Phase I Study of Dalteparin in Combination With Sunitinib in Patients With Metastatic Clear Cell Renal Carcinoma

The Role of Anticoagulation in Tumor Thrombus Associated with Renal Cell Carcinoma: A Literature Review

Tumor thrombus (TT) is a complication of renal cell carcinoma (RCC) for which favorable medical management remains undefined. While radical nephrectomy has been shown to increase overall survival in RCC patients, surgical interventions such as cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) utilized to perform TT resection carry high mortality rates. While it has been documented that RCC with TT is associated with venous thromboembolism (VTE) development, anticoagulation use in these patients remains controversial in clinical practice. Whether anticoagulation is associated with improved survival outcomes remains unclear. Furthermore, if anticoagulation is initiated, there is limited evidence for whether direct oral anticoagulants (DOACs), heparin, or warfarin serve as the most advantageous choice. While the combination of immunotherapy and tyrosine kinase inhibitors (TKIs) has been shown to improve the outcomes of RCC, the clinical benefits of this combination are not well studied prospectively in cases with TT. In this literature review, we explore the challenges of treating RCC-associated TT with special attention to anticoagulation. We provide a comprehensive overview of current surgical and medical approaches and summarize recent studies investigating anticoagulation in RCC patients undergoing surgery, targeted therapy, and/or immunotherapy. Our goal is to provide clinicians with updated clinical insight into anticoagulation for RCC-associated TT patients.

Cancer-associated thrombosis and drug-drug interactions of antithrombotic and antineoplastic agents

Venous thromboembolism (VTE) is often associated with malignant diseases and notably contributes to morbidity and mortality in patients with cancer. Cancer-associated thrombosis (CAT) brings additional costs to health expenditures and has a negative impact on oncological outcomes. Either the recurrence rate of VTE or bleeding complications are also higher in patients with cancer. Prophylactic anticoagulation has been recommended in peri-surgical periods, inpatient settings, and high-risk ambulatory patients. Although various risk stratification scores are used, none are ideal for identifying patients who can benefit from anticoagulant prophylaxis. New risk scoring systems or biomarkers are needed to identify patients who are more likely to benefit from prophylaxis with low bleeding risk. The questions about the patients who will be given prophylaxis and those who develop thromboembolism, with which drug, and how long they will be treated are still not fully answered. Anticoagulation is the cornerstone of the treatment, but management of CAT remains complex. Low molecular weight heparins and direct oral anticoagulants are effective and safe options for the treatment of CAT. Recognizing adverse effects, drug-drug interactions, and accompanying conditions that cause dose adjustment is crucial. Prevention and treatment of VTE in patients with cancer require a multidisciplinary and patient-based approach. PLAIN LANGUAGE SUMMARY: Cancer-associated thrombosis is a significant cause of mortality and morbidity in patients with cancer. Chemotherapy, surgery, and/or use of central venous access remarkably increase the risk of thrombosis. Prophylactic anticoagulation should be considered not only in inpatient follow-up and during peri-surgical period but also ambulatory patients with a high risk of thrombosis. Many parameters, such as drug-drug interactions, primary side of cancer, and comorbidities of patients should be considered when selecting anticoagulant drugs. More accurate risk stratification scores or biomarkers are still an unmet need.

The 5 most frequently asked questions about factor Xa inhibitors

Direct oral anticoagulants (DOACs) are commonly used oral factor Xa inhibitors in recent years. However, in some special clinical situations, the appropriate use of these anticoagulants may be of concern. In this article, we address the 5 commonly asked questions regarding their use for the treatment of venous thromboembolism, including in the setting of obesity, renal impairment, gastrointestinal (GI) malignancy, catheter-related thrombosis, and drug-drug interactions. Data on the use of DOACs in the presence of significant obesity or renal failure are mainly observational. Some DOACs are shown to have an increased risk of bleeding in patients with unresected luminal GI malignancy but not others, so selection of appropriate patients is the key. Furthermore, literature on the use of DOACs for catheter-related thrombosis or when drug-drug interactions are of concern is limited, and more research is welcome.

Identification of key genes of the ccRCC subtype with poor prognosis

Clear cell renal carcinoma has been reported in many research studies as a rather heterogeneous disease. Identification of different subtypes and their molecular characteristics can help in choosing a more effective treatment and predicting a response to it. In this study, using multi-omics clustering of RNA-Seq data of patients with clear cell renal carcinoma from TCGA. Specific genes were identified for the most aggressive ccRCC subtype associated with metastasis and a subtype associated with a more favorable course of the disease. Among them were genes associated with blood clotting (FGA, FGG) and genes associated with changes in the immune characteristics of a tumor (ENAM, IGFBP1, IL6). In addition, an association of hub genes of poor survival ccRCC subtype with the levels of infiltration of endothelial cells, hematopoietic stem cells, T cells NK and mast cells was revealed. It was shown that MFI2, CP, FGA, and FGG expression can predict the response to sunitinib, while the APOB, ENAM, IGFBP1, and MFI2 expression predict the response to nivolumab. The results obtained provide insight into the genetic characteristics underlying the aggressive subtype of ccRCC and may help develop new approaches to the treatment of this disease.

