Cytoreductive Nephrectomy for Patients with Metastatic Sarcomatoid and/or Rhabdoid Renal Cell Carcinoma Treated with Immune Checkpoint Therapy

Deferred cytoreductive nephrectomy in patients with metastatic renal cell carcinoma: A systematic review and patient-level meta-analysis

There has been much controversy regarding the order in which cytoreductive nephrectomy (CN) and systemic therapy (ST) are applied for patients with metastatic renal cell carcinoma (mRCC). We aimed to investigate the role of deferred CN (dCN) in mRCC, particularly in the current era of immunotherapy. A systematic literature search was conducted on PubMed, Embase, and Scopus for studies comparing dCN versus any non-dCN strategy, in any temporal sequence, with the provision of Kaplan-Meier curves for overall survival (OS). A graphical reconstructive algorithm was used to obtain OS of individual patients, which was then pooled under random-effects individual patient data (IPD) meta-analysis using Cox-models to determine hazard ratios (HRs) and 95% CI. Altogether, 12 studies (5,350 patients) were analyzed. dCN (ST followed by CN) was associated with significantly improved OS over nondeferred CN (CN followed by ST, ST alone, or CN alone) (HR = 0.60, 95% CI, 0.53-0.67, P < 0.001). Subgroup comparisons restricted to studies comparing dCN versus upfront CN (uCN, CN then ST) were also in favor of dCN (HR = 0.69, 95% CI, 0.61-0.78, P < 0.001), even among those in which immunotherapy as ST was used in all patients (HR = 0.57, 95% CI, 0.39-0.84, P = 0.005). In mRCC patients suitable for CN, dCN is associated with significantly improved OS over nondeferred CN strategies, including uCN. Although limited by inclusion of nonrandomized studies and immortal time bias, this meta-analysis strengthens existing guidelines to offer dCN to surgically fit patients who do not progress on ST in the current age of immunotherapy.

Immune-Based and Novel Therapies in Variant Histology Renal Cell Carcinomas

Renal cell carcinoma (RCC) is a heterogeneous disease that represents the most common type of kidney cancer. The classification of RCC is primarily based on distinct morphological and molecular characteristics, with two broad categories: clear cell RCC (ccRCC) and non-clear cell RCC (nccRCC). Clear cell RCC is the predominant subtype, representing about 70-80% of all RCC cases, while non-clear cell subtypes collectively make up the remaining 20-30%. Non-clear cell RCC encompasses many histopathological variants, each with unique biological and clinical characteristics. Additionally, any RCC subtype can undergo sarcomatoid dedifferentiation, which is associated with poor prognosis and rapid disease progression. Recent advances in molecular profiling have also led to the identification of molecularly defined variants, further highlighting the complexity of this disease. While immunotherapy has shown efficacy in some RCC variants and subpopulations, significant gaps remain in the treatment of rare subtypes. This review explores the outcomes of immunotherapy across RCC subtypes, including rare variants, and highlights opportunities for improving care through novel therapies, biomarker-driven approaches, and inclusive clinical trial designs.

Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma Treated with Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis of Individual Patient Data

BACKGROUND AND OBJECTIVE

The role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) in the era of immune checkpoint inhibitors (ICIs) is controversial. We aimed to investigate the survival benefit of CN in patients with mRCC treated with ICIs.

METHODS

We searched the EMBASE, MEDLINE, and Web of Science databases up to August 26, 2023 to identify studies comparing overall survival (OS) for patients with mRCC treated with ICIs with or without CN. We reconstructed individual patient data using published Kaplan-Meier curves and performed one- and two-stage meta-analyses using 6-mo and 12-mo landmarks to control for immortal time bias. We also performed subgroup analyses for patients treated with first-line ICI or upfront CN.

KEY FINDINGS AND LIMITATIONS

We identified eight eligible studies involving a total of 2319 patients. There were statistically significant differences in baseline characteristics (age, clear cell histology, International mRCC Database Consortium scores) between the ICI + CN and ICI-alone groups. Combined CN + ICI therapy was associated with superior OS in the primary analysis (hazard ratio [HR] 0.45, 95% confidence interval [CI] 0.37-0.54) and secondary analyses, and in subgroup analyses for patients receiving first-line ICI therapy (HR 0.39, 95% CI 0.30-0.48) and upfront CN (HR 0.52, 95% CI 0.40-0.69).

