Clinical Trial Details
— Status: Completed
Administrative data
| NCT number |
NCT04295174 |
| Other study ID # |
S-20160005 |
| Secondary ID |
|
| Status |
Completed |
| Phase |
|
| First received |
|
| Last updated |
|
| Start date |
January 1, 2018 |
| Est. completion date |
January 1, 2020 |
Study information
| Verified date |
March 2020 |
| Source |
Odense University Hospital |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Observational
|
Clinical Trial Summary
Kidney cancer is a highly malignant disease with 950 new cases every year in Denmark.
Diagnosis and treatment of kidney cancer patients presents many challenges because that early
stages of the disease are often asymptomatic and the disease is thus often at advanced stage
or even metastatic when discovered. Metastasis is a predictor of bad prognosis, because the
presence of metastases excludes the possibility of curative treatment (surgery). Systemic
(medical) treatment is used for metastatic disease. It is of increasing importance to monitor
how patients are responding to the treatment and switch to a different product if the tumor
is not responding. Improved methods for detection of metastatic lesions would be of great
advantaged for the clinicians in order to select the optimal treatment strategy for the
patients.
In the present study we aim to identify tumor markers in the blood and more specific we want
to investigate whether circulating tumor-DNA can be used as a biomarker for monitoring the
development of the disease during and after treatment. We want a better understanding of the
tumor's heterogeneity and development. Furthermore we want to evaluate the diagnostic value
of dual time FDG- PET/CT for the detection of bone and lymph node metastases in patients with
kidney cancer
Description:
Background Renal cell carcinoma (RCC) represents 2-3% of all malignancies, and the European
prevalence is approximately 84,400 cases per year [1]. In Denmark 950 new cases of Kidney
Cancer (KC) are diagnosed per year, and the incidence is increasing annually. KC is more
common in men than in women and the cancer debuts most frequently in the age of 60-70 years
[2]. Early stages of KC are often asymptomatic and the disease is thus often at advanced
stage or even metastatic when discovered. Metastases including lymph node metastases are a
predictor of bad prognosis. Surgical removal of cancerous lymph nodes has been shown to
improve response to systemic treatment and prolong survival [3], but the current methods for
detection of especially lymph node metastases are insufficient. Improved methods for
detection of metastatic lesions at the time of diagnosis would be of great help for the
clinicians who have to select the optimal treatment strategy for the patients. Surgery is the
only curative treatment and also the predominant choice of treatment when possible. Systemic
treatment is only used in case of metastatic disease. Metastatic KC is generally
non-responsive to chemotherapeutics and radiation therapy [2], but a range of other systemic
treatment options has been developed over the last decade. This means that it is of
increasing importance to monitor how patients are responding to the selected treatment and
switch to a different product if the tumor is not responding. The number of patients with KC
identified by chance has increased along with an increasing use of routine imaging for a
number of others disorders [4]. It is still likely that new and improved methods for early
detection of cancer would improve the survival in KC patients.
PET/CT:
Positron Emission Tomography (PET) combined with computed tomography (CT) is a
well-established method of diagnosing and staging several types of cancer.
2-deoxy-2-[18F]fluoro-D-glucose (FDG) is the most common PET tracer used in oncologic
studies. PET/CT is not a standard modality in the diagnosis and staging of RCC [5]. The
sensitivity as to detection of the primary tumor is hampered by the physiological excretion
of FDG in the urine. Furthermore, histological characteristics of the tumor such as grade and
expression of glucose transporters can affect the FDG uptake negatively [6]. However, PET/CT
performs well in detection of extra-renal metastases [7, 8] and proved to be of prognostic
value in recurrent RCC [9].
