Renal cell carcinoma (RCC), a cancer that originates in the proximal convoluted tubule of the kidney, is most frequently diagnosed at the advanced stage, limiting potential treatment options.

Ulka Vaishampayan, MD, director of the phase 1 clinical trials program in the Karmanos Cancer Institute at Wayne State University in Detroit, Michigan, and Neeraj Agarwal, MD, director of the genitourinary oncology program at the University of Utah in Salt Lake City, spoke with Cancer Therapy Advisor about treatment recommendations for patients newly diagnosed with metastatic RCC.

 “For newly diagnosed patients with metastatic kidney cancer, I first determine if they have resectable metastases. It is preferable to put these patients in remission by surgical resection, ablation, or cryotherapy of their lesion.

“But the majority of these patients don’t fit the criteria for resection. Most patients have multiple areas of metastases given the nature of advanced RCC,” said Dr Vaishampayan.

Yet there are options for the majority of patients who do not have resectable metastases. “Three classes of treatment options are currently offered to patients with newly diagnosed metastatic RCC, noted Dr Agarwal. “They are the VEGF–tyrosine kinase inhibitors (TKIs) sunitinib and pazopanib, which are offered to about 80% of patients, high-dose interleukin-2, which is offered to about 15% of patients, and temsirolimus, which is offered to about 5% of patients.”

Dr Agarwal added that high-dose interleukin-2 is the best treatment option for patients with excellent performance status: “high-dose interleukin-2, approved in 1992, was the first approved immunotherapy. Around 10% of patients who undergo this treatment experience long-term, durable responses that persist even a decade after treatment.

“An additional 30% experience partial response or stable disease with clinically meaningful survival benefit, yet there are no known biomarkers predicting which patients will respond to this therapy.

“Most patients have only acute high-dose IL [interleukin]-2 related toxicity with very rare long-term toxicity,” he said.

Dr Vaishampayan noted that “patients undergoing high-dose interleukin-2 therapy must have robust cardiopulmonary function, they cannot have brain metastases, and they have to have PR [progesterone receptor] cell histology. Only about 5% to 10% of my patients fit the criteria that allow them to go on high-dose interleukin-2.”

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As the majority of patients cannot undergo interleukin-2 therapy, clinical trial enrollment can be an option. “Usually we have clinical trials in every setting. If there is a clinical trial, they will be offered participation in that. If no clinical trials fit the patient, then I would use sunitinib or pazopanib, the anti-VEGF therapies,” said Dr Vaishampayan.