The current status of chemotherapy for advanced renal carcinoma

Phase II trial of taxol in patients with metastatic renal cell carcinoma

Based on results of previous Phase I studies, 18 patients with documented metastatic renal cell carcinoma received Taxol 250 mg/m2 as a 24-h infusion, repeated every 21 days in this Phase II study. All patients received premedication with dexamethasone, diphenhydramine, and cimetidine. There were no responses in the 18 patients treated.

Phase II trial of combination chemotherapy with dacarbazine, cyclophosphamide, cisplatin, doxorubicin, and vindesine (DECAV) in advanced renal cell cancer

Eighteen patients with advanced renal cell cancer were evaluated for objective response to a combination chemotherapy regimen twenty-eight-day (d) cycles, with dacarbazine (200 mg/sq m/d, d1,2,3); cyclophosphamide (400 mg/sq m/d, d1); cisplatin (100 mg/sq m/d, d1); doxorubicin (50 mg/sq m/d, d1); vindesine (1.5 mg/sq m/d, d1,2) (DECAV). One response in 16 patients was observed (6.25%; 95% confidence limits are 0-30%). No major toxicity occurred. An important point is that the only complete remission was observed in a patient with sarcomatoid cell renal cancer. At this dose with this schedule this combination regimen appears to have no activity in renal cell carcinoma.

Phase II trial of misonidazole (MISO) and cyclophosphamide (CYC) in metastatic renal cell carcinoma

In animal models pre-treatment with misonidazole, a hypoxic cell radiosensitizer, enhances the antineoplastic effects of alkylating agent chemotherapy. Laboratory data suggest that hypoxic tumor cells may be more resistant to chemotherapy because of suboptimal drug delivery, reduced rates of cell division, or because hypoxia confers relative drug resistance. The therapeutic potential depends on the tumor type, doses of radiosensitizer and alkylating agent, the time interval between drug administration, and the ratio of sensitization of normal and malignant tissues. A Phase II trial of misonidazole and cyclophosphamide was initiated by the Eastern Cooperative Oncology Group to determine the response rate and toxicity in patients with metastatic renal cell cancer. Patients received 5 gm/m2 of misonidazole intravenously two hr before 1200 mg/m2 of cyclophosphamide every 3 wk. Patients with prior chemotherapy or radiotherapy received 1000 mg/m2 of cyclophosphamide. Misonidazole was discontinued after a total dose of 15 gm/m2. The median total misonidazole dose was 23.5 gm (range 4.5-34.5 gm). The median number of cyclophosphamide cycles was 2 (range 1-12). Of the 30 patients evaluable for response, only one patient had an objective partial response. Twenty-nine patients had stable or progressive disease. One patient remains on cyclophosphamide after 9 mo. Estimated median survival is 4.8 mo. There have been no lethal toxicities; however, 9 patients (25%) experienced life-threatening leukopenia and an additional 42% experienced severe hematologic toxicity. Eight patients had WBC less than 1000 on days 7-14 of cycle 1. Thrombocytopenia and grade 3 anemia occurred in 1 and 2 patients, respectively. Moderate or severe nausea and vomiting occurred in 47% and 19% of patients, respectively. Only 3 patients experienced severe neurotoxicity. Four additional patients had moderate neurotoxicity. In summary, misonidazole in this dosing schedule does not enhance the antitumor activity of cyclophosphamide in renal cell carcinoma.

Primary resistance of renal adenocarcinoma to 1,2,4-triglycidylurazol (TGU, NSC 332488), a new triexpoxide cytostatic agent--a phase II study of the EORTC early clinical trials group

Fourteen patients with metastatic renal adenocarcinoma without prior chemotherapy were treated with 1,2,4-triglycidylurazol (TGU, NSC-332488), a new triepoxide alkylating agent. TGU was chosen for this study among other triepoxides because of its high antitumour activity in animal models, its relatively good water solubility and the expected favourable therapeutic index. The starting dose was 800 mg/m2 i.v. (600 mg/m2 for patients with prior extensive radiotherapy) every 4 weeks. No objective tumour regression was seen in this favourable group of patients. Leuko- and thrombocytopenia were the most important side-effects. Severe cumulative and prolonged thrombocytopenia was seen. Other toxicities observed were nausea with or without vomiting in all patients and local phlebitis in some.

