Feasibility and efficacy of neoadjuvant sunitinib before nephron‐sparing surgery

Abstract

Study type – Therapy (case series) Level of Evidence 4 OBJECTIVE To investigate efficacy of neoadjuvant tyrosine kinase‐inhibitor therapy (TKI) before imperative nephron‐sparing surgery (NSS), as NSS in patients with large locally advanced or centrally located tumours can be challenging, and TKI therapy might result in a reduction of primary tumour burden and increase the feasibility of NSS. PATIENTS AND METHODS This was a multicentre retrospective review and prospective pilot study of patients undergoing neoadjuvant sunitinib before planned NSS from February 2006 to February 2009. All patients underwent confirmatory biopsy for clear cell renal cell carcinoma. Patients received two 28‐day cycles of sunitinib before NSS. Demographics/tumour characteristics, tumour response (by the Response Evaluation Criteria In Solid Tumors), outcomes and complications were analysed. RESULTS Twelve patients (seven men and five women; mean age 60.1 years, tumours on 14 renal units) were given TKI before NSS for imperative indications. The mean pretreatment tumour diameter was 7.1 cm; all patients had a decrease in size of the primary tumour after TKI, with a mean reduction in maximum diameter of 1.5 cm (21.1%). Four of 14 and 10 of 14 primary tumours had a partial response and stable disease after TKI. NSS was achievable in all 14 kidneys. Four patients had a concurrent metastasectomy. The mean warm ischaemia time was 22.5 min; postoperative dialysis was not required in any patients. Final pathology revealed negative tumour margins in all 14 tumours. The mean creatinine and estimated glomerular filtration rate (before/after NSS) were 1.34/1.40 mg/dL (P = 0.431) and 57.7/53.4 mL/min/1.73 m2 (P = 0.475), respectively. At a mean follow‐up of 23.9 months, 10 of the 12 patients were alive, one died from metastatic RCC and none required dialysis. Three of the 14 renal units developed delayed urinary leaks, all in patients who also received postoperative sunitinib. All leaks resolved with conservative measures. CONCLUSIONS Neoadjuvant TKI followed by NSS is safe and feasible, with all patients achieving a reduction in maximum tumour diameter, and with NSS being achievable with negative margins and with no requirement for postoperative dialysis. Further investigation is required.

Neoadjuvant targeted therapy in patients with renal cell carcinoma

“…У 4 (28,5 %) больных зарегистрировали частичный ответ, у остальных 10 из 12 с первичными опухолями отмечена стабилизация на фоне таргетной терапии. Всем 12 пациентам опухоли удалили, выполнив ре-зекцию почки [20].…”

“…В ито-ге 37 (70 %) пациентам из 52 выполнили нефрэктомию Таблица 1. Неоадъювантная таргетная терапия у больных ПКР [20][21][22][23][24][35][36][37][38][39][40][41][42][43] …”

Surgical management of renal cell carcinoma: Canadian Kidney Cancer Forum Consensus

“…All attempted PNs were successful with negative margins. 165 Other studies demonstrate that PN is feasible after TKI therapy, but they do not provide efficacy data to support the use of systemic therapy prior to PN. 158 Neoadjuvant therapy has been studied in patients with IVC thrombus to assess if it can downsize the thrombus and improve surgical resectability.…”

Re: Phase 2 Trial of Neoadjuvant Axitinib in Patients with Locally Advanced Nonmetastatic Clear Cell Renal Cell Carcinoma

“…In recent years, several studies [3][4][5] have investigated the use of neoadjuvant targeted therapies in nonmetastatic ccRCC, demonstrating several advantages by improving surgical resection of the tumor. This has determined a changing surgical approach from RN to partial nephrectomy [5], thus preserving cardiovascular and renal function and improving overall survival.…”