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Dahm P, Ergun O, Uhlig A, Bellut L, Risk MC, Lyon JA, Kunath F. Cytoreductive nephrectomy in metastatic renal cell carcinoma. Cochrane Database Syst Rev 2024; 6:CD013773. [PMID: 38847285 PMCID: PMC11157663 DOI: 10.1002/14651858.cd013773.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Abstract
BACKGROUND Nephrectomy is the surgical removal of all or part of a kidney. When the aim of nephrectomy is to reduce tumor burden in people with established metastatic disease, the procedure is called cytoreductive nephrectomy (CN). CN is typically combined with systemic anticancer therapy (SACT). SACT can be initiated before or immediately after the operation or deferred until radiological signs of disease progression. The benefits and harms of CN are controversial. OBJECTIVES To assess the effects of cytoreductive nephrectomy combined with systemic anticancer therapy versus systemic anticancer therapy alone or watchful waiting in newly diagnosed metastatic renal cell carcinoma. SEARCH METHODS We performed a comprehensive search in the Cochrane Library, MEDLINE, Embase, Scopus, two trial registries, and other gray literature sources up to 1 March 2024. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated SACT and CN versus SACT alone or watchful waiting. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. Primary outcomes were time to death from any cause and quality of life. Secondary outcomes were time to disease progression, treatment response, treatment-related mortality, discontinuation due to adverse events, and serious adverse events. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS Our search identified 10 records of four unique RCTs that informed two comparisons. In this abstract, we focus on the results for the two primary outcomes. Cytoreductive nephrectomy plus systemic anticancer therapy versus systemic anticancer therapy alone Three RCTs informed this comparison. Due to the considerable heterogeneity when pooling across these studies, we decided to present the results of the prespecified subgroup analysis by type of systemic agent. Cytoreductive nephrectomy plus interferon immunotherapy versus interferon immunotherapy alone CN plus interferon immunotherapy compared with interferon immunotherapy alone probably increases time to death from any cause (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.51 to 0.89; I²= 0%; 2 studies, 326 participants; moderate-certainty evidence). Assuming 820 all-cause deaths at two years' follow-up per 1000 people who receive interferon immunotherapy alone, the effect estimate corresponds to 132 fewer all-cause deaths (237 fewer to 37 fewer) per 1000 people who receive CN plus interferon immunotherapy. We found no evidence to assess quality of life. Cytoreductive nephrectomy plus tyrosine kinase inhibitor therapy versus tyrosine kinase inhibitor therapy alone We are very uncertain about the effect of CN plus tyrosine kinase inhibitor (TKI) therapy compared with TKI therapy alone on time to death from any cause (HR 1.11, 95% CI 0.90 to 1.37; 1 study, 450 participants; very low-certainty evidence). Assuming 574 all-cause deaths at two years' follow-up per 1000 people who receive TKI therapy alone, the effect estimate corresponds to 38 more all-cause deaths (38 fewer to 115 more) per 1000 people who receive CN plus TKI therapy. We found no evidence to assess quality of life. Immediate cytoreductive nephrectomy versus deferred cytoreductive nephrectomy One study evaluated CN followed by TKI therapy (immediate CN) versus three cycles of TKI therapy followed by CN (deferred CN). Immediate CN compared with deferred CN may decrease time to death from any cause (HR 1.63, 95% CI 1.05 to 2.53; 1 study, 99 participants; low-certainty evidence). Assuming 620 all-cause deaths at two years' follow-up per 1000 people who receive deferred CN, the effect estimate corresponds to 173 more all-cause deaths (18 more to 294 more) per 1000 people who receive immediate CN. We found no evidence to assess quality of life. AUTHORS' CONCLUSIONS CN plus SACT in the form of interferon immunotherapy versus SACT in the form of interferon immunotherapy alone probably increases time to death from any cause. However, we are very uncertain about the effect of CN plus SACT in the form of TKI therapy versus SACT in the form of TKI therapy alone on time to death from any cause. Immediate CN versus deferred CN may decrease time to death from any cause. We found no quality of life data for any of these three comparisons. We also found no evidence to inform any other comparisons, in particular those involving newer immunotherapy agents (programmed death receptor 1 [PD-1]/programmed death ligand 1 [PD-L1] immune checkpoint inhibitors), which have become the backbone of SACT for metastatic renal cell carcinoma. There is an urgent need for RCTs that explore the role of CN in the context of contemporary forms of systemic immunotherapy.