Effects of BAP1, Ki-67 index, and Id-1 in patients with clear cell renal carcinoma and their correlation with clinical features and prognosis

Background

Clear cell renal carcinoma (CCRCC) is a multigene-related tumor. The aim of the present study was to analyze the expression of breast cancer 1-associated protein 1 (BAP1), Ki-67, and inhibitor of differentiation-1 (Id-1) in CCRCC patients and their correlation with clinical features and prognosis.

Methods

A total of 45 CCRCC patients who were diagnosed and treated at our hospital from January 2016 to January 2018 were included in the present study. BAP1, Ki-67, and Id-1 protein expression in the CCRCC tissue group and adjacent mucosa group was compared. The correlation between BAP1, Ki-67, and Id-1 proteins, and the clinical characteristics and the prognosis of CCRCC patients, were analyzed. Multiple logistic regression was used to analyze the risk factors that affect the prognosis of CCRCC patients.

Results

The negative rate of BAP1 in the CCRCC group was higher than that in the adjacent mucosa group. There were more patients with a Ki-67 index >10 and a higher Id-1-positive rate in the CCRCC tissue group. BAP-1, Ki-67 index, and Id-1 protein expression were not correlated with age, sex, surgical method, microscopic necrosis, and degree of sarcomatoid characteristics of CCRCC patients (P>0.05), but were related to tumor diameter, pathological stage, TNM stage, and World Health Organization (WHO)/Internal Society of Urologic Pathology (ISUP) grade. The Kaplan-Meier survival curve showed that the average survival time of the BAP1-negative group, Ki-67 index >10 group, and Id-1 protein-positive group was shorter than that of the BAP1-positive group, Ki-67 index ≤10 group, and Id-1 protein-negative group, respectively. Pathological staging, WHO/ISUP classification, negative BAP1, Ki-67 index >10, and positive Id-1 protein were independent risk factors affecting CCRCC patients (P<0.05).

Conclusions

The expression of BAP1 in CCRCC patients decreased, and the expression of Ki-67 and Id-1 protein increased. Abnormal expression levels of BAP1, Ki-67, and Id-1 proteins were involved in the occurrence and development of CCRCC, and closely related to the prognosis of patients. These can be used as molecular markers for predicting the prognosis of CCRCC patients and as potential targets for tumor treatment.

Oral Intake of Royal Jelly Has Protective Effects Against Tyrosine Kinase Inhibitor-Induced Toxicity in Patients with Renal Cell Carcinoma: A Randomized, Double-Blinded, Placebo-Controlled Trial

Background: Although tyrosine kinase inhibitors (TKIs) are still recommended as the standard therapy in renal cell carcinoma (RCC), the high frequency of adverse events is a weakness of this therapy. Because royal jelly (RJ) possesses anti-inflammatory and antioxidant properties, we assessed its protective effects on TKI-induced toxicities in RCC patients. Methods: We enrolled 33 patients with advanced RCC who were assigned to start TKI therapy in combination with a randomized, double-blinded, placebo-controlled RJ trial consisting of a placebo group with 17 subjects and an RJ group with 16 subjects. Results: Fatigue and anorexia frequencies in the RJ group were significantly lower than in the placebo group (p = 0.003 and 0.015, respectively). A statistically significant correlation between RJ and fatigue or anorexia was detected in sunitinib-treated patients. The dose reduction- or discontinuation-free periods were significantly longer (p = 0.013) in the RJ group than in the placebo group. Furthermore, similar observations were made in sunitinib-treated patients (p = 0.016). Conclusions: Our clinical trial showed that RJ exerted protective effects against TKI-induced fatigue and anorexia and lowered TKI dose reduction or discontinuation. Hence, RJ is beneficial for maintaining the quality of life and medication compliance in TKI-treated RCC patients.

Therapeutic Targeting of Sunitinib-Induced AR Phosphorylation in Renal Cell Carcinoma

Androgen receptor (AR) plays a crucial role in the development and progression of prostate cancer. AR expression has also been reported in other solid tumors, including renal cell carcinoma (RCC), but its biological role here remains unclear. Through integrative analysis of a reverse phase protein array, we discovered increased expression of AR in an RCC patient-derived xenograft model of acquired resistance to the receptor tyrosine kinase inhibitor (RTKi) sunitinib. AR expression was increased in RCC cell lines with either acquired or intrinsic sunitinib resistance in vitro An AR signaling gene array profiler indicated elevated levels of AR target genes in sunitinib-resistant cells. Sunitinib-induced AR transcriptional activity was associated with increased phosphorylation of serine 81 (pS81) on AR. Additionally, AR overexpression resulted in acquired sunitinib resistance and the AR antagonist enzalutamide-induced AR degradation and attenuated AR downstream activity in sunitinib-resistant cells, also indicated by decreased secretion of human kallikrein 2. Enzalutamide-induced AR degradation was rescued by either proteasome inhibition or by knockdown of the AR ubiquitin ligase speckle-type POZ protein (SPOP). In vivo treatment with enzalutamide and sunitinib demonstrated that this combination efficiently induced tumor regression in a RCC model following acquired sunitinib resistance. Overall, our results suggest the potential role of AR as a target for therapeutic interventions, in combination with RTKi, to overcome drug resistance in RCC.Significance: These findings highlight the therapeutic potential of targeting the androgen receptor to overcome RCC resistance to receptor tyrosine kinase inhibitors. Cancer Res; 78(11); 2886-96. ©2018 AACR.