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Dahm P, Ergun O, Uhlig A, Bellut L, Risk MC, Lyon JA, Kunath F. Cytoreductive nephrectomy in metastatic renal cell carcinoma. Cochrane Database Syst Rev 2024; 6:CD013773. [PMID: 38847285 PMCID: PMC11157663 DOI: 10.1002/14651858.cd013773.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2024]
Abstract
BACKGROUND Nephrectomy is the surgical removal of all or part of a kidney. When the aim of nephrectomy is to reduce tumor burden in people with established metastatic disease, the procedure is called cytoreductive nephrectomy (CN). CN is typically combined with systemic anticancer therapy (SACT). SACT can be initiated before or immediately after the operation or deferred until radiological signs of disease progression. The benefits and harms of CN are controversial. OBJECTIVES To assess the effects of cytoreductive nephrectomy combined with systemic anticancer therapy versus systemic anticancer therapy alone or watchful waiting in newly diagnosed metastatic renal cell carcinoma. SEARCH METHODS We performed a comprehensive search in the Cochrane Library, MEDLINE, Embase, Scopus, two trial registries, and other gray literature sources up to 1 March 2024. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated SACT and CN versus SACT alone or watchful waiting. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. Primary outcomes were time to death from any cause and quality of life. Secondary outcomes were time to disease progression, treatment response, treatment-related mortality, discontinuation due to adverse events, and serious adverse events. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS Our search identified 10 records of four unique RCTs that informed two comparisons. In this abstract, we focus on the results for the two primary outcomes. Cytoreductive nephrectomy plus systemic anticancer therapy versus systemic anticancer therapy alone Three RCTs informed this comparison. Due to the considerable heterogeneity when pooling across these studies, we decided to present the results of the prespecified subgroup analysis by type of systemic agent. Cytoreductive nephrectomy plus interferon immunotherapy versus interferon immunotherapy alone CN plus interferon immunotherapy compared with interferon immunotherapy alone probably increases time to death from any cause (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.51 to 0.89; I²= 0%; 2 studies, 326 participants; moderate-certainty evidence). Assuming 820 all-cause deaths at two years' follow-up per 1000 people who receive interferon immunotherapy alone, the effect estimate corresponds to 132 fewer all-cause deaths (237 fewer to 37 fewer) per 1000 people who receive CN plus interferon immunotherapy. We found no evidence to assess quality of life. Cytoreductive nephrectomy plus tyrosine kinase inhibitor therapy versus tyrosine kinase inhibitor therapy alone We are very uncertain about the effect of CN plus tyrosine kinase inhibitor (TKI) therapy compared with TKI therapy alone on time to death from any cause (HR 1.11, 95% CI 0.90 to 1.37; 1 study, 450 participants; very low-certainty evidence). Assuming 574 all-cause deaths at two years' follow-up per 1000 people who receive TKI therapy alone, the effect estimate corresponds to 38 more all-cause deaths (38 fewer to 115 more) per 1000 people who receive CN plus TKI therapy. We found no evidence to assess quality of life. Immediate cytoreductive nephrectomy versus deferred cytoreductive nephrectomy One study evaluated CN followed by TKI therapy (immediate CN) versus three cycles of TKI therapy followed by CN (deferred CN). Immediate CN compared with deferred CN may decrease time to death from any cause (HR 1.63, 95% CI 1.05 to 2.53; 1 study, 99 participants; low-certainty evidence). Assuming 620 all-cause deaths at two years' follow-up per 1000 people who receive deferred CN, the effect estimate corresponds to 173 more all-cause deaths (18 more to 294 more) per 1000 people who receive immediate CN. We found no evidence to assess quality of life. AUTHORS' CONCLUSIONS CN plus SACT in the form of interferon immunotherapy versus SACT in the form of interferon immunotherapy alone probably increases time to death from any cause. However, we are very uncertain about the effect of CN plus SACT in the form of TKI therapy versus SACT in the form of TKI therapy alone on time to death from any cause. Immediate CN versus deferred CN may decrease time to death from any cause. We found no quality of life data for any of these three comparisons. We also found no evidence to inform any other comparisons, in particular those involving newer immunotherapy agents (programmed death receptor 1 [PD-1]/programmed death ligand 1 [PD-L1] immune checkpoint inhibitors), which have become the backbone of SACT for metastatic renal cell carcinoma. There is an urgent need for RCTs that explore the role of CN in the context of contemporary forms of systemic immunotherapy.
