Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer

Adjuvant therapy for high-risk renal cell carcinoma patients

For most cases of renal cell carcinoma (RCC), the standard of care is surgical resection as monotherapy or as part of a multimodal approach. In patients with early localized disease, radical nephrectomy is associated with a favorable prognosis, whereas patients with advanced disease are rarely cured. A significant number of patients undergoing surgery for localized RCC experience recurrence, suggesting that there are some individuals in whom surgical excision is necessary but insufficient. In these patients, the development of effective adjuvant strategies is imperative. In this article, we review the prognostic variables and comprehensive staging algorithms for identifying patients at high risk for disease recurrence. Additionally, we review data from completed adjuvant RCC trials and highlight relevant ongoing trials.

Presurgical therapy in metastatic renal cell carcinoma

The standard approach for managing patients with metastatic renal cell carcinoma consists of a cytoreductive nephrectomy followed by immunotherapy, chemotherapy or a targeted agent. Optimal timing of surgery and systemic therapy is not known, and has not been researched. A number of questions arise. First, in the era of antivascular therapy, is cytoreductive nephrectomy a necessity? Second, is it possible that pretreatment with systemic therapy prior to cytoreductive nephrectomy improves surgical outcome and survival? Third, which agents are best suited for an integration of surgery with systemic therapy, both in the metastatic and the nonmetastatic setting? This review will address each of these questions and summarize ongoing trials that are designed to provide some of the answers.

Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma: Is It Still Imperative in the Era of Targeted Therapy?

In the era before cytokine therapy, controversy existed about the need for cytoreductive nephrectomy in treating patients with metastatic renal cell carcinoma. In 1978, Dekernion showed that nephrectomy alone had no effect on survival. During this period, removal of the malignant kidney was confined to palliative therapy in some settings of metastatic RCC, such as pain related to the kidney mass, intractable hematuria, erythrocytosis, uncontrolled hypertension, or poorly controlled hypercalcemia. When interleukin-2 was approved by the Food and Drug Administration in 1992, the role of nephrectomy was reexamined. After a decade of controversy, two randomized controlled studies established that cytoreductive surgery has a role in properly selected patients and offers a survival advantage when done before cytokine therapy. Unfortunately, the mechanisms underlying this benefit remain poorly understood. Immunotherapy may work best when there is a small volume of cancer present, and removing a large primary tumor may prevent the seeding of additional metastases. Data have also suggested that primary tumors were capable of producing immunosuppressive compounds that might decrease the efficacy of immunotherapy. Another hypothesis suggested that removing the kidney altered the acid/base status of the patient to such an extent that the growth of the tumor was hindered. With the emergence in 2006 of two targeted agents for advanced renal cell carcinoma, the role of cytoreductive nephrectomy has re-emerged as a source of controversy. Although evidence-based medical practice suggests a role for nephrectomy before the use of targeted agents, the arguments for and against this practice will be weighed.

Treatment of patients with metastatic renal cell cancer: a RAND Appropriateness Panel

BACKGROUND

New developments in the treatment of patients with metastatic renal cell cancer (MRCC) have suggested a need to reevaluate the role of systemic therapies. The authors convened a panel of medical and urologic oncologists to rate the appropriateness of the main options.

METHODS

The authors used the RAND/University of California-Los Angeles Appropriateness Method to evaluate systemic therapy options and cytoreductive nephrectomy. After a comprehensive literature review, an expert panel rated the appropriateness of systemic options (108 permutations) and cytoreductive nephrectomy (24 permutations) for patients with MRCC.

RESULTS

The appropriateness evaluation indicated that 27.3% of permutations were rated "appropriate," 46.9% were rated "inappropriate," and 25.8% were rated "uncertain." There was a high rate of agreement (95%). Sunitinib and sorafenib were rated appropriate for patients with low-to-moderate risk regardless of prior treatment. Temsirolimus was rated appropriate for first-line therapy for higher risk patients. Interferon-alpha and low-dose interleukin-2 were rated inappropriate or uncertain. In patients who received prior immunotherapy, cytokines were rated inappropriate. In all permutations for evaluating systemic therapy, enrollment into an investigational trial was considered appropriate, treatment with bevacizumab was uncertain, and thalidomide was inappropriate regardless of risk status or prior therapy. For good surgical risk patients with planned immunotherapy, nephrectomy was rated appropriate in patients who had limited metastatic burden regardless of tumor-related symptoms and in symptomatic patients regardless of metastatic burden. Only the most favorable combination of surgical risk, metastatic burden, and symptoms generated an "appropriate" rating for patients with planned targeted therapy.

CONCLUSIONS

The current results begin the process of defining an appropriate role for cytokines, newer targeted therapies, and surgery in the treatment of MRCC.

Implications of B7-H1 expression in clear cell carcinoma of the kidney for prognostication and therapy

B7-H1 encompasses a recently discovered cell surface glycoprotein within the B7 family of T-cell co-regulatory molecules. B7-H1 expression can be induced on activated T lymphocytes and is normally expressed by macrophage lineage cells. In addition, some human tumors acquire the ability to aberrantly express B7-H1. Tumor-associated B7-H1, as well as B7-H1 on activated lymphocytes, has been shown to impair antigen-specific T-cell function and survival in vitro. In contrast, in vivo monoclonal antibody-mediated blockade of B7-H1 has been shown to potentiate antitumoral responses in several murine cancer models. Consequently, tumor-associated B7-H1 has garnered much attention in the recent literature as a potential inhibitor of host antitumoral immunity. Our group has recently reported that B7-H1 is aberrantly expressed in both primary and metastatic renal cell carcinoma (RCC) as revealed via immunohistochemical staining of both fresh-frozen and paraffin-embedded nephrectomy specimens. In addition, we have shown that B7-H1 expression by clear cell RCC tumors (or infiltrating mononuclear cells) correlates with aggressive pathologic features, including advanced tumor-node-metastasis stage, tumor size, higher nuclear grade, and coagulative necrosis. In one study of 306 patients, with a median clinical follow-up of 11 years, we reported that RCC B7-H1 expression correlates with increased risk of disease progression, cancer-specific death, and overall mortality even after multivariate adjustment. Five-year cancer-specific survival rates in this study were 42% and 83% for patients harboring B7-H1(+) versus B7-H1(-) RCC tumors, respectively. Such associations may relate to the recognized ability of B7-H1 to inhibit T-cell-mediated antitumoral immunity. In summary, B7-H1 encompasses a potent independent predictor of prognosis for patients with RCC and an extremely promising target to facilitate immunotherapeutic responses during the management of this treatment-refractory tumor.

