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Zhang Z, Xiong L, Wu Z, Liu H, Ning K, Peng Y, Yu C, Ding Y, Weng D, Xia J, Jiang L, Guo S, Han H, Zhou F, Dong P. Neoadjuvant combination of pazopanib or axitinib and programmed cell death protein-1-activated dendritic cell-cytokine-induced killer cells immunotherapy may facilitate surgery in patients with renal cell carcinoma. Transl Androl Urol 2021; 10:2091-2102. [PMID: 34159090 PMCID: PMC8185689 DOI: 10.21037/tau-21-406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Radical/cytoreductive nephrectomy or nephron-sparing surgery may be thought to be not safe or unfeasible in some renal cell carcinoma (RCC) patients in which tumor is locally advanced or highly complicated. Neoadjuvant therapy may reduce the volume of the tumor, thus facilitates surgery. The aim the study is to evaluate the efficacy and safety of neoadjuvant combination of pazopanib or axitinib and PD-1-activated dendritic cell-cytokine-induced killer (PD-1/DC-CIK) cell immunotherapy in those patients. Methods Data from 16 RCC patients who received neoadjuvant pazopanib (Group P, n=9) or axitinib (Group A, n=7) plus PD-1/DC-CIK cells immunotherapy were reviewed retrospectively. A total of 9 participants that were potential candidates for radical/cytoreductive nephrectomy (RN/CN) had locally advanced tumor and 5 participants with partial nephrectomy (PN) absolute indications had highly complicated tumors. The efficacy outcomes were based on volume changes of the primary tumor, lymph nodes, and tumor thrombus in 13 participants with complete computed tomography (CT) imaging. The treatment-related toxicities and surgical complications were also reported. Results With a median of 2.1 months treatment, the overall volume of the tumors decreased by a median of 42.30% [interquartile range (IQR): 19.37–66.78%]. Specifically, the median reduction of tumor volume was 88.77 and 15.50 cm3 in group P and group A, respectively (P=0.014). However, participants in Group P were more likely to experience grade 3 or 4 treatment-related adverse events (AEs) than those in Group A (44.4% vs. 0). Finally, all participants were candidates for appropriate surgery after neoadjuvant therapy (as assessed by the surgeon), and 10 participants accepted surgery, including 5 PN, 4 RN/CN, and 1 lymph node dissection. A solitary participant had Clavien grade IV acute renal failure required dialysis and another had grade II lymphatic leakage. Conclusions Neoadjuvant combination of pazopanib or axitinib and PD-1/DC-CIK cells immunotherapy was well-tolerated and could effectively reduce the volume of tumors in locally advanced or highly complicated RCC patients.
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Affiliation(s)
- Zhiling Zhang
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Longbin Xiong
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zeshen Wu
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Huiming Liu
- State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Kang Ning
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yulu Peng
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Chunping Yu
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ya Ding
- State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Biotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Desheng Weng
- State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Biotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jianchuan Xia
- State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Biotherapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lijuan Jiang
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shengjie Guo
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hui Han
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Fangjian Zhou
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Pei Dong
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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2
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Bilen MA, Jiang JF, Jansen CS, Brown JT, Harik LR, Sekhar A, Kissick H, Maithel SK, Kucuk O, Carthon B, Master VA. Neoadjuvant Cabozantinib in an Unresectable Locally Advanced Renal Cell Carcinoma Patient Leads to Downsizing of Tumor Enabling Surgical Resection: A Case Report. Front Oncol 2021; 10:622134. [PMID: 33598435 PMCID: PMC7882722 DOI: 10.3389/fonc.2020.622134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/15/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction Cabozantinib (XL-184) is a small molecule inhibitor of the tyrosine kinases c-Met, AXL, and VEGFR2 that has been shown to reduce tumor growth, metastasis, and angiogenesis. After the promising results from the METEOR and CABOSUN trials, cabozantinib was approved for use in the first- and second-line setting in patients with advanced RCC. Previously, targeted therapies have been used in the neoadjuvant setting for tumor size reduction and facilitating nephrectomies. The increased response rates with cabozantinib in metastatic renal cell carcinoma (mRCC), along with the other neoadjuvant TKI data, strongly support an expanded role for cabozantinib in the neoadjuvant setting. Case Description We report on a 59-year-old gentleman presenting with an unresectable 21.7 cm left renal cell carcinoma (RCC) with extension to soft tissue and muscles of the thoracic cage, psoas muscle, posterior abdominal wall, tail of pancreas, splenic flexure of colon, and inferior margin of spleen. Presurgical, neoadjuvant systemic therapy with cabozantinib was initiated for 11 months in total. Initially after 2 months of cabozantinib, magnetic resonance imaging (MRI) revealed a significant reduction (44.2%) in tumor diameter from 21.7 to 12.1 cm with decreased extension into adjacent structures. After 11 months total of cabozantinib, the corresponding MRI showed grossly stable size of the tumor and significant resolution of invasion of adjacent structures. After washout of cabozantinib, radical resection, including nephrectomy, was successfully performed without any major complications, either intra-operative or perioperative. Negative margins were achieved. Conclusions This is a report of neoadjuvant cabozantinib downsizing a tumor and enabling surgical resection in this patient with locally advanced RCC. Our findings demonstrate that neoadjuvant cabozantinib to facilitate subsequent surgical resection may be a feasible option for patients presenting with unresectable RCC.
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Affiliation(s)
- Mehmet A Bilen
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, United States.,Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - James F Jiang
- Department of Urology, Emory University, Atlanta, GA, United States
| | | | - Jacqueline T Brown
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, United States.,Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - Lara R Harik
- Department of Pathology, Emory University, Atlanta, GA, United States
| | - Aarti Sekhar
- Department of Radiology, Emory University, Atlanta, GA, United States
| | - Haydn Kissick
- Department of Urology, Emory University, Atlanta, GA, United States
| | | | - Omer Kucuk
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, United States.,Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - Bradley Carthon
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, United States.,Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - Viraj A Master
- Winship Cancer Institute of Emory University, Atlanta, GA, United States.,Department of Urology, Emory University, Atlanta, GA, United States
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Jin H, Zhang M, Jin K, Hu C. Adjuvant targeted therapy combined with surgery for advanced and metastatic renal cell carcinoma: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2021; 100:e23956. [PMID: 33545974 PMCID: PMC7838006 DOI: 10.1097/md.0000000000023956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The aim of this systematic review and meta-analysis is to evaluate the efficacy and safety of adjuvant targeted therapy by sunitinib combined with surgery in the treatment of advanced or metastatic renal cell carcinoma. METHODS PubMed/Medline, Web of Science, Cochrane Library, ClinicalTrials.gov (http://www.ClinicalTrials.gov), China National Knowledge Infrastructure (CNKI) will be searched for clinical research articles related to the efficacy and safety of adjuvant therapy combined with surgery in the treatment of advanced and metastatic RCC. The identification, inclusion and exclusion flow charts will be conducted according to the PRISMA guidelines. The quality assessment will be done by Quadas-2 evaluation tool. Key parameters including OS in 10, 20, 30, and 40 months, PFS in 10, 20, and 30 months, objective response rate (ORR), stable disease (SD) rate, progressive disease (PD) rate, median OS and PFS, types of AEs and their occurrence rates, etc will be extracted. The evaluation of the efficacy and safety will be pooled by CMA. RESULTS This systematic review will provide evidence on the efficacy and safety of adjuvant therapy by sunitinib combined with surgery in treating advanced and metastatic RCC. CONCLUSION The study aims to generalize data concerning the response rate, OS, PFS and rates of adverse effects of the perioperative use of sunitinib in advanced and metastatic RCC patients. The evidence provided by this systematic review and meta-analysis will help guide the clinical decision making and enlighten the future management of advanced or metastatic RCC. REGISTRATION This protocol has been registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY registration number: INPLASY2020110093; INPLASY DOI number: 10.37766/inplasy2020.11.0093 Available at: https://inplasy.com).
