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Molecular Biomarkers of Prognosis in Advanced Renal Cell Carcinoma Patients Treated With Pazopanib Plus Interferon Alpha (INF-2A) in a Phase I/II Study by the Spanish Oncology Genitourinary Group

Published:March 17, 2022DOI:https://doi.org/10.1016/j.clgc.2022.03.008

      Abstract

      Introduction

      The therapeutic repertoire available for advanced renal cell carcinoma (RCC), including tyrosine kinase inhibitors (TKIs) and immunotherapy, required for molecular biomarkers for response.

      Patients and Methods

      This was a phase I to II trial on the combination of pazopanib with interferon-alpha (INF-2A) as first-line treatment for advanced RCC. The primary endpoint was recommended phase II dose (RP2D) and efficacy in terms of objective response rate (ORR, RECIST 1.1 criteria). Secondary endpoints included safety and a translational study of molecular biomarkers in serum and exosomes from peripheral blood samples at three-time points: baseline, 8 weeks of treatment, and progression of the disease.

      Results

      Between July 2011 and July 2017, 53 eligible patients were treated and followed up (I, n = 20; II, n = 33). Pazopanib 800 mg + INF-2A 3 MIUs showed a manageable safety profile; therefore, it was selected for dose expansion. Overall, grade 3/4 toxicities were reported in 24 (72.7%) patients. The ORR was 27.2%. The 12-month OS rate was 83.6% (median not reached), and after 30.9 months of follow-up, 24 (72.7%) patients were still alive. CCL2, IL8, TNF-α, and PD-L1 were significantly overexpressed after treatment initiation, while TGF-β1 and CCL5 were significantly decreased. TNF-α, endoglin, and PD-L1 expression are correlated with the response after treatment initiation.

      Conclusion

      The trial did not reach its pre-specified target ORR. However, OS was longer than expected with pazopanib monotherapy. Changes in the molecular profile suggest a crucial role of vascular remodeling and inflammatory-mediated immune cell infiltration in optimal response to pazopanib plus INF-2A.

      Keywords

      Abbreviations:

      ccRCC (Clear cell renal cell carcinoma), CI (Confidence intervals), CR (Complete response), DFS (Disease-free survival), DLT (Dose limiting toxicities), MTD (Maximum tolerated dose), PR (Partial response), RD (Recommended dose)

      Introduction

      Renal cell carcinoma (RCC) accounts for 90 to 95% of all renal cancers and approximately 3% of adult malignancies.
      • Siegel RL
      • Miller KD
      • Jemal A.
      Cancer statistics, 2019. CA.
      • Papale M
      • Vocino G
      • Lucarelli G
      • et al.
      Urinary RKIP/p-RKIP is a potential diagnostic and prognostic marker of clear cell renal cell carcinoma.
      Up to one-third of the patients are diagnosed when RCC has already spread (advanced RCC); the historical 5-year survival rate of RCC is low (< 10%).
      • Fisher R
      • Gore M
      • Larkin J.
      Current and future systemic treatments for renal cell carcinoma.
      • Climent MA
      • Muñoz-Langa J
      • Basterretxea-Badiola L
      • Santander-Lobera C.
      Systematic review and survival meta-analysis of real world evidence on first-line pazopanib for metastatic renal cell carcinoma.
      • Vachhani P
      • George S.
      VEGF inhibitors in renal cell carcinoma.
      • Howlader N
      • Noone N
      • Krapcho K
      • et al.
      SEER Cancer Statistics Review, 1975-2018.
      Multi-target inhibitors of receptors with tyrosine kinase activity (TKI); vascular endothelial growth factor (VEGF) and its receptor (VEGFR) have long been administered as first-line treatment for metastatic RCC (mRCC), including pazopanib.
      • Escudier B
      • Pluzanska A
      • Koralewski P
      • et al.
      Bevacizumab plus interferon alfa-2a for treatment of metastatic renal cell carcinoma: a randomised, double-blind phase III trial.
      • Motzer RJ
      • Hutson TE
      • Tomczak P
      • et al.
      Sunitinib versus Interferon Alfa in Metastatic Renal-Cell Carcinoma.
      • Sternberg CN
      • Davis ID
      • Mardiak J
      • et al.
      Pazopanib in locally advanced or metastatic renal cell carcinoma: results of a randomized phase III trial.
      • Motzer RJ
      • Escudier B
      • Powles T
      • et al.
      Long-term follow-up of overall survival for cabozantinib versus everolimus in advanced renal cell carcinoma.
      Immune checkpoint blockers (ICBs) have also improved treatment responses and survival substantially, leading to approval of the nivolumab and ipilimumab combination.
      • Motzer RJ
      • Tykodi SS
      • Escudier B
      • et al.
      Final analysis of the CheckMate 025 trial comparing nivolumab (NIVO) versus everolimus (EVE) with >5 years of follow-up in patients with advanced renal cell carcinoma (aRCC).
      ,
      • Tannir NM
      • McDermott DF
      • Escudier B
      • et al.
      Overall survival and independent review of response in CheckMate 214 with 42-month follow-up: First-line nivolumab + ipilimumab (N+I) versus sunitinib (S) in patients (pts) with advanced renal cell carcinoma (aRCC).
      To overcome treatment resistance, several trials have explored the combination of TKIs and ICBs to exploit the overlapping role of VEGFR and the immune system. In fact, in RCC the HIF-1α/VEGF axis promotes an immunosuppressive microenvironment that allows the formation of blood vessels and irrigation of tumors in response to hypoxia.
      • Bracarda S
      • Porta C
      • Sabbatini R
      • Rivoltini L.
      Angiogenic and immunological pathways in metastatic renal cell carcinoma: A counteracting paradigm or two faces of the same medal? The GIANUS review.
      Pembrolizumab-axitinib, avelumab-axitinib, and nivolumab-cabozantinib combinations have demonstrated improved survival, and tolerable safety profiles, which have led to the approval of the combinations in the first-line setting for mRCC.
      • Powles T
      • Plimack ER
      • Soulières D
      • et al.
      Pembrolizumab plus axitinib versus sunitinib monotherapy as first-line treatment of advanced renal cell carcinoma (KEYNOTE-426): extended follow-up from a randomised, open-label, phase 3 trial.
      • Motzer RJ
      • Penkov K
      • Haanen J
      • et al.
      Avelumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      • Choueiri TK
      • Powles T
      • Burotto M
      • et al.
      Nivolumab plus Cabozantinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      By the time of design of this trial, the combination of pazopanib with new immunotherapy checkpoint inhibitors (CPIs) was hypothesized as a possibly effective strategy to enhance antitumor activity in advanced RCC. The trial has as primary objective the tolerability of the combination in a dose-escalation phase followed by an expansion phase to address preliminary efficacy, with objective response rate (ORR) as a primary endpoint. Here we report the efficacy, safety, of pazopanib and IFN-2A and focus on the secondary prespecified exploratory assessment of the prognostic value of a subset of molecular biomarkers in a population of RCC patients treated with the proposed combination as a first-line in the context of a clinical trial.
      Identification of predictive factors of efficacy, and prognosis are essential for the optimization of treatment assignment and further development of therapeutic strategies. Translational retrospective studies have defined numerous factors that could predict single-agent therapies in RCC. VEGFR expression is correlated with response to anti-angiogenic agents such as Sunitinib,
      • You D
      • Song SH
      • Cho YM
      • et al.
      Predictive role of tissue-based molecular markers in patients treated with sunitinib for metastatic renal cell carcinoma.
      ,
      • Lee CH
      • Motzer RJ
      • Glen H
      • et al.
      Correlative serum biomarker analyses in the phase 2 trial of lenvatinib-plus-everolimus in patients with metastatic renal cell carcinoma.
      whereas immunity-related genes, such as high IL6 expression levels are correlated with PFS in RCC patients treated with pazopanib.
      • Tran HT
      • Liu Y
      • Zurita AJ
      • et al.
      Prognostic or predictive plasma cytokines and angiogenic factors for patients treated with pazopanib for metastatic renal-cell cancer: a retrospective analysis of phase 2 and phase 3 trials.
      Conversely, PD-L1 status has been described as a non-relevant predictive biomarker for mRCC.
      • Motzer RJ
      • Penkov K
      • Haanen J
      • et al.
      Avelumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      ,
      • Rini BI
      • Plimack ER
      • Stus V
      • et al.
      Pembrolizumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      • Motzer RJ
      • Rini BI
      • McDermott DF
      • et al.
      Nivolumab plus ipilimumab versus sunitinib in first-line treatment for advanced renal cell carcinoma: extended follow-up of efficacy and safety results from a randomised, controlled, phase 3 trial.
      • Motzer RJ
      • Choueiri TK
      • McDermott DF
      • et al.
      Biomarker analyses from the phase III CheckMate 214 trial of nivolumab plus ipilimumab (N+I) or sunitinib (S) in advanced renal cell carcinoma (aRCC).
      Several studies have defined combined scores for the expression of molecular biomarkers as prognostic of efficacy and survival, with no single gene associations but rather an implication of angiogenesis and inflammation-related molecular pathways.
      • Harmon CS
      • Deprimo SE
      • Figlin RA
      • et al.
      Circulating proteins as potential biomarkers of sunitinib and interferon-α efficacy in treatment-naïve patients with metastatic renal cell carcinoma.
      ,
      • Motzer RJ
      • Hutson TE
      • Hudes GR
      • et al.
      Investigation of novel circulating proteins, germ line single-nucleotide polymorphisms, and molecular tumor markers as potential efficacy biomarkers of first-line sunitinib therapy for advanced renal cell carcinoma.
      For example, the combined signature for TIMP-1, M-CSF, IL-18BP, ANG-2, and VEGF correlates with survival in mRCC patients treated with lenvatinib plus everolimus.
      • Lee CH
      • Motzer RJ
      • Glen H
      • et al.
      Correlative serum biomarker analyses in the phase 2 trial of lenvatinib-plus-everolimus in patients with metastatic renal cell carcinoma.
      The use of molecular signatures has facilitated the identification of biological pathways relevant for treatment response and prognosis. For instance, angiogenesis plays an important role in response to VEGFR TKIs monotherapy; however, surprisingly, there was no association with prognosis when ICBs were co-administered.
      • Motzer RJ
      • Robbins PB
      • Powles T
      • et al.
      Avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma: biomarker analysis of the phase 3 JAVELIN Renal 101 trial.
      ,
      • McDermott DF
      • Huseni MA
      • Atkins MB
      • et al.
      Clinical activity and molecular correlates of response to atezolizumab alone or in combination with bevacizumab versus sunitinib in renal cell carcinoma.
      Few prospective trials have addressed the potential prognosis of molecular biomarkers in mRCC treated with TKI and ICB combinations,
      • Motzer RJ
      • Robbins PB
      • Powles T
      • et al.
      Avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma: biomarker analysis of the phase 3 JAVELIN Renal 101 trial.
      ,
      • McDermott DF
      • Huseni MA
      • Atkins MB
      • et al.
      Clinical activity and molecular correlates of response to atezolizumab alone or in combination with bevacizumab versus sunitinib in renal cell carcinoma.
      so that further studies are required.

