Bone Metastases in Renal Cell Carcinoma: Impact of Immunotherapy on Survival

Background/Aim

We performed a multicenter retrospective observational study to investigate the impact of immune checkpoint inhibitors (ICIs) on the survival of patients with bone metastases (BMs) from renal cell cancer (RCC).

Patients and Methods

A total of 98 patients with metastatic RCC (mRCC) treated with ICIs were retrospectively enrolled. All patients received standard treatments with nivolumab alone or in combination with ipilimumab from December 2015 to March 2022. The primary endpoint was median overall survival (OS).

Results

Forty-three patients (44%) had radiological evidence of BMs. No statistically significant difference in OS was reported between the BM population and the entire population (p=0.254).

Conclusion

Our study suggests some degree of ICI activity to treat patients with BMs from RCC, historically associated with a poorer prognosis.

Robotic approach with neoadjuvant chemotherapy in adult Wilms' tumor: A feasibility study report and a systematic review of the literature

Objective

The incidence of Wilms' tumor (WT) among adult individuals accounts for less than 1% of kidney cancer cases, with a prognosis usually less favorable when compared to younger individuals and an overall survival rate of 70% for the adult patients versus 90% for the pediatric cases. The diagnosis and treatment of WT are complex in the preoperative setting; neoadjuvant chemotherapy (NAC) or robotic surgery has rarely been described. This study aimed to review the literature of robotic surgery in WT and report the first adult WT management using both NAC and robotic strategy.

Methods

We reported a case of WT managed in a multidisciplinary setting. Furthermore, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations, a systematic review of the literature until August 2020 of WT treated with a robotic approach was carried out.

Results

A 33-year-old female had a diagnosis of WT. She was scheduled to NAC, and according to the clinical and radiological response to a robotic radical nephrectomy with aortic lymph nodes dissection, she was managed with no intraoperative rupture, a favorable surgical outcome, and a follow-up of 25 months, which did not show any recurrence. The systematic review identified a total number of 230 cases of minimally invasive surgery reported in the literature for WT. Of these, approximately 15 patients were carried out using robotic surgery in adolescents while none in adults. Moreover, NAC has not been administered before minimally invasive surgery in adults up until now.

Conclusion

WT is a rare condition in adults with only a few cases treated with either NAC or minimally invasive approach so far. The advantage of NAC followed by the robotic approach could lead to favorable outcomes in this complex scenario. Notwithstanding, additional cases of adult WT need to be identified and investigated to improve the oncological outcome.

Immune checkpoint inhibitor-induced neurologic toxicity: a case report and literature review

Immune checkpoint inhibitors (ICIs) are approved for the treatment of head and neck carcinoma. They have significantly improved survival in these patients but may cause immune-related adverse events (irAEs), some of which may be serious. The report presents a rare case of a neurologic adverse event associated with programmed death-1 inhibitor monotherapy. Neurologic irAEs (NirAEs) can occur in various and atypical forms, be potentially disabling and occur at various times during and after treatment. Prompt identification and drug withdrawal are essential to improve outcomes. A high dose of systemic corticosteroid has been recommended for the management of NirAEs, although optimal immunomodulatory treatment is still debated.

Darolutamide in hormone-sensitive and castration-resistant prostate cancer

Introduction: Important changes in the treatment of prostate cancer have taken place in recent years. Non-metastatic castration-resistant prostate cancer (nmCRPC) has been clinically delineated. In this setting, three drugs have been approved in high-risk disease: apalutamide, enzalutamide and darolutamide.Areas covered:This manuscript aims to profile darolutamide, its clinical development, pharmacologic properties, efficacy and safety. We presented the results of published clinical studies, but we also investigated ongoing ones.Expert opinion: An indirect comparison with the other two aforementioned drugs emerged. While the clinical efficacy is comparable, the toxicity profile is different for darolutamide, resulting in greater tolerance. We must wait for the results of the trials that study darolutamide in hormone-sensitive disease, both in the metastatic phase and in the localized phase. Clinical experience will also be important to determine ever more personalized treatments for patients.

