Prognostic Factors for Survival With Gemcitabine Plus 5-fluorouracil Based Regimens for Metastatic Renal Cancer

Patient-derived renal cell carcinoma organoids for personalized cancer therapy

Background

Kidney cancer is one of the most common solid tumors. The advancement of human kidney cancer research and treatment has been hindered by a lack of research models that faithfully recapitulate the diversity of the disease.

Methods

We established an effective three‐dimensional culture system for generating kidney cancer organoids from clinical renal cell carcinoma samples. Renal cell carcinoma (RCC) organoids were characterized by H&E staining, immunofluorescence, whole‐exome sequencing, RNA sequencing and single‐cell RNA sequencing. The use of RCC organoids in personalized cancer therapy was assessed by testing their responses to treatment drugs and chimeric antigen receptor T cells.

Results

Using this organoid culture system, 33 kidney cancer organoid lines from common kidney cancer subtypes, including clear cell renal cell carcinoma (ccRCC), papillary renal cell carcinoma (pRCC), and chromophobe renal cell carcinoma (chRCC), were generated. RCC organoids preserved the histological architectures, mutational landscapes, and transcriptional profile of the parental tumor tissues. Single‐cell RNA‐sequencing revealed inter‐ and intra‐tumoral heterogeneity in RCC organoids. RCC organoids allowed for in vitro drug screening and provided a tool for assessing the efficacy of chimeric antigen receptor T cells.

Conclusions

Patient‐derived RCC organoids are valuable pre‐clinical models for academic research and personalized medicine.

Analysis of the factors influencing the survival time of patients with sarcomatoid renal cell carcinoma

The aim of the present study was to identify the factors influencing the survival time of patients with sarcomatoid renal cell carcinoma (SRCC). Between January 2000 and September 2017, a total of 21 patients were enrolled, all of whom were diagnosed with SRCC. In total, eight prognostic factors were analyzed using the Kaplan-Meier estimator, a log-rank test and Cox's proportional hazards model. The log-rank test results revealed that there was a significant association between the proportion of sarcoma elements and survival time of patients with SRCC (P<0.05). In addition, there was a significant association between post-operative drug treatment and SRCC survival time (P<0.05). The results of the Kaplan-Meier estimate demonstrated that the survival curve of post-operative drug treatment was significantly greater compared with the survival curve of patients who did not undergo drug treatment (P<0.05). The survival curve of patients with a proportion of sarcoma elements <50% was significantly greater compared with the survival curve of patients with a proportion of sarcoma elements ≥50% (P<0.05). Furthermore, the Cox's proportional hazards model revealed that the mortality risk in post-operative patients without drug treatment was 5.822 times greater compared with that of patients with drug treatment (P<0.05). Mortality risk in patients with a proportion of sarcoma elements ≥50% was 4.682 times higher compared with that of patients with sarcoma elements <50% (P<0.05). Finally, post-operative drug therapy was revealed to be a protective factor which significantly affected the survival time of patients with SRCC [risk ratio (RR)=0.172], in addition to the proportion of sarcoma elements ≥50% (RR=4.682). In conclusion, drug therapy should be promoted upon patient diagnosis with SRCC and attention should be given to the proportion of sarcomatoid components.

Nuclear expression of Lyn, a Src family kinase member, is associated with poor prognosis in renal cancer patients

Background

8000 cases of renal cancer are diagnosed each year in the UK, with a five-year survival rate of 50 %. Treatment options are limited; a potential therapeutic target is the Src family kinases (SFKs). SFKs have roles in multiple oncogenic processes and promote metastases in solid tumours. The aim of this study was to investigate SFKs as potential therapeutic targets for clear cell renal cell carcinoma (ccRCC).

Methods

SFKs expression was assessed in a tissue microarray consisting of 192 ccRCC patients with full clinical follow-up. SFK inhibitors, dasatinib and saracatinib, were assessed in early ccRCC cell lines, 786-O and 769-P and a metastatic ccRCC cell line, ACHN (± Src) for effects on protein expression, apoptosis, proliferation and wound healing.

Results

High nuclear expression of Lyn and the downstream marker of activation, paxillin, were associated with decreased patient survival. Conversely, high cytoplasmic expression of other SFK members and downstream marker of activation, focal adhesion kinase (FAK) were associated with increased patient survival. Treatment of non-metastatic 786-O and 769-P cells with dasatinib, dose dependently reduced SFK activation, shown via SFK (Y⁴¹⁹) and FAK (Y⁸⁶¹) phosphorylation, with no effect in metastatic ACHN cells. Dasatinib also increased apoptosis, while decreasing proliferation and migration in 786-O and 769-P cell lines, both in the presence and absence of Src protein.

Conclusions

Our data suggests that nuclear Lyn is a potential therapeutic target for ccRCC and dasatinib affects cellular functions associated with cancer progression via a Src kinase independent mechanism.

