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Guo L, An T, Huang Z, Chong T. A network meta-analysis evaluating the efficacy and safety of adjuvant therapy after nephrectomy in renal cell carcinoma. BMC Urol 2024; 24:55. [PMID: 38454397 PMCID: PMC10921661 DOI: 10.1186/s12894-024-01441-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/28/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND In the past few years, there has been a continuous rise in the occurrence of renal cell carcinoma (RCC), with RCC recurrence becoming the primary factor behind fatalities. Despite numerous clinical trials, the impact of different medications on the long-term survival of patients with RCC after surgery remains uncertain. This network meta-analysis aimed to evaluate the impact of various medications on the survival and safety of drugs in individuals with RCC following nephrectomy. METHODS We conducted a thorough search in various databases, including CNKI, WAN FANG DATA, VIP, Web of Science, Cochrane Library (CENTRAL), PubMed, Scopus, and Embase, for articles published prior to June 2, 2023. This meta-analysis incorporated randomized controlled trials (RCTs). RESULTS The analysis included 17 studies with 14,298 participants. The findings from the disease-free survival (DFS) analysis indicated that pembrolizumab demonstrated efficacy in enhancing DFS among patients with RCC following nephrectomy when compared to the placebo group (HR = 0.83, 95%CI 0.70 to 0.99). None of the drugs included in the study significantly improved overall survival (OS) and recurrence-free survival (RFS) after nephrectomy. For adverse events (AEs), sorafenib, pazopanib, sunitinib, and nivolumab plus ipilimumab interventions showed a higher incidence of adverse events compared with placebo. CONCLUSION The network meta-analysis yielded strong evidence indicating that pembrolizumab could potentially enhance DFS in patients with RCC following nephrectomy, surpassing the effectiveness of a placebo.
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Affiliation(s)
- Lingyu Guo
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Fifth Road, Xi'an, 710000, China
| | - Tian An
- Department of Dermatology and Plastic Surgery, The Second Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Xianyang, China
| | - Zhixin Huang
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Fifth Road, Xi'an, 710000, China
| | - Tie Chong
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 West Fifth Road, Xi'an, 710000, China.
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Esteban-Villarrubia J, Romero Ferreiro C, Carril-Ajuria L, Carretero-González A, Iacovelli R, Albiges L, Castellano D, de Velasco G. Meta-analysis of perioperative immunotherapy in renal cell carcinoma: Available, but the jury is still out. Urol Oncol 2023; 41:391.e13-391.e21. [PMID: 37331822 DOI: 10.1016/j.urolonc.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION While surgical management of renal cell carcinoma (RCC) is curative for many patients, others may relapse and could benefit from adjuvant treatments. Immune checkpoint inhibitors (ICI) have been proposed as a potential adjuvant therapy for improving survival in these patients, but the benefit/risk ratio of ICI in the perioperative setting remains unclear. METHODS A systematic review and a meta-analysis of phase III trials of perioperative ICI (anti PD1/PD-L1 alone or in combination with anti-CTLA4 agents) in RCC was conducted. RESULTS The analysis included results from 4 phase III trials, comprising 3,407 patients. ICI did not show a significant increase in disease-free survival (Hazard Ratio [HR] 0.85; 95% confidence interval [CI] 0.69-1.04; p: 0.11) or overall survival [OS] (HR 0.73; 95% CI 0.40-1.34; p: 0.31). High-grade adverse events were more frequent in the immunotherapy arm (OR 2.65; 95% CI 1.53-4.59; p: <0.001), and high-grade treatment-related adverse events were 8 times more frequent in the experimental arm (OR: 8.07; 95% CI: 3.14-20.75; p: <0.001). Subgroup analyses showed statistically significant differences favoring the experimental arm in females (HR: 0.71; 95 CI 0.55-0.92; p: 0.009), in sarcomatoid differentiation (HR: 0.60 95% CI 0.41-0.89; p: 0.01), and PD-L1 positive tumors (HR HR: 0.74; 95% CI 0.61-0.90; p: 0.003). No significant effect was found in patients according to age, type of nephrectomy (radical vs. partial), and stage (M1 without evidence of disease vs. M0 patients). CONCLUSION Our comprehensive meta-analysis generally suggests that immunotherapy does not confer a survival advantage in the perioperative setting for RCC, with the exception of one positive study. While the overall results are not statistically significant, individual patient factors and other variables may play a role in determining who benefits from immunotherapy. Therefore, despite the mixed findings, immunotherapy may still be a viable treatment option for certain patients, and further studies are needed to determine which patient subgroups would be most likely to benefit.
