Simultaneous Tumor Shrinkage and Bronchial Perforation Induced by Nivolumab plus Cabozantinib Combination Therapy in a Patient with Collecting Duct Carcinoma

Vascular endothelial growth factor receptor tyrosine kinase inhibitors are known to cause perforation as one of their severe side effects, and postoperative and postradiation therapy are known risk factors. However, there are few studies on perforation following tumor shrinkage. A 78-year-old woman with postoperative recurring left collecting duct carcinoma of the right hilar lymph nodes and mediastinum underwent eight courses of nivolumab plus cabozantinib, resulting in tumor shrinkage. Three days after the last administration, she developed fever and cough and was hospitalized for right lobar pneumonia. The patient received long-term antibiotics for bronchial fistula with the destruction of the bronchial wall and secondary lung abscess. When using nivolumab plus cabozantinib combination therapy for a tumor with bronchial invasion, physicians should be aware of bronchial perforation as the tumor shrinks.

Renal Cell Carcinoma of Variant Histology: Biology and Therapies

The term variant histology renal cell carcinomas (vhRCCs), also known as non-clear cell RCCs, refers to a diverse group of malignancies with distinct biologic and therapeutic considerations. The management of vhRCC subtypes is often based on extrapolating results from the more common clear cell RCC studies or basket trials that are not specific to each histology. The unique management of each vhRCC subtype necessitates accurate pathologic diagnosis and dedicated research efforts. Herein, we discuss tailored recommendations for each vhRCC histology informed by ongoing research and clinical experience.

Collecting duct carcinoma with retroperitoneal mass as initial presentation: a rare case report

BACKGROUND

Collecting duct carcinoma (CDC) is a rare renal tumor, originating from the distal collecting duct. CDC rarely presents as a primary tumor outside the renal system.

CASE PRESENTATION

In this study, we report a rare case of collecting duct carcinoma, with an initial presentation of retroperitoneal lymph node metastasis, and no identifiable primary renal tumor on CT, at the time of diagnosis. The patient was a 64-year-old man presenting with lower back pain. Preoperative CT showed a round, soft tissue mass, measuring 6.7 × 4.4 × 3.3 cm, in the left retroperitoneum with no exact occupying lesion in the left kidney. Clinically, ectopic pheochromocytoma was considered to be a differential diagnosis, and tumor resection was performed. Postoperative pathological results demonstrated that the mass was a fused lymph node, and the tumor cells were destroying the structure. The final diagnosis was lymph node metastatic collecting duct carcinoma, by histology and immunohistochemistry. No further treatment was performed as no space occupying lesion was found in the kidney. Three months later, CT was reexamined, and a mass of 3.6 cm in diameter, was found in the lower left kidney, along with multiple soft tissue masses, in the left renal hilum. Considering recurrence or metastasis, the patient was recommended to undergo surgical treatment, but the patient refused. Four months later, CT was re-examined. The tumor had rapidly progressed but the patient refused treatment again. As per the author's press release (eleven months after the first discovery), the patient is still alive.

CONCLUSION

CDC is a rare malignant renal carcinoma, with a high chance of rapid progress, regional lymph nodes involvement and metastasis. It presents diagnostic challenges to clinicians and pathologists, particularly, in the absence of radiographically detectable intrarenal lesions. Definite diagnosis is based on pathological examination combined with immunohistochemical staining.

Gemcitabine plus platinum-based chemotherapy in combination with bevacizumab for kidney metastatic collecting duct and medullary carcinomas: Results of a prospective phase II trial (BEVABEL-GETUG/AFU24)

BACKGROUND

Renal medullary carcinoma (RMC) and collecting duct carcinoma (CDC) are rare entities with a poor outcome. First-line metastatic treatment is based on gemcitabine + platinum chemotherapy (GC) regimen but retrospective data suggest enhanced anti-tumour activity with the addition of bevacizumab. Therefore, we performed a prospective assessment of the safety and efficacy of GC + bevacizumab in metastatic RMC/CDC.

METHODS

We conducted a phase 2 open-label trial in 18 centres in France in patients with metastatic RMC/CDC and no prior systemic treatment. Patients received bevacizumab plus GC up to 6 cycles followed, for non-progressive disease, by maintenance therapy with bevacizumab until progression or unacceptable toxicity. The co-primary end-points were objective response rates (ORRs) and progression-free survival (PFS) at 6 months (ORR-6; PFS-6). PFS, overall survival (OS) and safety were secondary end-points. At interim analysis, the trial was closed due to toxicity and lack of efficacy.