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Affiliation(s)
- Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Onuralp Ergun
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Annemarie Uhlig
- Department of Urology, University Medical Center, Goettingen, Germany
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
| | - Laura Bellut
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Department of Urology and Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Michael C Risk
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Jennifer A Lyon
- Library Services, Children's Mercy Hospital, Kansas City, Missouri, USA
- Center for Evidence-Based Policy, Portland, Oregon, USA
| | - Frank Kunath
- UroEvidence@Deutsche Gesellschaft für Urologie, Berlin, Germany
- Medizinische Fakultät am Medizincampus Oberfranken, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Urology and Pediatric Urology, Klinikum Bayreuth GmbH, Bayreuth, Germany
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Goswamy R, Kalemoglu E, Master V, Bilen MA. Perioperative systemic treatments in renal cell carcinoma. Front Oncol 2024; 14:1362172. [PMID: 38841158 PMCID: PMC11151741 DOI: 10.3389/fonc.2024.1362172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/03/2024] [Indexed: 06/07/2024] Open
Abstract
In this review, we aim to provide a comprehensive assessment of the evolving landscape of the perioperative management in renal cell carcinoma (RCC), emphasizing its dynamic and intricate nature. We explore academic and clinical insights into the perioperative treatment paradigm of RCC. Up-to-date treatment options are discussed and the evolving role of neoadjuvant and adjuvant therapy in RCC is highlighted.
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Affiliation(s)
- Rohit Goswamy
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - Ecem Kalemoglu
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, United States
| | - Viraj Master
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States
| | - Mehmet Asim Bilen
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
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3
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Tobe T, Terakawa T, Hara T, Ueki H, Shiraishi Y, Wakita N, Okamura Y, Bando Y, Furukawa J, Nakano Y, Harada K, Fujisawa M. The Efficacy of Presurgical Therapy With Avelumab and Axitinib for Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus. Clin Genitourin Cancer 2023; 21:613.e1-613.e6. [PMID: 37236863 DOI: 10.1016/j.clgc.2023.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Taisuke Tobe
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Tomoaki Terakawa
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.
| | - Takuto Hara
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hideto Ueki
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yusuke Shiraishi
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Naoto Wakita
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yasuyoshi Okamura
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yukari Bando
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Junya Furukawa
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuzo Nakano
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kenichi Harada
- Department of Urology, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Masato Fujisawa
- Department of Urology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Kaur J, Patil G, Geynisman DM, Ghatalia P. Role of perioperative immunotherapy in localized renal cell carcinoma. Ther Adv Med Oncol 2023; 15:17588359231181497. [PMID: 37529159 PMCID: PMC10387776 DOI: 10.1177/17588359231181497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 05/24/2023] [Indexed: 08/03/2023] Open
Abstract
Immunotherapy has proven effective in metastatic renal cell carcinoma (RCC). The current standard of treatment in localized RCC is partial or complete nephrectomy. However, after surgery, there is a high recurrence rate and survival rates ranging from 53% to 85% depending on the stage of disease at presentation. Given clinical response to immunotherapies in metastatic RCC, these therapies are being tested as monotherapy and in combination with vascular endothelial growth factor receptor tyrosine kinase inhibitors in the (neo)adjuvant setting. Here we describe the current landscape of these treatments in localized RCC.
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Affiliation(s)
- Jasmeet Kaur
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | | | - Daniel M. Geynisman
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Studentova H, Spisarova M, Kopova A, Zemankova A, Melichar B, Student V. The Evolving Landscape of Cytoreductive Nephrectomy in Metastatic Renal Cell Carcinoma. Cancers (Basel) 2023; 15:3855. [PMID: 37568671 PMCID: PMC10417043 DOI: 10.3390/cancers15153855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
The role of cytoreductive nephrectomy in metastatic renal cell carcinoma (RCC) has been studied intensively over the past few decades. Interestingly, the opinion with regard to the importance of this procedure has switched from a recommendation as a standard of care to an almost complete refutation. However, no definitive agreement on cytoreductive nephrectomy, including the pros and cons of the procedure, has been reached, and the topic remains highly controversial. With the advent of immune checkpoint inhibitors, we have experienced a paradigm shift, with immunotherapy playing a crucial role in the treatment algorithm. Nevertheless, obtaining results from prospective clinical trials on the role of cytoreductive nephrectomy requires time, and once some data have been gathered, the standards of systemic therapy may be different, and we stand again at the beginning. This review summarizes current knowledge on the topic in the light of newly evolving treatment strategies. The crucial point is to recognize who could be an appropriate candidate for immediate cytoreductive surgery that may facilitate the effect of systemic therapy through tumor debulking, or who might benefit from deferred cytoreduction in the setting of an objective response of the tumor. The role of prognostic factors in management decisions as well as the technical details associated with performing the procedure from a urological perspective are discussed. Ongoing clinical trials that may bring new evidence for transforming therapeutic paradigms are listed.
