Immunotherapy In Renal Cell Carcinoma Research Articles

A spatial architecture-embedding HLA signature to predict clinical response to immunotherapy in renal cell carcinoma.

An important challenge in the real-world management of patients with advanced clear-cell renal cell carcinoma (aRCC) is determining who might benefit from immune checkpoint blockade (ICB). Here we performed a comprehensive multiomics mapping of aRCC in the context of ICB treatment, involving discovery analyses in a real-world data cohort followed by validation in independent cohorts. We cross-connected bulk-tumor transcriptomes across >1,000 patients with validations at single-cell and spatial resolutions, revealing a patient-specific crosstalk between proinflammatory tumor-associated macrophages and (pre-)exhausted CD8+ T cells that was distinguished by a human leukocyte antigen repertoire with higher preference for tumoral neoantigens. A cross-omics machine learning pipeline helped derive a new tumor transcriptomic footprint of neoantigen-favoring human leukocyte antigen alleles. This machine learning signature correlated with positive outcome following ICB treatment in both real-world data and independent clinical cohorts. In experiments using the RENCA-tumor mouse model, CD40 agonism combined with PD1 blockade potentiated both proinflammatory tumor-associated macrophages and CD8+ T cells, thereby achieving maximal antitumor efficacy relative to other tested regimens. Thus, we present a new multiomics and spatial map of the immune-community architecture that drives ICB response in patients with aRCC.

Macrophage-Derived Nanosponges Adsorb Cytokines and Modulate Macrophage Polarization for Renal Cell Carcinoma Immunotherapy.

Renal cell carcinoma (RCC) is a hot tumor infiltrated by large numbers of CD8+ T cells and is highly sensitive to immunotherapy. However, tumor-associated macrophages (TAMs), mainly M2 macrophages, tend to undermine the efficacy of immunotherapy and promote the progression of RCC. Here, macrophage-derived nanosponges are fabricated by M2 macrophage membrane-coated poly（lactic-co-glycolic acid）（PLGA）, which could chemotaxis to the CXC and CC chemokine subfamily-enriched RCC microenvironment via corresponding membrane chemokine receptors. Subsequently, the nanosponges act like cytokine decoys to adsorb and neutralize broad-spectrum immunosuppressive cytokines such as colony stimulating factor-1(CSF-1), transforming growth factor-β（TGF-β）, and Lnterleukin-10（IL-10）, thereby reversing the polarization of M2-TAMs toward the pro-inflammatory M1 phenotype, and enhancing the anti-tumor effect of CD8+ T cells. To further enhance the polarization reprogramming efficiency of TAMs, DSPE-PEG-M2pep is conjugated on the surface of macrophage-derived nanosponges for specific recognition of M2-TAMs, and the toll like receptors 7/8（TLR7/8） agonist, R848, is encapsulated in these nanosponges to induce M1 polarization, which result in significant efficacy against RCC. In addition, these nanosponges exhibit undetectable biotoxicity, making them suitable for clinical applications. In summary, a promising and facile strategy is provided for immunomodulatory therapies, which are expected to be used in the treatment of tumors, autoimmune diseases, and inflammatory diseases.

Abstract LB257: Possible involvement of PDL1 intrinsic signaling to acquired resistance to immunotherapy for renal cell carcinoma (RCC)