      Material and Methods

      Study Design and Patient Selection

      This was a multicenter, open-label, single-arm clinical phase I/II trial (EudraCT 2010-020950-32) that included a translational study of serum biomarkers conducted at 10 hospitals in Spain. The study was performed in 2 stages given the novelty of the regimen proposed at the time of study design. The first stage (Phase I design; dose escalation) consisted of a preliminary safety and efficacy analysis of the combination of a daily oral dose of pazopanib plus subcutaneous INF-2A, 3 times per week. In the first stage, patients were recruited for 5 dose levels following a 3+3 scheme. Five dose levels (DL) were defined with increasing doses of Pazopanib and INF-2A (DL1: 400/3 million units (MIUs); DL2 600/3MIUs; DL3800/3 MIUs; DL4 800/6MIUs/;DL5 800/9MIUs). Continuation of treatment was conditioned by the presence of Dose Limiting Toxicities (DLTs). In case only one of the three patients showed a DLT, 3 or more patients were included at that dose level; on the contrary if DLT was observed in the first two patients included for a specific dose level, that dose was considered too toxic and no further patients were treated at that dose. Patients with RCC or other types of primary tumors were included in this phase. Continuous safety monitoring during phase I was performed by an independent expert committee of oncologists and in agreement with the site investigators, who were periodically provided the safety information.
      In the second phase (Phase II design, dose expansion), we evaluated the effectiveness of the combination at the selected dose in patients who were diagnosed with locally advanced RCC (unresectable or metastatic) without prior treatment. Patients should have ≥ 18 years, ECOG 0 to 1, adequate hematological, liver and kidney function, any gastrointestinal abnormalities that could affect the administration of the study treatment, and any medical or psychiatric condition that could interfere with the study procedures. The primary endpoint was ORR according to RECIST 1.1 criteria and was evaluated through computed axial tomography (CT) or magnetic resonance imaging (MRI) every eight weeks until the progression of disease (PD). Safety was evaluated in terms of the frequency, type, and severity of adverse events (AEs) throughout the study period (CTCAE version 4.0), while efficacy secondary endpoints included progression-free survival (PFS), and overall survival (OS).
      Simon's optimal two-stage design was used under the assumptions of a 20% undesirable response rate (null hypothesis), and a 40% target response rate (5% type 1 error rate, and 80% power). Eighteen eligible and evaluable subjects were required for the efficacy analysis. Based on the first stage of Simon's design, 4 patients were reported as responders [complete response (CR) or partial response (PR)] to proceed for the second stage. At the end of the second stage (N = 33), at least 10 responders were required for further studies. To be evaluable for efficacy, a subject had to meet the eligibility criteria and receive at least two treatment cycles (1 cycle = 28 days). Safety population was defined as any patient with at least one treatment dose.
      All patients provided written informed consent. This study was conducted in accordance with the principles of the Declaration of Helsinki and local applicable regulations. An institutional ethics committee for clinical research evaluated and approved the study (EudraCT: 2010-020950-32).

