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Zarba M, Fujiwara R, Yuasa T, Koga F, Heng DYC, Takemura K. Multidisciplinary systemic and local therapies for metastatic renal cell carcinoma: a narrative review. Expert Rev Anticancer Ther 2024:1-11. [PMID: 38813778 DOI: 10.1080/14737140.2024.2362192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 05/28/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Systemic and local therapies for patients with metastatic renal cell carcinoma (mRCC) are often challenging despite the evolution of multimodal cancer therapies in the last decade. In this review, we will focus on recent multidisciplinary approaches for patients with mRCC. AREAS COVERED Systemic therapies for patients with mRCC have been garnering attention particularly after the approval of immuno-oncology (IO) agents, including anti-programmed death 1/programmed death-ligand 1. IO combinations have significantly prolonged overall survival in patients with mRCC in the first-line setting. Regarding local therapies, cytoreductive nephrectomy (CN) has become less common in the post-Cancer du Rein Metastatique Nephrectomie et Antiangiogéniques (CARMENA) trial era, even though CN may still benefit selected patients with mRCC. In addition, metastasis-directed local therapies, namely metastasectomy or stereotactic radiotherapy, particularly for oligo-metastatic lesions or brain metastases, may have a prognostic impact. Several ablative techniques are also evolving while maintaining high local control rates with acceptable safety. EXPERT OPINION Multimodal cancer therapies are essential for conquering complex cases of mRCC. Modern systemic therapies including IO-based combination therapy as well as local therapies including CN, metastasectomy, stereotactic radiotherapy, and ablative techniques appear to improve oncologic outcomes of patients with mRCC, although appropriate patient selection is indispensable.
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Affiliation(s)
- Martin Zarba
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Canada
| | - Ryo Fujiwara
- Department of Genitourinary Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Yuasa
- Department of Genitourinary Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Daniel Y C Heng
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Canada
| | - Kosuke Takemura
- Department of Genitourinary Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Green H, Taylor A, Khoo V. Beyond the Knife in Renal Cell Carcinoma: A Systematic Review-To Ablate or Not to Ablate? Cancers (Basel) 2023; 15:3455. [PMID: 37444565 DOI: 10.3390/cancers15133455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Intensified systemic therapy in metastatic renal cell carcinoma (mRCC) has led to improved patient outcomes. Patients commonly require local control of one or a few metastases. The aim was to evaluate metastasis-directed ablative therapies in extracranial mRCC. Two databases and one registry were searched, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, for all prospective and matched-pair case-control mRCC studies of radiofrequency ablation (RFA), cryotherapy, microwave ablation (MWA), and stereotactic body radiotherapy (SBRT). Eighteen studies were identified. Fourteen investigated SBRT in 424 patients. Four thermal ablation studies were identified: two cryotherapy (56 patients) and two RFA studies (90 patients). The median participant number was 30 (range 12-69). The combined median follow-up was 17.3 months (range 8-52). Four SBRT studies reported local control (LC) at 12 months, median 84.4% (range 82.5-93). Seven studies (six SBRT and one cryotherapy) reported an LC rate of median 87% (79-100%). Median overall survival (OS) was reported in eight studies (five SBRT, two cryotherapy, and one RFA) with a median of 22.7 months (range 6.7-not reached). Median progression-free survival was reported in seven studies (five SBRT, one cryotherapy, and one RFA); the median was 9.3 months (range 3.0-22.7 months). Grade ≥ 3 toxicity ranged from 1.7% to 10%. SBRT has excellent local control outcomes and acceptable toxicity. Only four eligible thermal ablative studies were identified and could not be compared with SBRT. Translationally rich definitive studies are warranted.
