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Gu L, Peng C, Li H, Jia T, Chen X, Wang H, Du S, Tang L, Liang Q, Wang B, Ma X, Zhang X. Neoadjuvant therapy in renal cell carcinoma with tumor thrombus: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2024; 196:104316. [PMID: 38432444 DOI: 10.1016/j.critrevonc.2024.104316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/26/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024] Open
Abstract
To evaluate the efficacy, feasibility and safety of neoadjuvant therapy (NAT) for renal cell carcinoma with tumor thrombus (RCC-TT) in terms of response, perioperative and oncological outcomes, and compare the results between neoadjuvant and non-neoadjuvant groups. Overall, 29 single-arm studies and 5 cohort studies were included. Of the 204 patients undergoing NAT, 16.2% were level I, 35.3% level II, 24.0% level III and 18.6% level IV thrombus. Most of patients underwent preoperative targeted therapy, immunotherapy-based combination therapy was applied in 5.4% patients. The total reduction rate of thrombus level was 29.4%. NAT is associated with a shorter operative time, less blood loss (p<0.05 for both). Rate of complications and oncological outcomes were similar between two groups. Overall, 32.1% (34/106) ≥ grade 3 adverse events occurred in patients undergoing NAT. Neoadjuvant therapy is safe and feasible with acceptable perioperative outcomes in RCC-TT.
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Affiliation(s)
- Liangyou Gu
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Cheng Peng
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Huaikang Li
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Tongyu Jia
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Xinran Chen
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Hanfeng Wang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Songliang Du
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Lu Tang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Qiyang Liang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Baojun Wang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Xin Ma
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
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Chen J, Liu Z, Peng R, Liu Y, Zhang H, Wang G, Tian X, Pei X, Wang J, Zhang S, Wang H, Ma L. Neoadjuvant stereotactic ablative body radiotherapy combined with surgical treatment for renal cell carcinoma and inferior vena cava tumor thrombus: a prospective pilot study. BMC Urol 2024; 24:31. [PMID: 38310214 PMCID: PMC10838433 DOI: 10.1186/s12894-024-01405-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/11/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Surgical treatment for renal cell carcinoma (RCC) and inferior vena cava (IVC) tumor thrombus (TT) is difficult, and the postoperative complication rate is high. This study aimed to explore the safety and oncologic outcomes of neoadjuvant stereotactic ablative body radiotherapy (SABR) combined with surgical treatment for RCC and IVC-TT. METHODS Patients with RCC and IVC-TTs were enrolled in this study. All patients received neoadjuvant SABR focused on the IVC at a dose of 30 Gy in 5 fractions, followed by 2 ~ 4 weeks of rest. Then, radical nephrectomy and IVC tumor thrombectomy were performed for each patient. Adverse effects, perioperative outcomes, and long-term prognoses were recorded. RESULTS From June 2018 to January 2019, 8 patients were enrolled-4 with Mayo grade II TT and 4 with Mayo grade III TT. Four (50%) patients had complicated IVC wall invasion according to CT/MRI. All patients received neoadjuvant SABR as planned. Short-term local control was observed in all 8 patients. Only Grade 1-2 adverse events were reported. In total, 3 (37.5%) laparoscopic surgeries and 5 (62.5%) open surgeries were performed. The median operation time was 359 (IQR: 279-446) min, with a median intraoperative bleeding volume of 750 (IQR: 275-2175) ml. The median postoperative hospital stay was 7 (5-10) days. With a 26-month (range: 5-41) follow-up period, the estimated mean overall survival was 30.67 ± 5.38 months. CONCLUSIONS This is the first preoperative radiotherapy study in Asia that focused on patients with TT. This study revealed the considerable safety of neoadjuvant SABR for RCC with IVC-TT. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trials Registry on 2018-03-08 (ChiCTR1800015118). For more information, please see the direct link ( https://www.chictr.org.cn/showproj.html?proj=25747 ).
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Affiliation(s)
- Jiyuan Chen
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Ran Peng
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, 100191, China
| | - Yunchong Liu
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Guoliang Wang
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China
| | - Xinlong Pei
- Department of Radiology, Peking University Third Hospital, Beijing, 100191, China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, 100191, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China.
| | - Hao Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, 100191, China.
- Cancer Center, Peking University Third Hospital, Beijing, 100191, China.
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, 100191, China.