RESULTS

From 2015 to 2019, 34 of the 41 planned patients have been enroled. After a median follow-up of 25 months, ORR-6 and PFS-6 were 29.4% and 47.1%, respectively. Median OS was 11.1 months (95% confidence interval [CI]: 7.6-24.2). Seven patients (20.6%) discontinued bevacizumab because of toxicities (hypertension, proteinuria, colonic perforation). Grade 3-4 toxicities were reported in 82% patients, the most common being haematologic toxicities and hypertension. Two patients experienced grade 5 toxicity (subdural haematoma related to bevacizumab and encephalopathy of unknown origin).

CONCLUSION

Our study showed no benefit for bevacizumab added to chemotherapy in metastatic RMC and CDC with higher than expected toxicity. Consequently, GC regimen remains a therapeutic option for RMC/CDC patients.

[Collecting duct carcinoma and renal medullary carcinoma in the age of new therapies]

Collecting duct carcinoma (also known as Bellini tumour) and renal medullary carcinoma are two extremely rare and aggressive renal cancers. They are both less responsive to conventional treatments used in clear cell renal carcinoma. There are very few studies evaluating their optimal management and currently, at the metastatic stage, polychemotherapy based on platinum salts remains the most widely used. The emergence of new treatments such as anti-angiogenic TKIs, immunotherapy or treatments targeting specific genetic abnormalities, opens up a new field of possibilities in the management of these cancers. The evaluation of the response to these treatments is therefore essential. In this article, we will review the status of their management and the various studies that have evaluated recent treatments in these two cancers.

Collecting duct carcinoma: Epidemiology, clinical characteristics and survival

INTRODUCTION

Collecting duct carcinoma (CDC) is a rare renal malignancy. We relied on a large population-based cohort to address epidemiology, clinical characteristics, and treatment of CDC patients. We also tested survival in the overall cohort, as well as in stage-specific fashion.

MATERIALS AND METHODS

Within Surveillance, Epidemiology, and End Results (2004-2018) database, we identified 399 CDC patients. Based on Kaplan-Meier plots survival estimates, conditional survival rates were derived according to disease stage. Cox regression models tested for predictors of cancer specific mortality (CSM).

RESULTS

Overall, 273 (68.4%) patients were male, 236 (59.2%) had T3-4 stages, 148 (37.1%) had lymph node invasion, and 156 (39.1%) had distant metastases at initial diagnosis. Nephrectomy alone was commonest in stage I-II (n = 91/99, 92%) and III (n = 94/116, 81%). Combination of both nephrectomy and systemic therapy was commonest in stage IV (n = 62/172, 36%). In the overall cohort, median cancer specific survival was 18 months. Provided a disease-free interval of 24 months, five-year Kaplan-Meier estimated survival at diagnosis increased from 74.2 to 91.0% in stage I-II, from 31.1 to 65.3% in stage III, and from 6.3 to 34.1% in stage IV. In multivariable Cox regression models addressing CSM, systemic therapy (Hazard Ratio [HR]: 0.47, P = 0.020), nephrectomy (HR: 0.37, P < 0.001) and combination of both (HR: 0.28, P < 0.001) exhibited a strong protective effect.

CONCLUSION

Despite its highly aggressive phenotype and dismal survival, CDC is sensitive to nephrectomy and/or systemic therapy. Moreover, even for advanced stage, a more favorable prognosis can be achieved in patients, who benefit of disease-free interval after diagnosis and initial treatment.

"Collecting duct carcinoma of the kidney: diagnosis and implications for management"

Collecting duct carcinoma of the kidney is a rare and aggressive subtype of renal cell carcinoma (RCC) arising from the distal convoluted tubules. At the time of diagnosis, patients are more frequently symptomatic, with advanced locoregional stage, and have metastatic disease. The 2016 WHO Classification of Tumours of the Urinary System defined diagnostic criteria for this entity. However, the diagnostic features continue to evolve, with typical, but not entirely specific, histologic and immunophenotypic characteristics. In addition, the lack of consistent molecular alterations makes collecting duct carcinoma a diagnosis of exclusion, with historical cases being re-classified as fumarate hydratase deficient RCC, ALK rearranged RCC, renal medullary carcinoma or high-grade urothelial carcinoma. The rarity and poor prognosis of the tumor makes it difficult to reach consensus guidelines to guide therapy. In this manuscript we review the clinicopathologic features of collecting duct carcinoma including pathologic diagnostic criteria, molecular characteristics and differential diagnosis, and their possible implications for management.