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Affiliation(s)
- Harshani Green
- Royal Marsden Hospitals NHS Foundation Trust, London SW3 6JJ, UK
- Institute of Cancer Research, London SW7 3RP, UK
| | - Alexandra Taylor
- Royal Marsden Hospitals NHS Foundation Trust, London SW3 6JJ, UK
- Institute of Cancer Research, London SW7 3RP, UK
| | - Vincent Khoo
- Royal Marsden Hospitals NHS Foundation Trust, London SW3 6JJ, UK
- Institute of Cancer Research, London SW7 3RP, UK
- Department of Medical Imaging and Radiation Science, Monash University, Clayton, VIC 3800, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC 3010, Australia
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Xian F, Wu J, Zhong L, Xu G. Efficacy and safety of PD1/PDL1 inhibitors combined with radiotherapy and anti-angiogenic therapy for solid tumors: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e33204. [PMID: 36897735 PMCID: PMC9997836 DOI: 10.1097/md.0000000000033204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/15/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND The triple combination of programmed cell death 1 (PD1)/programmed cell death ligand 1 (PDL1) inhibitors, radiotherapy (RT), and anti-angiogenesis agents has been widely used in the treatment of solid tumors and has shown positive efficacy. We conducted a meta-analysis to evaluate the efficacy and safety of PD1/PDL1 inhibitors combined with anti-angiogenic agents and RT for the treatment of solid cancers. METHODS A systematic search of PubMed, Embase, Cochrane Library, and Web of Science databases was conducted from inception to October 31, 2022. Studies involving patients with solid cancers who received PD1/PDL1 inhibitors combined with RT and anti-angiogenic agents treatment that reported overall response rate, complete remission rate, disease control rate, and adverse events (AEs) were included. A random-effects or fixed-effects model was used for the pooled rates, and 95% confidence intervals (CIs) were determined for all outcomes. The quality of the included literature was assessed using the methodological index for nonrandomized studies critical appraisal checklist. Egger test was used to assess the publication bias in the included studies. RESULTS Ten studies (4 nonrandomized controlled trials and 6 single-arm trials), including 365 patients, were identified and included in the meta-analysis. The pooled overall response rate after treatment with PD1/PDL1 inhibitors combined with RT and anti-angiogenic agents was 59% (95% CI: 48-70%), whereas the disease control rate and complete remission rate were 92% (95% CI: 81-103%) and 48% (95% CI: 35-61%), respectively. Moreover, the meta-analysis showed that compared with triple-regimen, monotherapy or dual-combination treatment did not improve overall survival (hazard ratio = 0.499, 95% CI: 0.399-0.734) and progression-free survival (hazard ratio = 0.522, 95% CI: 0.352-0.774). The pooled rate of grade 3 to 4 AEs was 26.9% (95% CI: 7.8%-45.9), and the common AEs to triple therapy included leukopenia (25%), thrombocytopenia (23.8%), fatigue (23.2%), gastrointestinal discomfort (22%), increased alanine aminotransferase (22%), and neutropenia (21.4%). CONCLUSION In the treatment of solid tumors, PD1/PDL1 inhibitors combined with RT and anti-angiogenic drugs achieved a positive response and better survival benefits than monotherapy or dual therapy. In addition, combination therapy is tolerable and safe. REGISTRATION PROSPERO ID: CRD42022371433.
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Affiliation(s)
- Feng Xian
- Department of Oncology, Nanchong Central Hospital, The Second Clinical Institute of North Sichuan Medical College, Nanchong, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jing Wu
- Department of Operations Management, Nanchong Central Hospital, The Second Clinical Institute of North Sichuan Medical College, Nanchong, China
| | - Liming Zhong
- Department of Operations Management, Nanchong Central Hospital, The Second Clinical Institute of North Sichuan Medical College, Nanchong, China
| | - Guohui Xu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Stereotactic Body Radiotherapy for Kidney Cancer: Ready for Prime Time? Clin Oncol (R Coll Radiol) 2023; 35:163-176. [PMID: 36443137 DOI: 10.1016/j.clon.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
The standard treatment for renal cell carcinoma (RCC) is surgery. However, a number of patients will not be candidates for surgical treatment or will reject this therapeutic approach. Therefore, alternative approaches are required. Historically, radiotherapy has been considered an ineffective treatment for RCC due to the radioresistance of renal tumour cells to conventional fractionation and the increased rate of toxicity. Stereotactic body radiotherapy (SBRT) is a radiotherapy technique that provides a non-invasive ablative treatment with remarkable rates of local control in both primary tumours and metastases in several locations, with a low associated morbidity due to the highly conformal dose and the use of image-guided techniques. Current evidence shows that a higher dose per fraction, achieving a higher biological effective dose, can overcome the radioresistance of RCC cells. Therefore, SBRT, as well as the combination of SBRT and new emerging immune therapies, has a potential role in the local treatment of primary RCC and oligometastatic RCC patients.
