NCCN Guidelines® Insights: Kidney Cancer, Version 2.2024

The NCCN Guidelines for Kidney Cancer provide multidisciplinary recommendations for diagnostic workup, staging, and treatment of patients with renal cell carcinoma (RCC). These NCCN Guidelines Insights focus on the systemic therapy options for patients with advanced RCC and summarize the new clinical data evaluated by the NCCN panel for the recommended therapies in Version 2.2024 of the NCCN Guidelines for Kidney Cancer.

Kidney Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Kidney Cancer focus on the screening, diagnosis, staging, treatment, and management of renal cell carcinoma (RCC). Patients with relapsed or stage IV RCC typically undergo surgery and/or receive systemic therapy. Tumor histology and risk stratification of patients is important in therapy selection. The NCCN Guidelines for Kidney Cancer stratify treatment recommendations by histology; recommendations for first-line treatment of ccRCC are also stratified by risk group. To further guide management of advanced RCC, the NCCN Kidney Cancer Panel has categorized all systemic kidney cancer therapy regimens as "Preferred," "Other Recommended Regimens," or "Useful in Certain Circumstances." This categorization provides guidance on treatment selection by considering the efficacy, safety, evidence, and other factors that play a role in treatment selection. These factors include pre-existing comorbidities, nature of the disease, and in some cases consideration of access to agents. This article summarizes surgical and systemic therapy recommendations for patients with relapsed or stage IV RCC.

424 A phase 1b/2 randomized study of AVB-S6–500 in combination with cabozantinib versus cabozantinib alone in patients with advanced clear cell renal cell carcinoma who have received front-line treatment

Background

In clear cell renal cell carcinoma (ccRCC) the constitutive expression of hypoxia induced factor 1-α leads to increased expression of AXL. AXL overexpression has been associated with the development of resistance to VEGF inhibitors and suppression of the innate immune response through inhibition of macrophage-driven inflammation. AVB-S6-500 (AVB-500) is recombinant fusion protein dimer containing an extracellular region of human AXL combined with the human immunoglobulin G1 heavy chain (Fc), which demonstrates highly potent, specific AXL inhibition. In mouse ccRCC xenograft models, AVB-500 showed significantly more tumor reduction in combination with pazopanib versus pazopanib alone. In a Ph1b study of AVB-500 plus chemotherapy in platinum-resistant ovarian cancer (NCT03639246), no dose limiting toxicity (DLT) or treatment discontinuation due to adverse events was observed. The recommended phase 2 dose (RP2D) of 15 mg/kg was established by a model-informed drug development (MIDD) approach.

Methods

The P1b portion of this trial is a 3+3 dose escalation study to evaluate safety, pharmacokinetics, and pharmacodynamics of AVB 500 in combination with cabozantinib 60 mg daily. Dose levels of AVB-500 may include 15, 20, and 25 mg/kg every two weeks. The primary objective is to evaluate safety and tolerability. Secondary objectives include identification of the RP2D of AVB-500 and clinical activity. Key eligibility criteria include clear cell histology RCC and at least one prior line of therapy administered in the advanced or metastatic setting.

Results

As of July 21, 2021, seven patients have received at least one dose of AVB-500 15 mg/kg and cabozantinib, with six patients ongoing treatment. No DLTs were observed. Trough levels at C1D15 were above the minimally efficacious concentration (MEC) identified from MIDD and GAS6 (AXL ligand) levels were suppressed prior to C2D1. Partial responses were observed in 3 of 5 patients (table 1); all patients demonstrated tumor decrease from baseline.

Abstract 424 Table 1

Preliminary clinical activity in NCT04300140

Conclusions

AVB-500 in combination with cabozantanib demonstrates promising preliminary clinical activity and tolerability in patients with ccRCC. AVB-500 15 mg/kg is the presumptive RP2D with C1D15 AVB-500 troughs consistently above MECs observed. Safety, PK/PD and clinical activity will be updated at the time of presentation. (NCT04300140)

Ethics Approval

This study has obtained ethics approval from WIRB Institutional Review Board®, Protocol ID #20200159, and all subjects provided informed consent prior to taking part in this study.