Evolving principles of surgical management and prognostic factors for outcome in renal cell carcinoma

The generally accepted principles for the surgical management of renal cell carcinoma (RCC) were first described more than 30 years ago. Since then, much has changed in the understanding of the basic biology and genetics of kidney cancer. Improvements in cross-sectional imaging has allowed for more accurate preoperative clinical staging of renal tumors, and the necessity of completing all the components of the radical nephrectomy have been questioned. Surgical techniques have also evolved, and technology has advanced to make possible new methods of managing renal tumors. The TNM staging system is currently the most extensively used system to provide prognostic information for RCC. However, data published in the last few years has led to significant controversies as to whether further revisions are needed and whether improvements can be made with the introduction of new, more accurate and predictive prognostic factors. Furthermore, the recent discovery of molecular tumor markers are expected to revolutionize the staging of RCC and lead to the development of new therapies based on molecular targeting. This review will examine the evolving principles in the surgical management of RCC as well as provide an update on current staging modalities and prognostic factors.

The role of nephron sparing surgery for metastatic (pM1) renal cell carcinoma

PURPOSE

Studies have demonstrated increased time to progression when cytoreductive nephrectomy is performed for metastatic renal cell carcinoma. We evaluated the role of nephron sparing surgery in these patients.

MATERIALS AND METHODS

We selected all patients with pM1 renal cell carcinoma treated with nephron sparing surgery or radical nephrectomy, and all patients with pM0 renal cell carcinoma undergoing nephron sparing surgery for solitary kidney from 1970 to 2002 from the Mayo Clinic Nephrectomy Registry.

RESULTS

We identified 16 patients who underwent nephron sparing surgery for pM1 renal cell carcinoma. Solitary kidney was present in 12, 3 had bilateral synchronous disease and 1 had elective nephron sparing surgery. Cancer specific survival rates at 1, 3 and 5 years were 81%, 49% and 49%, respectively. We identified 404 patients who underwent radical nephrectomy for pM1 renal cell carcinoma. Cancer specific survival rates at 1, 3 and 5 years were 51%, 21% and 13%, respectively. The pM1 nephron sparing surgery for solitary kidney cases were more likely to have early (33% vs 10%, p = 0.009) or late (50% vs 19%, p = 0.018) complications compared with pM1 radical nephrectomy cases. There were no significant differences in early (p = 0.475) or late (p = 0.350) complications between pM1 nephron sparing surgery cases and 139 pM0 nephron sparing surgery cases.

CONCLUSIONS

Cancer specific survival rates in pM1 nephron sparing surgery cases were comparable to pM1 radical nephrectomy cases. Although there were differences in early and late complications between the pM1 nephron sparing surgery and pM1 radical nephrectomy groups, there were no differences when compared with imperative pM0 nephron sparing surgery cases. This study demonstrates that nephron sparing surgery can achieve adequate cytoreductive therapy while preserving renal function, with postoperative complication rates similar to those of pM0 nephron sparing surgery cases.

C-reactive protein is an informative predictor of renal cell carcinoma-specific mortality

BACKGROUND

C-reactive protein (CRP) represents a promising prognostic variable in patients with sporadic renal cell carcinoma (RCC). It was hypothesized that CRP can improve the prognostic ability of standard RCC-specific mortality (RCC-SM) predictors in patients treated with nephrectomy for all stages of RCC.

METHODS

Radical nephrectomy was performed in 314 patients from 2 European centers. Life table, Kaplan-Meier, and Cox regression analyses addressed RCC-SM. Covariates included age, gender, TNM stage, tumor size, Fuhrman grade, and histologic subtype.

RESULTS

The median survival of the cohort was 19.9 years. Age ranged from 10 to 77 years. Most patients were male (69%). T-stages were distributed as follows: T1-121 (38.7%), T2-45 (14.4%), T3-140 (44.7%), T4-7 (2.2%). CRP values ranged from 1.0 to 358.0 mg/L (mean 40.9, median 11.0 mg/L). In multivariable analyses, CRP was an independent predictor of RCC-SM (P = .003). The consideration of CRP in the multivariable model increased the predictive accuracy by 3.7% (P < .001). Moreover, the model with CRP performed 2.4% and 4.6% better than the UCLA Integrated Staging System (UISS) at, respectively, 2 and 5 years.

CONCLUSIONS

CRP represents an informative predictor of RCC-SM. Its routine use could allow better risk stratification and risk-adjusted follow-up of RCC patients.

[Palliative and supportive therapy in cases of renal cell carcinoma]

At the time of diagnosis, 25-30% of all patients with renal cell carcinoma already present with metastatic disease. Furthermore, 20-30% of patients with renal cell carcinoma will have progressive disease despite radical nephrectomy with complete tumor resection. In this review, we discuss the current therapeutic options for patients with metastatic renal cell carcinoma: These include palliative radical nephrectomy, surgery of metastasis, tumor embolisation and medical treatment options (e.g. immunotherapy, chemotherapy and targeted therapy), as well as supportive pain treatment.

Role of Cytokine Therapy in 2006 and Beyond for Metastatic Renal Cell Cancer

Metastatic renal cell cancer (mRCC) has a long history as a disease with poor prognosis and limited therapeutic options. Immunotherapy has been the mainstay of treatment since the 1980s, and there have been a number of largely phase II studies examining various schedules of interferon-alpha and interleukin-2 based treatments. With the development of molecular targeted drugs the armentarium against mRCC has significantly expanded and cytokine treatments should be only directed at those most likely to benefit with durable remissions and prolonged survival.

Relationship between age at diagnosis and clinicopathologic features of renal cell carcinoma

OBJECTIVES

To analyse the influence of age at diagnosis on tumour characteristics and cancer-specific survival in renal cell carcinoma (RCC).

METHODS

Data on age, tumour characteristics, and survival for 4774 patients from 12 European RCC databases were recorded. Patients were divided into four groups according to age at diagnosis: < or =40, >40 and <60, > or =60 and <80, and > or =80 yr. The following variables were analysed: TNM stage, Fuhrman grade, tumour size, symptoms at diagnosis, ECOG performance status (PS), and cancer-specific survival. The groups were compared for usual clinical and pathologic variables, and cancer-specific survival.

RESULTS

The four groups accounted for 288 (6%), 1839 (38.5%), 2499 (52.3%), and 148 cases (3.2%), respectively. Differences were found among groups for tumour stage, symptoms at diagnosis, ECOG PS, Fuhrman grade (p<0.001), tumour size, M stage, and histologic subtype (p: 0.02). Patients < or =40 yr were more likely to have papillary or chromophobe RCCs and less likely to have clear-cell RCCs. No significant difference was found among groups for N stage (p: 0.15). The 5-yr cancer-specific survival rates for the four age categories were 85%, 74%, 70%, and 69%, respectively. In multivariate analysis age category remained an independent prognostic parameter (p<0.001).

CONCLUSIONS

Renal tumours diagnosed in younger age are characterized by lower tumour stages and grades as well as favourable histologic patterns compared with tumours in older patients. Basic research is required for explaining such a relationship between age, tumour aggressiveness, and therefore tumour biology.

Kinase inhibitors in the treatment of renal cell carcinoma

Immunotherapy confers a small but significant overall survival advantage in metastatic renal cell carcinoma (RCC) but a need exists to develop more effective systemic therapies. Angiogenesis has a key role in the pathophysiology of renal cell carcinoma and vascular endothelial growth factor (VEGF) is an important mediator of this process. Sunitinib, sorafenib and axitinib are new agents which belong to a class of drugs called kinase inhibitors and inhibit the VEGF, platelet-derived growth factor (PDGF) and c-KIT receptor tyrosine kinases. Temsirolimus inhibits the mammalian target of rapamycin (mTOR). All these agents have shown significant activity with manageable toxicity in metastatic RCC in phase 2 studies in patients generally pretreated with immunotherapy, whilst prolonged progression-free survival in a phase 3 study has been reported with sorafenib in comparison with placebo. Further phase 3 trials are recruiting and the combination of kinase inhibitors with other therapies is under investigation.

Tyrosine Kinase Inhibitors Compared with Cytokine Therapy for Metastatic Renal Cell Carcinoma: Overview of Recent Clinical Trials Differentiating Clinical Response and Adverse Effects

Metastatic renal cell carcinoma has long been recognized as an aggressive, therapy-refractory epithelial cancer. Two decades of clinical experience with the biologic response modifiers, such as interferon and interleukin-2, have produced little in the way of clinically meaningful benefit for patients, with the notable exception of a very small number of patients treated with high-dose interleukin-2. The paradigm shifting development in the understanding of the molecular biology of clear-cell renal cancer and the rapid introduction of kinase inhibitors into our therapeutic armamentarium has provided clinicians and their patients real hope. Two important phase III trials are reviewed and placed into historical context with previous trials of biologic response modifiers.

Improving Outcomes with Novel Therapies for Patients with Newly Diagnosed Renal Cell Carcinoma

With the approval of sunitinib and sorafenib, 2 new multitargeted tyrosine kinase inhibitors, for the treatment of advanced renal cell carcinoma (RCC), the natural history and prognosis of patients with this disease has significantly improved. These drugs were approved based upon clinical data demonstrating robust, unprecedented response rates in one case and dramatic prolongation of progression-free survival in the other. In both cases, these results were seen in study patients in whom standard therapy had failed and who, on average, carried substantial disease burden. Important challenges today include integrating these therapies with other standard therapeutic options and into other advanced-stage RCC patient populations. This article addresses current data and practice patterns regarding the clinical use of tyrosine kinase inhibitors in patients with advanced-stage RCC, including dose modifications and alternative dosing, the current role of debulking nephrectomy, and use in patients with indolent disease. Finally, a summary of the more common side effects and management strategies for these is also discussed. Ultimately, more clinical data is needed to address the chronic use of these agents alone, in combination with other agents, with radiation therapy, and in sequence.

Histologic subtype of metastatic renal cell carcinoma predicts response to combined immunochemotherapy with interleukin 2, interferon alpha and 5-fluorouracil

OBJECTIVES

Combined immunochemotherapy with interleukin 2 (IL-2), interferon alpha (IFN-alpha), and 5-fluorouracil (5-FU) is an established first-line therapy for metastatic renal cell carcinoma (RCC). However, data on histologic parameters predictive of clinical benefit are rare. In this study, we evaluated the response to immunochemotherapy in the main histologic subtypes of renal cell carcinoma and performed a subgroup analysis of inoperable patients.

METHODS

From 164 patients treated with one or two cycles of combined immunochemotherapy, radical nephrectomy had revealed 22 cases of papillary RCC (pRCC; 13.4%) and 131 cases of clear cell RCC (ccRCC; 79.9%). In the remaining 11 (6.7%) their disease was inoperable. The overall response rates were evaluated according to World Health Organization criteria.

RESULTS

For ccRCC and inoperable disease, responses of 34.4% and 27.3% after one cycle and 28.8% and 16.7% after two cycles, respectively, were noted. In contrast, no patient with pRCC showed any response after two cycles of combined immunochemotherapy.

CONCLUSIONS

No objective response was seen in patients with pRCC. Hence, the use of immunotherapeutic agents must be questioned in this histologic subtype.

[Unusual metastasis of renal carcinoma]

Renal carcinoma, the third most common urological cancer, induces presence of metastases in 75% of cases. The most affected sites for metastasis are the lungs, the lymphatic system, bones, the liver, adrenal glands and the brain with sometimes a cancer free period of several years prior to evolutionary recurrence of the disease. The aim of this literature review is to report on secondary uncommon renal localizations by underlining their clinical significance, as well as main characteristics, in order to provide guidelines for effective patient diagnosis and therapeutic management.

Solitary massive right ventricular metastasis of renal cell carcinoma without inferior vena cava or right atrium involvement

Right ventricular metastases from renal cell carcinoma without inferior vena cava or right atrium involvement are rare. A 67-year-old male presented with hematuria and congestive heart failure. Computed tomography revealed a left renal mass. In addition, an intra-cardiac mass was found during the preoperative workup, causing right ventricular outflow tract obstruction. His past medical history included previous coronary bypass grafting. The patient underwent combined radical nephrectomy and removal of right ventricular mass. Pathology confirmed renal cell carcinoma with extensive sarcomatoid features in both the left kidney and right ventricle. His postoperative recovery was unremarkable.

Perioperative immunomodulation with interleukin-2 in patients with renal cell carcinoma: results of a controlled phase II trial

We conducted a non-randomised controlled phase II trial to investigate the role of preoperative administration of interleukin-2 (IL-2) in patients with renal cell carcinoma undergoing tumour nephrectomy. A total of 120 consecutive patients were allocated alternately to the two study groups: perioperative immunomodulation with IL-2 (IL-2 group; n=60) and perioperative immunomonitoring without immunomodulation (control group; n=60). Patients from the IL-2 group received four doses of 10 × 10⁶ IU m⁻² twice daily subcutaneously a week before operation followed by a daily maintenance dose of 3 × 10⁶ IU m⁻² subcutaneously until a day before the operation. Parameters of cellular and humoral immunity (leucocytes, T-cell markers CD3, CD4, and CD8, B-cell marker CD19, monocyte marker CD14, natural killer (NK) cell markers CD16, CD56, and CD57, activation markers CD6, CD25, CD28, and CD69, progenitor cell marker CD34, as well as IL-2, IL-6, IL-10, soluble IL-2 receptor, IL-1 receptor antagonist, transforming growth factor-β1, and vascular endothelial growth factor) were measured in peripheral venous blood at various intervals. Interleukin-2-related toxicity was WHO grade 1 (24%), 2 (67%), and 3 (9%). In the postoperative period, T-cell markers, activation markers, and NK cell markers decreased, and IL-6 and IL-10 increased. However, all these alterations were significantly less accentuated in patients who had been pretreated with IL-2. Median follow-up was 40 months. Tumour-specific survival in the IL-2 group and the control group was 98 vs 81% after 1 year and 86 vs 73% after 5 years (P=0.04). A similar effect was found for progression-free survival. We conclude that IL-2 can be safely administered in the perioperative period and modulates immunological parameters. However, to validate the survival data, a larger randomised phase III trial is needed.

