From the Guidelines
For oligometastatic renal cell carcinoma (RCC) patients who have progressed on nivolumab and ipilimumab, the recommended treatment approach typically involves targeted therapy with tyrosine kinase inhibitors (TKIs), with cabozantinib being the preferred agent at a starting dose of 60 mg orally once daily, as supported by the most recent guideline evidence 1. This approach is based on the latest clinical practice guidelines, which suggest that cabozantinib is the preferred first-line monotherapy for advanced RCC, and can also be considered in the second-line setting for patients who have progressed on prior therapies, including immunotherapy combinations like nivolumab and ipilimumab. The rationale for this approach is that TKIs, such as cabozantinib, target the VEGF pathway, which is often upregulated after immunotherapy failure, and have demonstrated efficacy in improving outcomes in patients with advanced RCC. Alternative options, such as axitinib, lenvatinib plus everolimus, or sunitinib, may also be considered, but the choice of therapy should be based on the patient's performance status, comorbidities, and prior treatment toxicities, as well as the specific characteristics of the oligometastatic disease. In addition to systemic therapy, local therapies, such as stereotactic body radiation therapy (SBRT) or surgical metastasectomy, should be considered to achieve local control of the oligometastatic sites, as this multimodal approach may improve outcomes in this patient population, as suggested by the society for immunotherapy of cancer consensus statement 1. Regular monitoring with imaging every 2-3 months is essential to assess response to therapy and adjust the treatment plan as needed. Overall, the goal of therapy in this setting is to improve outcomes, including overall survival, progression-free survival, and quality of life, while minimizing toxicity and optimizing patient care.
From the Research
Treatment Approach for Oligometastatic Renal Cell Carcinoma (RCC)
The user's question regarding the recommended treatment approach for oligometastatic Renal Cell Carcinoma (RCC) patients who have progressed on nivolumab and ipilimumab is addressed below, with the term "embolisms" replaced by "pembrolizumab" as per the request.
Current Treatment Options
- For patients with metastatic RCC, combination therapies such as cabozantinib plus nivolumab have shown promising efficacy 2, 3.
- Pembrolizumab and cabozantinib have demonstrated encouraging preliminary efficacy and a manageable toxicity profile in patients with metastatic RCC 4.
- The combination of pembrolizumab and cabozantinib has also shown promising activity in other cancers, such as recurrent metastatic head and neck squamous cell carcinoma 5.
Considerations for Second-Line Therapy
- A real-world comparison of nivolumab and cabozantinib as second-line therapy in patients with advanced RCC found distinct results when stratified into clinico-pathological features 6.
- The choice of second-line therapy may depend on factors such as patient age, prior treatment, and risk criteria.
Potential Treatment Approach
- Based on the available evidence, a potential treatment approach for oligometastatic RCC patients who have progressed on nivolumab and ipilimumab could be the combination of pembrolizumab and cabozantinib 4, 5.
- However, the optimal treatment approach should be determined on a case-by-case basis, taking into account individual patient characteristics and prior treatment history.