[Renal cell carcinoma: Drug therapy and prognostic models]

Renal cell carcinoma (RCC) represents the sixth-leading cancer-specific cause of death worldwide. This is mainly caused by metastatic or locally advanced RCC. Approximately 25-30% of patients present with metastasis during the initial diagnosis. Furthermore, 20-30% of patients develop metastatic disease following initial curative surgery. Metastatic RCC is characterized by a poor prognosis with a median overall survival of less than 2 years. Today, targeted therapies such as VEGF receptor inhibitors and antagonists as well as mTOR inhibitors represent the standard of care in metastatic RCC. Conventional chemotherapies or cytokine-based medications have been abandoned due to inferior clinical efficacy compared with targeted therapies. In Germany, sunitinib, pazopanib, temsirolimus, and bevacizumab have been approved for first-line treatment and sorafenib, axitinib, and everolimus for second-line treatment. Prognostic models, assessing individual risk profiles, have been developed in the last 15 years, which are crucial for the design of trials, patient counseling, and initiation of goal-directed therapies.

Sunitinib in combination with gemcitabine for advanced solid tumours: a phase I dose-finding study

BACKGROUND

This phase I, dose-finding study determined the maximum tolerated dose (MTD), safety, and pharmacokinetics of sunitinib plus gemcitabine in patients with advanced solid tumours.

METHODS

Two schedules with sunitinib (25-50 mg per day) and IV gemcitabine (750-1250 mg m(-2)) in escalating doses were studied. First, patients received sunitinib on a 4-weeks-on-2-weeks-off schedule (Schedule 4/2) plus gemcitabine on days 1, 8, 22, and 29. Second, patients received sunitinib on a 2-weeks-on-1-week-off schedule (Schedule 2/1) plus gemcitabine on days 1 and 8. The primary endpoint was determination of MTD and tolerability.

RESULTS

Forty-four patients received the combination (Schedule 4/2, n=8; Schedule 2/1, n=36). With no dose-limiting toxicities (DLTs) at maximum dose levels on Schedule 2/1, MTD was not reached. Grade 4 treatment-related AEs and laboratory abnormalities included cerebrovascular accident, hypertension, and pulmonary embolism (n=1 each), and neutropenia (n=3), thrombocytopenia and increased uric acid (both n=2), and lymphopenia (n=1). There were no clinically significant drug-drug interactions. Antitumor activity occurred across dose levels and tumour types. In poor-risk and/or high-grade renal cell carcinoma patients (n=12), 5 had partial responses and 7 stable disease ≥ 6 weeks.

CONCLUSION

Sunitinib plus gemcitabine on Schedule 2/1 with growth factor support was well tolerated and safely administered at maximum doses of each drug, without significant drug-drug interactions.

DDX31 regulates the p53-HDM2 pathway and rRNA gene transcription through its interaction with NPM1 in renal cell carcinomas

Studies of renal cell carcinoma (RCC) have led to the development of new molecular-targeted drugs but its oncogenic origins remain poorly understood. Here, we report the identification and critical roles in renal carcinogenesis for DDX31, a novel nucleolar protein upregulated in the vast majority of human RCC. Immunohistochemical overexpression of DDX31 was an independent prognostic factor for patients with RCC. RNA interference (RNAi)-mediated attenuation of DDX31 in RCC cells significantly suppressed outgrowth, whereas ectopic DDX31 overexpression in human 293 kidney cells drove their proliferation. Endogenous DDX31 interacted and colocalized with nucleophosmin (NPM1) in the nucleoli of RCC cells, and attenuation of DDX31 or NPM1 expression decreased pre-ribosomal RNA biogenesis. Notably, in DDX31-attenuated cells, NPM1 was translocated from nucleoli to the nucleoplasm or cytoplasm where it bound to HDM2. As a result, HDM2 binding to p53 was reduced, causing p53 stablization with concomitant G(1) phase cell-cycle arrest and apoptosis. Taken together, our findings define a mechanism through which control of the DDX31-NPM1 complex is likely to play critical roles in renal carcinogenesis.

Expression and prognostic significance of Src family members in renal clear cell carcinoma

BACKGROUND

The aim of this study was to determine whether Src family kinases (SFK) are expressed in renal cell cancer and to assess their prognostic significance.

METHODS

mRNA expression levels were investigated for the 8 SFK members by quantitative real-time PCR in 19 clear cell cancer tissue samples. Immunohistochemical staining was utilised to assess expression of Src kinase, dephosphorylated Src kinase at Y(530) (SrcY(530)), phosphorylated Src at Y(419) (SrcY(419)) and the downstream focal adhesion kinase (FAK) marker at the Y(861) site (FAK Y(861)) in a cohort of 57 clear cell renal cancer specimens. Expression was assessed using the weighted histoscore method.

RESULTS

Src, Lyn, Hck, Fgr and Fyn were the most highly expressed in renal cancer. All members were more highly expressed in T2 disease, and furthermore expression levels between T2 and T3 disease showed a significant decrease for Lck, Lyn, Fyn, Blk and Yes (P=0.032). Assessment of membrane, cytoplasm and nuclear expression of Src kinase, SrcY(530) and SrcY(419) were not significantly associated with cancer-specific survival. High expression of cytoplasmic FAK Y(861) was associated with decreased cancer-specific survival (P=0.001). On multivariate analysis, cytoplasmic FAK Y(861) was independently associated with cancer-specific survival (hazard ratio 3.35, 95% CI 1.40-7.98, P=0.006).

CONCLUSION

We have reported that all SFK members are expressed in renal cell carcinoma. The SFK members had their highest levels of expression before the disease no longer being organ confined. We hypothesise that these SFK members are upregulated before the cancer spreading out-with the organ and given that Src itself is not associated with cancer-specific survival but the presence of FAK Y(861), a downstream marker for SFK member activity is associated with decreased cancer-specific survival, we hypothesise that another SFK member is associated with decreased cancer-specific survival in renal cell cancer.