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Sosa-Fajardo P, Blanco-Suarez JM, Pineda-Munguía Á, Rubí-Olea L, Peleteiro-Higuero P, Gajate P, Zafra-Martín J, Siva S, Bossi A, López-Campos F, Couñago F. Stereotactic body radiation therapy for kidney cancer. Where do we stand? Int J Urol 2023; 30:437-445. [PMID: 36746747 DOI: 10.1111/iju.15156] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/12/2023] [Indexed: 02/08/2023]
Abstract
At present, surgery is still the gold standard for the local treatment of renal cancer. Nonetheless, in several clinical scenarios, stereotactic body radiation therapy (SBRT) also known as stereotactic ablative body radiotherapy (SABR) is emerging as a highly effective ablative technique in fragile patients and those with significant comorbidities, as well as in cases where percutaneous therapy (cryoablation or radiofrequency) is not viable. However, considering the intrinsic radioresistance of renal tumors, the optimal treatment schemes have not been established. In oligometastatic patients, it has been reported that the control of the oligometastases can be a potentially curable approach. Being a technique than can be administered exclusively or in combination with systemic therapy, treatment individualization based on patient characteristics is key. Another scenario under investigation is oligoprogression, where SBRT offers the possibility of delaying further lines of systemic therapy by eliminating subclones of resistant tumor with ablative doses, with the additional opportunity of stimulating the immune system (immunomodulatory role). In this review, we have conducted an analysis of recently published studies that test the role of this technique in different clinical scenarios of this disease. We have found promising results that make SBRT a potent therapeutic approach with low toxicity. We also comment on ongoing studies that will generate the necessary evidence needed for the implementation of this technique in our daily clinical practice.
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Affiliation(s)
- Paloma Sosa-Fajardo
- Department of Radiation Oncology, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), University Hospital Virgen del Rocio, Universidad de Sevilla, Sevilla, Spain
| | - Jesús M Blanco-Suarez
- Department of Radiation Oncology, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), University Hospital Virgen del Rocio, Universidad de Sevilla, Sevilla, Spain
| | | | - Luz Rubí-Olea
- Radiation Oncology Department, University Regional Hospital, Málaga, Spain
| | - Paula Peleteiro-Higuero
- Radiation Oncology Department, University Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Pablo Gajate
- Medical Oncology Department, Ramon y Cajal Hospital, IRYCIS, Madrid, Spain
| | - Juan Zafra-Martín
- Group of Translational Research in Cancer Immunotherapy, Health and Medical Research Centre (CIMES), Institute of Biomedical Research in Malaga (IBIMA), University of Malaga (UMA), Malaga, Spain.,Department of Radiation Oncology, Virgen de la Victoria University Hospital, Malaga, Spain.,Faculty of Medicine, University of Malaga (UMA), Malaga, Spain
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Alberto Bossi
- Department of Radiation Oncology, University Hospitals Gasthuisberg, Leuven, Belgium
| | | | - Felipe Couñago
- Radiation Oncology Department, GenesisCare Madrid Clinical Director, San Francisco de Asis and La Milagrosa Hospitals, National Chair of Research and Clinical Trials, GenesisCare, Madrid, Spain
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Le Guevelou J, Sargos P, Siva S, Ploussard G, Ost P, Gillessen S, Zilli T. The Emerging Role of Extracranial Stereotactic Ablative Radiotherapy for Metastatic Renal Cell Carcinoma: A Systematic Review. Eur Urol Focus 2023; 9:114-124. [PMID: 36151031 DOI: 10.1016/j.euf.2022.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/12/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022]
Abstract
CONTEXT Although the management of metastatic renal cell carcinoma (mRCC) has been revolutionized by the advent of new systemic agents, still few patients experience a long-term durable response. Stereotactic ablative radiotherapy (SABR) is nowadays commonly used as metastasis-directed therapy (MDT), but limited data exist on how best to implement this strategy as part of a multimodal approach. OBJECTIVE To evaluate the potential role of extracranial SABR in mRCC and to identify future therapeutic developments of SABR in different disease settings. EVIDENCE ACQUISITION A systematic review was conducted in May 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement on the PubMed database. Thirty-four studies were selected for inclusion in this systematic review. EVIDENCE SYNTHESIS SABR has been used with four main goals: (1) eradication of the whole metastatic burden in synchronous and metachronous oligometastatic patients, resulting in a long-term local control (LC) rate of >90% and median progression-free survival (PFS) ranging between 8 and 15 mo; (2) eradication of oligoprogressive lesions, enabling an extension of the duration of the systemic therapy by approximately 9 mo; (3) improvement of the response to systemic therapy in polymetastatic patients, resulting in an overall response rate ranging from 17% to 56%; and (4) cytoreduction in polymetastatic mRCC patients, with LC rates ranging between 71% and 100%, and preservation of the renal function, but unclear PFS and overall survival impact. Overall, the combination of SABR and systemic agents has been associated with overall good tolerance, with grade ≥3 toxicity ranging from 0% to 13%. CONCLUSIONS Current data highlight the role of SABR as an emerging MDT treatment option in both oligometastatic and oligoprogressive extracranial mRCC, able to ensure long-term disease control and delay the use of next-line systemic therapies. The use of SABR for cytoreduction in the de novo metastatic disease and as an immunological booster in the polymetastatic setting remains investigational and warrants further investigations. PATIENT SUMMARY Radiotherapy delivered with ablative doses (>6 Gy per fraction) is a promising treatment strategy for patients diagnosed with metastatic renal cell carcinoma. Excellent outcome results have been observed in patients with a limited number of metastases, improving metastasis-free survival by several months. For patients with a few metastases progressing under systemic therapy, radiotherapy allows an extension of the duration of the ongoing therapy by several months.
