Personalized approach to systemic therapy of renal cancer

ABSTRACT

Introduction: Multiple studies have recently reported promising results in the treatment of renal cancer (RCC), so its clinical management is currently undergoing a paradigm shift. Optimal sequencing of the agents showing efficacy and specific criteria for selection of therapies are yet to be prospectively defined.

Areas covered: The review aims to address the recent developments in the clinical management of RCC and the incorporation of clinical factors and biomarkers in customizing therapeutic decisions. A literature search was conducted to review the therapeutic trials in RCC that have led to changes in practice and paradigms.

Expert opinion: The validated biomarkers are based on clinical criteria. The impact of nephrectomy in metastatic RCC management is minimal and systemic therapy should take priority. The next randomized trial is proposing to address the question whether cytoreductive nephrectomy will enhance efficacy in the contemporary immunotherapy era. Besides surgical resection of oligometastatic disease, non-invasive local therapies such as cryoablation, radiofrequency ablation, and stereotactic brachytherapy radiation should be incorporated into the management plan for selected patients. Retrospective studies provide limited guidance regarding the role of genomic biomarkers in predicting therapeutic efficacy. This paper summarizes the recent updates in the management of kidney cancer and provides guidance to personalizing therapy in RCC.

KEYWORDS:

• Kidney cancer
• BAP-1
• PBRM-1
• angiogenesis
• programmed death
• immune checkpoint
• tyrosine kinase inhibitors

Article highlights

• Therapy of RCC is undergoing a paradigm shift

• Systemic therapy should take priority in synchronous metastatic RCC management

• Antiangiogenic and immune checkpoint inhibition are the main mechanisms of therapy

• Local therapies such as surgery, cryoablation or stereotactic radiation should be considered in oligometastatic disease

• Ipilimumab and nivolumab combination demonstrated remarkable efficacy in sarcomatoid RCC.

• Genomic biomarkers need prospective validation in future studies

Declaration of interest

U Vaishampayan has received research support, consulting fees and honoraria from Bristol Myers Squibb, Exelixis, Pfizer and Bayer Inc. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosure

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded