Toripalimab plus axitinib versus sunitinib as first-line treatment for advanced renal cell carcinoma: RENOTORCH, a randomized, open-label, phase III study

BACKGROUND

Immune checkpoint inhibitors in combination with tyrosine kinase inhibitors are standard treatments for advanced clear cell renal cell carcinoma (RCC). This phase III RENOTORCH study compared the efficacy and safety of toripalimab plus axitinib versus sunitinib for the first-line treatment of patients with intermediate-/poor-risk advanced RCC.

PATIENTS AND METHODS

Patients with intermediate-/poor-risk unresectable or metastatic RCC were randomized in a ratio of 1 : 1 to receive toripalimab (240 mg intravenously once every 3 weeks) plus axitinib (5 mg orally twice daily) or sunitinib [50 mg orally once daily for 4 weeks (6-week cycle) or 2 weeks (3-week cycle)]. The primary endpoint was progression-free survival (PFS) assessed by an independent review committee (IRC). The secondary endpoints were investigator-assessed PFS, overall response rate (ORR), overall survival (OS), and safety.

RESULTS

A total of 421 patients were randomized to receive toripalimab plus axitinib (n = 210) or sunitinib (n = 211). With a median follow-up of 14.6 months, toripalimab plus axitinib significantly reduced the risk of disease progression or death by 35% compared with sunitinib as assessed by an IRC [hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.49-0.86; P = 0.0028]. The median PFS was 18.0 months in the toripalimab-axitinib group, whereas it was 9.8 months in the sunitinib group. The IRC-assessed ORR was significantly higher in the toripalimab-axitinib group compared with the sunitinib group (56.7% versus 30.8%; P < 0.0001). An OS trend favoring toripalimab plus axitinib was also observed (HR 0.61, 95% CI 0.40-0.92). Treatment-related grade ≥3 adverse events occurred in 61.5% of patients in the toripalimab-axitinib group and 58.6% of patients in the sunitinib group.

CONCLUSION

In patients with previously untreated intermediate-/poor-risk advanced RCC, toripalimab plus axitinib provided significantly longer PFS and higher ORR than sunitinib and had a manageable safety profile TRIAL REGISTRATION: ClinicalTrials.gov NCT04394975.

[Analysis of the results of occupational health examination of radiation workers in Shaanxi Province]

Objective: To analyze the results of occupational health examinations of radiation workers in Shaanxi Province, and to provide basis and reference for effectively conduct occupational health monitoring. Methods: From April 2016 to January 2022, a questionnaire survey was conducted to collect the basic information on occupational health examinations of qualified radiation workers in Shaanxi Province from 2016 to 2021. Based on the abnormal rate of occupational health among radiation workers, 1018 people were randomly selected using a cluster stratified sampling method to analyze the occupational health examination results of different positions, types of work, gender, length of service, and exposure doses. Results: The chromosomal aberration rates of peripheral blood lymphocytes among radiation workers in Shaanxi Province from 2016 to 2021 were 0.26% (10/3876), 0.77% (27/3512), 0.16% (16/10153), 0.09% (13/14769), 0.10% (13/13399), and 0.12% (20/16671), respectively. The abnormal rates of thyroid ultrasound examination were 32.33% (150/464), 24.46% (649/2653), 55.24% (786/1423), 32.89% (888/2700), 35.69% (1475/4133), and 42.51% (1993/4688), respectively. There was a statistically significant difference in the abnormal rates among different years (P<0.05). The abnormal rate of renal function examination in male radiation workers was higher than that in females (P<0.05). Compared with non medical users, the abnormal rates of renal function, thyroid function, and blood routine examination in medical radiation workers were higher (P<0.05), and the abnormal rates of renal function, thyroid function, and blood routine examination in medical applications were higher than those in radiation diagnosis, nuclear medicine, and radiation therapy (P<0.05). The abnormal rates of electrocardiogram, chest X-ray, blood pressure, thyroid function, and blood routine increased with the length of service (P<0.05). The abnormal rates of blood pressure, liver function, kidney function, thyroid function, and blood routine examination increased with the exposure dose (P<0.05) . Conclusion: The occupational health status of radiation workers is not optimistic. Occupational health monitoring should be strengthened, especially interventional radiation diagnosis occupational health examination, as well as changes in the indicators of sensitive organs such as eye lens and thyroid, so as to ensure the health of radiation workers.

[Synchronous primary bilateral macronodular adrenal hyperplasia with renal cell carcinoma: a case series of three patients]

Three cases of synchronous primary bilateral macronodular adrenal hyperplasia(PBMAH) and renal cell carcinoma (RCC) in the Department of Urology of Peking Union Medical College Hospital were retrospectively reviewed. The clinical features, imaging features, treatment methods and pathological features of these patients were analyzed. It was found that the genetic relationship between synchronous PBMAH and RCC needs further research. And RCC is easy to be misdiagnosed. We should pay high attention to imaging features to find out whether there are lesions in bilateral kidneys when we deal with bilateral adrenal lesions. Laparoscopic approach is recommended for PBMAH and RCC. Total or partial nephrectomy should be performed according the tumor size and location of the renal mass. Patients with PBMAH should be closely followed up after bilateral adrenalectomy to avoid delay in diagnosis or treatment of RCC.

[Comparison of early postoperative effects between anterior bladder and posterior bladder approaches in robotic assisted laparoscopic radical prostatectomy]

Objective: To examine the effect of robotic assisted laparoscopic radical prostatectomy with different approaches on early postoperative effects. Methods: Totally 44 patients (average age of 65.9 years, range: 46 to 81 years) underwent robotic assisted laparoscopic radical prostatectomy by a single operator at Department of Urology, Peking Union Medical Collage Hospital from March 2018 to March 2020 were retrospectively analyzed. The mean age was 65.9 years (range: 46 to 81 years), including 24 cases in the anterior bladder approach group (anterior approach group) and 20 cases in the posterior bladder approach group (posterior approach group). The preoperative clinical data, perioperative related data and postoperative urinary control recovery were compared between the two groups by t test, χ² test or Fisher exact test. Results: In terms of clinical data, there was no difference in age, prostate volume, preoperative prostate specific antigen and Gleason score(all P>0.05). There was no significant difference in operation time ((184±43) minutes vs. (193±42) minutes, t=-0.599, P=0.55), bleeding volume ((218±88) ml vs. (225±115) ml, t=-0.244, P=0.81), postoperative stage (T2/T3: 15/9 vs. 12/8, χ²=0.029, P=0.87) and positive rate of cutting edge (29.2% (7/24) vs. 30.0% (6/20), χ²=0.004, P=0.95). In terms of postoperative urinary control, patient rates who achieved urinary control immediately after extubation was significantly higher for the posterior approach group than the anterior approach group (30.0% (6/20) vs. 4.2% (1/24), P=0.04). There was no significant difference between two groups for those who achieved urinary control 3 months after operation (6 cases vs. 11 cases, P=0.06), 6 months after operation (20 cases vs. 19 cases, P=0.36) and those who achieved urinary control 12 months after operation (23 cases vs. 19 cases, P=1). Conclusion: For robotic assisted laparoscopic radical prostatectomy, the posterior approach does not prolong the operation time, does not increase the amount of bleeding, and improves the short-term postoperative urinary control.