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Yuan W, Li F. Roles of microRNA-186 and vascular endothelial growth factor in hepatocellular carcinoma complicated with portal vein tumor thrombus. Exp Ther Med 2020; 20:3860-3867. [PMID: 32855736 DOI: 10.3892/etm.2020.9092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/26/2018] [Indexed: 12/21/2022] Open
Abstract
The present study aims to investigate the role and underlying mechanism of microRNA (miR)-186 in patients with hepatocellular carcinoma (HCC) complicated with portal vein tumor thrombus. Blood samples from 29 HCC patients with portal vein tumor thrombus were collected between January 2014 and September 2015 in Huai'an First People's Hospital, while blood from 36 HCC patients without vein tumor thrombus was also collected in the same period. In addition, tumor thrombus specimens were collected from the HCC patients with portal vein tumor thrombus, and peritumoral tissues of the tumor thrombus were used as the control. Reverse transcription-quantitative polymerase chain reaction, ELISA and western blot analyses were applied to detect vascular endothelial growth factor (VEGF) expression at the mRNA and protein levels. Bioinformatics prediction was used to predict the target of miR-186, and then miR-186 expression was detected. Furthermore, dual-luciferase reporter assay was used to validate whether miR-186 directly targeted VEGF. Following transfection with agomiR-186, the expression levels of miR-186 and VEGF were detected, while MTT assay was used to detect EA.hy926 cell proliferation subsequent to small interfering RNA (siRNA) silencing. The results identified that VEGF was significantly increased in the tumor thrombus and blood samples of HCC patients with vein tumor thrombus at the mRNA and protein levels, while miR-186 expression was significantly decreased (P<0.05). Following silencing VEGF by siRNA transfection, the proliferation of EA.hy926 cells was inhibited. In addition, VEGF expression was significantly decreased and cell proliferation was reduced when upregulating miR-186. Dual-luciferase reporter assay demonstrated that miR-186 regulated VEGF expression through complementary binding to 3'-untranslated region. In conclusion, VEGF was significantly increased in tumor thrombus and blood samples from HCC patients with vein tumor thrombus, which may be associated with the downregulation of miR-186. Thus, miR-186 may promote the development and progression of vein tumor thrombus in HCC.
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Affiliation(s)
- Weidong Yuan
- Department of Hepatobiliary Surgery, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Fuguang Li
- The Second Ward of General Surgery Department, Ankang City Central Hospital, Ankang, Shaanxi 725000, P.R. China
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Game of thrones: immunotherapy versus molecular targeted therapy in renal cell cancer scenarios. Int Urol Nephrol 2019; 51:2107-2117. [DOI: 10.1007/s11255-019-02264-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/19/2019] [Indexed: 12/22/2022]
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Wang J, Wu S, Huang T. Expression and role of VEGFA and miR-381 in portal vein tumor thrombi in patients with hepatocellular carcinoma. Exp Ther Med 2018; 15:5450-5456. [PMID: 29904424 PMCID: PMC5996705 DOI: 10.3892/etm.2018.6129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/17/2017] [Indexed: 12/18/2022] Open
Abstract
The aim of the present study was to examine the expression and role of vascular endothelial growth factor A (VEGFA) and microRNA (miRNA or miR)-381 in tumor thrombi from patients with hepatocellular carcinoma and portal vein tumor thrombus (PVTT). Tumor thrombi and adjacent paired tissues were collected from 39 patients with hepatocellular carcinoma with PVTT. VEGFA expression levels were assessed using reverse transcription-quantitative polymerase chain reaction and western blotting. miRNAs that may regulate VEGFA expression were predicted using bioinformatics analysis and confirmed via a dual luciferase reporter assay. The effects of VEGFA and its upstream miRNA on proliferation of the proliferation of EAhy926 human venous endothelial cells were analyzed using an MTT assay. Compared with the paired adjacent tissues, VEGFA was significantly upregulated at both the mRNA and protein level in tumor thrombi (P<0.05). VEGFA was predicted to be a target of miR-381 and this was confirmed experimentally. miR-381 expression was significantly downregulated in tumor thrombi from patients with PVTT compared with paired adjacent tissues (P<0.05). In addition, transfection with antagomirs against miR-381 or short interfering RNA against VEGFA significantly inhibited EAhy926 cell proliferation (P<0.05). In conclusion, the results of the present study indicate that VEGFA is upregulated in tumor thrombi whereas miR-381 is downregulated. VEGFA is regulated by miR-381 and both may be associated with the development of PVTT.
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Affiliation(s)
- Jing Wang
- Experimental Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Shuzhi Wu
- Institute for Viral Disease Control and Prevention, Shandong Center for Disease Control and Prevention, Jinan, Shandong 250014, P.R. China
| | - Tianren Huang
- Experimental Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
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Froehner M, Heberling U, Zastrow S, Toma M, Wirth MP. Growth of a Level III Vena Cava Tumor Thrombus Within 1 Month. Urology 2016; 90:e1-2. [DOI: 10.1016/j.urology.2015.12.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/04/2015] [Accepted: 12/15/2015] [Indexed: 12/01/2022]
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Borregales LD, Adibi M, Thomas AZ, Wood CG, Karam JA. The role of neoadjuvant therapy in the management of locally advanced renal cell carcinoma. Ther Adv Urol 2016; 8:130-41. [PMID: 27034725 PMCID: PMC4772353 DOI: 10.1177/1756287215612962] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In the past decade, the armamentarium of targeted therapy agents for the treatment of metastatic renal cell carcinoma (RCC) has significantly increased. Improvements in response rates and survival, with more manageable side effects compared with interleukin 2/interferon immunotherapy, have been reported with the use of targeted therapy agents, including vascular endothelial growth factor (VEGF) receptor tyrosine kinase inhibitors (sunitinib, sorafenib, pazopanib, axitinib), mammalian target of rapamycin (mTOR) inhibitors (everolimus and temsirolimus) and VEGF receptor antibodies (bevacizumab). Current guidelines reflect these new therapeutic approaches with treatments based on risk category, histology and line of therapy in the metastatic setting. However, while radical nephrectomy remains the standard of care for locally advanced RCC, the migration and use of these agents from salvage to the neoadjuvant setting for large unresectable masses, high-level venous tumor thrombus involvement, and patients with imperative indications for nephron sparing has been increasingly described in the literature. Several trials have recently been published and some are still recruiting patients in the neoadjuvant setting. While the results of these trials will inform and guide the use of these agents in the neoadjuvant setting, there still remains a considerable lack of consensus in the literature regarding the effectiveness, safety and clinical utility of neoadjuvant therapy. The goal of this review is to shed light on the current body of evidence with regards to the use of neoadjuvant treatments in the setting of locally advanced RCC.
