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Notes from the Eigth International Kidney Cancer Symposium

01/25/2010

We are grateful to patient advocate Katherine Phillion for sharing her notes from our fall kidney cancer meeting.

Eigth International Kidney Cancer Symposium

September 2009

Management of Small Renal Masses and Localized Renal Carcinoma

Case Presentation and Background

Robert G. Uzzo, M.D., FACS

There are a lot of options available to manage small (<4cm) tumors that are limited to the kidney

- cut it out via surgery

- ablate it via freezing (cryo) or heating (RFA)

- watch it

In selecting an approach, the surgeon’s goal is to maximize disease free survival and minimize negative side effects…Selection is often based on the surgeon’s training/comfort level with each option and his/her evaluation of the trade-offs associated with each approach. Relative to an open partial nephrectomy (Nx), there is

- increased risk of chronic kidney disease w/ a radical Nx (removal of entire kidney)

- increased complication rate w/ laparoscopic Nx (minimally invasive or small incision)

- no long term efficacy data on thermal ablation…and ability to salvage (patient advocate perspective: if it doesn’t work, next step is not clear as scarring from cryo/RFA makes subsequent surgery more difficult)

- increased patient anxiety w/ surveillance and no biomarkers or predictors of growth

To help make option selection more objective, Fox Chase Cancer Center has documented a surgeon friendly system which can be found at www.nephrometry.com

AUA small renal mass guidelines:

- cancer control is top priority

- preservation of renal function is high priority (take out part vs. all of kidney when possible)

- minimally invasive surgery is encouraged when appropriate

	Major Urologic Complication	Local recurrence-free survival
OPNx	6.3%	97.4%
LPNx	9.0%	98.4%
ORNx	1.3%	98.1%
LRNx	3.4%	99.2%

Cryo	4.9%	90.6%
RFA	6.0%	87.0%

O = Open

L = Laparascopic

* Ablation date is early w/ RFA and cryo treating smaller tumors with shorter follow-up

Chronic Kidney Disease Implications in Kidney Tumor Surgery

Paul Russo, M.D., FACS

Chronic kidney disease (CKD) is a progressive loss of kidney function over a period of months/years. CKD is

- increasing in prevalence due to increasing obesity, high blood pressure and diabetes.

- Bad as it is an independent risk factor for cardiovascular disease, hospitalization and death.

Surgeons are questioning whether over-use of radical nephrectomy is negatively impacting survival by causing CKD. Preserving renal function is important so partial nephrectomies should be considered for small renal masses as this approach is thought to be protective of kidney function.

Thermal Ablation

Jeffrey A. Cadeddu, M.D

In management of small renal masses, for the right patient partial nephrectomy is a good approach as it is nephron-sparing and provides excellent local cancer control. It is important to recognize that with a partial nephrectomy comes complications and recovery. Also, pre-surgical biopsies are important to make sure tumor is not benign…you don’t want to do an unnecessary surgery on a benign tumor.

An alternative to partial nephrectomy in the management of small renal masses is thermal ablation.

Ablation refers to a local method that destroys the tumor without removing it. Cryoablation is a freezing technique and Radio Frequency Ablation is a heating technique. Advantages of ablation relative to a partial nephrectomy are that ablation has less complications and can be done on an outpatient basis or w/ 1 day hospital stay. Disadvantages are less competitive/no long tem efficacy data on ablation and ability to salvage. Initial data suggests that RFA is similar to partial nephrectomy as a preserver of renal function. Radiographic follow-up is required. Dr. Cadeddu suggests annual imaging after the 1^st year vs. images every 6 months for active surveillance. Another advantage of ablation relative to active surveillance is that patient drop out rate from the surveillance program can be as high as 40%. It is important to have an experienced doctor perform the ablation procedure.

Active Surveillance

Michael A.S. Jewett, M.D., FRCSC, FACS

The most common presentation of renal cell carcinoma is the small renal mass (< 4 cm) which is usually detected incidentally and without metastatic disease.

Not all renal masses are kidney cancer. Biopsy is recommended to determine if tumor is benign. Twenty percent of tumors < 4 cm are benign. Belief is that the smaller the mass, the less the metastatic rate and the greater the survival. Experience is showing that small tumors initially grow at a negligible rate even if biopsy proves the tumor is renal cell carcinoma.