      Molecular Biomarkers

      Potential prognostic value for efficacy and emergence of treatment resistance of specific biomarkers including TGF-Beta, CXCL12, CCL2, CXCL5, CXCL2, IL-8, MIF, S100A9, TNF-alfa, ENDOGLIN, and PDL1 were assessed from blood samples taken from patients from the second phase at 3 time points throughout the study: day 0 (baseline or before experimental treatment), day 1 (first CT scan reevaluation; ie, first eight weeks after the experimental treatment initiation) and day 2 (PD or end of treatment). The biomarkers were selected based on the treatment mechanism of action and previous reports on prognostic molecular biomarkers for mRCC.
      • You D
      • Song SH
      • Cho YM
      • et al.
      Predictive role of tissue-based molecular markers in patients treated with sunitinib for metastatic renal cell carcinoma.
      • Lee CH
      • Motzer RJ
      • Glen H
      • et al.
      Correlative serum biomarker analyses in the phase 2 trial of lenvatinib-plus-everolimus in patients with metastatic renal cell carcinoma.
      • Tran HT
      • Liu Y
      • Zurita AJ
      • et al.
      Prognostic or predictive plasma cytokines and angiogenic factors for patients treated with pazopanib for metastatic renal-cell cancer: a retrospective analysis of phase 2 and phase 3 trials.
      ,
      • Harmon CS
      • Deprimo SE
      • Figlin RA
      • et al.
      Circulating proteins as potential biomarkers of sunitinib and interferon-α efficacy in treatment-naïve patients with metastatic renal cell carcinoma.
      ,
      • Motzer RJ
      • Hutson TE
      • Hudes GR
      • et al.
      Investigation of novel circulating proteins, germ line single-nucleotide polymorphisms, and molecular tumor markers as potential efficacy biomarkers of first-line sunitinib therapy for advanced renal cell carcinoma.
      Biomarkers were determined in serum and microvesicles. Microvesicles were obtained using Exoquick (System Biosciences, Mountain View, CA, USA). The quantification of CCL2, CXCL2, CXCL5, IL-8, CXCL12, MIF, S100A9, TNF-alpha, endoglin, PD-L1 was performed using a custom magnetic bead-based Luminex assay (R&D Systems, MN, USA) using Luminex 200 analyzer (Luminex xMAP Technology, Luminex, Austin, TX, USA). TGF-beta quantification was performed using a Human TGF-β1 Quantikine ELISA (R&D Systems).

      Statistics

      Descriptive statistics were used to characterize patients. Continuous variables are presented as the mean and standard deviation, and the median (range). The results of categorical variables are presented as frequency and 95% two-sided confidence intervals for estimates. The follow-up was measured for each patient as the time elapsed between initiation of study treatment and last contact date and date of death, whichever occurs later. Median Follow up was the median value of all patients. The PFS and OS were estimated using the Kaplan–Meier method. The biomarker expression was analyzed following a general linear model (GLM, to analyze the effects of the intra-patient factors (time, time of the interaction, and responders/long-responders) and inter-patients patients (responders / long-responders) on biomarker values. Normality of biomarker distributions was assessed and statistical parametric (t test) and non-parametric (Man-Whitney) tests were used as indicated. Data reported here represent those in the study database created on October 23, 2014. All analyses were performed using SPSS, 22.0 (IBM Corp, Armonk, NY, USA) and R (x64 v3.5.1 for Windows, https://cran.r-project.org).

      Results

      From July 2011 through April 2013, 20 patients were included to initiate protocol therapy in the phase I stage (Table S1 and S2). Three patients with DLT were reported, and all of the cases were liver-related (level 2 = 1 Grade 4 transaminitis; level 4 = 1 G3 transaminitis and 1 G3 subhepatic hematoma). The RP2D corresponded to pazopanib 800 mg daily + INF-2A 3 MIUs 3 times per week (Figure 1). Subsequently, 42 locally advanced/metastatic RCC patients were screened between February 2014 and December 2015, and 33 eligible patients were included in the study. All 33 were considered evaluable (75.8% were males). The median age at inclusion was 59.3 (37.7-74.8) years (Table 1).
      Figure 1
      Figure 1Patients flowchart through phase I and phase II. AE = Adverse Event; IFN-2A = Interferon-2; MIU = Million International Units; PI = Principal Investigator Mg = milligrams.
      Table 1General Demographic and Clinical Characteristics at Baseline in Advanced RCC Patients
      Expansion Phase (II)
      GenderMale25 (75.8%)
      Female8 (24.2%)
      Mean (range) age at inclusion59.3 (37.7-74.8)
      ECOG PS022 (66.7%)
      111 (33.3%)
      Heng prognosisIntermediate22 (66.7%)
      Good11 (33.3%)
      Histological diagnosisccRCC locally advanced27 (81.8%)
      ccRCC unresectable4 (12.1%)
      Other types
      1 patient with papillary tube type I + ccRCC and 1 patient with localized and resectable ccRCC.
      2 (6.1%)
      Histological grade11 (3,0)
      28 (24,2)
      314 (42.4%)
      42 (6.1%)
      Unknown8 (24.2%)
      Metastases location
      For the escalation phase, percentages are calculated based on the total number of patients with metastases (n = 5); for the expansion phase these have been calculated for the total number of patients (n = 33). In both cases, one patient could be reported with more than one location.
      Lung and/or thorax23 (69.7%)
      Bone15 (45.5%)
      Kidney9 (27.3%)
      Lymphatic nodes7 (21.2%)
      Adrenal gland6 (18.2%)
      Intestine and/or peritoneum5 (15.2%)
      Pancreas5 (15.2%)
      Liver4 (12.1%)
      Soft tissue4 (12.1%)
      Previous nephrectomyNo3 (9.1%)
      Yes30 (90.9%)
      29 patients with previous surgical treatment and 1 patient with palliative radiotherapy.
      Abbreviations: ccRCC = clear cell renal cell carcinoma; ECOG PS= Eastern Cooperative Oncology Group Performance status; RCC = Renal cell carcinoma.
      a 1 patient with papillary tube type I + ccRCC and 1 patient with localized and resectable ccRCC.
      b For the escalation phase, percentages are calculated based on the total number of patients with metastases (n = 5); for the expansion phase these have been calculated for the total number of patients (n = 33). In both cases, one patient could be reported with more than one location.
      c 29 patients with previous surgical treatment and 1 patient with palliative radiotherapy.
      Twenty-nine patients finished treatment per-protocol (Figure 1), and at the end of the study, 2 patients remained on therapy (Table S3).