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Affiliation(s)
| | - Mehrad Adibi
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arun Z. Thomas
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher G. Wood
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A. Karam
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1373, Houston, TX 77030, USA
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Thomas AZ, Adibi M, Borregales LD, Karam JA, Wood CG. Cytoreductive surgery in the era of targeted molecular therapy. Transl Androl Urol 2016; 4:301-9. [PMID: 26815334 PMCID: PMC4708236 DOI: 10.3978/j.issn.2223-4683.2015.04.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Cytoreductive nephrectomy (CN) was regarded standard of care for patients with metastatic renal cell carcinoma (mRCC) in the immunotherapy era. With the advent of targeted molecular therapy (TMT) for the treatment of mRCC, the routine use of CN has been questioned. Up to date evidence continues to suggest that CN remains an integral part of treatment in appropriately selected patients. This review details the original context in which the efficacy of CN was established and rationale for the continued use of cytoreductive surgery in the era of TMT.
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Affiliation(s)
- Arun Z Thomas
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Mehrad Adibi
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Leonardo D Borregales
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Jose A Karam
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Christopher G Wood
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, USA
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Presurgical treatment with axitinib in renal cell carcinoma patients with venous extension. Int Cancer Conf J 2015. [DOI: 10.1007/s13691-014-0203-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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11
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Bex A, Powles T, Karam JA. Role of targeted therapy in combination with surgery in renal cell carcinoma. Int J Urol 2015; 23:5-12. [DOI: 10.1111/iju.12891] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 07/07/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Axel Bex
- Department of Urology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Thomas Powles
- Department of Medical Oncology; Barts Cancer Institute; Experimental Cancer Medicine Centre; Queen Mary University of London; London UK
| | - Jose A Karam
- Department of Urology; The University of Texas MD Anderson Cancer Center; Houston Texas USA
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12
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Husillos Alonso A, Carbonero García M, González Enguita C. Is there a role for systemic targeted therapy after surgical treatment for metastases of renal cell carcinoma? World J Nephrol 2015; 4:254-262. [PMID: 25949939 PMCID: PMC4419135 DOI: 10.5527/wjn.v4.i2.254] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/18/2015] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
Metastatic renal cell carcinoma (mRCC) is a challenging disease. Despite the new targeted therapies, complete remissions occur only in 1%-3% of the cases, and the most effective first-line treatment drugs have reached a ceiling in overall survival (ranging from 9 to 49 mo). Metastasectomy remains to be the only curative option in most patients with mRCC. Prognostic nomograms have been recently published, so we have tools to classify patients in risk groups, allowing us to detect the cases with the higher risk of recurrence after metastasectomy. Although sparse, there is some evidence of effectiveness of neoadjuvant targeted therapy before metastasectomy; but with an increase in surgical complications due to the effects of these new drugs in tissue healing. We have aimed to answer the question: Is there a role for systemic targeted therapy after surgical treatment for metastases of renal cell carcinoma? We have made a search in Pubmed database. As far as we know, evidence is low and it’s based in case reports and small series of patients treated with adjuvant drugs after neoadjuvant therapy plus metastasectomy in cases of partial response to initial systemic treatment. Despite the limitations and high risk of bias, promising results and cases with long-term survival with this approach have been described. Two ongoing clinical trials may answer the question that concerns us.
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Westesson KE, Klink JC, Rabets JC, Fergany AF, Klein EA, Stephenson AJ, Rini BI, Navia J, Krishnamurthi V. Surgical Outcomes After Cytoreductive Nephrectomy With Inferior Vena Cava Thrombectomy. Urology 2014; 84:1414-9. [DOI: 10.1016/j.urology.2014.05.078] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 04/04/2014] [Accepted: 05/02/2014] [Indexed: 11/28/2022]
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Nakayama T, Saito K, Fujii Y, Abe-Suzuki S, Nakanishi Y, Kijima T, Yoshida S, Ishioka J, Matsuoka Y, Numao N, Koga F, Kihara K. Pre-operative risk stratification for cancer-specific survival in patients with renal cell carcinoma with venous involvement who underwent nephrectomy. Jpn J Clin Oncol 2014; 44:756-61. [PMID: 24872404 DOI: 10.1093/jjco/hyu072] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The aim of this study is to identify the pre-operative prognostic factors and create a risk stratification model for patients with renal cell carcinoma with extension into the renal vein or inferior vena cava. METHODS The study cohort included 61 patients with renal cell carcinoma extending into the renal vein or inferior vena cava that underwent operations between 1993 and 2012. Cancer-specific survival rates were estimated, and univariate and multivariate analyses were carried out to determine the prognostic factors. A simple risk stratification model was developed for these patients. RESULTS The median follow-up period of the current patient cohort was 33.7 months. Their 1, 3 and 5-year cancer-specific survival were 89, 70 and 65%, respectively. On multivariate analysis, the level of tumor thrombus extension (extension into the supradiaphragm), presence of distant metastasis and elevation of lactate dehydrogenase and C-reactive protein were independent negative prognostic factors for cancer-specific survival. Cancer-specific survival rates were clearly discriminated by the stratification according to the scoring model (P < 0.001). The concordance index of the new model was 0.80. CONCLUSIONS We demonstrated a simple risk stratification model with four pre-operative independent prognostic factors for patients with renal cell carcinoma with venous involvement. This may be a useful decision-making model in the management of such patients.