There is a growing body of Canadian and U.S. data that suggests active surveillance of the small renal mass with delayed treatment for progression appears to be a reasonable initial management option in selected patients (older or infirm)…this approach is not yet recommended for young and fit.

Active surveillance requires regular imaging and careful measurement of tumor size/volume. The optimal surveillance protocol is unknown. The progression trigger(s) for metastatic disease is not yet defined.

In Canadian and U.S. studies there is a notable 1.5-2% risk of progression to metastatic disease even though the renal mass is still of small size (~2.5cm) suggesting that an additional prognostic factor besides tumor size needs to be identified and monitored.

Management of Locally Advanced Kidney Cancer

Case Presentation and Background

Allan Pantuck, M.D., FACS

The TMN staging system is a common language/basis to communicate the extent of disease and assists in evaluating a treatment path. TMN stage T1 and T2 tumors are limited to the kidney. T3 and T4 tumors are locally advanced if there is lymph node disease in a single region and no distant mets.

T1 – tumor is limited to the kidney, < 4cm (1a), 4-7 cm (1b)

T2 – tumor is limited to the kidney but > 7 cm

T3a – tumor directly invades adrenal gland or fat

T3b – tumor extends into the renal vein or vena cava below the diaphragm

T3c – tumor extends into the vena cava above diaphragm or invades the vena cava wall

T4 – tumor invades beyond Gerota’s facia (the layer of tissue encapsulating the kidney)

N0 – no regional lymph node mets

N1 – mets in a single regional lymph node

N2 – mets in more than one regional lymph node

M0 – no distant mets

M1 – distant mets

Risk of disease progression/recurrence and consequently decreased survival increases with increasing TMN stage and increases with increasing tumor grade (runs from 0 to 4). For small renal masses, median survival for grade 4 tumors is only 11 months. Another factor known as the ECOG score which is a measure of a patient’s general well-being is also important in considering the risk of disease progression/recurrence. An ECOG score of 0 denotes perfect health and 5 denotes death. Directionally, patients with higher ECOG scores do not do as well as patients with lower ECOG scores.

Lymph Node Dissection

Michael L. Blute, M.D.

For patients without distant mets, 5/10 yr survival is 48/32%. Patients with distant mets have a 5 yr survival of 7%

Whether to cut out lymph nodes during a nephrectomy is controversial. The CT scan sensitivity for nodes > 1 cm is 95%...only about 42% of these nodes are disease positive.

PRO: Lymph node dissection (LND) offers

- improved staging and prognostication (a doctor's prediction about a disease path)

- improved survival in patients with confirmed advanced kidney cancer whose nodes are positive but do not have distant mets

CON: Lack of proven survival benefit studies

In the overall management of kidney cancer, he recommends:

T 1a/1b: No LND

T2-4, N0, M0: LND based on pathological features @ surgery if possible/Mayo/MSK pre-op nomogram

cT2-4, N+, M0: LND is standard of care

cTany, N+/-, M+: cytoreductive surgery then LND

Neoadjuvant Therapy for Locall Advanced Disease

Eric Jonasch, M.D.

Neoadjuvant therapy refers to systemic drug treatment given to people with cancer prior to surgery. For local control of the primary tumor, an optimal neoadjuvant therapy:

1. Is safe

2. Decreases size of primary tumor

3. Results in tumor downstaging to potentially permit resection of a technically difficult to remove tumor or allow for partial nephrectomy (ie retraction of IVC thrombus, or decreased invasion into adjacent organs).

Local control of primary tumor: summary table of neoadjuvant trials results -

Study	Patient population	# of Pts	Safe?	Primary Tumor Shrinks	Amount of Shrinkage	Down-staging?
Sorafenib (UNC/ prospective)	≥T2 RCC; sorafenib 400 mg BID x 4–8 wks prior to Nx	30	Yes	64%	11% (range, 0–40%)	Yes
Bevacizumab (+/- erlotinib) (MDACC/prospective)	RCC Pts w/mets prior to Nx; treatment x 8 wks	50	Yes	51%	***	No
Sunitinib (CCF/prospective)	‘Unresectable’ RCC	18	Yes	72%	19% (range, 1-64%)	Yes
Sunitinib (Netherlands/retrospective)	M+ pts w/ primary	17	Yes	59%	12% (range, 2-33%)
Sunitinib (CCF/retrospective)	‘Unresectable’ RCC	19	Yes	42%	24% (range, 2-46%)

Did current neoadjuvant therapy:

1. Decrease size of primary mass? YES

2. Convert complete to partial nephrectomy? IN SOME CASES

3. Result in retraction of IVC thrombus, or decreased invasion into adjacent organs? NOT TOO OFTEN.

4. Change biology of primary tumor from invasive to noninvasive. UNPROVEN

However, we need better drugs.

