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Perspectives on the Evolution in Treating Kidney Cancer- Monty Pal and Jaime Landman

Monty Pal & Jaime Landman | March 13, 2020

Perspectives on the Evolution in Treating Kidney Cancer- Monty Pal and Jaime Landman

Monty Pal and Jaime Landman discuss the value of collaboration with multiple disciplines to effectively manage patients diagnosed with kidney cancer. They provide a historical overview of the treatment of kidney cancer bringing the conversation to revolutionary advances, adding their view on the impact of survival in this patient population.

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Sumanta Kumar Pal, MD

Sumanta (Monty) Kumar Pal, MD, is an internationally recognized leader in the area of genitourinary cancers, including kidney, bladder, and prostate cancer. He is the Co-director of City of Hope's Kidney Cancer Program and is the head of the kidney and bladder cancer disease. Dr. Pal sits on the Editorial Board for clinical genitourinary cancer and is a reviewer for multiple journals including The Journal of Clinical Oncology, The Journal of Urology, European Urology, and many others.

Jaime Landman, MD

Jaime Landman, MD, director of the UCI Health Center for Urological Care, is an internationally recognized urologist and expert in diseases and conditions of the kidneys, including kidney stones and benign and malignant tumors. He is experienced in all forms of minimally invasive kidney surgery, including robot-assisted surgery and percutaneous cryoablation. Dr. Landman, who founded the UCI Health Ablative Oncology Center, has performed more than 2,000 advanced minimally invasive kidney procedures. He is dedicated to improving the techniques and technology associated with minimally invasive surgery.

Videos
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Clinical Conversations by Experts
Everyday Urology - Oncology Insights
Publications focusing on urologic cancer treatments through original manuscripts
By Ashley Baker
Published Date: March 2020

The earliest renal biopsies were obtained by open surgical techniques performed by urologists or transplant surgeons, or by pathologists at the time of autopsy. In 1951, physicians in Copenhagen published the first clinical report of percutaneous renal biopsy.1 They placed patients in a seated position and used intravenous pyelogram (IVP) as the imaging guide. Not surprisingly, both the yield and quality of biopsy tissue samples were low by contemporary standards, with only about half to two-thirds of specimens permitting histologic examination.
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By Daniel George, MD and Robert G. Uzzo, MD

Published Date: September 2018

A 62-year-old man presents with a one-week history of hematuria. Ultrasound and computed tomography identify a 7-cm exophytic anterior left renal tumor, adenopathy, and two
small lung nodules. No bone or central nervous system lesions are detected. His Eastern Cooperative Oncology Group (ECOG) performance-status (PS) and Memorial Sloan-Kettering Cancer Center (MSKCC) scores are 1. The patient asks whether to undergo cytoreductive nephrectomy. What do you tell him? 

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By Anil Kapoor, MD
Published Date: March 2018

Urologists are primed to acquire the knowledge to use targeted agents and immuno-oncologic (IO) therapies for the treatment of advanced and metastatic renal cell carcinoma (RCC). Toxicities are manageable given appropriate patient/caregiver education, on-call, and nursing support, and multi-disciplinary care with consulting specialists. 
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Library Resources
The State-of-the-Evidence in Brief Reviews by Experts
June 17, 2021
The arguments in favor of partial nephrectomy (PN) over radical nephrectomy (RN) for patients with localized renal cell carcinoma (RCC) have been diverse and compelling,1 leading many to advocate for PN whenever feasible, even for potentially aggressive tumors.2 However, some patients with tumors with increased oncologic potential and/or high complexity may not be well-served by PN, and exactly where the appropriate boundaries between PN and RN should reside remains a point of great controversy.3  Many academic urologists are naturally biased in favor of PN because they enjoy the surgical challenges inherent to the procedure, and there are many patients, such as those with preexisting chronic kidney disease (CKD), who clearly benefit from a nephron-sparing approach.4,5  From a practical standpoint, a policy of PN whenever potentially feasible encourages referral to tertiary care centers.
Written by Zachary Klaassen, MD, MSc and Christopher J.D. Wallis, MD, PhD
April 21, 2020

The rapid spread of COVID-19 has had dramatic effects throughout the world on healthcare systems with impacts far beyond the patients actually infected with the disease. Patients with severe kidney cancer must rely on data and recommendations as to who can safely defer treatment until after the pandemic is over versus those that should be treated without delay. 

