Why CAR T cell therapy fails in renal cell carcinoma

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Abstract
Chimeric antigen receptor (CAR) T cell therapy has transformed the treatment landscape of hematologic malignancies, yet its clinical efficacy in solid tumors remains limited. Renal cell carcinoma (RCC) presents a striking paradox: despite its established responsiveness to immune modulation and the expression of targetable tumor antigens, CAR-T therapies have failed to produce durable clinical benefit. This failure has often been attributed to antigen heterogeneity or lack of tumor specificity; however, accumulating clinical and experimental evidence suggests that antigen recognition alone does not determine therapeutic success in RCC. In this review, we discuss evidence that CAR-T failure in RCC may reflect consistent biological constraints suggesting a systemic mismatch between engineered T cells and the renal tumor ecosystem. Across clinical studies targeting multiple RCC-associated antigens, CAR-T cells demonstrate limited tumor trafficking, rapid functional decline, and poor intratumoral persistence, with little evidence of antigen-driven escape. We examine three interrelated barriers underlying this failure: immune exclusion driven by abnormal vasculature, hypoxia, and suppressive myeloid populations; profound metabolic competition and bioenergetic stress imposed by the uniquely rewired RCC microenvironment; and the insufficiency of antigen targeting in the absence of environmental support for sustained T cell function. We further discuss how these insights necessitate a shift from generic CAR-T platforms toward RCC-adapted cellular therapies. Strategies that enhance tumor homing, improve metabolic fitness, tolerate hypoxia, and actively remodel the myeloid-dominated microenvironment may be essential for achieving durable efficacy. Finally, we outline implications for clinical trial design, patient selection, and biologically rational combination strategies. Reframing CAR-T therapy as a systems-level intervention, rather than a target-restricted cytotoxic approach, may be critical for unlocking its potential in renal cell carcinoma.

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