Abstract Immune checkpoint inhibitor (ICI) therapy has shown unprecedented results in RCC treatment, but durable responses have been hampered by acquired resistance (AR, initially respond but eventually develop cancer progression). Mechanisms for AR remain ambiguous. Previously, we reported elevated blood GPNMB to strongly associate with AR development. To study molecular mechanisms for AR-linked GPNMB elevation, we created an ICI-resistant RenCa (R-RenCa) mouse model by repeated selection of largest tumors in mice treated with PD1 Ab ICI. Parental cells (Gpnmblow) respond to ICI (S-RenCa), while R-RenCa is completely unresponsive to ICI and acquired Gpnmb overexpression (but PDL1 remained unchanged), recapitulating strong association of GPNMB with AR development. R-RenCa tumors displayed more immunosuppressive and angiogenic phenotypes and enhanced response to anti-Gpnmb Ab. In probing for genetic alterations unique to R-RenCa, whole exome seq analysis showed R-RenCa to bear a greater tumor mutation burden (184.9 and 174.6 mut/Mb for R- and S-RenCa, respectively) but no somatic mutations in beta-2 microglobulin and IFN-signal molecule genes known to be involved in AR. RNA-seq analysis showed; more transcriptionally active genes in R-RenCa tumors (heatmap analysis); more responsive genes to ICI (Volcano analysis); and dysregulation in microphthalmia (Mitf) family gene expression. Mitf RNA was upregulated 3-fold, but Tfe3 and other members downregulated 2-3-fold. RNA start sites of Mitf transcripts are highly heterogenous in R-RenCa compared to S-RenCa (Sashimi plot), indicating generation of more isoforms. Since Gpnmb promoter has E-boxes (DNA binding sites) for Mitf factor, we examined whether Mitf is responsible for Gpnmb expression using promoter-Luc reporter assays and found 4-fold higher in R-RenCa, which was lost completely in E-box-mutated promoter. In seeking transcriptional activators for Mitf gene, we found Sox10 factor to be upregulated in R-RenCa. The molecular link of Sox10-Mitf-Gpnmb was shown by the data of gene-knock down experiments that Sox10-siRNA diminished Mitf and Gpnmb expression completely, and Mitf-siRNA had no effect on Sox10 expression but diminished Gpnmb expression. We then studied mechanisms for Sox10 activation and found PDL1 signaling (triggered by Ab-crosslinking) to induce Sox10 RNA expression in tumor cells, which was 80% abrogated by deleting the RMLDVEKC cytoplasmic motif known to protect tumor cells from IFN cytotoxicity. For human relevance of Sox10-Mitf axis activation, we employed nested qRT-PCR of cell-free RNA (cfRNA) isolated from plasma of RCC patients (n=3) immediately before and after AR. SOX10 and MITF cfRNAs were increased by 2.3 ± 0.85 and 1.77 ± 0.05-fold, respectively, between these two time points. Thus, PDL1 signaling is involved in AR by dysregulating the SOX10-MITF-GPNMB cascade, indicating the potential of the cascade-targeting to break AR hindrance for ICI therapy. Citation Format: Jin-Sung Chung, Lei Guo, Vinita Popat, Ponciano D. Cruz, Lin Xu, Hans Hammers, Kiyoshi Ariizumi. Possible involvement of PDL1 intrinsic signaling to acquired resistance to immunotherapy for renal cell carcinoma (RCC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB257.

Identification of ANKRD13D as a potential target in renal cell carcinomas.

The correlation of the expression of ankyrin repeat domain (ANKRD) family members with renal cell carcinoma prognosis was investigated. The GEPIA2, GEO2R, UALCAN, GDC, OncoLnc, TIMER, PanglaoDB, CancerSEA, and Tabula Muris databases were used. Twelve ANKRD family members were identified as having overexpressed renal cell carcinoma samples. The ANKRD13D was identified as a renal cell carcinoma-specific target by cross-referencing the multiple survival databases. To clarify the role of ANKRD13D, the expression of NAKRD13D was analyzed at the single-cell level. ANKRD13D was mainly expressed in immune cells and positively correlated with Treg cell infiltration. The expression of ANKRD13D was also positively correlated with PDCD1, CTLA4, LAG3, TNFSF14, and ISG20. The overexpression of ANKRD13D in Treg was confirmed using reverse transcription-quantitative polymerase chain reaction. The structure of ANKRD13D was predicted using AlphaFold. In conclusion, we identified ANKRD13D as a key immune regulator, and targeting ANKRD13D with immune checkpoints blockade may be a promoting strategy for renal cell carcinoma immunotherapy.

Targeting oxidative phosphorylation to increase the efficacy of immune-combination therapy in renal cell carcinoma

BackgroundImmune checkpoint inhibitors (ICIs) are the standard of care for metastatic renal cell carcinoma (RCC); however, most patients develop de novo or acquired resistance to ICIs. Oxidative phosphorylation (OXPHOS) has...

Established and emerging biomarkers of immunotherapy in renal cell carcinoma.

Immunotherapies, such as immune checkpoint inhibitors, have heralded impressive progress for patient care in renal cell carcinoma (RCC). Despite this success, some patients' disease fails to respond, and other patients experience significant side effects. Thus, development of biomarkers is needed to ensure that patients can be selected to maximize benefit from immunotherapies. Improving clinicians' ability to predict which patients will respond to immunotherapy and which are most at risk of adverse events-namely through clinical biomarkers -is indispensable for patient safety and therapeutic efficacy. Accordingly, an evolving suite of therapeutic biomarkers continues to be investigated. This review discusses biomarkers for immunotherapy in RCC, highlighting current practices and emerging innovations, aiming to contribute to improved outcomes for patients with RCC.

