HORMONES AND THE KIDNEY: POSSIBLE THERAPEUTIC ROLE OF TESTOSTERONE IN A PATIENT WITH REGRESSION OF METASTASES FROM RENAL ADENOCARCINOMA

Randomized Phase II Study Comparing Thalidomide With Medroxyprogesterone Acetate in Patients With Metastatic Renal Cell Carcinoma

Purpose

To investigate escalating doses of thalidomide compared with medroxyprogesterone in patients with metastatic renal cell carcinoma (RCC), who had either progressed after first-line immunotherapy or who were not suitable for immunotherapy.

Patients and Methods

Thalidomide was started at 100 mg/d orally (PO) and escalated by 100 mg/d every 2 weeks to the maximum dose of 400 mg/d. Medroxyprogesterone was given at a fixed dose of 300 mg PO daily.

Results

Sixty patients were entered (thalidomide:medroxyprogesterone = 29:31; median age, 59 [thalidomide], 60 [medroxyprogesterone]; No. of patients assessable for response, 22 [thalidomide], 26 [medroxyprogesterone]). In the thalidomide arm, there was no objective response seen. The best response was SD in three patients lasting 5+, 6+, and 12 months, respectively. All patients in the medroxyprogesterone arm progressed. There was no difference in overall survival between the two arms; median survival in the thalidomide arm was 8.2 months compared with 4.8 months in the medroxyprogesterone arm (P = .62). Hazard ratio was 0.88 (95% CI, 0.67 to 1.94). Median duration of treatment was 73 days (range, 14 to 364 days) in the thalidomide arm, and 84 days (range, 7 to 175 days) in the medroxyprogesterone arm. The high incidence of toxicity in the thalidomide arm, mainly somnolence, constipation, fatigue and paraesthesia, meant that only 30.8% of patients were able to tolerate the maximum dose of 400 mg/d of treatment.

Conclusion

Thalidomide is not superior to medroxyprogesterone acetate in patients with metastatic RCC. Its risk/benefit ratio does not favor its use in this patient population.

Hormonal therapy for metastatic renal cell carcinoma combined androgen and provera followed by high dose tamoxifen

The purpose of this phase II study was to determine the effectiveness of hormonal therapy with combined high dose androgen and provera or tamoxifen in patients with advanced renal cell carcinoma. 30 patients with metastatic renal cell carcinoma received testosterone propionate 100 mg intramuscularly (i.m.) 5 times weekly plus provera 400 mg (i.m.) twice weekly until disease progression developed. 20 patients, most of whom had previously failed to respond to androgen and provera, received tamoxifen 100 mg/m2 daily. Of the 30 patients treated with androgen and provera, 3 (10%) developed partial responses of brief duration. 2 of 20 patients (10%) experienced tumour response with tamoxifen, one instance of complete disappearance of pulmonary metastases in a patient whose primary tumour was questionably persistent at post mortem and another case demonstrating disease stability. Combined hormonal therapy offers very little therapeutic advantage in advanced renal cell carcinoma. Tamoxifen, in high dose, exerts anti-tumour effects in a small cohort of cases.

Update in cancer chemotherapy: genitourinary tract cancer, Part 1

An update of the state of the art of cancer chemotherapeutic treatment of genitourinary tract cancer is described in this multi-part series. Included in the review are cancers of the kidney, bladder, prostate, testicle, ovary, uterus, vulva, and gestational trophoblastic neoplasms. Part 1 focuses on the kidney.In this heterogeneous group of tumors, the major triumphs of cancer chemotherapy are in the control of the less common of these tumors, namely, gestational trophoblastic neoplasms in women, in combination with surgery in the control of the embryonal cell cancer of the testis in men, and in combination with surgery and radiation therapy in the control of the Wilms' tumor in children. Important progress is being made in the control of the other tumors of the genitourinary tract with the use of cancer chemotherapy.