Silibinin inhibits the invasion and migration of renal carcinoma 786-O cells in vitro, inhibits the growth of xenografts in vivo and enhances chemosensitivity to 5-fluorouracil and paclitaxel

Silibinin is a flavonoid antioxidant that is widely used for its anti-hepatotoxic properties. It exerts a dose-dependent inhibition on the invasion and migration of 786-O renal cell carcinoma (RCC) cells in the absence of cytotoxicity. 786-O cells were treated with silibinin at various concentrations, up to 50 µM, for a defined period and then subjected to gelatin zymography, casein zymography, and Western blot to investigate the impacts of silibinin on metalloproteinase (MMP) -2, -9, urokinase plasminogen activator (u-PA), and MAPK pathway signaling proteins, respectively. The results showed that silibinin decreased MMP-2, MMP-9, u-PA, p-p38, and p-Erk1/2 expressions in a concentration-dependent manner. The reduced expressions of MMP-2 and u-PA, as well as inhibition of cell invasion were obtained in the cultures pre-treated with PD98059 (Erk1/2 inhibitor) and SB203580 (p38 inhibitor). An in vivo anti-tumor study with a nude mice xenograft model by a subcutaneous inoculation of 786-O cells demonstrated small solid tumors after eight days following cell inoculation. There was a 70.1% reduction in tumor volume and 69.7% reduction in tumor weight by silibinin feeding on day 44, compared to those of controls. Moreover, combination treatment with silibinin and 5-fluorouracil, paclitaxel, vinblastine, or RAD-001 enhanced the chemosensitivity of 5-fluorouracil and paclitaxel. In conclusion, silibinin inhibits the invasion and migration of 786-O cells in vitro, inhibits the growth of xenografts in vivo, and enhances chemosensitivity to 5-fluorouracil and paclitaxel. © 2011 Wiley-Liss, Inc.

[Treatment of metastatic renal cancer: current validity of immunotherapy]

OBJECTIVE

To assess the significance and effects of conventional immunotherapy for management of disseminated renal cancer.

MATERIALS AND METHODS

Historical data from studies conducted with cytokines, interferon, and interleukin are reviewed, their combinations are evaluated, and the different relevant studies available are compared.

DISCUSSION

While diverse, results are poor in terms of objective response and its duration. Historical series using interleukin-2 achieved, despite severe side effects, disease remissions, some of them complete.

CONCLUSIONS

Currently, after the advent of new drugs, use of conventional immunotherapy may be indicated for specific patients with a good general condition undergoing previous nephrectomy for a clear cell carcinoma at least 12 months before occurrence of metastasis in a single organ, preferably the lung, and with normal levels of hemoglobin, calcium, and lactate dehydrogenase, looking for that small percentage of stable and sustained responses.

Combining estimates of interest in prognostic modelling studies after multiple imputation: current practice and guidelines

Background

Multiple imputation (MI) provides an effective approach to handle missing covariate data within prognostic modelling studies, as it can properly account for the missing data uncertainty. The multiply imputed datasets are each analysed using standard prognostic modelling techniques to obtain the estimates of interest. The estimates from each imputed dataset are then combined into one overall estimate and variance, incorporating both the within and between imputation variability. Rubin's rules for combining these multiply imputed estimates are based on asymptotic theory. The resulting combined estimates may be more accurate if the posterior distribution of the population parameter of interest is better approximated by the normal distribution. However, the normality assumption may not be appropriate for all the parameters of interest when analysing prognostic modelling studies, such as predicted survival probabilities and model performance measures.

Methods

Guidelines for combining the estimates of interest when analysing prognostic modelling studies are provided. A literature review is performed to identify current practice for combining such estimates in prognostic modelling studies.

Results

Methods for combining all reported estimates after MI were not well reported in the current literature. Rubin's rules without applying any transformations were the standard approach used, when any method was stated.

Conclusion

The proposed simple guidelines for combining estimates after MI may lead to a wider and more appropriate use of MI in future prognostic modelling studies.

Prognostic factors for survival in metastatic renal cell carcinoma: update 2008

A variety of prognostic factor models to predict survival in patients with metastatic renal cell carcinoma have been developed. Diverse populations of patients with variable treatments have been used for these analyses. A variety of clinical, pathologic, and molecular factors have been studied, but current models use predominantly easily obtained clinical factors. These approaches are reviewed, and current approaches to further refine and develop these techniques are reviewed.

A phase II trial of gemcitabine plus capecitabine for metastatic renal cell cancer previously treated with immunotherapy and targeted agents

PURPOSE

We assessed the clinical activity and safety of gemcitabine plus capecitabine in patients with metastatic renal cell cancer previously treated with immunotherapy.

MATERIALS AND METHODS

In this phase II trial patients received 1,000 mg/m(2) gemcitabine intravenously on days 1, 8 and 15, plus 830 mg/m(2) capecitabine orally twice daily on days 1 to 21 of 28-day cycles. The primary end point was progression-free survival time. Secondary end points included overall survival time, objective response rate and toxicity.

