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Gu L, Peng C, Liang Q, Huang Q, Lv D, Zhao H, Zhang Q, Zhang Y, Zhang P, Li S, Xu J, Chen L, Xie Y, Li J, Guo G, Zhang X, Wang B, Ma X. Neoadjuvant toripalimab plus axitinib for clear cell renal cell carcinoma with inferior vena cava tumor thrombus: NEOTAX, a phase 2 study. Signal Transduct Target Ther 2024; 9:264. [PMID: 39362847 PMCID: PMC11450193 DOI: 10.1038/s41392-024-01990-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 09/10/2024] [Accepted: 09/24/2024] [Indexed: 10/05/2024] Open
Abstract
The potential benefit of neoadjuvant toripalimab plus axitinib in cases with clear cell renal cell carcinoma (ccRCC) and inferior vena cava tumor thrombus (IVC-TT) remains unclear. NEOTAX was a phase 2 study to investigate the efficacy and safety of neoadjuvant toripalimab plus axitinib in patients with ccRCC and IVC-TT (ChiCTR2000030405). The primary endpoint was the down-staging rate of IVC-TT level. Secondary endpoints included change in TT length, response rate, percentage change in surgical approach, surgical morbidity, progression-free survival (PFS), safety, and biomarker analyses. In all, 25 patients received study treatment, 44.0% (11/25) patients had a reduction in thrombus level, and none experienced an increase in Mayo level. The median change in tumor thrombus length was -2.3 cm (range: -7.1 to 1.1 cm). Overall, 61.9% (13/21) patients experienced changes in surgical strategy compared with planned surgery, three patients experienced major complications. The median PFS was 25.3 months (95% CI: 17.0-NE). The 1-year PFS was 89.1% (95% CI: 62.7-97.2). No any of grade 4 or 5 treatment-related adverse event was identified. Biopsy samples of non-responders exhibited increased T cytotoxic cell infiltration, but these cells were predominantly PD-1 positive. Biopsy samples of responders exhibited lower T helper cells, however, their subtype, regulatory T cells remained unchanged. In surgical samples of the TT, non-responders exhibited increased CD8T_01_GZMK_CXCR4 subset T cells. NEOTAX met preset endpoints proving that toripalimab in combination with axitinib downstages IVC-TT in a significant proportion of patients leading to simplification in the procedure of surgery.
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MESH Headings
- Humans
- Carcinoma, Renal Cell/drug therapy
- Carcinoma, Renal Cell/pathology
- Carcinoma, Renal Cell/genetics
- Middle Aged
- Female
- Vena Cava, Inferior/pathology
- Male
- Aged
- Axitinib/therapeutic use
- Axitinib/administration & dosage
- Axitinib/pharmacology
- Kidney Neoplasms/drug therapy
- Kidney Neoplasms/pathology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/administration & dosage
- Neoadjuvant Therapy
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/pharmacology
- Adult
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Affiliation(s)
- Liangyou Gu
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Cheng Peng
- Department of Urology, Chinese PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
| | - Qiyang Liang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
| | - Qingbo Huang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Deqiang Lv
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Houming Zhao
- Department of Urology, Chinese PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
| | - Qi Zhang
- China National Center for Bioinformation, Beijing, China
- Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Yu Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Peng Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Shichao Li
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Junnan Xu
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Luyao Chen
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yongpeng Xie
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinhang Li
- Department of Pathology, Chinese PLA General Hospital, Beijing, China
| | - Gang Guo
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
| | - Baojun Wang
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
| | - Xin Ma
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
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2
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Marandino L, Campi R, Amparore D, Tippu Z, Albiges L, Capitanio U, Giles RH, Gillessen S, Kutikov A, Larkin J, Motzer RJ, Pierorazio PM, Powles T, Roupret M, Stewart GD, Turajlic S, Bex A. Neoadjuvant and Adjuvant Immune-based Approach for Renal Cell Carcinoma: Pros, Cons, and Future Directions. Eur Urol Oncol 2024:S2588-9311(24)00211-6. [PMID: 39327187 DOI: 10.1016/j.euo.2024.09.002] [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: 06/28/2024] [Revised: 08/22/2024] [Accepted: 09/07/2024] [Indexed: 09/28/2024]
Abstract
CONTEXT Immune-oncology strategies are revolutionising the perioperative treatment in several tumour types. The perioperative setting of renal cell carcinoma (RCC) is an evolving field, and the advent of immunotherapy is producing significant advances. OBJECTIVE To critically review the potential pros and cons of adjuvant and neoadjuvant immune-based therapeutic strategies in RCC, and to provide insights for future research in this field. EVIDENCE ACQUISITION We performed a collaborative narrative review of the existing literature. EVIDENCE SYNTHESIS Adjuvant immunotherapy with pembrolizumab is a new standard of care for patients at a higher risk of recurrence after nephrectomy, demonstrating a disease-free survival and overall survival benefit in the phase 3 KEYNOTE-564 trial. Current data do not support neoadjuvant therapy use outside clinical trials. While both adjuvant and neoadjuvant immune-based approaches are driven by robust biological rationale, neoadjuvant immunotherapy may enable a stronger and more durable antitumour immune response. If neoadjuvant single-agent immune checkpoint inhibitors demonstrated limited activity on the primary tumour, immune-based combinations may show increased activity. Overtreatment and a risk of relevant toxicity for patients who are cured by surgery alone are common concerns for both neoadjuvant and adjuvant strategies. Biomarkers helping patient selection and treatment deintensification are lacking in RCC. No results from randomised trials comparing neoadjuvant or perioperative immune-based therapy with adjuvant immunotherapy are available. CONCLUSIONS Adjuvant immunotherapy is a new standard of care in RCC. Both neoadjuvant and adjuvant immunotherapy strategies have potential advantages and disadvantages. Optimising perioperative treatment strategies is nuanced, with the role of neoadjuvant immune-based therapies yet to be defined. Given strong biological rationale for a pre/perioperative approach, there is a need for prospective clinical trials to determine clinical efficacy. Research investigating biomarkers aiding patient selection and treatment deintensification strategies is needed. PATIENT SUMMARY Immunotherapy is transforming the treatment of kidney cancer. In this review, we looked at the studies investigating immunotherapy strategies before and/or after surgery for patients with kidney cancer to assess potential pros and cons. We concluded that both neoadjuvant and adjuvant immunotherapy strategies may have potential advantages and disadvantages. While immunotherapy administered after surgery is already a standard of care, immunotherapy before surgery should be better investigated in future studies. Future trials should also focus on the selection of patients in order to spare toxicity for patients who will be cured by surgery alone.