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Affiliation(s)
| | - Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental University
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University
| | - Shiho Abe-Suzuki
- Department of Human Pathology, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Toshiki Kijima
- Department of Urology, Tokyo Medical and Dental University
| | | | | | - Yoh Matsuoka
- Department of Urology, Tokyo Medical and Dental University
| | - Noboru Numao
- Department of Urology, Tokyo Medical and Dental University
| | - Fumitaka Koga
- Department of Urology, Tokyo Medical and Dental University
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Karam JA, Devine CE, Urbauer DL, Lozano M, Maity T, Ahrar K, Tamboli P, Tannir NM, Wood CG. Phase 2 trial of neoadjuvant axitinib in patients with locally advanced nonmetastatic clear cell renal cell carcinoma. Eur Urol 2014; 66:874-80. [PMID: 24560330 DOI: 10.1016/j.eururo.2014.01.035] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 01/28/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous studies have shown a modest impact of tyrosine kinase inhibitors on primary renal tumors. Those studies were mostly retrospective or heterogeneous in their eligibility criteria with regard to histology, disease stage, duration of therapy, and time off therapy prior to surgery. OBJECTIVE To prospectively investigate the safety and efficacy of axitinib in downsizing tumors in patients with nonmetastatic biopsy-proven clear cell renal cell carcinoma (ccRCC). DESIGN, SETTING, AND PARTICIPANTS This was a single-institution, single-arm phase 2 clinical trial. Patients with locally advanced nonmetastatic biopsy-proven ccRCC were eligible. INTERVENTION Patients received axitinib 5mg for up to 12 wk. Axitinib was continued until 36h prior to surgery. Patients underwent partial or radical nephrectomy after axitinib therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was objective response rate prior to surgery. Secondary outcomes included safety, tolerability, and quality of life. A dedicated radiologist independently reviewed all computed tomography scans to evaluate for response using Response Evaluation Criteria in Solid Tumors (RECIST). RESULTS AND LIMITATIONS A total of 24 patients were treated. Twenty-two patients continued axitinib for 12 wk; 1 patient continued axitinib for 11 wk and underwent surgery as planned. One patient stopped treatment at 7 wk due to adverse events (AEs). Median reduction of primary renal tumor diameter was 28.3%. Eleven patients experienced a partial response per RECIST; 13 had stable disease. There was no progression of disease while on axitinib. The most common AEs were hypertension, fatigue, oral mucositis, hypothyroidism, and hand-foot syndrome. Postoperatively, 2 grade 3 and 13 grade 2 complications were noted. No grade 4 or 5 complications occurred. Functional Assessment of Cancer Therapy-Kidney Specific Index-15 changed over time, with quality of life worsening while on therapy, but by week 19, it was not statistically different from screening. Limitations include single-arm design and small patient numbers. CONCLUSIONS Axitinib was clinically active and reasonably well tolerated in the neoadjuvant setting in patients with locally advanced nonmetastatic ccRCC. PATIENT SUMMARY In this prospective clinical trial, we found that axitinib, when given prior to surgery, results in significant shrinking of kidney cancers. Larger studies are needed prior to further clinical use. TRIAL REGISTRATION This clinical trial was registered with clinicaltrials.gov (NCT01263769).