[Establishment and primary clinical application of metabolic evaluation database of urolithiasis]

Objective: To establish the metabolic evaluation database of urolithiasis, perform metabolic evaluation, and provide instructions for treatment and prevention of urolithiasis. Methods: This metabolic evaluation database was developed by JAVA and was established by Oracle11g database and Browser/Server framework. We extracted the clinical data of all patients who had complete information, and analyzed their risk factors of stone formation, stone-related medical history, blood and urine tests results and 24-hour urine analysis. Results: A total of 360 patients diagnosed as urolithiasis were included in this research. Male to female ratio was 1.9∶1, and the urolithiasis was first diagnosed at (35.5±13.5) years old. Family history was positive in 39.7% of patients. Metabolic syndrome occurred in 35.0% of patients. Overweight or obesity occurred in 73.2% and 50.0% of male patients, respectively. Abdominal obesity in 62.3% and 56.1% of male and female patients, respectively. Among all patients, 67.5% had high urine sodium, 53.6% had hypercalciuria, 41.1% had hypocitraturia, 29.7% had hyperuricosuria, 22.5% had hypomagnesuria, 15.8% had hyperoxaluria, 11.7% had hyperphosphoraturia, and 36.4% had low urinary volume. Conclusions: The prevalence of overweight or obesity, abdominal obesity, hypertension, diabetes, and metabolic syndrome in stone patients were significantly higher than those in general population. The number of 24-hour urinary abnormalities was positively associated with body mass index. The interventions on high urinary sodium, low urinary volume, obesity and metabolic syndrome were important to the treatment of urolithiasis. This database would facilitate the metabolic evaluation, provide evidence for the treatment and prevention of urolithiasis, and lay foundation for finding important controllable risk factors of urinary stone.

Nd3+/Yb3+ cascade-sensitized single-band red upconversion emission in active-core/active-shell nanocrystals

Lanthanide-doped upconversion nanomaterials (UCNMs) have promoted extensive interest for its biological research and biomedical applications, benefiting from low autofluorescence background, deep light penetration depth, and minimal photo-damage to biological tissues. However, owing to the 980 nm laser-induced overheating issue and the attenuation effect associated with conventional multi-peak emissions, the usage of UCNMs as fluorescent bioprobes is still limited. To address these issues, an effective strategy has been proposed to tune both the excitation and emission peaks of UCNMs into the first biological window (650 ∼ 900 nm), where the light absorption by water and hemoglobin in biological tissues is minimal. Based on the Nd³⁺/Yb³⁺ cascade-sensitized upconversion process and efficient exchange-energy transfer between Mn²⁺ and Er³⁺ in conjunction with the active-core@active-shell nanostructured design, we have developed a new class of upconversion nanoparticles (UCNPs) that exhibit strong single-band red emission upon excitation of an 808 nm near-infrared laser. Hopefully, the well-designed KMnF₃:Yb/Er/Nd@ KMnF₃:Yb/Nd core-shell nanocrystals will be considered a promising alternative to conventionally used UCNPs for biolabeling applications without the concern of the overheating issue and the attenuation constraints.

[The study of renal safety in elderly patients with benign prostatic hyperplasia treated with α receptor blockers]

Objective: To investigate the renal safety in patients with benign prostatic hyperplasia treated with tamsulosin hydrochloride. Methods: A retrospective analysis of 10 cases of patients, who had renal dysfunction after treatment with long-term tamsulosin hydrochloride. Results: The average duration of oral medicine was 2 to 24 months with an average of 7.2 months. The serum creatinine after discontinuation of tamsulosin hydrochloride decreased from 132.5 μmol/L (100-208 μmol/L, normal 59-104 μmol/L) to 95.7 μmol/L (73-122 μmol/L, normal: 59-104 μmol/L) (F=10.385, P=0.000). Conclusion: Preliminary results show that taking tamsulosin hydrochloride might lead to renal damage in old patients with benign prostatic hyperplasia. Safety is the premise, and the right medicine should be chosen for different side effects in order to protect the safety of patient.

