Optimal management of metastatic renal cell carcinoma: an algorithm for treatment

Cavoatrial hypernephroma resection on cardiopulmonary bypass: Mild/normo-versus moderate hypothermia

INTRODUCION

Renal cell carcinoma (RCC) is one of the most prevalent malignant tumors. It extends up into the systemic veins and right atrium. Surgical extraction of such extensions is usually carried out using cardiopulmonary bypass (CPB) with moderate hypothermic (MH) being frequently applied in order to obtain a clear surgical field. However, due to obvious disadvantages of hypothermia, approaches with mild/normothermia (NT) during CPB have also been established. The current study aims to compare the outcomes of patients undergoing RCC tumor and extensions resection using MH versus NT.

MATERIAL AND METHODS

This is a retrospective, non-randomized study. All patients who underwent RCC tumor and extensions resection for stage III or IV (Staehler) RCC in a single center between 2006 and 2020 were included. During surgery, MH or NT were applied. CPB was realized using aortic and bicaval cannulation. We compared the procedural times, transfusion requirements and postoperative outcomes, respectively between the MH and NT groups.

RESULTS

A total of 24 consecutive patients (n(NT) = 12, n(MH) = 12) were included in the study (median age NT 68.5 and MH 66.5). The study only showed a significant difference in heart-lung machine times (median CPB time NT 45.5 min and MH 110.0 min, p = 0.004). All other results, loss of drainage, administration of blood products, as well as the postoperative course and mortality were comparable in both groups.

CONCLUSION

The results showed a high perioperative and long-term mortality. The perioperative course was similar after surgery with NT or MH. Therefore, NT which minimizes potential complications of MH should be preferred.

"Real world" treatment of metastatic renal cell carcinoma in a joint community-academic cohort: progression-free survival over three lines of therapy

BACKGROUND

New targeted therapeutics approved for metastatic renal cell carcinoma (mRCC) offer multiple options in each line of therapy; however, there are few prospective data beyond the first-line settings, and overall comparative effectiveness data are limited. In the targeted therapy era, progression-free survival (PFS) has been the most common regulatory end point for demonstrating the benefit of new therapies.

PATIENTS AND METHODS

Drawing on a joint community-academic retrospective mRCC registry, we analyzed all patients who had undergone at least 1 line of systemic therapy (N = 325) for PFS. Patients were grouped according to treatment choice (sorafenib, sunitinib, temsirolimus, everolimus, and "other") for up to 3 lines of therapy. PFS by treatment choice and line of therapy was evaluated using Kaplan-Meier and Cox regression analyses.

RESULTS

PFS was longest in patients treated with sunitinib in the first and second lines of therapy. First-line PFS for sorafenib, sunitinib, temsirolimus, everolimus, and "other" was 6.9, 8.9, 4.2, not analyzed (too few patients), and 10.8 months, respectively. Second-line PFS was 4.6, 7.0, 3.2, 3.8, and 4.1 months, respectively. Third-line PFS was 4.5, 4.6, 9.9, 4.2, and 2.9, months, respectively. The risk of progression in patients treated with temsirolimus was about twice that of patients treated with sunitinib in the first and second lines of therapy.

CONCLUSION

Patients treated with sunitinib had the longest PFS in the first and second lines of therapy. PFS from practice-based data appear consistent with trial-based expectations; however, practice variation was still evident.

[Renal cell carcinoma]

Approximately 85% of all malignant tumors of the kidney are renal cell carcinomas (RCC). Sonography is the leading examination for early detection of kidney tumors. The treatment of RCC has been enriched in recent years by new therapeutic options for localized and metastatic cancer. The classification of RCC is based on TNM and UICC criteria. The so-called Motzer criteria are being increasingly employed to assess prognosis and monitor therapy and as the basis for reaching decisions on choosing the type of systemic treatment.

Castration-resistant prostate cancer: new science and therapeutic prospects

There is a growing number of new therapies targeting different pathways that will revolutionize patient management strategies in castration-resistant prostate cancer (CRPC) patients. Today there are more clinical trial options for CRPC treatment than ever before, and there are many promising agents in late-stage clinical testing. The hypothesis that CRPC frequently remains driven by a ligand-activated androgen receptor (AR) and that CRPC tissues exhibit substantial residual androgen levels despite gonadotropin-releasing hormone therapy, has led to the evaluation of new oral compounds such as abiraterone and MDV 3100. Their results, coupled with promising recent findings in immunotherapy (eg sipuleucel-T) and with agents targeting angiogenesis (while awaiting the final results of the CALGB trial 90401) will most probably impact the management of patients with CRPC in the near future. Other new promising agents need further development. With our increased understanding of the biology of this disease, further trial design should incorporate improved patient selection so that patient populations are those who may be most likely to benefit from treatment.