Written by Zachary Klaassen, MD, MSc and Christopher J.D. Wallis, MD, PhD
March 17, 2020

Cancers of the kidney and renal pelvis comprise the sixth most common newly diagnosed tumors in men, the tenth most common in women in the United States, and account for an estimated 65,340 people new diagnoses and 14,970 cancer-related deaths in 2018 in the United States. Despite ongoing stage migration as a result of widespread use of axial abdominal imaging for non-specific abdominal complaints,

Written by Zachary Klaassen, MD, MSc and Christopher J.D. Wallis, MD, PhD
December 19, 2019
The United States (U.S.) is currently in an opioid epidemic. Although the U.S. makes up only 4% of the global population, Americans consume 80% of worldwide opioids. Data from the U.S. National Institute on Drug Abuse indicates that 21-29% of patients prescribed opioids for chronic pain misuse them, and 8-12% of patients subsequently develop an opioid use disorder.
Written by Christopher J.D. Wallis, MD PhD and Zachary Klaassen, MD MSc
November 20, 2019
Renal cancers are common, accounting for an estimated 65,340 new diagnoses and 14,970 attributable death in 2018 in the United States.1 The “Epidemiology and Etiology of Kidney Cancer” is discussed at length in the linked article in the UroToday Center of Excellence series.
Written by Zachary Klaassen, MD, MSc
December 6, 2019

With the widespread dissemination of abdominal imaging, there has been a stage migration in kidney cancer. However, this appears to have plateaued since 20071. There remains a significant proportion (~16%) of patients newly diagnosed with renal cell carcinoma who presented with advanced-stage disease and a further subset of those with localized disease are at high risk of recurrence. 

Written by Christopher J.D. Wallis, MD, PhD and Zachary Klaassen, MD, MSc
April 16, 2019
Kidney cancer is the 6th most common malignancy among men and 10th most among women.1 Renal cell carcinoma (RCC) accounts for the vast majority of these tumors.
Written by Christopher J.D. Wallis, MD, PhD
April 16, 2019
Renal cancers are common, accounting for an estimated 65,340 new diagnoses and 14,970 attributable deaths in 2018 in the United States.1 In the article, "Epidemiology and Etiology of Kidney Cancer" both topics are discussed at great length.
Written by Christopher J.D. Wallis, MD, PhD
January 29, 2019
The small size and, in benign states, almost inconspicuous appearance of the adrenals belies both their physiologic and pathophysiologic complexity. As a result of this complexity, management of adrenal disorders often requires the involvement of endocrinologists, cardiologists, nephrologists, and anesthesiologists in addition to urologists.
Written by Christopher J.D. Wallis, MD, PhD
November 20, 2018
Kidney cancer is a broad, encompassing term that borders on colloquial. While most physicians are referring to renal cell carcinoma when they say “kidney cancer”, a number of other benign and malignant lesions may similarly manifest as a renal mass.
Written by Christopher J.D. Wallis, MD, PhD
November 20, 2018
As has been highlighted in the accompanying article on the Epidemiology and Etiology of Kidney Cancer, cancers of the kidney and renal pelvis comprise the 6th most common newly diagnosed tumors in men and 10th most common in women.
Expert Commentary
The State-of-the-Evidence in Brief Reviews by Experts
Written by Bishoy M. Faltas, MD
Englander Institute for Precision Medicine, Weill Cornell Medicine
Renal cell carcinoma (RCC) accounts for approximately 2% of all cancers. The predisposing risk factors for RCC are still not well-defined. Understanding germline genetic predisposition for RCC in different ethnic groups is an area of unmet need.
Written by Zhamshid Okhunov, MD
Department of Urology, University of California, Irvine Urology
Though nephrectomy is the gold standard treatment for renal cell carcinoma, 20%-40% of patients have a recurrence and 20-30% of patients present with metastatic disease1.
Written by Zhamshid Okhunov, MD
Department of Urology, University of California, Irvine Urology
Partial nephrectomies are the standard of care with treatment of T1a or T1b tumors due to their better functional outcomes and decrease cardiovascular morbidity.
Written by Zhamshid Okhunov, MD
Department of Urology, University of California, Irvine Urology
Laparoscopic renal surgery (LRS) has long been recognized for its improvements over open renal surgery for patient quality of life.
Conference Coverage
Conference Highlights from Recent Conference Coverage
Presented by Toni K. Choueiri, MD
(UroToday.com) In conjunction with the Scientific Congress held as part of the American Society of Clinical Oncology’s (ASCO) Annual Meeting in May 2020, an Educational Symposium was convened on August 8 to 10th. In a session entitled “Too Many Choices: How to Select the Best Treatment for Your Patient With Kidney Cancer”, Toni Choueiri, MD, presented a plenary talk discussing the subsequent lines of therapy for patients with metastatic renal cell carcinoma (RCC) who have previously received immunotherapy.
Presented by Jaleh Fallah, MD
The 2020 American Society of Clinical Oncologists (ASCO) virtual education program featured a session on the evolution of renal cell carcinoma (RCC) treatment, including a presentation by Dr. Jaleh Fallah from the Cleveland Clinic discussing sequencing and combining targeted and immunotherapy. Over the last couple of years, trials have utilized combination therapy to continue improving outcomes among patients with metastatic RCC. 

