Clinical decision-making for immunotherapy in metastatic renal cell carcinoma

Curr Opin Urol. 2018 Jan;28(1):29-34. doi: 10.1097/MOU.0000000000000456.


Purpose of review: To review the treatment options in metastatic renal cell carcinoma (mRCC) in the light of new immunotherapy results.

Recent findings: Second-line treatment strategies for treatment of mRCC after progression on first-line VEGF-targeted therapy have recently undergone a major change. Treatment guidelines currently recommend the use of either nivolumab, a programmed cell death 1 (PD-1) inhibitor, or cabozantinib, an inhibitor of multiple receptor tyrosine kinases, as preferred choices. Many factors influence the decision, but there are no predictive markers to guide the choice. It is not known at what stage, it is most appropriate to offer a checkpoint inhibitor (CPI) such as nivolumab; various factors influence this decision including the adverse event profile and the age of the patient. Recent positive first-line trial results with cabozantinib, with the combination of two CPIs (a PD-1-PD-L1 inhibitor and a CTLA-4 inhibitor) and with a CPI with a VEGF inhibitor suggest that the first-line treatment paradigm will change rapidly, with consequential changes in second-line recommendations.

Summary: The treatment landscape in mRCC is changing rapidly and recent trial results suggest that CPI treatment combined with either another CPI or a VEGF inhibitor may be appropriate as first-line therapy in the future.

Publication types

  • Review

MeSH terms

  • Antineoplastic Agents, Immunological / pharmacology
  • Antineoplastic Agents, Immunological / therapeutic use
  • Antineoplastic Combined Chemotherapy Protocols / pharmacology
  • Antineoplastic Combined Chemotherapy Protocols / therapeutic use*
  • B7-H1 Antigen / antagonists & inhibitors
  • B7-H1 Antigen / immunology
  • CTLA-4 Antigen / antagonists & inhibitors
  • CTLA-4 Antigen / immunology
  • Carcinoma, Renal Cell / epidemiology
  • Carcinoma, Renal Cell / immunology
  • Carcinoma, Renal Cell / pathology
  • Carcinoma, Renal Cell / therapy*
  • Clinical Decision-Making*
  • Comorbidity
  • Humans
  • Immunotherapy / methods*
  • Immunotherapy / trends
  • Kidney Neoplasms / epidemiology
  • Kidney Neoplasms / immunology
  • Kidney Neoplasms / pathology
  • Kidney Neoplasms / therapy*
  • Programmed Cell Death 1 Receptor / antagonists & inhibitors
  • Programmed Cell Death 1 Receptor / immunology
  • Protein Kinase Inhibitors / pharmacology
  • Protein Kinase Inhibitors / therapeutic use
  • Randomized Controlled Trials as Topic
  • Treatment Outcome


  • Antineoplastic Agents, Immunological
  • B7-H1 Antigen
  • CD274 protein, human
  • CTLA-4 Antigen
  • CTLA4 protein, human
  • PDCD1 protein, human
  • Programmed Cell Death 1 Receptor
  • Protein Kinase Inhibitors