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Olsen TA, Martini DJ, Evans ST, Goldman JM, Bilen MA. Symptomatic methemoglobinemia in a patient with metastatic clear cell renal cell carcinoma treated with pembrolizumab and axitinib combination therapy: a case report. J Med Case Rep 2021; 15:72. [PMID: 33602288 PMCID: PMC7893948 DOI: 10.1186/s13256-020-02637-w] [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: 09/18/2020] [Accepted: 12/15/2020] [Indexed: 11/14/2022] Open
Abstract
Background Combination regimens that include immune checkpoint (ICI) and vascular endothelial growth factor (VEGF) inhibition have opened the door to new treatment opportunities for patients with metastatic renal cell carcinoma (mRCC). While these treatment options have provided improved tolerability and better outcomes compared to older regimens, many patients still experience a myriad of treatment-related adverse events. Given that these regimens were recently approved for mRCC, the complete side effect profile may not be fully elucidated yet. Case presentation We report a case of a 73-year old White male with mRCC who was managed with an ICI-VEGF inhibitor combination regimen. He experienced a partial response (Fig. 1) but had side effects including symptomatic cyanosis diagnosed as methemoglobinemia which led to treatment discontinuation. Upon holding his therapy, his methemoglobinemia and cyanosis resolved.
Conclusions Combination VEGF-ICI therapy provide novel regimens for advanced solid tumor malignancies including mRCC. While shown to have improved efficacy in clinical trials, it is crucial that oncologists uncover the full side effect profile of these novel agents especially as their use becomes more standard in the management of advanced malignancies. To our knowledge, this is the first reported case of a patient experiencing symptomatic methemoglobinemia as an adverse event associated with a VEGF-ICI combination regimen. While the cause of this side effect is unclear, in this paper we attempt to elucidate a process that is in line with the mechanism of action of these therapies to explain how these agents, specifically the axitinib, could have caused the methemoglobin to rise to a symptomatic level.
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Affiliation(s)
- T Anders Olsen
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA.,Winship Cancer Institute of Emory University, 1365 Clifton Rd, Atlanta, GA, USA
| | - Dylan J Martini
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA.,Winship Cancer Institute of Emory University, 1365 Clifton Rd, Atlanta, GA, USA
| | - Sean T Evans
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA.,Winship Cancer Institute of Emory University, 1365 Clifton Rd, Atlanta, GA, USA
| | - Jamie M Goldman
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA.,Winship Cancer Institute of Emory University, 1365 Clifton Rd, Atlanta, GA, USA
| | - Mehmet Asim Bilen
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA. .,Winship Cancer Institute of Emory University, 1365 Clifton Rd, Atlanta, GA, USA.
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George S, Bukowski RM. Biomarkers in clear cell renal cell carcinoma. Expert Rev Anticancer Ther 2014; 7:1737-47. [DOI: 10.1586/14737140.7.12.1737] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Predictive factors for response to treatment in patients with advanced renal cell carcinoma. Invest New Drugs 2012; 30:2443-9. [PMID: 22644070 DOI: 10.1007/s10637-012-9836-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/10/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The analysis of predictive factors of response may aid in predicting which patients with advanced renal cell carcinoma (RCC) would be good candidates for systemic treatments. MATERIALS AND METHODS The expression of several biomarkers was retrospectively analyzed using immunohistochemistry (IHC), as well as 2 analytical variables in 135 patients with advanced RCC treated with cytokines (CK) and/or new targeted drugs (NTD). RESULTS 67 patients were treated solely with NTD and 68 with CK (23 also received NTD). Univariate analysis: HIF1α did not correlate significantly with response to these drugs. Overexpression of CAIX was associated with more responses (%) to NTD (64.7 vs. 21.1; p = 0.004) and CK (22.6 vs. 0; p = 0.038). PTEN demonstrated predictive value of response to sunitinib (70.8 vs. 34.1; p = 0.005). p21 was associated with a lower response to sunitinib (35.9 vs. 65.4; p = 0.025). Thrombocytosis was not significantly associated with response to NTD, although it was with CK (0 vs. 20; p = 0.017). Neutrophilia correlated with a lower response to NTD (29.6 vs. 57.5; p = 0.045), although not with CK. Multivariate analysis: Overexpression of CAIX was an independent predictor of significantly higher response to NTD and CK; OR = 8.773 (p < 0.001). CONCLUSIONS Our findings highlight the usefulness of CAIX in selecting patients with advanced RCC as candidates for systemic treatment. PTEN and p21 may be important in predicting response to sunitinib. Thrombocytosis and neutrophilia correlate well with response to CK and NTD, respectively.
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Prognostic Factors and Predictive Models in Renal Cell Carcinoma: A Contemporary Review. Eur Urol 2011; 60:644-61. [PMID: 21741163 DOI: 10.1016/j.eururo.2011.06.041] [Citation(s) in RCA: 246] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 06/20/2011] [Indexed: 12/24/2022]
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Mukherji D, Larkin J, Pickering L. Sunitinib for metastatic renal cell carcinoma. Future Oncol 2010; 6:1377-85. [DOI: 10.2217/fon.10.94] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Sonpavde G, Hutson TE. Novel antiangiogenic agents in the treatment of refractory renal cell carcinoma. Clin Genitourin Cancer 2009; 6 Suppl 1:S29-36. [PMID: 19891127 DOI: 10.3816/cgc.2008.s.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The approvals of sunitinib, sorafenib, and temsirolimus have dramatically altered the management of renal cell carcinoma. The combination of bevacizumab and interferon-alpha was recently approved in Europe and could receive regulatory approval in the United States. A recent randomized trial reported improved outcomes with everolimus following first-line tyrosine kinase inhibitors (TKIs). Despite enhanced outcomes with these agents, they are not curative, and more effective therapy is essential. Other novel antiangiogenic agents are being evaluated, including TKIs, monoclonal antibodies, and agents against other novel targets. Additionally, novel combinations of antiangiogenic agents are emerging. The rapid expansion in the therapeutic armamentarium holds the promise of further enhancing outcomes.