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Affiliation(s)
- Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Catherine E Devine
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana L Urbauer
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marisa Lozano
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapati Maity
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kamran Ahrar
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pheroze Tamboli
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Timsit MO, Albiges L, Méjean A, Escudier B. Neoadjuvant treatment in advanced renal cell carcinoma: current situation and future perspectives. Expert Rev Anticancer Ther 2014; 12:1559-69. [DOI: 10.1586/era.12.142] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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17
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Hatakeyama S, Yoneyama T, Hamano I, Murasawa H, Narita T, Oikawa M, Hagiwara K, Noro D, Tanaka T, Tanaka Y, Hashimoto Y, Koie T, Ohyama C. Prognostic benefit of surgical management in renal cell carcinoma patients with thrombus extending to the renal vein and inferior vena cava: 17-year experience at a single center. BMC Urol 2013; 13:47. [PMID: 24125174 PMCID: PMC3852853 DOI: 10.1186/1471-2490-13-47] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/11/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Management of renal cell carcinoma (RCC) with tumor thrombus extending to the renal vein and inferior vena cava (IVC) is challenging. The aim of this study was to evaluate the benefit of surgical management in such patients. METHODS From February 1995 to February 2013, 520 patients were treated for RCC at Hirosaki University Hospital, Hirosaki, Japan. The RCC patients with tumor thrombus extending to the renal vein (n = 42) and IVC (n = 43) were included in this study. The records of these 85 patients were retrospectively reviewed to assess the relevant clinical and pathological variables and survival. Prognostic factors were identified by multivariate analysis. The benefit of surgical management was evaluated using propensity score matching to compare overall survival between patients who received surgical management and those who did not. RESULTS RCC was confirmed by pathological examination of surgical or biopsy specimens in 74 of the 85 patients (87%). Sixty-five patients (76%) received surgical management (radical nephrectomy with thrombectomy). Distant metastasis was identified in 45 patients (53%). The proportion of patients with tumor thrombus level 0 (renal vein only), I, II, III, and IV was 49%, 13%, 18%, 14%, and 5%, respectively. The estimated 5-year overall survival rate was 70% in patients with thrombus extending to the renal vein and 23% in patients with thrombus extending to the IVC. Multivariate analysis identified thrombus extending to the IVC, presence of distant metastasis, surgical management, serum albumin concentration, serum choline esterase concentration, neutrophil-lymphocyte ratio, and Carlson comorbidity index as independent prognostic factors. In propensity score-matched patients, overall survival was significantly longer in those who received surgical management than those who did not. CONCLUSIONS Surgical management may improve the prognosis of RCC patients with thrombus extending to the renal vein and IVC.
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Affiliation(s)
- Shingo Hatakeyama
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Takahiro Yoneyama
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Itsuto Hamano
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Hiromi Murasawa
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Takuma Narita
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Masaaki Oikawa
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Kazuhisa Hagiwara
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Daisuke Noro
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Toshikazu Tanaka
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Yoshimi Tanaka
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Yasuhiro Hashimoto
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takuya Koie
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
| | - Chikara Ohyama
- Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, 036-8562 Hirosaki, Japan
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Early ultrasonographic evaluation of tumor thrombus level during sunitinib therapy for renal cell carcinoma. J Med Ultrason (2001) 2013; 40:463-5. [PMID: 27277462 DOI: 10.1007/s10396-013-0448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 03/27/2013] [Indexed: 10/26/2022]
Abstract
A 72-year-old man presenting with a 14-cm left renal mass, an inferior vena cava (IVC) tumor thrombus, and pulmonary metastases underwent renal mass biopsy that revealed clear cell renal cell carcinoma. Because of metastases and the extent of the tumor thrombus, sunitinib was administered, which resulted in a marked reduction in the tumor thrombus (from level III to level II after 11 weeks of treatment). Ultrasonography, preceding computed tomography, showed a slight shrinkage of the tumor thrombus level in the first 2 weeks. Therefore, ultrasound may be advantageous to monitor the IVC tumor thrombus level during the early phase of targeted therapy.
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Bex A, Haanen J. Do targeted agents offer clinical benefit as presurgical therapy? World J Urol 2013; 32:3-8. [DOI: 10.1007/s00345-013-1041-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 02/05/2013] [Indexed: 01/05/2023] Open
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20
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Whitson JM, Reese AC, Meng MV. Population based analysis of survival in patients with renal cell carcinoma and venous tumor thrombus. Urol Oncol 2013; 31:259-63. [DOI: 10.1016/j.urolonc.2010.11.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 11/22/2010] [Accepted: 11/23/2010] [Indexed: 10/17/2022]
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21
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Bex A, Powles T. Selecting patients for cytoreductive nephrectomy in advanced renal cell carcinoma: who and when. Expert Rev Anticancer Ther 2012; 12:787-97. [PMID: 22716495 DOI: 10.1586/era.12.54] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Renal cell carcinoma presents with metastatic disease in approximately 30% of patients at the time of diagnosis. Cytoreductive nephrectomy (CN) of the primary tumor in the face of metastatic disease is part of a multimodality approach including systemic therapy that is based on evidence from randomized trials in the cytokine era. Data from the pretargeted therapy era showed that CN had a clear role in metastatic renal cell carcinoma, increasing life expectancy by approximately 6 months. The substantial improvement in outcomes reported for targeted therapy has challenged the previous role of CN. However, despite the absence of data from Phase III trials, available evidence suggests that some patients may benefit substantially from CN in the era of targeted therapy. This review summarizes current arguments for CN and how to best select patients for surgery. Ongoing trials are key in generating evidence towards a personalized approach to debulking nephrectomy.