FDG is accumulated in cells with increased glycolysis, in particular cancer cells. FDG
accumulation is not specific to tumors and is also seen in benign processes such as
inflammation and infection. This makes it difficult to distinguish malignant neoplastic lesions
from the benign ones [10]. In recent years the concept of dual-time point (DTP) imaging has
evolved. The increase in FDG uptake seems to continue for hours after injection in malignant
tissue whereas FDG uptake in normal or inflamed tissue reaches maximum uptake earlier and
declines thereafter. Thus, late imaging is thought to result in increased FDG uptake,
decreased blood and urine activity and, thus, a better target-to-background ratio and,
therefore, a higher sensitivity [11]. Several studies using DTP PET/CT have been performed on
tumors in the breast, liver, lung, and prostate. Results indicate that the pattern and rate
of FDG uptake over time vary considerably between malignant and benign processes and that DTP
PET/CT allows for distinction between them [12,13]. Hitherto, the use of DTP imaging in RCC
was scantily reported. A recent paper considered the value of DTP imaging of the primary
renal tumor but not of the metastases [14].
Circulating tumor DNA There is a general and increasing interest in circulating cancer
biomarkers because they might constitute representative readouts of both primary tumor and
metastatic deposits. Furthermore, circulating markers may provide a tool for monitoring
response to systematic adjuvant therapies even after the primary tumor has been removed.
Promising results have been obtained for blood-born cell free DNA (cfDNA) which can be
isolated from a simple blood sample, often referred to as a liquid biopsy. In contrast to
tissue biopsies, detection of cfDNA from peripheral blood is a minimally invasive way to
monitor the disease during treatment and follow-up.
cfDNA is assumed to be released from most or all of the cells in the body and is present in
healthy as well as sick individuals. Several studies report that specific alterations from
tumor tissue is mirrored in cfDNA and that it is thus possible to discriminate circulating
tumor DNA (ctDNA) from normal cfDNA. Studies applying sequencing of somatic mutations in
well-known cancer driver genes like TP53, PIK3CA, and KRAS have been reported and promising
results have been obtained for using these markers for early detection of recurrence in
colorectal cancer [15] breast cancer [16] and lung cancer [17]. A drawback in this approach
is that a considerable fraction of solid tumors do not contain mutations in these candidate
genes. This challenge can be met by using next generation sequencing of tumor tissue to
identify tumor-specific alterations which may then be monitored in plasma. Two recent studies
applied low-coverage whole genome sequencing of tumor tissue to detect tumor-specific
breakpoint and subsequently used PCR-based assays targeting these breakpoints to detect and
monitor ctDNA burden in patients with colorectal cancer [18] and breast cancer [19]. The
method proved to be highly sensitive and specific in the discrimination between patients with
and without recurrence, and they were able to detect metastatic recurrence with a lead time
of 10 and 11 months, respectively, compared to conventional methods. Furthermore, Reinert and
co-workers [18] also demonstrated that the level of ctDNA varied with administration of
therapy and that ctDNA may be used as a tool to monitor treatment response. One of the most
significant and early hallmarks of tumors are genomic instability which represents a driving
force behind the development of therapy resistance and metastasization. Genomic instability
is one of the major challenges in the systemic treatment of cancer because the resulting
tumor heterogeneity is not only difficult to uncover, but also dynamic and thus challenging
to monitor in time. Genetic profiles of tumors are commonly obtained from tissues biopsies,
however these may not reveal relevant tumor heterogeneity and the invasiveness of the
procedure makes them unsuitable for sequential monitoring during disease progression. ctDNA
may represent a minimally invasive way to monitor not only tumor load but also tumor
heterogeneity and evolution towards metastasis.
Hypotheses
1. Increase in FDG uptake continues for hours after injection. Late imaging (DTP FDG
PET/CT) should result in increased FDG uptake, decreased blood and urine activity and,
thus, a better lesion-to-background ratio. By combining this with the pathological
report it might be possible to get a better staging of the kidney cancer patients.
2. Tumor burden, heterogeneity and dissemination is reflected in circulating tumor-DNA
(ctDNA), which can be measured in a simple blood sample. Analysis of ctDNA can be
expected to provide information about changes in tumor load before - and during
treatment, and in patients with metastatic disease and during their treatment.