      Efficacy

      Overall, the ORR was 27.2% and the disease control rate (DCR) was 91.1%, with 1 (3%) patients achieving a CR, 8 (24.2%) a PR, and 22 (66.7%) of the patients had stable disease (SD). The median duration of response was 16.3 (5.8-26.2) months. After a median follow-up of 30.9 months (range: 3.7-41.2), the median PFS was 12.7 (0.9–32.4) months and progression events were reported in 20 patients (PD = 18; death = 2) (Figure 2A). The median OS was not reached, with 12 monthly OS rate of 83.6% (95% CI: 70.4-96.8) (Figure 2B). At the end of the follow-up, 24 patients (72.7%) were still alive. PD was the cause of death in 8 patients, and one patient died due to renal necrosis.
      Figure 2 (
      Figure 2(A) Progression-free survival and. (B) Overall survival for advanced RCC patients (phase II).

      Molecular Prognostic Biomarkers

      For those patients of expansion phase (RCC patients), the trial included an exploratory study of molecular biomarkers from peripheral blood samples, including gene expression of the relevant tumor, angiogenesis, and immune response mediators. The evolution of the expression levels of blood molecular biomarkers was assessed at 3 time points: before treatment initiation, after 8 weeks of treatment exposure, and once PD was confirmed. Peripheral blood samples were available for 21 (63.6%), 14 (42.4%), and 10 (30.3%) patients for each time point, respectively. A total of 11 biomarkers (CCL2, CXCL2, CXCL5, IL-8, CXCL12, MIF, S100A9, TNF-α, endoglin, PD-L1, and TGF-β1) were assessed in blood serum and exosomes. Overall, there were statistically significant increases in CCL2, IL8, TNF-α, and PD-L1 serum expression levels at 8 weeks after the start of the experimental treatment (Figure 3). Conversely, TGF-β1 and CCL5 serum expression levels decreased significantly at 8 weeks after the start of the experimental treatment (Figure 3). S100A9 expression in exosomes decreased significantly, with a similar but not significant trend in serum (Figure 3).
      Figure 3
      Figure 3Molecular biomarker expression profiles. Box plot representing the median (inner line), 25% and 75% quartiles (Box) and CI (cap line) for the expression of each marker. Patients were stratified as: non-responders (blue) or responders (CR/PR)/long responders (PFS >18 months) (orange both).
      Stratified analysis of the biomarker expression levels revealed no statistically significant differences between responder patients (CR/PR) or long-term responders (PFS >18 months) and non-responders at baseline. After 8 weeks of treatment, the expression levels of TNF-α in serum, endoglin in exosomes, and PD-L1 in both sample types were significantly more elevated in responders/long-term survivors when compared to non-responders (P value .003, 0.02, .011, and .003 respectively) (Figure 3). However, these differences were not observed by the time of PD (Figure 3). No significant differences were observed between responders/long-responders and non-responders in biomarker evolution from baseline to PD in the GLM analysis.

      Safety

      All patients reported at least one AE and at least one treatment-related AE (TRAE). The most frequent TRAEs throughout the study period were fatigue (90.9%), diarrhea (57.6%), and anorexia (57.6%) (Table 2). Grade ≥ 3 TRAEs were reported at least once in 24 (72.7%) patients, being the most frequent: hypertension (21.2%), fatigue (15.2%), and mucositis (12.1%). Treatment-related SAEs (19 events) were also reported in 11 (33.3%) patients, including 3 cardiovascular events, 2 liver-related events and 2 febrile events (Table 2). No treatment-related deaths were reported.
      Table 2Summary of Safety Relevant Findings During Expansion Phase
      Expansion Phase
      Any gradeGrade 3/4
      Treatment related AEsa33 (100.0%)24 (75.8%)
      Fatigue30 (90.9%)5 (15.2%)
      Anorexia19 (57.6%)1 (3.0%)
      Diarrhea19 (57.6%)3 (9.1%)
      Hypertension16 (48.5%)7 (21.2%)
      Mucositis11 (33.3%)4 (12.1%)
      Nausea11 (33.3%)-
      Fever10 (30.3%)1 (3.0%)
      Arthralgia8 (24.2%)-
      Hair color changes7 (21.2%)-
      Vomiting7 (21.2%)1 (3.0%)
      Dysgeusia6 (18.2%)-
      Palmar-plantar erythrodysesthesia6 (18.2%)-
      Rash6 (18.2%)1 (3.0%)
      Laboratory treatment-related AEs
      Increased transaminases7 (21.2%)3 (9.1%)
      Platelet count decrease5 (15.2%)1 (3.0%)
      Neutrophil count decreased4 (12.1%)4 (12.1%)
      Hypophosphatemia2 (6.1%)-
      White blood cell count decreased2 (6.1%)-
      Increased lipase1 (3.0%)-
      Increased serum amylase1 (3.0%)2 (6.1%)
      Hypertriglyceridemia1 (3.0%)-
      Proteinuria1 (3.0%)-
      Treatment-related SAEs11 (33.3%)10 (30.3%)
      Cardiovascular events
      Including 1 G3 transient ischemic attack, 2 G4 thromboembolic events.
      -3 (9.1)
      Liver disorder/hepatotoxicity-2 (6.1)
      Skin/mucosa-related events
      Including 1 G3 eczema and 1 G3 mucositis.
      -2 (6.1)
      Fever1 (3.0%)1 (3.0%)
      Reversible posterior leukoencephalopathy syndrome-1 (3.0%)
      Acute kidney injury-1 (3.0%)
      Neutrophil count decreased-1 (3.0%)
      Abbreviations: AEs = Adverse events; SAE = Serious adverse events.
      aPercentages are calculated based on number of patients exposed to treatment and completing at least one treatment dose.
      b Including 1 G3 transient ischemic attack, 2 G4 thromboembolic events.
      c Including 1 G3 eczema and 1 G3 mucositis.

