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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
Pembrolizumab in Combination with Lenvatinib as First-Line Treatment for Non Clear Cell Renal Cell Carcinoma (nccRCC), KEYNOTE-B61 - Laurence Albiges
The Upcoming 2022 European International Kidney Cancer Symposium - Samra Turajlic
Overcoming Misinformation in the Diagnosis and Treatment of Kidney Cancer for Patients and Caregivers - Dena Battle
Surgical Simulator for Laparoscopic Partial Nephrectomy for Renal Cell Carcinoma - Gonzalo Vitagliano
The PDIGREE Trial - Define Rational Sequencing in Combination Treatment of mRCC - Tian Zhang
Effect of 3-Dimensional Virtual Reality Models for Surgical Planning of Robotic-Assisted Partial Nephrectomy on Surgical Outcomes - Ketan Badani
PDIGREE: An adaptive phase III trial of PD-inhibitor Nivolumab and Ipilimumab (IPI-NIVO) with VEGF TKI Cabozantinib (CABO) in Metastatic Untreated RCC (Alliance A031704). -Tian Zhang
Kidney Cancer Patient Survey Findings: Impacts from the COVID-19 Pandemic - Dena Battle
Superfluous Hospital Expenditure Associated with Unnecessary Renal Cyst Surveillance - Lee Ponsky & Laura Bukavina
The Use of Active Surveillance in Metastatic Kidney Disease - Jaime Landman and Monty Pal
First-line Immuno-Oncology Combination Therapies in Metastatic Renal-cell Carcinoma: Results from the International Metastatic RCC Database Consortium - Shaan Dudani
First-line Therapy Options for Metastatic Renal Cell Carcinoma - Tian Zhang
The Role of Cytoreductive Nephrectomy in Patients with Metastatic Renal Cell Carcinoma - Neeraj Agarwal, MD
The Dynamic Landscape of mRCC and the PDIGREE Trial - Tian Zhang
Newly Approved Treatment Options for the Management of Metastatic Kidney Cancer- Lauren Harshman and Toni Choueiri
Advances of Systemic Treatments in Renal Cell Carcinoma - Jens Bedke
Targeted Therapies with Immunotherapies In Kidney Cancer - Thomas Powles
Office-based, Ultrasound-Guided Renal Mass Biopsy: Technique and Results - Jaime Landman
Rapidly Evolving Landscape in Metastatic Renal Cell Carcinoma- Rana McKay
Frontline Data from Keynote 426 - Sandy Srinivas
Paradigm Changing Data for Kidney Cancer - Primo Lara
Patient Advocacy and Resources in Kidney Cancer - Dena Battle
Perspectives on the Evolution in Treating Kidney Cancer- Monty Pal and Jaime Landman
Treatment Strategies in Kidney Cancer and the Results of CARMENA - Toni Choueiri
Physician-Scientist Review Articles
State of the Evidence Review Articles
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,
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.
Physician-Scientist Commentaries
State of the Evidence Review Articles
Written by Pietro Diana, Tobias Klatte, Daniele Amparore, et al.
The incidence of renal cell carcinoma (RCC) is increasing, with over 430.000 new cases diagnosed per year and over 175.000 new deaths per year in 2020 worldwide.1 Although most RCCs are diagnosed at an early stage in asymptomatic patients2 and up to 25% present with metastasis showing a 1-year and 5-year survival of 39% and 12%.3
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 Written by Physician-Scientist
Presented by Robert J. Motzer, MD
On Sunday, September 11, 2022, in Presidential Symposium II at the ESMO Annual Congress, Dr. Motzer presented highly awaited results from the CheckMate 914 trial, examining the role of adjuvant nivolumab and ipilimumab in patients treated with nephrectomy for localized renal cell carcinoma at a high risk of relapse.
Presented by Thomas B. Powles, MBBS, MRCP, MD
The 2022 ESMO annual meeting featured a kidney cancer session, including a discussant presentation by Dr. Tom Powles discussing two key abstracts including “IMmotion010: efficacy and safety from the Phase III study of atezolizumab vs placebo as adjuvant therapy in patients with renal cell carcinoma (RCC) at increased risk of recurrence after resection” presented by Dr. Axel Bex, and “Phase III RandOmized Study Comparing PErioperative Nivolumab versus Observation in Patients with RCC Undergoing Nephrectomy (PROSPER, ECOG-ACRIN EA8143), a National Clinical Trials Network trial” presented by Dr. Mohamad Allaf.
Presented by Steven Campbell, MD, PhD
The 2022 Annual Meeting of the American Urological Association was host to an AUA guidelines update session focused on renal masses, presented by Dr. Steven Campbell, MD, PhD.
Presented by Costas Lallas MD, Brian Lane MD, Michigan State University, Lee Ponsky MD, Jaime Landman MD
Friday morning at the 2022 AUA kicked off with a panel discussion consisting of thought leaders in the management of incidentally found 3cm solid renal masses. Dr. Costas Lallas, MD moderated the session which began with four-minute presentations from each panelist.
Presented by David Braun, MD, PhD
During the 2022 International Kidney Cancer Symposium (IKCS): Europe meeting focusing on biomarker discovery in renal cell carcinoma (RCC), Dr. David Braun discussed the potential of single-cell RNA sequencing to facilitate biomarker discovery. In doing so, he emphasized how single-cell RNA sequencing can improve our understanding of the underlying biology of RCC, with important implications for both biomarker discovery and therapeutics.
Presented by Samra Turajlic, PhD, MBBS, MRCP
In the tenth session of the 2022 International Kidney Cancer Symposium (IKCS): Europe meeting focusing on biomarker discovery in renal cell carcinoma (RCC), Dr. Samra Turajlic presented on the value of T cell receptor (TCR)-related metrics for understanding and predicting the response of immune checkpoint inhibition in clear cell renal cell carcinoma.
Presented by Sam S. Chang, MD, MBA
The SIU 2021 annual meeting included a plenary session with the AUA lecture provided by Dr. Sam Chang discussing the 2021 AUA Guideline for renal masses and localized cancer, specifically evaluation, management, and follow-up.
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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