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Affiliation(s)
- Laura Marandino
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK; European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group, Arnhem, The Netherlands.
| | - Riccardo Campi
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group, Arnhem, The Netherlands; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, Florence, Italy.
| | - Daniele Amparore
- European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group, Arnhem, The Netherlands; Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Orbassano, Italy
| | - Zayd Tippu
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK; Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London, UK
| | - Laurence Albiges
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Umberto Capitanio
- IRCCS San Raffaele Scientific Institute, Urological Research Institute (URI), Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Rachel H Giles
- VHL Europa, Vlaardingen, The Netherlands; International Kidney Cancer Coalition, Duivendrecht, The Netherlands
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Alexander Kutikov
- Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - James Larkin
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Thomas Powles
- Barts Cancer Institute, Cancer Research UK Experimental Cancer Medicine Centre, Queen Mary University of London, London, UK; Royal Free National Health Service Trust, London, UK
| | - Morgan Roupret
- GRC 5 Predictive Onco-Uro, Department of Urology, AP-HP, Pitié Salpétrière Hospital, Sorbonne University, Paris, France
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK; CRUK Cambridge Centre, Cambridge, UK
| | - Samra Turajlic
- Skin and Renal Units, The Royal Marsden NHS Foundation Trust, London, UK; Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK; Melanoma and Kidney Cancer Team, The Institute of Cancer Research, London, UK
| | - Axel Bex
- The Royal Free London NHS Foundation Trust, London, UK; UCL Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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3
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Bilen MA, Vo BT, Liu Y, Greenwald R, Davarpanah AH, McGuire D, Shiradkar R, Li L, Nazha B, Brown JT, Williams S, Session W, Russler G, Caulfield S, Joshi SS, Narayan VM, Filson CP, Ogan K, Kucuk O, Carthon BC, Del Balzo L, Cohen A, Boyanton A, Prokhnevska N, Cardenas MA, Sobierajska E, Jansen CS, Patil DH, Nicaise E, Osunkoya AO, Kissick H, Master VA. Neoadjuvant cabozantinib restores CD8+ T cells in patients with locally advanced non-metastatic clear cell renal cell carcinoma: a phase 2 trial. RESEARCH SQUARE 2024:rs.3.rs-4849400. [PMID: 39149474 PMCID: PMC11326393 DOI: 10.21203/rs.3.rs-4849400/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Cabozantinib is an oral multikinase inhibitor approved for treatment in metastatic renal cell carcinoma (RCC). We hypothesized that neoadjuvant cabozantinib could downstage localized tumors, facilitating partial nephrectomy, and facilitating surgery in patients with locally advanced tumors that would require significant adjacent organ resection. We, therefore, conducted a phase 2, single-arm trial of cabozantinib treatment for 12 weeks in 17 patients with locally advanced biopsy-proven non-metastatic clear cell RCC before surgical resection. Six patients (35%) experienced a partial response, and 11 patients (65%) had stable disease. We identified that plasma cell-free DNA (cfDNA), VEGF, c-MET, Gas6, and AXL were significantly increased while VEGFR2 decreased during cabozantinib treatments. There was a trend towards CD8+ T cells becoming activated in the blood, expressing the proliferation marker Ki67 and activation markers HLA-DR and CD38. Cabozantinib treatment depleted myeloid populations acutely. Importantly, immune niches made up of the stem-like CD8+ T cells and antigen presenting cells were increased in every patient. These data suggest that cabozantinib treatment was clinically active and safe in the neoadjuvant setting in patients with locally advanced non-metastatic clear cell RCC and activated the anti-tumor CD8+ T cell response. The trial is registered at ClinicalTrials.gov under registration no. NCT04022343.