      Discussion

      Currently, there are multiple treatment options from which mRCC patients and their oncologists can choose. Efficacy of both sunitinib and pazopanib has been confirmed in real-world evidence studies, with a favorable quality-of-life and cost-effective profiles reported.
      • Climent MA
      • Muñoz-Langa J
      • Basterretxea-Badiola L
      • Santander-Lobera C.
      Systematic review and survival meta-analysis of real world evidence on first-line pazopanib for metastatic renal cell carcinoma.
      ,
      • Iacovelli R
      • Verzoni E
      • De Braud F
      • Procopio G.
      First line treatment of metastatic renal cell carcinoma: two standards with different toxicity profile.
      • Beaumont JL
      • Salsman JM
      • Diaz J
      • et al.
      Quality-adjusted time without symptoms or toxicity analysis of pazopanib versus sunitinib in patients with renal cell carcinoma.
      • Amdahl J
      • Diaz J
      • Sharma A
      • et al.
      Cost-effectiveness of pazopanib versus sunitinib for metastatic renal cell carcinoma in the United Kingdom.
      • Villa G
      • Hernández-Pastor LJ.
      Budget impact analysis of first-line treatment with pazopanib for advanced renal cell carcinoma in Spain.
      These two TKIs have long been the most commonly used treatments for good- and intermediate-risk mRCC patients. The combination of ICBs (ie, nivolumab and ipilimumab) or the combination of ICBs with TKIs, such as axitinib or cabozantinib, achieved considerably improved efficacy and have become the standard of care for first-line treatment of high-risk mRCC patients.
      • Tannir NM
      • McDermott DF
      • Escudier B
      • et al.
      Overall survival and independent review of response in CheckMate 214 with 42-month follow-up: First-line nivolumab + ipilimumab (N+I) versus sunitinib (S) in patients (pts) with advanced renal cell carcinoma (aRCC).
      ,
      • Powles T
      • Plimack ER
      • Soulières D
      • et al.
      Pembrolizumab plus axitinib versus sunitinib monotherapy as first-line treatment of advanced renal cell carcinoma (KEYNOTE-426): extended follow-up from a randomised, open-label, phase 3 trial.
      • Motzer RJ
      • Penkov K
      • Haanen J
      • et al.
      Avelumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      • Choueiri TK
      • Powles T
      • Burotto M
      • et al.
      Nivolumab plus Cabozantinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      Head-to-head comparisons of efficacy have been proposed in a number of meta-analyses and reviews, suggesting that clinical decisions may be personalized based on factors such as toxicity profiles, administration route, patient comorbidities, and financial considerations.
      • Unverzagt S
      • Moldenhauer I
      • Nothacker M
      • et al.
      Immunotherapy for metastatic renal cell carcinoma.
      ,
      • Rousseau B
      • Kempf E
      • Desamericq G
      • et al.
      First-line antiangiogenics for metastatic renal cell carcinoma: A systematic review and network meta-analysis.
      In such a context, the determination of predictive factors is essential for the optimal treatment assignment.
      In our cohort, the molecular analysis did not identify any biomarker whose expression levels could be used at baseline as a prognosis factor for treatment efficacy. However, the stratified analysis revealed a significant positive correlation between the inflammatory cytokine TNF-α, the hypoxia-inducible TGF-β1 regulator Endoglin, the immune system suppressor PD-L1, and treatment response and efficacy (ie, CR/PR or PFS >18 months) at eight weeks. TNF-α is a pro-inflammatory factor that also targets the tumor-associated vasculature (TAV) by inducing hyperpermeability and destruction of the vascular lining.
      • van Horssen R
      • ten Hagen TLM
      • Eggermont AMM.
      TNF-α in cancer treatment: molecular insights, antitumor effects, and clinical utility.
      In sum the upregulation of Endoglin and the general downregulation observed in TGF-β1 expression suggest angiogenesis disruption at 8 weeks post-treatment initiation in the responders, as expected with VEGFR inhibitors. In fact, upregulation of pro-angiogenic pathways at baseline has been previously described as a predictive factor for the efficacy of TKIs such as sunitinib in mRCC, confirming the role of angiogenesis in tumor growth and prognosis in such a setting.
      • Motzer RJ
      • Robbins PB
      • Powles T
      • et al.
      Avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma: biomarker analysis of the phase 3 JAVELIN Renal 101 trial.
      ,
      • McDermott DF
      • Huseni MA
      • Atkins MB
      • et al.
      Clinical activity and molecular correlates of response to atezolizumab alone or in combination with bevacizumab versus sunitinib in renal cell carcinoma.
      ,
      • Voss MH
      • Kuo F
      • Chen D
      • et al.
      Integrated biomarker analysis for 412 renal cell cancer (RCC) patients (pts) treated on the phase 3 COMPARZ trial: Correlating common mutation events in PBRM1 and BAP1 with angiogenesis expression signatures and outcomes on tyrosine kinase inhibitor (TKI) therapy.
      However, angiogenesis molecular signatures tested in prospective trials were not correlated with response or prognosis for TKIs and ICBs combinations.
      • Motzer RJ
      • Robbins PB
      • Powles T
      • et al.
      Avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma: biomarker analysis of the phase 3 JAVELIN Renal 101 trial.
      ,
      • McDermott DF
      • Huseni MA
      • Atkins MB
      • et al.
      Clinical activity and molecular correlates of response to atezolizumab alone or in combination with bevacizumab versus sunitinib in renal cell carcinoma.
      A reduction in TGF-β1 expression has also been linked to decreased proliferative and metastatic potential in RCC.
      • Liu Y
      • Shang D.
      Transforming growth factor-β1 enhances proliferative and metastatic potential by up-regulating lymphoid enhancer-binding factor 1/integrin αMβ2 in human renal cell carcinoma.
      Moreover, the inflammatory mediators CCL2, IL8, and S100A9 were upregulated after eight weeks of pazopanib and INF-2A combination independent of treatment outcome. CCL2 is an important chemokine that promotes monocyte, macrophage, and T cell infiltration within the tumor microenvironment, which may be an indicator of better prognosis. However the role of CCL2 expression in RCC has been controversial; on the one hand, correlating with the worst prognosis and RCC recurrence,
      • Yang Y
      • Zhai C
      • Chang Y
      • et al.
      High expression of chemokine CCL2 is associated with recurrence after surgery in clear-cell renal cell carcinoma.
      and on the other hand, promoting cancer cell ER-stress mediated apoptosis in cell models.
      • Taubert H
      • Eckstein M
      • Epple E
      • et al.
