Over the past decade, major advances have been made in the treatment of advanced and metastatic
renal cell carcinomas, specifically clear cell
carcinomas. For many years the optimal approach was sequential; thus, monotherapies [principally
tyrosine kinase inhibitors (TKIs)] targeting angiogenesis until toxicity or progressive disease developed. The rationale was the common mechanisms of action of the targeting agents and avoidance of the risk of overlapping toxicities.
Immune checkpoint inhibitors (ICIs) are effective monotherapies, and combinations thereof with anti-angiogenic agents were thus later considered. Synergistic interactions were reported in vitro. Clinical efficacy was evident in three pivotal phase III trials with
axitinib-
pembrolizumab,
cabozantinib-
nivolumab, and
lenvatinib-
pembrolizumab combinations. Two other combinations showed interesting results but did not improve overall survival. However, the data aided our understanding of the new therapeutic approaches. A combination of the ICIs
nivolumab and
ipilimumab was the first to evidence better progression-free and overall survival compared to
sunitinib in patients with intermediate or unfavourable prognoses as evaluated by the International mRCC Database Consortium (IMDC). Here we focus on the TKI-ICI combinations, emphasising the rationale of their use and the clinical results. To date, no
biomarker facilitating the selection of an optimal treatment by disease and patient status has been reported.