An update on the pathology of collecting duct & papillary renal cell carcinoma with a discussion of SNP-Arrays as an emerging laboratory technique

The diagnostic criteria and management of renal cell carcinoma (RCC) has evolved significantly in the last two decades. Increased molecular profiling of RCC has yielded further refinement of existing diagnostic categories. This is particularly true for papillary RCC, which has evolved into multiple molecularly distinct entities. Collecting duct carcinoma, on the other hand, continues to be defined based on traditional histology-based criteria, although it is now possible to exclude various categories of tumors that share overlapping morphologic features. In this context, it is important to note that pathology laboratories have varying degrees of access to complex molecular technologies required to profile tumors in routine clinical practice. Single nucleotide polymorphism (SNP) based copy number profiling represents one modality of testing which is becoming widely available and is being increasingly utilized to profile renal tumors. In this special Seminars issue, we explore the evolution of Collecting Duct & Papillary RCC as diagnostic entities, with a detailed discussion of SNP array-based copy number profiling in contemporary clinical practice.

[Collecting duct carcinoma]

Collecting duct carcinoma (Bellini duct carcinoma) is a very rare disease with poor prognosis. Primary tumor surgery is not advisable, even though it is the therapy of choice for suspected malignant space-occupying renal masses. Chemotherapy seems to be inferior to new therapeutic concepts based on single case reports. Immunotherapy with nivolumab and axitinib and additive radiotherapy significantly prolongs survival. At the same time, targeted therapy with cabozantinib seems promising. However, due to the short median survival and the side effects of these therapies, a purely supportive approach should be discussed. It should be decided with the patient whether a systemic therapy should be started or whether a palliative, supportive therapy concept offers more quality of life.

Complete response to combination therapy using nivolumab and ipilimumab for metastatic, sarcomatoid collecting duct carcinoma presenting with high expression of programmed death-ligand 1: a case report

BACKGROUND

Collecting duct carcinoma and sarcomatoid renal cell carcinoma are tumors with poor prognosis. Immune checkpoint inhibitors have been established as the standard treatment for advanced renal cell carcinoma. Some cases of remission of collecting duct carcinoma and sarcomatoid renal cell carcinoma have been reported using immune checkpoint inhibitor interventions. Specifically, sarcomatoid renal cell carcinoma expresses high levels of programmed death-ligand 1, an immune checkpoint protein, and immune checkpoint inhibitors have been reported to be highly effective for treating sarcomatoid renal cell carcinoma.

CASE PRESENTATION

We describe the case of a 70-year-old Japanese male who underwent radical right nephrectomy for a right renal mass identified on computed tomography. The pathological examination demonstrated that the renal mass was urothelial carcinoma and collecting duct carcinoma with sarcomatoid changes, and programmed death-ligand 1 was highly expressed with a tumor proportion score of more than 10%. There was no evident submucosal connective tissue invasion in the urothelial carcinoma component, and collecting duct carcinoma was diagnosed as primary cancer. The tumor-node-metastasis classification was pT3aN0, venous invasion 1, lymphovascular invasion 0, and Fuhrman nuclear grade 4. Two months after the nephrectomy, multiple metastases were observed in both lungs, the right hilar lymph node, and the S6 segment of the right liver lobe. We initiated first-line combination therapy with nivolumab (240 mg, fixed dose) and ipilimumab (1 mg/kg). One day after administration, the patient developed drug-induced interstitial pneumonia, thus we applied steroid injections. After one administration of immunotherapy, the metastatic lesion showed complete response within 6 months, which was maintained after 3 years.

CONCLUSION

We report the first case of complete response to a single dose of combination therapy with nivolumab and ipilimumab for metastatic collecting duct carcinoma with sarcomatoid changes and high expression of programmed death-ligand 1. This case suggests high expectations for immune checkpoint inhibitors as treatment for sarcomatoid-transformed renal carcinoma tumors that express high levels of programmed death-ligand 1.

A rare curative case of collecting duct carcinoma

Collecting duct carcinoma (CDC) is a rare form of renal carcinoma that has a poor prognosis. To date, there has been no report that the survival time of a patient with metastatic CDC could be more than six years. We present a case of rapidly advanced recurrence of CDC after nephrectomy that completely responded surgical intervention followed by targeted therapy with sorafenib and nivolumab.