RESULTS

Of 84 patients enrolled 83 were evaluable for response and toxicity. A total of 65 patients had intermediate or poor risk prognosis. Median progression-free survival and overall survival were 4.6 (95% CI 3.7-7.3) and 17.9 months (95% CI 13.2-23.6), respectively. There were 6 partial responses and 1 complete response (objective response rate 8.4% [95% CI 3.5-16.6]). Two patients remain in unmaintained remission close to 3 years from the initiation of gemcitabine plus capecitabine treatment. On multivariate analysis more than 3 disease sites were significantly associated with shorter progression-free survival and patients with thrombocytosis, more than 3 disease sites or anemia had a significantly increased risk of death. Adverse events occurring at least once in more than 5% of patients included grade 3 or greater neutropenia (83%), grade 2 or greater hand-foot syndrome (13%), grade 3 or greater thrombocytopenia (12%), grade 3 or greater thromboembolic events (8%), grade 3 or greater fatigue (8%) and grade 2 or greater mucositis (6%).

CONCLUSIONS

At the doses and schedule tested gemcitabine plus capecitabine demonstrated modest clinical activity in metastatic renal cell cancer after cytokine failure and produced significant neutropenia. A modified gemcitabine plus capecitabine regimen may be evaluated in patients with metastatic renal cell cancer after failure of approved targeted therapies.

The efficacy and safety of irinotecan cisplatin and mitomycin chemotherapy in sunitinib pre-treated metastatic clear cell renal cancer

Background

Sunitinib is widely used as first-line treatment for metastatic clear cell renal cancer (MCRC). No reports are known of treatment after sunitinib failure. As irinotecan, cisplatin, and mitomycin-C (IPM) chemotherapy has been reported to influence MCRC after progression on cytokine therapy, we report on the outcome of 11 patients treated with IPM after sunitinib failure.

Patients and methods

Eleven patients with progression of disease on sunitinib therapy were treated with 4, monthly cycles of monthly IPM.

Results

Nine out of 11 patients progressed during IPM therapy. The median time to progression was 1.4 months (95% CI: 0.7–2.1 months), while the overall survival was 4.2 months (95% CI: 0.9–2.3). Overall 10 patients have died of progressive renal cancer. One patient had a radiological response to therapy and remains progression free 11 months after treatment. Four of the 10 patients required a dose reduction for grade 3 or 4 toxicities.

Conclusions

IPM alone does not appear to benefit patients with MCRC who previously progressed during sunitinib therapy. The median progression-free survival and overall survival for these patients is short.

Lenalidomide therapy for metastatic renal cell carcinoma

PURPOSE

Treatments for refractory metastatic renal cell cancer (RCC) are limited. Oral lenalidomide, a thalidomide-based drug having enhanced immunomodulatory and antiangiogenic properties and reduced toxicity, was evaluated for safety and efficacy in this setting.

METHODS

In an open-label, single-center phase II trial, adults (> or =18 years old) with newly diagnosed RCC seen at our institution between December 2003 and April 2004 were recruited to receive at least three 28-day cycles (21 days on drug and 7 days off) of oral lenalidomide (25 mg/d). The dose was reduced as needed in cases of toxicity. The primary endpoint was tumor response rate. Secondary endpoints were time to tumor progression, response duration, 6-month and 12-month progression-free survival, overall survival, and safety.

RESULTS

Thirty-nine of 40 patients (97%) were evaluable for response. Many in the evaluable population [63 (38-73) years; male, 73% (29/39)]; Zubrod performance status < or =1, 97% (38/39) had the clear cell histotype [85% (33/39)], had undergone previous immunotherapy or chemotherapy [59% (23/39)]; and had > or =2 metastatic sites [69% (27/39)]. Most [92% (36/39)] completed at least 3 treatment cycles (12 weeks). A complete response was observed in 1 patient (3%), partial response in 3 (8%), stable disease in 21 (53%), and progressive or unknown-status disease in 15 (38%). Time to tumor progression was < or =6 months in 24 patients (62%), 6 to 12 months in 6 (15%), and >12 months in 9 (23%). Median response duration was 6 (2-22) months and median overall survival was 17 months (0.80-39.6). The most common treatment-related adverse event was grade < or =2 fatigue [60% (24/40)]. The most common laboratory abnormalities were grade > or =3 neutropenia [50% (20/40)] and thrombocytopenia [28% (11/40)].

CONCLUSION

Lenalidomide is a safe and effective therapy for refractory metastatic RCC. Further studies of lenalidomide in this setting are warranted.

Renal cancer

In Europe, renal cancer (that is neoplasia of the kidney, renal pelvis or ureter (ICD-9 189 and ICD-10 C64-C66)) ranks as the seventh most common malignancy in men amongst whom there are 29,600 new cases each year (3.5% of all cancers). Tobacco, obesity and a diet poor in vegetables are all acknowledged risk factors, along with specific occupational and environmental factors. A familial history of renal carcinoma is also likely to increase the risk. Renal carcinoma may remain clinically occult for most of its course. The classic presentation of pain, haematuria, and flank mass occurs in only 9% of patients and is often indicative of advanced disease. Approximately 30% of patients with renal carcinoma present with metastatic disease, 25% with locally advanced renal carcinoma and 45% with localized disease. Metastases are typically found in the lung, soft tissue, bone, liver, cutaneous sites, and central nervous system. The most important staging technique is a computed tomography (CT) scan of the whole abdomen. Survival rates are more favourable for patients with tumours confined to the kidney. Five-year survival for patients with metastatic renal carcinoma is comprised between 0 and 20%. Radical nephrectomy is the standard intervention for renal cancer. Intrinsic resistance to chemotherapy has long been a hallmark of renal carcinoma. Limited options are available for the systemic therapy, and no chemotherapeutic regimen is accepted as a standard of care. Biologic agents represent the major effective therapies for widespread metastatic renal cancer. An antiangiogenic strategy, the neutralization of VEGF, can slow the growth rate of advanced cancer.