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Affiliation(s)
- Hongyu Jin
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu
| | - Man Zhang
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University; Key Laboratory of Obstetric & Gynecologic and Pediatric Disease and Birth Defects of Ministry of Education
| | - Kun Jin
- Department of Urology, Institute of Urology
| | - Chenggong Hu
- Department of Critical Care Unit, West China Hospital, Sichuan University, Chengdu, China
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Elective Cytoreductive Nephrectomy After Checkpoint Inhibitor Immunotherapy in Patients With Initially Unresectable Metastatic Clear Cell Renal Cell Carcinoma. Clin Genitourin Cancer 2020; 18:361-366. [PMID: 32417157 DOI: 10.1016/j.clgc.2020.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 01/16/2023]
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Carvalho FLF, Zheng C, Witmer K, O'neill J, Lynch JH, Kowalczyk KJ. Complications associated with perioperative use of tyrosine kinase inhibitor in cytoreductive nephrectomy. Sci Rep 2019; 9:15272. [PMID: 31649310 PMCID: PMC6813342 DOI: 10.1038/s41598-019-51548-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 10/01/2019] [Indexed: 11/09/2022] Open
Abstract
Recent clinical trials have investigated the benefit of combining tyrosine kinase inhibitors (TKIs) and cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma. Our goal is to determine whether the perioperative use of TKIs increases the postoperative morbidity following CN in renal cell carcinoma patients. We identified 627 patients with Stage IV renal cell carcinoma who underwent CN from 2007–2010 utilizing the SEER-Medicare database. Eighty-two patients treated with TKIs were matched (3:1) to 246 controls. We calculated 30- and 90-day incidence rates of postoperative complications and mortality. On unadjusted analysis, TKI use prior to CN was associated with higher overall complication rate within 30 days (HR = 2.73, 95% CI: 1.09–6.8) after surgery. On multivariate analysis, perioperative TKI use was independently associated with higher risk for postoperative complications within 30 days (HR = 2.93, 95% CI: 1.17–7.36), as well as 90 days (HR = 1.84, 95% CI: 1.02–3.32) after nephrectomy. A higher Charlson comorbidity index also emerged to represent an independent risk factor for postoperative complications within 30 days (HR = 2.41, 95% CI: 1.44–4.02) and 90 days (HR = 2.23, 95% CI: 1.51–3.29) after nephrectomy. TKI treatment was not associated with an increased postoperative mortality at 30 and 90 days after surgery. Thus, TKI treatment was associated with an increased complication rate but not overall mortality following CN. Our results suggest that renal surgeons should be aware of possibly increased complications following CN in renal cell carcinoma patients, when TKI treatment is administered.
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Affiliation(s)
- Filipe L F Carvalho
- Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA.
| | - Chaoyi Zheng
- Department of Biostatistics, Bioinformatics, and Biomathematics, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Kenneth Witmer
- Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - John O'neill
- Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - John H Lynch
- Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Keith J Kowalczyk
- Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA
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6
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Jin H, Zhang J, Shen K, Hao J, Feng Y, Yuan C, Zhu Y, Ma X. Efficacy and safety of perioperative appliance of sunitinib in patients with metastatic or advanced renal cell carcinoma: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15424. [PMID: 31096438 PMCID: PMC6531174 DOI: 10.1097/md.0000000000015424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The aim of this systematic review and meta-analysis is to comprehensively evaluate the efficacy and safety of the perioperative use of sunitinib in patients with metastatic and advanced renal cell carcinoma (RCC). MATERIALS AND METHODS We searched authenticated databases for related clinical studies. The baseline characteristics, parameters concerning the efficacy and safety of the perioperative use of sunitinib were extracted for subsequent comprehensive analysis. The parameters which reflected the efficacy and safety as overall survival (OS), progression-free survival (PFS), occurrence rate of all-grade and grade ≥3 adverse effects (AEs) were carefully pooled using comprehensive meta-analysis. RESULTS We finally recruited 411 patients from 14 eligible studies. We found proteinuria (75.0%, 95% CI 62.1%-84.6%), anemia (71.6%, 95% CI 60.9%-80.3%), athesia (60.0%, 95% CI 40.3%-77.0%), pause symptoms (59.2%, 95% CI 49.2%-68.4%), arterial hypertension (53.1%, 95% CI 43.2%-62.7%), and thrombocytopenia (52.5%, 95% CI 44.8%-60.0%) to be the most common all-grade AEs. And arterial hypertension, athesia, cutaneous toxicity, hypophosphatemia, leukopenia, pain, pause syndrome, renal dysfunction, and thrombocytopenia were the most common types of grade ≥3 AEs. In addition, objective response rate (ORR) of sunitinib to both the original and metastatic tumor sites increased with the use of sunitinib, so did the OS and PFS. CONCLUSION Common all-grade and grade ≥3 AEs were carefully monitored. The perioperative use of sunitinib showed superior ORR, OS, and PFS rates. Nevertheless, more studies are required to further verify these findings.
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Affiliation(s)
- Hongyu Jin
- Department of Biotherapy and Cancer Center, State Key Laboratory of Biotherapy, West China Hospital
- West China School of Medicine
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jing Zhang
- Department of Biotherapy and Cancer Center, State Key Laboratory of Biotherapy, West China Hospital
- West China School of Medicine
| | - Kai Shen
- Department of Biotherapy and Cancer Center, State Key Laboratory of Biotherapy, West China Hospital
- West China School of Medicine
| | | | | | | | | | - Xuelei Ma
- Department of Biotherapy and Cancer Center, State Key Laboratory of Biotherapy, West China Hospital
- West China School of Medicine
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7
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Grivas NK. Neoadjuvant targeted therapy for advanced renal cell carcinoma: Where do we stand? Urol Ann 2019; 11:115-116. [PMID: 30787586 PMCID: PMC6362785 DOI: 10.4103/0974-7796.250549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Nikolaos K Grivas
- Department of Urology, "G. Hatzikosta" General Hospital, Ioannina, Greece
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8
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Assessment of the risk of antiangiogenic agents before and after surgery. Cancer Treat Rev 2018; 68:38-46. [DOI: 10.1016/j.ctrv.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/16/2018] [Accepted: 05/07/2018] [Indexed: 12/13/2022]
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9
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Guo G, Cai W, Li H, Gao J, Ma X, Dong J, Fu W, Zhang X. Presurgical neoadjuvant targeted molecular therapy for kidney cancer with concomitant vena cava tumor embolus: A clinical study. Oncol Lett 2017; 14:369-375. [PMID: 28693178 DOI: 10.3892/ol.2017.6131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/19/2017] [Indexed: 11/06/2022] Open
Abstract
The present study aimed to investigate presurgical neoadjuvant targeted therapy for patients with kidney cancer and vena cava tumor embolus, in order to examine its indications, therapeutic effects and optimal timing of surgery. Between June 2009 and June 2014, 12 patients from The People's Liberation Army General Hospital (Beijing, China) were diagnosed with kidney cancer with superior vena cava tumor embolus, and received presurgical neoadjuvant targeted therapy (sorafenib 400 mg twice a day or sunitinib 50 mg/day) for a median of 13.3 weeks. Patients included 8 males and 4 females, with a median age of 49.8 years. Kidney cancer was present on the left side in 3 patients and in the right side in 9 patients. The median tumor embolus length was 9.7 cm (range, 6.5-14.0 cm). Tumor embolus levels II, III and IV, classified by the Mayo Clinic standard, were observed in 2, 6 and 4 patients, respectively. Median treatment time and average targeted therapy discontinuation time were observed to be longer in sunitinib-treated patients compared with sorafenib-treated patients. In total, 2 patients in the present study had partial remission (PR) and 8 patients had stable disease (SD); for tumor embolus, 4 patients had PR and 8 patients had SD. Tumor embolus length decreased by a median value of 18.7% (range, 0.0-42.1%) or 1.8 cm (range, 0.1-5.2 cm). Tumor diameter decreased by a median value of 8.6% (range, 0.0-38.9%) or 0.7 cm (range, 0.0-3.5 cm). The level of the tumor thrombus, classified by the Mayo Clinic standard, was observed to decrease following sunitinib treatment, including two cases downgraded from tumor thrombus level IV to II, one case from level IV to III and two cases from level III to II. Presurgical neoadjuvant targeted molecular therapy may have the potential to reduce the tumor stage of patients, as well as decreasing the surgical difficulty for radical nephrectomy.
