Does obesity influence the prognosis of metastatic renal cell carcinoma in patients treated with vascular endothelial growth factor-targeted therapy?

BACKGROUND

Obesity increases the risk for renal cell carcinoma (RCC). However, it has only recently been identified as an independent positive prognostic factor for localized RCC.

OBJECTIVE

To determine whether obesity influences long-term prognosis in metastatic RCC patients receiving vascular endothelial growth factor-targeted therapy.

DESIGN, SETTING, AND PARTICIPANTS

In 116 patients with metastatic RCC who received antiangiogenic agents (sunitinib, sorafenib, axitinib, bevacizumab) in 2005-2010, we evaluated whether body mass index (BMI), a body surface area (BSA) above the European average, the visceral fat area (VFA), or s.c. fat area (SFA) were of predictive relevance.

MEASUREMENTS

BMI was categorized based on current World Health Organization definitions. BSA was stratified according to the European average for men (1.98 m(2)) and women (1.74 m(2)). VFA and SFA were dichotomized using the median of the observed distribution as the cutoff. The primary endpoints of this study were time to progression and overall survival time.

RESULTS AND LIMITATIONS

The whole population had median progression-free and overall survival times of 8.3 months and 20.5 months, respectively. In contrast to BMI and BSA, higher than average VFA and SFA levels were significant predictors of longer progression-free and overall survival times. The major limitations of this study are its retrospective design and its heterogeneous patient population.

CONCLUSION

This is the first study to identify high VFA and SFA levels as positive predictive biomarkers for patients who receive first-line antiangiogenic agents for metastatic RCC.

Partial nephrectomy using porcine small intestinal submucosa

BACKGROUND

Whenever technically feasible and oncologically justified, nephron-sparing surgery is the current standard of care for localized renal cell carcinomas (RCC). The main complications of partial nephrectomy, especially for large and centrally located tumors, are urinary leakage and parenchymal bleeding. We prospectively evaluated the pros and cons of using porcine small intestinal submucosa (SIS, Surgisis®) to close the renal defect after nephron-sparing surgery.

METHODS

We used Surgisis® (Cook medical, Bloomington, IN, USA) to secure and compress the capsular defect after tumor resection in 123 patients submitted to 129 partial nephrectomies between August 2003 and February 2011.

RESULTS

The median tumor size was 3.7 cm (range 1.1-13.0 cm). Procedures were performed with cold ischemia in 24 cases (18.2%), with warm ischemia in 46 (35.6%), and without ischemia in 59 cases (44.8%). In the total group of patients, 4 (3.1%) developed urinary fistula, and only 2 (1.6%) required postoperative transfusions due to hemorrhage after the application of the small intestinal submucosa membrane.

CONCLUSION

Small intestinal submucosa is an easy-to-use biomaterial for preventing complications such as postoperative bleeding and urinary fistula in nephron-sparing surgery, especially in cases where tumor excision causes significant renal capsular and/or renal pelvic defects.

Inhibition of glycogen synthase kinase-3β counteracts ligand-independent activity of the androgen receptor in castration resistant prostate cancer

In order to generate genomic signals, the androgen receptor (AR) has to be transported into the nucleus upon androgenic stimuli. However, there is evidence from in vitro experiments that in castration-resistant prostate cancer (CRPC) cells the AR is able to translocate into the nucleus in a ligand-independent manner. The recent finding that inhibition of the glycogen-synthase-kinase 3β (GSK-3β) induces a rapid nuclear export of the AR in androgen-stimulated prostate cancer cells prompted us to analyze the effects of a GSK-3β inhibition in the castration-resistant LNCaP sublines C4-2 and LNCaP-SSR. Both cell lines exhibit high levels of nuclear AR in the absence of androgenic stimuli. Exposure of these cells to the maleimide SB216763, a potent GSK-3β inhibitor, resulted in a rapid nuclear export of the AR even under androgen-deprived conditions. Moreover, the ability of C4-2 and LNCaP-SSR cells to grow in the absence of androgens was diminished after pharmacological inhibition of GSK-3β in vitro. The ability of SB216763 to modulate AR signalling and function in CRPC in vivo was additionally demonstrated in a modified chick chorioallantoic membrane xenograft assay after systemic delivery of SB216763. Our data suggest that inhibition of GSK-3β helps target the AR for export from the nucleus thereby diminishing the effects of mislocated AR in CRPC cells. Therefore, inhibition of GSK-3β could be an interesting new strategy for the treatment of CRPC.

[Assessment of residual tumours after systemic treatment of metastatic seminoma: ¹⁸F-2-fluoro-2-deoxy-D-glucose positron emission tomography - meta-analysis of diagnostic value]

BACKGROUND

Meta-analysis evaluating the accuracy and sensitivity of FDG (2-[(18)F]-fluoro-2-deoxy-D-glucose) positron emission tomography (PET) to predict viable residual tumours in patients with metastatic seminoma.

MATERIAL AND METHODS

Altogether 5 studies with 130 patients were identified. Both FDG PET and the size of the residual lesions on conventional computed tomography (CT; lesions either ≤ or > 3 cm) were correlated with the presence or absence of viable residual tumour.

RESULTS

The specificity (92 vs 59%), sensitivity (72 vs 63%), positive (70 vs 28%) and negative (93 vs 86%) predictive value of FDG PET were superior to data obtained by assessing residual tumour size (either ≤ or > 3 cm) applying CT scans alone.