 

Presented by Ashkan Malayeri, MD
(UroToday.com) The Society of Urologic Oncology held a virtual meeting on Saturday, July 18, 2020, in place of the usual meeting held at the American Urological Association annual meeting. This virtual meeting was divided into sessions on bladder cancer, kidney cancer, and prostate cancer. In the session on kidney cancer, Ashkan Malayeri, MD, presented an "Update on Emerging and Novel Imaging in Renal Cell Carcinomas (RCCs)," focusing on four areas: radiomics and radiogenomics of RCCs, machine learning and artificial intelligence.
Presented by Axel S. Merseburger, MD, PhD
The virtual EAU 2020 meeting featured a thematic session discussing immunotherapy combinations for intermediate-poor risk metastatic renal cell carcinoma (mRCC). Axel Merseburger, MD, PhD, discussed the utility of combining Immuno-Oncology (IO) treatment with TKIs.
Presented by Toni K. Choueiri, MD
Tyrosine kinase inhibitors and immune checkpoint inhibitors have become standard of care for patients with advanced renal cell carcinoma (RCC). Cabozantinib inhibits tyrosine kinases involved in tumor growth, angiogenesis, and immune regulation, including MET, VEGFR, and TAM kinases (Tyro3, AXL, MER), and may promote an immune-permissive tumor environment, resulting in enhanced response to immune checkpoint inhibitors.
Presented by Rana R. McKay, MD
Checkmate-214 established combination nivolumab/ipilimumab as an effective first-line therapy for patients with metastatic RCC1. Treatment with nivolumab/ipilimumab begins with an induction phase with 4 cycles of ipi/nivo given every 3 weeks, followed by a maintenance phase with nivolumab given every 2 weeks.
Presented by Pavlos Msaouel, MD, PhD
San Francisco, CA (UroToday.com) The incorporation of combination immunotherapy and immunotherapy/anti-angiogenic therapy combinations has changed the first-line treatment landscape
Presented by Ziad Bakouny, MD, MSc
San Francisco, CA (UroToday.com) The role for cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (RCC) was established in the cytokine era. In the current era, with more effective
Presented by Nizar M. Tannir, MD
San Francisco, CA (UroToday.com) Data from CheckMate-214 at 17.5 months of minimum follow-up led to approval of combination nivolumab/ipilimumab for first-line treatment of IMDC
Presented by Adrien Bernstein, MD
Washington, DC (UroToday.com) The second session on renal cell carcinoma at the SUO focused on the management of advanced disease. Dr. Brugarolas was invited to present data
Presented by Suzanne B. Merrill, MD
Washington, DC (UroToday.com) At the kidney cancer session at the 20th Annual Meeting of the Society for Urologic Oncology, Dr. Suzanne Merrill discussed stratified surveillance
Presented by Eoin MacCraith
Athens, Greece (UroToday.com) Dr. Eoin MacCraith continued the PET imaging session with a nice overview of the use of PET-FDG in renal cell carcinoma (RCC)
Presented by Ricardo A. Rendon, MD
Athens, Greece (UroToday.com) Dr. Ricardo Rendon presented on the adjuvant treatment of high-risk renal cell carcinoma (RCC). The cancer-specific survival (CSS)
Presented by Toni K. Choueiri, MD
Barcelona, Spain (UroToday.com) Sarcomatoid differentiation can occur in all subtypes of renal cell carcinoma (RCC) and is associated with an aggressive phenotype.
Presented by Eric Jonasch, MD
Barcelona, Spain (UroToday.com) Hypoxia-inducible factor (HIF)-2α is a transcription factor that is a key oncogenic driver in renal cell carcinoma (RCC)
Presented by Marc-Oliver Grimm, MD
Barcelona, Spain (UroToday.com) In pretreated metastatic renal cell carcinoma (RCC), single agent checkpoint blockade immunotherapy with the PD-1
Presented by Tim Q. Eisen, PhD, MB, BChir
