Nivolumab plus Cabozantinib versus Sunitinib for Advanced Renal-Cell Carcinoma

mRNA vaccines for prostate cancer: A novel promising immunotherapy

The treatment of advanced prostate cancer (PCa) primarily based on androgen deprivation therapy (ADT); however, patients inevitably progress to the castration-resistant prostate cancer (CRPC) stage. Despite the recent advancements in CRPC treatment with novel endocrine drugs that further inhibit androgen receptor signaling, resistance ultimately develops, underscoring the urgent need for new effective therapeutic strategies. Therapeutic cancer vaccines, a form of immunotherapy, exert anti-cancer effects by activating the host's immune system. Over the past few decades, various conventional therapeutic PCa vaccines based on cells, microbes, proteins, peptides, or DNA have been developed and tested in patients with advanced PCa. These attempts have largely failed to improve survival, with the sole exception of sipuleucel-T, which extended the median overall survival of asymptomatic or minimally symptomatic metastatic CRPC (mCRPC) patients by four months. The rapid development and high efficacy of mRNA vaccines during the COVID-19 pandemic have garnered worldwide attention. Compared to conventional vaccines, mRNA vaccines offer several unique advantages, including high production efficiency, low cost, high safety, strong immune response induction, and high adaptability and precision. These attributes make mRNA vaccines a promising frontier in the treatment of advanced PCa.

A fc-engineered NKG2D × B7-H3 bispecific antibody enhances the antitumor activity by orchestrating cytotoxic lymphocytes

B7-H3, an immune-checkpoint molecule that is overexpressed in several cancer types, has been identified as a promising immunotherapy target. However, most immunotherapy approaches against B7-H3+ tumor cells focus on manipulating the T cells. Natural killer (NK) cells, another important part of the cellular immune system, also exhibit anti-tumor properties and play complementary roles in tumor eradication with T cells. In this study, natural killer group 2D (NKG2D), an activating receptor in most cytotoxic immune cells, was selected for engaging NK cells. We obtained specific anti-NKG2D nanobodies via phage display and developed a series of B7-H3 × NKG2D bispecific antibodies (bsAb) with different formats to fight against the B7-H3+ tumor cells. Through functional comparison of candidate antibodies in vitro, B1-C53 was selected and further modified with the optimized Fc fragment (known as FC-C53) to enhance anti-tumor immunity by antibody-dependent cell-mediated cytotoxicity (ADCC). Stronger tumor lysis mediated by FC-C53 was demonstrated both in vitro and in vivo when simultaneously directed at both NK cells and CD8+ T cells, particularly after the additional administration of a B7-H3 × CD3 bispecific T cell engager that targets B7-H3 with another epitope. Overall, we provided a strategy based on the B7-H3 × NKG2D antibody to improve the anti-B7-H3 immunotherapy approaches by orchestrating cytotoxic lymphocytes.

Deciphering molecular pathways in urological cancers: a gateway to precision therapeutics

BACKGROUND

Urological cancers, including prostate, kidney, bladder, testicular, and penile cancers, pose a significant health challenge, particularly in their metastatic stages. Surgical interventions remain fundamental, but recent advancements in medical therapies like chemotherapy, immunotherapy, and targeted therapies have shown promise in improving patient outcomes.

AIM OF REVIEW

This review aims to explore the current landscape of targeted therapies in urological cancers, focusing on the role of key signaling pathways such as phosphatidylinositol 3-kinase/protein kinase B (PI3K/Akt), mechanistic (mammalian) target of rapamycin (mTOR), growth factor-related mechanisms, c-Mesenchymal-epithelial transition factor (c-Met)/ hepatocyte growth factor (HGF), programmed cell death protein 1 and its ligand programmed death-ligand 1 (PD-1/PD-L1), and steroid hormone receptor pathways in tumor progression and therapeutic resistance. Key scientific concepts of review Dysregulation of pathways like PI3K/Akt and mTOR contributes to tumorigenesis, metastasis, and resistance to treatment, underscoring their relevance as therapeutic targets. Tyrosine kinase inhibitors and immune checkpoint inhibitors have demonstrated efficacy but face challenges such as intrinsic resistance and treatment-related toxicities. Integrating insights from signaling pathway research with clinical practice holds potential for developing more effective treatment paradigms, enhancing the efficacy of targeted therapies, and improving survival rates for patients with urological cancers.

Effectiveness and Safety of Second-line Tyrosine Kinase Inhibitors After Discontinuation of First-line Immune-oncology Combination Therapy Because of Adverse Events in the Patients With Metastatic Renal Cell Carcinoma

INTRODUCTION

Effectiveness and safety of second-line tyrosine kinase inhibitors (TKIs) in patients with metastatic renal cell carcinoma (mRCC) for whom first-line immuno-oncology (I-O) combination therapy was discontinued because of adverse events (AEs) remain to be determined.

PATIENTS AND METHODS

Clinicopathological data were retrospectively collected from 34 institutions between August 2018 and January 2022 for 243 patients with mRCC who received second-line TKIs after first-line I-O combination therapy. Two patients who requested discontinuation of first-line I-O combination therapy were excluded. Oncological outcomes and safety were compared between patients who discontinued first-line I-O combination therapy because of progressive disease (Group PD) and AEs (Group AE). First- and second-line overall survival (OS) were defined as the time from the start of first- and second-line therapy to death, respectively. Propensity score matching was applied to adjust prognostic factors between the 2 groups.

RESULTS

There were 179 patients in Group PD and 62 patients in Group AE. Objective response rate and disease control rate were similar between the 2 groups. Progression-free survival (PFS), second-line OS, and first-line OS were significantly longer in Group AE than in Group PD (median 13.6 months vs. 8.5 months, P = 0.005; median not reached [NR] vs. 19.5 months, P = .005; median NR vs. 30.8 months, P = .012, respectively). After propensity score matching, PFS and second-line OS were still significantly longer and first-line OS tended to be longer in Group AE than in Group PD. There were no significant differences in the occurrence of AEs of any grade, including severe grades of 3 or greater, between the 2 groups.

CONCLUSION

Second-line TKIs are safe and at least as effective in patients with mRCC who discontinued first-line I-O combination therapy because of AEs as they are in patients who discontinued because of PD.

Thymidine kinase 1 indicates resistance to immune checkpoint plus tyrosine kinase inhibition in renal cell carcinoma

PURPOSE

Immune checkpoint plus tyrosine kinase inhibition (IO + TKI) has emerged as the first-line therapy in metastatic renal cell carcinoma (RCC), but no biomarker can predict its efficacy. Thymidine kinase 1 (TK1) is closely associated with immune evasion in tumors.

METHODS

Metastatic RCC patients treated by IO + TKI were enrolled from two cohorts (ZS-MRCC, n = 45; Javelin-101, n = 726). High-risk localized RCC were also enrolled (ZS-HRRCC, n = 40). TK1 was assessed by RNA-sequencing in all cohorts, and the immune contexture was assessed by flow cytometry and immunohistochemistry.

RESULTS

Higher TK1 expression was found in patients resistant to IO + TKI therapy (p = 0.025). High-TK1 group showed poor progression-free survival (PFS) in both the ZS-MRCC cohort (P = 0.008) and the Javelin-101 cohort (P = 0.036). By multivariate Cox regression, high-TK1 was determined as an independent factor for poor PFS (hazard ratio (HR) = 3.855, P = 0.002). High-TK1 expression was associated with decreased granzyme B+ CD8+ T cells (ρ=-0.22, P = 0.18), increased PD1+ CD4+ T cells (ρ = 0.33, P = 0.04), increased PDL1+ macrophages (ρ = 0.45, P < 0.001), and increased regulatory T cells (ρ = 0.35, P = 0.03). A novel random forest (RF) risk score was built by machine learning based on TK1 and immunologic parameters. Combined IO + TKI therapy surpassed sunitinib monotherapy in the low RF risk score group (HR = 0.158, P < 0.001), but was inferior to sunitinib in the high RF risk score group (HR, 2.195, P < 0.001).

CONCLUSION

High-TK1 expression could be a potential indicator for therapeutic resistance, poor PFS and immune evasion in metastatic RCC under IO + TKI therapy. The novel RF risk score may help stratify patients for IO + TKI therapy.

Belzutifan's role in the treatment landscape of clear cell renal cell carcinoma

The treatment of metastatic clear cell renal cell carcinoma (RCC) has changed significantly in the last 20 years with the advent of targeted therapies and immune checkpoint inhibitors. Belzutifan, a hypoxia-inducible factor-2 alpha (HIF-2α) inhibitor, has a novel mechanism of action and was approved by the United States Food and Drug Administration (FDA) in 2023 for patients with advanced RCC. In the phase III LITESPARK-005 trial, patients receiving belzutifan had significant improvement in progression-free survival (PFS) compared with everolimus (PFS rate at 12 months: 33.4% vs. 17.1%; PFS rate at 18 months: 24.0% vs. 8.3%, respectively), as well as in objective response rate compared with everolimus (22.7% vs. 3.5%, respectively). There was no significant difference in median overall survival, with 21.4 months for belzutifan and 18.1 months for everolimus (hazard ratio [HR] 0.88; p = 0.20). In clinical practice, patients on belzutifan most often require intervention for anemia and hypoxia. This article describes the current preferred treatment options in clear cell RCC, the pharmacology of belzutifan, clinical trial data for belzutifan in clear cell RCC, our clinical experience with belzutifan and managing associated anemia and hypoxia, and future directions of belzutifan in RCC treatment.