Aim The primary purposes of these prospective trials are to investigate the use of DTP FDG
PET/CT in staging of lung, bone- and lymph node metastasis in patients with KC and to
investigate if ctDNA can be used as a tool for assessment of tumor load, tumor heterogeneity,
dissemination, for monitoring during treatment and disease progression in KC patients.
KIDSTAGE I: DTP FDG PET/CT for detection of lung-, bone- and lymph node metastases in
patients with KC Population All patients diagnosed with KC in The Urological Department and
in The Oncological Department of OUH are eligible for enrolment in the study.
Inclusion criteria:
- KC patients at Urological- and Oncological departments of OUH
- Written consent
- Able to speak and understand Danish
Exclusion criteria:
- Patients below 18 years of age
- Patients with mental impairment
- Withdrawal of consent
- Other malignancy Methods Patients included in the study will have a DTP FDG-PET/CT scan.
The scans will be performed before the nephrectomy/administration of oncological
treatment. The Department of Nuclear Medicine perform the scans with acquisition 1 and 3
hours after administration of the FDG tracer. Images are interpreted by a specialist in
nuclear medicine. Images are interpreted based on visual evaluation with supplementary
measurements of Standardized uptake values (SUV). SUVmax will be determined for both the
early and late acquisition (SUVearly and SUVlate). A retention index (RI) will be
calculated as (SUVlate - SUVearly)/SUVearly.
Primary target imaging variables will be "metastases to the lungs" (yes/no), "metastases to
lymph nodes" (yes/no) and "metastases to bone" (yes/no). Secondary analyses will be
lesion-based. In according to lymph node detection, lesion-based describe each lymph node
group. Activity in regional lymph nodes will be recorded according to their location; "renal
hilus (dx/sin)", "retroperitoneal para aortic" and "para cavale"[2]. During the nephrectomy
the lymph nodes from the above mentioned stations will be removed and placed in separate
containers marked as: "renal hilus dx.", "renal hilus sin.", "para aortic" and "para cavale".
Pathologists will examine the tissue samples. The results of the PET/CT will not be available
to the pathologist. The results of the PET/CT will be compared to results of histological
examination (Gold Standard) and sensitivity, specificity, positive and negative predictive
value will be calculated.
Results regarding lung and bone metastases will be compared to the results of the diagnostic
CT scan of thorax/abdomen that is already made for each patient as a part of the standard
examination program. In case of agreement between the scans, the patient will proceed to
clinical treatment as usual. In case of disagreement between the modalities concerning bone,
a Magnetic Resonance Imaging (MRI) will be performed of the lesion of interest. If the
results after MRI are still inconclusive a bone biopsy with emphasis on getting marrow tissue
as well as bone matrix, will be performed. This will in many cases not be possible due to the
size of the lesion and in these cases MRI will serve as reference standard.
All results will be coded and given an ID according to patient´s CPR number using the RedCap
informatic coding system.
KIDSTAGE II: Circulating biomarkers in KC and tumor heterogeneity Population All patients
with KC at The Urological Department of OUH who undergo surgery and all patients admitted at
the departments at OUH who undergo kidney biopsy for suspect renal tumor will be considered
potentially suitable for the enrolment.
Inclusion criteria:
- Patients with KC without metastases treated at Urological Department of OUH
- Written consent
- Able to speak and understand Danish Exclusion criteria
- As in KIDSTAGE I Methods Sample collection A blood sample (20 ml) will be taken
pre-operatively from each patient participating in the study. The sample collection will
be repeated at the first postoperative day while the patient is still hospitalized and
after 2 weeks, 3, 6 and 12 months. All samples will be coded and given an ID according
to patient´s CPR number using the RedCap informatic coding system. Furthermore, a biopsy
of the tumor on the surgically removed kidney will be sent to the Department of
Pathology. The tumor sample will also be coded according to RedCap. Sizes of the
histological specimen as ported for the study will be of 5 mm x 5 mm x 5mm.
Sample analysis The blood samples will be delivered to the Department of Clinical Genetics at
OUH and will be centrifuged to separate plasma from blood cells and both fractions will be
stored at -80C. Isolation of DNA from tumor tissue, lymphocytes and plasma (cfDNA) will be
performed using commercial kits.
