Prolonged Response to Cytoreductive Surgery and Sunitinib in an Elderly Patient with Synchronous Multiple Metastases from Renal Cell Carcinoma

One third of patients with renal cell cancer have metastatic disease at diagnosis. Until now the outcome of these patients has been poor due to the variable natural history of the disease and the lack of effective therapy. Multitargeted therapy of advanced renal cell cancer appears to be a better option than immunotherapy. We report the case of an elderly patient with skin, lung, bone and brain metastases and widespread intraabdominal disease treated with cytoreductive surgery and sunitinib, resulting in a prolonged response.

Targeted therapy of kidney cancer: keeping the art around the algorithms

BACKGROUND

Therapy for metastatic kidney cancer is actively evolving, particularly in the results of registration drug trials that have led to the approval of vascular endothelial growth factor pathway drugs such as sorafenib, sunitinib, pazopanib, bevacizumab, and axitinib, with focus on patients with good- or intermediate-risk criteria and clear cell histology. Mammalian target of rapamycin (mTOR) drugs such as everolimus and temsirolimus pivotal trials emphasize experiences in the setting of prior treatment or high-risk features. Interferon and interleukin 2 also are part of the treatment algorithms.

METHODS

The results of pivotal trials and the underlying context for the development of a cogent, cohesive treatment plan for an individual are reviewed, touching on decision points such as nephrectomy, metastasectomy, and medical initiation and discontinuation time points.

RESULTS

To the extent that these drug therapies are essential for achieving best outcomes for patients, these pivotal trial results and associated guidelines exist within a multidimensional, multidisciplinary context of many other disease features, comorbid features, and non-drug treatment decisions. Other dimensions include investigational targeted therapies, patient selection strategies, surgical strategies, and immunotherapies, some of which are in active development.

CONCLUSIONS

Clinicians should work toward the best use of drug sequencing and selection strategies based on core data derived from prospective randomized trials. To address individual patient needs, they should also recognize and emphasize individualized goals, to the extent that these are different from issues that were directly addressed in the trials.

Patient-based strategy for systemic treatment of metastatic renal cell carcinoma

There were only a few options 3 years ago to treat metastatic renal cell carcinoma (mRCC), a disease with a very poor prognosis. With the approval of targeted therapies for mRCC since December 2005, this situation has changed dramatically. Currently, oncologists can choose between several promising options to improve the longevity and quality of their patients' lives. A widely accepted treatment scheme for targeted therapies in mRCC does not yet exist. Based on a selective literature search, drawing on studies with six targeted therapies for mRCC, and including data from the latest American Society of Clinical Oncology (ASCO) and European Society for Medical Oncology (ESMO) Annual Meetings, this review introduces the available therapies, evaluates patient-specific criteria for their application and suggests an algorithm for a patient-based treatment scheme. Clinical experiences with sequential therapies are summarized and potential combination therapies discussed. In conclusion, the crucial criteria of the treatment scheme we propose are the tumor burden and the disease pace, as well as the quality of life of a patient. These define whether tumor control or tumor remission should be the primary therapeutic goal. This scheme suggests which kind of therapeutic sequence to pursue to optimize patient care in mRCC.

Treating the individual: The need for a patient-focused approach to the management of renal cell carcinoma

Five targeted agents have shown efficacy in advanced renal cell carcinoma. These agents were evaluated in pivotal phase III clinical trials using different treatment settings and different patient populations. As patients encountered in 'real life' clinical practice are frequently under-represented in phase III trials, making treatment decisions based on phase III data alone may have limitations. In order to support treatment decisions for patients who do not fit within the inclusion criteria of many phase III trials, physicians must consider additional data sources such as expanded access programmes, sub- and retrospective analyses, and also clinical experience. The suitability of a specific targeted agent for a given patient group, e.g. elderly, will depend on a number of factors, including disease-, patient- and treatment-related characteristics. Here, we identify the need for an individualised patient-focused approach to the management of advanced renal cell carcinoma in clinical practice. In order to optimise therapy for individual patients, we present a schema providing guidance on the wide range of parameters that should be considered when making treatment decisions. We recommend the integration of this approach into everyday clinical practice.