Decoding driver and phenotypic genes in cancer: Unveiling the essence behind the phenomenon

Gray hair, widely regarded as a hallmark of aging. While gray hair is associated with aging, reversing this trait through gene targeting does not alter the fundamental biological processes of aging. Similarly, certain oncogenes (such as CXCR4, MMP-related genes, etc.) can serve as markers of tumor behavior, such as malignancy or prognosis, but targeting these genes alone may not lead to tumor regression. We pioneered the name of this class of genes as "phenotypic genes". Historically, cancer genetics research has focused on tumor driver genes, while genes influencing cancer phenotypes have been relatively overlooked. This review explores the critical distinction between driver genes and phenotypic genes in cancer, using the MAPK and PI3K/AKT/mTOR pathways as key examples. We also discuss current research techniques for identifying driver and phenotypic genes, such as whole-genome sequencing (WGS), RNA sequencing (RNA-seq), RNA interference (RNAi), CRISPR-Cas9, and other genomic screening methods, alongside the concept of synthetic lethality in driver genes. The development of these technologies will help develop personalized treatment strategies and precision medicine based on the characteristics of relevant genes. By addressing the gap in discussions on phenotypic genes, this review significantly contributes to clarifying the roles of driver and phenotypic genes, aiming at advancing the field of targeted cancer therapy.

CDK4/6 Inhibition With Abemaciclib in Patients With Previously Treated Advanced Renal Cell Carcinoma

BACKGROUND

Preclincal data provide a rationale for cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitors alone and in combination with HIF-2α inhibitors in treatment of clear cell renal cell carcinoma (ccRCC), with randomized phase 2 clinical trials currently open exploring the combination of palbociclib with belzutifan vs belzutifan in treatment resistant ccRCC (NCT05468697). However, single agent activity for CDK4/6 inhibitors in ccRCC has not been reported. In this multi-center phase 1b clinical trial (NCT04627064), we investigated the safety and efficacy of monotherapy with abemaciclib, an oral CDK4/6 inhibitor in patients with advanced pretreated RCC.

METHODS

Adult patients with advanced RCC with a clear cell component and ECOG status of ≤ 2 progressing after at least 1 prior regimen including immunotherapy and a VEGFR TKI received abemaciclib 200 mg twice daily in 4-week cycles until progression or unacceptable toxicity. The primary objective was to evaluate the objective response rate (ORR) of abemaciclib with a secondary endpoint of safety. First imaging was performed after 8 weeks or 2 cycles. Response was assessed per RECIST 1.1 and toxicity graded per CTCAE v5.0.

RESULTS

Eleven patients were enrolled between December 31, 2020 and October 03, 2023. Median age was 62 years (range 54-68); 73% (n = 8) had IMDC intermediate risk disease and 1 patient had translocation RCC with a clear cell component. Median number of prior therapies was 4 (range 1-9). ORR was 0% (0/11; 8 progressive disease, 1 stable disease stopping for clinical progression, 2 not evaluable with clinical progression). About 27% (n = 3) experienced grade ≥3 treatment-related adverse events (diarrhea n = 1, nausea n = 1, neutropenia n = 1).

CONCLUSION

In patients with heavily pretreated metastatic RCC, abemaciclib monotherapy had no clinically meaningful activity without new toxicity signals. This data will offer important insight into interpretation of results for ongoing trials exploring CDK4/6 inhibition in combination with HIF-2α inhibitors and immunotherapy.

Insights into the impact of chromosome 3p mutations in advanced renal cell carcinoma treated with immune-based combinations or targeted therapy: A single-center experience

BACKGROUND

Immune-based combinations have transformed first-line treatment for metastatic renal cell carcinoma (mRCC), but reliable biomarkers for patient selection remain elusive. Chromosome 3p mutations (e.g., VHL, PBRM1, SETD2, BAP1) have shown inconsistent prognostic and predictive value. This retrospective study assessed the prognostic impact of tissue-based biomarkers, focusing on 3p mutations in mRCC.

PATIENTS AND METHODS

A single-center retrospective analysis included mRCC patients treated with immunocombinations or tyrosine kinase inhibitors (TKIs). We evaluated mutations in 14 genes, including VHL, PBRM1, SETD2, and BAP1. Primary endpoints were overall survival (OS) and progression-free survival (PFS). Prognostic factors were analyzed using univariate and multivariate models.

RESULTS

Among the included 38 patients, the most common mutations were in VHL (45 %), PBRM1 (42 %), and SETD2 (26 %), with these latter more frequent in males (p = 0.012). Most patients (74 %) received immune-based combinations; 26 % received TKIs. SETD2 mutations were associated with primary refractoriness (30 %). Median OS was not reached; brain metastases (p = 0.001) and BAP1 mutations (p = 0.025) predicted worse OS, while PBRM1 mutations trended toward improved OS (p = 0.845). Median PFS was 14.1 months. Higher tumor grade (p = 0.038) and worse ECOG PS (p = 0.008) negatively impacted PFS, while 3p mutations showed no significant effect on PFS.

CONCLUSIONS

ECOG PS and brain metastases were confirmed as poor prognostic factors. VHL and PBRM1 mutations may suggest a better prognosis, while SETD2 and BAP1 mutations portend worse outcomes. Larger studies are needed to confirm these findings.

Adverse events of hepatic function disorder in Japanese patients with radically unresectable or metastatic renal cell carcinoma treated with pembrolizumab plus axitinib: a post-marketing surveillance study

BACKGROUND

Post-marketing surveillance focusing on hepatic function disorder was requested owing to its higher incidence in the pembrolizumab plus axitinib group than in the sunitinib group in KEYNOTE-426. We aimed to evaluate the prevalence and risk factors of adverse events (AEs) of hepatic function disorder in patients with unresectable/metastatic renal cell carcinoma (RCC) treated with pembrolizumab plus axitinib in real-world clinical practice in Japan.

METHODS

Patients were observed for 9 months after starting treatment with pembrolizumab plus axitinib.

RESULTS

In total, 193 patients were included in the safety analysis set (median age, 70 years). Most patients did not have a history of hepatic function disorder before starting treatment (96.4%, 186/193). The median treatment period was 27.1 weeks. At the 9-month data cut-off, 62.2% (120/193) of patients discontinued treatment, the most common reason being any AE in 31.1% (60/193). The incidence of AEs of hepatic function disorder was 30.1% (58/193) for any grade and 15.0% (29/193) for grade ≥ 3. Most AEs of hepatic function disorder occurred within 3 months from starting treatment. AEs of hepatic function disorder were the reason for discontinuation of pembrolizumab in 9.3% (18/193) of patients; axitinib, 7.3% (14/193); and both pembrolizumab and axitinib, 5.2% (10/193). No background factors were identified as being associated with the occurrence of AEs of hepatic function disorder.

CONCLUSION

There were no new safety signals for AEs of hepatic function disorder, and the incidence was consistent with that reported in KEYNOTE-426, in Japanese patients with radically unresectable/metastatic RCC treated with pembrolizumab plus axitinib.

Impact of Estimated Glomerular Filtration Rate and Serum C-Reactive Protein Level to Overall Survival After Second-Line Targeted Therapy Following Immuno-Oncology Combination Therapy for Advanced Renal Cell Carcinoma

OBJECTIVES

Immune checkpoint inhibitor (ICI)-based combination therapies are first-line treatments for locally advanced or metastatic renal cell carcinoma (mRCC). However, second-line treatment efficacy remains uncertain due to limited large randomized trials. This study evaluated real-world oncological outcomes after second-line treatments in patients who received combination ICIs as first-line treatment.

METHODS

Among 467 patients who received ICI combination therapy as first-line treatment for mRCC between January 2018 and January 2024, those who received cabozantinib (Cabo) or axitinib (Axi) as second-line treatment were included in this study. The patient characteristics at the initiation of second-line treatment, progression-free survival (PFS), and overall survival (OS) were compared between the two groups. Prognostic factors associated with OS after the initiation of second-line treatment were evaluated.

RESULTS

The Cabo and Axi groups included 87 and 45 patients, respectively. Median OS and PFS after the initiation of secondary treatment were 32 and 9 months in the Cabo group (p = 0.269), and 33 and 12 months in the Axi group (p = 0.399). Multivariable analysis identified serum C-reactive protein (CRP) ≥ 0.6 mg/dL and estimated glomerular filtration rate (eGFR) < 40 mL/min/1.73 m2 at the start of secondary treatment as independent predictors of OS. Stratification by these factors revealed a significant OS difference (p < 0.001).

CONCLUSIONS

Oncological outcomes after the initiation of secondary treatment did not differ significantly between the Cabo and Axi groups. An eGFR < 40 mL/min/1.73 m2 and CRP ≥ 0.6 mg/dL at the start of Cabo or Axi treatment were independent OS predictors after secondary treatment.

Pembrolizumab-axitinib versus nivolumab-cabozantinib as first-line therapy in patients with metastatic renal cell carcinoma: a retrospective real-world comparison (ARON-1)

BACKGROUND

The optimal first-line therapy for metastatic renal cell carcinoma (mRCC) remains uncertain, despite recent advancements in immune-based combinations. This retrospective study compares the effectiveness of pembrolizumab plus axitinib (PA) and nivolumab plus cabozantinib (NC) as first-line treatments for mRCC in a real-world setting.