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Affiliation(s)
- Gang Guo
- Department of Urologic Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Wei Cai
- Department of Urologic Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Hongzhao Li
- Department of Urologic Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Jiangping Gao
- Department of Urologic Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Xin Ma
- Department of Urologic Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Jun Dong
- Department of Urologic Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Weijun Fu
- Department of Urologic Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Xu Zhang
- Department of Urologic Surgery, The People's Liberation Army General Hospital, Beijing 100853, P.R. China
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10
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Thomas AZ, Adibi M, Borregales LD, Karam JA, Wood CG. Cytoreductive surgery in the era of targeted molecular therapy. Transl Androl Urol 2016; 4:301-9. [PMID: 26815334 PMCID: PMC4708236 DOI: 10.3978/j.issn.2223-4683.2015.04.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Cytoreductive nephrectomy (CN) was regarded standard of care for patients with metastatic renal cell carcinoma (mRCC) in the immunotherapy era. With the advent of targeted molecular therapy (TMT) for the treatment of mRCC, the routine use of CN has been questioned. Up to date evidence continues to suggest that CN remains an integral part of treatment in appropriately selected patients. This review details the original context in which the efficacy of CN was established and rationale for the continued use of cytoreductive surgery in the era of TMT.
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Affiliation(s)
- Arun Z Thomas
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Mehrad Adibi
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Leonardo D Borregales
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Jose A Karam
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Christopher G Wood
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
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11
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Initial Experience of Sorafenib Neoadjuvant Therapy Combined with Retroperitoneoscopy in Treating T2 Large Renal Carcinoma. BIOMED RESEARCH INTERNATIONAL 2015; 2015:609549. [PMID: 26421296 PMCID: PMC4573231 DOI: 10.1155/2015/609549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 01/30/2015] [Accepted: 02/26/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To investigate the safety and feasibility of sorafenib neoadjuvant therapy combined with retroperitoneoscopic radical nephrectomy (RRN) in treating T2 large renal cell carcinoma (RCC). METHODS Retrospectively analyzed 5 cases (2 males and 3 females, aged 52-73 years) of T2 stage large RCC who receive preoperative sorafenib targeted treatment (400 mg bid for 1-3 months) and RRN between March, 2013, and July, 2014. Patient information, therapeutic regimen, drug adverse effect, tumor changes before and after surgery, and perioperative parameters were recorded. RESULTS During the sorafenib therapy adverse effects included 2 cases of hypertension (Grade I toxicity), 1 case of hand-foot syndrome (Grade I), and 1 case of diarrhea (Grade II), which were all tolerable for patients. CT scan and histopathological tests confirmed significant reduction in the longest dimension (LD) and medium density (MD) of the tumor after therapy as well as tumor hemorrhage, necrosis, and cystic degeneration. All 5 patients received RRN surgery successfully around 2 weeks after drug discontinuation with only 1 case of perioperative complication. CONCLUSIONS Sorafenib neoadjuvant therapy could significantly reduce the size and aggressiveness of T2 large renal tumors, thus reducing the operative challenge and enabling patients who were previously disqualified for operation to receive surgical treatment.
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12
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Tomita Y. Treatment strategies for advanced renal cell carcinoma: A new paradigm for surgical treatment. Int J Urol 2015; 23:13-21. [PMID: 26347163 DOI: 10.1111/iju.12899] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/12/2015] [Indexed: 11/30/2022]
Abstract
The induction of targeted drugs for the treatment of metastatic renal cell carcinoma has changed the treatment strategy for systemic therapy. Surgical treatment for metastatic renal cell carcinoma should also be reconsidered in the light of the effect of targeted drugs. The clinical benefit of cytoreductive nephrectomy for cases of metastatic renal cell carcinoma was proved in randomized trials in the cytokine era. However, at present, there has not been level 1 evidence for this in the targeted therapy era. Patients with better performance status and without poor risk factors tend to benefit from cytoreductive nephrectomy. Two ongoing large-scale randomized studies might shed light on this issue. One of the remarkable differences in the efficacy between cytokines and targeted drugs, particularly tyrosine kinase inhibitors, is the reduction in the size of the primary tumors by tyrosine kinase inhibitors, including sunitinib and axitinib. Initial experiences with targeted therapy suggest that the neoadjuvant setting of tyrosine kinase inhibitors could be a viable option when the primary tumor shows local invasion and/or is unresectable. The present study does not support the routine neoadjuvant use of sunitinib because of the possibility of disease progression during the neoadjuvant therapy, and modest response and benefit. Axitinib, in contrast, shows larger reduction in the size of the primary tumor and might be used in the near future. Another issue is the combination of targeted therapy with metastasectomy. There is a lack of evidence for improved prognosis resulting from the neoadjuvant setting of tyrosine kinase inhibitors followed by metastasectomy. Further studies are warranted to investigate this.
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Affiliation(s)
- Yoshihiko Tomita
- Departments of Urology and Molecular Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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13
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Bex A, Powles T, Karam JA. Role of targeted therapy in combination with surgery in renal cell carcinoma. Int J Urol 2015; 23:5-12. [DOI: 10.1111/iju.12891] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 07/07/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Axel Bex
- Department of Urology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Thomas Powles
- Department of Medical Oncology; Barts Cancer Institute; Experimental Cancer Medicine Centre; Queen Mary University of London; London UK
| | - Jose A Karam
- Department of Urology; The University of Texas MD Anderson Cancer Center; Houston Texas USA
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Zekri J, Dreosti LM, Ghosn M, Hamada E, Jaloudi M, Khorshid O, Larbaoui B. Multidisciplinary management of clear-cell renal cell carcinoma in Africa and the Middle East: current practice and recommendations for improvement. J Multidiscip Healthc 2015; 8:335-44. [PMID: 26251610 PMCID: PMC4524587 DOI: 10.2147/jmdh.s85538] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The management of renal cell carcinoma (RCC) has evolved considerably in recent years. This report represents the consensus of 22 relevant medical specialists from Africa and the Middle East region engaged in the management of RCC. Partial or radical nephrectomy is the standard of care for most patients with localized RCC. It is essential that patients are followed up appropriately after surgery to enable local and distant relapses to be identified and treated promptly. The treatment of advanced/metastatic disease has changed dramatically with the introduction of targeted therapies. Follow-up of these patients enables therapy optimization and assessment of response to treatment. There was universal agreement on the importance of management of RCC by a multidisciplinary team supported by a multidisciplinary tumor board. Barriers hindering this approach were identified. These included lack of awareness of the benefits of multidisciplinary team role, poor communication among relevant disciplines, time constraints, and specifics of private practice. Other challenges include shortage of expert specialists as urologists and oncologists and lack of local management guidelines in some countries. Solutions were proposed and discussed. Medical educational initiatives and awareness activities were highlighted as keys to encouraging cooperation between specialties to improve patients’ outcome. Establishing combined genitourinary cancer clinics and formal referral systems should encourage a culture of effective communication. Joining forces with professionals in peripheral areas and the private sector is likely to help standardize care. Sustained action will be required to ensure that all patients with RCC in the region benefit from up-to-date care.
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Affiliation(s)
- Jamal Zekri
- College of Medicine, King Faisal Specialist Hospital and Research Centre, Alfaisal University, Jeddah, Saudi Arabia
| | - Lydia M Dreosti
- Department of Medical Oncology, University of Pretoria, Pretoria, South Africa
| | - Marwan Ghosn
- Faculty of Medicine Hematology, Oncology Department, Saint Joseph University, Beirut, Lebanon
| | - Emad Hamada
- Faculty of Medicine, Cairo University, Kasr Alainy, Cairo, Egypt
| | - Mohamed Jaloudi
- Oncology Hematology Department, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Ola Khorshid
- National Cancer Institute, Cairo University, Kasr El Ainy, Cairo, Egypt
| | - Blaha Larbaoui
- Oncology Service, Université Djillali Liabés, Sidi Bel Abbés, Algeria
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Heterogeneous drug target expression as possible basis for different clinical and radiological response to the treatment of primary and metastatic renal cell carcinoma: suggestions from bench to bedside. Cancer Metastasis Rev 2015; 33:321-31. [PMID: 24337954 DOI: 10.1007/s10555-013-9453-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Metastatic disease occurs in a significant percentage of patients with renal cell carcinoma (RCC) and is usually associated with an overall poor prognosis. However, not all of the sites of metastases seem to have the same prognostic significance in patients receiving targeted agents. Indeed, patients with lung-only metastases seem to present a better survival than patients with other sites, whereas liver and bone metastases are associated with a worst prognosis. Some clinical studies suggest that metastatic sites are more responsive than primary tumors. This event may be due to intratumor heterogeneity in terms of somatic mutations, chromosome aberrations, and tumor gene expression, primarily centered around Von Hippel-Lindau (VHL) pathway, such as VHL mutations, HIF levels, vascular endothelial growth factor (VEGF) isoforms, and VEGF receptor levels. Nevertheless, these data do not completely explain the discordant biological behavior between primary tumor and metastatic sites. Understanding the causes of this discordance will have profound consequences on translational research and clinical trials in RCC. In this review, we overview current data on the differences between primary RCC and metastases in terms of drug target expression and clinical/radiological response to targeted agents, thus describing the prognostic role of different metastatic sites in RCC patients.