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Affiliation(s)
- Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Onuralp Ergun
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Annemarie Uhlig
- Department of Urology, University Medical Center, Goettingen, Germany
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
| | - Laura Bellut
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Michael C Risk
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Jennifer A Lyon
- Library Services, Children's Mercy Hospital, Kansas City, Missouri, USA
- Center for Evidence-Based Policy, Portland, Oregon, USA
| | - Frank Kunath
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Medizinische Fakultät am Medizincampus Oberfranken, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Urology and Pediatric Urology, Klinikum Bayreuth GmbH, Bayreuth, Germany
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2
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Welsh SJ, Thompson N, Warren A, Priest AN, Barrett T, Ursprung S, Gallagher FA, Zaccagna F, Stewart GD, Fife KM, Matakidou A, Machin AJ, Qian W, Ingleson V, Mullin J, Riddick ACP, Armitage JN, Connolly S, Eisen TGQ. Dynamic biomarker and imaging changes from a phase II study of pre- and post-surgical sunitinib. BJU Int 2022; 130:244-253. [PMID: 34549873 DOI: 10.1111/bju.15600] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore translational biological and imaging biomarkers for sunitinib treatment before and after debulking nephrectomy in the NeoSun (European Union Drug Regulating Authorities Clinical Trials Database [EudraCT] number: 2005-004502-82) single-centre, single-arm, single-agent, Phase II trial. PATIENTS AND METHODS Treatment-naïve patients with metastatic renal cell carcinoma (mRCC) received 50 mg once daily sunitinib for 12 days pre-surgically, then post-surgery on 4 week-on, 2 week-off, repeating 6-week cycles until disease progression in a single arm phase II trial. Structural and dynamic contrast-enhanced magnet resonance imaging (DCE-MRI) and research blood sampling were performed at baseline and after 12 days. Computed tomography imaging was performed at baseline and post-surgery then every two cycles. The primary endpoint was objective response rate (Response Evaluation Criteria In Solid Tumors [RECIST]) excluding the resected kidney. Secondary endpoints included changes in DCE-MRI of the tumour following pre-surgery sunitinib, overall survival (OS), progression-free survival (PFS), response duration, surgical morbidity/mortality, and toxicity. Translational and imaging endpoints were exploratory. RESULTS A total of 14 patients received pre-surgery sunitinib, 71% (10/14) took the planned 12 doses. All underwent nephrectomy, and 13 recommenced sunitinib postoperatively. In all, 58.3% (seven of 12) of patients achieved partial or complete response (PR or CR) (95% confidence interval 27.7-84.8%). The median OS was 33.7 months and median PFS was 15.7 months. Amongst those achieving a PR or CR, the median response duration was 8.7 months. No unexpected surgical complications, sunitinib-related toxicities, or surgical delays occurred. Within the translational endpoints, pre-surgical sunitinib significantly increased necrosis, and reduced cluster of differentiation-31 (CD31), Ki67, circulating vascular endothelial growth factor-C (VEGF-C), and transfer constant (KTrans , measured using DCE-MRI; all P < 0.05). There was a trend for improved OS in patients with high baseline plasma VEGF-C expression (P = 0.02). Reduction in radiological tumour volume after pre-surgical sunitinib correlated with high percentage of solid tumour components at baseline (Spearman's coefficient ρ = 0.69, P = 0.02). Conversely, the percentage tumour volume reduction correlated with lower baseline percentage necrosis (coefficient = -0.51, P = 0.03). CONCLUSION Neoadjuvant studies such as the NeoSun can safely and effectively explore translational biological and imaging endpoints.