METHODS

Patient data were collected from 55 centers across 16 countries, encompassing individuals diagnosed with mRCC receiving first-line treatment with PA or NC between January 2016 and October 2023. Clinical and tumor features and treatment responses were recorded. The primary endpoints were overall response rate (ORR), overall survival (OS), progression-free survival (PFS), and time to second progression. Statistical analyses included Kaplan-Meier survival estimates, Cox proportional hazard models, and chi-square tests.

RESULTS

A total of 760 patients with a median age of 64 years (range, 29-88) were included. Of them, 607 received PA, and only 153 NC. In the overall study population, ORR was 59% for and 49% for PA. Median OS was 55.7 months and not reached (NR) for PA and NC, respectively (P = .51), while median PFS was longer with NC (27.6 months) than for PA (16.2 months, P = .003). Subgroup analysis suggested a PFS benefits for NC in male, younger patients, intermediate risk group, clear cell histology, and lung involvement, as well as ORR favored NC in good risk patients. Multivariate analysis identified first-line therapy as a significant factor associated with PFS.

CONCLUSIONS

In this certainly biased retrospective comparison, NC demonstrated superior ORR and longer PFS compared to PA in mRCC. These findings underscore the importance of considering individual patient characteristics and risk profiles when selecting first-line therapy for mRCC.

Health-related quality-of-life profile and clinical outcomes in first-line advanced renal cell carcinoma: a modeling analysis based on the CheckMate 9ER study

BACKGROUND

For patients with advanced renal cell carcinoma, maintaining quality of life during treatment is a priority. The phase III CheckMate 9ER study demonstrated improved efficacy and health-related quality of life (HRQoL) outcomes with first-line cabozantinib plus nivolumab (CaboNivo) versus sunitinib (Sun) and underscored the need to improve understanding of the relationship between clinical efficacy and the patient treatment experience. In this work, we investigated the relationship between changes in HRQoL and clinical outcomes, as well as identifying symptom-based patient profiles that could predict disease course and clinical outcomes.

MATERIALS AND METHODS

This post hoc analysis of CheckMate 9ER used the patient-reported outcomes 19-item Functional Assessment of Cancer Therapy-Kidney Symptom Index (FKSI-19) to evaluate HRQoL. Cox proportional modeling was used to investigate the association between early changes in FKSI-19 scores and clinical outcomes, while latent class analysis (LCA) was used to identify symptom-based patient profiles.

RESULTS

The nature of patient-reported symptoms was similar at baseline and 13 weeks for CaboNivo and Sun, but symptom frequency varied between arms. Early worsening of bone pain [hazard ratio (HR) 1.45, P = 0.010] and sleep quality (HR 1.45, P = 0.007) were associated with increased risk of mortality. The LCA identified three distinct subgroups of patients by symptom burden and risk profile. Patients in the limited symptoms class at week 13 were more likely to have received CaboNivo (limited: 63.4%; moderate-to-severe: 45.9%; severe: 38.5%), had a longer duration of treatment (>122 weeks: 37.2% versus 14.7% versus 17.9%), and were generally less likely to experience disease progression (61.6% versus 55.1% versus 76.9%) than other symptom classes.

CONCLUSIONS

This post hoc analysis identified an association between efficacy and HRQoL based on data from CheckMate 9ER. These results highlight the necessity of balancing treatment choice, tolerability, and HRQoL to optimize treatment outcomes and support shared decision-making.

Phase 2, two-stage study of avelumab and axitinib in patients with mismatch repair proficient recurrent or persistent endometrial cancer

OBJECTIVE

Combinations of immune checkpoint inhibitors (ICIs) and antiangiogenic agents have demonstrated potent clinical activity across multiple tumor types. We hypothesized that the combination of axitinib, a highly potent inhibitor of VEGFR1-3, with the anti-PD-L1 antibody avelumab would be well tolerated and effective in the treatment of recurrent MMRP EC.

METHODS

We conducted an investigator-initiated, single-arm phase 2 study of avelumab/axitinib in MMRP EC (NCT02912572). Eligible participants had recurrent EC of any histology that was MMRP, measurable disease, no upper limit of prior therapies and no prior ICI treatment. Co-primary endpoints were objective response rate (ORR) and progression-free survival rate at 6 months (PFS6). Targeted next-generation sequencing and multiplexed immunofluorescence were performed.

RESULTS

Thirty-five patients initiated protocol therapy. There were 14 objective responses (ORR 40 %, 95 % CI 23.9 %-57.9 %), including 1 confirmed CR, 1 unconfirmed CR, 8 confirmed PRs, and 4 unconfirmed PRs. Thirteen patients (37.1 %) had stable disease (SD), and 6 (17.1 %) patients had progressive disease (PD). The confirmed objective response rate (ORR) was 25.7 % (95 % CI 12.5 % to 43.3 %), estimated median DOR was 13.8 months, PFS at 6 months was 55.8 %, and the estimated median PFS was 7 months. The most common G3+ treatment-related toxicities were hypertension (37.1 %), ALT increased (5.7 %) and AST increased (5.7 %); 5 (14.3 %) patients discontinued protocol therapy because of toxicity. Objective response rate was 48 % in TP53 mutated tumors and 28.6 % in NSMP tumors.

CONCLUSIONS

Avelumab and axitinib had an acceptable safety profile and demonstrated encouraging activity in recurrent MMRP EC.

CircRNA GRAMD4 induces NBR1 expression to promote autophagy and immune escape in renal cell carcinoma

The tumor microenvironment (TME) in renal cell carcinoma (RCC) frequently exhibits significant immune cell infiltration. However, tumor cells often manage to evade immune surveillance. This study revealed the mechanism by which circular RNA circGRAMD4 regulates NBR1. CircGRAMD4 is markedly elevated in RCC, and its high levels are correlated with a poor prognosis. Notably, the absence of circGRAMD4 has been demonstrated to result in a significant inhibition of renal cancer cell growth. This inhibition has been attributed to an enhanced anti-tumor immunity mediated by CD8+ T cells. Mechanistically, circGRAMD4 interacts with the RBM4 protein, stabilizing the autophagic cargo receptor NBR1 mRNA. This interaction promotes NBR1 expression, which in turn leads to the degradation of MHC-I molecules through macroautophagy/autophagy pathways. Consequently, this process affects renal cancer cell antigen presentation, induces CD8+ T cell dysfunction, and contributes to tumor immune escape. Moreover, by inhibiting circGRAMD4 and using immune checkpoint blockers (ICB), the immunosuppressive TME is altered to prevent tumor immune evasion, ultimately increasing the effectiveness of ICB treatment. The discovery highlights the significant impact of circGRAMD4 on RCC immune escape and proposes that blocking circGRAMD4 could serve as a promising immunotherapy strategy when combined with ICB to enhance patient outcomes.

The emerging role of lymphocyte-activation gene 3 targeting in the treatment of solid malignancies

PD-(L)1-based immune checkpoint inhibitor therapies have profoundly impacted the treatment of many solid malignancies. Although the addition of CTLA-4 checkpoint inhibitors can enhance anticancer activity, it also significantly increases the rate of immune-related adverse events. Therefore, there has been much interest in identifying additional immune checkpoints to improve the outcomes seen with PD-1-based therapy while minimizing additional side effects. One such target, lymphocyte-activation gene 3 (LAG-3), has long been recognized as an important inhibitor of T-cell function via modulation of the T-cell receptor pathway. Several drugs targeting LAG-3 have been developed, including most prominently the monoclonal antibody relatlimab. To date, the most significant demonstration of efficacy in targeting LAG-3 has been the use of relatlimab with the PD-1 inhibitor nivolumab in the treatment of advanced melanoma. The combination of nivolumab plus relatlimab is more efficacious compared to PD-1 inhibition alone, as has been previously seen with the combination of CTLA-4 inhibitor ipilimumab with nivolumab. However, nivolumab plus relatlimab offers a potentially more favorable toxicity profile. Here, the authors review the mechanism of the LAG-3 pathway and its rationale as a target for anticancer therapy as well as currently available data regarding the use of LAG-3 agents in treating melanoma and other solid tumors. Other investigational agents that target LAG-3 via novel mechanisms are also reviewed.

Kidney Injury Molecule-1 Expression in Pathological T1b Clear Cell Renal Cell Carcinoma: A Putative Biomarker of High Immune-Inflamed Status and Recurrence

Kidney injury molecule-1 (KIM-1) is a potential prognostic marker of advanced-stage clear cell renal cell carcinoma (ccRCC) and is associated with tumor immunogenicity. Little is known about its role in early-stage ccRCC, especially in pathological T1b (pT1b) disease, which shows a higher recurrence rate than pT1a disease. Resected specimens from 112 pT1b ccRCC cases were reviewed and immunohistochemically analyzed for KIM-1 expression. High membranous KIM-1 expression was defined as H score ≥ 140, based on the immunoreactive intensity and area, and cytoplasmic expression in ≥ 10% of cancer cells was considered as high cytoplasmic KIM-1 expression. KIM-1 expression status was compared with clinicopathological variables, including tumor-associated immune cell (TAIC) status. Among the 112 cases, high membranous and cytoplasmic KIM-1 expression was observed in 30 (27%) and 38 (34%) cases, respectively. High membranous KIM-1 expression was significantly associated with a higher nuclear grade, tumor necrosis, hot TAIC status, and shorter recurrence-free survival (RFS) and cancer-specific survival, whereas high cytoplasmic expression was only related to a higher nuclear grade. Multivariate Cox regression analysis revealed that high membranous KIM-1 expression and tumor necrosis were independent predictors of shorter RFS. Our results indicate that membranous KIM-1 expression could be a biomarker for predicting postnephrectomy recurrence in pT1b ccRCC.