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Hongo F, Oishi M, Ueda T, Naitoh Y, Nakamura T, Naya Y, Kamoi K, Okihara K, Miki T. Complete response of sunitinib therapy for renal cell cancer recurrence in the native kidney after renal transplantation: a case report. BMC Res Notes 2014; 7:526. [PMID: 25124932 PMCID: PMC4138390 DOI: 10.1186/1756-0500-7-526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/08/2014] [Indexed: 12/28/2022] Open
Abstract
Background No case report has yet shown that sunitinib therapy for the postoperative recurrence of renal cancer in a native kidney after renal transplantation can achieve complete response (CR). Case presentation A tumor was detected in the right native kidney of a 35-year-old Japanese male 10 years after renal transplantation. A tumor thrombus that reached the atrium was detected, which suggested cT3cN0M0. Because of the risk of perioperative complications, preoperative therapy with sunitinib was selected and 8 courses were administered. The size of the primary tumor was reduced by 33%, while that of the tumor thrombus was decreased by 39.5%. Right nephrectomy and removal of the tumor thrombus were then performed. Contrast-enhanced computed tomography (CT) four months after surgery suggested local relapse. Sunitinib was administered for 9 months, which led to complete response (CR). Conclusions This study presented the case of sunitinib therapy for renal cancer in the native kidney after renal transplantation. The therapeutic efficacy and safety for such cases should be discussed.
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Affiliation(s)
- Fumiya Hongo
- Department of Urology, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kamigyo-ku, Kyoto 602-8566, Japan.
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Ye DW, Zhang HL. Critical appraisal of sorafenib in the treatment of Chinese patients with renal cell carcinoma. Onco Targets Ther 2014; 7:925-35. [PMID: 24944516 PMCID: PMC4057324 DOI: 10.2147/ott.s41828] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Renal cell carcinoma (RCC) accounts for 3% of all malignancies, and is the most aggressive cancer of the genitourinary system. Metastatic RCC is naturally resistant to chemotherapy and radiotherapy, and immunotherapy is of little benefit. In recent years, the emergence of molecular-targeted therapies has largely changed the therapeutic approach to metastatic RCC. These novel multikinase inhibitors have now become first-choice therapy because of their activity in inhibiting both cell proliferation and tumor angiogenesis. Sorafenib is the first tyrosine kinase inhibitor found to be effective in treating patients with metastatic RCC. Due to its good efficacy and safety, this agent is recommended as both first-line and second-line therapy for metastatic RCC in the People's Republic of China. Sorafenib seems to be more effective in patients of Chinese ethnicity than in western patients, and is well tolerated with a manageable toxicity profile, even at higher dosages and when used in combination with other anticancer agents. Novel biomarkers for predicting the efficacy of sorafenib have potential clinical value for guiding individualized targeted therapy.
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Affiliation(s)
- Ding-Wei Ye
- Correspondence: Ding-Wei Ye, Department of Urology, Fudan University, Shanghai Cancer Center, 270 Dong An Road, Shanghai, 200032, People’s Republic of China, Tel +86 6417 5590 1807, Fax +86 6443 8640, Email
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Raman A, Jawale A, Grant A. Radical nephrectomy and vena caval thrombectomy with the use of cardiopulmonary bypass. ANZ J Surg 2014; 84:560-3. [DOI: 10.1111/ans.12559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Avi Raman
- Urology; Royal Newcastle Centre; Newcastle New South Wales Australia
| | - Atul Jawale
- Surgery; John Hunter Hospital; Newcastle New South Wales Australia
| | - Alexander Grant
- Urology; Royal Newcastle Centre; Newcastle New South Wales Australia
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Bhatt VR, Ganti AK, Schwarz JK, Wang J. Safety and efficacy of preoperative sorafenib therapy in facilitating cytoreductive surgery in renal cell carcinoma. Future Oncol 2014; 10:703-6. [DOI: 10.2217/fon.14.5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Vijaya R Bhatt
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Apar Kishor Ganti
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Internal Medicine, Division of Hematology & Oncology, VA Nebraska Western Iowa Health Care System, Omaha, NE, USA
| | - James K Schwarz
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jue Wang
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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20
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Karam JA, Devine CE, Urbauer DL, Lozano M, Maity T, Ahrar K, Tamboli P, Tannir NM, Wood CG. Phase 2 trial of neoadjuvant axitinib in patients with locally advanced nonmetastatic clear cell renal cell carcinoma. Eur Urol 2014; 66:874-80. [PMID: 24560330 DOI: 10.1016/j.eururo.2014.01.035] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 01/28/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous studies have shown a modest impact of tyrosine kinase inhibitors on primary renal tumors. Those studies were mostly retrospective or heterogeneous in their eligibility criteria with regard to histology, disease stage, duration of therapy, and time off therapy prior to surgery. OBJECTIVE To prospectively investigate the safety and efficacy of axitinib in downsizing tumors in patients with nonmetastatic biopsy-proven clear cell renal cell carcinoma (ccRCC). DESIGN, SETTING, AND PARTICIPANTS This was a single-institution, single-arm phase 2 clinical trial. Patients with locally advanced nonmetastatic biopsy-proven ccRCC were eligible. INTERVENTION Patients received axitinib 5mg for up to 12 wk. Axitinib was continued until 36h prior to surgery. Patients underwent partial or radical nephrectomy after axitinib therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was objective response rate prior to surgery. Secondary outcomes included safety, tolerability, and quality of life. A dedicated radiologist independently reviewed all computed tomography scans to evaluate for response using Response Evaluation Criteria in Solid Tumors (RECIST). RESULTS AND LIMITATIONS A total of 24 patients were treated. Twenty-two patients continued axitinib for 12 wk; 1 patient continued axitinib for 11 wk and underwent surgery as planned. One patient stopped treatment at 7 wk due to adverse events (AEs). Median reduction of primary renal tumor diameter was 28.3%. Eleven patients experienced a partial response per RECIST; 13 had stable disease. There was no progression of disease while on axitinib. The most common AEs were hypertension, fatigue, oral mucositis, hypothyroidism, and hand-foot syndrome. Postoperatively, 2 grade 3 and 13 grade 2 complications were noted. No grade 4 or 5 complications occurred. Functional Assessment of Cancer Therapy-Kidney Specific Index-15 changed over time, with quality of life worsening while on therapy, but by week 19, it was not statistically different from screening. Limitations include single-arm design and small patient numbers. CONCLUSIONS Axitinib was clinically active and reasonably well tolerated in the neoadjuvant setting in patients with locally advanced nonmetastatic ccRCC. PATIENT SUMMARY In this prospective clinical trial, we found that axitinib, when given prior to surgery, results in significant shrinking of kidney cancers. Larger studies are needed prior to further clinical use. TRIAL REGISTRATION This clinical trial was registered with clinicaltrials.gov (NCT01263769).