Barcelona, Spain (UroToday.com) Four large, randomized Phase 3 clinical trials (S-TRAC, ASSURE, PROTECT, and ATLAS) evaluated adjuvant VEGF tyrosine kinase inhibitors in patients with resected renal cell carcinoma (RCC).
Presented by Chung-Han Lee, MD, PhD
Barcelona, Spain (UroToday.com) Altered glucose and glutamine metabolism is a hallmark of renal cell carcinoma (RCC). Abnormal glucose metabolism, known as the Warburg effect, deprives the citric acid cycle (TCA cycle) of critical metabolites.
Barcelona, Spain (UroToday.com) Renal tumor biopsy (RTB) for RCC, especially for small renal masses, is recommended by international guidelines if the RTB pathology will change treatment management – either favoring surveillance or ablative therapy. Yet, its usage remains relatively low and uptake is sporadic. Its accuracy is reported to be quite high
Barcelona, Spain (UroToday.com) Renal tumor biopsy (RTB) for renal cell carcinoma (RCC), especially for small renal masses, is recommended by international guidelines if the RTB pathology will change treatment management – either favoring surveillance or ablative therapy. Yet, its usage remains relatively low and uptake is sporadic. Its accuracy is reported to be quite high in more recent series but can be very institutional dependent. 
Presented by Axel Bex, MD, PhD
Barcelona, Spain (UroToday.com) The current standard for advanced localized renal cell carcinoma (RCC) is nephrectomy. Unfortunately, for better or worse, the series of adjuvant therapy
Presented by Marc-Oliver Grimm
Barcelona, Spain (UroToday.com) Dr. Marc-Oliver Grimm provided an overview of the many changes in the landscape for advanced renal cell carcinoma at the urogenital cancer treatment at a glance session. He started by highlight that the guidelines for advanced kidney cancer have been revamped recently
Barcelona, Spain (UroToday.com) In this session, Dr. Mir reviewed the role of neoadjuvant therapy in renal cell carcinoma. She reviewed the definition of neoadjuvant therapy, its rationale, how to assess response, the newest data and its future. Neoadjuvant therapy is defined as intervention given prior to primary treatment with the goal of downstaging primary tumors to possibly improve surgical intervention.
Barcelona, Spain (UroToday.com) In this session, Professor Kuczyk heeded caution regarding minimally invasive partial nephrectomy for complex surgical cases. Clinically T1b or T2 disease, endophytic or central tumors have greater risk profiles and should likely be performed at higher volume centers by high volume surgeons. Dr. Kuczyk stated that hospitals are putting pressure on surgeons to attract more business by utilizing newer technology or techniques,
Presented by Daniel Yick Chin Heng, MD, MPH
San Francisco, CA (UroToday.com) Dr. Heng's presentation focused on second- and third-line therapies for metastatic renal cell carcinoma. In order, to decide which 2nd line therapy patients should receive, there are several determinants.
Phoenix, Arizona (UroToday.com) Dr. Tannir gave a discussion on why cytoreductive nephrectomy should not be the standard of care in metastatic renal cell carcinoma (RCC). Dr. Tannir believes that cytoreductive nephrectomy is for intermediate risk patients only. In the cytokine era cytoreductive nephrectomy was shown to prolong overall survival by 6-7 months.1,2
Munich, Germany (UroToday.com) Dr. Laurence Albiges gave a talk on the challenges faced by established frontline therapies in renal cancer. In the ESMO meeting in 2017, the Checkmate 214 trial was presented, which compared sunitinib to Nivolumab + ipilimumab in the treatment of metastatic renal cell carcinoma (mRCC) patients. This trial demonstrated a benefit in favor of the nivolumab + ipilimumab 

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