Current status and future perspective of immunotherapy for renal cell carcinoma

Current status and future perspective of immunotherapy for renal cell carcinoma

Role of Immunotherapy in Renal Cell Carcinoma; A Case Study

Introduction: The most common cancer of kidney is- renal cell carcinoma. Early diagnosis can make a hope from the recovery of the disease. The incidence of renal cell carcinoma is commonly found in elderly aged patients. Sometimes it occurs in one kidney whereas, sometimes it effects both kidneys. Smoking, overweight, taking excessive painkillers can increase the chance of renal cell carcinoma. Case Presentation: A 57 years old Bangladeshi diabetic male patient, was diagnosed as right sided renal cell carcinoma (stage pT3cN0G2) along with the chief complaint of recurrent gross hematuria came to outdoor in April 2020. After confirmed diagnosis surgery had done followed by medications. From 10/03/2022, patient started 1 cycle of oral therapy with tablet Sunitinib. After that, immunotherapy and targeted therapy were advised to start with injection Pembrolizumab 200mg every three weeks followed by tablet Axitinib 5mg for every two weeks. Patient received 17 cycles of Pembrolizumab followed by Axitinib and got the last cycle at 24/02/2024. Conclusion: With the minimal side effects, it is evident that, Pembrolizumab has shown a positive response to the patient. It has added the new standard care of treatment of renal cell carcinoma at intermediate-high or high risk of recurrence following nephrectomy or following nephrectomy and resection of metastatic lesions.

Immunotherapy in renal cell carcinoma

Immunotherapy in renal cell carcinoma

TIGIT may Serve as a Potential Target for the Immunotherapy of Renal Cell Carcinoma.

This study aims to explore whether TIGIT is an effective target for the immunotherapy of renal cell cancer (RCC) with PD-1 as a positive control. The expression of TIGIT and PD-1 in RCC and peripheral blood mononuclear cells (PBMC) and the correlation between TIGIT and PD-1 are evaluated. The expression of TIGIT and PD-1 is inhibited, and then the proliferation, apoptosis, and migration are assessed. TIGIT expression is positively related to the expression of PDCD1, BTLA, ICOS, and FOXP3 (p<0.05). TIGIT expression in the PBMC, TIL, RCC, and adjacent normal tissues is higher than PD-1 expression. Blocking the TIGIT and PD-1 signaling pathways significantly inhibits the proliferation, migration, and invasion of RCC cells and promotes their apoptosis. These effects are more evident in TIGIT inhibitors than in PD-1 inhibitors. TIGIT inhibitor mainly regulates the expression of differential genes to achieve the reconstruction of immune killing and restore the killing effect on the RCC, and its mechanism by which TIGIT functions overlap that of PD-1 inhibitor. TIGIT may become a target for the immunotherapy of RCC, and there is a theoretical basis for the combination of TIGIT inhibitors and PD-1 inhibitors for the treatment of RCC.

Meta-analysis of perioperative immunotherapy in renal cell carcinoma: Available, but the jury is still out.

While surgical management of renal cell carcinoma (RCC) is curative for many patients, others may relapse and could benefit from adjuvant treatments. Immune checkpoint inhibitors (ICI) have been proposed as a potential adjuvant therapy for improving survival in these patients, but the benefit/risk ratio of ICI in the perioperative setting remains unclear. A systematic review and a meta-analysis of phase III trials of perioperative ICI (anti PD1/PD-L1 alone or in combination with anti-CTLA4 agents) in RCC was conducted. The analysis included results from 4 phase III trials, comprising 3,407 patients. ICI did not show a significant increase in disease-free survival (Hazard Ratio [HR] 0.85; 95% confidence interval [CI] 0.69-1.04; p: 0.11) or overall survival [OS] (HR 0.73; 95% CI 0.40-1.34; p: 0.31). High-grade adverse events were more frequent in the immunotherapy arm (OR 2.65; 95% CI 1.53-4.59; p: <0.001), and high-grade treatment-related adverse events were 8 times more frequent in the experimental arm (OR: 8.07; 95% CI: 3.14-20.75; p: <0.001). Subgroup analyses showed statistically significant differences favoring the experimental arm in females (HR: 0.71; 95 CI 0.55-0.92; p: 0.009), in sarcomatoid differentiation (HR: 0.60 95% CI 0.41-0.89; p: 0.01), and PD-L1 positive tumors (HR HR: 0.74; 95% CI 0.61-0.90; p: 0.003). No significant effect was found in patients according to age, type of nephrectomy (radical vs. partial), and stage (M1 without evidence of disease vs. M0 patients). Our comprehensive meta-analysis generally suggests that immunotherapy does not confer a survival advantage in the perioperative setting for RCC, with the exception of one positive study. While the overall results are not statistically significant, individual patient factors and other variables may play a role in determining who benefits from immunotherapy. Therefore, despite the mixed findings, immunotherapy may still be a viable treatment option for certain patients, and further studies are needed to determine which patient subgroups would be most likely to benefit.

