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Vasudev N.S.,Clinical Research Fellow | Larkin J.M.G.,Renal Cancer Unit
Clinical Medicine Insights: Oncology | Year: 2011

Advances in our understanding of renal cancer biology have led to a new treatment paradigm in renal cancer. Tyrosine kinase inhibitors (TKI), that target the intracellular kinase domain of the VEGF receptor, have become established as the most successful class of agent in this disease. Three TKIs are currently approved for use in patients with advanced disease. Newer, more potent inhibitors have reached phase III clinical testing, meaning others are likely to follow. In 2009, pazopanib became the most recent TKI to receive FDA approval. This review sets out to discuss the key opportunities and challenges associated with TKI use in RCC, focusing particularly on pazopanib. We also review the current place of pazopanib in the management of patients with advanced disease, in what is a rapidly evolving therapeutic landscape. © the author(s), publisher and licensee Libertas Academica Ltd. Source


Bex A.,Netherlands Cancer Institute | Larkin J.,Renal Cancer Unit | Blank C.,Netherlands Cancer Institute
Current Oncology Reports | Year: 2011

Treatment for patients with metastatic non-clear cell renal cancer (RCC), who constitute 25% of all RCC patients, is largely undefined and tested algorithms remain unsatisfactory. Response rates to targeted therapy are not as high as in patients with clear cell subtypes, but novel agents provide a clinically meaningful response in some individuals. The research leading to characterization of the pathways involved in clear cell renal cancer has been recognized as a role model for the development of therapies based on genetic and molecular tumor characteristics. Similar research now provides increasing insight into signal transduction in non-clear cell subtypes. This review will present and discuss the current evidence of pathways involved in the most common non-clear cell subtypes. In addition, we will review how this may lead to the development of new treatment modalities. New targets and clinical trials will be highlighted. © 2011 Springer Science+Business Media, LLC. Source


Stewart G.D.,University of Edinburgh | Stewart G.D.,Scottish Collaboration On Translational Research into Renal Cell Cancer SCOTRRCC | Stewart G.D.,University of Cambridge | Powles T.,Renal Cancer Unit | And 14 more authors.
Oncotarget | Year: 2016

Background: Genetic intratumoral heterogeneity (ITH) hinders biomarker development in metastatic clear cell renal cancer (mccRCC). Epigenetic relative to genetic ITH or the presence of consistent epigenetic changes following targeted therapy in mccRCC have not been evaluated. The aim of this study was to determine methylome/genetic ITH and to evaluate specific epigenetic and genetic changes associated with sunitinib therapy. Patients and methods: Multi-region DNA sampling performed on sequential frozen pairs of primary tumor tissue from 14 metastatic ccRCC patients, in the Upfront Sunitinib (SU011248) Therapy Followed by Surgery in Patients with Metastatic Renal Cancer: a Pilot Phase II Study (SuMR; ClinicalTrials.gov identifier: NCT01024205), at presentation (biopsy) and after 3-cycles of 50mg sunitinib (nephrectomy). Untreated biopsy and nephrectomy samples before and after renal artery ligation were controls. Ion Proton sequencing of 48 key ccRCC genes, and MethylCap-seq DNA methylation analysis was performed, data was analysed using the statistical computing environment R. Results: Unsupervised hierarchical clustering revealed complete methylome clustering of biopsy and three nephrectomy samples for each patient (14/14 patients). For mutational status, untreated biopsy and all treated nephrectomy samples clustered together in 8/13 (61.5%) patients. The only methylation target significantly altered following sunitinib therapy was VHL promoter region 7896829 which was hypermethylated with treatment (FDR=0.077, P<0.001) and consistent for all patients (pre-treatment 50% patients had VHL mutations, 14% patients VHL hypermethylation). Renal artery ligation did not affect this result. No significant differences in driver or private mutation count was found with sunitinib treatment. Conclusions: Demonstration of relative methylome homogeneity and consistent VHL hypermethylation, after sunitinib, may overcome the hurdle of ITH present at other molecular levels for biomarker research. Source


Stewart G.D.,University of Edinburgh | Stewart G.D.,Scottish Collaboration On Translational Research into Renal Cell Cancer SCOTRRCC | O'Mahony F.C.,University of Edinburgh | O'Mahony F.C.,Scottish Collaboration On Translational Research into Renal Cell Cancer SCOTRRCC | And 23 more authors.
Clinical Cancer Research | Year: 2015

Purpose: The aim of this study was to investigate the effect of VEGF-targeted therapy (sunitinib) on molecular intratumoral heterogeneity (ITH) in metastatic clear cell renal cancer (mccRCC). Experimental Design: Multiple tumor samples (n = 187 samples) were taken from the primary renal tumors of patients with mccRCC who were sunitinib treated (n = 23, SuMR clinical trial) or untreated (n = 23, SCOTRRCC study). ITH of pathologic grade, DNA (aCGH), mRNA (Illumina Beadarray) and candidate proteins (reverse phase protein array) were evaluated using unsupervised and supervised analyses (driver mutations, hypoxia, and stromal-related genes). ITH was analyzed using intratumoral protein variance distributions and distribution of individual patient aCGH and gene-expression clustering. Results: Tumor grade heterogeneity was greater in treated compared with untreated tumors (P = 0.002). In unsupervised analysis, sunitinib therapy was not associated with increased ITH in DNA or mRNA. However, there was an increase in ITH for the driver mutation gene signature (DNA and mRNA) as well as increasing variability of protein expression with treatment (P < 0.05). Despite this variability, significant chromosomal and transcript changes to key targets of sunitinib, such as VHL, PBRM1, and CAIX, occurred in the treated samples. Conclusions: These findings suggest that sunitinib treatment has significant effects on the expression and ITH of key tumor and treatment specific genes/proteins in mccRCC. The results, based on primary tumor analysis, do not support the hypothesis that resistant clones are selected and predominate following targeted therapy. © 2015 AACR. Source


Bex A.,Netherlands Cancer Institute | Gore M.,Renal Cancer Unit | Mulders P.,Radboud University Nijmegen | Sternberg C.N.,San Camillo and Forlanini Hospitals
BJU International | Year: 2012

What's known on the subject? and What does the study add? With recent improvements in the prognosis for patients with metastatic renal cell carcinoma (mRCC), focus is now shifting towards maximising clinical benefit from targeted therapies. Factors other than efficacy data are increasingly being considered when selecting a treatment strategy, with a view towards optimising clinical outcomes. This review examines the development and efficacy of targeted agents for the management of mRCC and discusses the potential factors, including resistance mechanisms, sequential therapy, prognostic and predictive markers of response, and adverse event management, that may contribute to successful individually tallored treatment of patients with this disease. Targeted agents have substantially improved outcomes for patients with metastatic renal cell carcinoma (mRCC). Treatment focus is now shifting towards achieving a continuum of care such that long-term benefit and extended survival may be achieved through the optimal use of targeted agents. To achieve this goal, a number of factors which impact on treatment selection and outcomes need to be considered when treating patients with mRCC, such as the optimal sequence of targeted therapies (and the related issue of resistance mechanisms). Recent advances are also likely to impact on the future treatment of mRCC. Examples include the identification of predictive biomarkers as well as a consideration of patient risk profiles or the safety profile of the selected targeted agent. In addition, attention is focusing on re-defining the role of surgery for the treatment of RCC in the context of targeted therapies. This review examines the recent and future advances that offer the potential for personalizing treatment by selecting the most appropriate treatment for each patient with a view towards optimizing clinical outcomes. © 2012 BJU International. Source

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