Place de la néphrectomie dans la prise en charge des cancers du rein métastatiques

Metastatic kidney cancer is still a devastating disease but it represents a very heterogeneous situation. Some patients will have a median survival limited to some months, while others will live several years. If the initial diagnosis of kidney cancer at metastatic stage is quite uncommon, it raises the question of whether or not performing initial nephrectomy. The point was long debated as it was suggested that initial nephrectomy could result in a spontaneous metastase regression and protect against local complications (hematuria, local pain,...). Today, nephrectomy must not be systematic, as effective alternative treatments are often available. Furthermore spontaneous postoperative metastasis regression is unusual. Two recent prospective randomized trials clarified the impact of initial nephrectomy. It is now accepted that initial surgery prior to systemic immunotherapy results in 30% survival benefit. However this procedure should only be considered for highly selected cases: patients in otherwise good condition (ECOG 0-1), macroscopically complete local resection, no supra-hepatic caval thrombus, and patients suitable for systemic immunotherapy treatment. Several questions remain unanswered, such as lymph node dissection to be performed, and its real survival impact. Furthermore the definition of "suitable" patients for immunotherapy has to be clarified, based on the recent results from the Percy Quatro study. It would probably be more effective to consider only patients with an expected good survival benefit using immunotherapy, such as those classified as "good prognosis" based on the CRECY criteria. Finally the development of new drugs, targeting mainly the angiogenic pathway may lead to different future indications in this setting.

Metastatic Prostate Cancer—Does Treatment of the Primary Tumor Matter?

PURPOSE

In recent years there has been increased interest in adjuvant therapy for prostate cancer. This trend has engendered a tendency toward overlooking the issue of therapy to the primary tumor in advanced disease. We reviewed the effect of treating the principal disease bulk on overall treatment outcome in patients with advanced and metastatic cancer. Specifically we evaluated the role of surgical tumor cytoreduction.

MATERIALS AND METHODS

We performed a comprehensive literature review to evaluate the role of surgical debulking on the outcome of advanced cancer, including any published evidence supporting a benefit of this therapy for prostate cancer.

RESULTS

Even in cancers for which adjuvant chemotherapy and radiation are used liberally there is a clear benefit to optimal surgical debulking for local control and survival. The beneficial role of maximal surgical cytoreduction has been clearly demonstrated in advanced ovarian cancer and gastrointestinal carcinomatosis. Maximal debulking of brain, liver and lung metastasis has translated into longer survival. Removal of the primary tumor has been proved to increase survival in randomized trials of metastatic renal cell cancer. It appears that patients with node positive and possibly metastatic prostate cancer have a better response to androgen ablation with surgical removal of the gland.

CONCLUSIONS

Surgical cytoreduction of cancer results in a more favorable and durable response to systemic therapy. It is reasonable to explore aggressive surgical therapy for advanced prostate cancer.

Adjuvant subcutaneous interleukin-2 in patients with resected renal cell carcinoma: a pilot study

BACKGROUND

A pilot study was conducted to investigate the toxicity and tolerance to low-dose subcutaneous interleukin-2 (IL-2) for patients with resected renal cell carcinoma (RCC) at high risk for recurrent disease (TNM stages III and IV resected distant metastases).

PATIENTS AND METHODS

Patients with surgically resected locally advanced (T3-4 or N1-2) or metastatic RCC were randomly assigned to 1 of 4 treatment groups that received different dose levels and schedules of subcutaneous IL-2 as follows: dose level 1, 4 MIU/m2 per day, every other week for 24 weeks (n = 10); dose level 2, 8 MIU/m2 per day, every other week for 24 weeks (n = 9); dose level 3, 4 MIU/m2 per day, weeks 1-4, 9-12, and 17-20 (n = 11); and dose level 4, 8 MIU/m2 per day, weeks 1-4, 9-12, and 17-20 (n = 10). Interleukin-2 was administered in 2 daily doses on days 1-5 of each week indicated. A dose level was considered tolerable if no more than 2 patients experienced grade 3/4 toxicity.

RESULTS

Forty-one patients were entered in the study and 40 were evaluable for toxicity. Therapy was well tolerated at all dose levels and schedules, with most patients (98%) experiencing mild-to-moderate constitutional symptoms. Grade 3/4 toxicity was seen in 8 patients (20%). Interleukin-2 dose reductions were required in 7 patients, and no patient discontinued therapy secondary to toxicity. Of 39 patients evaluable for efficacy, 31 have experienced relapse (79%), and 15 have died (38%). Median survival was 1.4 years, and the 3-year disease-free survival rate was 33%. Median overall survival has not been reached; however, the 3-year survival rate was 70%. There was no statistically significant difference between any of the treatment arms with respect to disease-free survival or 3-year survival (P > 0.54 and P >or= 0.09 for all pairwise comparisons), schedules (dose level 1/2 vs. 3/4; P = 0.46 and P = 0.5), or dose of IL-2 administered (dose level 1/3 vs. 2/4; P = 0.99 and P = 0.1).

CONCLUSION

Subcutaneous IL-2 was well tolerated for 6 months in patients with surgically resected RCC at high risk of recurrence. Future adjuvant trials in this setting are not likely to include IL-2 in view of the clinical efficacy and favorable toxicity profiles of selected multitargeted kinase inhibitors.

Targeted Approaches for Treating Advanced Clear Cell Renal Carcinoma

The mainstay of any curative treatment in renal cell carcinoma (RCC) is surgery. In the case of metastatic disease at presentation, a radical nephrectomy is recommended to good performance status patients prior to the start of cytokine treatment. Interferon (IFN)-a offers in a small but significant percentage of patients advantage in overall survival. Interleukin (IL)-2-based therapy gives similar survival rates. To date, hormonal therapy and chemotherapy do not have a proven impact on survival. Recent insights demonstrate that the majority of clear cell RCC harbor abnormalities of the von Hippel-Lindau (VHL) gene. This gene plays a key role in the stimulation of angiogenesis by vascular endothelial growth factor (VEGF) in this highly vascularized tumor. This opens interesting new treatment strategies including blockade of VEGF with the monoclonal antibody bevacizumab (Avastin) and inhibition of VEGF receptor tyrosine kinases with small oral molecules such as sunitinib (SU11248, Sutent) or PTK787. Likewise, inhibition of the Raf kinase pathway with oral sorafenib (Bay 43-9006, Nexavar) or inhibition of the mTOR pathway with intravenous CCI-779 are under investigation. Preliminary clinical results with all these compounds are promising, and the results of ongoing first-line phase III studies will become available in the next years.

