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Abstract
Sunitinib is an oral multikinase inhibitor that blocks the vascular endothelial growth factor receptor (VEGFR), platelet-derived growth factor receptor (PDGFR) alpha and beta, c-kit, and other receptors. These attributes have proven to be efficacious in the treatment of metastatic renal cell carcinoma (RCC), unresectable gastrointestinal stromal tumors (GIST), and well-differentiated advanced pancreatic neuroendocrine tumors (PNET). Though activity has been reported in other tumor types, phase III trials have not yet demonstrated improved survival outcomes in these cancers. Most side effects including hypertension, hand-foot syndrome, and diarrhea are generally well manageable. This review will detail the preclinical data leading up to the results of the pivotal phase III clinical trials that have led to the widespread use of sunitinib in advanced RCC, GIST, and PNET.
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Gore ME, Larkin JMG. Challenges and opportunities for converting renal cell carcinoma into a chronic disease with targeted therapies. Br J Cancer 2011; 104:399-406. [PMID: 21285971 PMCID: PMC3049574 DOI: 10.1038/sj.bjc.6606084] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 11/25/2010] [Accepted: 12/13/2010] [Indexed: 01/19/2023] Open
Abstract
Optimum efficacy is the primary goal for any cancer therapy, and entails controlling tumour growth and prolonging survival as far as possible. The prognosis for patients with metastatic renal cell carcinoma (mRCC) has greatly improved with the introduction of targeted therapies. This review examines the development and efficacy of targeted agents for the management of mRCC, the challenges offered by their rapid emergence, and discusses how mRCC treatment may evolve in the future. Improvements in progression-free survival and overall survival rates, observed with targeted agents, indicate that it may now be possible to change mRCC from a rapidly fatal and largely untreatable condition into a chronic disease. The major challenges to further advances in targeted therapy for mRCC include overcoming drug resistance, identifying the most effective sequence or combination of targeted agents, optimising clinical trial design and managing the cost of treatment.
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Affiliation(s)
- M E Gore
- Department of Medicine, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK.
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Mayer EL, Dhakil S, Patel T, Sundaram S, Fabian C, Kozloff M, Qamar R, Volterra F, Parmar H, Samant M, Burstein HJ. SABRE-B: an evaluation of paclitaxel and bevacizumab with or without sunitinib as first-line treatment of metastatic breast cancer. Ann Oncol 2010; 21:2370-2376. [PMID: 20497961 DOI: 10.1093/annonc/mdq260] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The vascular endothelial growth factor (VEGF) pathway can be targeted through VEGF neutralization or VEGF receptor (VEGFR) blockade using tyrosine kinase inhibition. Because laboratory models suggest that combining these approaches might be synergistic, we sought to evaluate the feasibility and efficacy of combining sunitinib with paclitaxel + bevacizumab (PB). METHODS Patients with human epidermal growth factor receptor 2 (HER2)-negative, metastatic breast cancer receiving first-line chemotherapy were randomized to PB or PB with sunitinib (PBS), with planned escalation of the sunitinib dose. RESULTS Forty-six patients were randomized to PB or PBS with sunitinib dosed at 25 mg p.o. daily. Patients receiving PBS encountered substantial toxicity that precluded adequate treatment. The percentage of patients with grade ≥3 adverse events was greater in the PBS arm than the PB arm (83% versus 57%), and sunitinib dosing was modified in 78% of patients, most often due to neutropenia, febrile neutropenia, and fatigue. In addition, 44% of patients had sunitinib dose reduction to 12.5 mg, and 39% required discontinuation. Patients receiving PBS had more bevacizumab treatment interruptions and discontinuations because of toxicity. Median treatment duration was longer in the PB arm compared with the PBS arm (14.1 versus 11.1 weeks), reflecting early treatment discontinuation of PBS. Because of poor tolerability of the addition of sunitinib to PB, the planned sunitinib dose escalation was halted and the study accrual was terminated. CONCLUSION Adding sunitinib to standard doses of bevacizumab plus paclitaxel for metastatic breast cancer is not feasible. Different strategies will be required to evaluate whether there is additional clinical benefit to combining VEGF/VEGFR-targeted agents.