      Immune Cell-associated protein expression helps to predict survival in muscle-invasive urothelial bladder cancer patients after radical cystectomy and optional adjuvant chemotherapy.
      Overall, these findings highlight the role of vascular remodeling and inflammatory-mediated immune cell infiltration in the achievement of an optimal response with the proposed treatment combination. Such involvement of angiogenesis differs from those reported in previous studies.
      • Motzer RJ
      • Robbins PB
      • Powles T
      • et al.
      Avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma: biomarker analysis of the phase 3 JAVELIN Renal 101 trial.
      ,
      • McDermott DF
      • Huseni MA
      • Atkins MB
      • et al.
      Clinical activity and molecular correlates of response to atezolizumab alone or in combination with bevacizumab versus sunitinib in renal cell carcinoma.
      Inflammation and activation of either innate or adaptive immune responses seem to have prognostic value for TKI and ICB combinations, despite the exact underlying mechanism remaining unclear.
      • Motzer RJ
      • Robbins PB
      • Powles T
      • et al.
      Avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma: biomarker analysis of the phase 3 JAVELIN Renal 101 trial.
      ,
      • McDermott DF
      • Huseni MA
      • Atkins MB
      • et al.
      Clinical activity and molecular correlates of response to atezolizumab alone or in combination with bevacizumab versus sunitinib in renal cell carcinoma.
      Moreover, PD-L1 expression and tumor mutational burden did not differentiate prognosis in mRCC patients receiving the combination treatment, limiting the application of these biomarkers in mRCC.
      • Rini BI
      • Plimack ER
      • Stus V
      • et al.
      Pembrolizumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      • Motzer RJ
      • Rini BI
      • McDermott DF
      • et al.
      Nivolumab plus ipilimumab versus sunitinib in first-line treatment for advanced renal cell carcinoma: extended follow-up of efficacy and safety results from a randomised, controlled, phase 3 trial.
      • Motzer RJ
      • Choueiri TK
      • McDermott DF
      • et al.
      Biomarker analyses from the phase III CheckMate 214 trial of nivolumab plus ipilimumab (N+I) or sunitinib (S) in advanced renal cell carcinoma (aRCC).
      This highlights the complex role of the immune system in mRCC and promotes further research to identify the key immune pathways and players involved in treatment responsiveness.
      Our prospective data showed a significant increase in TNF-α in responders and a consecutive decrease at PD that suggests potential use as a blood biomarker for early detection of lack of efficacy and progression. After PD, PD-L1 overexpression, especially in responders, and downregulation of TGF-β1, which has been linked to an immune-active profile,
      • Taubert H
      • Eckstein M
      • Epple E
      • et al.
      Immune Cell-associated protein expression helps to predict survival in muscle-invasive urothelial bladder cancer patients after radical cystectomy and optional adjuvant chemotherapy.
      suggest the use of immune checkpoint blockade therapy plus a TGF-β inhibitor as a subsequent line of treatment.
      The limited number of patients and samples available for the molecular analysis was the major limitation of our trial. In addition, the low number of pre-specified molecular biomarkers to be investigated in our trial may have limited the potential determination of prognostic signatures in response to TKI and immunotherapy in mRCC and more comprehensive studies will be required to confirm our findings.
      Regarding the feasibility of our therapeutic approach, the cytokines IL-2 and INF-2A alone or in combination with 5-fluorouracil were the common alternatives for systemic immune-mediated therapy of mRCC until the emergence of biologic agents. Therefore, our trial is a potential precursor of the combination of VEGFR inhibitors and ICBs that are currently considered standard of care for high-risk mRCC. Response to pazopanib plus INF-2A was consistent with the findings of previous studies with single-agent pazopanib, but the ORR was lower compared to those reported for TKI and ICB combinations.
      • Sternberg CN
      • Davis ID
      • Mardiak J
      • et al.
      Pazopanib in locally advanced or metastatic renal cell carcinoma: results of a randomized phase III trial.
      ,
      • Powles T
      • Plimack ER
      • Soulières D
      • et al.
      Pembrolizumab plus axitinib versus sunitinib monotherapy as first-line treatment of advanced renal cell carcinoma (KEYNOTE-426): extended follow-up from a randomised, open-label, phase 3 trial.
      • Motzer RJ
      • Penkov K
      • Haanen J
      • et al.
      Avelumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      • Choueiri TK
      • Powles T
      • Burotto M
      • et al.
      Nivolumab plus Cabozantinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      Our trial did not reach its pre-specified target ORR. The observed ORR of 27.2% was closer to the initial null hypothesis (20%). Nevertheless, the OS in our trial reached a 12-month rate of 83.6%, and 72.7% of patients remained alive after 30.9 months of follow-up, which was longer than that expected with TKI monotherapy and was in the range of that reported in recent phase III trials of combination.
      • Tannir NM
      • McDermott DF
      • Escudier B
      • et al.
      Overall survival and independent review of response in CheckMate 214 with 42-month follow-up: First-line nivolumab + ipilimumab (N+I) versus sunitinib (S) in patients (pts) with advanced renal cell carcinoma (aRCC).
      ,
      • Powles T
      • Plimack ER
      • Soulières D
      • et al.
      Pembrolizumab plus axitinib versus sunitinib monotherapy as first-line treatment of advanced renal cell carcinoma (KEYNOTE-426): extended follow-up from a randomised, open-label, phase 3 trial.
      ,
      • Choueiri TK
      • Powles T
      • Burotto M
      • et al.
      Nivolumab plus Cabozantinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
      The rate of events of special interests such as hypertension, platelet count decrease, or liver-related issues were not higher than those reported previously.
      • Sternberg CN
      • Davis ID
      • Mardiak J
      • et al.
      Pazopanib in locally advanced or metastatic renal cell carcinoma: results of a randomized phase III trial.
      ,
      • Powles T
      • Bracarda S
      • Chen M
      • et al.
      Characterisation of liver chemistry abnormalities associated with pazopanib monotherapy: a systematic review and meta-analysis of clinical trials in advanced cancer patients.
      Furthermore, most of them were low grades and they were resolved within protocol recommendations. Despite a tolerable safety profile and promising efficacy, the combination has been clearly surpassed by the approved TKI and ICB combinations, which seem more active and are, in general terms, better tolerated than INF-2A.