Conclusions on Optimal Systemic Control For High Risk Patients:

- Anti-angiogenic agents are capable of reducing primary tumors, but not consistently.

- There is no evidence that anti-angiogenic agents are anti-metastatic

- Monitoring tools/markers need to be developed that can measure efficacy of anti-metastatic drugs

As a patient advocate I point out that in the summary table of neoadjuvant trials results for local control: There is a learning curve to use these drugs safely and effectively. The current neoadjuvant therapy approaches were safe in the hands of experienced clinicians…an example is that some patients had incomplete wound healing and had to have their treatment approach altered “on the run”.”

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Emerging Applications of VEGF and mTOR-Targeted Therapy

Case Presentation and Background

Brian I. Rini, M.D.

When kidney cancer spreads in the body, it is called metastatic disease. Metastatic disease is the focus of presentations in this session. Dr. Rini presented a stage IV kidney cancer case and discussed initial treatment and follow-up options…subsequent presentations in this session of the symposium were designed to test/influence how the doctor might treat a similar patient in the future.

Standards of Care and Current Single-Agent Clinical Trials

Robert A. Figlin, M.D.

To treat kidney cancer multiple agents are available:

Agent		Route of administration	Type of Agent
Sutent®	sunitinib malate	oral	TKI
Nexavar®	sorafenib tosylate	oral	TKI
Torisel®	temsirolimus	infusion	mTOR inhibitor
Afinitor®	everolimus	oral	mTOR inhibitor
Avastin®	Bevacizumab	infusion	Monoclonal antibody	Figlin bias is Bev + IFN if go w/ this approach
Votrient®	pazopanib	oral	TKI	6th approved for kidney cancer since 2005

Dr. Figlin said

- they are starting to understand agents better and how to use them to treat the patient in front of them

- patterns of relapse are different than a decade ago and

- sequential targeted therapy is the standard of care for kidney cancer.

Current treatment strategy is to select a first line therapy based on a patient’s prognosis and select a 2^nd line therapy based on prior therapy.

Sunitinib superior to IFN-α in first-line setting (PFS, OS benefit)
Sorafenib superior to placebo in second-line setting (PFS benefit)
Bevacizumab + IFN-α superior to IFN-α alone
Temsirolimus associated with survival improvements over IFN-α, particularly in poor-risk patients
Afinitor® (everolimus) beneficial after first-line sunitinib/sorafenib

Nurses are important in managing proactively side effects w/ the patients.

New Standards for Clear Cell Kidney Cancer Therapy:

Limitations of Single Agent Targeted Therapy for metastatic kidney cancer

Few patients attain complete responses
Continued treatment appears required
Resistance usually develops in 6-12 months
Survival benefit with targeted agents:
- Sunitinib – 4.6-month survival benefit vs IFN-α1
- Sorafenib, bevacizumab, everolimus – No overall survival benefit demonstrated. As a patient I point out that survival benefit is hard to prove w/ some of the cross-over trial designs that allow the patient w/ progressive disease to receive the investigational drug however I am glad to see the patients get the drug.
- Temsirolimus – 3.5-month overall survival benefit vs IFN-α in poor-prognosis patients

I note that this information may be disappointing to you however please recognize that I am a 15 year survivor of stage IV kidney cancer…and we have 6 more treatment options than we had in 2005. New developments continue and the doctors continue to evaluate different combinations and sequences. I am reminded that more than ever, it is most important for some one with kidney cancer to get to a Center of Excellence (COE) for treating kidney cancer. The KCA can refer you to one. If not possible to have all treatment at a COE, make sure your home town Doc consults with a COE.