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Affiliation(s)
- Mehmet A Bilen
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - BaoHan T Vo
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Yuan Liu
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rachel Greenwald
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Amir H Davarpanah
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Donald McGuire
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
| | - Rakesh Shiradkar
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Liping Li
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Bassel Nazha
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jacqueline T Brown
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sierra Williams
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Wilena Session
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Greta Russler
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Sarah Caulfield
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Pharmaceutical Services, Emory University School of Medicine, Atlanta, GA, USA
| | - Shreyas S Joshi
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Vikram M Narayan
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Kenneth Ogan
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Omer Kucuk
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Bradley Curtis Carthon
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Luke Del Balzo
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Athena Cohen
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Adriana Boyanton
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Ewelina Sobierajska
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Caroline S Jansen
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Dattatraya H Patil
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Edouard Nicaise
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Adeboye O Osunkoya
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Haydn Kissick
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
| | - Viraj A Master
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
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4
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Blackmur JP, Armitage JN, Jones JO, Riddick ACP, Mitchell TJ, Ince WHJ, Appukutty S, Warren AY, Fife K, O'Carrigan B, Stewart GD. 'Case of the Month' from Addenbrooke's Hospital, Cambridge, UK: surgery after near complete response to combined immunotherapy and tyrosine kinase inhibitor therapy for metastatic renal cell carcinoma with inferior vena cava tumour thrombus. BJU Int 2024. [PMID: 39014977 DOI: 10.1111/bju.16472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Affiliation(s)
- James P Blackmur
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - James N Armitage
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James O Jones
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Antony C P Riddick
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thomas J Mitchell
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - William H J Ince
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sona Appukutty
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anne Y Warren
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Fife
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Brent O'Carrigan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Grant D Stewart
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
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5
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Huang J, Wang Y, Xu F, Wang Z, Wu G, Kong W, Cheoklong NG, Tricard T, Wu X, Zhai W, Zhang W, Zhang J, Zhang D, Chen S, Lian Y, Chen Y, Zhang J, Huang Y, Xue W. Neoadjuvant toripalimab combined with axitinib in patients with locally advanced clear cell renal cell carcinoma: a single-arm, phase II trial. J Immunother Cancer 2024; 12:e008475. [PMID: 38862251 PMCID: PMC11168135 DOI: 10.1136/jitc-2023-008475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND A combination of axitinib and immune checkpoint inhibitors (ICIs) demonstrated promising efficacy in the treatment of advanced renal cell carcinoma (RCC). This study aims to prospectively evaluate the safety, efficacy, and biomarkers of neoadjuvant toripalimab plus axitinib in non-metastatic clear cell RCC. METHODS This is a single-institution, single-arm phase II clinical trial. Patients with non-metastatic biopsy-proven clear cell RCC (T2-T3N0-1M0) are enrolled. Patients will receive axitinib 5 mg twice daily combined with toripalimab 240 mg every 3 weeks (three cycles) for up to 12 weeks. Patients then will receive partial (PN) or radical nephrectomy (RN) after neoadjuvant therapy. The primary endpoint is objective response rate (ORR). Secondary endpoints include disease-free survival, safety, and perioperative complication rate. Predictive biomarkers are involved in exploratory analysis. RESULTS A total of 20 patients were enrolled in the study, with 19 of them undergoing surgery. One patient declined surgery. The primary endpoint ORR was 45%. The posterior distribution of πORR had a mean of 0.44 (95% credible intervals: 0.24-0.64), meeting the predefined primary endpoint with an ORR of 32%. Tumor shrinkage was observed in 95% of patients prior to nephrectomy. Furthermore, four patients achieved a pathological complete response. Grade ≥3 adverse events occurred in 25% of patients, including hypertension, hyperglycemia, glutamic pyruvic transaminase/glutamic oxaloacetic transaminase (ALT/AST) increase, and proteinuria. Postoperatively, one grade 4a and eight grade 1-2 complications were noted. In comparison to patients with stable disease, responders exhibited significant differences in immune factors such as Arginase 1(ARG1), Melanoma antigen (MAGEs), Dendritic Cell (DC), TNF Superfamily Member 13 (TNFSF13), Apelin Receptor (APLNR), and C-C Motif Chemokine Ligand 3 Like 1 (CCL3-L1). The limitation of this trial was the small sample size. CONCLUSION Neoadjuvant toripalimab combined with axitinib shows encouraging activity and acceptable toxicity in locally advanced clear cell RCC and warrants further study. TRIAL REGISTRATION NUMBER clinicaltrials.gov, NCT04118855.
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Affiliation(s)
- Jiwei Huang
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yueming Wang
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Fan Xu
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Zaoyu Wang
- Department of Pathology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Guangyu Wu
- Department of Radiology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Wen Kong
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - N G Cheoklong
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Thibault Tricard
- Department of Urology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Xiaorong Wu
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Wei Zhai
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | | | | | - Ding Zhang
- The Medical Department, 3D Medicines Inc, Shanghai, China
| | - Shuyin Chen
- Shanghai Junshi Biosciences Co Ltd, Shanghai, China
| | - Yuqing Lian
- Shanghai Junshi Biosciences Co Ltd, Shanghai, China
| | - Yonghui Chen
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jin Zhang
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yiran Huang
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Wei Xue
- Department of Urology, RenJi Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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6
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Goswamy R, Kalemoglu E, Master V, Bilen MA. Perioperative systemic treatments in renal cell carcinoma. Front Oncol 2024; 14:1362172. [PMID: 38841158 PMCID: PMC11151741 DOI: 10.3389/fonc.2024.1362172] [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: 12/27/2023] [Accepted: 05/03/2024] [Indexed: 06/07/2024] Open
Abstract
In this review, we aim to provide a comprehensive assessment of the evolving landscape of the perioperative management in renal cell carcinoma (RCC), emphasizing its dynamic and intricate nature. We explore academic and clinical insights into the perioperative treatment paradigm of RCC. Up-to-date treatment options are discussed and the evolving role of neoadjuvant and adjuvant therapy in RCC is highlighted.
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Affiliation(s)
- Rohit Goswamy
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - Ecem Kalemoglu
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, United States
| | - Viraj Master
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States
| | - Mehmet Asim Bilen
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
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7
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Katsu A, Yanagi M, Yoshioka M, Motoda N, Takata H, Kono H, Kimata R, Hamasaki T, Kondo Y. Preoperative rapid growth of inferior vena cava tumor thrombus in renal cell carcinoma. IJU Case Rep 2024; 7:230-233. [PMID: 38686075 PMCID: PMC11056267 DOI: 10.1002/iju5.12709] [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: 12/21/2023] [Accepted: 02/09/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction We present the case of a rapidly growing inferior vena cava tumor thrombus in renal cell carcinoma. Case presentation We present a case of a 66-year-old woman with right renal cell carcinoma with a tumor thrombus extending 2 cm into the inferior vena cava on an initial Imaging. Radical surgery was performed 6 weeks after the first visit. Intraoperatively, the tumor thrombus was confirmed to have grown near the diaphragm. The tumor was resected using an inferior vena cava clamping just below the diaphragm. The tumor thrombus and renal cell carcinoma were completely removed. There was no recurrence 6 months postoperatively. Conclusion Inferior vena cava tumor thrombus in renal cell carcinoma can grow in a short period, suggesting that preoperative imaging evaluation at the appropriate time is important. Once inferior vena cava tumor thrombus of renal cell carcinoma occurs, surgery should not be delayed unless there is an urgent reason.