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Affiliation(s)
- Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Catherine E Devine
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana L Urbauer
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marisa Lozano
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapati Maity
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kamran Ahrar
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pheroze Tamboli
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Patard JJ, Porta C, Wagstaff J, Gschwend JE. Optimizing treatment for metastatic renal cell carcinoma. Expert Rev Anticancer Ther 2014; 11:1901-11. [DOI: 10.1586/era.11.177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Köpke T, Bierer S, Wülfing C, Tiemann A, Hertle L, Herrmann E. Multimodality treatment paradigms for renal cell carcinoma: surgery versus targeted agents. Expert Rev Anticancer Ther 2014; 9:763-71. [DOI: 10.1586/era.09.37] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Bhatt VR, Ganti AK. Sorafenib in squamous cell carcinoma of the head and neck: molecular basis and potential role. Future Oncol 2014; 10:17-20. [DOI: 10.2217/fon.13.212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Vijaya R Bhatt
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Apar Kishor Ganti
- Department of Internal Medicine, Division of Hematology & Oncology, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Internal Medicine, Division of Hematology & Oncology, VA Nebraska Western Iowa Health Care System, Omaha, NE, USA
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Koie T, Ohyama C, Okamoto A, Yamamoto H, Imai A, Hatakeyama S, Yoneyama T, Hashimoto Y. Presurgical therapy with axitinib for advanced renal cell carcinoma: a case report. BMC Res Notes 2013; 6:484. [PMID: 24267160 PMCID: PMC4222084 DOI: 10.1186/1756-0500-6-484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 11/21/2013] [Indexed: 01/14/2023] Open
Abstract
Background Targeted therapy with tyrosine kinase inhibitors has been shown to reduce tumor volumes and prolong the survival of patients with metastatic renal cell carcinoma. Tyrosine kinase inhibitors, particularly sunitinib, have recently been used in neoadjuvant and presurgical settings. Axitinib is a promising second-line therapy option for advanced or metastatic renal cell carcinoma. Herein, we report a patient with advanced renal cell carcinoma who received presurgical treatment with axitinib. Case presentation A 73-year-old man was transported by ambulance to a community hospital with chief complaints of high fever and a gait disorder. Computed tomography screening revealed a hypervascular tumor (size, 9 × 8.5 cm) in the lower pole of the left kidney. Upon admission to our hospital, his general condition was poor and his performance status was judged as 3, based on the Eastern Cooperative Oncology Group performance status criteria. After biopsy for the renal tumor, he received 5 mg of axitinib twice daily for 3 months. No serious adverse events were reported during this treatment. The tumor diameter shrank by 56%. Left radical nephrectomy was performed, and there were no intraoperative or postoperative complications. Pathological examination indicated a pT3aN0M0, Furman grade 3, clear cell renal cell carcinoma with necrosis, hyaline degeneration, and hemosiderosis. The patient was asymptomatic and disease-free at 1 year post-diagnosis. Conclusion This case study demonstrate that presurgical therapy with axitinib is feasible and might have several potential advantages for patients with advanced renal cell carcinoma.
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Affiliation(s)
- Takuya Koie
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki 036-8562, Japan.
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Abstract
The landscape of treatment for advanced/metastatic renal cell carcinoma (mRCC) has advanced significantly in the last decade and continues to evolve with the approval of new drugs targeting the vascular endothelial growth factor (VEGF) and its receptors and mammalian target of rapamycin (mTOR). Currently available oral VEGF tyrosine kinase inhibitors (TKIs) approved for treatment of mRCC include sorafenib, sunitinib, pazopanib, and axitinib. This review focuses on pazopanib, a multikinase VEGF TKI indicated for patients with treatment-naïve and cytokine-refractory mRCC. This article describes the preclinical and clinical evolution of pazopanib, with an emphasis on its development and role in mRCC. Pivotal trials are discussed that demonstrate the efficacy and safety of pazopanib and its important role in the treatment of patients with mRCC in comparison to other available treatment options. The clinical path of pazopanib continues to develop further, with several ongoing studies exploring its role in neoadjuvant and adjuvant RCC. Furthermore, its potential role in sequential and combination studies with other VEGFR and non-VEGFR targeted agents is discussed. Overall, pazopanib is a unique VEGF TKI, with a different and more favorable safety profile compared with other members of the VEGF TKI family and represents an attractive alternative for patients with mRCC.
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Affiliation(s)
- Shilpa Gupta
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa FL, USA
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26
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Aziz SA, Sznol JA, Adeniran A, Parisi F, Kluger Y, Camp RL, Kluger HM. Expression of drug targets in primary and matched metastatic renal cell carcinoma tumors. BMC Clin Pathol 2013; 13:3. [PMID: 23374878 PMCID: PMC3575219 DOI: 10.1186/1472-6890-13-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 01/28/2013] [Indexed: 02/05/2023] Open
Abstract
UNLABELLED BACKGROUND Targeted therapies in renal cell carcinoma can have different effects on primary and metastatic tumors. To pave the way for predictive biomarker development, we assessed differences in expression of targets of currently approved drugs in matched primary and metastatic specimens from 34 patients. METHODS Four cores from each site were embedded in tissue microarray blocks. Expression of B-Raf, C-Raf, cKIT, FGF-R1, HIF-2α, mTOR, PDGF-Rβ, VEGF-R1, VEGF-R2, VEGF-R3, VEGF, VEGF-B, VEGF-C, VEGF-D, MEK1, and ERK1/2 was studied using a quantitative immunofluorescence method. RESULTS No significant differences were observed in global expression levels in primary and metastatic renal cell carcinoma tumors, with the exception of MEK, which had higher expression in metastatic than primary specimens. Similarly, more ki67 positive cells were seen in metastatic specimens. Correlations between marker expression in primary and metastatic specimens were variable, with the lowest correlation seen for FGF-R1 and VEGF-D. There were no significant differences in the degree of heterogeneity in primary versus metastatic tumors. CONCLUSIONS Expression of most of the studied markers was similar in primary and metastatic renal cell carcinoma tumors, suggesting that predictive biomarker testing for these markers can be conducted on either the primary or metastatic tumors for most markers.
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Affiliation(s)
- Saadia A Aziz
- Department of Medicine and Yale Cancer Center, 333 Cedar St,, WWW213, New Haven, CT, 06520, USA.
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27
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Aziz SA, Sznol J, Adeniran A, Colberg JW, Camp RL, Kluger HM. Vascularity of primary and metastatic renal cell carcinoma specimens. J Transl Med 2013; 11:15. [PMID: 23316728 PMCID: PMC3561185 DOI: 10.1186/1479-5876-11-15] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 01/09/2013] [Indexed: 12/11/2022] Open
Abstract
Purpose Anti-angiogenic therapies are among the most commonly used drugs in renal cell carcinoma. Tumor vascularity, defined by microvessel area, may be associated with response to these drugs. Clinical studies suggest that metastatic sites are more responsive than primary tumors. Our purpose was to characterize microvessel area (MVA) in matched primary and metastatic samples and in samples of different histologies. Methods We employed a method of automated, quantitative analysis of in situ tumor components to identify the area of CD-34 staining endothelial cells within renal cell carcinoma tumors. MVA was assessed in corresponding primary and metastatic samples from 34 patients, as well as in 334 primary nephrectomy specimens with variable histologies. Results MVA measurements from different parts of the same tumor correlated well (R = 0.75), indicating that MVA was fairly uniform within a tumor. While MVA was slightly higher in primary tumors than corresponding metastatic sites, the difference was not statistically significant (P = 0.1). MVA in paired primary and metastatic samples correlated moderately well (R = 0.36). MVA was higher in clear cell than papillary histology and oncocytomas (P < 0.0001 and P = 0.018, respectively). Conclusions Lack of significant differences MVA in matched primary and metastatic samples suggests that both types of tumors should respond to anti-angiogenic drugs. This should be confirmed on additional cohorts. Given the small cohort, future predictive biomarker studies entailing MVA measurements should include specimens from both sites. Clear cell carcinomas are more vascular than other histologic subtypes, which may explain the higher response rates to anti-angiogenic therapies in clear cell tumors.
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Affiliation(s)
- Saadia A Aziz
- Department of the School of Medicine, Yale University School of Medicine, New Haven, CT, USA
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28
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Bex A, Powles T. Selecting patients for cytoreductive nephrectomy in advanced renal cell carcinoma: who and when. Expert Rev Anticancer Ther 2012; 12:787-97. [PMID: 22716495 DOI: 10.1586/era.12.54] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Renal cell carcinoma presents with metastatic disease in approximately 30% of patients at the time of diagnosis. Cytoreductive nephrectomy (CN) of the primary tumor in the face of metastatic disease is part of a multimodality approach including systemic therapy that is based on evidence from randomized trials in the cytokine era. Data from the pretargeted therapy era showed that CN had a clear role in metastatic renal cell carcinoma, increasing life expectancy by approximately 6 months. The substantial improvement in outcomes reported for targeted therapy has challenged the previous role of CN. However, despite the absence of data from Phase III trials, available evidence suggests that some patients may benefit substantially from CN in the era of targeted therapy. This review summarizes current arguments for CN and how to best select patients for surgery. Ongoing trials are key in generating evidence towards a personalized approach to debulking nephrectomy.