A genomic mutation spectrum of collecting duct carcinoma in the Chinese population

BACKGROUND

Renal collecting duct carcinoma (CDC) is a rare and lethal subtype of renal cell carcinoma (RCC). The genomic profile of the Chinese population with CDC remains unclear. In addition, clinical treatments are contradictory. In this study, we aimed to identify the genomic mutation spectrum of CDC in the Chinese population.

METHODS

Whole-exome sequencing was performed using the Illumina Novaseq™ 6000 platform. MuTect2 detects single-nucleotide variants (SNVs) and small scale insertions/deletions (INDELs). The identified mutations were annotated with ANNOVAR and validated by Sanger sequencing. Control-FREEC was used to detect copy number variation (CNV), and GISTIC was applied to detect frequently mutated altered regions. These data were compared with associated The Cancer Genome Atlas cohorts.

RESULTS

Ten normal-matched CDC patients were included. The mean tumour mutation burden was 1.37 Mut/Mb. Six new recurrent somatic mutated genes were identified, including RBM14, MTUS1, GAK, DST, RNF213 and XIRP2 (20% and 2 of 10, respectively), and validated by Sanger sequencing. In terms of common mutated genes, SETD2 was altered in both CDC and other RCC subtypes but not in bladder urothelial carcinoma (BLCA); CDKN2A was a driver gene in both CDC (SNV: 10%, 1 of 10) and BLCA but not in other RCC subtypes. Next, 29 amplifications and 6 deletions of recurrent focal somatic CNVs were identified by GISTIC2.0, which displayed differences from kidney renal clear cell carcinoma (KIRC), kidney renal papillary cell carcinoma (KIRP) and BLCA cohorts. Of note, CDKN2A (CNV alteration: 30%, 3 of 10) and CDKN2A-AS1 were the only overlapping genes of these four cohorts. Importantly, the CDKN2A mutation in our cohort differed from previous studies in urinary carcinomas. Moreover, CDKN2A-altered cases had significantly worse overall survival than wild-type cases in both KIRC and KIRP cohorts. In addition, the most frequently altered genomic pathway of our CDC cohort was the CDKN2A-mediated p53/RB1 pathway.

CONCLUSIONS

Our study offers the first genomic spectrum of the Chinese population with CDC, which differs from that of the Western population. The altered CDKN2A-mediated p53/RB1 pathway might provide new insight into potential therapeutic targets for CDC patients.

Collecting duct carcinoma: A single-institution retrospective study

PURPOSE

Collecting duct carcinoma is a rare pathologic entity with a paucity of clinical data in the literature. We aim to evaluate our institutional experience with the management of this disease.

MATERIALS AND METHODS

All renal tumors in the Mayo Clinic Nephrectomy Registry were re-reviewed retrospectively by an expert urologic pathologist. Cases of collecting duct carcinoma were identified. Descriptive statistics were used to characterize these cases. Overall survival and metastases-free survival were estimated using Kaplan-Meier methodology.

RESULTS

Between 1970 and 2018, a total of 21 cases were identified with an incidence of 0.2%. Cases were seen predominantly in men (N = 17, 81%) with a median age at diagnosis of 57 years old. At the time of nephrectomy, high grade disease (grade 3 or 4) was noted in the majority of patients (90%). The median times to local recurrence and distant metastases were 5.6 and 5.1 months, respectively. Median overall survival occurred at 1.5 years. Median distant metastases-free survival among M0 patients occurred at 0.5 years. Four patients with localized disease and small tumor size who underwent nephrectomy lived longer than 10 years. No systemic therapies achieved a durable response in the metastatic setting.

CONCLUSION

The Mayo Clinic nephrectomy registry contains 21 patients with collecting duct carcinoma over nearly 50 years. Early local recurrence and distant metastases were seen after nephrectomy. However, M0 patients with a small tumor may have long-term benefits from nephrectomy. Neither chemotherapy nor targeted therapy resulted in a durable response in the metastatic setting.

Systemic Therapies for the Management of Non-Clear Cell Renal Cell Carcinoma: What Works, What Doesn't, and What the Future Holds

Non-clear cell renal cell carcinoma (nccRCC) is a broad term that refers to a diverse group of tumors, each with its own distinct biologic and therapeutic profile. The management of nccRCCs is often based on extrapolating data from clinical trials in the more common clear cell renal cell carcinoma, but our emerging prospective and retrospective clinical experience in nccRCC allows us to make more precise recommendations tailored to each histology. The systemic therapy options for metastatic nccRCC include targeted therapies such as tyrosine kinase inhibitors, immune checkpoint inhibitors, and, for specific rare subtypes, cytotoxic chemotherapy. Each nccRCC histology may respond differently to these regimens, which makes accurate pathologic diagnosis imperative. In the present review, we discuss the available clinical and biological data that can help guide systemic therapy recommendations for specific nccRCC subtypes.