Active therapy or best supportive care after disease progression to both nivolumab and cabozantinib in metastatic renal cell carcinoma: The BEYOND study (Meet-Uro 19)

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Background: Nivolumab is approved in the second or further line of treatment for patients with metastatic renal cell carcinoma (mRCC); cabozantinib is approved in a similar setting of patients. Unfortunately, no evidence is currently available regarding the best treatment option after disease progression to both nivolumab and cabozantinib. The aim of this study is to compare the treatment choices after progression to nivolumab and cabozantinib including patients followed in best supportive care (BSC) or active therapy. Methods: In this retrospective observational study, we selected 42 patients from 8 Italian cancer centers. Enrolled patients had progressed to both nivolumab and cabozantinib and subsequently referred to active treatment or BSC. Primary endpoint of the study was the OS of patients on active treatment versus BSC. Secondary endpoints were ORR, PFS and OS of patients on active treatment who received sorafenib versus everolimus. Results: The median age was 65 years, 76.2% were male. The majority of patients had undergone nephrectomy (78.6%), had clear cell histology (83%) and were at intermediate-poor risk at the diagnosis (85.7%). The most frequent site of metastatic disease in the general population and in patients referred to BSC was the lung (73.8% and 88.9%, respectively). For patients referred to active treatment, the most frequent site of metastasis was bone (70.8%). Sunitinib (71.4%), nivolumab (64.3%), and cabozantinib (54.7%) were the most commonly used drugs in the I, II and III lines of treatment, respectively. After progression to both nivolumab and cabozantinib 42.9% of patients were referred to BSC, while 57.1% received active treatment (28.6% everolimus, 16.7% sorafenib, 4.8% sunitinib, 4.8% IL2-HD, 2.4% lenvatinib + everolimus). Median OS was 13 (95% CI: 4-NR) and 3 months (95% CI: 2-4) in patients on active treatment versus BSC ( p=0.001). Patients treated with sorafenib had better disease control when compared with those treated with everolimus (SD 71.4% versus 16.7%, PD 14.3% versus 58.3%; p=0.03), but no significant advantage in terms of PFS (5 versus 3 months, 95% CI: 2-6 versus 2-5; p= 0.5) and OS (NR versus 13 months, 95% CI: 3-NR versus 2-NR; p=0.2) was observed. Conclusions: After treatment with both nivolumab and cabozantinib, when possible, the choice of an active treatment seems to produce an OS advantage when compared with BSC. However, although sorafenib seems to demonstrate better results, we cannot indicate which is the drug of choice, as no significant advantage was shown in terms of OS or PFS from the comparison between sorafenib and everolimus. The limitations of this study are given by the size of the sample examined and its retrospective nature. Further studies are needed to confirm whether active treatment choice is associated with improved OS.

Clinical Outcomes and Safety of Patients Treated with NAb-Paclitaxel Plus Gemcitabine in Metastatic Pancreatic Cancer: The NAPA Study

BACKGROUND

The phase III MPACT trial demonstrated the superiority of gemcitabine (Gem) combined with Nab-paclitaxel (Nab-P) versus gemcitabine alone in previously untreated patients with metastatic pancreatic ductal adenocarcinoma (PDAC). The purpose of this study was to evaluate the effect of Gem/Nab-P in routine clinical practice.

METHODS

From January 2015 to December 2018, patients with metastatic PDAC receiving firstline treatment with a combination of gemcitabine and Nab-paclitaxel were included in a multicentre retrospective observational study. Exploratory analyses of efficacy, and prognostic and predictive markers, were performed.

RESULTS

The cohort comprised 115 patients (median age 65 [range 50-84] years) with good performance status (ECOG PS 0-1). The median overall survival (OS) was 11 months (95% CI; 9-13) and the median progression-free survival (PFS) was 6 months (95% CI 5-7). Partial response and stable disease were achieved in 44 and 30 patients, respectively, yielding an overall disease control rate (DCR) of 64.3%. Grade 3-4 hematological toxicity frequency was 22.61% for neutropenia, 5.22% for anemia, and 3.48% for thrombocytopenia. Grade 3 asthenia was recorded in 2.61% of patients. No grade 4 non-hematological events were reported. Dose reduction was necessary in 51.3% of the patients.