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Affiliation(s)
- Sarah J Welsh
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
| | - Nicola Thompson
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anne Warren
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew N Priest
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Tristan Barrett
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Stephan Ursprung
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Ferdia A Gallagher
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Fulvio Zaccagna
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
| | - Kate M Fife
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
| | - Athena Matakidou
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
- GlaxoSmithKline, Brentford, UK
| | - Andrea J Machin
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wendi Qian
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Victoria Ingleson
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jean Mullin
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antony C P Riddick
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
| | - James N Armitage
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
| | - Stephen Connolly
- Department of Urology, Mater Misericordiae University Hospital, University College Dublin, Dublin 7, Ireland
| | - Timothy G Q Eisen
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cancer Research UK Cambridge Centre Urological Malignancies Programme, University of Cambridge, Cambridge, UK
- Roche, Welwyn Garden City, UK
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Haque K, McNew M, Flowers A, Bhargava P, Sangster G, Chu Q. Metastatic renal cell carcinoma presenting as subcutaneous nodule. Radiol Case Rep 2022; 17:1973-1976. [PMID: 35432677 PMCID: PMC9010887 DOI: 10.1016/j.radcr.2022.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/13/2022] [Indexed: 11/19/2022] Open
Abstract
Renal cell carcinoma is frequently undiagnosed until it reaches an advanced metastatic stage. Renal cell cancers are also seen as incidental findings on imaging, and rarely can present as physical examination findings. We report a rare case where metastatic renal cell carcinoma presented as a solitary 2 cm subcutaneous chest wall nodule in an otherwise asymptomatic male patient. Initial ultrasound evaluation showed a solid vascular subcutaneous mass, a fine needle aspiration suggested metastatic renal cell cancer, and later, excision biopsy, and CT scan of the abdomen made the final diagnosis of stage IV renal cell carcinoma. The differential diagnosis of a 2 cm nodule can be broad and in appropriate clinical setting should include consideration of malignancy and/ metastasis.
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Affiliation(s)
- Kabiul Haque
- Department of Family Medicine, Louisiana State University, Shreveport, LA, 71103
| | - Margaret McNew
- Department of Family Medicine, Louisiana State University, Shreveport, LA, 71103
| | - Ashley Flowers
- Departments of Radiology, Louisiana State University, Shreveport, LA, 71103, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Peeyush Bhargava
- Departments of Radiology, Louisiana State University, Shreveport, LA, 71103, University of Texas Medical Branch, Galveston, TX 77555, USA
- Corresponding author
| | - Guillermo Sangster
- Departments of Radiology, Louisiana State University, Shreveport, LA, 71103, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Quyen Chu
- Departments of Radiology, Louisiana State University, Shreveport, LA, 71103, University of Texas Medical Branch, Galveston, TX 77555, USA
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Abstract
Kidney cancer accounts for 2% of cancer related deaths. Historically, a patient with a solid renal mass would undergo surgery without biopsy given the previously low diagnostic yield of biopsy and the fear of tumor seeding. This led to a high rate of resection for benign masses. With the rising incidence of renal masses discovered on imaging, improvements in biopsy technique and advancements in pathologic evaluation of biopsy samples of renal masses, renal mass biopsy now plays an important role in selected patients with renal masses. Coaxial core needle biopsy is the preferred technique with a low rate of complications and a high diagnostic yield. This article will discuss indications, methods, utility, limitations and complications of renal mass biopsy.
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Affiliation(s)
- Keith B Quencer
- Department of Radiology, University of Utah, Salt Lake City, UT.
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Hartl DM, Guerlain J, Bresuskin I, Baudin E, Lamartina L, Hadoux J, Leboulleux S, Schlumberger M. Surgery in the context of kinase inhibitor therapy for locally invasive thyroid cancer. Eur J Surg Oncol 2019; 46:650-655. [PMID: 31582321 DOI: 10.1016/j.ejso.2019.09.184] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023] Open
Abstract
Kinase inhibitors (KI) for advanced and aggressive forms of differentiated, medullary and anaplastic thyroid carcinoma have been shown to provide significant tumor response, locally and in distant metastases. Their use, however, may also increase the risk for local complications such as fistula formation and bleeding, and head and neck surgeons may be solicited to palliatively remove potentially dangerous lesions before initiating these systemic treatments. During KI therapy for progressive metastatic and/or locally invasive disease, surgery may be urgently necessary to secure the airway or for symptomatic neck lesions. Finally, there are more and more reports of surgery following KI therapy that suggest a new neoadjuvant paradigm for extensive lesions. In this review, we aim to discuss the literature regarding surgery before, during and after KI therapy in the context of progressive metastatic and/or locally invasive thyroid cancer.