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Affiliation(s)
- Akifumi Katsu
- Department of UrologyNippon Medical School Musashikosugi Hospital1‐383, Kosugimachi211‐8533KanagawaJapan
| | - Masato Yanagi
- Department of UrologyNippon Medical School Musashikosugi Hospital1‐383, Kosugimachi211‐8533KanagawaJapan
| | - Masato Yoshioka
- Department of SurgeryNippon Medical School Musashikosugi HospitalKawasakiKanagawaJapan
| | - Norio Motoda
- Department of PathologyNippon Medical School Musashikosugi HospitalKawasakiKanagawaJapan
| | - Hideyuki Takata
- Department of SurgeryNippon Medical School Musashikosugi HospitalKawasakiKanagawaJapan
| | - Hiroyoshi Kono
- Department of UrologyNippon Medical School Musashikosugi Hospital1‐383, Kosugimachi211‐8533KanagawaJapan
| | - Ryoji Kimata
- Department of UrologyNippon Medical School Musashikosugi Hospital1‐383, Kosugimachi211‐8533KanagawaJapan
| | - Tsutomu Hamasaki
- Department of UrologyNippon Medical School Musashikosugi Hospital1‐383, Kosugimachi211‐8533KanagawaJapan
| | - Yukihiro Kondo
- Department of UrologyNippon Medical School HospitalTokyoJapan
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8
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Iwatani K, Kimura S, Urabe F, Matsukawa A, Aikawa K, Yanagisawa T, Shimizu K, Miki K, Kimura T, Miki J. Preoperative Tyrosine Kinase Inhibitors Before Percutaneous Cryoablation for Clinical T1b Renal Tumors. Cureus 2024; 16:e60345. [PMID: 38883051 PMCID: PMC11177236 DOI: 10.7759/cureus.60345] [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: 04/30/2024] [Accepted: 05/15/2024] [Indexed: 06/18/2024] Open
Abstract
Purpose To treat renal cell carcinoma, local ablative therapy is a viable alternative treatment option. Traditionally, cryoablation has been used for the treatment of T1a renal tumors. However, recent technological developments have expanded its application to encompass select T1b renal tumors. Here, we present a retrospective study of the utilization of preoperative tyrosine kinase inhibitors (TKIs) to induce tumor shrinkage and achieve favorable outcomes in percutaneous cryoablation (PCA). Methods We retrospectively evaluated the data from nine patients with clinical T1b renal tumors who underwent PCA. Six patients with TKI pretreatment at our institution between 2016 and 2018 were included in the study. We evaluated the safety and efficacy of preoperative TKIs prior to PCA. Results All patients received axitinib with a median treatment duration of 80.5 days (IQR: 49-85). All patients experienced tumor shrinkage (median: 13.5 mm; IQR: 7-16); five experienced downstaging to T1a following tumor shrinkage. There were no severe adverse events (common terminology criteria for adverse events (CTCAE) grade ≥ 3) in TKIs. After the discontinuation of TKIs for two weeks, all PCA procedures were performed successfully without any severe complications. During a median follow-up of 46 months, no local recurrence was observed in any of these cases. Conclusion In cases with large renal tumors, TKI pretreatment prior to PCA had potential benefits in terms of tumor shrinkage and long-term local control rate. Further well-designed studies in larger populations are needed to validate our findings.
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Affiliation(s)
- Kosuke Iwatani
- Department of Urology, The Jikei University School of Medicine, Kashiwa Hospital, Chiba, JPN
| | - Shoji Kimura
- Department of Urology, The Jikei University School of Medicine, Kashiwa Hospital, Chiba, JPN
| | - Fumihiko Urabe
- Department of Urology, The Jikei University School of Medicine, Tokyo, JPN
| | - Akihiro Matsukawa
- Department of Urology, The Jikei University School of Medicine, Tokyo, JPN
| | - Koichi Aikawa
- Department of Urology, The Jikei University School of Medicine, Tokyo, JPN
| | | | - Kanichiro Shimizu
- Department of Radiology, The Jikei University School of Medicine, Kashiwa Hospital, Chiba, JPN
| | - Kenta Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, JPN
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, JPN
| | - Jun Miki
- Department of Urology, The Jikei University School of Medicine, Kashiwa Hospital, Chiba, JPN
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9
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Zhu M, Liu Z, Zhou Y, Jiang Z, Chen S, Wang W, Shi B, Zhu Y. Effects of neoadjuvant VEGF‑TKI treatment on surgery for renal cell carcinoma: A systematic review and meta‑analysis. Oncol Lett 2024; 27:162. [PMID: 38449796 PMCID: PMC10915807 DOI: 10.3892/ol.2024.14295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/26/2024] [Indexed: 03/08/2024] Open
Abstract
To evaluate the effects of neoadjuvant vascular endothelial growth factor-tyrosine kinase inhibitor (VEGF-TKI) treatment on surgery in patients with renal cell carcinoma (RCC), sources from Embase, PubMed and the Cochrane Library databases collected from inception to December, 2022 were used for analysis in the present study, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data regarding surgical outcomes were collected. The pooled effect sizes were calculated in terms of the risk ratio (RR)/standard mean difference (SMD) with 95% confidence intervals (CIs) using the random-effects model. Subgroup and sensitivity analyses were used to explore the source of heterogeneity within the data. In total, 9 identified articles involving 829 patients (336 in the neoadjuvant + surgery group; 493 in the surgery group) were included in the present study, according to the criteria. The results demonstrated that there were no significant differences in blood loss (SMD=-0.11; 95% CI, -0.63-0.41; P=0.68), postoperative length of hospital stay or total length of hospital stay (SMD=0.23; 95% CI, -0.55-1.01; P=0.57) or complications (RR=1.16; 95% CI, 0.80-1.67; P=0.44) between the two groups. However, neoadjuvant therapy reduced the operation time (SMD=-0.67; 95% CI, -1.25- -0.09; P=0.02) and resulted in a greater proportion of patients choosing partial nephrectomy (RR=1.84; 95% CI, 1.47-2.31; P<0.00001). In the subgroup analysis, the blood loss was significantly lower in patients with RCC with inferior vena cava tumor thrombus in the neoadjuvant group (SMD=-1.10; 95% CI, -1.82- -0.38; P=0.003). In conclusion, the results of the present study indicated that neoadjuvant VEGF-TKI treatment in patients with RCC shortened operation time, decreased blood loss and did not cause an increase in perioperative complications. In addition, this treatment modality may encourage patients to opt for partial nephrectomy to preserve renal function.