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Affiliation(s)
- Axel Bex
- The Netherlands Cancer Institute, Division of Surgical Oncology, Department of Urology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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22
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Peters I, Winkler M, Jüttner B, Teebken OE, Herrmann TR, von Klot C, Kramer M, Reichelt A, Abbas M, Kuczyk MA, Merseburger AS. Neoadjuvant targeted therapy in a primary metastasized renal cell cancer patient leads to down-staging of inferior vena cava thrombus (IVC) enabling a cardiopulmonary bypass-free tumor nephrectomy: a case report. World J Urol 2012; 32:245-8. [PMID: 23053210 DOI: 10.1007/s00345-012-0955-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/14/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND We report on a 62-year-old gentleman presenting at our urological department with an advanced renal cell cancer of the right kidney (10 cm in diameter), with an extensive caval vein thrombus (level IV) and bilateral pulmonary metastases. Another suspicious lesion at the left hemithorax was radiologically described. METHOD A presurgical, neoadjuvant systemic therapy with sunitinib, a tyrosine kinase inhibitor, was initiated for 4 cycles in total (50 mg/day; 4 weeks on/2 weeks off). The cytoreductive nephrectomy was performed following the fourth cycle of sunitinib and after a 14-day break. Transesophageal echocardiography was used for intraoperative monitoring of the caval vein thrombus. Systemic treatment with sunitinib was continued 4 weeks after surgery. RESULTS A significant reduction in tumor size, metastatic sites and down-staging of IVC from level IV to level III according to Novick classification was achieved. CONCLUSION Significant down-staging of the tumor caval vein thrombus which initially reached the right atrium enabled us to perform surgery limited to the abdominal cavity without extracorporeal circulation nor hypothermia.
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Affiliation(s)
- Inga Peters
- Department of Urology and Uro-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Chiba H, Hirose T, Shimoda N, Kanagawa K. [A case of advanced renal cell carcinoma with inferior vena cava thrombus treated with sunitinib as neoadjuvant therapy]. Nihon Hinyokika Gakkai Zasshi 2012; 103:623-626. [PMID: 23120997 DOI: 10.5980/jpnjurol.103.623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A 70 year old woman had a right renal tumor with vena cava thrombus up to right atrium. We started medical treatment with sunitinib at a dose of 50 mg as neoadjuvant therapy. In 2 months, the vena cava thrombus shrank to the same level of the diaphragm. After stopping sunitinib for 2 weeks, a nephrectomy and thrombectomy was performed with extracorporeal circulation. Pathological diagnosis was clear cell carcinoma, G2. The TNM stage was pT3bN0M0. There were no viable cells at the tip of the thrombus. There is no recurrence during 9 months after the operation. Although we had to stop medication due to thrombocytopenia, it was possible to continue to take sunitinib for 3 months and achieved the operation. Because of down-staging of the tumor thrombus, we didn't have to do thoracic surgery. These results suggest that neoadjuvant therapy with molecular target drug may reduce surgical invasion.
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Is there a role for neoadjuvant targeted therapy to downsize primary tumors for organ sparing strategies in renal cell carcinoma? Int J Surg Oncol 2012; 2012:250479. [PMID: 22778936 PMCID: PMC3388285 DOI: 10.1155/2012/250479] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 04/26/2012] [Accepted: 05/07/2012] [Indexed: 12/19/2022] Open
Abstract
With an increasing number of small renal masses being diagnosed organ-preserving treatment strategies such as nephron-sparing surgery (NSS) or radiofrequency and cryoablation are gaining importance. There is evidence that preserving renal function reduces the risk of death of any cause, cardiovascular events, and hospitalization. Some patients have unfavourable tumor locations or large tumors unsuitable for NSS or ablation which is a clinical problem especially in those with imperative indications to preserve renal function. These patients may benefit from downsizing primary tumors by targeted therapy. This paper provides an overview of the current evidence, safety, controversies, and ongoing trials.
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Pooleri GK, Nair TB, Sanjeevan KV, Thomas A. Neo adjuvant treatment with targeted molecules for renal cell cancer in current clinical practise. Indian J Surg Oncol 2012; 3:114-9. [PMID: 23730100 PMCID: PMC3392483 DOI: 10.1007/s13193-011-0100-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 10/21/2011] [Indexed: 12/19/2022] Open
Abstract
Target molecule Treatment (TMT) have emerged as the primary treatment in metastatic renal cell carcinoma. Majority of the patients in pivot trials were post nephrectomy cases. The benefit of cytoreductive nephrectomy in the era of TMT is debated. The role of these molecules in the adjuvant settings and in neo adjuvant/pre surgical role has evoked interest. In this review the different molecules used in the treatment of metastatic renal cancer and its effect on the primary renal tumour is discussed. Information available in the public domain about the presurgical/neoadjuvant targeted molecular treatment (TMT) is reviewed to understand the benefits and adverse effects of this modality of treatment. Sunitinib and sorafenib are the most commonly used and effective molecules in the neo adjuvant/re surgical treatment of renal cell carcinoma . Bevacizumab is less effective and has more chance of surgical complications in these settings mainly due to poor wound healing secondary to prolonged wash off period . The patent and the surgeon should be aware of the unpredictability and possible adverse effects before advising these molecule pre operatively. The response of the primary renal tumour to the target molecule is different from that of the metastatic tumour. The side effects of the molecules and its effect on the peri operative morbidity and mortality should also be considered when we advise these molecules as pre surgical/neo adjuvant treatment.