COSMIC-021 Phase Ib Study of Cabozantinib Plus Atezolizumab: Results from the Locally Advanced or Metastatic Urothelial Carcinoma Cohorts

PURPOSE

The COSMIC-021 study assessed the safety and efficacy of cabozantinib plus atezolizumab in advanced solid tumors. Presented here are results from the expansion cohorts with advanced urothelial carcinoma (UC).

METHODS

This phase Ib study (ClinicalTrials.gov identifier: NCT03170960) enrolled patients with inoperable locally advanced/metastatic UC into four tumor cohorts: first-line cisplatin-eligible (cis-eligible), first-line cisplatin-ineligible (cis-ineligible), previous platinum-containing chemotherapy (previous chemotherapy-treated), and previous immune checkpoint inhibitor (ICI)-treated. Patients received oral cabozantinib 40 mg once daily and intravenous atezolizumab 1,200 mg once every 3 weeks. The primary end point was objective response rate (ORR), as assessed by the investigator per RECIST v1.1 every 6 weeks for 12 months and every 12 weeks thereafter; the secondary end point was safety.

RESULTS

A total of 121 patients (previous ICI-treated cohort, n = 31, and each of the other cohorts, n = 30) received study treatment from March 2018 to November 2021. The ORR (95% CI) was 30% (15 to 49) for cis-eligible, 20% (8 to 39) for cis-ineligible, 27% (12 to 46) for previous chemotherapy-treated, and 10% (2 to 26) for previous ICI-treated cohorts. The median progression-free survival (95% CI) was 5.5 (1.6 to 11.6), 5.6 (3.1 to 11.1), 5.4 (1.6 to 7.6), and 3.0 (1.8 to 5.5) months, respectively. Grade 3 or 4 treatment-related adverse events (TRAEs) were experienced by 43%, 67%, 57%, and 45% of patients, respectively. TRAEs led to discontinuation of all treatment components in 17%, 13%, 3%, and 19%, respectively. No grade 5 TRAEs were reported in any cohort.

CONCLUSION

The novel combination of cabozantinib plus atezolizumab exhibited clinical activity in advanced UC that is cis-eligible, cis-ineligible, or previously treated with platinum-containing chemotherapy; clinical activity in previous ICI-treated UC was modest. The toxicity profile was consistent with that previously reported for the combination.

Pembrolizumab plus Lenvatinib in patients with metastatic Renal Cell Carcinoma: real-world evidences from the international ARON- 1 study

BACKGROUND

Pembrolizumab plus lenvatinib is a treatment option for metastatic Renal Cell Carcinoma (mRCC). In the ARON-1 study we investigated we the real-world experiences gained from the use of this combination for mRCC.

METHODS

We retrospectively investigated real-world clinical outcomes of mRCC patients receiving pembrolizumab plus lenvatinib within the ARON-1 study. Overall survival (OS) was calculated from the start of pembrolizumab plus lenvatinib to death for any cause. Progression-Free Survival (PFS) was defined as the time from the start of pembrolizumab to progression or death from any cause. Duration of response (DoR) was defined as the time from the start of pembrolizumab to disease progression or death, whichever occurred first, in patients who achieved complete remission (CR) or partial response (PR). Overall Response Rate (ORR) was defined as the proportion of patients who achieve a CR or PR per RECIST criteria. Adverse events were retrospectively collected from electronic and paper charts and categorized by the Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

RESULTS

Overall, we included 202 mRCC patients treated with pembrolizumab plus lenvatinib. The median follow-up time was 15.1 months. The median OS was not reached (NR), with a median PFS of 25.6 months and an Overall Response Rate (ORR) of 59%. The median Duration of Response (DoR) was 26.2 months. G3-G4 adverse events (AEs) were observed in 92 patients (46%), with hypertension being the most common AE (13%).

CONCLUSIONS

Pembrolizumab plus lenvatinib is an effective and tolerable treatment for mRCC also in the real-world setting.

Prognostic Value of B7-H3 and a Novel Scoring System in Localized Renal Cell Carcinoma

Background and Objectives: Renal cell carcinoma (RCC) is a biologically heterogeneous malignancy, and traditional prognostic models often fail to provide accurate risk stratification. B7-H3 (CD276), an immune checkpoint molecule, has been implicated in RCC progression but remains underexplored as a prognostic biomarker. Materials and Methods: This retrospective study analyzed 52 patients with localized RCC who underwent nephrectomy. Immunohistochemical staining was used to assess B7-H3 expression. A novel prognostic scoring system, the Renal Immune Prognostic Index (RIPI), incorporating B7-H3 expression, tumor necrosis, tumor grade, and pathological staging, was developed and validated. Kaplan-Meier survival analysis and Cox proportional hazard models were employed to evaluate disease-free survival (DFS) and overall survival (OS). Results: High B7-H3 expression was significantly associated with shorter DFS (12 vs. 54 months; p = 0.001) and OS (70 vs. 123 months; p = 0.002). The RIPI demonstrated strong prognostic performance, stratifying the patients into distinct risk groups with a C-index of 0.82. The high-risk patients had a median DFS of 14 months, compared with 125 months in the low-risk group (p < 0.001). Conclusions: B7-H3 expression serves as a significant prognostic biomarker in localized RCC, correlating with poorer survival outcomes. The integration of B7-H3 into the RIPI enhances risk stratification by incorporating both molecular and pathological features. These findings support the incorporation of immune biomarkers into clinical practice and highlight B7-H3 as a potential target for novel therapeutic strategies in RCC.

JS-K induces ferroptosis in renal carcinoma cells by regulating the c-Myc-GSTP1 Axis

JS-K is a precursor drug of nitric oxide (NO) and inhibits tumor growth through various mechanisms. Ferroptosis, a form of cell death closely related to lipid peroxidation, is increasingly being recognized for its role in cancer biology. However, the relevance of ferroptosis in the anti-tumor effects of JS-K is yet to be defined. The cytotoxic effects of erastin and JS-K were evaluated in various renal cell carcinoma (RCC) cell lines and normal human renal epithelial cells. Cell viability and the intracellular levels of ferrous ions, glutathione (GSH), lipid peroxides, and malondialdehyde (MDA) were measured using standard in vitro assays. The expression levels of specific proteins were analyzed by western blotting. Subcutaneous xenografts of RCC were established in a nude mouse model, and the anti-tumor effects of JS-K were assessed by histological and immunohistochemical methods. Erastin selectively inhibited the growth of RCC cells without affecting normal renal cells. In addition, JS-K induced ferroptosis in RCC cells by reducing cellular GSH levels, increasing lipid peroxidation, and elevating ferrous ion levels, and the effects of JS-K were neutralized by N-acetylcysteine (NAC). At the molecular level, JS-K downregulated GSTP1 by blocking the transcription factor c-Myc. Finally, JS-K inhibited tumor growth in a mouse model by inducing ferroptosis. JS-K induces ferroptosis in RCC cells by depleting glutathione through the inhibition of the c-Myc-GSTP1 axis.

Enhanced efficacy of ipilimumab plus nivolumab in angiogenic subtypes of metastatic clear-cell renal cell carcinoma

In metastatic clear-cell renal cell carcinoma (mccRCC), choosing between immuno-oncology (IO) combinations and IO plus anti-VEGF therapies is uncertain. The BIONIKK trial revealed that ipilimumab plus nivolumab (Ipi/Nivo) achieved a 70% objective response rate in angiogenic cluster1/2 versus 41% in cluster4/5, which featured T-effector/cell-cycle signatures (p = 0.048). Complete responses were exclusively observed in cluster1/2 (p = 0.012), with longer progression-free survival (p = 0.014). Ipi/Nivo may particularly benefit angiogenic mccRCC, supporting molecular subtype-based treatment strategies.

High real-world incidence of hepatic dysfunction from cabozantinib plus nivolumab for Japanese patients with metastatic renal cell carcinoma

OBJECTIVE

The real-world incidence of hepatic dysfunction after combination therapy with cabozantinib plus nivolumab (CABO+NIVO) in Japanese patients with metastatic renal cell carcinoma remains undetermined; hence, this study aimed to determine the incidence of hepatotoxicity in these patients.

METHODS

A total of 48 patients treated with CABO+NIVO were enrolled in this study. Alanine aminotransferase (ALT) levels were used to evaluate liver dysfunction because of its liver specificity.

RESULTS

ALT elevation of any grade was found in 30 patients (63%), and grade 3 elevation was found in eight patients (17%). No grade 4 or 5 elevations were observed. Female gender and a higher body mass index were independent predictive factors for ALT elevation. All patients were managed with dose reduction or interruption of cabozantinib and concomitant use of hepatoprotective agents without high-dose corticosteroids. Of the seven patients that underwent cabozantinib rechallenge after grade 3 ALT elevation, only two (23%) required re-interruption due to repeat grade 3 ALT elevation.