Steroid hormone receptors in normal and malignant human renal tissue: relationship with progestin therapy

Documented hormone dependence of renal tumors in animal models, hypothetical hormonal environment of human kidney neoplasms and their controversial response to endocrine therapy prompted us to undertake a prospective multicentric cooperative study to evaluate the hormone-dependence/responsiveness of renal tumors. Patients with renal carcinoma were stratified according to the TNM classification and after nephrectomy were treated with high-dose medroxyprogesterone acetate (MPA). Specimens of tumor and healthy surrounding kidney tissue were studied for titration of steroid receptor proteins (78 for androgen, AR, 89 for estrogen, ER, and progestin, PgR). Their true receptor nature was estimated. Very low titers (on an average less than 10 fmol/mg protein) were found, especially for ER and PgR in neoplastic samples. Occurrence rate of AR was low for both tissues (less than 20%), whereas ER and PgR were detected at a higher frequency in healthy parenchyma than in tumor tissue (42.2 vs 23.3% and 30.7 vs 11.2%, respectively). AR was moderately affected by metastatic status of the disease and by sex. All three steroid receptors were simultaneously detected in normal tissue in 11.7% of cases and in tumor tissue in only 3.8%. No significant correlation between receptor status in the tumor and clinical response to hormone therapy was found. In 27 cases who received adjuvant MPA therapy, relapses were respectively 43.8 and 18.2% in the patients with negative receptors or with at least one detectable receptor. In metastatic renal carcinoma, stabilization of the disease with MPA was achieved more frequently in receptor-negative patients. Therefore, we conclude that the receptor assay is not a valid tool to select renal carcinoma patients for therapy with MPA.

Chemotherapy by bronchial arterial infusion for pulmonary metastases of renal cell carcinoma

Bilateral multiple pulmonary metastases of renal cell carcinoma were treated by repeated bronchial arterial infusion of chemotherapeutic drugs, such as mitomycin C, carboquone, doxorubicin and nitrosourea. Of 12 patients treated 2 had a complete response, 3 had a partial response, 2 had no change and 5 had progression of the disease. The over-all response rate was 42 per cent. Since metastatic renal cell carcinoma is unresponsive to ordinary treatment bronchial arterial infusion alone or in combination with an operation appears promising.

Clinical trial of cisplatinum (NSC 119875) in metastatic renal cell carcinoma

Thirty-two patients with metastatic renal cell carcinoma were treated with cisplatinum, 100 mg./M2 at twenty-eight-day intervals. The drug was given intravenously after first assuring adequate hydration. Response could be determined in 23 patients. There were no partial or complete responses, although 1 patient had less than a 50 per cent reduction in pulmonary lesions and 7 patients had stabilization of their disease for periods ranging from three to seven months. It is concluded that the therapeutic value of cisplatinum in the treatment of advanced renal carcinoma is negligible when used as a single agent.

Aggressive versus conservative management of stage IV renal cell carcinoma

Improved modalities to treat metastatic renal cell carcinoma will require an aggressive surgical and chemotherapeutic approach. Nephrectomy with hormonal and non-hormonal chemotherapy does improve median survival and 3-year survival significantly. The use of xenogeneic specific immune ribonucleic acid and Bacillus Calmette-Guerin offers promising immunotherapeutic modalities that may be combined with surgical and chemotherapeutic regimens. Early diagnosis of metastatic disease is important to evaluate properly the results of various modalities of treatment and possibly to improve the efficiency of these modalities. The management of solitary metastatic nodules should involve aggressive resection of the primary and metastatic nodule. Adjuvant hormonal and non-hormonal chemotherapy should be considered in all stages of the disease.

Current status of the therapy of advanced renal carcinoma

A preclinical murine renal model system is available for evaluation of the effectiveness of therapeutic agents. Clinical review reveals that objective response rates to hormonal agents reported since 1971 have been substantially lower than those reported prior to 1971. Many chemotherapeutic agents have not been adequately evaluated clinically or with the experimental model. Vinblastine to date may be the most active single agent with a 25% objective response rate. At the present time, it is uncertain whether combination chemotherapy or hormonal chemotherapy add to response rates obtained with single agents. There is some evidence that immunotherapy may be of some adjuvant benefit and, thus may provide an additional avenue of investigation.

Decreased incidence of renal tumors in DMN treated Balb/C mice after orchiectomy

Dimethylnitrosamine (DMN) induced a significant incidence (45.5%) of kidney epithelial tumors in adult male Balb/C mice. The proportion of mice with renal tumors orchiectomized after DMN injection was reduced to 25.6%; whereas the proportion of tumor bearing animals at other sites, such as lung, liver, and lymphatic tissue, increased compared to intact DMN treated animals and controls. This experiment confirms other studies in rats and mice showing that androgens play a role in initiation and progression of nitrosamine induced renal cancer, paralleling the finding of increased male susceptibility in human renal cancer.

The phase II evaluation of Bacillus Calmette-Guerin plus megestrol acetate in patients with metastatic renal adenocarcinoma

The case is reported of a patient with pulmonary metastases from a renal adenocarcinoma who experienced subjective improvement and objective tumor regression on Bacillus Calmette-Guerin (BCG) and megestrol acetate therapy. In a subsequent Phase II trial, no objective responses were noted among 15 patients treated with megestrol acetate (160 mg/day X 56 days) and BCG (five immunizing doses intradermally, every 2 weeks X 5). It is concluded that this treatment regimen is not clinically useful in patients with metastatic renal adenocarcinoma.