Strategies for overcoming RCC challenges

Combination therapy – have additional challenges of inadequate activity and/or enhanced toxicity
Sequential therapy – Several new agents showing activity

Investigational Targeted Agents in the clinical trial pipeline:

Agent	Efficacy	Route Administered	Where in pipeline?
AV951	PR 20%; SD 72% Median PFS not reached at 13 mos	oral	Phase II	Bhargava P et al. 2009 ASCO Genitourinary Cancers Symposium. A5032.
Axitinib	PR 21%; SD 34% Median PFS 7.4 mos	oral	Phase II	Rini BI et al. ASCO 2007. A5032.
Pazopanib Median PFS: All patients No prior therapy Cytokine-treated ORR: All patients No prior therapy Cytokine-treated Median OS*	Pazopanib Placebo (n=290) (n=145) 9.2 mos 4.2 mos 11.1 mos 2.8 mos 7.4 mos 4.2 mos 30% 3% 32% 4% 29% 3% 21.1 mos 18.7 mos	oral	Phase III	Sternberg CN et al. ASCO 2009. A5021. Global, randomized, double-blinded * 48% of placebo-treated patients switched to pazopanib upon progression. Survival benefit is hard to prove w/ cross-over trial design that allows the patient w/ PD to receive the investigational drug.

PR = partial response, SD = stable disease, PD = progressive disease, PFS = progression free survival, ORR = overall response rate, OS = overall survival

Intermittent Therapy with Tyrosinekinase Inhibitors

Viktor Grunwald, M.D.

TKI’s or tyrosine kinase inhibitors interfere with the reproduction of cancer cells by blocking one or more growth pathways. Different drugs target different pathways. Current approach is sequential targeted therapy or continuous administration of drugs until either toxicity or PD prevail.

Based on success in CML patients, in kidney cancer doctors are trying an intermittent therapy approach to reduce toxicity and preserve the anti-tumor effect of the drugs. They are looking for the right marker to monitor/use w/ each drug to guide drug administration as dose/administration schedule will be key to success. Dr. Grunwald believes that drug wash out can be safely applied w/in a window of several weeks. As a patient I was glad to see that he backed this belief by presenting data that suggests that TKI wash out prior to a second therapy is associated with a better response…this data will make my next wash out less stressful.

Wash Out (days)	# Patients	Overall Response Rate
>30	25	6 (24%)
<30	25	0 ( 0%)

1^st line treatment: Bevacizumab or Sorafenib

2^nd line treatment: Sunitinib

Dr.Grunwald also believes the best continuous vs.intermittent drug dosing approach will be specific to each drug.

Therapy Re-Challenge

Thomas E. Hutson, D.O., PharmD.

Dr. Hustson presented the concept of rechallenging a patient to the drug that had given him the most benefit. Idea came out of dilemma of what to do (phase I trial, treatment or hospice) after patient had done all of the available therapies and still had a good performance status. The following rechallenge experience is w/ Sunitinib in a 4^th, 5^th or 6^th line setting.

Several centers pooled their data to find a group of 23 patients who had Sunitinib as a 1^st, 2^nd or 3^rd therapy, went on to receive a variety of other treatments and subsequently were rechallenged w/ Sunitinib. Results were as follows:

- Median PFS for the group was 7 months.

- Patients who had an initial response to Sunitinib were likely to have a PR or SD w/ rechallenge.

- Best response: PR / SD / PD was 5 (22%) / 17 (75%) / 1 (4%)

- For the majority of the patients, PFS with initial Sunitinib was > PFS with rechallenge.

PFS (months)

Initial 13.7

Rechallenge 7.2

- Patients w/ > 6 months between initial Sunitinib and rechallenge had greatest response rate and PFS.

He points out that these results were in a highly select group of patients and that further studies are required. He posed the question “Does it take a certain amount of time to reset the resistance pathways so that people can respond again?” It is possible that a rechallenge benefit may not be limited to Sunitinib …and that what is important is a rechallenge w/ the drug that had given the patient the most benefit.

(PR = partial response, SD = stable disease, PD = progressive disease, PFS = progression free survival, ORR = overall response rate, OS = overall survival)

Alternative Dosing Schemas of VEGF and mTOR therapy in metastatic RCC

Toni K. Choueiri, M.D., M.S.