KIDSTAGE IIa: DNA isolated from tumor tissue will be subjected to low coverage (approximately
1-3 X) whole genome sequencing with 2 X 100 paired end reads and long inserts. Sequencing
will be performed using an Illumina HiSeq1500 located at Department of Clinical Genetics in
Odense. The large somatic mutations will be filtered to avoid known germline copy number
variations and will finally be validated as somatic mutations by personalized assay of DNA
from lymphocytes. A considerable number of large somatic mutations are expected to be
identified in all tumors using this pipeline. A smaller number of 2-3 mutations from each
tumor will be implemented in a personalized PCR set-up covering the breakpoints of identified
somatic mutations. Quantification will be performed using digital PCR and a number of
housekeeping genes will be used for normalization. The assays will be applied to 1) plasma
samples to detect and quantify ctDNA and 2) DNA isolated from the cell fraction of the blood
sample in order to validate that the mutations are somatic.
KIDSTAGE IIb: For 20 patients tumor heterogeneity will be studied by isolating DNA from 4
independent biopsies from the resected primary tumor and from normal tissue (normal blood
cells). Whole exome sequencing is performed at 100X coverage, suspected somatic point
mutations are called by comparing sequences from tumor and normal tissue [20] validation and
accurate estimates of allele frequencies are obtained by ultra deep (>1000X) targeted
sequencing of suspected mutations. The subclonal structure is deciphered by bioinformatics
analysis. This procedure was successfully applied in one of our previous studies [21]. In
order to determine to what extent the heterogeneity is reflected in ctDNA, the ultra deep
sequencing will also be performed on the ctDNA from the same patient.
Sample storage discharge Purified samples will be anonymously stored in a research biobank
for a maximum period of 10 years from collection. After that time, all samples will be
destroyed. In case of performance of further analyses on the samples, than to those
illustrated in the present protocol, both for the aims of the present study or for new
studies, explicit allowance will be previously requested to the ethical committee and to the
respective organs in charge for these purposes
KIDSTAGE III: Circulating biomarkers in metastatic KC and tumor evolution Population All
patients with metastatic KC treated at The Oncological Department of OUH will be considered
potentially suitable for the enrolment.
Inclusion criteria:
- Patients with histologically verified and metastatic KC treated in Oncological
Department of OUH
- Written consent
- Able to speak and understand Danish Exclusion criteria
- As in KIDSTAGE I Methods Sample collection For patients with metastatic KC in the "good"
and "intermediate" prognosis groups the first line treatment is Pazopanib 800 mg given
daily. This is given continuously until progression. Evaluation of treatment response is
performed by a clinical control at the Department of Oncology every 4 week and with a
CT-scan every 3 month. For patients in the poor prognosis group and for patients with
not clear-cell-type the first line treatment is Sunitinib 50 mg. This is given daily for
4 weeks and then a break for 2 weeks. Evaluation of treatment response is performed by a
clinical control at the Department of Oncology every 6 week and with a CT-scan every 3
month.
A blood sample (20 ml) will be taken from each patient before initiating the oncological
treatment. Sample collection will be repeated after 2 weeks, 3, 6 and 12 months. All samples
will be coded and given an ID according to patient´s CPR number using the RedCap informatic
coding system. An ultrasound guided biopsy of the primary tumor and the metastases will be
taken and sent to the Department of Pathology, OUH. This is a standard procedure for patients
with metastatic disease, who are planned for oncological treatment. The tumor sample will
also be coded according to RedCap.
Sample analysis KIDSTAGE IIIa: As in KIDSTAGE IIa KIDSTAGE IIIb: For 20 patients tumor
evolution is studied by isolating DNA from biopsies from primary tumor, metastasis and normal
cells. Like in IIb whole exome sequencing, variant calling and ultra deep sequencing are
performed. The genomic evolution from primary tumor tp metastasis is deciphered by
bioinformatics analysis, as we reported previously [22,23]. In order to determine to what
extent this evolution is reflected in ctDNA, ultra deep sequencing will be performed on ctDNA
too.