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Affiliation(s)
- Ginil Kumar Pooleri
- Uro-Oncology division, Department of Urology, Amrita Institute of Medical Sciences, AIMS-Ponekkara(PO), Kochi 41, Kerala India
| | - Tiyadath Balagopalan Nair
- Department of Urology, Amrita Institute of Medical Sciences, AIMS-Ponekkara(PO), Kochi 41, Kerala India
| | - Kalavampara V. Sanjeevan
- Department of Urology, Amrita Institute of Medical Sciences, AIMS-Ponekkara(PO), Kochi 41, Kerala India
| | - Appu Thomas
- Department of Urology, Amrita Institute of Medical Sciences, AIMS-Ponekkara(PO), Kochi 41, Kerala India
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Kenney PA, Wood CG. Integration of surgery and systemic therapy for renal cell carcinoma. Urol Clin North Am 2012; 39:211-31, vii. [PMID: 22487764 DOI: 10.1016/j.ucl.2012.01.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Proper integration of surgery and systemic therapy is essential for improving outcomes in renal cell carcinoma (RCC). There is no current role for adjuvant therapy after nephrectomy for clinically localized disease. The potential benefits of neoadjuvant therapy for locally advanced nonmetastatic disease are in need of further study. In metastatic disease, the proper integration of cytoreductive surgery and systemic therapy remains to be elucidated. Presurgical targeted therapy is feasible and may be beneficial. Pending the results of randomized controlled trials, upfront cytoreductive nephrectomy in appropriate patients will likely continue as the paradigm of choice in metastatic RCC.
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Affiliation(s)
- Patrick A Kenney
- Urologic Oncology, Department of Urology, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1373, Houston, TX 77030, USA
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27
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Schrader AJ, Steffens S, Schnoeller TJ, Schrader M, Kuczyk MA. Neoadjuvant therapy of renal cell carcinoma: a novel treatment option in the era of targeted therapy? Int J Urol 2012; 19:903-7. [PMID: 22640774 DOI: 10.1111/j.1442-2042.2012.03065.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The study was carried out to evaluate the effectiveness, toxicity and optimal duration of neoadjuvant therapy for patients with organ-confined or locally advanced renal cell carcinoma in the era of targeted agents. A literature review was carried out using Medline/Pubmed articles, as well as congress reports from the last five American Society of Clinical Oncology, American Urological Association and European Association of Urology Annual Meetings. Neoadjuvant targeted therapy is feasible and shows toxicity similar to that seen in a palliative setting. Most studies recommend an application for 2-4 months. The current data situation is best for sunitinib. Surgery can apparently be carried out the day right after discontinuing the drug. However, even sunitinib leads to only a mean 10% decrease in primary tumor size, and one-quarter to one-fifth of all patients show local tumor progression during treatment. Few patients (approximately 12%) with a vena cava tumor thrombus achieve a significant decrease in its level under neoadjuvant therapy; here too, progression is observed in a significant number of cases. Even the new targeted agents show limited effectiveness in achieving relevant remissions of the primary tumor. Furthermore, tumor progression is seen in a significant percentage of patients during neoadjuvant therapy. Thus, even today in the era of targeted agents, a neoadjuvant approach should only be made in patients with localized or locally advanced renal cell carcinoma, which primarily seem to be absolutely inaccessible by (partial) nephrectomy.
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Bex A, Blank C, Meinhardt W, van Tinteren H, Horenblas S, Haanen J. A phase II study of presurgical sunitinib in patients with metastatic clear-cell renal carcinoma and the primary tumor in situ. Urology 2011; 78:832-7. [PMID: 21802123 DOI: 10.1016/j.urology.2011.05.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 05/19/2011] [Accepted: 05/24/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate response rate (RR) of the primary tumor after presurgical sunitinib before planned cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (mRCC). Secondary endpoints were safety and if this strategy can be used to identify patients who progress rapidly and may not benefit from CN. METHODS Prospective study to detect a 25% response evaluation criteria in solid tumors RR (RECIST-RR) in the primary tumor (Simon two-stage design). CN was performed after 2 cycles of sunitinib 50 mg/d. Response in the primary tumor and metastatic sites, change of longest diameter of the primary tumor (Δ-LDT), progression-free survival (PFS), and adverse events were assessed. RESULTS Twenty-two patients with primary mRCC were included. The trial did not enter the second stage because only 1 primary tumor responded partially in the first stage (4.5%). Median Δ-LDT was -9.5% (range 2.2 to -36%). A >10% Δ-LDT was significantly associated with a high probability to survive 2 years (P = .01). At metastatic sites, 7 patients developed a partial response (31.8%), 7 stable disease (31.8%), and 8 progressive disease (36.4%). Subsequently 3 (13.6%) developed a complete response after CN and continued taking sunitinib. Median PFS is 7 months (range 0-41). Median follow-up is 23 months (range 2-41). Median overall survival has not been reached. CONCLUSIONS Downsizing of primary tumors after 2 cycles of sunitinib is modest but associated with long-term survival. Patients with progression of metastases after pretreatment have short survival and are unlikely to benefit from CN.
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Affiliation(s)
- Axel Bex
- Department of Urology, Cancer Institute, Amsterdam, the Netherlands.