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Affiliation(s)
- Hana Studentova
- Department of Oncology, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University, 771 47 Olomouc, Czech Republic; (H.S.); (M.S.); (A.K.); (A.Z.); (B.M.)
| | - Martina Spisarova
- Department of Oncology, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University, 771 47 Olomouc, Czech Republic; (H.S.); (M.S.); (A.K.); (A.Z.); (B.M.)
| | - Andrea Kopova
- Department of Oncology, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University, 771 47 Olomouc, Czech Republic; (H.S.); (M.S.); (A.K.); (A.Z.); (B.M.)
| | - Anezka Zemankova
- Department of Oncology, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University, 771 47 Olomouc, Czech Republic; (H.S.); (M.S.); (A.K.); (A.Z.); (B.M.)
| | - Bohuslav Melichar
- Department of Oncology, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University, 771 47 Olomouc, Czech Republic; (H.S.); (M.S.); (A.K.); (A.Z.); (B.M.)
| | - Vladimir Student
- Department of Urology, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University, 771 47 Olomouc, Czech Republic
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Aldin A, Besiroglu B, Adams A, Monsef I, Piechotta V, Tomlinson E, Hornbach C, Dressen N, Goldkuhle M, Maisch P, Dahm P, Heidenreich A, Skoetz N. First-line therapy for adults with advanced renal cell carcinoma: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023; 5:CD013798. [PMID: 37146227 PMCID: PMC10158799 DOI: 10.1002/14651858.cd013798.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Since the approval of tyrosine kinase inhibitors, angiogenesis inhibitors and immune checkpoint inhibitors, the treatment landscape for advanced renal cell carcinoma (RCC) has changed fundamentally. Today, combined therapies from different drug categories have a firm place in a complex first-line therapy. Due to the large number of drugs available, it is necessary to identify the most effective therapies, whilst considering their side effects and impact on quality of life (QoL). OBJECTIVES To evaluate and compare the benefits and harms of first-line therapies for adults with advanced RCC, and to produce a clinically relevant ranking of therapies. Secondary objectives were to maintain the currency of the evidence by conducting continuous update searches, using a living systematic review approach, and to incorporate data from clinical study reports (CSRs). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, conference proceedings and relevant trial registries up until 9 February 2022. We searched several data platforms to identify CSRs. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating at least one targeted therapy or immunotherapy for first-line treatment of adults with advanced RCC. We excluded trials evaluating only interleukin-2 versus interferon-alpha as well as trials with an adjuvant treatment setting. We also excluded trials with adults who received prior systemic anticancer therapy if more than 10% of participants were previously treated, or if data for untreated participants were not separately extractable. DATA COLLECTION AND ANALYSIS All necessary review steps (i.e. screening and study selection, data extraction, risk of bias and certainty assessments) were conducted independently by at least two review authors. Our outcomes were overall survival (OS), QoL, serious adverse events (SAEs), progression-free survival (PFS), adverse events (AEs), the number of participants who discontinued study treatment due to an AE, and the time to initiation of first subsequent therapy. Where possible, analyses were conducted for the different risk groups (favourable, intermediate, poor) according to the International Metastatic Renal-Cell Carcinoma Database Consortium Score (IMDC) or the Memorial Sloan Kettering Cancer Center (MSKCC) criteria. Our main comparator was sunitinib (SUN). A hazard ratio (HR) or risk ratio (RR) lower than 1.0 is in favour of the experimental arm. MAIN RESULTS We included 36 RCTs and 15,177 participants (11,061 males and 4116 females). Risk of bias was predominantly judged as being 'high' or 'some concerns' across most trials and outcomes. This was mainly due to a lack of information about the randomisation process, the blinding of outcome assessors, and methods for outcome measurements and analyses. Additionally, study protocols and statistical analysis plans were rarely available. Here we present the results for our primary outcomes OS, QoL, and SAEs, and for all risk groups combined for contemporary treatments: pembrolizumab + axitinib (PEM+AXI), avelumab + axitinib (AVE+AXI), nivolumab + cabozantinib (NIV+CAB), lenvatinib + pembrolizumab (LEN+PEM), nivolumab + ipilimumab (NIV+IPI), CAB, and pazopanib (PAZ). Results per risk group and results for our secondary outcomes are reported in the summary of findings tables and in the full text of this review. The evidence on other treatments and comparisons can also be found in the full text. Overall survival (OS) Across risk groups, PEM+AXI (HR 0.73, 95% confidence interval (CI) 0.50 to 1.07, moderate certainty) and