Targeting Alpha-Ketoglutarate Disruption Overcomes Immunoevasion and Improves PD-1 Blockade Immunotherapy in Renal Cell Carcinoma.

The Warburg effect-related metabolic dysfunction of the tricarboxylic acid (TCA) cycle has emerged as a hallmark of various solid tumors, particularly renal cell carcinoma (RCC). RCC is characterized by high immune infiltration and thus recommended for immunotherapeutic interventions at an advanced stage in clinical guidelines. Nevertheless, limited benefits of immunotherapy have prompted investigations into underlying mechanisms, leading to the proposal of metabolic dysregulation-induced immunoevasion as a crucial contributor. In this study, a significant decrease is found in the abundance of alpha-ketoglutarate (αKG), a crucial intermediate metabolite in the TCA cycle, which is correlated with higher grades and a worse prognosis in clinical RCC samples. Elevated levels of αKG promote major histocompatibility complex-I (MHC-I) antigen processing and presentation, as well as the expression of β2-microglobulin (B2M). While αKG modulates broad-spectrum demethylation activities of histone, the transcriptional upregulation of B2M is dependent on the demethylation of H3K4me1 in its promoter region. Furthermore, the combination of αKG supplementation and PD-1 blockade leads to improved therapeutic efficacy and prolongs survival in murine models when compared to monotherapy. Overall, the findings elucidate the mechanisms of immune evasion in anti-tumor immunotherapies and suggest a potential combinatorial treatment strategy in RCC.

Bibliometric analysis on the progress of immunotherapy in renal cell carcinoma from 2003-2022

ABSTRACT The incidence and mortality rates of renal cell carcinoma (RCC) have been increasing annually due to obesity and environmental pollution. Although immunotherapy of RCC has been studied for decades, few comprehensive bibliometric analyses exist on the treatment. Therefore, the purpose of this bibliometric analysis was to identify scientific achievements of the global research on RCC immunotherapy from 2003 to 2022 and discuss research trends. Data were retrieved from the Clarivate Web of Science Core Collection using a set retrieval strategy. The Bibliometrics tool Cite Space 6.2 R2 (Chaomei Chen, Drexel University) was used to analyze 4,841 articles. The USA had the most publications (n = 1,864); Harvard University was identified as the leading institution (n = 264); and Dr. Toni K. Choueiri, was the most productive researcher in the field (n = 55). Keyword analysis showed that nivolumab, immune checkpoint inhibitors, tumor microenvironment, everolimus, cabozantinib, resistance, pembrolizumab and ipilimumab were the main hotspots and frontier directions of RCC. By analyzing the results of bibliometrics, national and international researchers can better understand the current research status of RCC immunotherapy and identify new directions for future research. However, the analysis also identified pockets of insularity, highlighting a need for greater collaboration and cooperation among researchers to advance the field of RCC immunotherapy.

Tumor Microenvironment in Renal Cell Carcinoma: What is the Current Impact?

Tweetable abstract Tumor microenvironment plays a critical role in tumor progression and response to therapy. Recent studies show the potential of gene expression signatures and T cells to predict response to immunotherapy in renal cell carcinoma.

Early Integration of Palliative Care for Patients Receiving Systemic Immunotherapy for Renal Cell Carcinoma.

Early Integration of Palliative Care for Patients Receiving Systemic Immunotherapy for Renal Cell Carcinoma.

Identification of immune cell infiltration profiles in renal cell carcinoma and their clinical significance.