Growth rate of renal carcinoma as demonstrated by repeat angiography

Thirteen patients with renal carcinoma, primarily not operated upon, were re-evaluated 1 to 71 months after the first nephroangiography. Tumour progression could be demonstrated in 7 cases with a maximum linear diametric growth rate of 0.5 cm/2.5 months. The reasons for absence of growth in the remainder are not apparent, but probably related to the state of immunologic defense mechanism of the host.

Oestrogen-binding components in human renal cell carcinoma

Specific binding of [3H]oestradiol-17beta by the cytosol fraction of human renal cell carcinoma was studied. The binding reaction displayed marked ligand specificity and high affinity of binding. Unlabelled oestradiol, oestriol and oestrone inhibited the binding of [3H]oestradiol-17beta to the cytosol binding sites, wehereas all other steroids tested turned out to be only weak or insignificant competitors for the oestrogen binding sites. Scatchard analyses suggested the existence of a single class of binding sites. The dissociation constant of the oestradiol-binding complex was found to be 2.51 +/¿.75 x 10(-9) mol/l. The number of binding sites was limited (17.5 +/- 3.8 fmoles per mg of cytosol protein). Sucrose gradient centrifugation revealed these binding components to be macromolecules either displaying a complex sedimentation pattern (peaks at 3.5 S, 4S, 5.7S and, in addition, high molecular weight aggregates) or sedimenting in the 4S region alone. By agar gel electrophoresis it could be demonstrated that the oestradiol-inding components migrated into the receptor region of the gel. Binding of [3H]oestradiol-17beta to these entities was markedly reduced, when the cytosol was heated (60 min at 45 degrees C) prior to the reaction with the labelled hormone. Since the specific binding components exhibit properties of oestradiol receptors in target tissues, a direct effect of oestradiol on human renal cell carcinoma is suggested.

Nonhormonal chemotherapy for disseminated renal cell carcinoma

Twenty-five patients with disseminated renal cell carcinoma have been followed for eleven months. These patients have been treated with CCNU, bleomycin, methotrexate, and platinum in various combinations. The results have been discussed in light of other studies using chemotherapeutic agents against this disease process.

Hormones in the treatment of metastatic renal cancer

Metastatic renal adenocarcinoma has been highly resistant to most therapeutic approaches. However, hormonal treatment has been reported to induce significant subjective or objective improvement. Two groups of patients receiving either androgens or progestogens were evaluated. The number of responses was disappointing. Furthermore, neither of the 2 regimens appeared to increase the mean surival between detection of metastases and fatal outcome.

Renal cell carcinoma: natural history and chemotherapeutic experience

Eght-four patients with renal cell carcinoma were analyzed retrospectively in order to 1) determine the effectiveness of systemic chemotherapy-hormonal and non-hormmonal, 2) identify the clinical features of renal cell carcinoma that may be important in prognosis and 3) characterize the paraneoplastic features of renal cell carcinoma. Metastatic disease was present at diagnosis in 57 per cent of the cases and developed within 1 year in an additional 19 per cent of the cases were paradoxically associated with a longer survival (20 months median) compared to single-organ metastasis (5 to 11 months median). Paraneoplastic syndromes occurred in up to 40 per cent of patients with variable survival. Metastatic disease was unresponsive objectively to either primary nephrectomy or to a variety of chemotherapy trials.

Is nephrectomy justified in patients with metastatic renal carcinoma?

The survival data of 93 patients with metastatic renal carcinoma are discussed with respect to the site of metastasis and whether nephrectomy was performed as part of the initial treatment. Analysis of the cumulative survival rates revealed that nephrectomy significantly increased survival only for those patients pesenting exclusively with osseous metastases. Nephrectomy did not alter survival for patients with pulmonary and/or soft tissue metastases.

Medroxyprogesterone acetate (Provera) in the treatment of metastatic renal cancer

Eighty patients with advanced metastatic renal cancer have been treated with hormones, chiefly medroxyprogesterone acetate (Provera). This progestational compound is remarkably free from side-effects and can be given in high dosage for long periods without serious complications. Ninety per cent of cases had multiple metastases: in 76% more than one organ was involved and nearly 50% were seriously ill or "terminal".Subjective improvement occurred in at least 55%. In 11 patients there was marked improvement in the radiological or clinical signs of tumour within 2 to 6 weeks of commencing treatment or changing to a different hormone. In two further cases improved general health was associated with stationary metastases for 20 months. A significant objective response occurred in 16% of the total series. A favourable response was seen more often in men (21%) than in women (8%). If deaths within 6 weeks are excluded the objective response rate in men is increased to 27%. Although the response of advanced renal cancer to hormonal treatment is usually incomplete and of brief duration, it is possible for such treatment to offer a "new lease of life" to a seriously ill patient, even in old age, for 2 to 3 years.