Ulka Vaishampayan, MD, professor of oncology at Wayne State University, and chief of the Solid Tumor Program at Barbara Ann Karmanos Cancer Institute, discusses the considerations when giving patients with metastatic renal cell carcinoma (RCC) systemic therapy followed by cytoreductive nephrectomy.

If a patient presents with a primary lesion and metastatic disease, they are typically given systemic therapy first because the efficacy of systemic therapy has greatly improved, explains Vaishampayan. After, cytoreductive nephrectomy is considered. A new SWOG trial will assess the efficacy of treating patients with contemporary immunotherapy upfront, then randomizing patients to receive cytoreductive nephrectomy or continue on systemic therapy, says Vaishampayan.

Systemic therapy upfront should be considered for patients with synchronous metastatic disease. After, cytoreductive nephrectomy should be considered for these patients. The decision regarding the nephrectomy would depend on the patient’s response to treatment, how they are feeling overall, and what kind of performance status they are maintaining, concludes Vaishampayan.

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Ulka Vaishampayan, MD, discusses the considerations when giving patients with metastatic renal cell carcinoma systemic therapy followed by cytoreductive nephrectomy.

Dr. Vaishampayan on Systemic Therapy Followed by Cytoreductive Nephrectomy in mRCC

Ulka Vaishampayan, MD, professor of oncology at Wayne State University, and the chief of the Solid Tumor Program at Barbara Ann Karmanos Cancer Institute, discusses the shifting role of cytoreductive nephrectomy in renal cell carcinoma.

Historically, cytoreductive nephrectomy demonstrated an overall survival benefit in patients with metastatic kidney cancer, explains Vaishampayan. Cytoreductive nephrectomy was considered the first step in the management of patients who resented with primary and metastatic disease and had good performance status, says Vaishampayan.

The CARMENA trial compared cytoreductive nephrectomy with anti-VEGF therapy. Historically, this was looked at with interferon because that was the only treatment available that was previously applicable to the majority of patients. The CARMENA trial showed that with contemporary anti-VEGF therapy, cytoreductive nephrectomy did not appear to have benefit. As a result, the trial caused a paradigm shift in how treatment is approached, concludes Vaishampayan.

Ulka Vaishampayan, MD, discusses the shifting role of cytoreductive nephrectomy in renal cell carcinoma.

Dr. Vaishampayan on the Shifting Role of Cytoreductive Nephrectomy in RCC

Ulka Vaishampayan, MD, professor of oncology at Wayne State University, and the chief of the Solid Tumor Program at Barbara Ann Karmanos Cancer Institute, discusses the current role of cytoreductive nephrectomy in metastatic renal cell carcinoma.

The phase III CARMENA trial showed that 20% of patients never made it to systemic therapy and had worse outcomes as a result. Therefore, if a patient presents with a primary lesion and metastatic disease, they should receive systemic therapy first, because it is known to benefit the primary and metastatic sites. Cytoreductive nephrectomy can be considered after, says Vaishampayan.

Although this is thought to be the optimal approach, it has never been formally evaluated in a clinical trial. To that end, a SWOG trial will evaluate whether up-front immunotherapy followed by cytoreductive nephrectomy versus continued systemic therapy is the optimal approach, concludes Vaishampayan.

Dr. Vaishampayan on the Role of Cytoreductive Nephrectomy in mRCC

Ulka Vaishampayan, MD, professor of oncology at Wayne State University, and the chief of the Solid Tumor Program at Barbara Ann Karmanos Cancer Institute, discusses trials that examine frontline immunotherapy for metastatic kidney cancer.

The CheckMate-214, KEYNOTE-426, and JAVELIN Renal 101 trials explore immunotherapy as a first-line treatment, explains Vaishampayan.

The KEYNOTE-426 and JAVELIN Renal 101 trials examine axitinib (Inlyta) combined with pembrolizumab (Keytruda) and avelumab (Bavencio), respectively, says Vaishampayan. The KEYNOTE-426 trial led to the 

FDA approval of axitinib plus pembrolizumab

 for the frontline treatment of patients with advanced renal cell carcinoma (RCC), and JAVELIN Renal 101 was the basis for the 

 as well. Data from the KEYNOTE-426 trial showed that pembrolizumab/axitinib led to a 47% reduction in the risk of death versus sunitinib (HR, 0.53; 95% CI, 0.38-0.74; 

 <.0001). Meanwhile, the avelumab/axitinib combination led to a 31% reduction in the risk of disease progression or death compared with sunitinib (Sutent) in an intent-to-treat population of patients with treatment-naïve advanced RCC, regardless of PD-L1 expression.

The CheckMate-214 trial evaluated the combination of nivolumab (Opdivo) combined with low-dose ipilimumab (Yervoy), concludes Vaishampayan, which is now available for intermediate- or poor-risk patients with advanced RCC.

Ulka Vaishampayan, MD, discusses trials that examine frontline immunotherapy for metastatic kidney cancer.

Dr. Vaishampayan on Immunotherapy Trials in Kidney Cancer

Ulka Vaishampayan, MD, professor of oncology at Wayne State University, and the chief of the Solid Tumor Program at Barbara Ann Karmanos Cancer Institute, discusses the role of immunotherapy in metastatic renal cell carcinoma (mRCC). 

Historically, immunotherapy with high-dose interleukin 2 was effective in about 10% of patients, says Vaishampayan. However, many patients with mRCC were not able to receive the cytokine therapy due to its significant toxicites, she adds.

Immune checkpoint therapy has since become an effective approach for the majority of this patient population, as it has allowed patients to experience long-term complete remissions without unreasonable toxicities, concludes Vaishampayan. 

Ulka Vaishampayan, MD, discusses the utility of immunotherapy in metastatic renal cell carcinoma.
 

Ulka Vaishampayan, MD

Articles

Dr. Vaishampayan on Systemic Therapy Followed by Cytoreductive Nephrectomy in mRCC

Dr. Vaishampayan on the Shifting Role of Cytoreductive Nephrectomy in RCC

Dr. Vaishampayan on the Role of Cytoreductive Nephrectomy in mRCC

Dr. Vaishampayan on Immunotherapy Trials in Kidney Cancer

Dr. Vaishampayan on Immunotherapy in mRCC