A Phase I/II study of GTI-2040 and capecitabine in patients with renal cell carcinoma

BACKGROUND

Fluoropyrimidine based therapy has modest activity in patients with metastatic renal carcinoma and inhibition of ribonucleotide reductase is synergistic in model systems. GTI-2040 is a 20-mer phosphorothioate oligonucleotide complimentary to the R2 component of ribonucleotide reductase that has activity in renal cancer models.

METHODS

Metastatic renal carcinoma patients without prior fluoropyrimidine therapy and normal organ function were treated with oral capecitabine 880 mg/m(2) twice daily along with continuous infusion GTI-2040 starting at 148 mg/m(2)/day for 21 days, for each 28-day cycle. After completion of the phase I portion, the phase II study portion sought to rule out a null hypothesized 10% response rate versus an alternative 25% response rate utilizing alpha and beta errors of 0.05 and 0.2, respectively. GTI-2040 pharmacokinetics and effects on ribonucleotide reductase expression in peripheral mononuclear cells were evaluated in a subset of patients.

RESULTS

Based on one dose limiting toxicity in nine patients in the phase I portion, the phase II portion was conducted using the previously recommended 185 mg/m(2)/day dose of GTI-2040. Twenty-six patients were enrolled in the phase II portion to obtain 18 fully evaluable for response. Only one patient, treated at a GTI 2040 dose of 185 mg/m(2)/day in the phase I portion of the protocol, responded. Toxicities and GTI-2040 pharmacokinetics were consistent with previously reported results. R2 expression in peripheral mononuclear cells was too variable for accurate interpretation.

CONCLUSION

Further study of GTI-2040 and capecitabine in metastatic renal cancer at this dose and schedule is not indicated. Further study is necessary to determine whether lack of activity is due to inadequate target inhibition or inadequate effect of appropriate targeting.

Renal cell carcinoma guideline

OBJECTIVES

The European Association of Urology (EAU) Guideline Group for renal cell carcinoma (RCC) prepared this guideline to help urologists assess the evidence-based management of RCC and to incorporate the guideline recommendations into their clinical practice.

METHODS

The recommendations provided in the current guideline are based on a systematic literature search using MedLine, the Cochrane Central Register of Controlled Trials, and publications and review articles.

RESULTS

A limited number of prospective randomised studies are available with high-level evidence. Most publications concerning RCC are based on retrospective analyses, including some larger multicentre validation studies and well-designed controlled studies.

CONCLUSIONS

It must be stressed that the current guideline contains information for the treatment of an individual patient according to a standardised general approach. Updated recommendations concerning diagnosis, treatment, and follow-up can improve the clinical handling of patients with RCC.

A phase II study of gemcitabine and capecitabine in metastatic renal cancer: a report of Cancer and Leukemia Group B protocol 90008

BACKGROUND

The objective of this study was to verify previous reports of activity with gemcitabine plus a fluoropyrimidine in patients with metastatic renal cell cancer in a multiinstitutional setting.

METHODS

Eligibility included a Zubrod performance status from 0 to 2, no prior gemcitabine or fluoropyrimidine therapy, and normal organ function. Patients received gemcitabine at a dose of 1000 mg/m2 on Days 1, 8, and 15 and capecitabine at a dose of 830 mg/m2 twice daily on Days 1 through 21 on a 28-day cycle with specified dose reductions for baseline renal insufficiency. The primary endpoint was the response rate, which was assessed every 8 weeks. The statistical plan tested the hypothesis that the response rate was 5% versus an alternative of 15%.

RESULTS

Sixty patients were enrolled, and 4 of those patients never started treatment. Of the 56 evaluable patients, 79% of patients underwent prior nephrectomy, 75% of patients received prior systemic therapy, and 75% of patients had clear cell histology. Risk stratification revealed that 34%, 43%, and 16% of patients were in Risk Groups 1, 2, and 3, respectively. Toxicity (graded according to the National Cancer Institute's Common Toxicity Criteria [version 2.0]) included Grade 3 or 4 neutropenia in 45% of patients, Grade 2 or greater fatigue in 32% of patients, Grade 2 or greater nausea in 29% of patients, Grade 2 or greater hand-foot reaction in 39% of patients, and Grade 2 or greater diarrhea in 22% of patients. Six patients responded (11%; 95% confidence interval, 4-22%), and the overall median survival was 14.5 months.

CONCLUSIONS

Gemcitabine plus capecitabine had modest activity in patients with metastatic renal cancer, although the degree of activity and its associated toxicity would not support further evaluation in a Phase III trial of unselected patients. More focused investigations to identify patients most likely to benefit or to enhance activity with additional agents would be reasonable.