CONCLUSIONS

This is the first study to examine hepatic dysfunction caused by CABO+NIVO in Japanese patients. The incidence of hepatic dysfunction was higher in real-world patients than in global patients found in pivotal phase 3 trials. Cabozantinib appeared to be a major cause of hepatic dysfunction since dose reduction or interruption of cabozantinib without the use of corticosteroids resolved hepatotoxicity. In addition, additional care should be taken when treating female or obese patients with CABO+NIVO.

Olanzapine for Managing Side Effects From Antiangiogenic Tyrosine-Kinase Inhibitors

CONTEXT

Side effects from tyrosine kinase inhibitors (TKIs) are common and burdensome. Olanzapine is useful for managing symptoms from conventional chemotherapy, but its role in treating TKI-related side effects is unclear.

OBJECTIVES

Examine the efficacy of olanzapine for TKI-induced nausea, vomiting, anorexia, weight loss, and insomnia.

METHODS

All patients prescribed olanzapine with lenvatinib, cabozantinib, axitinib, or tivozanib at Mayo Clinic between January 2018 and June 2024 were assessed for inclusion. For baseline assessment, clinical notes documenting symptoms and indication(s) for starting olanzapine were reviewed. Notes and portal messages from the first three months after starting olanzapine were then evaluated for qualitative descriptions of change in symptom burden. Data were categorized as "improved," "worsened," "stable," or "missing data," with each symptom domain analyzed independently, when olanzapine was prescribed for multiple interrelated symptoms.

RESULTS

Sixty patients received olanzapine, most commonly 5 mg (n = 37, 61.7%) or 2.5 mg (n = 16, 26.6%). Indications included nausea without vomiting (n = 35), anorexia (n = 25), nausea with vomiting (n = 16), weight loss (n = 16), and insomnia (n = 11). It was given for multiple symptoms in 32 patients. Within the first 3 months, 85% of patients had improvement in nausea without vomiting, 93% in nausea with vomiting, 74% in appetite, and 85% in sleep. Among 34 patients with weight loss prior to olanzapine, 50% gained weight (median: 6.1 kg), 26% stabilized (±1 kg), and 24% continued to lose weight. Only 4 patients discontinued olanzapine due to side effects.

CONCLUSION

Olanzapine appears effective in treating TKI-induced nausea, vomiting, anorexia, insomnia, and weight loss, warranting further investigation in prospective studies.

Activity of lenvatinib-based therapy in previously treated patients with metastatic renal cell carcinoma: A European multicenter study (LENVA-LAT)

BACKGROUND AND OBJECTIVE

Lenvatinib's activity after immune checkpoint inhibitors (ICI) combination therapy in renal cell carcinoma (RCC) remains unknown. We aimed to describe the real-world outcomes of patients with metastatic RCC (mRCC) treated with lenvatinib after failure of the prior standard of care.

METHODS

Multicenter retrospective study including patients with mRCC treated with lenvatinib-based therapies beyond first-line therapy between 2020 and 2024. The primary endpoints were objective response rate (ORR) and time-to-treatment failure (TTF). Secondary endpoints included disease control rate (DCR), overall survival (OS), and safety.

RESULTS

We included 133 patients, with a median age of 61 years. Clear-cell was the main subtype (82.0 %). Before lenvatinib treatment, 15.8 %, 51.9 %, and 27.8 % of patients showed favorable, intermediate, and poor risk disease, respectively, according to the International Metastatic RCC Database Consortium (IMDC). Moreover, patients received a median of 3 previous lines of treatment, including ICIs (90.2 %) and cabozantinib (90.2 %). Lenvatinib was given alone (45.9 %) or in combination with everolimus (33.8 %), pembrolizumab (18.0 %) or investigational agents (2.3 %). The ORR and DCR were 29.1 % and 67.7 %, respectively, with no differences between regimens or lines of treatment. With a median follow-up time of 13.5 months, the median TTF and OS were 6.2 and 9.6 months. Toxicity was manageable with dose modifications required in 34.6 %. The discontinuation rate was 9.8 %, with one toxic death.

CONCLUSION

Lenvatinib-based regimens were active and safe for heavily pre-treated patients with mRCC. These findings provide evidence to support its use in daily practice.

Integration analysis of PLAUR as a sunitinib resistance and macrophage related biomarker in ccRCC, an in silicon and experimental study

Sunitinib remains the preferred systemic treatment option for specific patients with advanced RCC who are ineligible for immune therapy. However, it's essential to recognize that Sunitinib fails to elicit a favourable response in all patients. Moreover, most patients eventually develop resistance to Sunitinib. Therefore, identifying new targets associated with Sunitinib resistance is crucial. Utilizing multiple datasets from public cohorts, we conducted an exhaustive analysis and identified a total of 8 microRNAs and 112 mRNAs displaying significant expression differences between Sunitinib responsive and resistant groups. A particular set of six genes, specifically NIPSNAP1, STK40, SDC4, NEU1, TBC1D9, and PLAUR, were identified as highly significant via WGCNA. To delve deeper into the resistance mechanisms, we performed additional investigations using cell, molecular, and flow cytometry tests. These studies confirmed PLAUR's pivotal role in fostering Sunitinib resistance, both in vitro and in vivo. Our findings suggest that PLAUR could be a promising therapeutic target across various cancer types. In conclusion, this investigation not only uncovers vital genes and microRNAs associated with Sunitinib resistance in RCC but also introduces PLAUR as a prospective therapeutic target for diverse cancers. The outcomes contribute to advancing personalized healthcare and developing superior therapeutic strategies.

The fragility index of randomized controlled trials in advanced/metastatic renal cell cancer

PURPOSE

The fragility index (FI) has been applied as a supplement to the noncomprehensive P-values to assess the robustness of randomized controlled trials (RCTs). The objective of this study is to evaluate the statistical robustness of RCTs of advanced/metastatic renal cell cancer (a/mRCC) using the FI.

MATERIALS AND METHODS

RCTs related to a/mRCC published in the 4 highest-impact general medical journals and the 25 highest-impact urological journals between January 1, 2000, and December 31, 2023, were identified from PubMed database. The FI was calculated by using Fisher's exact test. Spearman's correlation analysis was conducted to assess potential correlates regarding FI.

RESULTS

16 eligible RCTs were screened with a median total sample size of 654.5 (IQR, 461-847) and a median patients lost to follow-up of 14 (IQR, 3-23). The median FI was 12.5 (IQR, 8.5-27), suggesting that a switch in outcomes in only 13 patients would have reversed the significance of the trials. The number of patients lost to follow-up exceeded or equaled to the FI in 7 (44%) RCTs. P-values were negatively associated with the FI, while the number of patients lost to follow-up and patients enrolled were not statistically significant.

CONCLUSION

Not all RCTs associated with a/mRCC are as statistically robust as previously considered and should therefore be construed carefully. We suggest that additional reporting of FI in urological RCTs as a supplement to the P-value to assist readers in concluding reliably by considering the fragility of the outcomes.

AO Spine Clinical Practice Recommendations: Current Systemic Oncological Treatments with the Largest Impact on Patients with Metastatic Spinal Disease

Study DesignLiterature review with clinical recommendation.ObjectiveTo provide the readers with a concise curation of the latest literature in recent advances in systemic oncological therapies and their implications for decision-making in patients with metastatic spinal disease. This review aims to enhance spine specialist's understanding of modern oncological treatments to facilitate optimal timing and planning of local interventions.MethodsThe latest literature in the topic of advances in oncology was reviewed by a multidisciplinary group of experts in metastatic spinal disease and clinical recommendations were formulated. The recommendations were dichotomously graded into strong and conditional (weak) based on the integration of scientific methodology and content expert opinion. This opinion considered experience and practical issues such as risks, burdens, costs, patient values, and circumstances.ResultsFour high-impact studies were reviewed, demonstrating significant advancements in systemic treatments for metastatic cancers commonly affecting the spine. These studies showed improved survival outcomes and efficacy across breast cancer, colorectal cancer, prostate cancer, and renal cell carcinoma. The findings have important implications for surgical/radiotherapy planning, including considerations for timing of interventions, wound healing, and the potential for extended survival affecting construct durability requirements.ConclusionsRecent advances in systemic oncological treatments have important implications for managing metastatic spinal disease. Understanding these developments is crucial for spine specialists to optimize decision-making through a multidisciplinary approach, particularly regarding timing of local interventions, strategy of the surgical approach and reconstruction.[Formula: see text].

Biomarkers in advanced renal cell carcinoma: current practice and future directions

PURPOSE OF REVIEW

This review focuses on contemporary research into potential prognostic and therapeutic biomarkers for advanced renal cell carcinoma (RCC) published over the past 18 months. Beyond serum lab values, there is no consensus on the use of specific biomarkers for this purpose. Potential biomarkers being investigated consist of genetic, protein, immunologic, and radiologic candidates.

RECENT FINDINGS

New insights in genomic biomarkers include a better understanding of VHL mutational heterogeneity, tumor mutational burden, and the importance of genes like PBRM1 and SETD2 . Protein biomarkers such as C-reactive protein (CRP) and PDZK1 have demonstrated utility in predicting disease progression, therapeutic response, and survival, while immunologic biomarkers like PSMD2, cytokines, and Tregs continue to shed light on the tumor microenvironment and immune evasion. Emerging imaging biomarkers, from CAIX-targeted radiotracers to PSMA-based PET-CT, offer noninvasive diagnostic and prognostic tools that may revolutionize RCC management.