Sample storage discharge As in KIDSTAGE II Sample size Annually 100-120 patients diagnosed
with KC undergo surgery at The Urological Department of OUH and 70-80 patients with
metastatic KC are treated at The Oncological Department of OUH. Approximately 75 patients
will be a realistic no of patients to enroll in the overall study. Since this is an
explorative study and no other larger studies have investigated this, it has not been
possible to make power calculations for the sample size.
Feasibility The patients will be enrolled in the study when a diagnosis of KC has been made
in The Urological Department or in The Oncological Department of OUH. Contact to the patients
will be facilitated by Louise Geertsen. Collection of blood samples will be performed by
technicians or by Louise Geertsen.
Sequencing, data analysis and ddPCR will be performed at the Department of Clinical Genetics
at OUH. The department has the Illumina HiSeq technology and computing power for Next
Generation Sequencing (NGS) and has implemented NIPT as a clinical analysis. Prof. Torben A.
Kruse and his team has years of experience with NGS and cancer research, and comprehensive
technical and bioinformatical knowledge including detection of breakpoints and copy number
variations from NGS has been obtained[20,21,22,23]. The DTP PET/CT scans will be performed at
The Department of Nuclear Medicine, OUH. The department has years of experience in performing
and interpreting FDG PET/CT and DTP FDG PET/CT [24,25,26]. The images will be interpreted by
Jane Simonsen, PhD and consultant at The Department of Nuclear Medicine or a substitute for
her. Histological examination of tumor biopsies will be facilitated by our collaboration
partner Niels Marcussen, professor and consultant at the Department of Pathology.
Ethics
Ethical aspects to be considered in KIDSTAGE I:
Most patients will be 60 years of age or older at the time of diagnosis, and few if any will
be younger than 50 years. In Denmark the theoretical lifetime risk of dying due to cancer is
approximately 25% for a 25-year old subject. For each Sv the risk of inducing cancer is
increased by 5% compared to the overall risk in the population. By exposure of a radiation
dose of 28 mSv = 0.028 (0.03) the risk increases by 5% * 0.03 = 0.2% after participation in
the study. However, the risk is age-dependent and due to the national guidelines [27] the
present project can be considered as a category IIb research project, because all patients
will be above the age of 50 years. For a research project of this category to be approved,
the benefits of the project should be expected to be "directed towards diagnosis, cure or
prevention of disease" - which is exactly the case for the present study. The increased risk
due to radiation has to be held up against the potential benefit for the patient
participating in the study and for future patients. The potential benefit for the patient
participating in the study is foremost a possibly better staging of the disease. Furthermore,
if the study on lymph nodes shows trends towards usefulness in detecting lymph node
metastases, then this could be of immense benefit for future patients.
Ethical considerations that apply in KIDSTAGE II and III: When we determine the DNA sequence
of the entire genetic material, there is a small risk of finding genetic defects in the
genome. Some genetic defects can cause hereditary diseases and can affect the health of the
patient and the patient´s family. In some cases, it is possible to treat or even prevent the
disease caused by that gene defect and in other cases it is not. In the written information
that the patient is given, this risk will be mentioned and the patient is given the
opportunity to decide how much information they want to know of their own genetic material.
In situations where we find a defect in the genome that can cause disease in the long term,
and where the patient wanted to be informed, the patient will be invited for an interview in
the clinic. During this interview, there will be a genetic counsellor present. The genetic
counsellor will inform the patient about what the information means for the patient and the
patient's family.
The above mentioned studies (Project-ID S-20160005), the patient information sheets and the
informed consent form was approved by The Regional Scientific Ethical Committees for Southern
Denmark February 4, 2016 and by the local data protection agency "Datatilsynet" in October
2016 with the Professor MD Lars Lund as main supervisor for PhD student Louise Geertsen. The
trial will be conducted in accordance with Good Clinical Practice, Declaration of Helsinki.