      Conclusions

      In conclusion, the combination of VEGFR inhibitors and immunotherapy is an active approach for the treatment of RCC; however there is still a need for prognostic markers that optimize treatment assignment. Our study identified vascular remodeling and inflammation as potential key drivers to achieve optimal response to pazopanib plus INF-2A in advanced RCC. Further research on molecular biomarkers of prognosis and early detection of treatment resistance would be required to facilitate the design of the optimal sequential therapeutic strategy and optimal treatment assignment.

      Clinical Practice Points

      • What is already known about this subject?
      Recently, dual combination of immunotherapy with immune checkpoint inhibitors (ICIs) plus vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs) have led to a significant overall survival advantage (OS) in mRCC; however there is a lack of prognostic markers to facilitate optimal therapeutic assignment.
      • What are the new findings?
      Pazopanib and INF-2A are safe and provide an acceptable efficacy that seems to correlate with vascular remodeling and inflammatory response.
      • How might it impact on clinical practice in the foreseeable future?
      SOGUG 2010 trial positions pazopanib as a potential TKI for combination with ICIs in future clinical trials. We provide insights on potential molecular determinants of response to TKI and immunotherapy combinations in advanced RCC.

      Author Contributions

      Study conceptualization, supervision, project administration, validation, writing, review and editing of the current manuscript: Dr. Xavier García del Muro.
      Manuscript review and editing and investigation: Dr. Xavier García del Muro, Dr. Ignacio Durán, Dr. Jose Luis Perez-Gracia, Dr. Miguel Ángel Climent, Dr. Begoña Mellado, Dr. Juan A. Virizuela, Dr. Daniel E. Castellano, Dr. Aranzazu González del Alba, Dr. Iciar Carbonero, Dr. Carlos Álvarez-Fernández, Dr. Jesús García-Donas, Dr. Marta Gil-Martin, Dr. Alvaro González Hernández.

      Disclosure

      This work was supported by GSK/Novartis through a collaborative grant to the sponsor. The sponsor, the Spanish Oncology Genitourinary Group, was involved in the design of the study, the collection, analysis, and interpretation of data as well as final approval of the manuscript. Medical writing assistance and statistical analyses were provided by Pau Doñate Ph.D. and Jordi Curto MSc, respectively (MFAR Clinical Research S.L, Barcelona) and funded by the sponsor.
      Dr. Climent received honoraria from BMS, Astellas, Janssen, MSD, Sanofi, Bayer, Roche, Pfizer, Novartis, and Ipsen; had an advisory role for BMS, MSD, Bayer, EUNSA, Pfizer, Roche, Janssen, Pierre Fabre, and Ipsen; and received travel and accommodation expenses from Janssen, Astellas, Roche, Ipsen, MSD. Dr. Perez-Gracia received research grants and support from Roche, BMS, MSD, and Seattle Genetics; participated in speakers bureau and advisory boards for Roche, BMS, Ipsen, MSD, and Seattle Genetics; and received travel support from Roche, MSD, and BMS. Dr. Álverez-Fernandez had an advisory role for AstraZeneca, Pfizer, Boehringer Ingelheim, and Roche; and received travel and accommodation expenses from Roche, Pfizer, and Astellas Pharma. All other co-authors declare to have no conflict of interest. Dr. Gil-Martin declares Nothing to disclose related to this job; Speaking honoraria have been received from Roche, Astra Zeneca, Pharmamar; Registration and attending scientific meetings from Roche, Pharmamar, MSD, Clovis, GSK.

      Acknowledgments

      The authors thank all participating sites.