Autologous renal cell cancer vaccines using heat shock protein-peptide complexes

Investigations into the role of heat shock proteins (HSPs) in immune response have progressed well into a third decade, and indications of their use for the treatment of renal cell carcinoma (RCC) in the adjuvant setting will be revealed in the near future when a randomized phase III clinical trial is completed. Additional ongoing and planned randomized clinical trials will test the efficacy of HSP-based vaccines in more advanced stages of RCC. This review describes the compelling scientific rationale behind testing HSPs in RCC against the backdrop of other immunotherapeutic approaches in this indication.

Laparoscopic management of advanced renal cell carcinoma with level I renal vein thrombus

OBJECTIVES

To present our series of laparoscopic radical nephrectomy in patients with level I tumor thrombus. The existence of renal vein tumor thrombus presents a technical challenge in securing hilar control during the resection of a renal mass. To our knowledge, this experience represents one of the largest series of laparoscopic nephrectomy for renal cell carcinoma associated with a macroscopic renal vein thrombus.

METHODS

From April 2002 to June 2004, 12 patients (8 men and 4 women) were diagnosed with renal masses. In addition to computed tomography, cavography and magnetic resonance imaging were used to determine the levels of tumor thrombi preoperatively in those who had suspicious involvement of the renal vein on computed tomography.

RESULTS

Laparoscopic nephrectomy was performed in a standard fashion. Hand-assisted laparoscopic nephrectomy was used in 6 cases involving large tumors with bulky hilar adenopathy. All renal veins were stapled using an endoscopic vascular stapler. Intraoperative laparoscopic ultrasonography was used to delineate the extent of the vein thrombus in 4 cases to enable proper stapler positioning. No intraoperative complications occurred, and 2 cases were electively converted to open nephrectomy. The postoperative narcotic requirements and hospitalization times were low. Pathologic examination of the tumor specimens demonstrated negative resection margins in all patients.

CONCLUSIONS

In carefully selected patients, laparoscopic resection of renal masses with level I renal vein thrombi is feasible. Because of technical considerations that may be identified intraoperatively, early conversion to open nephrectomy should be anticipated. Long-term results regarding oncologic control continue to be assessed.

Treatment for renal cancer: are we beyond the cytokine era?

Cytokines have been the mainstay of treatment for metastatic renal cancer for the past 20 years. Response rates of patients treated with these agents are low, and toxicity is high, but there is evidence from large multicenter randomized trials that indicate that there are survival benefits with interferon-based immunotherapy. A large number of new small molecule inhibitors are emerging that have caused considerable interest in the oncology community. The evidence for benefit from these compounds is based on small studies, using progression-free survival as an end-point. New compounds may provide an improvement in survival for patients with metastatic renal cancer; however, any trial of these agents should be tested against established, standard cytokine therapy.

Contemporary techniques and safety of cardiovascular procedures in the surgical management of renal cell carcinoma with tumor thrombus

OBJECTIVE

Renal cell carcinomas often form venous thrombi that extend into the vena cava. Frequently, cardiovascular consultation is necessary for complete surgical excision. We sought to investigate the risk factors, surgical techniques, and outcomes of patients treated for renal cell carcinoma with venous extension.

METHODS

We reviewed the records of 46 consecutive patients who underwent surgical management of renal cell carcinoma with venous extension between 1991 and 2005. Data on patient history, staging, surgical techniques, morbidity, and survival were analyzed.

RESULTS

There were 29 men and 17 women with a mean age of 60.2 +/- 12.0 years. Twenty-five (54%) procedures were completed with cardiovascular assistance. Nephrectomy was performed in 44 (96%) cases. Three (7%) patients underwent right heart venovenous bypass, and 2 (5%) patients underwent cardiopulmonary bypass with circulatory arrest. Fourteen (32%) patients had perioperative complications, including 1 (2%) perioperative death. Patients who required cardiovascular procedures (inferior vena cava clamping, right heart venovenous bypass, and cardiopulmonary bypass with circulatory arrest) had higher risks of perioperative complications (P < .02). The 1-, 2-, and 5-year overall survival rates were 78%, 69%, and 56%.

CONCLUSIONS

This large series demonstrates that aggressive treatment of renal cell carcinoma with venous thrombus provides favorable outcomes. Our 5-year survival is among the highest of recent reviews, and our perioperative morbidity and mortality rates are comparable with those of other series. Tumors that require cardiovascular procedures are associated with increased complications when compared with radical nephrectomy and thrombectomy alone. Nevertheless, this aggressive treatment approach offers encouraging patient survival.

A phase I, pharmacokinetic and pharmacodynamic dose escalation trial of weekly paclitaxel with interferon-α2b in patients with solid tumors

PURPOSE

Paclitaxel and interferon have demonstrated anti-angiogenic activity in vitro and in vivo. The toxicity, pharmacokinetics, and pharmacodynamics of paclitaxel with interferon-alpha2b (IFN-alpha2b) were assessed in patients with solid tumors to assess the feasibility of this novel anti-angiogenic regimen.

METHODS

IFN-alpha2b (1 million units) was administered twice daily by subcutaneous injection. Paclitaxel was given weekly over 1 h starting at 30 mg/m2 and increased to 50 mg/m2. Cycles were repeated every 4 weeks.

RESULTS

Nineteen patients with a variety of solid tumors were enrolled. Dose-limiting toxicity in cycle 1 was observed at 50 mg/m2. Eleven patients were treated at 40 mg/m2 with no undue toxicity. Pharmacokinetic parameter comparison studies were completed in 11 patients who received days 1 and 29 paclitaxel. Mean paclitaxel clearance and area under the curve (0-infinity) were not statistically different from days 1 to 29. There was a 50% increase in the average Cmax from days 1 to 29. There was also a 73% decrease of matrix metalloproteinase-9 (MMP-9) levels in these 11 patients from days 1 to 29 (p < 0.0005). All three patients with cutaneous angiosarcomas experienced clinically meaningful remissions. In addition, minor responses were observed in one patient with heavily pretreated ovarian cancer and another with adrenocortical carcinoma.

CONCLUSION

This trial details the inability to dose escalate to the maximum tolerated dose of weekly paclitaxel when combined with low-dose interferon. However, this low-dose regimen caused a significant decrease in MMP-9 and demonstrated anti-cancer activity in cutaneous angiosarcomas.