Renal cell carcinoma (RCC) is the most common malignancy of the urinary system, accounting for 3.7% of all new malignancies. The prognosis of RCC patients is still poor, especially patients in advanced stage. Limited studies have fully clarified the role of immune cell infiltration profiles in the prognosis and immunotherapy of RCC. In current study, we evaluated the abundance of the 22 tumor-infiltrating immune cells (TIICs) with CIBERSORT methods. The correlation between TIICs and clinicopathological parameters, tumor immune dysfunction and exclusion (TIDE) score and immunophenoscore (IPS) of RCC patients were also explored. Significant correlations were obtained between TIICs subpopulation and specific clinicopathologic parameters of RCC, including age, gender, tumor grade, clinical stage, T stage and distant metastasis. Moreover, RCC patients with high level of memory activated CD4 T cells, follicular helper T cells and regulatory T cells had a worse overall survival (OS) rate. RCC patients with high level of CD 8 + T cells and M1 macrophages had a lower TIDE score and higher anti-CTLA IPS, higher anti-PD1 IPS as well as higher anti-PD1/CTLA4 IPS. Our results clarified the immune cell infiltration profiles of RCC. RCC patients with high level of CD 8 + T cell and M1 macrophages had a lower TIDE score and higher IPS, suggesting that RCC patients with high level of CD 8 + T cell and M1 macrophages may benefit from immunotherapy.

Case Report: A Rising Cause of New-Onset Endocrinopathies After Immunotherapy

The use of immune checkpoint inhibitors (ICIs) has resulted in a shift in the treatment of oncologic malignancies. Checkpoint inhibitors are a type of immunotherapy that block proteins consequently allowing the immune system to attack cancer cells. ICIs not only cause tumor cell death but can also damage healthy cells and cause immune-related adverse effects. ICIs have been shown to cause endocrinopathies of the pituitary, thyroid, and adrenal glands as well as the pancreas. This case presents an adult patient with a recent hyperthyroidism diagnosis and no history of diabetes who presented with 2 episodes of diabetic ketoacidosis after undergoing immunotherapy for renal cell carcinoma.

Abstract 5071: Olverembatinib (HQP1351) enhances antitumor effects of immunotherapy in renal cell carcinoma (RCC)

Abstract In solid tumors, resistance to checkpoint inhibitors (CPIs) is frequently observed, partially due to upregulation of vascular endothelial growth factor A (VEGFA) and programmed death-ligand 1 (PD-L1). This culminates in an immunosuppressive tumor microenvironment and immune escape. Inhibitors against VEGF and the VEGF receptor (VEGFR) foster tumor vessel normalization and immunostimulatory reprogramming, in turn promoting treatment effects of immunotherapies. In recent years, TKIs, including axitinib, lenvatinib, and cabozantinib, plus immunotherapy have been approved to treat advanced RCC. Currently under clinical development for relapsed or refractory chronic myeloid leukemia and gastrointestinal tumor, olverembatinib (HQP1351) is a new-generation multikinase inhibitor with targets including VEGFR, fibroblast growth factor receptor (FGFR), SRC, BCR-ABL1, c-KIT, and platelet-derived growth factor receptor. The aim of this study was to assess whether olverembatinib combined with immunotherapy can promote inhibitory effects on RCC. In cell-free kinase assays, olverembatinib inhibited VEGFR1, -2, and -3 with IC50 values of 4.2, 6.1, and 4.1 nM, respectively. Compared to lenvatinib, olverembatinib had more potent antiproliferative effects on human umbilical vein endothelial cells. Olverembatinib also had antiproliferative activity in murine RCC lines RANCA and RAG, with IC50 values of 141 and 53 nM, respectively. When olverembatinib was coadministered with an anti-PD-1 antibody in a RANCA-derived syngeneic model, both agents exerted synergistic effects, with tumor growth inhibition rates reaching 60.6%. Mechanistically, olverembatinib influenced cancer cell proliferation directly by inhibiting phosphorylation of FGFR and downstream proteins. Increased cleavage of caspase-3 and poly (ADP-ribose) polymerase 1 were observed, suggesting induction of apoptosis. Olverembatinib also influenced proliferation of vascular endothelial cells by inhibiting phosphorylation of VEGFR, SRC, and downstream proteins Akt and extracellular signal-regulated kinases. Olverembatinib also reduced expression of PD-L1 in RCC cells. In tumor-infiltrating lymphocyte assays, olverembatinib increased numbers of cytotoxic T cells (CTL, CD8+) and natural-killer cells (NK, CD3−/CD49B+) in RANCA tumor tissues. Combined with an anti-PD-1 antibody, olverembatinib increased CTLs, NK cells, dendritic cells (DCs, MHC-II+/CD11C+), and M1 macrophages (F4/80+/CD11B+/CD86+) in RANCA tumor tissues, indicating an immunoregulatory effect of olverembatinib. Taken together, these data suggest that combining olverembatinib with a CPI confers synergistic antitumor effects in an RCC cancer mouse model by targeting tumor growth, angiogenesis, and immune regulation. This novel combination may provide an alternative approach to enhance treatment effects with CPIs in renal cancers. Citation Format: Guangfeng Wang, Eric Liang, Ping Min, Huidan Yu, Bingxing Wu, Dajun Yang, Yifan Zhai. Olverembatinib (HQP1351) enhances antitumor effects of immunotherapy in renal cell carcinoma (RCC). [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5071.