NIV+IPI (HR 0.69, 95% CI 0.69 to 1.00, moderate certainty) probably improve OS, compared to SUN, respectively. LEN+PEM may improve OS (HR 0.66, 95% CI 0.42 to 1.03, low certainty), compared to SUN. There is probably little or no difference in OS between PAZ and SUN (HR 0.91, 95% CI 0.64 to 1.32, moderate certainty), and we are uncertain whether CAB improves OS when compared to SUN (HR 0.84, 95% CI 0.43 to 1.64, very low certainty). The median survival is 28 months when treated with SUN. Survival may improve to 43 months with LEN+PEM, and probably improves to: 41 months with NIV+IPI, 39 months with PEM+AXI, and 31 months with PAZ. We are uncertain whether survival improves to 34 months with CAB. Comparison data were not available for AVE+AXI and NIV+CAB. Quality of life (QoL) One RCT measured QoL using FACIT-F (score range 0 to 52; higher scores mean better QoL) and reported that the mean post-score was 9.00 points higher (9.86 lower to 27.86 higher, very low certainty) with PAZ than with SUN. Comparison data were not available for PEM+AXI, AVE+AXI, NIV+CAB, LEN+PEM, NIV+IPI, and CAB. Serious adverse events (SAEs) Across risk groups, PEM+AXI probably increases slightly the risk for SAEs (RR 1.29, 95% CI 0.90 to 1.85, moderate certainty) compared to SUN. LEN+PEM (RR 1.52, 95% CI 1.06 to 2.19, moderate certainty) and NIV+IPI (RR 1.40, 95% CI 1.00 to 1.97, moderate certainty) probably increase the risk for SAEs, compared to SUN, respectively. There is probably little or no difference in the risk for SAEs between PAZ and SUN (RR 0.99, 95% CI 0.75 to 1.31, moderate certainty). We are uncertain whether CAB reduces or increases the risk for SAEs (RR 0.92, 95% CI 0.60 to 1.43, very low certainty) when compared to SUN. People have a mean risk of 40% for experiencing SAEs when treated with SUN. The risk increases probably to: 61% with LEN+PEM, 57% with NIV+IPI, and 52% with PEM+AXI. It probably remains at 40% with PAZ. We are uncertain whether the risk reduces to 37% with CAB. Comparison data were not available for AVE+AXI and NIV+CAB. AUTHORS' CONCLUSIONS Findings concerning the main treatments of interest comes from direct evidence of one trial only, thus results should be interpreted with caution. More trials are needed where these interventions and combinations are compared head-to-head, rather than just to SUN. Moreover, assessing the effect of immunotherapies and targeted therapies on different subgroups is essential and studies should focus on assessing and reporting relevant subgroup data. The evidence in this review mostly applies to advanced clear cell RCC.
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Affiliation(s)
- Angela Aldin
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Burcu Besiroglu
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Eve Tomlinson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carolin Hornbach
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nadine Dressen
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marius Goldkuhle
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Axel Heidenreich
- Department of Urology, Uro-oncology, Special Urological and Robot-assisted Surgery, University Hospital of Cologne, Cologne, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Jones JO, Ince WHJ, Welsh SJ, Stewart GD. Activity of Immunotherapy Regimens on Primary Renal Tumours: A Systematic Review. KIDNEY CANCER 2022. [DOI: 10.3233/kca-220012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND: Immune checkpoint inhibitors (ICPIs) are widely used in treating metastatic renal cell carcinoma (RCC). Cytoreductive nephrectomy (CN) forms part of multimodality treatment in advanced disease, however there is no prospective evidence for its use in the ICPI era. Trials of neoadjuvant ICPIs in RCC are underway; understanding the anticipated effect of ICPIs on the primary tumour may help clinical decision making in both localised and advanced settings. METHODS: A systematic search (PubMed, Web of Science, clinicaltrials.gov) of English literature from 2012 to 2022 was performed according to PRISMA guidelines. 2,398 records were identified, 54 were included in the analysis. RESULTS: In the metastatic setting, response in the primary tumour (≥30% reduction in size) is seen in 33–56% of patients treated with dual ICPI or ICPI + VEGFR-TKI. Pathological complete response rates were 14% for patients undergoing CN after a period of ICPI therapy. In the neoadjuvant setting there is a single published trial of VEGFR-TKI + ICPI, 30% of patients had a≥30% reduction in size of the primary. This appears superior to single agent ICPI. Grade 3 adverse event rates are comparable to the metastatic setting. CONCLUSIONS: A period of ICPI combination therapy followed by nephrectomy may be considered for selected patients as a strategy to manage metastatic disease. In the neoadjuvant setting, it is not clear whether ICPI + VEGFR-TKI is superior to VEGFR-TKI alone. There is minimal data on whether either CN after ICPI in metastatic patients, or neoadjuvant ICPI therapy for localised disease, improves long term survival.
