38 Kidney Cancer Journal
T A B L E O F C O N T E N T S
CARMENA Trial: Will It Reset the Paradigm
on Initial Cytoreductive Nephrectomy in
Targeted Therapy Era?
ocation, location, location.” Anyone in the market
looking at real estate is likely to hear this mantralike
advice. But what if you had a patient with
metastatic renal cell carcinoma (mRCC) staring at the
prospect of initial cytoreductive nephrectomy or initial
targeted therapy as options. As a medical oncologist or
urologist evaluating this case in the targeted therapy era,
you should be accustomed to following what might be
another mantra—“selection, selection, selection.” Yes,
cytoreductive nephrectomy is the preferred standard in selected patients.
And yet, targeted therapy may be the appropriate choice for other patients.
In any case, the selection of patients plays a critical role in day-to-day
patient care as well as in clinical trial design.
The Plenary Session at the 2018 meeting of the American Society of
Clinical Oncology (ASCO) is likely to have a lasting and significant impact
on the management of mRCC. For those of us who have closely followed
the debate over the initial use of CN in the targeted therapy era, then
“selection, selection, selection” of appropriate candidates for each modality
should be the buzz words guiding the decision making process. But one
can argue that this has always been true. Guidelines from the National
Comprehensive Cancer Network (NCCN) and other groups have touted the
importance of careful selection of patients undergoing nephrectomy on the
basis of published risk models such as the Memorial Sloan-Kettering Cancer
Center (MSKCC) paradigm. At the Plenary Session, there were four studies
deemed to have the greatest potential impact on patient care out of the
more than 5,800 abstracts featured as part of the 2018 ASCO Annual
Meeting. One of these studies is the CARMENA (Cancer du Rein Metastatique
Nephrectomie et Antiangiogeniques) trial.
A comprehensive report on CN in the targeted therapy era is presented
in this issue of the Kidney Cancer Journal by my esteemed colleague, Michael
Blute, MD, who has analyzed virtually all of the current studies leading
up to CARMENA. Like other presentations at ASCO over the years, the
CARMENA trial is a striking phenomenon, debunking myths and in some
cases shattering preconceptions of long standing standards of care. Is it
pivotal? Probably. Can it markedly change the paradigm as a so-called
Editorial Mission
The purpose of Kidney Cancer Journal is to serve as a comprehensive
resource of information for physicians regarding
advances in the diagnosis and treatment of renal cell carcinoma.
Content of the journal focuses on the impact of translational
research in oncology and urology and also provides a forum for
cancer patient advocacy. Kidney Cancer Journal is circulated to
medical oncologists, hematologist-oncologists, and urologists.
Editor-in-Chief
Robert A. Figlin, MD, FACP
Steven Spielberg Family Chair in Hematology Oncology
Professor of Medicine and Biomedical Sciences
Director, Division of Hematology Oncology
Deputy Director, Samuel Oschin Comprehensive
Cancer Institute
Cedars-Sinai Medical Center
Los Angeles, California
Medical Advisory Board
Michael B. Atkins, MD
Deputy Director
Lombardi Comprehensive Cancer Center
Professor of Oncology and Medicine,
Georgetown University Medical Center
Washington, DC
Ronald M. Bukowski, MD
Emeritus Staff & Consultant
CCF Taussig Cancer Center
Professor of Medicine
CCF Lerner College of Medicine of CWRU
Cleveland, Ohio
Robert J. Motzer, MD
Attending Physician
Memorial Sloan-Kettering
Cancer Center
New York, NY
Christopher G. Wood, MD, FACS
Douglas E. Johnson, MD Professorship
Professor & Deputy Chairman
Department of Urology
M.D. Anderson Cancer Center
Houston, Texas
Nurse Advisory Board
Nancy Moldawer, RN, MSN
Nursing Director
Cedars-Sinai Medical Center
Samuel Oschin Comprehensive Cancer Institute
Los Angeles, California
Laura Wood, RN, MSN, OCN
Renal Cancer Research Coordinator
Cleveland Clinic Taussig Cancer Center
Cleveland, Ohio
Patient Advocate
William P. Bro
Chief Executive Officer
Kidney Cancer Association
Publishing Staff
Stu Chapman, Executive Editor
Jenny Chapman, Director, Business Development
Gloria Catalano, Production Director
Michael McClain, Design Director
Business and Administration Office
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Editorial Offices
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© Copyright 2018 Genitourinary Publishing. All rights reserved.
None of the contents may be reproduced in any form without the
permission of the publisher.
About the Cover
Possible mechanisms underlying immune-related adverse events,
potentially related to use of checkpoint inhibitors, are depicted.
These include increasing T-cell activity against antigens in tumors,
elevated levels of preexisting autoantibodies, rising level of inflammatory
cytokines, and enhanced inflammation due to binding of
anti-CTLA-4 antibody with CTLA-4 on normal tissue. (Reprinted
with permsission of New England Journal of Medicine and Michael
A. Postow, MD).
40 Journal Club
41 Medical Intelligence
42 Optimizing Benefit and Limiting Immune-Related Adverse Effects
Following Checkpoint Inhibitor Blockade
50 ASCO 2018: Highlights From the Meeting Through the Lens of a
Key Opinion Leader
54 Controversies and Consensus Surrounding Initial Cytoreductive
Nephrectomy vs Targeted Therapy: What Is the Optimal Approach?
E D I TOR ’ S M E M O
(continued on page 63)
Robert A. Figlin, MD
“L