Steroid hormone receptors in normal and malignant human renal tissue: relationship with progestin therapy

Documented hormone dependence of renal tumors in animal models, hypothetical hormonal environment of human kidney neoplasms and their controversial response to endocrine therapy prompted us to undertake a prospective multicentric cooperative study to evaluate the hormone-dependence/responsiveness of renal tumors. Patients with renal carcinoma were stratified according to the TNM classification and after nephrectomy were treated with high-dose medroxyprogesterone acetate (MPA). Specimens of tumor and healthy surrounding kidney tissue were studied for titration of steroid receptor proteins (78 for androgen, AR, 89 for estrogen, ER, and progestin, PgR). Their true receptor nature was estimated. Very low titers (on an average less than 10 fmol/mg protein) were found, especially for ER and PgR in neoplastic samples. Occurrence rate of AR was low for both tissues (less than 20%), whereas ER and PgR were detected at a higher frequency in healthy parenchyma than in tumor tissue (42.2 vs 23.3% and 30.7 vs 11.2%, respectively). AR was moderately affected by metastatic status of the disease and by sex. All three steroid receptors were simultaneously detected in normal tissue in 11.7% of cases and in tumor tissue in only 3.8%. No significant correlation between receptor status in the tumor and clinical response to hormone therapy was found. In 27 cases who received adjuvant MPA therapy, relapses were respectively 43.8 and 18.2% in the patients with negative receptors or with at least one detectable receptor. In metastatic renal carcinoma, stabilization of the disease with MPA was achieved more frequently in receptor-negative patients. Therefore, we conclude that the receptor assay is not a valid tool to select renal carcinoma patients for therapy with MPA.

Follow-up of patients after nephrectomy for renal cell carcinoma

Follow-up of patients after nephrectomy for renal cell carcinoma is often inadequate. The sooner secondary lesions are identified and treated the better. Routine annual admission of these patients is urged for abdominal angiography, bone scan, chest roentgenograms, and specialized diagnostic procedures as indicated.

Chemotherapy of advanced renal cell carcinoma with vinblastine and CCNU

Forty-four patients with advanced renal cell carcinoma (stage IV) were divided into 3 groups. The 23 patients in group 1 received CCNU alone,the 6 patients in group 2 received CCNU and vinblastine and the 15 patients in group 3 received methyl CCNU and vinblastine. The over-all response, subjective and objective, was 30% in group 1, 60% in group 2 and 54% in group 3. These results are compared to other existing modalities of treatment and appear to be superior.

Medroxyprogesterone acetate (Provera) in the treatment of metastatic renal cancer

Eighty patients with advanced metastatic renal cancer have been treated with hormones, chiefly medroxyprogesterone acetate (Provera). This progestational compound is remarkably free from side-effects and can be given in high dosage for long periods without serious complications. Ninety per cent of cases had multiple metastases: in 76% more than one organ was involved and nearly 50% were seriously ill or "terminal".Subjective improvement occurred in at least 55%. In 11 patients there was marked improvement in the radiological or clinical signs of tumour within 2 to 6 weeks of commencing treatment or changing to a different hormone. In two further cases improved general health was associated with stationary metastases for 20 months. A significant objective response occurred in 16% of the total series. A favourable response was seen more often in men (21%) than in women (8%). If deaths within 6 weeks are excluded the objective response rate in men is increased to 27%. Although the response of advanced renal cancer to hormonal treatment is usually incomplete and of brief duration, it is possible for such treatment to offer a "new lease of life" to a seriously ill patient, even in old age, for 2 to 3 years.

The use of progestogen in the treatment of metastatic carcinoma of the kidney and uterine body

The effect of the progestogen medroxyprogesterone acetate on metastases from renal, endometrial and other tumours has been studied in 25 patients. Seven patients with renal and endometrial tumours had a useful response, pulmonary metastases and a large primary renal tumour showing the greatest effect. Bony metastases were unaffected by the drug and were treated by local radiotherapy. If a response occurred, it did so within 3 months.