastasis and review of the world literature

Two cases of spontaneous regression of lung metastases are presented. One is the first report of regression of metastases after irradiation of a dominant metastasis. The world literature is reviewed, and 67 documented cases have been found including the two now reported. Attention is drawn to the use of immunotherapy in the treatment of advanced renal cancer.

Embolization for genitourinary disorders

Fourteen patients with various genitourinary disorders underwent arterial embolization. The procedure was useful in facilitating surgical removal of hypernephromas, in decreasing tumor-induced hypercalcemia, and in diminishing proteinuria secondary to renal failure. Patients with priapism due to excessive arterial inflow responded well. Results of embolization performed because of bleeding varied. When bleeding was localized to a single vessel or to an area supplied by such a vessel, embolization was successful. However, when hemorrhage was diffuse or due to multiple vessel inflow, arterial embolization was not entirely effective.