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Affiliation(s)
| | - Carmen Romero Ferreiro
- Scientific Support Unit (i+12), Instituto de Investigación Sanitaria Hospital Universitario 12 de Octubre (imas12), Madrid, Spain; Faculty of Health Sciences, Universidad Francisco de Vitoria, Madrid, Spain
| | | | | | - Roberto Iacovelli
- Medical Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Laurence Albiges
- Department of Cancer Medicine, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Daniel Castellano
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Guillermo de Velasco
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
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Ciccarese C, Strusi A, Arduini D, Russo P, Palermo G, Foschi N, Racioppi M, Tortora G, Iacovelli R. Post nephrectomy management of localized renal cell carcinoma. From risk stratification to therapeutic evidence in an evolving clinical scenario. Cancer Treat Rev 2023; 115:102528. [PMID: 36905896 DOI: 10.1016/j.ctrv.2023.102528] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/13/2023]
Abstract
Standard treatment for localized non-metastatic renal cell carcinoma (RCC) is radical or partial nephrectomy. However, after radical surgery, patients with stage II-III have a substantial risk of relapse (around 35%). To date a unique standardized classification for the risk of disease recurrence still lack. Moreover, in the last years great attention has been focused in developing systemic therapies with the aim of improving the disease-free survival (DFS) of high-risk patients, with negative results from adjuvant VEGFR-TKIs. Therefore, there is still a need for developing effective treatments for radically resected RCC patients who are at intermediate/high risk of relapse. Recently, interesting results came from immune-checkpoint inhibitors (ICIs) targeting the PD-1/PD-L1 pathway, with a significant benefit in terms of disease-free survival from adjuvant pembrolizumab. However, the conflicting results of diverse clinical trials investigating different ICI-based regimens in the adjuvant setting, together with the still immature data on the overall survival advantage of immunotherapy, requires careful considerations. Furthermore, several questions remain unanswered, primarily regarding the selection of patients who could benefit the most from immunotherapy. In this review, we have summarized the main clinical trials investigating adjuvant therapy in RCC, with a particular focus on immunotherapy. Moreover, we have analyzed the crucial issue of patients' stratification according to the risk of disease recurrence, and we have described the possible future prospective and novel agents under evaluation for perioperative and adjuvant therapies.
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Affiliation(s)
- Chiara Ciccarese
- Medical Oncology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Alessandro Strusi
- Medical Oncology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Daniela Arduini
- Medical Oncology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Pierluigi Russo
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy; Urology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Giuseppe Palermo
- Urology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Nazario Foschi
- Urology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Marco Racioppi
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy; Urology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Giampaolo Tortora
- Medical Oncology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Roberto Iacovelli
- Medical Oncology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy.
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The Continuing Question of Adjuvant Therapy in Clear Cell Renal Cell Carcinoma. Cancers (Basel) 2022; 14:cancers14246018. [PMID: 36551504 PMCID: PMC9776072 DOI: 10.3390/cancers14246018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
Treatment advances in kidney cancer continually evolve. The focus of treatment options continues with oral vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs) or intravenous immune checkpoint inhibitors (ICIs). Multiple trials exploring the role of adjuvant treatment after cytoreductive nephrectomy in high-risk clear cell renal cell carcinoma are currently ongoing. The discovery of biomarkers may help determine which patients benefit from these treatments, but these are not yet available outside clinical studies. Trials with combination therapies are also ongoing, especially using novel therapies with new mechanisms of action, and will hopefully provide more clues on proper patient and therapy selection in the adjuvant setting.