Targeted Approaches for Treating Advanced Clear Cell Renal Carcinoma

The mainstay of any curative treatment in renal cell carcinoma (RCC) is surgery. In the case of metastatic disease at presentation, a radical nephrectomy is recommended to good performance status patients prior to the start of cytokine treatment. Interferon (IFN)-a offers in a small but significant percentage of patients advantage in overall survival. Interleukin (IL)-2-based therapy gives similar survival rates. To date, hormonal therapy and chemotherapy do not have a proven impact on survival. Recent insights demonstrate that the majority of clear cell RCC harbor abnormalities of the von Hippel-Lindau (VHL) gene. This gene plays a key role in the stimulation of angiogenesis by vascular endothelial growth factor (VEGF) in this highly vascularized tumor. This opens interesting new treatment strategies including blockade of VEGF with the monoclonal antibody bevacizumab (Avastin) and inhibition of VEGF receptor tyrosine kinases with small oral molecules such as sunitinib (SU11248, Sutent) or PTK787. Likewise, inhibition of the Raf kinase pathway with oral sorafenib (Bay 43-9006, Nexavar) or inhibition of the mTOR pathway with intravenous CCI-779 are under investigation. Preliminary clinical results with all these compounds are promising, and the results of ongoing first-line phase III studies will become available in the next years.

Novel kinase inhibitors in renal cell carcinoma: progressive development of static agents

The rapidly expanding knowledge regarding neoplastic diseases is providing a plethora of new targets for drug discovery and development as exemplified by recent data in renal cell carcinoma. The initial experience with molecularly "targeted" agents has demonstrated that development of the newer non-cytotoxic agents will provide unique challenges requiring modification of many traditional drug development concepts and methods. We discuss recently reported data from a few renal cell carcinoma trials with putative cytostatic agents and highlight issues that need to be addressed for efficient development of cytostatic agents during various phases of clinical development.

Predicting hospital mortality among injured children using a national trauma database

PURPOSE

The purpose of this study was to develop a model that accurately predicts mortality among injured children based on components of the initial patient evaluation and that is generalizable to diverse acute care settings. Important predictive variables obtained in an emergency setting are frequently missing in even large national databases, limiting their effectiveness for developing predictions. In this study, a model predicting pediatric trauma mortality was developed using a national database and methods to handle missing data that may avoid biases that can occur restricting analyses to complete cases.

METHODS

Records of pediatric patients included in the National Pediatric Trauma Registry (NPTR) between 1996 and 1999 were used as a training set in a logistic regression model to predict hospital mortality using vital signs, Glasgow Coma Scale (GCS) score, and intubation status. Multiple imputation was applied to handle missing data. The model was tested using independent data from the NPTR and National Trauma Data Bank (NTDB).

RESULTS

Complete case analysis identified only GCS-eye and intubation status as predictors of mortality. A model based on complete case analysis had good discrimination (c-index = 0.784) and excellent calibration (Hosmer-Lemeshow c-statistic, 6.8) (p > 0.05). Using multiple imputation, three additional predictors of mortality (systolic blood pressure, pulse, and GCS-motor) were identified and improved model performance was observed. The model developed using multiple imputation had excellent discrimination (c-index, 0.947-0.973) in both test datasets. Calibration was better in the NPTR testing set than in the NTDB (Hosmer-Lemeshow c-statistic, 9.2 for NPTR [p > 0.05] and 258.2 for NTDB [p < 0.05]). At a probability cutoff that minimized misclassification in the training set, the false-negative and false-negative rates of the model were better than those obtained with either the Revised Trauma Score (RTS) or Pediatric Trauma Score using data from the NPTR testing set. Although the false-positive rates were lower with the RTS using data from the NTDB, the false-negative rates of the proposed model and the RTS were similar in this test dataset.

CONCLUSIONS

Using multiple imputation to handle missing data, a model predicting pediatric trauma mortality was developed that compared favorably with existing trauma scores. Application of these methods may produce predictive trauma models that are more statistically reliable and applicable in clinical practice.

Novel kinase inhibitors in renal cell carcinoma: progressive development of static agents

The rapidly expanding knowledge regarding neoplastic diseases is providing a plethora of new targets for drug discovery and development as exemplified by recent data in renal cell carcinoma. The initial experience with molecularly "targeted" agents has demonstrated that development of the newer non-cytotoxic agents will provide unique challenges requiring modification of many traditional drug development concepts and methods. We discuss recently reported data from a few renal cell carcinoma trials with putative cytostatic agents and highlight issues that need to be addressed for efficient development of cytostatic agents during various phases of clinical development.

Kidney cancer: identification of novel targets for therapy

Kidney cancer, although relatively rare when compared to other malignancies, occurs not uncommonly in patients with renal disease and is often discovered incidentally during the initial nephrologic work-up, or by the savvy clinician who is familiar with the paraneoplastic signs. While surgical approaches are generally curative when the disease is confined to the kidney, one-third of the cases that present in the metastatic form and require conventional medical therapy are associated with a truly dismal patient survival rate. In light of the emerging knowledge of the molecular mechanisms of kidney cancer oncogenesis, several novel and promising therapeutic approaches are emerging. In this review, we summarize the current state of kidney cancer diagnosis and therapy, as well as some of the novel treatments that capitalize on those newly elucidated molecular pathways that are deranged in this disease.