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Affiliation(s)
- E L Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston MA.
| | - S Dhakil
- Department of Oncology and Internal Medicine, Cancer Center of Kansas, Wichita, KS
| | - T Patel
- Department of Oncology and Internal Medicine, The Mark H. Zangmeister Center, Columbus, OH
| | | | - C Fabian
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - M Kozloff
- Department of Oncology, Ingalls Memorial Hospital, Harvey IL
| | - R Qamar
- Oncology Alliance, Glendale WI
| | - F Volterra
- Department of Medicine (Oncology), Eastchester Cancer Care, Bronx, NY
| | - H Parmar
- Department of Avastin BioOncolgy, Genentech, Inc., South San Francisco, CA
| | - M Samant
- Department of Biostatistics, Genentech, Inc., South San Francisco, CA, USA
| | - H J Burstein
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston MA
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Heng DY. Targeted therapy for metastatic renal cell carcinoma: current treatment and future directions. Ther Adv Med Oncol 2010; 2:39-49. [PMID: 21789125 PMCID: PMC3126007 DOI: 10.1177/1758834009352498] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
An understanding of vascular endothelial growth factor (VEGF) and mammalian target of rapamycin (mTOR) pathways has greatly changed the way metastatic renal cell carcinoma (RCC) is treated. Based on available phase III randomized trials, anti-VEGF agents such as sunitinib, sorafenib, bevacizumab-based therapy, and mTOR-targeted agents such as temsirolimus and everolimus have been used in the treatment armamentarium for this disease. Now that agents directed against these pathways have largely replaced immunotherapy as the standard of care, new questions have emerged and are the subject of ongoing clinical trials. The development of new targeted therapies including axitinib, pazopanib, cediranib, volociximab, tivozanib (AV-951), BAY 73-4506, and c-met inhibitors such as GSK1363089 and ARQ197 may potentially expand the list of treatment options. Sequential and combination targeted therapies are currently under investigation in advanced disease as are adjuvant and neo-adjuvant approaches around nephrectomy.
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Affiliation(s)
- Daniel Y.C. Heng
- BC Cancer Agency, 600 West 12 Avenue, Vancouver, British Columbia, V5Z 4E6, Canada
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Abstract
Sunitinib is an oral multikinase inhibitor that blocks the vascular endothelial growth factor receptor (VEGFR), platelet-derived growth factor receptor (PDGFR) alpha and beta, c-kit, and other receptors. These attributes have proven to be efficacious in the treatment of metastatic renal cell carcinoma (RCC) and unresectable gastrointestinal stromal tumors (GIST). Most side effects, including hypertension, hand-foot syndrome, and diarrhea are generally well manageable. Clinical trials are underway to determine the efficacy of sunitinib in other tumor types including metastatic breast, colorectal, and lung cancers. This chapter will detail the preclinical data leading to the results of the pivotal phase III clinical trials that have led to the widespread use of sunitinib in metastatic RCC and advanced GIST.
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Kruck S, Merseburger AS, Kruck S, Merseburger AS, Gakis G, Kramer MW, Stenzl A, Kuczyk MA. An update on the medical therapy of advanced metastatic renal cell carcinoma. ACTA ACUST UNITED AC 2009; 42:501-6. [DOI: 10.1080/00365590802203983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Stephan Kruck
- Department of Urology, Eberhard-Karls-University, Tuebingen, Germany
| | | | - Stephan Kruck
- Department of Urology, Eberhard-Karls-University, Tuebingen, Germany
| | | | - Georgios Gakis
- Department of Urology, Eberhard-Karls-University, Tuebingen, Germany
| | - Mario W. Kramer
- Department of Urology, Eberhard-Karls-University, Tuebingen, Germany
| | - Arnulf Stenzl
- Department of Urology, Eberhard-Karls-University, Tuebingen, Germany
| | - Markus A. Kuczyk
- Department of Urology, Hannover Medical School, Hannover, Germany
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Salvage Therapy with Bevacizumab–Sunitinib Combination after Failure of Sunitinib Alone for Metastatic Renal Cell Carcinoma: A Case Series. Eur Urol 2009; 56:207-11; quiz 211. [DOI: 10.1016/j.eururo.2009.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 01/02/2009] [Indexed: 11/23/2022]
