Stereotactic Ablative Radiation for Systemic Therapy-naïve Oligometastatic Kidney Cancer

BACKGROUND

Evidence-based guidelines for the management of systemic therapy-naïve oligometastatic renal cell carcinoma (RCC) are lacking.

OBJECTIVE

To evaluate the potential of stereotactic ablative radiotherapy (SAbR) to provide longitudinal disease control while preserving quality of life (QOL) in patients with systemic therapy-naïve oligometastatic RCC.

DESIGN, SETTING, AND PARTICIPANTS

RCC patients with three or fewer extracranial metastases were eligible. SAbR was administered longitudinally to all upfront and, as applicable, subsequent metastases.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

This prospective phase II single-arm trial was powered to achieve a primary objective of freedom from systemic therapy for >1 yr in >60% of patients (using the Clopper and Pearson methodology). Secondary endpoints included progression-free survival (PFS), defined as the time from first SAbR to progression not amenable to SAbR (local failure at SAbR-treated sites, new metastases not amenable to SAbR, more than three new metastases, or brain metastases); patient-reported QOL metrics; local control (LC) rates; toxicity; cancer-specific survival (CSS); and overall survival (OS).

RESULTS AND LIMITATIONS

Twenty-three patients received SAbR to 33 initial and 57 total sites. The median follow-up was 21.7 mo (interquartile range 16.3-30.3). Exceeding the prespecified 60% benchmark, freedom from systemic therapy at 1 yr was 91.3% (95% confidence interval [CI]: 69.5, 97.8). One-year PFS was 82.6% (95% CI: 60.1, 93.1). QOL was largely unaffected. LC was 100%. There were no grade 3/4 toxicities, but there was one death due to immune-related colitis 3 mo after SAbR while on subsequent checkpoint inhibitor therapy, where a SAbR contribution could not be excluded. One-year OS was 95.7% (95% CI: 72.9, 99.4); one-year CSS was 100%.

CONCLUSIONS

SAbR for oligometastatic RCC was associated with meaningful longitudinal disease control while preserving QOL. These data support further evaluation of SAbR for systemic therapy-naïve oligometastatic RCC.

PATIENT SUMMARY

Sequential stereotactic radiation therapy can safely and effectively control metastatic kidney cancer with limited spread for over a year without compromising patients' quality of life.

Pancreatic tropism of metastatic renal cell carcinoma

Renal cell carcinoma (RCC) is characterized by a particularly broad metastatic swath, and, enigmatically, when the pancreas is a destination, the disease is associated with improved survival. Intrigued by this observation, we sought to characterize the clinical behavior, therapeutic implications, and underlying biology. While pancreatic metastases (PM) are infrequent, we identified 31 patients across 2 institutional cohorts and show that improved survival is independent of established prognostic variables, that these tumors are exquisitely sensitive to antiangiogenic agents and resistant to immune checkpoint inhibitors (ICIs), and that they are characterized by a distinctive biology. Primary tumors of patients with PM exhibited frequent PBRM1 mutations, 3p loss, and 5q amplification, along with a lower frequency of aggressive features such as BAP1 mutations and loss of 9p, 14q, and 4q. Gene expression analyses revealed constrained evolution with remarkable uniformity, reduced effector T cell gene signatures, and increased angiogenesis. Similar findings were observed histopathologically. Thus, RCC metastatic to the pancreas is characterized by indolent biology, heightened angiogenesis, and an uninflamed stroma, likely underlying its good prognosis, sensitivity to antiangiogenic therapies, and refractoriness to ICI. These data suggest that metastatic organotropism may be an indicator of a particular biology with prognostic and treatment implications for patients.

Abstract 4106: Outcomes of combined ipilimumab and nivolumab therapy following progression on nivolumab monotherapy in renal cell carcinoma: A retrospective cohort study

Background: Nivolumab was the first immune checkpoint inhibitor to gain FDA approval for use in the treatment of renal cell carcinoma (RCC), however only a quarter of patients respond to nivolumab monotherapy (Nivo). More recently, the combination of ipilimumab and nivolumab (Ipi/Nivo) gained approval as first-line therapy in RCC with better outcomes than previously described with Nivo. Whether Ipi/Nivo can rescue RCC patients who progress on Nivo is an important question that remains unanswered. We sought to evaluate the oncologic benefit of treating metastatic RCC patients with Ipi/Nivo following progression on Nivo at our institution.