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Affiliation(s)
- Axel Bex
- The Netherlands Cancer Institute, Division of Surgical Oncology, Department of Urology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Ueda K, Noguchi M, Suekane S, Moriya F, Nagayoshi R, Ejima K, Momozono K, Matsuoka K. Successful treatment of T4 renal cell carcinoma after a neoadjuvant targeted therapy using sunitinib: report of a case. Kurume Med J 2012; 58:95-8. [PMID: 22531125 DOI: 10.2739/kurumemedj.58.95] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the introduction of targeted therapy, treatment of metastatic renal cell carcinoma (RCC) has undergone dramatic changes. Responses to targeted therapy within the primary tumor and metastatic lesions are novel findings not seen with immunotherapeutic-based strategies. We report here a case of T4 RCC in which cytoreductive nephrectomy became possible after a neoadjuvant targeted therapy using sunitinib. Our experience with the present case suggests that targeted therapy in the neoadjuvant setting may have a variety of potential applications. Further investigations should be encouraged.
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Affiliation(s)
- Kousuke Ueda
- Department of Urology, Kurume University School of Medicine, Kurume University, Kurume, Japan
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31
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Firek P, Richter S, Jaekel J, Brehmer B, Heidenreich A. [Metastasectomy in renal cell cancer after neoadjuvant therapy with multi-tyrosine kinase inhibitors]. Urologe A 2012; 51:398-402. [PMID: 22113553 DOI: 10.1007/s00120-011-2762-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Metastatic renal cell carcinoma (mRCC) still poses a challenge to therapists in spite of the availability of multiple innovative molecular treatment options. Complete remission is rare and in cases of partial remission it is often unclear if necrosis or vital carcinoma tissue persists. We report on a cohort of patients who underwent metastasectomy after neoadjuvant therapy with multi-tyrosine kinase inhibitors (MTKI). METHODS In 2009 a total of 11 patients (7 male and 4 female) underwent metastasectomy after achievement of ≥ 3 months stable partial remission. All patients received either sunitinib (n=7, mean 5.5 cycles), bevacizumab and interferon (IFN)-α2a (n=2, mean 8.5 months), temsirolimus (n=1, mean 9 months) or a combination of sunitinib followed by temsirolimus (n=1). Of the patients 7 presented with retroperitoneal lymph node metastases with a mean diameter of 3.5-12 cm, 2 patients with pulmonary metastases, 1 patient with lymph node and pancreas tail metastases and 1 female patient showed residual disease in the vena cava. RESULTS All metastases were completely resected with negative surgical margins. In 82% of the cases histologically active, Ki-67 positive renal cell cancer tissue was identified. The following adjunctive interventions were necessary: vena cava resection with vascular prosthesis and reimplantation of the renal vein (n=3), partial liver resection (n=1), splenectomy (n=1) and pancreas tail resection (n=1). There were no significant perioperative complications but 1 patient developed fascial dehiscence and underwent revision surgery and 1 patient developed clinically insignificant pancreatitis. After a median follow-up of 12 months (range 8-19 months) 5 patients had no recurrence and 6 of the patients showed liver (n=3), lung (n=2) or bone (n=1) recurrences from which 3 patients died. CONCLUSIONS Metastasectomy of mRCC is associated with a low rate of complications in experienced centers. Surgical resection of metastatic disease is indicated to achieve complete remission with a favorable prognosis because of biologically active kidney cancer tissue. Patients with isolated and resectable metastases are ideal candidates for such a procedure.
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Affiliation(s)
- P Firek
- EURO-Prostatazentrum Aachen, Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinikum der RWTH Aachen, Pauwelsstrraße 30, 52074 Aachen, Deutschland.
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Fisher R, Gore M, Larkin J. Current and future systemic treatments for renal cell carcinoma. Semin Cancer Biol 2012; 23:38-45. [PMID: 22705280 DOI: 10.1016/j.semcancer.2012.06.004] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 06/05/2012] [Indexed: 12/19/2022]
Abstract
Systemic treatment of renal cell carcinoma has changed dramatically since 2007, with the development and approval of six new agents, which target complex molecular pathways regulating tumour angiogenesis and cell proliferation and survival. These treatments have significantly improved survival times in metastatic renal cell carcinoma, but remain palliative. A number of newer agents are in clinical development, which offer theoretical advantages over existing treatments, and research methodologies are adapting with the aim of defining an individualised approach to therapy which exploits the underlying tumour biology. This review will provide an overview of current and emerging systemic treatments and how they might be integrated with surgical therapy, with a particular focus on advanced, clear cell metastatic renal cell carcinoma.
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Pooleri GK, Nair TB, Sanjeevan KV, Thomas A. Neo adjuvant treatment with targeted molecules for renal cell cancer in current clinical practise. Indian J Surg Oncol 2012; 3:114-9. [PMID: 23730100 PMCID: PMC3392483 DOI: 10.1007/s13193-011-0100-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 10/21/2011] [Indexed: 12/19/2022] Open
Abstract
Target molecule Treatment (TMT) have emerged as the primary treatment in metastatic renal cell carcinoma. Majority of the patients in pivot trials were post nephrectomy cases. The benefit of cytoreductive nephrectomy in the era of TMT is debated. The role of these molecules in the adjuvant settings and in neo adjuvant/pre surgical role has evoked interest. In this review the different molecules used in the treatment of metastatic renal cancer and its effect on the primary renal tumour is discussed. Information available in the public domain about the presurgical/neoadjuvant targeted molecular treatment (TMT) is reviewed to understand the benefits and adverse effects of this modality of treatment. Sunitinib and sorafenib are the most commonly used and effective molecules in the neo adjuvant/re surgical treatment of renal cell carcinoma . Bevacizumab is less effective and has more chance of surgical complications in these settings mainly due to poor wound healing secondary to prolonged wash off period . The patent and the surgeon should be aware of the unpredictability and possible adverse effects before advising these molecule pre operatively. The response of the primary renal tumour to the target molecule is different from that of the metastatic tumour. The side effects of the molecules and its effect on the peri operative morbidity and mortality should also be considered when we advise these molecules as pre surgical/neo adjuvant treatment.
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Affiliation(s)
- Ginil Kumar Pooleri
- Uro-Oncology division, Department of Urology, Amrita Institute of Medical Sciences, AIMS-Ponekkara(PO), Kochi 41, Kerala India
| | - Tiyadath Balagopalan Nair
- Department of Urology, Amrita Institute of Medical Sciences, AIMS-Ponekkara(PO), Kochi 41, Kerala India
| | - Kalavampara V. Sanjeevan
- Department of Urology, Amrita Institute of Medical Sciences, AIMS-Ponekkara(PO), Kochi 41, Kerala India
| | - Appu Thomas
- Department of Urology, Amrita Institute of Medical Sciences, AIMS-Ponekkara(PO), Kochi 41, Kerala India
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Kenney PA, Wood CG. Integration of surgery and systemic therapy for renal cell carcinoma. Urol Clin North Am 2012; 39:211-31, vii. [PMID: 22487764 DOI: 10.1016/j.ucl.2012.01.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Proper integration of surgery and systemic therapy is essential for improving outcomes in renal cell carcinoma (RCC). There is no current role for adjuvant therapy after nephrectomy for clinically localized disease. The potential benefits of neoadjuvant therapy for locally advanced nonmetastatic disease are in need of further study. In metastatic disease, the proper integration of cytoreductive surgery and systemic therapy remains to be elucidated. Presurgical targeted therapy is feasible and may be beneficial. Pending the results of randomized controlled trials, upfront cytoreductive nephrectomy in appropriate patients will likely continue as the paradigm of choice in metastatic RCC.