Novel treatments for metastatic renal cell carcinoma

The mainstay of any curative treatment in renal cell carcinoma (RCC) is surgery. In case of metastatic disease at presentation a radical nephrectomy is recommended to good performance status patients prior to start of interferon-alfa treatment. Interferon-alpha (IFN-alpha) offers in a small but significant percentage of patients advantage in overall survival; interleukin-2 (IL-2) based therapy gives similar survival rates. To date hormonal and chemotherapy do not have a proven impact on survival. The recent new insights in the molecular biology of clear RCC has revealed a key-role for vascular endothelial growth factor (VEGF) in the stimulation of angiogenesis in this highly vascularized tumour. This opens interesting new treatment strategies including: blockage of VEGF with the monoclonal antibody bevacizumab and inhibition of VEGF receptor tyrosine kinases (with small oral molecules such as SU11248 or PTK787). Likewise, inhibition of the Raf kinase pathway (with oral Bay 43-9006) or inhibition of the mTOR pathway (with i.v. CCI-779) are under investigation. Preliminary clinical results with all these compounds are interesting and the results of ongoing phase III studies will become available in the next years.

Novel treatment strategies in clear-cell metastatic renal cell carcinoma

Metastatic renal-cell carcinoma (mRCC) is highly resistant to cytotoxic agents or hormones and is currently mainly treated with cytokine-based therapy. Transient responses and moderate survival advantages have been achieved in a subset of patients with these aspecific biological response modifiers. Side-effects are considerable, especially with high-dose interleukin (IL)-2. Efforts made in the field of specific immunotherapy have focused on optimization of dendritic cell vaccination and on administration of monoclonal antibodies, either cold (unconjugated) or hot (radioactively labeled). Furthermore, allogeneic bone marrow transplantation is able to induce remissions but, regrettably, is related to substantial morbidity and mortality. Neutralization of the biological activity of some immunosuppressive cytokines produced by RCC (IL-6 and tumor necrosis factor-alpha) with monoclonal antibodies is currently under investigation. Insights gained into the processes and pathways underlying carcinogenesis have led to the development of new treatment strategies. These treatments can be used for clear cell RCC, since they focus on blocking gene products that are upregulated by mutations in the von Hippel-Lindau gene. Specific strategies include anti-vascular endothelial growth factor monoclonal antibody (bevacizumab) or inhibition of its receptor kinases (oral SU11248 or PTK787), or targeting the Raf kinase pathway (by BAY 43-9006) or the mammalian target of rapamycin (mTOR) pathway (by CCI-779). Early clinical results are promising, but their place in the treatment of RCC has to be determined.

Chemotherapies and immunotherapies for metastatic kidney cancer

Most patients who develop kidney cancer are effectively treated with a radical nephrectomy; however, for those patients who present with or develop metastatic disease, the therapeutic options are limited. Interferon and interleukin-2 remain the standard therapies. Several studies have identified the optimal doses and schedules of these cytokines and groups of patients most likely to benefit from immunotherapy. Although cytotoxic chemotherapy continues to have a minor role in patients with clear cell renal carcinoma, it may become the treatment of choice for some patients with variant renal cancers. Novel agents targeting the vascular endothelial growth factor, its receptor, and other hypoxia-induced proteins are showing great promise and soon may expand the therapeutic options for patients with advanced kidney cancer.

Chemotherapy in metastatic renal cell cancer

Currently, there is no standard treatment for patients with advanced renal cell carcinoma (RCC) who do not respond to or progress after transient remission to first-line immunotherapy. At the end of the 1990s, no single chemotherapeutic drug, alone or in combination with interleukin-2 (IL-2) or interferon-alfa (IFN), had shown activity beyond the one expected by immunotherapy alone. New drugs on the market such as the pyrimidine analog gemcitabine or taxane-based chemotherapeutics may show promising tumor activity in combination with targeted therapy, but this has to be substantiated in upcoming trials. There is a great need to develop effective systemic therapy for advanced MRCC and to evaluate the efficacy of new drugs in clinical trials.

A Phase I trial of fixed dose rate gemcitabine and capecitabine in metastatic renal cell carcinoma

BACKGROUND

Metastatic renal cell carcinoma (RCC) has modest response rates to chemotherapy with gemcitabine and 5-fluorouracil (5-FU). Fixed dose rate gemcitabine infusion leads to enhanced intracellular accumulation of drug and possible augmented clinical effect. To determine the toxicity of this combination therapy in metastatic RCC, a Phase I trial was conducted.

METHODS

Patients with metastatic RCC were enrolled in a Phase I dose escalation trial. Patients received fixed dose rate gemcitabine on Days 1, 8, and 15 in combination with capecitabine, an oral 5-FU analog, given on Days 1-21 of a 28-day cycle.

RESULTS

Nine patients were enrolled at one of two dose levels. The initial dose level produced dose-limiting toxicity (DLT), including prominent palmar-plantar erythrodysesthesia (hand-foot syndrome). A modified second dose level also resulted in DLT, precluding further study. No central nervous system (CNS) toxicity was observed in three patients with CNS metastases. Two patients demonstrated an objective partial response.

CONCLUSIONS

Fixed dose rate gemcitabine in combination with capecitabine produced unacceptable toxicity in patients with advanced RCC. Further development of this schedule in RCC cannot be recommended.

Treatment of recurrent or metastatic renal cell carcinoma

The management of recurrent renal cell carcinoma is challenging as it requires close collaboration between surgeons, radiation oncologists and medical oncologists. To date, treatment options for metastatic disease have been of modest benefit. The disease has therefore been a good model for novel drug development programs. These endeavors are now bearing fruit with exciting preliminary data now emerging in relation to a number of novel agents.