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Affiliation(s)
- James O. Jones
- University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | | | - Sarah J. Welsh
- University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Grant D. Stewart
- University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
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Kuusk T, Bex A. Partial Nephrectomy for Metastatic Renal Cell Carcinoma: Con. EUR UROL SUPPL 2022; 44:81-83. [PMID: 36071821 PMCID: PMC9442326 DOI: 10.1016/j.euros.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Teele Kuusk
- Department of Urology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Axel Bex
- Specialist Centre for Kidney Cancer, The Royal Free London NHS Foundation Trust, London, UK
- UCL Division of Surgery and Interventional Science, London, UK
- Department of Urology, Antoni van Leeuwenhoek Hospital-The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Corresponding author
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Zondervan PJ, Bex A. What We Have Learnt from CARMENA and SURTIME and What Should Be Done Differently in Future Trials on Cytoreductive Nephrectomy. KIDNEY CANCER 2022. [DOI: 10.3233/kca-220004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Upfront cytoreductive nephrectomy (CN) was the standard treatment for selected patients with metastatic Renal Cell Carcinoma (RCC) in the cytokine era for many years. In the recent ‘targeted therapy era’ it has been re-challenged by both the CARMENA and SURTIME trials. As first-line therapy for treatment-naive metastatic clear-cell RCC has now changed to immune checkpoint inhibitor combination therapy (ICI), and previous studies concerning CN were built in the targeted therapy era, the role and sequence of CN needs to be revisited. Here we address what we have learnt from both trials and how future trials should be designed to investigate CN.
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Affiliation(s)
- Patricia J. Zondervan
- Department of Urology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Axel Bex
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Urology, The Royal Free Hospital and University College London, London, UK
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10
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Albiges L, Tannir NM, Burotto M, McDermott D, Plimack ER, Barthélémy P, Porta C, Powles T, Donskov F, George S, Kollmannsberger CK, Gurney H, Grimm MO, Tomita Y, Castellano D, Rini BI, Choueiri TK, Leung D, Saggi SS, Lee CW, McHenry MB, Motzer RJ. First-line Nivolumab plus Ipilimumab Versus Sunitinib in Patients Without Nephrectomy and With an Evaluable Primary Renal Tumor in the CheckMate 214 Trial. Eur Urol 2022; 81:266-271. [PMID: 34750035 DOI: 10.1016/j.eururo.2021.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/06/2021] [Indexed: 01/11/2023]
Abstract
We present an exploratory post hoc analysis from the phase 3 CheckMate 214 trial of first-line nivolumab plus ipilimumab (NIVO+IPI) versus sunitinib in a subgroup of 108 patients with advanced renal cell carcinoma (aRCC) without prior nephrectomy and with an evaluable primary tumor, a population under-represented in clinical trials. Patients with clear cell aRCC were randomized to NIVO+IPI every 3 wk for four doses followed by NIVO monotherapy, or sunitinib every day for 4 wk (6-wk cycle). Overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and primary tumor shrinkage were assessed. PFS and ORR were assessed per independent radiology review committee using RECIST version 1.1. With minimum study follow-up of 4 yr for intent-to-treat patients, OS favored NIVO+IPI (n = 53) over sunitinib (n = 55; hazard ratio 0.63, 95% confidence interval 0.40-1.0) among patients without prior nephrectomy. ORR was higher (34% vs 15%; p = 0.0041) and median duration of response was longer with NIVO+IPI versus sunitinib (20.5 vs 14.1 mo); the best overall response was partial response in either arm. A ≥30% reduction in the diameter of intact target renal tumors was achieved in 35% of patients with NIVO+IPI versus 20% with sunitinib. Safety was consistent with the global study population. In conclusion, in patients with aRCC without prior nephrectomy and with an evaluable primary tumor, NIVO+IPI showed survival benefits and renal tumor reduction versus sunitinib. This trial is registered at ClinicalTrials.gov as NCT02231749. PATIENT SUMMARY: In an exploratory analysis of a large global trial (CheckMate 214), we observed positive outcomes (both survival and tumor response to treatment) with nivolumab plus ipilimumab over sunitinib in a subgroup of patients with advanced kidney cancer who did not undergo removal of their primary kidney tumor. This subset of patients represents a population that has not been studied in clinical trials and for whom outcomes with new immunotherapy combination regimens are not yet known. We conclude that treatment with nivolumab plus ipilimumab offers these patients a survival benefit versus sunitinib, consistent with that observed in the overall study, as well as a notable kidney tumor reduction.