[Therapy strategies for advanced renal cell carcinoma]

The therapeutic regimen for metastatic renal cell cancer has changed substantially in the last years. Formerly, metastatic disease was regarded as being inoperable and had a disastrous prognosis. Nowadays, radical nephrectomy is the accepted urologic-oncologic standard therapy in metastatic primaries, if technically feasible. A complete resection of metastases may be curative, or can achieve a substantial palliative benefit. A better understanding of prognostic parameters helps in the selection of patients with a chance of benefiting from systemic immunochemotherapy. For patients with rapidly progressing tumors or sarcomatoid dedifferentiation, new effective chemotherapy regimens are available. New angiogenesis inhibitors such as sutent, avastin or sorafenib can potentially be effectively used in future therapeutic regimens.

Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis

PURPOSE

Surgery of the primary tumor usually is not advised for patients with metastatic breast cancer at diagnosis because the disease is considered incurable. In this population-based study, we evaluate the impact of local surgery on survival of patients with metastatic breast cancer at diagnosis.

METHODS

We included all 300 metastatic breast cancer patients recorded at the Geneva Cancer Registry between 1977 and 1996. We compared mortality risks from breast cancer between patients who had surgery of the primary breast tumor to those who had not and adjusted these risks for other prognostic factors.

RESULTS

Women who had complete excision of the primary breast tumor with negative surgical margins had a 40% reduced risk of death as a result of breast cancer (multiadjusted hazard ratio [HR], 0.6; 95% CI, 0.4 to 1.0) compared with women who did not have surgery (P = .049). This mortality reduction was not significantly different among patients with different sites of metastasis, but in the stratified analysis the effect was particularly evident for women with bone metastasis only (HR, 0.2; 95% CI, 0.1 to 0.4; P = .001). Survival of women who had surgery with positive surgical margins was not different from that of women who did not have surgery.

CONCLUSION

Complete surgical excision of the primary tumor improves survival of patients with metastatic breast cancer at diagnosis, particularly among women with only bone metastases.

Survival analysis after resection of metastatic disease followed by peptide vaccines in patients with Stage IV melanoma

BACKGROUND

Metastatic melanoma carries a poor prognosis, with a median survival of 7-9 months. Surgical resection of metastatic disease has been advocated to improve survival. Immunotherapy after metastasectomy may further improve the outcome for high-risk resected disease.

METHODS

Charts from patients treated on institutional vaccine trials were analyzed. Patients with American Joint Committee on Cancer (AJCC) Stage IV melanoma who underwent surgical resection of metastatic sites followed by treatment on a peptide vaccine trial were eligible for this study. Survival was calculated from the date of enrollment on the clinical trial.

RESULTS

Forty-one patients met inclusion criteria. The median age was 56.5 years, with approximately equal numbers of men and women. The ECOG performance status was 0 in all patients. Approximately 46% of patients underwent resection of visceral metastases before vaccine. The median follow-up was 5.6 years. The median overall survival was 3.8 years.

CONCLUSIONS

In selected patients with AJCC Stage IV melanoma, resection of metastatic disease followed by vaccine therapy can result in long-term survival.

Renal cell carcinoma

PURPOSE OF REVIEW

In this review we will highlight the recent novel contributions to the treatment of renal cell carcinoma in the fields of anti-angiogenesis, immunotherapeutics, and surgical management. In addition, this review will update recent advances in diagnostic and imaging modalities for renal cell carcinoma and dietary and environmental relationships to the epidemiology of this growing disease.

RECENT FINDINGS

Advancements in the use of innovative treatment strategies for the management of localized renal cell carcinoma and the introduction of new targeted therapeutics with benefit in the metastatic setting has produced a major impact on the treatment of this disease.

SUMMARY

The management of metastatic renal cell carcinoma has undergone a revolution in the past year with groundbreaking treatment strategies encompassing a broad range of therapeutic modalities. At the other end of the spectrum, emerging data is beginning to change our perspective about the management of small, localized renal tumors that are being discovered with increasing frequency. This review will update recent findings supporting diet and tobacco exposure as etiologic factors in the development of renal cell carcinoma, the molecular concepts that underlie the disease and the targeted therapeutics designed to inhibit specific kinase activities, and emerging use of minimally invasive therapies for localized disease.

Systemische Therapie des metastasierten Nierenzellkarzinoms

Cytokine-based immunotherapy was the only viable option in metastatic, nonresectable renal cell carcinoma (RCC) for many years. Systemic immunotherapy has become increasingly established as a standard therapy during the last 15 years. In this context, interleukin-2 (IL-2) and interferon-alpha (IFN-alpha) turned out to be the most effective single agents in RCC. Subsequently, the approved subcutaneous application of these compounds was the preferred administration route in Germany. Response rates with cytokine combination therapy were almost similar to those of more aggressive concepts using additional chemotherapeutic agents.Currently, new compounds targeting specific signaling pathways are readily available and have passed clinical testing. Such small molecules like tyrosine kinase inhibitors, monoclonal antibodies, or the mTOR inhibitor CCI-779 may dramatically change the established concepts of systemic RCC treatment. This paper gives an overview of established, current, and evolving concepts of systemic therapy in RCC.

Effect of Primary Tumor Extirpation in Breast Cancer Patients Who Present With Stage IV Disease and an Intact Primary Tumor

BACKGROUND

Currently, therapy for breast cancer patients with stage IV disease and an intact primary tumor is metastasis directed; the primary tumor is treated only when it causes symptoms. A recent review suggested that surgery may improve long-term survival in such patients. We evaluated the effect of surgery in such patients on long-term survival and disease progression.

METHODS

We reviewed the records of all breast cancer patients treated at our institution between 1997 and 2002 who presented with stage IV disease and an intact primary tumor. Information collected included demographics, tumor characteristics, site(s) of metastases, type/date of operation, use of radiotherapy, chemotherapy and hormonal therapy, disease progression (time to progression and location of progression) in the first year after diagnosis, and last follow-up. Overall and metastatic progression-free survival were compared between surgery and nonsurgery patients.

RESULTS

Of 224 patients identified, 82 (37%) underwent surgical extirpation of the primary tumor (segmental mastectomy in 39 [48%] and mastectomy in 43 [52%]), and 142 (63%) were treated without surgery. The median follow-up time was 32.1 months. After adjustment for other covariates, surgery was associated with a trend toward improvement in overall survival (P=.12; relative risk, .50; 95% confidence interval, .21-1.19) and a significant improvement in metastatic progression-free survival (P=.0007; relative risk, .54; 95% confidence interval, .38-.77).

CONCLUSIONS

Removal of the intact primary tumor for breast cancer patients with synchronous stage IV disease is associated with improvement in metastatic progression-free survival. Prospective studies are needed to validate these findings.

Metastatectomy prior to Immunochemotherapy for Metastatic Renal Cell Carcinoma

INTRODUCTION

We reviewed our experiences in performing cytoreductive metastatectomy before initiating systemic immunochemotherapy and tried to investigate potential prognostic factors for such an approach.

PATIENTS AND METHODS

A retrospective analysis of 57 patients who received interleukin-2, interferon-alpha, and 5-fluorouracil immunochemotherapy for metastatic renal cell carcinoma was conducted. Before undergoing immunochemotherapy, 20 of the 57 patients had received metastatectomy along with nephrectomy (metastatectomy group) and the other 37 nephrectomy alone (non-metastatectomy group).

RESULTS

The metastatectomy group demonstrated median disease-specific and progression-free survival of 23 and 13 months, respectively. The patients in the metastatectomy group were identified as having a better performance status and primarily demonstrating pulmonary metastasis compared with those in the non-metastatectomy group. As assessed in the metastatectomy group, factors such as the number of metastatic lesions, completeness of metastatectomy, and location of metastatic lesions (lung only vs. others) were observed to be significantly associated with overall survivals on univariate analysis.

CONCLUSIONS

Metastatectomy may still play a significant therapeutic role for metastatic renal cell carcinoma even in the era of immunochemotherapy as part of a multidisciplinary treatment approach in a selected group of patients in adequate general condition who have pulmonary-limited metastasis that can be completely resected.

Prospective randomized trial of natural interferon-alpha versus natural interferon-alpha plus cimetidine in advanced renal cell carcinoma with pulmonary metastasis

PURPOSE

In a preliminary non-randomized study, combination therapy with natural (i.e. non-recombinant) interferon-alpha plus cimetidine obtained a high response rate in patients with advanced renal cell carcinoma. We conducted a prospective randomized phase III trial to determine whether combination therapy with natural interferon-alpha plus cimetidine is superior to natural interferon-alpha alone in patients with advanced renal cell carcinoma with pulmonary metastasis.

METHODS

Patients received 5 million units (MU) natural interferon-alpha per day, five times a week, or the 5 MU natural interferon-alpha regimen plus a daily oral cimetidine. The primary and secondary end points were the response rate, and the time to progression (TTP), respectively.

RESULTS

Between April 1998 and March 2002, 71 patients from 32 institutions were randomly assigned to the 2 treatment groups. One patient in each group did not receive any natural interferon-alpha whatsoever. Two patients in the natural interferon-alpha alone group stopped treatment: on day 9 and on day 10, respectively. In the intent-to-treat analysis, 1 complete response (CR), 4 partial responses (PRs), 16 no changes (NCs), and 12 progressive diseases (PDs) were observed among the 36 patients in the interferon-alpha alone group with a response rate of 13.9%. Of the 35 patients in the natural interferon-alpha plus cimetidine group, there were two CRs, 8 PRs, 13 NCs, and 11 PDs, yielding a response rate of 28.6% (P=0.13). TTP ranged from 9 to 845 days (median 112 days) in the natural interferon-alpha-alone group, and from 31 to 1,568 days (median 125 days) in the natural interferon-alpha plus cimetidine group (P=0.87).

CONCLUSIONS

Combined treatment with natural interferon-alpha plus cimetidine for advanced renal cell carcinoma did not result in a significant improvement in response rates or TTP compared to natural interferon-alpha therapy alone.

Phase II Trial of Subcutaneous Interferon Followed by Intravenous Hybrid Bolus/Continuous Infusion Interleukin-2 in the Treatment of Renal Cell Carcinoma: Final Results of Cancer Biotherapy Research Group 95-09

OBJECTIVE

We conducted a phase II trial in metastatic renal cell cancer of outpatient subcutaneous (s.c.) interferon-alpha2b (IFN), followed by an inpatient hybrid schedule of bolus and continuous interleukin-2 (IL- 2).

METHODS

Treatment consisted of monthly IFN 10 MU/m(2) s.c. for 4 consecutive days, followed by 36 MIU/m(2) bolus IL-2, then 72-hour continuous intravenous (i.v.) infusion of 18 MIU/m(2) IL-2 per day. Between May 1997 and June 2000, 25 men and 11 women enrolled, with a median age of 57 years (range, 42-77), including 9 patients over 65. Prior treatment included nephrectomy (31), radiation (8), biotherapy (7), and chemotherapy (4). Sites of disease included 26 lung, 13 lymph node, 9 bone, 8 liver, 4 kidney, and 4 adrenal locations. Patients received an average of 3.1 treatment cycles (range, 1-6).

RESULTS

There was 1 complete and 3 partial responses, for a response rate of 11% (3% to 27%; 95% confidence interval [CI]); 40% had stable disease. Median failure-free survival was 2.5 months; median overall survival was 15.0 months. The 1-, 2-, and 5-year survival rates were 53%, 30%, and 12%, respectively. Only 8 patients required a reduction in IL-2 dose. The most frequent grade 3 or 4 toxicities were 11% fatigue, 9% renal insufficiency, and 7% hypotension.

CONCLUSIONS

Response and survival rates were similar to those seen in other multicenter trials using inpatient high-dose IL-2.

Renal cell carcinoma with nodal metastases in the absence of distant metastatic disease (clinical stage TxN1-2M0): the impact of aggressive surgical resection on patient outcome

PURPOSE

Nodal disease in the setting of metastatic renal cell carcinoma is associated with poor prognosis. However, to our knowledge the biology of nodal metastases in the absence of metastatic disease is unknown. We reviewed our experience with treating this subset of patients with aggressive surgical resection.

MATERIALS AND METHODS

A total of 2,643 patients underwent nephrectomy at our institution between 1993 and 2003, including 40 with positive lymph nodes but no systemic metastases. All 40 patients underwent nephrectomy with extended retroperitoneal lymphadenectomy and they are the subjects of this study. Pathological characteristics and clinical outcomes were assessed.

RESULTS

Median patient age was 58 years and 62% of the patients were male. Median tumor size was 11 cm. Local stage was T1 in 3% of cases, T2 in 17%, T3a in 30%, T3b in 47% and T4 in 3%. Perinephric fat invasion was present in 77% of patients and positive margins were identified in 17%. Nodal status was N1 in 30% of patients and N2 in 70%, including 10 with masses of matted nodes. Histology was conventional in 63% of cases and papillary in 17%. The remaining 20% of patients had sarcomatoid dedifferentiation. Excluding the 10 patients with matted nodes the median number of nodes harvested per patient was 7 with a median of 2 that were positive. Extranodal extension was present in 70% of cases, while in 70% disease recurred at a median of 4.9 months. Median actuarial disease specific survival was 20.3 months. At a median followup of 17.7 months 30% of patients had no evidence of disease, 8% had disease and 62% had died. On multivariate analysis more than 1 positive node was predictive of decreased recurrence-free survival (HR 2.83, 95% CI 1.06 to 7.61, p = 0.039) and overall survival (HR 9.33, 95% CI 1.85 to 47.09, p = 0.007).