[Case report of kidney cancer from JOUM 2010]

Three clinical cases have shown the superiority of sunitinib in first line therapy intermediate risk metastatic clear cell renal carcinoma and a best safety of bevacizumab plus interferon, the current lack of high level of evidence arguments for the neo-adjuvant treatment of kidney cancer, the importance to prevent mucositis during a mTOR inhibitors treatment and the diagnostic pitfalls of its pulmonary complications.

Breaking through a plateau in renal cell carcinoma therapeutics: development and incorporation of biomarkers

With the Food and Drug Administration approval of 6 novel targeted agents since December 2005 and limited comparative trials to discern relative efficacy, the treatment of metastatic renal cell carcinoma (RCC) has become immensely complex. The research community must look to novel ways in which to identify appropriate candidates for selected targeted therapies; one potential strategy is the use of clinical and molecular biomarkers. A growing body of knowledge-related von Hippel Lindau-driven pathways in this disease has highlighted the potential role of hypoxia-inducible factor subtypes in distinguishing RCC patients clinically. Techniques applied in other malignancies, such as gene expression and proteomic profiling, may also ultimately allow for clinical stratification. An emerging understanding of immunologic phenomena that may affect cancer progression (i.e., tumor infiltration by CD68 lymphocytes, memory T-cells, etc.) has unveiled a number of other potential biomarkers of response. Several vascular endothelial growth factor receptor-directed therapies classically thought to function as antiangiogenics may also have complex effects upon the tumor microenvironment including the associated immune cell milieu. As such, immunologic parameters could potentially predict response to current therapies. Finally, clinical biomarkers, such as hypertension, may predict the efficacy of several currently available targeted agents, although implementation of such biomarkers remains challenging. Herein, the clinical relevance of putative RCC biomarkers is examined in detail.

Efficacy and safety of sunitinib on metastatic renal cell carcinoma: a single-institution experience

PURPOSE

We assessed the efficacy and safety of the tyrosine kinase inhibitor sunitinib in Korean patients with metastatic renal cell carcinoma (mRCC).

MATERIALS AND METHODS

Between September 2007 and December 2009, all twenty-one patients who had mRCC with a clear-cell component were retrospectively reviewed. Sunitinib was administered orally at a dose of 50 mg daily until disease progression or intolerance to treatment occurred. The primary end point of this study was the objective tumor response assessed by Response Evaluation Criteria in Solid Tumors (RECIST), and the secondary end points were progression-free survival (PFS) and overall survival (OS) rates as well as assessment of adverse effects.

RESULTS

After a median of 17.4 months (range, 5.7-33.1 months) of treatment, 11 patients (52.4%) had an objective response with a complete response in 1 patient (4.8%), and a partial response in 10 patients (47.6%) as the best tumor response. The median PFS was 13.4 months (95% confidence interval [CI], range, 12.3-14.5 months), and the median OS was 28.1 months (95% CI, 21.8-34.4 months). All patients experienced adverse events of some sort, but the studied treatment protocol was well tolerated and most patients experienced reversible grade 1 or 2 toxicities.

CONCLUSIONS

Sunitinib was efficacious in the treatment of metastatic clear-cell RCC, and was well tolerated in Korean patients. Although sunitinib treatment-related adverse events such as hand-foot syndrome and facial/generalized edema were observed with a higher incidence than in Western trials, they were mainly mild to moderate, and readily managed.

Bevacizumab as a treatment option in advanced renal cell carcinoma: an analysis and interpretation of clinical trial data

The availability of molecularly targeted agents has improved outcomes for patients with renal cell carcinoma (RCC), a disease long considered refractory to systemic therapy. The hypervascularity observed in RCC tumors, which is driven by the inactivation of the vonHippel-Lindau gene, provided a rationale for targeting angiogenesis, in particular vascular endothelial growth factor (VEGF). Bevacizumab, a potent and specific anti-VEGF monoclonal antibody, has demonstrated significant clinical benefits when used in combination with interferon-alfa (IFN-alpha) for the treatment of metastatic RCC in two randomized phase III trials. The use of bevacizumab with IFN-alpha received approval in Europe for the first-line treatment of patients with advanced or metastatic RCC, and more recently this combination was approved for use in patients with mRCC in the United States. Bevacizumab with IFN-alpha has also been recommended by the National Comprehensive Cancer Network for first-line therapy of relapsed or metastatic unresectable RCC with predominantly clear cell histology. Two phase II studies suggest that bevacizumab has single-agent activity, which is characterized by encouraging progression-free survival rates and evidence of tumor regressions in patients with advanced or metastatic RCC. Here we review these trials along with recent and ongoing studies that explore the combination of bevacizumab with other targeted agents, its optimal sequencing with tyrosine kinase inhibitors, and its combination with low-dose IFN-alpha. Collectively, these studies allow the role of bevacizumab-based therapy to be defined in the context of a new and evolving algorithm for the treatment of patients with advanced RCC.