Hereditary leiomyomatosis and renal cell carcinoma syndrome-associated renal cell carcinoma: Morphological appraisal with a comprehensive review of differential diagnoses

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is an autosomal dominant syndrome wherein affected individuals are at risk for the development of cutaneous leiomyomas, early-onset multiple uterine leiomyomas, and an aggressive subtype of renal cell cancer. HLRCC is caused by germline mutations in the fumarate hydratase (FH) gene, which inactivates the enzyme and alters the function of the tricarboxylic acid/Krebs cycle. This article reviews the hitherto described morphologic features of HLRCC-associated renal cell carcinoma (RCC) and outlines the differential diagnosis and ancillary use of immunohistochemistry and molecular diagnostics for these tumors. The morphologic spectrum of HLRCC-associated RCC is wide and histologic features, including tumor cells with prominent nucleoli, perinucleolar halos, and multiple architectural patterns within the same tumor, which are suggestive of this diagnosis. FH immunohistochemistry in conjunction with genetic counseling and germline FH testing are the important parameters for detection of this entity. These kidney tumors warrant prompt treatment as even smaller sized lesions can demonstrate aggressive behavior and systemic oncologic treatment in metastatic disease should, if possible, be part of a clinical trial. Screening procedures in HLRCC families should preferably be evaluated in large cohorts.

Collecting duct carcinoma and endemic nephropathy - case reportS and literature review

Although collecting duct carcinoma is a subtype of renal cell carcinoma, several studies implicate association with urothelial carcinoma. The coexistence of collecting duct carcinoma and another renal neoplasm is rare. Endemic nephropathy is a renal disease causing chronic renal failure. It is highly associated with urothelial neoplasm and occurs in endemic villages in Bosnia, Croatia, Bulgaria, Romania and Serbia. Recent studies have confirmed the important role of exposure to aristolochic acid as an etiologic factor. We present three cases of collecting duct carcinoma with literature overview. In one case, we describe collecting duct carcinoma with metachronous urothelial carcinoma of the pyelon and urinary bladder in an endemic nephropathy patient. To our knowledge, this is the first case report describing this coexistence. Certain similarities between collecting duct carcinoma and urothelial carcinoma were found, e.g., higher incidence in female compared to male, higher mean age, and multifocal and multicentric occurrence of the tumor. Our observations support the hypothesis that collecting duct carcinoma and urothelial carcinoma could be connected.

A rare case of collecting duct carcinoma with first presentation of respiratory symptoms

We are reporting a rare case of collecting duct carcinoma in a 45years old male who was seeking for medical treatment of his persistent cough, dyspnea and weight loss. Chest x-ray revealed multiple focal opacities. Axial Contrast enhanced CT scan for the abdomen and pelvis showed right renal upper pole mass and D11 vertebral sclerotic metastasis. A core tissue biopsy for histopathology and immunohistochemistry was provisionally diagnosed as a clear cell carcinoma, however further immunohistochemical studies and histopathology consultation confirmed a Non-clear cell carcinoma, collecting duct carcinoma, that opens eyes on establishing earlier and accurate diagnosis of this rare tumor.

A Case of Metastatic Collecting Duct Carcinoma Whose Massive Skull Bone Metastasis was Prominently Reossified by Gemcitabine Plus Cisplatin Chemotherapy Combined with Zoledronic Acid

The present case underwent right laparoscopic radical nephrectomy for collecting duct carcinoma (CDC). Recurrence occurred in the lung and the bone (skull and lumber vertebra) in 2011. Gemcitabine plus cisplatin (GC) chemotherapy and monthly zoledronic acid (ZA) was then started. The massive skull bone metastases were prominently reossified after several courses of the therapy. The patient received 16 courses of GC chemotherapy and monthly ZA, and pulmonary metastases and reossified skull bone metastases were stable for 23 months. Although we cannot verify the adoptive effect of ZA on the reossification, this combination may be effective for CDC bone metastases.

Collecting duct carcinoma of the kidney: Disease characteristics and treatment outcomes from the National Cancer Database

OBJECTIVE

To use a large population-level database to assess survival outcomes for collecting duct renal cell carcinoma (CDRCC).