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Atkins MB, Choueiri TK, Cho D, Regan M, Signoretti S. Treatment selection for patients with metastatic renal cell carcinoma. Cancer 2009; 115:2327-33. [PMID: 19402069 PMCID: PMC2762357 DOI: 10.1002/cncr.24231] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The availability of approved agents with distinct mechanisms of action has encouraged investigations to identify optimal treatment strategies for specific patients and specific tumor features. Study of tumors from patients treated with interleukin-2 (IL-2) has suggested that response was unlikely in patients with tumors with papillary features or low carbonic anhydrase IX (CAIX) expression. A model combining histologic features and CAIX expression separated patients into 2 groups of roughly equal size, with 96% of the responding patients being in the favorable prognostic group. Additional studies have begun to identify molecular features that might predict response to IL-2 therapy. In contrast, clinical trial data suggest that temsirolimus was relatively more active than interferon in patients with tumors containing non-clear cell features. Furthermore, pathologic examination showed no correlation of response with CAIX expression, but an apparent association with high expression of either phospho-AKT or phospho-S6, proteins either upstream or downstream of mammalian target of rapamycin. Preliminary investigations of tumor specimens from patients receiving vascular endothelial growth factor-targeted therapy suggested that high hypoxia-inducible factor expression might predict response. In addition, response appeared more likely in tumors with mutated or methylated VHL genes; however, substantial antitumor activity was still observed in patients with VHL wild-type tumors, particularly in patients treated with either sunitinib or axitinib, rather than bevacizumab or sorafenib. Although these data provide some guidance in treatment selection, considerably more research is needed to identify and validate selection models for particular treatment approaches, and to enable rational and optimal utilization of the available treatment options.
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Affiliation(s)
- Michael B Atkins
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, MASCO Bldg., Room 412, 375 Longwood Avenue, Boston, MA 02115, USA.
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Porta C, Imarisio I, Paglino C, Ferraris E, Mensi M, Rovereto B. Prognostic factors in advanced renal cell cancer. EJC Suppl 2008. [DOI: 10.1016/j.ejcsup.2008.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
Several vascular endothelial growth factor (VEGF)-targeted agents, administered either as single agents or in combination with chemotherapy, have been shown to benefit patients with advanced-stage malignancies. VEGF-targeted therapies were initially developed with the notion that they would inhibit new blood vessel growth and thus starve tumours of necessary oxygen and nutrients. It has become increasingly apparent, however, that the therapeutic benefit associated with VEGF-targeted therapy is complex, and probably involves multiple mechanisms. A better understanding of these mechanisms will lead to future advances in the use of these agents in the clinic.
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Affiliation(s)
- Lee M Ellis
- Department of Surgical Oncology, Unit 444, University of Texas M.D. Anderson Cancer Center, PO Box 301402, Houston, Texas 77230-1402, USA.
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Signoretti S, Regan M, Atkins M. Carbonic anhydrase IX as a predictive biomarker of response to kidney cancer therapy. BJU Int 2008; 101 Suppl 4:31-5. [PMID: 18430120 DOI: 10.1111/j.1464-410x.2008.07646.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sabina Signoretti
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Affiliation(s)
- Thomas E Hutson
- Texas Oncology, PA, Baylor Sammons Cancer Center, Dallas, TX 75246, USA.
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Golshayan AR, Brick AJ, Choueiri TK. Predicting outcome to VEGF-targeted therapy in metastatic clear-cell renal cell carcinoma: data from recent studies. Future Oncol 2008; 4:85-92. [PMID: 18241003 DOI: 10.2217/14796694.4.1.85] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Attempts to predict outcome in patients with metastatic clear-cell renal cell carcinoma (RCC) have conventionally been based on pretherapy clinical factors such as performance status, disease-free interval, number of metastatic sites and several laboratory variables. These factors were developed before the era of VEGF-targeted therapy. Recent analysis from trials with anti-VEGF agents indicate that these factors continue to be of major importance in patient prognostication. Additionally, several serum and molecular markers, many of which relate to certain alterations of the von Hippel-Lindau pathway, are currently being investigated. Responses to VEGF-targeted agents appear to be related to a greater modulation of serum VEGF and soluble VEGF receptor levels. The impact of von Hippel-Lindau gene status on response to VEGF-targeted therapy was tested in a large study and was not found to predict a higher response rate to these agents. However, a subset of von Hippel-Lindau mutations that predict a 'loss of function' of the von Hippel-Lindau gene seem to have the best response to these agents. Future prognostic models will incorporate molecular markers with clinical variables to refine prognosis and prediction in metastatic clear-cell RCC patients treated with novel VEGF-targeted agents. These models, if externally and prospectively validated, will culminate in the rational selection of patients for specific VEGF-directed therapeutics.
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Affiliation(s)
- Ali-Reza Golshayan
- Cleveland Clinic Taussig Cancer Center, 9500 Euclid Avenue, R-35, Cleveland, OH 44195, USA
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