CONCLUSION

Our results confirm the efficacy and safety of a first-line regimen comprising gemcitabine and Nab-paclitaxel in metastatic PDAC in a real-life population.

Immune Checkpoint Inhibitors in the Treatment of Renal Cancer: Current State and Future Perspective

Systemic treatment of renal cancer (RCC) has undergone remarkable changes over the past 20 years with the introduction of immunotherapeutic agents targeting programmed cell death (PD-1)/programmed death-ligand 1 (PD-L1) axis, as a single-agent or combined with anti-CTLA-4 monoclonal antibodies (MoAbs) or a multi-target vascular endothelial growth factor-(VEGF) tyrosine kinase inhibitor (TKI). In this paper, we review the main evidence on the use of Immune Checkpoint Inhibitors (ICIs) for RCC treatment from the first demonstration of activity of a nivolumab single agent in a phase I trial to the novel combination strategies (anti-PD-1 plus anti-CTLA4 or anti-PD-1 plus TKI). In addition, we discuss the use of anti-PD-1/PD-L1 agents in patients with non-clear cells and rare histological subtype RCC. Then, we critically examine the current findings in biomarkers that have been proposed to be prognostic or predictive to the response of immunotherapy including immune gene expression signature, B7-H1 expression, PBRM1 loss of function, PD-L1 expression, frame shift indel count, mutations in bromodomain-containing genes in patients with MiT family translocation RCC (tRCC), high expression of the T-effector gene signature, and a high myeloid inflammation gene expression pattern. To date, a single biomarker as a predictor of response has not been established. Since the dynamic behavior of the immune response and the different impact of ICI treatment on patients with specific RCC subtypes, the integration of multiple biomarkers and further validation in clinical trials are needed.

Impact of metastases directed radiation therapy on CDK4/6 inhibitors dose reduction and treatment discontinuation for metastatic HR+/HER2- breast cancer (MBC)

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Background: Cyclin-Dependent Kinase 4/6 inhibitors (CDK4/6i) represent the standard I-II line for hormonal receptors positive/human epidermal growth factor receptor 2 negative metastatic breast cancer (MBC) patients. Metastases directed radiotherapy (RT) for these patients is commonly used with palliative or radical schedules during systemic treatment. Although encouraging preliminary results were published, there is still a lack of robust data on the safety concerning RT during CDK4/6i treatment. Methods: we analyzed at Our Institution 85 consecutive patients treated in I (n=47) and II line (n=38) for MBC with CDK4/6i between April 2017 and September 2019 (22 ribociclib, 63 palbociclib). Overall, 25 (29.4%) patients received metastases directed RT during CDK4/6i treatment, including 14 concomitant (16.5%) and 11 sequential (12.9%). Estimated CDK4/6i half-life is 26 and 30 hours for palbociclib and ribociclib, respectively. Five half-lives are required to reduce drug concentration by 95-97%; thus, we also analyzed CDK4/6i treatment as non-concomitant or sequential to RT. Main endpoints of our analysis were impact of RT on CDK4/6i dose reduction and discontinuation, overall adverse events rate (any grade and grade ≥2), and neutropenia grade ≥2 as per CTCAE scale version 5.0. Results: at a median follow up of 12 months (range 3-29), we observed a CDK4/6i dose reduction in 35 patients (41.2%) and 5 patients (5.9%) discontinued treatment due to adverse events; 82 patients (96.5%) experienced any grade of toxicity, 72 (84.7%) a grade ≥2 and 70 patients (82.4%) neutropenia grade ≥2. We did not observe significant difference in terms of CDK4/6i dose reduction or discontinuation, any grade or grade ≥2 toxicity, neutropenia grade ≥2 in the comparison between patients receiving RT versus no RT and between patients receiving concomitant RT versus sequential RT versus no-RT (Table). Conclusions: our results showed that the prescription of a metastases directed RT during treatment with a CDK4/6i as I-II line for MBC did not significantly impact on dose reduction or discontinuation caused by an exceeding in adverse event rate. Although these promising results, caution should be used and cooperative initiatives strongly encouraged. [Table: see text]