Adjuvant immunotherapy in renal cell carcinoma: A systematic review and meta-analysis of randomized clinical trials.

671 Background: There has been interest in adjuvant immune checkpoint inhibition (ICI) following surgical resection in patients with high-risk renal cell carcinoma (RCC) given high recurrence rates and approvals of ICI in metastatic RCC. The primary objective of this analysis was to synthesize available data regarding the disease-free survival (DFS) benefit of adjuvant ICIs for patients with RCC. Methods: This systematic review was performed according to the PRISMA guidelines. The protocol was registered in PROSPERO (CRD42022361599). We searched PubMed, EMBASE, and relevant conference proceedings to identify phase III randomized controlled trials (RCTs) comparing adjuvant ICI versus placebo/observation. The primary outcome of interest was DFS. Results: Among the four included studies, one demonstrated a significant DFS benefit. There was considerable clinical and statistical heterogeneity (I2=64%) due to differences in inclusion criteria and interventions. While pooled results across the four studies did not demonstrate a significant benefit in DFS overall (HR 0.85, 95% CI 0.69-1.04), there was significant benefit among patients with positive PD-L1 expression (HR 0.72, 95% CI 0.55-0.94) or sarcomatoid features (HR 0.59, 95% CI 0.38-0.91). Conclusions: The evidence base to date regarding ICI as adjuvant therapy in RCC is mixed – conclusions are limited by considerable heterogeneity between studies. However, pooled analyses suggest that patients with positive PDL1 expression or sarcomatoid features are most likely to benefit from adjuvant immunotherapy.

Adjuvant immunotherapy in renal cell carcinoma: A living systematic review and network meta-analysis (NMA).

694 Background: The treatment landscape of localized renal cell carcinoma (RCC) is rapidly evolving. Recent trials have demonstrated contrasting efficacy with adjuvant immunotherapy. Therefore, we sought to assess the mixed treatment comparisons among different adjuvant treatment options using updated data from trials and quantified the absolute effect with these treatments stratified by risk categories. Methods: This living network meta-analysis was conducted using the living interactive evidence (LIvE) synthesis framework. We used stratified baseline risks of disease progression from observational data and at 5, 10, 15 years from the Leibovich risk stratification system (based on risk scores ranging from 0 to ≥15). Corresponding intervention risks were then approximated using relative effect estimates (from NMA) and baseline risks. The difference between CIRs and baseline risks were calculated to present absolute risk differences in each risk category. Results: This NMA included eight RCTs with 8480 participants and seven unique treatment options. Pembrolizumab (pembro; rank 1) was associated with improved disease-free survival (DFS) when compared to atezolizumab (atezo; rank 6; hazard ratio: 0.68; 0.49;0.93), and nivolumab-ipilimumab (nivoipi; rank 5; 0.68; 0.48-0.97). However, no statistically significant difference was observed between pembro and atezo for overall survival (0.53; 0.28-1.01). Survival data for nivoIpi was not reported. No new statistically significant differences were observed since last update. The absolute benefit of atezo and nivoipi was minimal with higher T and N patients (Table). The results were similar with increasing Leibovich risk scores. Conclusions: Current evidence favors the use of a risk adapted approach when offering adjuvant immunotherapy. Adjuvant pembrolizumab remains a preferred treatment in patients with RCC who underwent nephrectomy. [Table: see text]