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Affiliation(s)
- Meikai Zhu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Zhifeng Liu
- Department of Urology, Tai'an City Central Hospital, Tai'an, Shandong 271000, P.R. China
| | - Yongheng Zhou
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Zhiwen Jiang
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Shouzhen Chen
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Wenfu Wang
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Benkang Shi
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Yaofeng Zhu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
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10
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Gu L, Peng C, Li H, Jia T, Chen X, Wang H, Du S, Tang L, Liang Q, Wang B, Ma X, Zhang X. Neoadjuvant therapy in renal cell carcinoma with tumor thrombus: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2024; 196:104316. [PMID: 38432444 DOI: 10.1016/j.critrevonc.2024.104316] [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: 10/15/2023] [Revised: 01/26/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024] Open
Abstract
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.
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Affiliation(s)
- Liangyou Gu
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Cheng Peng
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Huaikang Li
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Tongyu Jia
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Xinran Chen
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Hanfeng Wang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Songliang Du
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Lu Tang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Qiyang Liang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Baojun Wang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Xin Ma
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
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11
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Ghoreifi A, Vaishampayan U, Yin M, Psutka SP, Djaladat H. Immune Checkpoint Inhibitor Therapy Before Nephrectomy for Locally Advanced and Metastatic Renal Cell Carcinoma: A Review. JAMA Oncol 2024; 10:240-248. [PMID: 38095885 DOI: 10.1001/jamaoncol.2023.5269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Importance The therapeutic landscape of advanced renal cell carcinoma (RCC) has rapidly evolved in the past 2 decades, with the advent of cytokines therapy followed by targeted therapies and novel immune checkpoint inhibitors (ICI). This article aims to review the current evidence and ongoing trials of neoadjuvant or prenephrectomy ICI therapy in patients with locally advanced and metastatic RCC. Observations A literature search was performed using the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and PubMed as well as relevant medical society meetings for English-language studies, articles, and abstracts published before January 31, 2023. Currently, level I evidence supports the use of ICI-based combination therapy as the first-line treatment of patients with metastatic RCC with the potential option of deferred nephrectomy in those who respond to treatment. Nevertheless, limited prospective data are available regarding the role and outcomes of nephrectomy (cytoreductive or consolidative) in conjunction with ICI therapy in both metastatic and locally advanced RCC. Although data from retrospective case series confirmed the feasibility and safety of deferred nephrectomy in this setting, the sequence of nephrectomy and whether it should be considered in patients with metastatic RCC is a common clinical dilemma. However, although neoadjuvant targeted therapy for nonmetastatic RCCs has been associated with some advantages yet not accepted as a standard, current data from a phase 3 randomized clinical trial failed to demonstrate the oncologic benefit of neoadjuvant nivolumab for locally advanced RCC. Conclusion and Relevance The findings of this review suggest that ICI-based combination therapy is the standard of care as the first-line treatment of patients with metastatic RCC. However, the role of neoadjuvant ICIs in locally advanced RCC is an active area of investigation. Deferred nephrectomy after ICI-based immunotherapy for metastatic RCC is feasible and safe yet should be performed in high-volume health centers by experienced surgeons. The multidisciplinary and careful approach is critical for treatment decisions.
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Affiliation(s)
- Alireza Ghoreifi
- Institute of Urology, Norris Cancer Center, University of Southern California, Los Angeles
| | - Ulka Vaishampayan
- Division of Hematology and Oncology, University of Michigan, Ann Arbor
| | - Ming Yin
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University College of Medicine, Columbus
| | - Sarah P Psutka
- Department of Urology, University of Washington School of Medicine, Fred Hutchinson Cancer Center, Seattle
| | - Hooman Djaladat
- Institute of Urology, Norris Cancer Center, University of Southern California, Los Angeles
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12
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Coco D, Leanza S. Robotic Radical Nephrectomy with Vena Cava Thrombus Extraction (RRN-VCTE) for Renal Cell Carcinoma: A Meta-Analysis of Surgical Technique and Outcomes. J Kidney Cancer VHL 2024; 11:5-11. [PMID: 38213481 PMCID: PMC10777058 DOI: 10.15586/jkcvhl.v11i1.288] [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: 06/17/2023] [Accepted: 11/29/2023] [Indexed: 01/13/2024] Open
Abstract
Renal cell carcinoma (RCC) with vena cava tumor thrombus is a challenging condition, which requires complex surgical management. Robotic radical nephrectomy with vena cava thrombus extraction (RRN-VCTE) has emerged as a promising and minimally invasive technique. This meta-analysis aims to review the surgical technique and outcomes of RRN-VCTE in patients with RCC and vena cava tumor thrombus. A comprehensive literature search was conducted using databases, including PubMed, Embase, and Cochrane Library. Studies published in English till October 2021 were included. Keywords used for the search included "robotic radical nephrectomy," "vena cava tumor thrombus," "surgical technique," and "outcomes." Studies that reported on patient outcomes and surgical techniques of RRN-VCTE were included. Statistical analysis was performed to assess the pooled outcomes. The meta-analysis included 16 studies comprising 298 patients who underwent RRN-VCTE. The majority of patients were males (62.4%) with a median age of 58.9 years. The median tumor size was 7.2 cm, and 93.9% of patients had level 3 or 4 vena cava thrombus. The mean operating time was 328 min, with a range of 248-423 min. Blood loss ranged from 100 to 1500 mL. The overall complication rate was 26.5%, with no reported deaths. The average hospital stay was 9.5 days. The 2-year and 5-year survival rates were 77.5 and 53.1%, respectively. RRN-VCTE is a promising and minimally invasive surgical technique for RCC with vena cava tumor thrombus, whch is associated with low complication rates and acceptable oncological outcomes. Further research is needed to confirm the long-term survival rates and compare RRN-VCTE outcomes with conventional surgical techniques. Nonetheless, RRN-VCTE appears to be a valuable option for patients with RCC and vena cava tumor thrombus.