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Affiliation(s)
- Jennifer Le Guevelou
- Department of Radiation Oncology, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia; Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France; Institut Universitaire du Cancer Oncopole, Toulouse, France
| | - Piet Ost
- Iridium Network, Radiation Oncology, Antwerp, Belgium; Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Thomas Zilli
- Department of Radiation Oncology, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland; Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland.
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Rizzo M, Porta C. Concurrent Stereotactic Ablative Radiotherapy and Antiangiogenic Targeted Agents: Redefining the Therapeutic Strategy. Eur Urol Oncol 2022; 6:212-213. [PMID: 36522250 DOI: 10.1016/j.euo.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022]
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Ali M, Mooi J, Lawrentschuk N, McKay RR, Hannan R, Lo SS, Hall WA, Siva S. The Role of Stereotactic Ablative Body Radiotherapy in Renal Cell Carcinoma. Eur Urol 2022; 82:613-622. [PMID: 35843777 DOI: 10.1016/j.eururo.2022.06.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/12/2022] [Accepted: 06/21/2022] [Indexed: 01/07/2023]
Abstract
CONTEXT Stereotactic ablative body radiotherapy (SABR) is an emerging treatment modality for primary and metastatic renal cell carcinoma (RCC). OBJECTIVE To review and summarise the evidence on the use of SABR in RCC in a narrative review. EVIDENCE ACQUISITION We performed an online search of the PubMed database from January 2000 through December 2021. Studies of SABR/stereotactic radiosurgery (SRS) targeting primary, extracranial, or intracranial metastatic RCC were included. EVIDENCE SYNTHESIS Two meta-analyses (including 54 studies), and 13 prospective and 20 retrospective studies were included in this review. In aggregate, SABR for 589 primary RCCs in 575 patients resulted in a local control rate of above 90% with grade 3-4 toxicity of 0-9%. Similarly, the local control rate ranged between 90% and 97% with SRS in 1225 patients with intracranial metastatic RCC. SABR was able to delay systemic therapy for at least 1 yr in 70-90% of oligometastatic RCC patients with grade 3-4 toxicity of <10%. As per the early data, the combination of SABR with systemic therapy for metastatic RCC, such as targeted therapy or immunotherapy, appears safe, feasible, and tolerable. CONCLUSIONS We outlined data supporting SABR in the key clinical scenarios of primary and metastatic, including oligometastatic, RCC in lieu of systemic therapy, in combination with systemic therapy, and palliation of brain and spinal metastases. PATIENT SUMMARY Stereotactic ablative body radiotherapy (SABR) is a relatively new treatment option in kidney cancer. Here, we review the published literature on the experience of using SABR in kidney cancer. The accumulated evidence demonstrates that SABR can be used safely and effectively to treat selected cases of primary or secondary kidney cancer.
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Affiliation(s)
- Muhammad Ali
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.
| | - Jennifer Mooi
- Department of Medical Oncology, Northern Health, Melbourne, Victoria, Australia
| | - Nathan Lawrentschuk
- Department of Urology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgery, Peter MacCallum cancer Centre, Melbourne, Victoria, Australia; Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Raquibul Hannan
- Department of Radiation Oncology, UT Southwestern Medical Centre, Dallas, TX, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, WI, USA
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
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