SUMMARY

There are several promising biomarkers currently under investigation for use in advanced RCC.

Clinical development of immuno-oncology therapeutics

Immuno-oncology (IO) is one of the fastest growing therapeutic areas within oncology. IO agents work indirectly via the host's adaptive and innate immune system to recognize and eradicate tumor cells. Despite checkpoint inhibitors being only introduced to the market since 2011, they have become the second most approved product category. Current Food and Drug Administration (FDA)-approved classes of IO agents include: immune checkpoint inhibitors (ICIs), chimeric antigen receptor T-cell therapy (CAR-T), bi-specific T-cell engager (BiTE) antibody therapy, T-cell receptor (TCR) engineered T cell therapy, tumor-infiltrating lymphocyte (TIL) therapy, cytokine therapy, cancer vaccine therapy, and oncolytic virus therapy. Cancer immunotherapy has made progress in multiple cancer types including melanoma, non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), and urothelial carcinoma; however, several cancers remain refractory to immunotherapy. Future directions of IO include exploration in the neoadjuvant/perioperative setting, combination strategies, and optimizing patient selection through improved biomarkers.

Immunotherapy Strategies After Immune Checkpoint Inhibitor Exposure in Renal Cell Carcinoma: A Review

Importance

Immune checkpoint inhibitors have transformed the treatment landscape for metastatic renal cell carcinoma; however, the failure of first-line therapeutic strategies remains a considerable challenge. Currently, clinicians face various issues, such as managing cases in patients who progress during treatment or relapse after adjuvant immunotherapy.

Observations

This review evaluates different strategies for treating patients with advanced kidney cancer previously exposed to immunotherapy. Evidence from other malignant neoplasms suggests potential effectiveness for rechallenging with immune checkpoint inhibitors. The most important available data are presented, including retrospective, prospective, and randomized clinical trials, to explore the role of immunotherapy in patients with renal cell carcinoma who have experienced prior failure of immune checkpoint inhibitors.

Conclusions and Relevance

Although retrospective data suggest modest effectiveness of an immunotherapy rechallenge treatment, larger phase 3 trials failed to demonstrate substantial benefit in progression-free survival and overall survival. Currently, no randomized evidence supports the use of agents targeting conventional immune checkpoints in patients with renal cell carcinoma who have previously received immunotherapy.

S2303: phase II/III trial of paclitaxel + ramucirumab ± nivolumab in gastric and esophageal adenocarcinoma (PARAMUNE)

TRIAL REGISTRATION NUMBER

NCT06203600.

Immunotherapy for Renal Cell Carcinoma-What More is to Come?

The treatment of renal cell carcinoma (RCC), a malignancy that is typically chemoresistant, has drastically evolved with the introduction of vascular endothelial growth factor receptor tyrosine kinase inhibitors (VEGFR TKIs) and immune checkpoint inhibitors (ICIs). The introduction of ICI-based regimens has significantly improved outcomes for patients with metastatic RCC. Currently, first-line therapy for patients with metastatic RCC involves multiple ICI-based regimens, either dual ICIs (with anti-cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA- 4) and anti-programmed cell death- 1 (PD- 1) therapies) or anti-PD- 1 therapy in combination with VEGFR TKIs. Despite improving patient outcomes with ICI-based regimens, durable responses remain uncommon, highlighting the need for innovative treatment strategies. In this review, we highlight the current standard of care ICI-based regimens followed by ongoing clinical trials with novel combinations of existing FDA-approved agents and targets. We also discuss novel immunotherapies currently in clinical trials, which aim to improve antitumor T cell immunity either by improving T cell activation or T cell navigation to the tumor microenvironment. The incorporation of these novel therapies offers the potential to improve RCC patient outcomes, particularly by enhancing the durability of treatment responses.

Application of extended immunotherapy in advanced clear cell renal cell carcinoma treated with first-line combination of immune-checkpoint inhibitor and tyrosine kinase inhibitor

PURPOSE

To evaluate the efficacy and safety of extended immunotherapy in first-line immune checkpoint inhibitors (ICIs)-tyrosine kinase inhibitors (TKIs) combination treatment for advanced renal cell carcinoma (RCC).

PATIENTS AND METHODS

We retrospectively analyzed data from patients with advanced RCC who received first-line ICIs-TKIs combination treatment at West China Hospital of Sichuan University between October 2018 and July 2024. Patients who are assessed as having a disease control status after 2 years of continuous treatment will continue to receive immune checkpoint inhibitors until the inhibitors are discontinued due to disease progression or death.

RESULT

A total of 86 patients were screened and 14 patients diagnosed with clear cell RCC (ccRCC) were enrolled. After 65 months of follow-up, three-year progression-free survival (PFS) rate was 71.4% and 4 year PFS rate was 59.5%. The 5 year overall survival (OS) rate was 58.3%. During extended treatment, one patient (7.1%) experienced a transition from stable disease (SD) to partial response (PR) and two patients (14.3%) experienced a transition from PR to complete response (CR). The best tumor shrinkage rates presenting after 24 months had longer PFS and OS compared to those presenting within 24 months (median PFS: not reached vs. 36 months; Hazard Ratio (HR) = 0.10, 95% CI 0.01-0.80, P = 0.03). For safety, extended immunotherapy did not increase treatment-related toxicities compared to safety profile before 24 months.

CONCLUSION

Our analysis of real-world data indicates that patients with extended immunotherapy after 24 months had potential survival benefits and manageable toxicity. Large-scale, prospective studies are still needed to further verify the conclusion.

Efficacy of First-Line Treatments for Advanced Renal Cell Carcinoma: A Bayesian Network Meta-analysis of Objective Response, Progression-Free Survival, and Overall Survival

OBJECTIVE

The purpose of this study was to indirectly compare pembrolizumab + lenvatinib to other treatments of interest for first-line advanced renal cell carcinoma (aRCC).

METHODS

A systematic literature review searched EMBASE, MEDLINE, and CENTRAL databases for relevant randomized controlled trials of interest up to 30 January 2024, with an updated search conducted on 17 March 2025. A fixed effect Bayesian network meta-analysis (NMA) was conducted to determine the relative treatment effects for overall survival (OS), progression-free survival (PFS), and objective response rate (ORR).

RESULTS

When comparing against other immune checkpoint inhibitors (ICI), a statistically significant improvement in PFS was demonstrated between pembrolizumab + lenvatinib compared with nivolumab + ipilimumab (hazard ratio (HR) = 0.53; 95% credible interval (CrI): 0.40-0.71), avelumab + axitinib (HR = 0.71; 95% Crl: 0.53-0.94), atezolizumab + bevacizumab (HR = 0.54; 95% CrI: 0.40-0.73), and pembrolizumab + axitinib (HR = 0.69; 95% CrI: 0.51-0.91). Treatment with pembrolizumab + lenvatinib resulted in no statistically significant difference between pembrolizumab + lenvatinib and other combination ICI-based therapies for OS. A statistically significant higher ORR was shown for pembrolizumab + lenvatinib compared with nivolumab + ipilimumab (odd ratio (OR) = 3.29; 95% Crl: 2.21-4.93), pembrolizumab + axitinib (OR = 1.92; 95% CrI: 1.27-2.94), atezolizumab + bevacizumab (OR = 4.05; 95% Crl: 2.71-6.05), bempegaldesleukin + nivolumab (OR = 6.20; 95% CrI: 3.69-10.48), and nivolumab (OR = 5.92; 95% CrI: 2.70-13.24).

CONCLUSIONS

The overall population analysis indicated that pembrolizumab + lenvatinib improves PFS and ORR compared with other approved ICI combination therapies in first-line aRCC. No significant differences in OS were observed between pembrolizumab + lenvatinib and other combination immune checkpoint inhibitor-based therapies.

Targeting polyunsaturated fatty acids desaturase FADS1 inhibits renal cancer growth via ATF3-mediated ER stress response

OBJECTIVE

Fatty Acid Desaturase 1 (FADS1) is a rate-limiting enzyme controlling the bioproduction of long-chain polyunsaturated fatty acids (PUFAs). Increasing studies suggest that FADS1 is a potential cancer target. Our previous research has demonstrated the significant role of FADS1 in cancer biology and patient survival, especially in kidney cancers. We aim to explore the underlying mechanism in this study.

METHOD AND RESULTS

We found that pharmacological inhibition or knockdown of the expression of FADS1 significantly reduced the intracellular conversion of long-chain PUFAs, effectively inhibits renal cancer cell proliferation, and induces cell cycle arrest. The stable knockdown of FADS1 also significantly inhibits tumor formation in vivo. Mechanistically, we showed that while FADS1 inhibition induces endoplasmic reticulum (ER) stress, FADS1 expression is augmented by ER-stress inducer, suggesting a necessary role of PUFA production in response to ER stress. FADS1-inhibition sensitized cellular response to ER stress inducers, leading to cell apoptosis. Also, FADS1 inhibition-induced ER stress leads to activation of the PERK/eIF2α/ATF4/ATF3 pathway. Inhibiting PERK or knockdown of ATF3 rescued FADS1 inhibition-induced ER stress and cell growth suppression, while ATF3-overexpression aggravates the FADS1 inhibition-induced cell growth suppression and leads to cell death. Metabolomic analysis revealed that FADS1 inhibition results in decreased level of UPD-N-Acetylglucosamine, a critical mediator of the unfolded protein response, as well as impaired biosynthesis of nucleotides, possibly accounting for the cell cycle arrest.