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Affiliation(s)
- Dana M Hartl
- Department of Head and Neck Oncology, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France.
| | - Joanne Guerlain
- Department of Head and Neck Oncology, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France
| | - Ingrid Bresuskin
- Department of Head and Neck Oncology, Thyroid Surgery Unit, Gustave Roussy, Villejuif, France
| | - Eric Baudin
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
| | - Livia Lamartina
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
| | - Julien Hadoux
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
| | - Sophie Leboulleux
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
| | - Martin Schlumberger
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and Paris Saclay University, Villejuif, France
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6
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Yamamoto Y, Otori T, Inoue R, Yano S, Hirata H, Matsumoto H, Matsuyama K, Matsuyama H. Pharmacokinetics of Neoadjuvant Axitinib Influenced the Efficacy in Patients With Advanced Renal Cell Carcinoma. J Clin Pharmacol 2019; 60:256-263. [PMID: 31538342 DOI: 10.1002/jcph.1521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/16/2019] [Indexed: 12/23/2022]
Abstract
Although axitinib shows a good objective response rate and acceptable tolerability for advanced renal cell carcinoma, substantial differences in drug concentrations among individuals have hampered the reliable administration of the drug in a neoadjuvant setting. This study aimed to evaluate the relationship between axitinib pharmacokinetics and clinical efficacy in patients with advanced renal cell carcinoma treated in a neoadjuvant setting. We retrospectively reviewed 16 patients who underwent neoadjuvant axitinib treatment from prospective phase 2 study cohorts treated with axitinib and assessed whether the drug concentration was associated with clinical efficacy for primary tumors of advanced metastatic/oligometastatic clear cell renal cell carcinoma. Axitinib was administered orally at a starting dose of 5 mg twice daily for 2 months in principle before the operation, and the axitinib pharmacokinetics were examined. Best response, reduction rate, adverse events (AEs), and surgical complication were assessed. Four patients (25.0%) showed a partial response, and 12 (75.0%) had stable disease, with a mean reduction rate of 22.8%. No progressive disease was noted, and 9 of the 16 patinets (56.3%) showed downstaging. The trough level of axitinib significantly correlated with the objective response rate (P = .0052) and best tumor reduction (P = .0128). All AEs could be safely managed until termination of the dosing period. With respect to perioperative complications, grade 2 anemia was observed. Neoadjuvant axitinib treatment showed acceptable antitumor activity and safety profile for advanced renal cell carcinoma. The pharmacokinetics of neoadjuvant axitinib influenced the efficacy in patients with advanced renal cell carcinoma.
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Affiliation(s)
- Yoshiaki Yamamoto
- Department of Urology, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Toru Otori
- Faculty of Pharmacy, Kindai University, Higashiosaka, Osaka, Japan
| | - Ryo Inoue
- Department of Urology, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Seiji Yano
- Department of Urology, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Hiroshi Hirata
- Department of Urology, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Hiroaki Matsumoto
- Department of Urology, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Kenji Matsuyama
- Faculty of Pharmacy, Daiichi College of Pharmaceutical Sciences, Fukuoka, Fukuoka, Japan
| | - Hideyasu Matsuyama
- Department of Urology, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
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Tschirdewahn S, Panic A, Püllen L, Harke NN, Hadaschik B, Riesz P, Horváth A, Szalontai J, Nyirády P, Baba HA, Reis H, Szarvas T. Circulating and tissue IMP3 levels are correlated with poor survival in renal cell carcinoma. Int J Cancer 2019; 145:531-539. [PMID: 30650187 DOI: 10.1002/ijc.32124] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/19/2018] [Indexed: 11/12/2022]
Affiliation(s)
- Stephan Tschirdewahn
- Department of Urology, West German Cancer CenterUniversity of Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Andrej Panic
- Department of Urology, West German Cancer CenterUniversity of Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Lukas Püllen
- Department of Urology, West German Cancer CenterUniversity of Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Nina N. Harke
- Department of Urology, West German Cancer CenterUniversity of Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Boris Hadaschik
- Department of Urology, West German Cancer CenterUniversity of Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Peter Riesz
- Department of UrologySemmelweis University Budapest Hungary
| | - Andras Horváth
- Department of UrologySemmelweis University Budapest Hungary
| | | | - Peter Nyirády
- Department of UrologySemmelweis University Budapest Hungary
| | - Hideo A. Baba
- Institute of Pathology, West German Cancer CenterUniversity of Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Henning Reis
- Institute of Pathology, West German Cancer CenterUniversity of Duisburg‐Essen, University Hospital Essen Essen Germany
| | - Tibor Szarvas
- Department of Urology, West German Cancer CenterUniversity of Duisburg‐Essen, University Hospital Essen Essen Germany
- Department of UrologySemmelweis University Budapest Hungary
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