MATERIALS AND METHODS

The National Cancer Database was queried for all cases of CDRCC and clear cell renal cell carcinoma (CCRCC) from 2004 to 2013. After removing patients with other cancer diagnoses, the analytic cohort was composed of 201,686 CCRCC and 577 CDRCC cases. Kaplan-Meier and cox proportional hazards analysis were employed to model survival.

RESULTS

Compared to CCRCC, patients with CDRCC presented with higher grade and stage, node positive, and metastatic disease (70.7% vs. 30.0% with metastasis; P<0.001). Overall median survival for CDRCC was 13.2 months (95% CI: 11.0-15.5) compared to the 122.5 months (95% CI: 121.0-123.9) for CCRCC. On multivariate analysis of the CDRCC cohort, increasing T stage, high-grade disease, and metastasis were predictors of mortality. Of 184 patients with metastatic CDRCC, 113 underwent cytoreductive nephrectomy (CNx) whereas the rest were treated with chemo/radiation or observed. Survival outcomes were improved in patients who received both CNx with chemo/radiation compared to CNx alone (hazard ratio = 0.51, 95% CI: 0.32-0.79) or chemo/radiation alone (hazard ratio = 0.57, 95% CI: 0.37-0.89) on multivariate analysis.

CONCLUSION

CDRCC is an aggressive subtype of renal cell carcinoma. Median survival is 13 months after diagnosis, drastically lower than for CCRCC. More than 70% of patients have metastatic disease at diagnosis. Chemo/radiation in addition to CNx is associated with a survival benefit over single mode therapy.

Collecting Duct Carcinoma With Cardiac Metastases: A Case Report & Literature Review

Collecting duct carcinoma (CDC), is a rare and aggressive form of renal cell carcinoma (RCC) accounting for around 1% of all renal malignancy. It affects younger patients and is associated with rapid progression, distant spread and poor prognosis. Cardiac metastases from all types of RCC, without involvement of the inferior vena cava are very rare. We present the case of a 54 year old man with a history of CDC, who presents with collapse and ventricular tachycardia secondary to multifocal cardiac metastases. We are not aware of any other reports in the literature of CDC and cardiac metastases.

Distal nephron neoplasms

Tumours of the distal nephron are uncommon but can create diagnostic difficulties. They may be divided into three groups-tumours of intercalated cell phenotype, those of principal cell phenotype and others with an unconfirmed distal nephron origin. Oncocytomas, chromophobe carcinoma and hybrid oncocytoma chromophobe carcinoma, all show features of intercalated cells and the distinction amongst these is one of the most common areas of diagnostic dilemma. Collecting duct carcinoma and renal medullary carcinoma are the most aggressive forms of renal cancer but recent evidence suggests they may respond to targeted therapy so their recognition becomes crucial to the management of these patients. There remains debate over the precise phenotype of both tubulocystic carcinoma and mucinous tubular and spindle cell carcinoma.

Management of renal collecting duct carcinoma: a systematic review and the McMaster experience

INTRODUCTION

Collecting duct carcinoma (cdc) is a rare, aggressive form of renal carcinoma that presents at an advanced stage and has a poor prognosis. Little is known concerning the optimal management of cdc. We present the results of a systematic review addressing the management of cdc and the McMaster University cdc series.

METHODS

The medline, Cochrane Library, and embase databases and conference proceedings were searched to identify studies relating to the management of cdc. Included studies reported on a minimum of 10 subjects receiving a single intervention. Series in which an evaluation of therapeutic effectiveness was not possible were excluded. The McMaster University (Hamilton, Ontario) series of 6 cases of cdc were retrospectively reviewed.

RESULTS

We identified 3 studies relevant to the management of cdc that included a total of 72 patients. A gemcitabine-cisplatin or -carboplatin regimen resulted in a 26% objective response rate in 23 patients with metastatic cdc. Two additional studies indicated that 49 patients treated with immunotherapy achieved no response. In the McMaster series, cytoreductive nephrectomy was performed in 4 of 6 patients. In 2 patients, mvac therapy (methotrexate-vinblastine-doxorubicin-cisplatin) achieved no response. No significant therapeutic complications occurred, but survival was poor (median: 11 months; range: 10-33 months).

CONCLUSIONS

Our review and clinical experience suggest that the current standard of care for metastatic cdc is a gemcitabine-cisplatin regimen.