Dr. Choueiri presented current FDA-approved schedules for kidney cancer drugs:

- Sunitinib: 50 mg PO QD (by mouth once a day), 4 wks on / 2 wks off

- Sorafenib: 400 mg PO BID (by mouth twice daily)

- Bevacizumab: 10 mg/kg IV (intravenous) q2weeks

- Temsirolimus: 25 mg IV weekly

- Everolimus: 10 mg PO QD (by mouth once a day)

Available information on alternative dosing schedules:

Sunitinib: NO difference in taking drug in AM or PM. There are studies in progress to determine whether 4/2 vs. continuous dosing schedule is better. He underscores the importance of getting to/staying at FDA recommended dosing as patients w/ the highest Sunitinib exposure have longer time to disease progression and greater overall survival. Challenge is management of the side effects at that dosing.

Sorafenib: Data from a Dr. Robert Amato study suggests patient benefit from rapid dose escalation to 800 mg… Prospective trials comparing the standard dose and the dose escalation strategy are required

Dose escalation upon progression (600 mg PO BID, by George et al ASCO 2008)	Rapid dose escalation (600 mg bid D 29-56; 800 mg bid D 57+, by Amato et al ASCO 2007)
• 14 patients • PFS: 3.4 months • ORR: 7% • 71% pts dose escalated	• 46 patients • PFS: 8.4 months • ORR: 55%! • 93% pts dose escalated

mTOR inhibitor: it is not known if daily dosing is better. Current mTORs target mTORC1…He advocates potentially using current mTOR drugs in combination w/ future drugs that target mTORC2.

Combination Therapy: Exisiting Data and Ongoing Clinical Trials

Keith Flaherty, M.D.

Dr. Flaherty focused his talk on clear cell RCC and targeted agents (not cytokines). Goal of combining agents is to find complete responses and improve overall survival. However, have to be careful in trial designs as synergy can play out in toxicity as well as efficacy. He reviewed early combination trials and several in progress. Toxicity has been a challenge…in combination, have not been able to get patients to full therapeutic doses of the individual drugs. Favorable results have been seen in Sorafenib w/ Bevacizumab: 52% response (48 patients: 25PR, 18SD, 4PD, 41 w/ tumor decrease), 14 month median PFS. The hope is that newer more potent drugs may be able to achieve these results individually. Not all combinations are equally promising…Bevacizumab w/ erlotinib is an example of one that did not pan out.

Abstract Presentation: Phase II trial of continuous once-daily dosing of sunitinib as first-line treatment in patients with metastatic renal cell carcinoma (mRCC)

Sun Y. Rha, M.D

120 patients were enrolled in this study to evaluate one year of continuous once daily dosing of 37.5 mg of sunitinib. Only 35% were able to stay on the continuous dosing for the planned one year of treatment. 65% discontinued the treatment due to side effects. 116 were evaluable for tumor response…Results should be available soon.

Prediction of Response and Toxicity in Metastatic RCC

Overview of Prognostic / Predictive Markers in Metastatic RCC

Robert J. Motzer, M.D.

Prognosis is a medical term to describe the likely outcome of a disease. Treatment for kidney cancer has changed over the last decade however the same factors that predict the aggressiveness of kidney cancer are valid for cytokine, chemo and targeted therapy. These factors include:

- Performance status

- Whether a nephrectomy has been done

- Extent/Sites of metastatic disease

- Various Biochemical parameters

No factor is an independent predictor of survival all of the time.

Prognostic factors not only are a tool for predicting patient outcome but they can also aid in individualizing patient treatment. Dr. Escudier looked at the Bevacizumab data and interpreted that patients who benefit most are the favorable and intermediate risk group and not so much the poor risk group.

For Temsirolimus, eligibility into the clinical trials was poor prognosis factors to determine if poor risk patients would benefit from the treatment…as a result we know that poor risk patients do benefit from this therapy. Now Temsirolimus is the standard of care for poor risk patients.

Doctors are also looking for molecular factors that may predict outcome. The best example is CAIX for IL-2 which was developed by Dr. Atkins’ group.

Dr. Motzer said, “The goal is to identify molecular features that predict the likelihood that a patient will respond to a therapy based on tumor biology. Then integrate the molecular predictive info with the clinical data to drive new drug development, clinical trials and therapy.”