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Affiliation(s)
- Patrick A Kenney
- Urologic Oncology, Department of Urology, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1373, Houston, TX 77030, USA
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The emerging role of targeted therapy in renal cell carcinoma (RCC): Is it time for a neoadjuvant or an adjuvant approach? Crit Rev Oncol Hematol 2012; 81:151-62. [DOI: 10.1016/j.critrevonc.2011.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 12/16/2010] [Accepted: 02/11/2011] [Indexed: 01/06/2023] Open
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Tobert CM, Uzzo RG, Wood CG, Lane BR. Adjuvant and neoadjuvant therapy for renal cell carcinoma: a survey of the Society of Urologic Oncology. Urol Oncol 2012; 31:1316-20. [PMID: 22264501 DOI: 10.1016/j.urolonc.2011.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 12/19/2011] [Accepted: 12/19/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Several systemic agents have been approved for patients with advanced renal cell carcinoma (RCC) and others are in various stages of development. We surveyed members of the Society of Urologic Oncology (SUO) regarding the importance of adjuvant and neoadjuvant systemic therapy for RCC and their participation in such trials. MATERIALS AND METHODS A survey was sent in October 2010 to 564 U.S. and Canadian members of the SUO and the SUO-Clinical Trials Committee with a valid e-mail address. A total of 136 urologic cancer specialists from a mixture of practice patterns responded to the questionnaire (24% participation rate). RESULTS At the time of the study, 75% participated in adjuvant or neoadjuvant treatment protocols, including 75% with adjuvant and 16% with neoadjuvant protocols. There was universal support for continued investigation of agents for adjuvant use in RCC with locoregional metastasis (100%) and nearly universal support for investigation of agents in patients with "high risk" (99%) and "intermediate risk" (91%) localized RCC after nephrectomy. The vast majority of respondents also supported investigation of neoadjuvant therapies in patients with advanced RCC (98%) or locally-advanced RCC (98%), with 70% also supporting neoadjuvant trials in patients with localized RCC. Importantly, 98% of respondents indicated interest in participating in future adjuvant and neoadjuvant trials. CONCLUSION Urologic cancer specialists surveyed in late 2010 demonstrated nearly universal support for trials to investigate the role of neoadjuvant and adjuvant therapies for RCC of all stages. With appropriate patient selection and outcome assessment, this widespread support indicates great potential for future clinical trials which will require the participation of urologic surgeons.
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Affiliation(s)
- Conrad M Tobert
- Spectrum Health Hospital System, Grand Rapids, MI 49546, USA; Michigan State University College of Human Medicine, Grand Rapids, MI 49546, USA
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Smaldone MC, Fung C, Uzzo RG, Haas NB. Adjuvant and neoadjuvant therapies in high-risk renal cell carcinoma. Hematol Oncol Clin North Am 2011; 25:765-91. [PMID: 21763967 DOI: 10.1016/j.hoc.2011.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The standard of care for renal cell carcinoma (RCC) is surgical resection as a monotherapy or as part of a multimodal approach. 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 because of the presence of micrometastatic disease at diagnosis. This review summarizes current algorithms used to identify patients at high risk for disease recurrence following the surgical resection of RCC, the outcomes of contemporary adjuvant systemic therapy trials, and the rationale supporting the use of neoadjuvant therapy.
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Affiliation(s)
- Marc C Smaldone
- Division of Urologic Oncology, Department of Surgery, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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Consolidative surgery after targeted therapy for renal cell carcinoma. Urol Oncol 2011; 31:914-9. [PMID: 22153755 DOI: 10.1016/j.urolonc.2011.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 10/04/2011] [Accepted: 10/05/2011] [Indexed: 01/16/2023]
Abstract
Renal cell carcinoma is the most lethal of the common genitourinary neoplasms, with 30% to 40% of patients eventually dying from disease progression. Although the recent development of targeted therapies against kidney cancer has yielded substantially improved tumor response rates and progression-free survival, these agents are still not curative. The integration of systemic therapies with surgery still represents the best management for select patients with advanced disease. Specifically, consolidative surgery may play a vital role in the management of this challenging patient population. However, concerns remain regarding the potential for increased surgical morbidity complicating the integration of surgery after targeted therapy. Careful patient selection and specific precautions to increase surgical safety should be implemented.
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Surgery and target agents for renal cell carcinoma treatment: the path between proper interaction. Urologia 2011; 78 Suppl 18:9-15. [PMID: 22081423 DOI: 10.5301/ru.2011.8769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Renal cell carcinoma accounts for 3% of all solid tumors and currently causes about 3,500 deaths/year in the UK. Once an orphan disease, it has undergone an impressive change in its natural history with an improvement in overall survival, thanks to the development of new target agents. INTRODUCTION In its management, renal cell carcinoma has been treated with both surgical and medical approaches. Nowadays, many more drugs are available, especially in the metastatic setting, so that we should reconsider the peculiar role of surgery and its interaction with target agents. CONCLUSIONS Cytoreductive nephrectomy still plays a major role in the management of the disease, though no really solid data have been still obtained. Adjuvant and neoadjuvant settings, instead, are still under evaluation, especially new adjuvant therapies involving the numerous target agents we have. Finally, metastasectomy has a controversial role, with some evidence of more efficacy than the medical treatment, though it shows too many biases to be considered certain. The picture that comes out suggests a complex frame, in which we have great power to act, but in which we need to better comprehend the interactions that could be created between surgery and medical therapies, to achieve an optimal multimodal treatment for renal cell carcinoma.
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Sorafenib in renal cell carcinoma. Crit Rev Oncol Hematol 2011; 80:314-22. [DOI: 10.1016/j.critrevonc.2011.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 12/22/2010] [Accepted: 01/18/2011] [Indexed: 11/19/2022] Open
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Kramer MW, Merseburger AS, Peters I, Waalkes S, Kuczyk MA. [Systemic and surgical management of metastatic renal cell carcinoma]. Urologe A 2011; 51:217-25. [PMID: 22009257 DOI: 10.1007/s00120-011-2713-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Several targeted therapies have become available for first-line (sunitinib, bevacizumab, pazopanib, temsirolimus) and second-line (sorafenib, pazopanib, everolimus) use in recent years. The superior outcomes achieved with these targeted agents have led to replacement of the formerly administered cytokines. New developments have raised the question of whether patients benefit from sequential therapies with tyrosine kinase inhibitors and/or whether combination regimes can improve clinical outcomes. This review gives an overview of the current therapeutic options for first- and second-line treatment in metastatic RCC as well as sequential and combination therapies. Adjuvant and neoadjuvant treatment options are being discussed. Furthermore, this review addresses surgical alternatives in the treatment of RCC.
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Affiliation(s)
- M W Kramer
- Klinik für Urologie und Urologische Onkologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Deutschland
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Abstract
Renal cell carcinoma represents the fifth most frequent malignant tumor in humans. At the time of diagnosis, 20% of the patients already manifest metastases. A further 20-30% of the patients develop systemic metastases in the postoperative course. Despite continued advances in pharmacological treatment options, cancer surgery tailored to the individual tumor findings constitutes the only curative treatment option.
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Affiliation(s)
- A Heidenreich
- Klinik und Poliklinik für Urologie, Universitätsklinikum Aachen, Pauwelsstrasse 30, Aachen, Germany.
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Thuret R, Maurin C, Sun M, Perrotte P, Karakiewicz P. Traitement du carcinome rénal métastatique. Prog Urol 2011; 21:233-44. [DOI: 10.1016/j.purol.2010.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 11/25/2010] [Indexed: 12/23/2022]
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Abstract
Three clinical cases have shown the superiority of sunitinib in first line therapy intermediate risk metastatic clear cell renal carcinoma and a best safety of bevacizumab plus interferon, the current lack of high level of evidence arguments for the neo-adjuvant treatment of kidney cancer, the importance to prevent mucositis during a mTOR inhibitors treatment and the diagnostic pitfalls of its pulmonary complications.
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Harshman LC, Yu RJ, Allen GI, Srinivas S, Gill HS, Chung BI. Surgical outcomes and complications associated with presurgical tyrosine kinase inhibition for advanced renal cell carcinoma (RCC). Urol Oncol 2011; 31:379-85. [PMID: 21353796 DOI: 10.1016/j.urolonc.2011.01.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 01/02/2011] [Accepted: 01/04/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Tyrosine kinase inhibitors (TKI) have dramatically changed the management paradigm of advanced renal cell carcinoma (RCC) and are increasingly being used preoperatively to achieve cytoreduction. OBJECTIVE To review our case series of post-TKI surgical procedures to add to the current perioperative efficacy and complication profile. MATERIALS AND METHODS Between October 2006 and February 2010, 14 cytoreductive nephrectomies, radical nephrectomies, and metastectomies were performed after neoadjuvant sunitinib or sorafenib for advanced RCC. During the same time frame, a control group of 73 consecutive patients underwent radical nephrectomy, cytoreductive nephrectomy, or metastectomy in the absence of prior systemic therapy. We compared the incidence of perioperative complications and outcomes after surgical procedures between the two cohorts. RESULTS Median preoperative renal mass size was 11 cm (6.7-24.2 cm). Primary tumor shrinkage was seen in 57%; median shrinkage was 18% (8%-25%). The median treatment period was 17 weeks, and the median time from TKI discontinuation was 2 weeks. Compared with a control group and after adjusting for confounding covariates, presurgical TKI use was not associated with a significant increase in perioperative complications (50% vs. 40%, P = 0.25) or perioperative bleeding (36% vs. 34%, P = 0.97) but was associated with increased incidence and grade of intraoperative adhesions (86% vs. 58%, P = 0.001; grade 3 vs. 1, P = 0.002). CONCLUSIONS Compared with the published reports, we observed less hemorrhagic and wound healing issues but a significant increase in incidence and severity of intraoperative adhesions, which can present a formidable technical challenge. Potential reasons for our lower complication rate could be increased time from TKI discontinuation to surgery, longer time to postoperative TKI re-initiation, increased use of preoperative angioembolization, and the lack of preoperative bevacizumab administration. Presurgical TKI therapy can permit effective surgical cytoreduction with a safety and complication profile equivalent to that of non-TKI-nephrectomy; however safety data continue to evolve, and preoperative TKI use requires further prospective investigation.