CONCLUSION

Our findings suggest that PUFA desaturation is crucial for rescuing cancer cells from persistent ER stress, supporting FADS1 as a new therapeutic target.

Systemic Treatment of Locally Advanced or Metastatic Non-Clear Cell Renal Cell Carcinoma

Non-clear cell renal cell carcinoma (nccRCC) represents a heterogenous group of malignancies with varying degrees of clinical aggressiveness and response to different systemic therapies. As the characterization of subtypes of nccRCC continues to evolve, it is important to understand the evidence around systemic treatments used in advanced or metastatic stages of specific subtypes. Here, we review the literature on systemic therapies in nccRCC, with a focus on prospective trials that included patients with papillary renal cell carcinoma (RCC), chromophobe RCC, RCC not further classified/unclassified RCC, translocation RCC, collecting duct RCC, and renal medullary carcinoma. We also review emerging treatments for other molecularly defined subtypes of this disease.

Differences at diagnosis between long-term survivors and not long-term survivors in metastatic renal cell carcinoma initially treated with TKI

INTRODUCTION

In recent years, significant advancements in the treatment of metastatic renal cell carcinoma (mRCC) have notably extended overall survival (OS) times, particularly with the introduction of tyrosine kinase inhibitors (TKIs) and combination immunotherapy. However, survival outcomes in mRCC remain highly variable.

MATERIALS AND METHODS

This study retrospectively analyzed clinical and demographic factors at diagnosis in patients treated for mRCC to identify predictors of long-term survival (defined as OS ≥ 48 months). Patients were categorized into long-term survivors (LTS) and non-long-term survivors (nLTS).

RESULTS

The analysis revealed that factors such as better Karnofsky Performance Status (KPS), normal baseline laboratory values (e.g., hemoglobin, calcium), and the presence of lung-only metastases were significantly associated with longer survival. Conversely, comorbid conditions like hypertension and dyslipidemia, poorer KPS, and certain adverse laboratory findings were more common in the nLTS group.

CONCLUSION

These findings underscore the importance of baseline prognostic factors in predicting survival outcomes and emphasize the need for personalized treatment strategies in mRCC.

Angiogenic and immune predictors of neoadjuvant axitinib response in renal cell carcinoma with venous tumour thrombus

Venous tumour thrombus (VTT), where the primary tumour invades the renal vein and inferior vena cava, affects 10-15% of renal cell carcinoma (RCC) patients. Curative surgery for VTT is high-risk, but neoadjuvant therapy may improve outcomes. The NAXIVA trial demonstrated a 35% VTT response rate after 8 weeks of neoadjuvant axitinib, a VEGFR-directed therapy. However, understanding non-response is critical for better treatment. Here we show that response to axitinib in this setting is characterised by a distinct and predictable set of features. We conduct a multiparametric investigation of samples collected during NAXIVA using digital pathology, flow cytometry, plasma cytokine profiling and RNA sequencing. Responders have higher baseline microvessel density and increased induction of VEGF-A and PlGF during treatment. A multi-modal machine learning model integrating features predict response with an AUC of 0.868, improving to 0.945 when using features from week 3. Key predictive features include plasma CCL17 and IL-12. These findings may guide future treatment strategies for VTT, improving the clinical management of this challenging scenario.

STARLITE 1: Phase 1b/2 Study of Combined 177Lu-Girentuximab plus Cabozantinib and Nivolumab in Treatment-naïve Patients with Advanced Clear-cell Renal Cell Carcinoma

This trial is evaluating the combination of 177Lu-girentuximab with nivolumab and cabozantinib to enhance the complete response rate in advanced clear-cell renal cell carcinoma (ccRCC). The aim is to activate cGAS-STING-induced antitumor immunity via targeted radioimmunotherapy damage to DNA. If successful, this approach could establish a novel paradigm that combines radiopharmaceuticals with immunotherapy and targeted therapy in ccRCC.

The prognostic value of the haemoglobin/red cell distribution width ratio in a cohort of pre-treated patients with renal cell carcinoma receiving nivolumab

BACKGROUND

Metastatic renal cell carcinoma (mRCC) has a dismal prognosis. Effective prognostic and predictive factors are needed. A higher haemoglobin (Hb) / red cell distribution width (RDW) ratio is known to be related to better outcomes. Here we evaluated the prognostic value of the Hb/RDW ratio in pre-treated mRCC patients receiving nivolumab.

MATERIAL AND METHODS

This is a sub-analysis of the retrospective Meet-URO 15 study, on pre-treated patients with mRCC, receiving nivolumab. The first objective was to investigate the prognostic role of Hb/RDW ratio, in terms of overall survival (OS) and progression-free survival (PFS).

RESULTS

356 were included in the present analysis. Patients were mainly males with a median age of 63 years. We classified patients in high and low Hb/RDW ratio, according to two different cut-offs: 0.9frequently used in literature, and 0.7, result of the time-dependent AUC analysis.. Median OS and PFS were 22.3 months (95 %CI 19.4-29.0) and 5.6 months (95 %CI 4.74.-7.53), respectively. At univariable analysis, higher Hb/RDW ratio was related to longer OS (p < 0.001) and PFS (p = 0.011); the multivariable model confirmed only the association between a Hb/RDW ratio ≥ 0.7 and better OS.

CONCLUSIONS

The Hb/RDW ratio is a manageable and practical prognostic tool in patients with cancer; its prognostic value for OS was confirmed in pre-treated mRCC patients, receiving nivolumab, only using a cut-off value derived from a time-dependent AUC.

Validation of five prognostic models treated with axitinib beyond first-line nivolumab plus ipilimumab therapy for metastatic renal cell carcinoma: a Japanese multicenter retrospective study

OBJECTIVE

To validate multiple prognostic models in metastatic renal cell carcinoma patients who received second-line axitinib following first-line nivolumab plus ipilimumab therapy.

METHODS

Five prognostic models (ACL, albumin, C-reactive protein, and lactate dehydrogenase; IMDC, International Metastatic Renal Cell Carcinoma Database Consortium; MSKCC, Memorial Sloan Kettering Cancer Center; ATP, axitinib treatment prediction; JMRC, Japanese metastatic renal cancer) to predict overall survival (OS) were validated and compared using data from 86 metastatic renal cell carcinoma patients who received second-line axitinib therapy following first-line nivolumab plus ipilimumab therapy at 34 hospitals affiliated with the Japan Urologic Oncology Group.

RESULTS

The Karnofsky performance status, time from initial diagnosis to first-line therapy, and hemoglobin, platelet, albumin, and C-reactive protein levels correlated with OS in univariate Cox regression analyses. Among these factors, only albumin had a significant impact on OS in the multivariate analysis. The integrated area under the curve (AUC) of the ACL, IMDC, MSKCC, ATP, and JMRC models were 0.78, 0.76, 0.76, 0.69, and 0.70, respectively. The ACL model showed a higher value than the others in the time-dependent AUC.

CONCLUSIONS

The accuracy of the five prognostic models (ACL, IMDC, MSKCC, ATP, and JMRC) created in the pre-immuno-oncology (IO) treatment cohort was maintained in the second-line axitinib group after nivolumab plus ipilimumab therapy. The ACL model demonstrated moderate accuracy in predicting OS with the fewest number of clinical variables.

Expanding horizons of cancer immunotherapy: hopes and hurdles

Background

Tumor displays various forms of tumor heterogeneity including immune heterogeneity that allow cancer cells to survive during conventional anticancer drug interventions. Thus, there is a strong rationale for overcoming anticancer drug resistance by employing the components of immune cells. Using the immune system to target tumor cells has revolutionized treatment. Recently, significant progress has been achieved at preclinical and clinical levels to benefit cancer patients.

Approach

A review of literature from the past ten years across PubMed, Scopus, and Web of Science focused on immunotherapy strategies. These include immune checkpoint inhibitors (ICIs), tumor-infiltrating lymphocyte therapy, antibody-drug conjugates (ADCs), cancer vaccines, CAR T-cell therapy, and the role of the gut microbiome.

Conclusion

While immunotherapy outcomes have improved, particularly for tumor types such as melanoma and non-small cell lung cancer (NSCLC), challenges persist regarding predictive biomarker identification and better management. Ongoing research on modifiers of immune function like gut microbiome-derived metabolites, next-generation ADCs, and new classes of biologics is warranted. Overall, continued investigation toward optimizing synergistic immunotherapeutic combinations through strategic drug delivery systems is imperative for preclinical and clinical success in cancer patients.

Real-World Treatment Patterns and Clinical Outcomes Among Patients with Metastatic Renal Cell Carcinoma Post-Immune-Oncology and Vascular Endothelial Growth Factor Receptor Targeted Therapies

BACKGROUND

The treatment landscape of metastatic renal cell carcinoma (mRCC) has evolved rapidly with the introduction of various immune-oncology (IO) agents and tyrosine kinase inhibitors (TKIs). We aimed to describe real-world treatment patterns and clinical outcomes of mRCC patients in post-IO and TKI settings.