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Kontovinis LF, Papazisis KT, Touplikioti P, Andreadis C, Mouratidou D, Kortsaris AH. Sunitinib treatment for patients with clear-cell metastatic renal cell carcinoma: clinical outcomes and plasma angiogenesis markers. BMC Cancer 2009; 9:82. [PMID: 19284623 PMCID: PMC2662874 DOI: 10.1186/1471-2407-9-82] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 03/12/2009] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Sunitinib is a protein tyrosine kinase-inhibitor targeting VEGFR, c-kit and PDGFR. It has been approved for the treatment of metastatic renal-cell carcinoma and gastrointestinal stromal tumors. Although it has been shown to prolong disease-free and overall survival in renal-cell carcinoma patients, only 70% of the treated population receive a clinical benefit (CB) from the treatment. Markers that could predict clinical benefit to sunitinib would be an important aid in monitoring and following their treatment. We assessed the outcome and plasma proangiogenic factors in patients with metastatic renal cell carcinoma (mRCC) treated with sunitinib in our institution. METHODS We have treated 42 patients with metastatic clear-cell renal carcinoma with sunitinib. Plasma concentrations of VEGF-A, sVEGFR2 and PDGF were determined by ELISA. RESULTS At the time of analysis 39 patients were evaluable for response and 30 patients had obtained a clinical benefit (CB). Median progression-free survival was 268 days (8.93 months) and median overall survival was 487 days (16.23 months). Interestingly, disease stabilization or objective response resulted in comparable overall survival. Most treatment-related adverse events were of mild-to-moderate intensity with one treatment-related death. Plasma sVEGFR2 and PDGF levels had no predictive value. Fold-increase in plasma VEGF was significantly lower in patients that obtained a CB as compared to patients that progressed after two cycles of treatment. Plasma VEGF did not increase in patients with initial CB at the time of progression. CONCLUSION Sunitinib showed substantial activity in mRCC. Disease stabilization or objective response resulted in comparable overall survival and both outcomes should be considered positive. Fold-increase in plasma VEGF predicts for CB and could be a candidate marker. Progression after initial CB is not associated with elevated plasma VEGF, implying a different mechanism of resistance.
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Affiliation(s)
- Loukas F Kontovinis
- 3rd Department of Medical Oncology, Theagenion Cancer Hospital, Al Simeonidi str. 2, 54007, Thessaloniki, Greece.
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Abstract
Renal cell cancer (RCC) is the most common form of cancer of the kidney and accounts for approximately 44,000 cases per year in the United States. Historically, only immunotherapy showed activity in metastatic RCC. The improved survival and quality of life for patients with metastatic RCC over the last several years are direct results of advances made in understanding the development of RCC. Three targeted therapies-sunitinib, sorafenib, and temsirolimus-have been approved for use in the United States recently. Current research is aimed at developing new drugs and combining available drugs to improve upon the responses and survival seen with approved single agents.
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Affiliation(s)
- Glenn S Kroog
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Vertical VEGF targeting: A combination of ligand blockade with receptor tyrosine kinase inhibition. Eur J Cancer 2008; 44:1922-30. [PMID: 18691881 DOI: 10.1016/j.ejca.2008.07.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Revised: 06/18/2008] [Accepted: 07/01/2008] [Indexed: 11/30/2022]
Abstract
The aim of this study was to examine the anti-tumour effects of dual vertical VEGF targeting consisting in the association between bevacizumab, a VEGF-depleting drug, and the VEGF receptor antityrosine kinase AZD2171. Mice bearing human head and neck CAL33 xenografted tumours were treated once daily for 11 d with either vehicle (controls), AZD2171 (2.5mg/kg/day, p.o.), bevacizumab (5mg/kg/day, i.p.) or the bevacizumab-AZD2171 combination. The AZD2171-bevacizumab combination produced additive effects on tumour growth and reduced the number of proliferating cells relative to control. Bevacizumab did not influence tumour vascular necrosis whilst AZD2171 (p=0.01) and the combination (p=0.01) increased it. The number of mature tumour cells decreased significantly with the combination treatment only (p=0.001), which induced the largest increase in the Bax/Bcl2 ratio (up to 25-fold) and a progressive 3-fold decrease in HIF1-alpha expression between 24h and 192h. The present data indicate that there is no redundancy in targeting the same angiogenic pathway with the presently tested clinically applicable drugs. The study provides a strong rationale for future clinical trials.