CONCLUSIONS

Nodal metastasis with renal cell carcinoma is an independent predictor of prognosis in patients with M0 disease. Even in the absence of distant metastatic disease patients with positive nodes should be targeted for aggressive surgical resection, followed by clinical trials of adjuvant therapy to improve the outcome.

Early renal cell cancer

Renal cell cancer (RCC) mostly arises from the proximal renal tubules and is classified as an adenocarcinoma. The most reliable treatment for RCC is surgical excision; chemotherapy or radiotherapy does not have a practical effect on RCC. In selected patients, immunotherapy, including cytokine administration, has survival benefits. There is no established definition of early RCC. Surgical removal of organ-confined disease (T1 and T2) is likely to achieve tumor-free status leading to good prognosis. Possible definitions, diagnosis and treatment options for T1 and T2 disease are discussed.

Designing clinical trials for kidney cancer based on newly developed prognostic and predictive tools

Several advances have been made in our understanding of the molecular aberrations in renal cell carcinoma that have led to the identification of novel prognostic and predictive biomarkers. At the same time, several novel agents targeting these molecular aberrations have shown promising efficacy in the therapy of advanced renal cancer. As these agents enter more advanced-stage clinical trials, efforts must be made to integrate exploration of these novel prognostic and predictive markers into clinical trial design. These elements then can be combined with more traditional prognostic features to form more robust prognostic models. Finally, predictive markers and prognostic models should be validated prospectively, either as part of clinical trials designed specifically for that purpose or as part of large phase-3 trials. Once validated, these features can be used to best inform prognosis and guide therapy based on individual patient characteristics.

Long-term outcomes of the surgical management of renal cell carcinoma

It has been 35 years since the radical nephrectomy was standardized by the work of Robson et al. (J Urol 101:297-301, 1969). Despite being based on a retrospective review of only 88 cases operated upon over a span of 15 years, this publication was an important milestone in the attempt to create uniformity in the staging of Renal cell carcinoma (RCC), and the measurement of surgical outcomes for RCC. Although this manuscript forms the basis for our contemporary measurement of the long-term results of RCC surgery and set the standard to which the entire subsequent literature was compared, contemporary research subsequently has questioned many of Robson's conclusions regarding RCC. In Robson's era, the majority of patients presented with large, symptomatic tumors, pre-operative staging was imprecise, and many patients had locally advanced disease at the time of surgery: of the 88 patients in Robson's series, 75% were managed through a thoracoabdominal incision. Since that time, advances in renal imaging and clinical staging have led to the increased detection of incidental, lower stage, organ-confined tumors more amendable to expanded surgical options. Surgical techniques have evolved and technological advances have made possible new methods of managing renal tumors in situ that have emphasized a transition from radical to less extirpative approaches. In addition, understanding of the basic biology and genetics of kidney cancer has led to improved prognostication and the development of effective immunotherapies for advanced disease. The current concepts and long-term outcomes of the surgical management of RCC will be reviewed to help elucidate some of these changes, from the evolution of open to laparoscopic to percutaneous, from radical to partial to ablative approaches.

Promising systemic therapy for renal cell carcinoma

In the United States, advanced kidney cancer accounts for over 12,000 deaths each year. Immunotherapy with either interferon or interleukin-2 (IL-2) has been the standard of care for over two decades. High-dose IL-2 can apparently cure 10% to 15% of patients treated, but due to the required inpatient care and the attendant toxicities, it is only administered to less than 1,000 patients per year in the United States (Chiron, personal communication). Interferon is a less active agent than IL-2 but it has still been shown to be superior to therapy with either megesterol or vinblastine. Interferon typically results in very few long-term responses and is given to most patients with metastatic kidney cancer. Median survival after interferon therapy is dependent on risk group but is typically 12 to 15 months. Thus, new therapies are urgently needed in this refractory disease. Novel compounds currently being tested in clinical trials are showing promise in advanced kidney cancer. The molecular targets of these drugs include interfering with the vascular endothelial growth factor receptors or the raf kinase pathway, angiogenesis inhibition, and antimicrotubule agents. A review of the preclinical and early clinical development of some of these novel compounds will be discussed.

Gene expression profiling predicts survival in conventional renal cell carcinoma

BACKGROUND

Conventional renal cell carcinoma (cRCC) accounts for most of the deaths due to kidney cancer. Tumor stage, grade, and patient performance status are used currently to predict survival after surgery. Our goal was to identify gene expression features, using comprehensive gene expression profiling, that correlate with survival.

METHODS AND FINDINGS

Gene expression profiles were determined in 177 primary cRCCs using DNA microarrays. Unsupervised hierarchical clustering analysis segregated cRCC into five gene expression subgroups. Expression subgroup was correlated with survival in long-term follow-up and was independent of grade, stage, and performance status. The tumors were then divided evenly into training and test sets that were balanced for grade, stage, performance status, and length of follow-up. A semisupervised learning algorithm (supervised principal components analysis) was applied to identify transcripts whose expression was associated with survival in the training set, and the performance of this gene expression-based survival predictor was assessed using the test set. With this method, we identified 259 genes that accurately predicted disease-specific survival among patients in the independent validation group (p < 0.001). In multivariate analysis, the gene expression predictor was a strong predictor of survival independent of tumor stage, grade, and performance status (p < 0.001).

CONCLUSIONS

cRCC displays molecular heterogeneity and can be separated into gene expression subgroups that correlate with survival after surgery. We have identified a set of 259 genes that predict survival after surgery independent of clinical prognostic factors.

Indications and contraindications for the use of laparoscopic surgery for renal cell carcinoma

Surgery remains the only treatment with a chance of cure for renal cell carcinoma. Laparoscopic radical nephrectomy (LRN) has developed to be a standard treatment for the management of suspected renal malignancy in many centers worldwide, with oncologic efficacy equal to that of open radical nephrectomy. LRN has considerable advantages over open surgery, such as decreased postoperative morbidity, decreased analgesic requirements, and shorter hospital stay and convalescence. Current indications for LRN include all patients with localized stage T1-2 renal tumors. LRN for stage T3 renal tumors may be technically feasible in individual situations, but cannot be considered standard treatment. Open radical nephrectomy is reserved for advanced renal tumors, according to the surgeon's judgment. Partial nephrectomy is well established and considered to be the standard management for all organ-confined tumors of <or=4 cm in diameter. The scope of partial nephrectomy, however, is expanding, and now includes patients with organ-confined renal tumors of <or=7 cm. Laparoscopic partial nephrectomy is a continuously evolving technique. Continuing developments allow the experienced laparoscopist to use laparoscopic surgery for virtually all patients who are eligible for elective partial nephrectomy. This review evaluates the current indications and contraindications for laparoscopic radical and partial nephrectomy.