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Affiliation(s)
- Laurence Albiges
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France.
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David McDermott
- Division of Medical Oncology, Beth Israel Deaconess Medical Center, Dana-Farber/Harvard Cancer Center, Boston, MA, USA
| | - Elizabeth R Plimack
- Department of Hematology and Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Philippe Barthélémy
- Medical Oncology, Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | | | - Thomas Powles
- Department of Urology, Barts Cancer Institute, Queen Mary University of London, Royal Free NHS Trust, London, UK
| | - Frede Donskov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Saby George
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | | | - Howard Gurney
- Department of Medical Oncology, Westmead Hospital and Macquarie University, Sydney, Australia
| | | | - Yoshihiko Tomita
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Daniel Castellano
- Medical Oncology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Brian I Rini
- Division of Hematology Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Toni K Choueiri
- Department of Medical Oncology, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David Leung
- Department of Imaging, Bristol Myers Squibb, Princeton, NJ, USA
| | | | - Chung-Wei Lee
- Department of Clinical Trials, Bristol Myers Squibb, Princeton, NJ, USA
| | - M Brent McHenry
- Department of Biostatistics, Bristol Myers Squibb, Princeton, NJ, USA
| | - Robert J Motzer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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11
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Méjean A, Bex A. Cytoreductive Nephrectomy: Still Necessary in 2021. EUR UROL SUPPL 2022; 36:49-50. [PMID: 35036961 PMCID: PMC8749015 DOI: 10.1016/j.euros.2021.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Arnaud Méjean
- Department of Urology, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France
| | - Axel Bex
- Department of Urology, The Royal Free London NHS Foundation Trust, University College London Division of Surgery and Interventional Science, London, UK.,The Netherlands Cancer Institute, Amsterdam, The Netherlands
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12
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Primary Renal Tumour Response in Patients Treated with Nivolumab and Ipilimumab for Metastatic Renal Cell Carcinoma: Real-world Data Assessment. EUR UROL SUPPL 2022; 35:54-58. [PMID: 35024632 PMCID: PMC8738899 DOI: 10.1016/j.euros.2021.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Following CARMENA and SURTIME, patients with metastatic renal cell carcinoma (mRCC) and International Metastatic RCC Database Consortium (IMDC) intermediate and poor risk receive systemic therapy with the primary tumour (primary) in place, with the option of deferred cytoreductive nephrectomy (CN) in responding patients. We retrospectively analysed the safety and efficacy of first-line nivolumab/ipilimumab in 71 primary mRCC patients (42.3% IMDC poor risk; 43.6% with more than three metastatic sites). The baseline mean primary diameter was 9.3 cm and median follow-up was 11.5 mo. Of 69 patients with at least one follow-up computed tomography scan, 23 (33.3 %) had a partial response (PR) of the primary after a median of 4.8 mo, which was associated with a 91.3% overall response rate at metastatic sites (MSs) and absence of progressive disease, irrespective of the IMDC risk. The complete response (CR) rate at MSs (n = 7 [10.1%]) is similar to the CR rate in CheckMate 214. Thirteen deferred CNs were performed (18.8%) after a median of 13 mo, rendering four patients disease free. Only 4.3% of primaries progressed; grade 3–4 immune-related adverse events occurred in 31.9%. Irrespective of the IMDC risk, patients with a PR in the primary had a 1-yr overall survival rate of 89% versus 67% in those without (p = 0.012). Patient summary Patients with metastatic kidney cancer receiving immunotherapy with nivolumab and ipilimumab had superior response at metastatic sites and better survival irrespective of International Metastatic RCC Database Consortium (IMDC) risk.
