Genomics will play a crucial role in the coming years in managing locally advanced kidney cancer, but the entry of new drugs also carry with it several challenges such as the issue of drug resistance and the role of emerging medical alternatives.
“Although VEGF and mTOR inhibitors are still the backbone of renal cell carcinoma (RCC) treatment, new treatments are coming,” said Dr. Bernard Escudier (FR). He, however, cautioned that challenges are around the corner with regards to the issue of drug resistance.
“Understanding and overcoming resistance is a major challenge and drugs to overcome resistance are needed,” he added. Escudier spoke in the afternoon session of the 6th European Multidisciplinary Meeting on Urological Cancers (EMUC) in Lisbon, Portugal, which tackled during the session on kidney cancer topics such as chemotherapy, extent of surgical procedures, prospects in genetic markers and new drugs in the pipeline, with the latter presented by Escudier.
In his overview lecture, Escudier listed several drugs being eyed as the next generation in the fight against kidney cancer which is the 13th most deadly cancer worldwide. Kidney cancer, although comparatively rare and accounts for only 4% of all adult malignancies in industrialized countries, kills many since 3 in 10 patients present with metastasis at the time of diagnosis. With a 25% mortality rate, it is the most malignant of urological tumours.
“There are several categories with regards to new drugs and these are drugs targeting the VEGR/mTOR pathway, those aimed to overcome resistance, drugs for new targets and immunotherapy,” said Escudier, mentioning the entry of so-called inhibitor drugs such as nintedanib, linifanib and cediranib, which are currently in phase 3 studies and with efficacies that are still unclear.
Drugs in development, meanwhile, includes AZD-8055, Buparlisib, MK-2206, GDC-0980/BEZ-235 and perifosine, which are either in phase 1 or 2 studies. Regarding immunotherapy he mentioned PD-1 blockade as a strategy for cancer immunotherapy, which experts consider a promising option in the coming years.
“New targets are arising, cMET being the most advanced one; and targeted immunotherapy is very promising, but when and how are the questions,” noted Escudier in his concluding remarks.
Meanwhile, Michael Blute (USA) spoke on defining the optimal extent of surgery and gave an comprehensive overview on the value-added role of lymph node dissection (LND) in the diagnosis, prognosis and oncologic control of renal cancer.
“Lymphadenectomy improves survival with renal cancer and nodal metastasis,” said Blute as he referred to studies that showed benefits of LND. “There is no increased risk…and careful retrospective studies suggest benefit beyond staging for high-risk patients.”
He added that accurate risk stratification tools are available to identify high-risk cases, and there is emerging data on retroperitoneal template for high-risk disease. For T1a and T1b disease no LND is recommended while for T2 to T4 disease (N0,M0) LND is based on pathological features.
Peter Fries (DE) discussed the various imaging for kidney cancer such as CT and MRI techniques. “CT is still an accurate and robust imaging modality for concise local or whole body staging in RCC,” he said while noting that tools like PET-CT has limits in local tumour staging, although it might help in monitoring distant metastases
“Contrast-Enhanced Ultrasound and fast MRI techniques are beneficial in unclear cases and potentially new monitoring techniques in patients with anti-angiogenetic therapy,” Fries added.