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Flaherty KT. The future of tyrosine kinase inhibitors: Single agent or combination? Curr Oncol Rep 2008; 10:264-70. [DOI: 10.1007/s11912-008-0040-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Création d’une unité de coordination de la prise en charge des tumeurs rares du rein de l’adulte. ONCOLOGIE 2008. [DOI: 10.1007/s10269-008-0900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ravaud A, Wallerand H, Culine S, Bernhard JC, Fergelot P, Bensalah K, Patard JJ. Update on the medical treatment of metastatic renal cell carcinoma. Eur Urol 2008; 54:315-25. [PMID: 18485581 DOI: 10.1016/j.eururo.2008.04.056] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Accepted: 04/22/2008] [Indexed: 12/17/2022]
Abstract
CONTEXT Metastatic renal cell carcinoma (mRCC) has long been treated only by immunotherapy with good results only in a small population of patients. In recent years, major improvements in treatment possibilities have occurred with the advent of anti-angiogenic drugs. In the past 2 yr, pivotal phase III trials have confirmed this major breakthrough by increasing the progression-free survival rates and/or overall survival rates provided by sunitinib, sorafenib, and bevacizumab, and more recently by the mTOR (mammalian target of rapamycin) inhibitors temsirolimus and everolimus. OBJECTIVE To update the previous review on smart drugs published in the European Journal in 2006 (Patard JJ, et al. Understanding the importance of smart drugs in renal cell carcinoma. Eur Urol 2006; 49:633-43). EVIDENCE ACQUISITION Critical review of published literature 2006-2008 (Pubmed website search words: renal cell carcinoma and/or targeted therapy and prospective trials) and more recent meeting abstracts (American Society of Clinical Oncology 2007). Quality assessment included prospective phase I-III trials and critical evaluations with low numbers of patients, retrospective analyses, and slide presentations of meeting abstracts. EVIDENCE SYNTHESIS This review presents the current situation and provides more recent data on sequential treatment, the association of targeted drugs, and the treatment of non-clear-cell histologies. CONCLUSIONS Treatment of mRCC with targeted therapy centers on at least two major pathways: angiogenesis and mTOR involving inhibiting drugs that may be used alone, in combination, or sequentially.
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Affiliation(s)
- Alain Ravaud
- Department of Medical Oncology, Hôpital Saint André, Bordeaux, France; University of Bordeaux 2 Victor Ségalen, Bordeaux, France
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Abstract
Cardiovascular toxicity is an important adverse effect of several classes of oncology drugs. Because cancer survivors are living longer, the late effects of cancer therapy must be addressed. Many patients diagnosed with cancer are already at an increased risk for cardiovascular disease before drug treatment. Select chemotherapy agents further complicate the issue because of their own ability to induce cardiovascular toxicities or exacerbate preexisting conditions. Hypertension, dyslipidemia, heart failure, and arrhythmia are known consequences of some cancer therapies. This review provides an overview of the epidemiology, mechanism of action, monitoring, and management of these cardiovascular effects.
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Affiliation(s)
- Bradi L. Frei
- University of the Incarnate Word, Feik School of Pharmacy, Department of Pharmacy Practice, frei@ uiwtx.edu
| | - Scott A. Soefje
- Cancer Therapy and Research Center, The University of Texas Health Science Center at San Antonio San Antonio, Texas
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Cowey CL, Rathmell WK. Using Molecular Biology to Develop Drugs for Renal Cell Carcinoma. Expert Opin Drug Discov 2008; 3:311-327. [PMID: 20648240 DOI: 10.1517/17460441.3.3.311] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND: Renal cell carcinoma is a disease marked by a unique biology which has governed it's long history of poor response to conventional cancer treatments. The discovery of the signaling pathway activated as a result of inappropriate constitutive activation of the hypoxia inducible factors (HIF), transcription factors physiologically and transiently stabilized in response to low oxygen, has provided a primary opportunity to devise treatment strategies to target this oncogenic pathway. OBJECTIVE: A review of the molecular pathogenesis of renal cell cancer as well as molecularly targeted therapies, both those currently available and those in development, will be provided. In addition, trials involving combination or sequential targeted therapy are discussed. METHODS: A detailed review of the literature describing the molecular biology of renal cell cancer and novel therapies was performed and summarized. RESULTS/CONCLUSION: Therapeutics targeting angiogenesis have provided the first class of agents which provide clinical benefit in a large majority of patients and heralded renal cell carcinoma as a solid tumor paradigm for the development of novel therapeutics. Multiple strategies targeting this pathway and now other identified pathways in renal cell carcinoma provide numerous potential opportunities to make major improvements in treating this historically devastating cancer.
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Affiliation(s)
- C Lance Cowey
- Department of Medicine, Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill
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Ravaud A. Current options for the treatment of locally advanced and metastatic renal cell carcinoma: focus on sunitinib. EJC Suppl 2007. [DOI: 10.1016/s1359-6349(07)70109-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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