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Affiliation(s)
- Danilo Coco
- Department of General Surgery, AST 1 Pesaro-Urbino, Pesaro, Italy
| | - Silvana Leanza
- Department of General Surgery, Carlo Urbani Hospital, AST 2, Jesi, Ancona, Italy
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13
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Williams CM, Myint ZW. The Role of Anticoagulation in Tumor Thrombus Associated with Renal Cell Carcinoma: A Literature Review. Cancers (Basel) 2023; 15:5382. [PMID: 38001642 PMCID: PMC10670835 DOI: 10.3390/cancers15225382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
Tumor thrombus (TT) is a complication of renal cell carcinoma (RCC) for which favorable medical management remains undefined. While radical nephrectomy has been shown to increase overall survival in RCC patients, surgical interventions such as cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) utilized to perform TT resection carry high mortality rates. While it has been documented that RCC with TT is associated with venous thromboembolism (VTE) development, anticoagulation use in these patients remains controversial in clinical practice. Whether anticoagulation is associated with improved survival outcomes remains unclear. Furthermore, if anticoagulation is initiated, there is limited evidence for whether direct oral anticoagulants (DOACs), heparin, or warfarin serve as the most advantageous choice. While the combination of immunotherapy and tyrosine kinase inhibitors (TKIs) has been shown to improve the outcomes of RCC, the clinical benefits of this combination are not well studied prospectively in cases with TT. In this literature review, we explore the challenges of treating RCC-associated TT with special attention to anticoagulation. We provide a comprehensive overview of current surgical and medical approaches and summarize recent studies investigating anticoagulation in RCC patients undergoing surgery, targeted therapy, and/or immunotherapy. Our goal is to provide clinicians with updated clinical insight into anticoagulation for RCC-associated TT patients.
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Affiliation(s)
- Chelsey M. Williams
- Department of Internal Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Zin W. Myint
- Division of Medical Oncology, Department of Internal Medicine, University of Kentucky, Lexington, KY 40536, USA
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14
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Kuusk T, Bex A. Adjuvant and Neoadjuvant Therapy in Renal Cell Carcinoma. Hematol Oncol Clin North Am 2023; 37:907-920. [PMID: 37369611 DOI: 10.1016/j.hoc.2023.05.020] [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: 06/29/2023]
Abstract
In locally advanced RCC, 6 phase 3 randomized controlled trials (RCTs) were designed in the perioperative setting with immune checkpoint inhibitor (ICI) monotherapy or combinations. Adjuvant trials with atezolizumab, pembrolizumab, and nivolumab with ipilimumab reported results, as did the only perioperative trial with nivolumab. Of these, only 1 year of adjuvant pembrolizumab improved disease-free survival (DFS) versus placebo, with the other trials showing no improvement in DFS. In the purely neoadjuvant setting, phase 1 b/2 ICI trials have demonstrated safety, efficacy, and dynamic changes of immune infiltrates, and provide a rationale for randomized trial concepts.
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Affiliation(s)
- Teele Kuusk
- Homerton University Hospital, London, UK; Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK; Department of Urology, The Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam 1066 CX, The Netherlands
| | - Axel Bex
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK; Department of Urology, The Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam 1066 CX, The Netherlands; Division of Surgery and Interventional Science, University College London, Pond Street, London NW3 2QG, UK.
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15
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Tobe T, Terakawa T, Hara T, Ueki H, Shiraishi Y, Wakita N, Okamura Y, Bando Y, Furukawa J, Nakano Y, Harada K, Fujisawa M. The Efficacy of Presurgical Therapy With Avelumab and Axitinib for Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus. Clin Genitourin Cancer 2023; 21:613.e1-613.e6. [PMID: 37236863 DOI: 10.1016/j.clgc.2023.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Taisuke Tobe
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Tomoaki Terakawa
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.
| | - Takuto Hara
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hideto Ueki
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yusuke Shiraishi
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Naoto Wakita
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yasuyoshi Okamura
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yukari Bando
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Junya Furukawa
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuzo Nakano
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kenichi Harada
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Masato Fujisawa
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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16
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Robinson MD, McNamara MG, Clouston HW, Sutton PA, Hubner RA, Valle JW. Patients Undergoing Systemic Anti-Cancer Therapy Who Require Surgical Intervention: What Surgeons Need to Know. Cancers (Basel) 2023; 15:3781. [PMID: 37568597 PMCID: PMC10417541 DOI: 10.3390/cancers15153781] [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: 06/13/2023] [Revised: 07/15/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
As part of routine cancer care, patients may undergo elective surgery with the aim of long-term cure. Some of these patients will receive systemic anti-cancer therapy (SACT) in the neoadjuvant and adjuvant settings. The majority of patients, usually with locally advanced or metastatic disease, will receive SACT with palliative intent. These treatment options are expanding beyond traditional chemotherapy to include targeted therapies, immunotherapy, hormone therapy, radionuclide therapy and gene therapy. During treatment, some patients will require surgical intervention on an urgent or emergency basis. This narrative review examined the evidence base for SACT-associated surgical risk and the precautions that a surgical team should consider in patients undergoing SACT.