Methods: A systematic medical record search was conducted to identify patients with RCC who had been treated with Ipi/Nivo following progression on Nivo from 2013 to Jan 31, 2018. Clinical benefit after starting Ipi/Nivo was measured by time to next therapy (TNT), overall survival (OS), and objective responses defined by RECIST v1.1. Kaplan Meier methods were used to analyze event-free survival.

Results: 90 RCC patients were treated with Nivo from 2013 until Jan 31st, 2018. 17 (19%) of these patients received Ipilimumab following progression. Baseline characteristics of this subgroup were similar to the entire cohort. 13 (76.5%) had intermediate or poor risk disease by the Heng prognostic risk score. 6 (35.3%) patients had one prior line of therapy and 11 (64.7%) had two or more prior lines of therapy. The median duration of nivolumab monotherapy was 11.9 (95% CI; 4.4 - 13.0) months. Following the addition of ipilimumab at progression, the median TNT was 3.9 (95% CI; 3.3 to 7.0) months and the median OS was 20.3 (95% CI; 12.1 - 22.1) months. There were no objective responses to Ipi/Nivo following Nivo alone. Stable disease was the best overall response in 5 (29%) patients, and the remainder demonstrated progressive disease. One patient had stable disease lasting 11 months. Immune related adverse events were observed in 8 (47%) of patients resulting in cessation of therapy for 1 patient.

Discussion: In this analysis, Ipi/Nivo did not confer substantial treatment benefit to patients who had already progressed on Nivo alone. The were no objective responses, and most patients were started on the next line of therapy at their first set of imaging studies. These patients still demonstrated approximately a 2-year OS suggesting that alternative agents, such as TKIs, remain effective treatments in this population. Prospective evaluation is warranted to further evaluate the utility of Ipi/Nivo following progression on Nivo alone.

Citation Format: Roy M. Elias, Nirmish Singla, Isaac A. Bowman, Payal Kapur, Raquibul Hannan, Hans Hammers, James Brugarolas. Outcomes of combined ipilimumab and nivolumab therapy following progression on nivolumab monotherapy in renal cell carcinoma: A retrospective cohort study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4106.

Thalidomide, clarithromycin, lenalidomide and dexamethasone therapy in newly diagnosed, symptomatic multiple myeloma

We studied T-BiRD (thalidomide [Thalomid(®)], clarithromycin [Biaxin(®)], lenalidomide [Revlimid(®)] and dexamethasone) in symptomatic, newly diagnosed multiple myeloma. In 28-day cycles, patients received dexamethasone 40 mg/day on days 1, 8, 15, 22, clarithromycin 500 mg twice daily on days 1-28; lenalidomide 25 mg/day on days 1-21; and thalidomide 100 mg/day (50 mg/day on days 1-7 of cycle 1 only) on days 1-28. Twenty-six patients received a median of 6 cycles (range 0-41). Overall response rate (ORR) was 80% for the group and 100% in 11 patients who underwent autologous stem cell transplantation as part of first-line therapy. The 4-year overall survival rate was 74.9%, and the median progression-free survival was 35.6 months. Eight patients discontinued due to regimen toxicity. Grade 3 non hematologic toxicity affected 12 patients (46.2%). T-BiRD is a highly active regimen with potential toxicity limitations. ClinicalTrials.gov identifier: NCT00538733.

Jean-Baptiste Sénac and his treatise on the heart

Jean-Baptiste Sénac's treatise on the heart is considered a landmark in the history of cardiology. In Traité de la structure du coeur, de son action, et de ses maladies (1749), Sénac dealt systematically with the anatomy, physiology, and pathology of the heart, offering the results of anatomical investigations and postmortem examinations. This paper focuses on Sénac's work on the muscular structure of the heart, as well as on the diseases of the cardiovascular system. It shows that palpitations, aneurysms, the dilatation and inflammation of the heart, valvular lesions, and blood clots, were among the problems frequently reported by Sénac and his contemporaries. Sénac's treatise is important because it reveals the state of the art in cardiology before the development of such diagnostic techniques as percussion of the chest and mediate auscultation.

Are health science faculty interested in medical history? An evaluative case study

This paper deals with the efforts of a medical library to stimulate interest in the history of medicine by utilizing its historical resources. It is based on a survey designed to evaluate the monthly publication of the library, the Bookman, and to determine the response of health science faculty to historical essays as well as to other sections of the publication. The results show that a large percentage of the faculty reads historical essays either regularly or occasionally, and reveal a trend contrary to the common belief that the teaching staff in health science centers is not interested in medical history. The authors suggest that a library with historical resources can contribute to the educational process in a medical community by actively publicizing its collections and providing opportunities for informal and self-initiated reading.