[Quantitative measurement of citric acid in urine using tandem liquid chromatography mass spectrometry]

Objective: To find a suitable method for the determination of citric acid in the urine of patients with stones, in order to provide a new method and basis for the prevention and treatment of stone. Methods: Liquid chromatography tandem mass spectrometry was used to analyze the citric acid in urine directly. And the accuracy, stability, repeatability and other indicators of the results were detected. Results: The results showed a good linear relationship with the concentration of citric acid in urine. y=50.31x+ 0.002 6 (R(2)=0.994 21). The results were stable, reproducible [intra-day (Coefficient of Variance) CV ≈1% and inter-day CV<10%], and the accuracy of which was comparable with that of the enzyme method (n=20, R=0.97). Conclusion: Using the method of this study to detect the content of citric acid in urine has the advantages of simple operation, good repeatability, accurate results, and low price. So it is worth to be popularized and applied in clinical practice.

[Surgery treatment of ectopic adrenocorticotrophic hormone syndrome]

OBJECTIVE

To investigation the diagnosis and treatment of ectopic adrenocorticotrophic hormone (ACTH) syndrome.

METHODS

The clinical characters of 57 cases of ecotopic ACTH syndrome from Jan. 1996 to Dec. 2016 were collected and analyzed. The 57 cases included 32 males and 25 females. The age ranged from 11 to 68 years (average 32 years). ACTH levels significantly increased from 16.5 to 365.6 pmol/L, with average 77.6 pmol/L (normal range <10.1 pmol/L). The pituitary MRI did not found lesions. The CT showed that their bilateral adrenal glands diffused small nodular changes or nodular hyperplasia. The 57 cases were divided into 3 groups according to different treatment options. In the study, 25 ectopic ACTH syndrome cases (44%) were group A, without identified source of ectopic hormone, were treated with bilateral or unilateral adrenalectomy due to the severity of the disease and difficulty of operation. Group B was composed of 16 cases (28%) diagnosed as ectopic ACTH syndrome by finding ectopic ACTH tumors and surgical resection. Group C included 16 cases (28%) with nonsurgical therapy. Different treatment results and prognosis were analyzed.

RESULTS

In the study, 40 cases of the 57 had been followed up for 6 months to 10 years. In group A, of the 25 cases with bilateral or unilateral adrenalectomy, 4 died of diabetes and severe pulmonary infection, 18 survived, and 3 were lost to the follow-up, and the survival rate was 81% (18/22). In group B, of the 16 cases with radical tumor resection, 5 died of tumor recurrence 0.5-6.0 years after operation, 3 survived, and 8 were lost to the follow-up, and the survival rate was 37.5% (3/8). In group C, of the 16 non-operation patients, 4 with radiotherapy and chemotherapy died of metastases, diabetes or pulmonary infection, 6 with chemotherapy died of pulmonary infection within 1 year and the others were lost to the follow-up, and the survival rate was 0.

CONCLUSION

Ectopic ACTH syndrome is difficult to treat. Adrenalectomy is effective for the management of ectopic ACTH syndrome, especially for those patients with severe Cushing's syndrome, but the primary tumor can not be located.

[Quantitative measurement of oxalic acid in urine by liquid chromatography combined with tandem mass spectrometry]

Objective: To find a suitable method for the determination of oxalic acid in the urine of patients with stones, in order to provide a new method and basis for the prevention and treatment of stone. Methods: Liquid chromatography combined with tandem mass spectrometry was used to analyze oxalic acid in urine directly.The accuracy, stability, repeatability and other indicators of the results were tested. Results: The results showed a good linear relationship with the concentration of oxalic acid in urine. y=58.524x-15.246 (R(2)=0.979 02). The results were stable, reproducible (the intra-day and inter-day coefficient of variation was less than 10% and 15%, respectively), and the accuracy was comparable with that of the enzyme method (N=20, R=0.93). Conclusion: Using the method of this study to detect the content of oxalic acid in urine has the advantages of simple operation, good repeatability, accurate results, and low price. It is worth to be popularized and applied in clinical practice.

Transverse evolution of a plasma channel in air induced by a femtosecond laser

We investigate the evolution of filamentation in air by using a longitudinal diffraction method and a plasma fluorescence imaging technique. The diameter of a single filament in which the intensity is clamped increases as the energy of the pump light pulse increases, until multiple filaments appear.