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Affiliation(s)
- Lauren C Harshman
- Division of Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Cost NG, Delacroix SE, Sleeper JP, Smith PJ, Youssef RF, Chapin BF, Karam JA, Culp S, Abel EJ, Brugarolas J, Raj GV, Sagalowsky AI, Wood CG, Margulis V. The impact of targeted molecular therapies on the level of renal cell carcinoma vena caval tumor thrombus. Eur Urol 2011; 59:912-8. [PMID: 21367518 DOI: 10.1016/j.eururo.2011.02.032] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 02/15/2011] [Indexed: 01/07/2023]
Abstract
BACKGROUND Targeted molecular therapies (TMTs) previously have demonstrated oncologic activity in renal cell carcinoma (RCC) by reducing the size of primary tumors and metastases. OBJECTIVE To assess the cytoreductive effect of TMTs on inferior vena cava tumor thrombi. DESIGN, SETTING, AND PARTICIPANTS A multi-institutional database of patients treated with TMTs for RCC was reviewed. The subset with in situ level II or higher caval thrombi (above renal vein) was assessed for radiographic response in thrombus size and level. Pre- and posttreatment characteristics of this population were assessed for predictors of response in height, diameter, and level of the tumor thrombi. MEASUREMENTS The main outcome measured was a change in the clinical level of tumor thrombus following TMT. We also measured radiographic responses in thrombus size and location before and after TMT. RESULTS AND LIMITATIONS Twenty-five patients met the inclusion criteria. Before TMT, thrombus level was II in 18 patients (72%), III in 5 patients (20%), and IV in 2 patients (8%). The first-line therapy was sunitinib in 12 cases; alternative TMTs were administered in 13. The median duration of therapy was two cycles (range: one to six cycles). Following TMT, 7 patients (28%) had a measurable increase in thrombus height, 7 (28%) had no change, and 11 (44%) had a decrease. One patient (4%) had an increase in thrombus-level classification, 21 (84%) had stable thrombi, and in 3 (12%) the thrombus level decreased. There was only one case (4%) where the surgical approach was potentially affected by tumor thrombus regression (level IV to III). No statistically significant predictors of tumor thrombus response to TMTs were found. Limitations include the descriptive and retrospective study design. Because TMTs were initiated according to physician and/or patient preferences, and not all patients were treated in anticipation of surgery, no conclusions could be drawn regarding selection and duration of therapy. Thus it may not be appropriate to extrapolate our experience to all patients with locally advanced RCC. Although this is the largest reported experience with in situ caval tumor thrombi treated with TMT, this series lacks sufficient statistical power to assess the usefulness of TMTs adequately in tumor thrombus cytoreduction. CONCLUSIONS TMT had a minimal clinical effect on RCC tumor thrombi. Only patients treated with sunitinib had clinical thrombus regression; however, the clinical magnitude and relevance of this effect is not clear and should be investigated prospectively.
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Affiliation(s)
- Nicholas G Cost
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9110, USA
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Abel EJ, Culp SH, Tannir NM, Matin SF, Tamboli P, Jonasch E, Wood CG. Primary tumor response to targeted agents in patients with metastatic renal cell carcinoma. Eur Urol 2011; 59:10-5. [PMID: 20952123 PMCID: PMC4378833 DOI: 10.1016/j.eururo.2010.09.034] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 09/27/2010] [Indexed: 01/18/2023]
Abstract
BACKGROUND The recent development of multiple targeted agents for metastatic renal cell carcinoma (mRCC) has changed the treatment paradigm; hence the benefit and optimal timing of cytoreductive nephrectomy is being reevaluated. OBJECTIVE To determine primary tumor response to treatment with targeted agents in patients with mRCC. DESIGN, SETTING, AND PARTICIPANTS We reviewed the clinical and radiographic data of all mRCC patients seen at our institution between November 2004 and December 2009 without prior systemic treatment who received targeted therapy with their primary tumor in situ. MEASUREMENTS Two independent reviewers measured the diameter of primary and metastatic tumors at baseline and subsequent scans, using Response Evaluation Criteria Solid Tumors (RECIST) v.1.1 to assess disease response. RESULTS AND LIMITATIONS We identified 168 consecutive patients with a median 15 mo of follow-up and a median maximum tumor diameter of 9.6 cm. Median maximum primary tumor response was -7.1% (interquartile range: -14.0 to -0.1). A total of 61 patients had multiple studies available for evaluation. In 43 patients with <10% decrease in primary tumor within in the first 60 d, median maximum response was -7.2% at 154 d versus -24.5% maximum response at 174.5 d for 18 patients with ≥10% decrease in primary tumor during the initial 60 d. CONCLUSIONS Decrease in primary tumor diameter >30% while on targeted therapy for mRCC is rare, with most patients demonstrating minimal or no decrease in primary tumor diameter. Early response predicts a better overall primary tumor response.
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Affiliation(s)
- E. Jason Abel
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Stephen H. Culp
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Nizar M. Tannir
- Department of Genitourinary Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Surena F. Matin
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Pheroze Tamboli
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Christopher G. Wood
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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Abstract
The principal surgical complication feared in a patient under anti-angiogenic targeted therapy is gastrointestinal perforation. It is therefore important to be alert to situations "potentially at risk" of perforation: diverticulitis, carcinomatosis, intra-abdominal abscess, history of external radiotherapy, colonoscopy in the 4 weeks preceding the treatment, inflammatory disease and gastrointestinal mucosal ulceration, colonic stent, NSAID. It is essential to make an early diagnosis, and for treatment to be conservative if possible, with nasogastric aspiration without surgery. Surgical treatment is only offered in the event of worsening or failure of medical treatment. The time periods between surgery and the initiation of anti-angiogenic treatment vary according to the medication. With bevacizumab: major surgery: 4 weeks; 6 weeks if the patient has comorbidities. Minor surgery (e.g. dental extraction): wait for the wound to heal. With insertion of a PAC, bevacizumab can be administered the day after the insertion if necessary. With TKI: it is recommended to wait for the scar to heal in cases of major surgery. There is no specific recommendation for mTOR inhibitors. The time periods between termination of an anti-angiogenic treatment and scheduling of surgery also vary depending on the medication. With bevacizumab: 6 to 8 weeks for scheduled surgery. In the event of emergency surgery, the surgeon must be aware of an increased risk of post-operative complications. With TKI, 2 days for sorafenib, and 4 days for sunitinib. There is no specific recommendation for mTOR inhibitors.
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Fisher R, Larkin J. Renal cell cancer: what can we learn from pre-operative studies? Front Oncol 2011; 1:51. [PMID: 22655250 PMCID: PMC3356090 DOI: 10.3389/fonc.2011.00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 11/23/2011] [Indexed: 11/29/2022] Open
Affiliation(s)
- Rosalie Fisher
- Department of Medical Oncology, Royal Marsden Hospital London, UK
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Bex A, Jonasch E, Kirkali Z, Mejean A, Mulders P, Oudard S, Patard JJ, Powles T, van Poppel H, Wood CG. Integrating Surgery with Targeted Therapies for Renal Cell Carcinoma: Current Evidence and Ongoing Trials. Eur Urol 2010; 58:819-28. [DOI: 10.1016/j.eururo.2010.08.029] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 08/17/2010] [Indexed: 12/18/2022]
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