A phase II trial of gefitinib (Iressa, ZD1839) in stage IV and recurrent renal cell carcinoma

PURPOSE

The epidermal growth factor receptor (EGFR) is overexpressed in 75 to 90% of renal cell carcinomas and may play a role in tumor initiation and progression. Gefitinib (Iressa, ZD1839) is a potent, selective EGFR-tyrosine kinase inhibitor. This trial was undertaken to assess the efficacy and toxicity of gefitinib in advanced renal cell carcinoma.

EXPERIMENTAL DESIGN

Oral gefitinib, 500 mg once daily, was given continuously. A single-dose reduction to 250 mg daily was allowed for toxicity. The primary end point was response rate (defined as complete remission + partial remission + stable disease). Secondary end points were progression-free survival, overall survival, toxicity, and correlation of response with EGFR status.

RESULTS

Twenty-one patients were enrolled on this study, and all are evaluable for response and toxicity. Patient characteristics were median age 61 (range, 35-78 years); 17 males, 4 females; median performance status 0 (range 0-2); median number of prior systemic therapies 1 (range, 0-3). The median and mean number of cycles of therapy received was 3 and 4.7 (range, 1-14+). The best response was stable disease in eight patients (38%). Median progression-free survival was 2.7 months. Median overall survival was 8.3 months. The difference in overall survival was significantly different between patients with progressive disease versus stable disease (6.1 months versus 16+ months; Log-Rank test P value < 0.0001). Three patients required a dose reduction, all for grade 3 diarrhea. There was no apparent correlation between EGFR status and stability of disease or progression of disease.

CONCLUSIONS

Gefitinib is without significant conventional activity in renal cell carcinoma. The relation of "stable disease" to treatment or to disease-related prognostic heterogeneity remains to be defined.

Active chemotherapy for sarcomatoid and rapidly progressing renal cell carcinoma

BACKGROUND

Immunotherapy is generally ineffective in patients with sarcomatoid renal cell carcinoma (RCC) and in patients with rapidly progressive metastatic or locally recurrent disease, with a median time to progression of approximately 2 months and a median survival of 4-7 months. Gemcitabine-based regimens have modest antitumor activity, whereas doxorubicin is often used to treat sarcomatoid RCC. Based on the antitumor activity of doxorubicin and gemcitabine in collecting duct carcinoma of the kidney, the authors used this combination to treat selected patients with sarcomatoid or rapidly progressing RCC.

METHODS

Eighteen patients (11 males and 7 females; median age, 53 years; range, 31-81 years) with RCC (56% sarcomatoid; 44% other) were treated at 2 institutions in a collaborative study that was not institutional review board reviewed. Seven patients received previous treatment with interferon or interleukin-2. Sites of metastases included the lung, soft tissue, bone, liver, and brain with 88% of patients having > or = 3 sites of disease. Treatment consisted of doxorubicin (50 mg/m2) and gemcitabine (1500 or 2000 mg/m2) every 2-3 weeks with granulocyte-colony-stimulating factor support.

RESULTS

A median of 5 courses was administered (range, 2-12 cycles). Therapy was well tolerated with no Grade 4 toxicities. Two patients had a complete response, five had a partial response, three had a mixed response, and one had stable disease. The median duration of response was 5 months (range, 2-21+ months).

CONCLUSIONS

These data suggested that the combination of doxorubicin and gemcitabine has antitumor activity in patients with sarcomatoid RCC or with rapidly progressing RCC. A prospective investigation of this combination in RCC is warranted.

Therapeutic Options for Variant Renal Cancer

Variant or nonclear cell renal cell cancer is a rare disease constituting only approximately 5% to 8% of the metastatic renal cell cancer population. Pathological criteria for the three main variant subtypes, papillary, chromophobe, and collecting duct, have been specified. Nonetheless, there may be subtypes within these variants, many poorly differentiated tumors cannot be reliably classified, and expertise in recognizing specific subtypes is not widespread. Expression analysis and other molecular techniques are beginning to clarify and standardize the pathological classification scheme. Because these classifications are relatively new and the number of patients with any one subtype is limited, little is known about appropriate therapies for patients with metastatic disease. Retrospective series strongly suggest that immunotherapy is not effective in any nonclear cell subtype. Case reports suggest that cytotoxic chemotherapy used for transitional cell cancers may be helpful in patients with collecting duct cancers. A central registry of patients with variant renal cell cancer should be created in which response to various therapies is recorded. Such a registry could provide support for a more formal multi-institutional study investigating a specific drug or regimen.

A clinical phase I trial of gemcitabine and treosulfan in uveal melanoma and other solid tumours

This trial was performed to define the maximum tolerated dose (MTD) of treosulfan administered in combination with a fixed dose of gemcitabine in uveal melanoma patients. Preclinical studies suggested synergistic activity against uveal melanoma. Gemcitabine (1 g/m2) and treosulfan (2.5-4 g/m2) were administered on days 1 and 8, and cycles were repeated on day 29 for a maximum of six cycles. For treosulfan, dose escalation cohorts of 2-4 patients were enrolled. An additional 25 patients were entered at treosulfan dose levels II (3 g/m2) and III (3.5 g/m2). Thirty three patients with uveal melanoma and six patients with other histologies were accrued. Side-effects were predominantly haematological. The MTD was 3.5 g/m2 of treosulfan together with 1 g/m2 of gemcitabine. In the uveal melanoma patients, one partial response (PR) and 15 stablisations of disease (SD) were recorded and whether this translates into a survival gain should be explored further.