METHODS

Using data from The US Oncology Network electronic health record database, iKnowMed, this retrospective cohort study included adult mRCC patients receiving subsequent treatments (index treatment) post-IO and TKI in combination or sequence between 1 January 2018 and 30 September 2020 and followed them until 30 April 2022. Treatment patterns were summarized descriptively. Overall survival (OS) and progression-free survival (PFS) from the index date was described using Kaplan-Meier analysis.

RESULTS

We identified 239 patients diagnosed with mRCC who received anticancer treatment post-IO and TKI therapies. The median age was 67 (range: 58, 73) years, 73.6% were male, and 61.5% had an intermediate/poor International Metastatic Renal Cell Carcinoma Database Consortium risk score. Among these, 29 (12.1%) received subsequent therapy at the line of therapy 2 (LOT2), 167 (69.8%) at LOT3, and 43 (18.0%) at LOT4+. The most common subsequent treatments were cabozantinib (38.5%) and axitinib (10.5%). The median OS for LOT2, LOT3, and LOT4+ was 18.0, 17.0, and 26.9 months, respectively. The median PFS for LOT2, LOT3, and LOT4+ was 6.1, 5.0, and 4.0 months, respectively.

CONCLUSIONS

In mRCC patients treated with IO and TKI in combination/sequence, subsequent LOT choice is diverse, with TKI-based treatments being the most preferred. There is a need for considering treatment sequencing studies and studies with a new mode of action in this population.

First-Line Ipilimumab with Nivolumab versus Immune Checkpoint Inhibitors with Tyrosine Kinase Inhibitors in Patients with Intermediate- or Poor-Risk Metastatic Clear Cell Renal Cell Carcinoma

Ipilimumab with nivolumab (Ipi + Nivo) and immune checkpoint inhibitors with tyrosine kinase inhibitors (ICI + TKI) are the first-line approved treatments for intermediate- and poor-risk metastatic clear cell renal cell carcinoma (mccRCC); however, they have not been compared head-to-head in prospective trials to guide treatment selection. Thereupon, we sought to compare survival outcomes of patients receiving first-line Ipi + Nivo versus ICI + TKI, using a large, real-world database among patients with intermediate- and poor-risk mccRCC. This retrospective cohort study used a nationwide electronic health record-derived deidentified database, where patients with mccRCC with intermediate- or poor-risk who received first-line Ipi + Nivo or ICI + TKI between 20 June, 2016, and 26 January, 2023, were included. Primary outcomes were real-world time to next therapy (rwTTNT) and real-world overall survival (rwOS), summarized via Kaplan-Meier survival estimates with 95% confidence intervals (CIs) and compared in the context of propensity score (PS) matching weighted analysis. Of the 12,707 patients in the dataset, 1,438 with mccRCC met eligibility and were included. After PS matching weighted analysis, no significant difference in rwOS was noted between both groups (HR 1.01, 95% CI 0.86-1.19; p = 0.91); however, rwTTNT was significantly shorter with Ipi + Nivo than with ICI + TKI (HR 0.78, 95% CI 0.68-0.89; p < 0.001). In this large real-world study, there was evidence that rwOS was comparable, while rwTTNT was superior in patients receiving ICI + TKI compared to those receiving Ipi + Nivo. These real-world data offer important guidance for clinicians in choosing between Ipi + Nivo and ICI + TKI as frontline treatment.

The Effectiveness and Safety Profile of Nivolumab-Plus-Ipilimumab in Previously Untreated Japanese Patients With Advanced or Metastatic Renal Cell Carcinoma (J-ENCORE Study)

OBJECTIVES

Combination therapy of nivolumab-plus-ipilimumab has been approved for advanced or metastatic renal cell carcinoma in Japan, but large-scale clinical data targeting Japanese patients is limited. To evaluate the early outcomes and factors related to early progression and response.

METHODS

J-ENCORE is an ongoing multicenter, prospective, observational study of the effectiveness and safety of nivolumab-plus-ipilimumab for patients in Japan with advanced or metastatic renal cell carcinoma. The objective response rate, duration of response, progression-free survival, overall survival, incidence of adverse events, and factors related to early progression within 3 months, and response were assessed.

RESULTS

We included 274 patients (median age: 68 years, 24.8% aged ≥ 75 years, 78.8% male). The median follow-up was 23.4 months. The objective response rate was 36.8%. Among responders, 63.3% had progression-free survival > 12 months. The median progression-free survival was 9.9 months; the 12-month overall survival was 76.3%. Of the patients, 77.0% experienced treatment-related adverse events, 42.3% experienced grade 3-4 events, and 1.1% experienced treatment-related death. Early progression was associated with female sex, poor risk status, liver metastasis, high baseline C-reactive protein levels, and high neutrophil-to-lymphocyte ratios. Responders were less likely to have bone metastases. Limitations include the observational nature of the study and a relatively short follow-up period.

CONCLUSIONS

This is the first prospective, real-world study to demonstrate the effectiveness and safety of nivolumab-plus-ipilimumab in Japan, with the results comparable to those of CheckMate 214. These findings support the use of nivolumab-plus-ipilimumab, although further studies with longer follow-up on nivolumab-plus-ipilimumab are needed.

TRAIL REGISTRATION

ClinicalTrials.gov identifier: NCT04043975; University Hospital Medical Information Network-Clinical Trial Registration: UMIN000036772.

Real-world insights into cabozantinib efficacy in hepatocellular carcinoma: Real-world cabozantinib efficacy in HCC

INTRODUCTION AND OBJECTIVES

Cabozantinib, a multi-kinase inhibitor targeting AXL and MET, is approved for second-line treatment of hepatocellular carcinoma (HCC). However, the combination of cabozantinib with immune checkpoint inhibitors (ICIs) remains controversial after the COSMIC-312 study. The role of AXL and MET expression in predicting cabozantinib response is unclear. This study aims to evaluate cabozantinib's efficacy with ICIs and the predictive value of AXL and MET expression.

MATERIALS AND METHODS

From January 2019 and December 2023, 50 advanced HCC patients treated with cabozantinib were retrospectively enrolled.

RESULTS

Overall, 74% of patients received prior immunotherapy, 72% had been treated with more than two different multiple kinase inhibitors (MKIs), and 58% received cabozantinib as a fifth-line or later therapy. Cabozantinib was used alone (60%), with ICIs (12%), or with chemotherapy (28%). A majority (70%) received a dosage exceeding 40 mg/day. The ORR to cabozantinib was 0%, while the DCR was 42.2%. median PFS was 3.3 months, and OS was 6.1 months. There was no significant difference in PFS or OS between patients receiving five or more lines of treatment and those receiving fewer. Cabozantinib plus ICIs showed longer PFS (6.7 vs. 3.2 months, p = 0.04) and a trend toward improved OS compared to cabozantinib alone. AXL expression may predict better outcomes. Common adverse effects included palmar-plantar erythrodysesthesia (24.2%) and hypertension.

CONCLUSIONS

This study highlights the potential of cabozantinib combined with immunotherapy in heavily pretreated HCC, with AXL expression as a possible predictive biomarker.

Decoding tumor angiogenesis: pathways, mechanisms, and future directions in anti-cancer strategies

Angiogenesis, a crucial process in tumor growth and metastasis, necessitates targeted therapeutic intervention. This review reviews the latest knowledge of anti-angiogenesis targets in tumors, with emphasis on the molecular mechanisms and signaling pathways that regulate this process. We emphasize the tumor microenvironment's role in angiogenesis, examine endothelial cell metabolic changes, and evaluated potential therapeutic strategies targeting the tumor vascular system. At the same time, we analyzed the signaling pathway and molecular mechanism of tumor angiogenesis in detail. In addition, this paper also looks at the development trend of tumor anti-angiogenesis drugs, including their future development direction and challenges, aiming to provide prospective insight into the development of this field. Despite their potential, anti-angiogenic therapies encounter challenges like drug resistance and side effects, necessitating ongoing research to enhance cancer treatment strategies and the efficacy of these therapies.

Clinical Outcomes and Safety Profile of Neoadjuvant PD-1 Inhibitors Combined With VEGFR-TKI Versus VEGFR-TKI in Nonmetastatic Renal Cell Carcinoma

OBJECTIVE

The effectiveness of combining immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) in neoadjuvant therapy for renal cell carcinoma (RCC) remains unclear. This study aim to compare the efficacy and safety of neoadjuvant ICI plus TKI combination therapy versus TKI monotherapy in locally RCC patients.

METHODS

This study included 185 cases of locally RCC disease(TanyNanyM0) receiving neoadjuvant therapy from 29 centers across China from January 2019 to Feburary 2024. Primary endpoint was the objective response rate (ORR) in all patients and patients with tumor thrombus (TT). Secondary endpoints included recurrence-free survival (RFS), overall survival (OS), surgical outcomes, and safety. Statistical analysis was performed to compare the results between 2 groups.

RESULTS

Combination therapy group had higher ORR compared to the TKI monotherapy group(30.9% vs. 16.3% in all patients, 34.5% vs. 15.6% in patients with TT) and pCR rate (14.8% vs. 0%). RFS rates were improved in patients with TT receiving combination therapy (P = .047). Furthermore, the combination therapy group had lower blood loss during surgery (200 mL vs. 300 mL, P = .004). The main limitation is the retrospective study design.

CONCLUSIONS

Neoadjuvant ICI plus TKI combination therapy showed promising efficacy and acceptable toxicity. These findings suggest that further investigation is warranted to explore the potential of this treatment approach.