CONCLUSIONS AND CLINICAL IMPLICATIONS

CN combined with ICI therapy in mRCC may be associated with superior OS. Further studies are needed to confirm this finding and identify the patients most likely to benefit from CN in this setting.

PATIENT SUMMARY

We compared outcomes after immune checkpoint inhibitor (ICI) therapy, which boosts the immune system to fight cancer, with or without nephrectomy (surgical removal of the kidney) in patients with metastatic kidney cancer. We found that the combination of nephrectomy and ICI therapy was associated with better survival than just ICI therapy.

Stage III xanthogranulomatous pyelonephritis with sarcomatoid degeneration

Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic condition characterized by destructive granulomatous disease of the kidney with uncertain etiology. Significant risk factors for XGP are represented by the coexistence of history of nephrolithiasis, diabetes mellitus, recurrent urinary tract infections and other immunocompromised conditions. It is also associated with higher risk of malignancy, reported in up to 11% of patients. We report a case of a 76-year-old female who presented to the emergency department with an insidious onset of abdominal and right lower back pain. She had a history of renal stones and diabetes mellitus. On physical examination, a painful fistulous orifice in skin on the right lumbar region was found. CT images showed a nonfunctioning right kidney replaced by multiple necrotic cavities with inflammatory involvement of the right hepatic lobe and a nephron-cutaneous fistula. These CT findings were strongly suggestive of XGP (III state). CT images obtained before and after the administration of intravenous contrast material showed also a hyper-vascularized renal mass with irregularly thickened walls confirmed by a targeted CEUS examination and suspicious for malignancy. Pathologic examination confirmed the chronic pyelonephritis and revealed evidence of a concomitant sarcomatoid lesion. This case underlines the central role of a multimodality imaging approach in the emergency department and how this affects the correct management and treatment of patients. In fact, MDCT is considered the current gold standard for the diagnosis and the staging of XPG but the contrast-enhanced ultrasound (CEUS) in selected patients can increase the diagnostic accuracy in the uncertain small renal masses detected on CT scans.

Clinical features and response to immune combinations in patients with renal cell carcinoma and sarcomatoid de-differentiation (ARON-1 study)

Metastatic renal cell carcinoma (mRCC) carrying sarcomatoid features (sRCC) has aggressive biology and poor prognosis. First-line immunotherapy (IO)-based combinations have improved the outcome of clear cell RCC patients, including that of sRCC. Real-world data confirming the adequate first-line management of sRCC is largely lacking. We investigated the clinical features and the outcome of sRCC patients treated with IO-based combinations within the ARON-1 study population (NCT05287464). The primary objective was to define the incidence and baseline clinical characteristics of sRCC compared with non-sRCC patients. The secondary objective was to describe the outcome of sRCC patients based on type of first-line treatment (IO + IO vs. IO + tyrosin kinase inhibitor [TKI]). We identified 1362 mRCC patients with IMDC intermediate or poor risk, 226 sRCC and 1136 non-sRCC. These two subgroups did not differ in terms of baseline characteristics. The median overall survival (OS) was 26.8 months (95%CI 21.6-44.2) in sRCC and 35.3 months (95%CI 30.2-40.4) in non-sRCC patients (p = .013). The median progression-free survival (PFS) was longer in non-sRCC patients compared to sRCC (14.5 vs. 12.3 months, p = .064). In patients treated with first-line IO + TKI the median OS was 34.4 months compared to 26.4 months of those who received IO + IO (p = .729). The median PFS was 12.4 months with IO + TKI and 12.3 months with IO + IO (p = .606). In conclusion, we confirm that sRCC are aggressive tumors with poor prognosis. IO-based combinations improve survival outcomes of sRCC patients, regardless from the type of strategy (IO + IO versus IO + TKI) adopted.