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29
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Bex A, Clarke N. Targeted caval cytoreduction: solid foundations or shifting sands? Eur Urol 2011; 59:919-20; discussion 921-2. [PMID: 21444147 DOI: 10.1016/j.eururo.2011.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 03/10/2011] [Indexed: 10/18/2022]
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Cost NG, Delacroix SE, Sleeper JP, Smith PJ, Youssef RF, Chapin BF, Karam JA, Culp S, Abel EJ, Brugarolas J, Raj GV, Sagalowsky AI, Wood CG, Margulis V. The impact of targeted molecular therapies on the level of renal cell carcinoma vena caval tumor thrombus. Eur Urol 2011; 59:912-8. [PMID: 21367518 DOI: 10.1016/j.eururo.2011.02.032] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 02/15/2011] [Indexed: 01/07/2023]
Abstract
BACKGROUND Targeted molecular therapies (TMTs) previously have demonstrated oncologic activity in renal cell carcinoma (RCC) by reducing the size of primary tumors and metastases. OBJECTIVE To assess the cytoreductive effect of TMTs on inferior vena cava tumor thrombi. DESIGN, SETTING, AND PARTICIPANTS A multi-institutional database of patients treated with TMTs for RCC was reviewed. The subset with in situ level II or higher caval thrombi (above renal vein) was assessed for radiographic response in thrombus size and level. Pre- and posttreatment characteristics of this population were assessed for predictors of response in height, diameter, and level of the tumor thrombi. MEASUREMENTS The main outcome measured was a change in the clinical level of tumor thrombus following TMT. We also measured radiographic responses in thrombus size and location before and after TMT. RESULTS AND LIMITATIONS Twenty-five patients met the inclusion criteria. Before TMT, thrombus level was II in 18 patients (72%), III in 5 patients (20%), and IV in 2 patients (8%). The first-line therapy was sunitinib in 12 cases; alternative TMTs were administered in 13. The median duration of therapy was two cycles (range: one to six cycles). Following TMT, 7 patients (28%) had a measurable increase in thrombus height, 7 (28%) had no change, and 11 (44%) had a decrease. One patient (4%) had an increase in thrombus-level classification, 21 (84%) had stable thrombi, and in 3 (12%) the thrombus level decreased. There was only one case (4%) where the surgical approach was potentially affected by tumor thrombus regression (level IV to III). No statistically significant predictors of tumor thrombus response to TMTs were found. Limitations include the descriptive and retrospective study design. Because TMTs were initiated according to physician and/or patient preferences, and not all patients were treated in anticipation of surgery, no conclusions could be drawn regarding selection and duration of therapy. Thus it may not be appropriate to extrapolate our experience to all patients with locally advanced RCC. Although this is the largest reported experience with in situ caval tumor thrombi treated with TMT, this series lacks sufficient statistical power to assess the usefulness of TMTs adequately in tumor thrombus cytoreduction. CONCLUSIONS TMT had a minimal clinical effect on RCC tumor thrombi. Only patients treated with sunitinib had clinical thrombus regression; however, the clinical magnitude and relevance of this effect is not clear and should be investigated prospectively.
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Affiliation(s)
- Nicholas G Cost
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9110, USA
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Abstract
Systemic therapy of metastatic renal cell carcinoma has completely changed in the last 5 years. Although a cure for the disease is still not achieved with systemic treatment in the majority of cases immunotherapy is no longer used. The therapeutic regiments are mainly based on angiogenic inhibitors such as sunitinib, sorafenib, pazopanib, everolimus and temsirolimus as well as the combination of bevacizumab with interferon. This article gives an overview of these treatment options and the clinical setting for their usage. To achieve a prolonged progression-free survival, a continuous therapy based on the new drugs is necessary. The major goal of the treatment remains to keep the disease stable as complete remission is only seen in 2-4% of cases. With these lengthy treatment regimes a schedule for sequenced administration of drugs is necessary for most of the patients. The optimal treatment sequence is unknown and should be chosen based on the individual course of the disease and the side effects as well as comorbidities. The role of neoadjuvant and adjuvant therapies remains unclear.
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Targeted therapies in renal cell cancer: recent developments in imaging. Target Oncol 2010; 5:95-112. [PMID: 20625845 PMCID: PMC2929340 DOI: 10.1007/s11523-010-0146-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 06/24/2010] [Indexed: 01/14/2023]
Abstract
Targeted therapy has significantly improved the perspectives of patients with metastatic renal cell cancer (mRCC). Frequently, these new molecules cause disease stabilization rather than substantial tumor regression. As treatment options expand with the growing number of targeted agents, there is an increasing need for surrogate markers to early assess tumor response. Here, we review the currently available imaging techniques and response evaluation criteria for the assessment of tumor response in mRCC patients. For computed tomography (CT), different criteria are discussed including the Response Evaluation Criteria in Solid Tumors (RECIST), the Choi criteria, the modified Choi criteria, and the size and attenuation CT (SACT) criteria. Functional imaging modalities are discussed, such as dynamic contrast-enhanced CT (DCE-CT), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), dynamic contrast-enhanced ultrasonography (DCE-US), and positron emission tomography (PET).
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