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Affiliation(s)
- Matthew D. Robinson
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
| | - Mairéad G. McNamara
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Hamish W. Clouston
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Paul A. Sutton
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Richard A. Hubner
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Juan W. Valle
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
- Department of Medical Oncology, ENETS Centre of Excellence, The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
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17
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Leow JJ, Ray S, Dason S, Singer EA, Chang SL. The Promise of Neoadjuvant and Adjuvant Therapies for Renal Cancer. Urol Clin North Am 2023; 50:285-303. [PMID: 36948672 DOI: 10.1016/j.ucl.2023.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Because metachronous metastatic disease will develop in 20% to 40% of patients with presumed localized renal cell carcinoma (RCC) treated surgically, research is focused on neoadjuvant and adjuvant systemic therapy, to improve disease-free and overall survival. Neoadjuvant therapies trialed include anti-vascular endothelial growth factor (VEGF) tyrosine kinase inhibitor (TKI) agents, or combination therapies (immunotherapy with TKI), and aim to improve resectability of locoregional RCC. Adjuvant therapies trialed include cytokines, anti-VEGF TKI agents, or immunotherapy. These therapeutics can facilitate the surgical extirpation of the primary kidney tumor in the neoadjuvant setting and improve disease-free survival in the adjuvant setting.
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Affiliation(s)
- Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Annex 1-L04-Uro, Singapore 308433, Singapore
| | - Shagnik Ray
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, Suite 3100, Columbus, OH 43212, USA
| | - Shawn Dason
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, Suite 3100, Columbus, OH 43212, USA
| | - Eric A Singer
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, 915 Olentangy River Road, Suite 3100, Columbus, OH 43212, USA
| | - Steven L Chang
- Division of Urology, Brigham and Women's Hospital, 45 Francis Street, Suite ASBII-3, Boston, MA 02115, USA.
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18
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Dason S, Mohebali J, Blute ML, Salari K. Surgical Management of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus. Urol Clin North Am 2023; 50:261-284. [PMID: 36948671 DOI: 10.1016/j.ucl.2023.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
Most kidney cancers are primary renal cell carcinomas (RCC) of clear cell histology. RCC is unique in its ability to invade into contiguous veins - a phenomenon terms venous tumor thrombus. Surgical resection is indicated for most patients with RCC and an inferior vena cava (IVC) thrombus in the absence of metastatic disease. Resection also has an important role in selected patients with metastatic disease. In this review, we discuss the comprehensive management of the patient with RCC with IVC tumor thrombus, emphasizing a multidisciplinary approach to the surgical techniques and perioperative management.
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Affiliation(s)
- Shawn Dason
- Department of Urology, Ohio State University, 915 Olentangy River Road, Ste 3100, Columbus, OH 43212, USA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Michael L Blute
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Keyan Salari
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, MA 02142, USA.
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19
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Dason S, Lacuna K, Hannan R, Singer EA, Runcie K. State of the Art: Multidisciplinary Management of Oligometastatic Renal Cell Carcinoma. Am Soc Clin Oncol Educ Book 2023; 43:e390038. [PMID: 37253211 DOI: 10.1200/edbk_390038] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Oligometastatic renal cell carcinoma (OM-RCC) refers to patients who have limited (typically up to 5) metastatic lesions. Although management principles may overlap, OM-RCC is distinguishable from oligoprogressive RCC, which describes progression of disease to a limited number of sites while receiving systemic therapy. Cytoreductive nephrectomy and metastasectomy are common surgical considerations in OM-RCC, and indications are discussed in this review. It is evident that stereotactic ablative radiotherapy is effective in RCC and is being applied increasingly in the oligometastatic setting. Finally, we will review advances in systemic therapy and the role of active surveillance before the initiation of systemic therapy.
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Affiliation(s)
- Shawn Dason
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Kristine Lacuna
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, NY
| | - Raquibul Hannan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eric A. Singer
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Karie Runcie
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, NY
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20
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Ray S, Singer EA, Dason S. Inferior vena cava thrombectomy for renal cell carcinoma: perioperative systemic therapy, cytoreductive nephrectomy, and complex cases. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:239. [PMID: 37082664 PMCID: PMC10113102 DOI: 10.21037/atm-23-1073] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Shagnik Ray
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Eric A Singer
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Shawn Dason
- Division of Urologic Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
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21
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Gold S, Taylor J, Margulis V. Renal cell carcinoma with inferior vena cava thrombus: did we make progress in oncologic outcomes and complications? Curr Opin Urol 2023; 33:142-146. [PMID: 36621845 DOI: 10.1097/mou.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Surgery for renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (TT) remains one of the most complex surgeries performed with high rates of associated complications and perioperative mortality. Surgical techniques and neoadjuvant therapies have an important role to play in improving outcomes. This review provides a narrative analysis of recent literature on patients with RCC and TT. RECENT FINDINGS Several imaging techniques are emerging that may improve diagnostic staging of tumor thrombus level. Robotic approaches to surgical resection for all thrombi levels is feasible and safe, while longer term outcomes for higher level thrombi continues to mature. Early data on neoadjuvant immunotherapy and radiotherapy have shown improvements in complication rates and intermediate term oncologic outcomes. SUMMARY Data suggests that neoadjuvant therapies and minimally invasive techniques may improve outcomes in patients undergoing surgical resection for RCC with tumor thrombus. Larger multiinstitutional series are needed to confirm the benefit of these techniques as well as the durable long term oncologic outcomes.