731 Concurrent immunotherapy and dipeptidyl peptidase-4 inhibition among patients with solid tumors

Background

Durable remissions are possible for patients with solid tumors treated with immune checkpoint inhibitors (IO); however, response rates remain relatively low. Recent preclinical data with dipeptidyl peptidase-4 inhibitors (DPP4i), widely used for diabetes management, have shown synergistic anti-tumor activity with IO in mouse models.1 2 However, there are no currently available data on concurrent use of DPP4i among patients treated with IO.

Methods

We performed a retrospective, IRB-approved, review of all patients with solid tumors treated with IO at Vanderbilt-Ingram Cancer Center and concurrent DDP4i treatment for diabetes mellitus through review of the electronic medical record. Inclusion criteria required patients were to be on DPP4i at the start of IO treatment. The cutoff date was June 22, 2021. Outcomes measured were objective response rate (ORR), time on treatment, time to next treatment (TTNT), immune-related adverse events (iRAE), and overall survival (OS). All patients were included in the toxicity analysis; however, patients treated in the adjuvant setting, those without measurable radiographic disease, and those without available post-treatment scan were excluded from the response analysis.

Results

In total, 34 patients were identified on concurrent IO plus DPP4i. The most common tumor types were melanoma (29%), renal cell carcinoma (21%), and non-small cell lung cancer (21%). Pembrolizumab was the most common IO agent (47%), followed by nivolumab (41%), ipilimumab (15%), atezolizumab (6%), and durvalumab (3%). Sitaglipitin (74%) was the most common DPP4i, followed by linagliptin (18%), saxagliptin (6%), and alogliptin (3%). 14/34 patients (41%) developed any grade IRAE while on treatment with 6/34 (18%) requiring discontinuation of IO. Of the 26 patients who met inclusion criteria for the response analysis, 18 (69%) had PR or CR, 4 (15%) had stable disease, and 4 (15%) had PD as best response (figure 1). The median follow-up time was 19.0 months (IQR: 11–25.2) and the median time on treatment was 10.1 months (95 CI: 4.9–14.5). The median TTNT was 23.9 months (95% CI:10.7–34.5) and median OS was 31.4 months (95% CI: 21.0-NE).

Conclusions

This analysis represents the first data on concurrent DPP4i with IO in the treatment of solid tumors. While the cohort for response analysis was small, the ORR was high. Prospective evaluation of IO plus DPP4-i is needed to determine potential clinical efficacy of this combination.

References

Barreira da Silva R, Laird ME, Yatim N, Fiette L, Ingersoll MA, Albert ML. Dipeptidylpeptidase 4 inhibition enhances lymphocyte trafficking, improving both naturally occurring tumor immunity and immunotherapy. Nat Immunol 2015;16(8):850–858. doi:10.1038/ni.3201.

Hollande C, Boussier J, Ziai J, et al. Inhibition of the dipeptidyl peptidase DPP4 (CD26) reveals IL-33-dependent eosinophil-mediated control of tumor growth. Nat Immunol. 2019;20(3):257–264. doi:10.1038/s41590-019-0321-5

Ethics Approval

Vanderbilt University Institutional Review Board approved this study under “exempt” status (IRB# 202314). All patient information was de-identified and secured.

Abstract 731 Figure 1

Swimmers plot. An illustration of clinical events for 26 patients treated with concurrent checkpoint inhibitor (IO) and dipeptidyl peptidase-4 inhibitors (DPP4i). The timeline begins on the date of IO initiation. Each subject is represented along the y axis, with various symbols noting events such as Partial Response (PR), Complete Response (CR), start date of next line of therapy, continued response, or death. Duration of follow up ended with either patient death or study completion (6/22/21)