EMUC15: Systemic treatment for metastatic kidney cancer

New drug combinations, side-effects of systemic therapy and prospects in the management of renal cell carcinoma were taken up in the second plenary session of the 7th European Multidisciplinary Meeting on Urological Cancers (EMUC15) with experts weighing in the pros and cons of radical or systemic therapies.

With Prof. Alessandro Volpe (IT) as moderator, an eight-member panel of experts from medical oncology, urology, radiation oncology and pathology discussed several clinical cases involving metastatic renal cell carcinoma (mRCC) and the prospects of drug combinations that may provide survival benefit or delay disease progression.

Issues such as biopsy, cytoreductive nephrectomy, bone metastasis, targeted agents and imaging techniques, among other topics, were examined with the audience interactively voting for their preferred management approaches.

Among the topics that cropped up during the discussion was the accuracy of renal biopsy, with the panelists noting that assessment of biopsy accuracy is limited since most studies are retrospective and single institutional. Moreover, the studied populations are different or mixed (from patients with small renal masses to those with metastatic disease) and there is a lack of the ideal reference standard in many cases.

On the role of cytoreductive nephrectomy (CR), the panel experts also discussed that CR therapy is applicable to large (symptomatic) tumours, and that there is a limited number and volume of metastatic disease. CR is also suitable to favorable/intermediate risk group and for selected patients without liver and brain metastasis.

Regarding bone metastasis, between 20% to 30% of patients have overt metastasis at diagnosis (median survival 20 months, 5-year survival 30%). Up to 35% of RCC patients will develop bone metastases (BMs) during disease progression. These BMs may result in severe bone pain and debilitating skeletal complications.

In targeted therapies, the discussion focused on current guidelines with sunitinib, bevacizumab and pazopanib as standard recommendations in the first-line and for patients with good or intermediate risks. For poor-risk patients, temsirolimusis is a standard recommendation in the first-line with either sunitinib or sorafenib as options.

Medical oncologists and panelist L. Albiges also noted emerging therapeutic combinations such those included in the studies Checkmate214 and IMmotion151 which involve a combination of several drugs such as Nivolumab and Ipilimumab (Checkmate) and MPDL3280A plua Bevacizumab (IMmotion). Both studies are in Phase 3.