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13
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Marandino L, Necchi A. Primary Renal Tumour Response to Immunotherapy: Lessons from Metastatic Disease and Insights into Earlier Settings. Eur Urol 2021; 80:330-332. [PMID: 34148713 DOI: 10.1016/j.eururo.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/03/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Laura Marandino
- Service of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
| | - Andrea Necchi
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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14
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Stellato M, Santini D, Verzoni E, De Giorgi U, Pantano F, Casadei C, Fornarini G, Maruzzo M, Sbrana A, Di Lorenzo G, Soraru M, Naglieri E, Buti S, De Vivo R, Napolitano A, Vignani F, Mucciarini C, Grillone F, Roviello G, Di Napoli M, Procopio G. Impact of Previous Nephrectomy on Clinical Outcome of Metastatic Renal Carcinoma Treated With Immune-Oncology: A Real-World Study on Behalf of Meet-URO Group (MeetUro-7b). Front Oncol 2021; 11:682449. [PMID: 34168997 PMCID: PMC8217989 DOI: 10.3389/fonc.2021.682449] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/11/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Immune-Oncology (IO) improves Overall Survival (OS) in metastatic Renal Cell Carcinoma (mRCC). The prognostic impact of previous Cytoreductive Nephrectomy (CN) and radical nephrectomy (RN), with curative intent, in patients treated with IO is not well defined. The aim of our paper is to evaluate the impact of previous nephrectomy on outcome of mRCC patients treated with IO. METHODS 287 eligible patients were retrospectively collected from 16 Italian referral centers adhering to the MeetUro association. Patients treated with IO as second and third line were included, whereas patients treated with IO as first line were excluded. Kaplan-Meier method and log-rank test were performed to compare Progression Free Survival (PFS) and OS between groups. In our analysis, both CN and RN were included. The association between nephrectomy and other variables was analyzed in univariate and multivariate setting using the Cox proportional hazard model. RESULTS 246/287 (85.7%) patients had nephrectomy before IO treatment. Median PFS in patients who underwent nephrectomy (246/287) was 4.8 months (95%CI 3.9-5.7) vs 3.7 months (95%CI 1.9-5.5) in patients who did not it (HR log rank 0.78; 95%CI 0.53 to 1.15; p = 0.186). Median OS in patients who had previous nephrectomy (246/287) was 20.9 months (95%CI 17.6-24.1) vs 13 months (95%CI 7.7-18.2) in patients who did not it (HR log rank 0.504; 95%CI 0.337 to 0.755; p = 0.001). In the multivariate model, nephrectomy showed a significant association with OS (HR log rank 0.638; 95%CI 0.416 to 0.980), whereas gland metastases were still associated with better outcome in terms of both OS (HR log rank 0.487; 95%CI 0.279 to 0.852) and PFS (HR log rank 0.646; 95%CI 0.435 to 0.958). CONCLUSIONS IO treatment, in patients who had previously undergone nephrectomy, was associated with a better outcome in terms of OS. Further prospective trials would assess this issue in order to guide clinicians in real word practice.
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Affiliation(s)
- Marco Stellato
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Daniele Santini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Elena Verzoni
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Italy
| | - Francesco Pantano
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Chiara Casadei
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori, Meldola, Italy
| | - Giuseppe Fornarini
- Onco-ematological Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Maruzzo
- Medical Oncology Unit 1, Department of Oncology, Istituto Oncologico Veneto IOV IRCCS, Padua, Italy
| | - Andrea Sbrana
- Department of Surgical, Medical and Molecular Pathology and Critical Area Medicine, University of Pisa, Pisa, Italy
| | | | - Mariella Soraru
- Oncology Unit, Camposampiero General Hospital, Padova, Italy
| | - Emanuele Naglieri
- Division of Medical Oncology, Istituto Tumori Bari Giovanni Paolo II—IRCCS, Bari, Italy
| | - Sebastiano Buti
- Medical Oncology Unit, University Hospital of Parma, Parma, Italy
| | - Rocco De Vivo
- Department of Oncology, San Bortolo General Hospital, Vicenza, Italy
| | - Andrea Napolitano
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Claudia Mucciarini
- U.O. Medicina Oncologica, Ospedale Ramazzini, Carpi-AUSL Modena, Carpi, Italy
| | - Francesco Grillone
- Azienda Ospedaliero-Universitario “Mater Domini”, Policlinico of Catanzaro, Catanzaro, Italy
| | | | - Marilena Di Napoli
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCCS Fondazione “G. Pascale”, Napoli, Italy
| | - Giuseppe Procopio
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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15
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Courcier J, Dalban C, Laguerre B, Ladoire S, Barthélémy P, Oudard S, Joly F, Gravis G, Chevreau C, Geoffrois L, Deluche É, Rolland F, Topart D, Culine S, Négrier S, Mahammedi H, Tantot F, Jamet A, Escudier B, Flippot R, Albigès L. Primary Renal Tumour Response in Patients Treated with Nivolumab for Metastatic Renal Cell Carcinoma: Results from the GETUG-AFU 26 NIVOREN Trial. Eur Urol 2021; 80:325-329. [PMID: 34103181 DOI: 10.1016/j.eururo.2021.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022]
Abstract
Primary tumour response may impact therapeutic strategies in metastatic renal cell carcinoma (mRCC) but remains unknown in the era of immune checkpoint inhibitors. We aimed to describe the response of the primary tumour in patients who did not undergo upfront cytoreductive nephrectomy (uCN) and were treated with nivolumab in the GETUG-AFU-26 NIVOREN phase 2 trial. Primary tumour response was prospectively assessed, as well as the overall response rate (ORR), progression-free survival (PFS), and overall survival (OS). Among 720 patients, 111 did not undergo uCN, mainly patients with intermediate (45%) and poor (49%) International mRCC Database Consortium (IMDC) risk. In the 111 patients, nivolumab was used in the second line for 63% of patients and the third line or more for 37%, with an ORR of 16% (95% confidence interval [CI] 1025%); with a median follow-up of 24.5 mo (95% CI 21.6-27.1), median PFS was 2.7 mo (95% CI 2.5-4.0) and median OS was 15.9 mo (95% CI 9.5-19.8). A total of 67 patients had an evaluable primary renal lesion, four of whom (6%) experienced shrinkage of more than 30%. Overall, patients who did not undergo uCN had adverse baseline characteristics and nivolumab activity against the primary tumour was limited. PATIENT SUMMARY: In this report, we observed that nivolumab was associated with a limited response of the primary tumour in previously treated patients with metastatic kidney cancer.
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Affiliation(s)
- Jean Courcier
- Department of Urology, UPEC-Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | | | | | | | | | - Stéphane Oudard
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Gwénaëlle Gravis
- Medical Oncology Department, Institut Paoli-Calmettes, Aix-Marseille Université, Marseille, France
| | | | - Lionel Geoffrois
- Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | | | | | - Delphine Topart
- Department of Medical Oncology, Montpellier University Hospital, Hôpital Saint Eloi, Montpellier, France
| | - Stéphane Culine
- Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | | | - Antoine Jamet
- Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
| | - Bernard Escudier
- Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
| | - Ronan Flippot
- Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France
| | - Laurence Albigès
- Gustave Roussy Cancer Campus, Université Paris-Saclay, Villejuif, France.
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16
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Garje R, An J, Greco A, Vaddepally RK, Zakharia Y. The Future of Immunotherapy-Based Combination Therapy in Metastatic Renal Cell Carcinoma. Cancers (Basel) 2020; 12:E143. [PMID: 31936065 PMCID: PMC7017064 DOI: 10.3390/cancers12010143] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 01/05/2023] Open
Abstract
In the past two decades, there has been a significant improvement in the understanding of the molecular pathogenesis of Renal Cell Carcinoma (RCC). These insights in the biological pathways have resulted in the development of multiple agents targeting vascular endothelial growth factor (VEGF), as well as inhibitors of the mammalian target of the rapamycin (mTOR) pathway. Most recently, checkpoint inhibitors were shown to have excellent clinical efficacy. Although the patients are living longer, durable complete responses are rarely seen. Historically, high dose interleukin 2 (IL2) therapy has produced durable complete responses in 5% to 8% highly selected patients-albeit with significant toxicity. A durable complete response is a surrogate for a long-term response in the modern era of targeted therapy and checkpoint immunotherapy. Numerous clinical trials are currently exploring the combination of immunotherapy with various targeted therapeutic agents to develop therapies with a higher complete response rate with acceptable toxicity. in this study, we provide a comprehensive review of multiple reported and ongoing clinical trials evaluating the combination of PD-1/PD-L1 inhibitors with either ipilimumab (a cytotoxic T-lymphocyte-associated protein 4, CTLA-4 inhibitor) or with anti-VEGF targeted therapy.
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Affiliation(s)
- Rohan Garje
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (J.A.); (Y.Z.)
| | - Josiah An
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (J.A.); (Y.Z.)
| | - Austin Greco
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA;
| | | | - Yousef Zakharia
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA 52242, USA; (J.A.); (Y.Z.)
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