Head-to-head comparisons of enhanced CT, 68Ga-PSMA-11 PET/CT and 18F-FDG PET/CT in identifying adverse pathology of clear-cell renal cell carcinoma: a prospective study

OBJECTIVES

Accurate preoperative prediction of adverse pathology is crucial for treatment planning of renal cell carcinoma (RCC). Previous studies have emphasized the potential of prostate-specific membrane antigen positron emission tomography / computed tomography (PSMA PET/CT) in differentiating between benign and malignant localized renal tumors. However, there is a scarcity of case reports elucidating the identification of aggressive pathological features using PET/CT. Our study was designed to prospectively compare the diagnostic value of enhanced CT, 68Ga-PSMA-11 and 18F-fluorodeoxyglucose (18F-FDG) PET/CT in clear-cell renal cell carcinoma (ccRCC) with necrosis or sarcomatoid or rhabdoid differentiation.

MATERIALS AND METHODS

A prospective case series of patients with a newly diagnosed renal mass who underwent enhanced CT, 68Ga-PSMA-11 and 18F-FDG PET/CT within 30 days prior to nephrectomy was included. Complete preoperative and postoperative clinicopathological data were recorded. Patients who received neoadjuvant targeted therapy, declined enhanced CT or PET/CT scanning, refused surgical treatment or had non-ccRCC pathological indications were excluded. Radiological parameters were compared within subgroups of pathological characteristics. Bonferroni corrections were used to adjust for multiple testing and statistical significance was set at a p-value less than 0.017.

RESULTS

Seventy-two patients were available for the final analysis. Enhanced CT demonstrated poor performance in identifying necrosis, sarcomatoid or rhabdoid differentiation and adverse pathology (all P > 0.05). The maximum standardized uptake value (SUVmax) of 68Ga-PSMA-11 PET/CT was more effective than 18F-FDG PET/CT in identifying tumor necrosis and adverse pathology, with an area under the curve (AUC) of 0.85 (cutoff value=25.26, p<0.001; Delong test z=2.709, p=0.007) for tumor necrosis and AUC of 0.90 (cutoff value=25.26, p<0.001; Delong test z=3.433, p<0.001) for adverse pathology. However, no significant statistical difference was found between 68Ga-PSMA-11 and 18F-FDG PET/CT in predicting sarcomatoid or rhabdoid feature (AUC of 0.91 vs.0.75, Delong test z=1.998, p=0.046). Subgroup analyses based on age, sex, tumor location, maximal diameter, stage and WHO/ISUP grade demonstrated that 68Ga-PSMA-11 PET/CT SUVmax had a significant predictive value for adverse pathology. Enhanced CT value and SUVmax demonstrated strong reliability [intraclass correlation coefficient (ICC) > 0.80], indicating a robust correlation.

CONCLUSIONS

68Ga-PSMA-11 PET/CT demonstrates distinct advantages in identifying aggressive pathological features of primary ccRCC when compared to enhanced CT and 18F-FDG PET/CT. Further research and assessment are warranted to fully establish the clinical utility of 68Ga-PSMA-11 PET/CT in ccRCC.

The Evolving Landscape of Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma

The role of cytoreductive nephrectomy in metastatic renal cell carcinoma (RCC) has been studied intensively over the past few decades. Interestingly, the opinion with regard to the importance of this procedure has switched from a recommendation as a standard of care to an almost complete refutation. However, no definitive agreement on cytoreductive nephrectomy, including the pros and cons of the procedure, has been reached, and the topic remains highly controversial. With the advent of immune checkpoint inhibitors, we have experienced a paradigm shift, with immunotherapy playing a crucial role in the treatment algorithm. Nevertheless, obtaining results from prospective clinical trials on the role of cytoreductive nephrectomy requires time, and once some data have been gathered, the standards of systemic therapy may be different, and we stand again at the beginning. This review summarizes current knowledge on the topic in the light of newly evolving treatment strategies. The crucial point is to recognize who could be an appropriate candidate for immediate cytoreductive surgery that may facilitate the effect of systemic therapy through tumor debulking, or who might benefit from deferred cytoreduction in the setting of an objective response of the tumor. The role of prognostic factors in management decisions as well as the technical details associated with performing the procedure from a urological perspective are discussed. Ongoing clinical trials that may bring new evidence for transforming therapeutic paradigms are listed.