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Affiliation(s)
- Samuel Gold
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jacob Taylor
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Institute of Urology and Reproductive Health, Sechenov University, Moscow, Russia
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22
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Klatte T, Welsh SJ, Riddick ACP, Karam JA, Stewart GD. Tyrosine kinase inhibitor treatment for renal cell carcinoma with inferior vena cava tumour thrombus: a quantitative summary. BJU Int 2023; 131:566-568. [PMID: 36638048 DOI: 10.1111/bju.15966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | - Sarah J Welsh
- University of Cambridge, Cambridge, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - José A Karam
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grant D Stewart
- University of Cambridge, Cambridge, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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23
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Tabbara MM, González J, Martucci M, Ciancio G. Current Approaches in Surgical and Immunotherapy-Based Management of Renal Cell Carcinoma with Tumor Thrombus. Biomedicines 2023; 11:204. [PMID: 36672712 PMCID: PMC9855836 DOI: 10.3390/biomedicines11010204] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults, with 30% of RCC diagnosed at locally advanced or metastatic stages of disease. A form of locally advanced disease is the tumor thrombus (TT), which commonly grows from the intrarenal veins, through the main renal vein, and up the inferior vena cava (IVC), and rarely, into the right cardiac chambers. Advances in all areas of medicine have allowed increased understanding of the underlying biology of these tumors and improved preoperative staging. Although the development of several novel system agents, including several clinical trials utilizing immune checkpoint inhibitors and combination therapies, has been shown to lower perioperative morbidity and increase post-operative recurrence-free and progression-free survival, surgery remains the mainstay of therapy to achieve a cure. In this review, we provide a description of specific surgical approaches and techniques used to minimize intra- and post-operative complications during radical nephrectomy and tumor thrombectomy of RCC with TT extension of various levels. Additionally, we provide an in-depth review of the major developments in neoadjuvant and adjuvant immunotherapy-based treatment and the impact of ongoing and recently completed clinical trials on the surgical treatment of advanced RCC.
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Affiliation(s)
- Marina M. Tabbara
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Javier González
- Servicio de Urología, Unidad de Transplante Renal, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Melanie Martucci
- Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
| | - Gaetano Ciancio
- Department of Surgery and Urology, Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL 33136, USA
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24
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Role of cytoreductive surgery in the era of immunotherapy. Curr Opin Urol 2022; 32:618-626. [PMID: 36081404 DOI: 10.1097/mou.0000000000001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The benefit of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) was first called into question in the tyrosine kinase inhibitors (TKIs) era. It remains undefined in the context of the recent development and approval of immune checkpoint inhibitors (ICIs) and level one evidence supporting the rapid adoption of dual ICI and combination ICI + TKI therapeutic approaches for mRCC. Our objective is to synthesize the available contemporary data regarding the safety, feasibility, and oncologic outcomes with CN for mRCC in the age of immunotherapy as well as to highlight trials in progress that will address this key knowledge gap. RECENT FINDINGS Data from the SURTIME and CARMENA trials provided insight to guide patient selection for CN in patients with mRCC receiving TKI-based treatment strategies. At present, there is a body of retrospective data supporting the safety and oncologic efficacy of CN in carefully selected patients with mRCC in both the upfront and delayed setting. The results of ongoing trials evaluating the safety and feasibility for CN as well as optimal patient selection and sequencing strategies are eagerly awaited. SUMMARY Although the optimal selection criteria and timing for CN remains to be established for patients with mRCC in the immunotherapy era, the available body of evidence underscores the importance of careful patient selection. Ongoing prospective studies, such as Cyto-KIK, PROBE, and NORDIC-SUN, will better define the role of CN in the rapidly evolving treatment landscape for mRCC.
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Stewart GD, Klatte T, Cosmai L, Bex A, Lamb BW, Moch H, Sala E, Siva S, Porta C, Gallieni M. The multispeciality approach to the management of localised kidney cancer. Lancet 2022; 400:523-534. [PMID: 35868329 DOI: 10.1016/s0140-6736(22)01059-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 12/12/2022]
Abstract
Historically, kidney cancer was approached in a siloed single-speciality way, with urological surgeons managing the localised stages of the disease and medical oncologists caring for patients if metastases developed. However, improvements in the management of localised kidney cancer have occurred rapidly over the past two decades with greater understanding of the disease biology, diagnostic options, and innovations in curative treatments. These developments are favourable for patients but provide a substantially more complex landscape for patients and clinicians to navigate, with associated challenging decisions about who to treat, how, and when. As such, the skill sets needed to manage the various aspects of the disease and guide patients appropriately outstrips the capabilities of one particular specialist, and the evolution of a multispeciality approach to the management of kidney cancer is now essential. In this Review, we summarise the current best multispeciality practice for the management of localised kidney cancer and the areas in need of further research and development.
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Affiliation(s)
- Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK; CRUK Cambridge Centre, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK; Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Tobias Klatte
- Department of Surgery, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK; Department of Urology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Laura Cosmai
- Division of Nephrology and Dialysis, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Axel Bex
- Specialist Centre for Kidney Cancer, Royal Free Hospital, London, UK; Division of Surgery and Interventional Science, University College London, London, UK; The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Benjamin W Lamb
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; School of Allied Health, Anglia Ruskin University, Cambridge, UK
| | - Holger Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Evis Sala
- CRUK Cambridge Centre, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK; Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Camillo Porta
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari, Italy; Division of Medical Oncology, AOU Consorziale Policlinico di Bari, Bari, Italy
| | - Maurizio Gallieni
- Division of Nephrology and Dialysis, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, Milan, Italy; Department of Clinical and Biomedical Sciences, Università di Milano, Milan, Italy
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