      Appendix. Supplementary materials

      References

        • Siegel RL
        • Miller KD
        • Jemal A.
        Cancer statistics, 2019. CA.
        Cancer J Clin. 2019; https://doi.org/10.3322/caac.21551
        • Papale M
        • Vocino G
        • Lucarelli G
        • et al.
        Urinary RKIP/p-RKIP is a potential diagnostic and prognostic marker of clear cell renal cell carcinoma.
        Oncotarget. 2017; https://doi.org/10.18632/oncotarget.16341
        • Fisher R
        • Gore M
        • Larkin J.
        Current and future systemic treatments for renal cell carcinoma.
        Semin Cancer Biol. 2013; https://doi.org/10.1016/j.semcancer.2012.06.004
        • Climent MA
        • Muñoz-Langa J
        • Basterretxea-Badiola L
        • Santander-Lobera C.
        Systematic review and survival meta-analysis of real world evidence on first-line pazopanib for metastatic renal cell carcinoma.
        Crit Rev Oncol Hematol. 2018; https://doi.org/10.1016/j.critrevonc.2017.11.009
        • Vachhani P
        • George S.
        VEGF inhibitors in renal cell carcinoma.
        Clin Adv Hematol Oncol. 2016; 14: 1016-1028
        • Howlader N
        • Noone N
        • Krapcho K
        • et al.
        SEER Cancer Statistics Review, 1975-2018.
        J Natl Cancer Inst. 2019; (http//seer.cancer.gov/csr/1975_2018/)
        • Escudier B
        • Pluzanska A
        • Koralewski P
        • et al.
        Bevacizumab plus interferon alfa-2a for treatment of metastatic renal cell carcinoma: a randomised, double-blind phase III trial.
        Lancet. 2007; https://doi.org/10.1016/S0140-6736(07)61904-7
        • Motzer RJ
        • Hutson TE
        • Tomczak P
        • et al.
        Sunitinib versus Interferon Alfa in Metastatic Renal-Cell Carcinoma.
        N Engl J Med. 2007; https://doi.org/10.1056/nejmoa065044
        • Sternberg CN
        • Davis ID
        • Mardiak J
        • et al.
        Pazopanib in locally advanced or metastatic renal cell carcinoma: results of a randomized phase III trial.
        J Clin Oncol. 2010; https://doi.org/10.1200/JCO.2009.23.9764
        • Motzer RJ
        • Escudier B
        • Powles T
        • et al.
        Long-term follow-up of overall survival for cabozantinib versus everolimus in advanced renal cell carcinoma.
        Br J Cancer. 2018; https://doi.org/10.1038/s41416-018-0061-6
        • Motzer RJ
        • Tykodi SS
        • Escudier B
        • et al.
        Final analysis of the CheckMate 025 trial comparing nivolumab (NIVO) versus everolimus (EVE) with >5 years of follow-up in patients with advanced renal cell carcinoma (aRCC).
        J Clin Oncol. 2020; https://doi.org/10.1200/jco.2020.38.6_suppl.617
        • Tannir NM
        • McDermott DF
        • Escudier B
        • et al.
        Overall survival and independent review of response in CheckMate 214 with 42-month follow-up: First-line nivolumab + ipilimumab (N+I) versus sunitinib (S) in patients (pts) with advanced renal cell carcinoma (aRCC).
        J Clin Oncol. 2020; https://doi.org/10.1200/jco.2020.38.6_suppl.609
        • Bracarda S
        • Porta C
        • Sabbatini R
        • Rivoltini L.
        Angiogenic and immunological pathways in metastatic renal cell carcinoma: A counteracting paradigm or two faces of the same medal? The GIANUS review.
        Crit Rev Oncol Hematol. 2019; https://doi.org/10.1016/j.critrevonc.2018.07.009
        • Powles T
        • Plimack ER
        • Soulières D
        • et al.
        Pembrolizumab plus axitinib versus sunitinib monotherapy as first-line treatment of advanced renal cell carcinoma (KEYNOTE-426): extended follow-up from a randomised, open-label, phase 3 trial.
        Lancet Oncol. 2020; https://doi.org/10.1016/S1470-2045(20)30436-8
        • Motzer RJ
        • Penkov K
        • Haanen J
        • et al.
        Avelumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
        N Engl J Med. 2019; 380: 1103-1115https://doi.org/10.1056/nejmoa1816047
        • Choueiri TK
        • Powles T
        • Burotto M
        • et al.
        Nivolumab plus Cabozantinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
        N Engl J Med. 2021; 384: 829-841https://doi.org/10.1056/nejmoa2026982
        • You D
        • Song SH
        • Cho YM
        • et al.
        Predictive role of tissue-based molecular markers in patients treated with sunitinib for metastatic renal cell carcinoma.
        World J Urol. 2015; https://doi.org/10.1007/s00345-014-1295-4
        • Lee CH
        • Motzer RJ
        • Glen H
        • et al.
        Correlative serum biomarker analyses in the phase 2 trial of lenvatinib-plus-everolimus in patients with metastatic renal cell carcinoma.
        Br J Cancer. 2021; https://doi.org/10.1038/s41416-020-01092-0
        • Tran HT
        • Liu Y
        • Zurita AJ
        • et al.
        Prognostic or predictive plasma cytokines and angiogenic factors for patients treated with pazopanib for metastatic renal-cell cancer: a retrospective analysis of phase 2 and phase 3 trials.
        Lancet Oncol. 2012; https://doi.org/10.1016/S1470-2045(12)70241-3
        • Rini BI
        • Plimack ER
        • Stus V
        • et al.
        Pembrolizumab plus Axitinib versus Sunitinib for Advanced Renal-Cell Carcinoma.
        N Engl J Med. 2019; https://doi.org/10.1056/nejmoa1816714
        • Motzer RJ
        • Rini BI
        • McDermott DF
        • et al.
        Nivolumab plus ipilimumab versus sunitinib in first-line treatment for advanced renal cell carcinoma: extended follow-up of efficacy and safety results from a randomised, controlled, phase 3 trial.
        Lancet Oncol. 2019; https://doi.org/10.1016/S1470-2045(19)30413-9
        • Motzer RJ
        • Choueiri TK
        • McDermott DF
        • et al.
        Biomarker analyses from the phase III CheckMate 214 trial of nivolumab plus ipilimumab (N+I) or sunitinib (S) in advanced renal cell carcinoma (aRCC).
        J Clin Oncol. 2020; https://doi.org/10.1200/jco.2020.38.15_suppl.5009
        • Harmon CS
        • Deprimo SE
        • Figlin RA
        • et al.
        Circulating proteins as potential biomarkers of sunitinib and interferon-α efficacy in treatment-naïve patients with metastatic renal cell carcinoma.
        Cancer Chemother Pharmacol. 2014; https://doi.org/10.1007/s00280-013-2333-4
        • Motzer RJ
        • Hutson TE
        • Hudes GR
        • et al.
        Investigation of novel circulating proteins, germ line single-nucleotide polymorphisms, and molecular tumor markers as potential efficacy biomarkers of first-line sunitinib therapy for advanced renal cell carcinoma.
        Cancer Chemother Pharmacol. 2014; https://doi.org/10.1007/s00280-014-2539-0
        • Motzer RJ
        • Robbins PB
        • Powles T
        • et al.
        Avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma: biomarker analysis of the phase 3 JAVELIN Renal 101 trial.
        Nat Med. 2020; https://doi.org/10.1038/s41591-020-1044-8
        • McDermott DF
        • Huseni MA
        • Atkins MB
        • et al.
        Clinical activity and molecular correlates of response to atezolizumab alone or in combination with bevacizumab versus sunitinib in renal cell carcinoma.
        Nat Med. 2018; https://doi.org/10.1038/s41591-018-0053-3
        • Iacovelli R
        • Verzoni E
        • De Braud F
        • Procopio G.
        First line treatment of metastatic renal cell carcinoma: two standards with different toxicity profile.
        Cancer Biol Ther. 2014; https://doi.org/10.4161/cbt.27150
        • Beaumont JL
        • Salsman JM
        • Diaz J
        • et al.
        Quality-adjusted time without symptoms or toxicity analysis of pazopanib versus sunitinib in patients with renal cell carcinoma.
        Cancer. 2016; https://doi.org/10.1002/cncr.29888
        • Amdahl J
        • Diaz J
        • Sharma A
        • et al.
        Cost-effectiveness of pazopanib versus sunitinib for metastatic renal cell carcinoma in the United Kingdom.
        PLoS One. 2017; https://doi.org/10.1371/journal.pone.0175920
        • Villa G
        • Hernández-Pastor LJ.
        Budget impact analysis of first-line treatment with pazopanib for advanced renal cell carcinoma in Spain.
        BMC Cancer. 2013; https://doi.org/10.1186/1471-2407-13-399
        • Unverzagt S
        • Moldenhauer I
        • Nothacker M
        • et al.
        Immunotherapy for metastatic renal cell carcinoma.
        Cochrane Database Syst Rev. 2017; https://doi.org/10.1002/14651858.CD011673.pub2
        • Rousseau B
        • Kempf E
        • Desamericq G
        • et al.
        First-line antiangiogenics for metastatic renal cell carcinoma: A systematic review and network meta-analysis.
        Crit Rev Oncol Hematol. 2016; https://doi.org/10.1016/j.critrevonc.2016.08.012
        • van Horssen R
        • ten Hagen TLM
        • Eggermont AMM.
        TNF-α in cancer treatment: molecular insights, antitumor effects, and clinical utility.
        Oncologist. 2006; https://doi.org/10.1634/theoncologist.11-4-397
        • Voss MH
        • Kuo F
        • Chen D
        • et al.
        Integrated biomarker analysis for 412 renal cell cancer (RCC) patients (pts) treated on the phase 3 COMPARZ trial: Correlating common mutation events in PBRM1 and BAP1 with angiogenesis expression signatures and outcomes on tyrosine kinase inhibitor (TKI) therapy.
        J Clin Oncol. 2017; https://doi.org/10.1200/jco.2017.35.15_suppl.4523
        • Liu Y
        • Shang D.
        Transforming growth factor-β1 enhances proliferative and metastatic potential by up-regulating lymphoid enhancer-binding factor 1/integrin αMβ2 in human renal cell carcinoma.
        Mol Cell Biochem. 2020; https://doi.org/10.1007/s11010-019-03676-8
        • Yang Y
        • Zhai C
        • Chang Y
        • et al.
        High expression of chemokine CCL2 is associated with recurrence after surgery in clear-cell renal cell carcinoma.
        Urol Oncol Semin Orig Investig. 2016; https://doi.org/10.1016/j.urolonc.2015.11.026
        • Taubert H
        • Eckstein M
        • Epple E
        • et al.
        Immune Cell-associated protein expression helps to predict survival in muscle-invasive urothelial bladder cancer patients after radical cystectomy and optional adjuvant chemotherapy.
        Cells. 2021; https://doi.org/10.3390/cells10010159
        • Powles T
        • Bracarda S
        • Chen M
        • et al.
        Characterisation of liver chemistry abnormalities associated with pazopanib monotherapy: a systematic review and meta-analysis of clinical trials in advanced cancer patients.
        Eur J Cancer. 2015; https://doi.org/10.1016/j.ejca.2015.03.019