Clear Cell Renal Cell Carcinoma: From Biology to Treatment

SIMPLE SUMMARY: Over the past two decades, biological discoveries have transformed the treatment strategies for renal cell carcinoma. These advances have led to the development of agents targeting pro-angiogenic pathways and the immunogenicity of renal cell carcinoma. This review will explore the biology of clear cell renal cell carcinoma and how these discoveries shaped previous therapies, current management, and future directions. ABSTRACT: The majority of kidney cancers are detected incidentally and typically diagnosed at a localized stage, however, the development of regional or distant disease occurs in one-third of patients. Over 90% of kidney tumors are renal cell carcinomas, of which, clear cell is the most predominate histologic subtype. Von Hippel Lindau (VHL) gene alterations result in the overexpression of growth factors that are central to the pathogenesis of clear cell carcinoma. The therapeutic strategies have revolved around this tumor suppressor gene and have led to the approval of tyrosine kinase inhibitors (TKI) targeting the vascular endothelial growth factor (VEGF) axis. The treatment paradigm shifted with the introduction of immune checkpoint inhibitors (ICI) and programed death-1 (PD-1) inhibition, leading to durable response rates and improved survival. Combinations of TKI and/or ICIs have become the standard of care for advanced clear cell renal cell carcinoma (ccRCC), changing the outlook for patients, with several new and promising therapeutic targets under development.