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Bottiglieri A, Sepe P, Stellato M, Pircher C, Fotia G, Leone AG, Guadalupi V, Claps M, Giannatempo P, Verzoni E, Procopio G. Optimal Choice of Adjuvant Treatment for Renal Cell Carcinoma Following Nephrectomy. Cancer Manag Res 2022; 14:3071-3081. [PMID: 36275783 PMCID: PMC9584769 DOI: 10.2147/cmar.s360441] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/13/2022] [Indexed: 11/29/2022] Open
Abstract
Renal cell carcinoma (RCC) is the fourteenth most common cancer worldwide. In about 55% of cases, it is diagnosed at a localised and/or locally advanced stage and therefore amenable to a curative approach. Although nephrectomy still represents the cornerstone of non-metastatic RCC (nmRCC) treatment, a relapse is observed in about 25–30% of patients undergoing curative surgery. Prognosis is drastically influenced by lymph nodal involvement. After the first disappointing results with a cytokine-based strategy, tyrosine kinase inhibitors (TKIs) were tested as adjuvant agents. Despite their efficacy in the metastatic setting, results in terms of disease-free survival (DFS) are not unequivocal and the overall survival (OS) benefit has not been demonstrated. Moreover, their toxicity profile induced a remarkable percentage of patients to discontinue the treatment. On the contrary, the KEYNOTE-564 trial showed the benefit of adjuvant pembrolizumab compared with placebo in terms of DFS with promising results in term of OS. Patients included were at intermediate or high risk of relapse, or patients with no evidence of disease after metastasectomy (M1 NED). The updated analysis presented at the American Society of Clinical Oncology Genito-Urinary (ASCO GU) 2022 confirmed the benefit of pembrolizumab versus placebo over time, although OS data are still immature. A longer follow-up and the several ongoing trials with immune checkpoint inhibitors (ICIs) will provide further data about adjuvant immuno-oncology (IO). Furthermore, the patients’ selection based on clinical or biological features will be crucial in order to identify who benefits most from treatments.
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Affiliation(s)
- Achille Bottiglieri
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy,Correspondence: Achille Bottiglieri, Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian 1, Milan, Italy, Tel +39 02 2390 2751, Email
| | - Pierangela Sepe
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marco Stellato
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Chiara Pircher
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Giuseppe Fotia
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | - Valentina Guadalupi
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Melanie Claps
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Patrizia Giannatempo
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Elena Verzoni
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Giuseppe Procopio
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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Mikhail M, Chua KJ, Khizir L, Tabakin A, Singer EA. Role of metastasectomy in the management of renal cell carcinoma. Front Surg 2022; 9:943604. [PMID: 35965871 PMCID: PMC9372304 DOI: 10.3389/fsurg.2022.943604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
Treatment of metastatic renal cell carcinoma (mRCC) has evolved with the development of a variety of systemic agents; however, these therapies alone rarely lead to a complete response. Complete consolidative surgery with surgical metastasectomy has been associated with improved survival outcomes in well-selected patients in previous reports. No randomized control trial exists to determine the effectiveness of metastasectomy. Therefore, reviewing observational studies is important to best determine which patients are most appropriate for metastasectomy for mRCC and if such treatment continues to be effective with the development of new systemic therapies such as immunotherapy. In this narrative review, we discuss the indications for metastasectomies, outcomes, factors associated with improved survival, and special considerations such as location of metastasis, number of metastases, synchronous metastases, and use of systemic therapy. Additionally, alternative treatment options and trials involving metastasectomy will be reviewed.
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Prunty M, Bukavina L, Psutka SP. Metastasectomy in kidney cancer: current indications and treatment approaches. Curr Opin Support Palliat Care 2021; 15:266-275. [PMID: 34610626 DOI: 10.1097/spc.0000000000000574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although systemic agents for the treatment of metastatic renal cell carcinoma (mRCC) have improved survival, remission and cure for mRCC remains rare with systemic therapy alone. However, there is a body of observational evidence supporting a survival benefit in mRCC among patients who undergo complete surgical consolidation including resection of the primary tumor and all metastatic deposits. In this review, we aim to synthesize recent evidence regarding metastasectomy (MTS), with or without concurrent systemic therapy, in mRCC. RECENT FINDINGS MTS is a critical component of mRCC patient care, alongside modern systemic therapy. Presently, there is a robust body of observational data supporting the association between surgical MTS and improved oncologic outcomes, especially when complete MTS is feasible. SUMMARY Among a retrospective, observational body of literature, MTS is associated with improved oncologic outcomes. However, it is impossible to discern to what degree these findings are biased by favorable tumor biology and patient selection, as opposed to being related to surgical MTS itself.
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Affiliation(s)
- Megan Prunty
- Department of Urology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Laura Bukavina
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, Washington, USA
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