[Systemic therapy of metastatic renal cell carcinoma: from many options to the therapeutic strategy]

In the last 5 years the paradigms for the treatment of metastatic renal cell cancer have fundamentally changed. Until 2005 systemic therapy was limited to the immunomodulating cytokines interferon-alfa and interleukin-2, in recent years, however, tyrosine kinase inhibitors, mTor inhibitors and monoclonal antibodies have been established for this therapeutic situation. Without validated predictive biomarkers it is currently not possible to select patients who are likely to benefit from a certain therapy. Therefore, most current guidelines stratify the patients into risk groups according to the MSKCC risk score. The resulting treatment algorithm for first-line therapy is limited to these new drugs within all risk groups. Since approval for more tyrosine kinase inhibitors and mTOR inhibitors is currently awaited, the number of treatment options will expand further in the near future. The present paper reviews the present study data and aims to provide practical advice for the treatment of patients suffering from metastatic renal cell cancer.

Safety and efficacy of sunitinib for metastatic renal-cell carcinoma: an expanded-access trial

BACKGROUND

Results from clinical trials have established sunitinib as a standard of care for first-line treatment of advanced or metastatic renal-cell carcinoma (RCC); however, many patients, particularly those with a poorer prognosis, do not meet inclusion criteria and little is known about the activity of sunitinib in these subgroups. The primary objective of this trial was to provide sunitinib on a compassionate-use basis to trial-ineligible patients with RCC from countries where regulatory approval had not been granted.

METHODS

Previously treated and treatment-naive patients at least 18 years of age with metastatic RCC were eligible. All patients received open-label sunitinib 50 mg orally once daily on schedule 4-2 (4 weeks on treatment, 2 weeks off). Safety was assessed regularly, tumour measurements done per local practice, and survival data collected where possible. Analyses were done in the modified intention-to-treat (ITT) population, which consisted of all patients who received at least one dose of sunitinib. This study is registered with ClinicalTrials.gov, NCT00130897.

FINDINGS

As of December, 2007, 4564 patients were enrolled in 52 countries. 4371 patients were included in the modified ITT population. This population included 321 (7%) patients with brain metastases, 582 (13%) with Eastern Cooperative Oncology Group (ECOG) performance status of 2 or higher, 588 (13%) non-clear-cell RCC, and 1418 (32%) aged 65 years or more. Patients received a median of five treatment cycles (range 1-25). Reasons for discontinuation included lack of efficacy (n=1168 [27%]) and adverse events (n=362 [8%]). The most common treatment-related adverse events were diarrhoea (n=1936 [44%]) and fatigue (n=1606 [37%]). The most common grade 3-4 adverse events were fatigue (n=344 [8%]) and thrombocytopenia (n=338 [8%]) with incidences of grade 3-4 adverse events similar across subgroups. In 3464 evaluable patients, the objective response rate (ORR) was 17% (n=603), with subgroup ORR as follows: brain metastases (26 of 213 [12%]), ECOG performance status 2 or higher (29 of 319 [9%]), non-clear-cell RCC (48 of 437 [11%]) and age 65 years or more (176 of 1056 [17%]). Median progression-free survival was 10.9 months (95% CI 10.3-11.2) and overall survival was 18.4 months (17.4-19.2).

INTERPRETATION

In a broad population of patients with metastatic RCC, the safety profile of sunitinib 50 mg once-daily (initial dose) on schedule 4-2 was manageable and efficacy results were encouraging, particularly in subgroups associated with poor prognosis who are not usually entered into clinical trials.

FUNDING

Pfizer Inc.

Metastatic Renal Cell Carcinoma: Many Treatment Options, One Patient

There has been a recent expansion of therapeutic options in metastatic renal cell carcinoma (RCC) targeted at the vascular endothelial growth factor and mammalian target of rapamycin pathways, which are fundamental to the biology of RCC. These treatment options have similarities in antitumor effect but also important differences in regards to clinical effects, toxicity and patient populations in which they have been investigated. Further, issues regarding the role of debulking nephrectomy, timing of therapy, and appropriate sequencing of agents have emerged as clinically relevant. There are thus potentially many different treatment approaches to each metastatic RCC patient. This review discusses how to integrate the available data regarding targeted therapy in metastatic RCC into personalized cancer care.