CONCLUSION

In view of the data currently available, FDG PET seems to be a clinically useful predictor of viable tumour in post-chemotherapy residuals of pure seminoma.

Caveolin 1 mRNA is overexpressed in malignant renal tissue and might serve as a novel diagnostic marker for renal cancer

Background & aim: Caveolae play a significant role in disease phenotypes, such as cancer, diabetes, bladder dysfunction and muscular dystrophy. The aim of this study was to elucidate the expression of caveolin (CAV)1 in the development of renal cell cancer (RCC) and to determine a possible prognostic relevance for optimal clinical management. Material & methods: 109 RCC and 81 corresponding normal tissue specimens from the same kidney were collected from patients undergoing surgery for renal tumors and subjected to total RNA extraction. Quantification of CAV1 mRNA expression was performed using real-time reverse transcription PCR with three endogenous controls for renal proximal tubular epithelial cells and the ΔΔCt method for calculation of relative quantities. Expression levels were correlated to clinical variables. Results: Tissue-specific mean CAV1 expression was significantly increased in RCC compared with normal renal tissue (p = 0.0003; paired Wilcoxon rank sum test). CAV1 expression was increased 1.9-fold in clear cell RCC compared with papillary RCC (p = 1.48 × 10–7; unpaired Wilcoxon rank sum test). Patients with advanced disease had higher CAV1 expression when compared with organ-confined disease (p = 0.019; unpaired Wilcoxon rank sum test). Moreover, mean tissue-specific CAV1 expression was increased in patients with distant metastasis at the time of diagnosis compared with patients without metastasis (p = 0.0058; unpaired Wilcoxon rank sum test). Conclusion: To our knowledge, this is the first study to show that CAV1 mRNA expression, using quantitative real-time PCR, is significantly higher in RCC compared with normal renal tissue and increases with tumor stage. CAV1 mRNA expression might serve as a candidate biomarker for objective prognosis indicating RCC aggressiveness. Our data encourage further investigations to determine the role of CAV1 in RCC.

Does male sex influence the prognosis of patients with renal cancer?

BACKGROUND

The aim of this study was to investigate the influence of sex on stage, grade, subtype, and prognosis of patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

This study included 1,810 patients treated by surgery for RCC at the University Hospitals of Hannover and Marburg between 1990 and 2005. The median follow-up was 54 months.

RESULTS

Of all the patients, 1,167 (64.5%) were men and 643 (35.5%) were women. Men were significantly younger (mean, 61.4 vs. 63.5 years; p < 0.001), and suffered more frequently from advanced tumor stages (45.2 vs. 37.6%; p = 0.002) and higher tumor grades (14.1 vs. 11.1%; p = 0.003). Kaplan Meier curves revealed a significant difference in cancer-specific survival between men and women (5-year survival 64.7 vs. 74.0%; p = 0.002). However, unlike tumor stage, grade, and N/M status, sex could not be retained as a significant independent prognostic marker in multivariate analysis.

CONCLUSIONS

RCC in men is characterized by higher tumor stages and more frequent metastasis at diagnosis along with inferior tumor-specific survival. However, as sex failed to qualify as an independent prognostic marker for cancer-specific survival, delayed diagnosis due to insufficient or neglected (routine) medical check-up and/or more aggressive tumor biology could be concurrently causative for the higher incidence of RCC in men.

Fibronectin 1 mRNA expression correlates with advanced disease in renal cancer

Background

Fibronectin 1 (FN1) is a glycoprotein involved in cellular adhesion and migration processes. The aim of this study was to elucidate the role of FN1 in development of renal cell cancer (RCC) and to determine a prognostic relevance for optimal clinical management.

Methods

212 renal tissue samples (109 RCC, 86 corresponding tissues from adjacent normal renal tissue and 17 oncocytomas) were collected from patients undergoing surgery for renal tumors and subjected to total RNA extraction. Detection of FN1 mRNA expression was performed using quantitative real time PCR, three endogenous controls, renal proximal tubular epithelial cells (RPTEC) as biological control and the ΔΔCt method for calculation of relative quantities.

Results

Mean tissue specific FN1 mRNA expression was found to be increased approximately seven fold comparing RCC and corresponding kidney control tissues (p < 0.001; ANOVA). Furthermore, tissue specific mean FN1 expression was increased approx. 11 fold in clear cell compared to papillary RCC (p = 9×10^-5; Wilcoxon rank sum test). Patients with advanced disease had higher FN1 expression when compared to organ-confined disease (p < 0.001; Wilcoxon rank sum test). Applying subgroup analysis we found a significantly higher FN1 mRNA expression between organ-confined and advanced disease in the papillary and not in the clear cell RCC group (p = 0.02 vs. p = 0.2; Wilcoxon rank sum test). There was an increased expression in RCC compared to oncocytoma (p = 0.016; ANOVA).

Conclusions

To our knowledge, this is the first study to show that FN1 mRNA expression is higher in RCC compared to normal renal tissue. FN1 mRNA expression might serve as a marker for RCC aggressiveness, indicating early systemic progression particularly for patients with papillary RCC.

Present state of target therapy for disseminated renal cell carcinoma

Both experimental and clinical researches focusing on advanced kidney cancer have increased continuously since the successful introduction of targeted therapy in the treatment of advanced metastatic renal cell carcinoma. Being refractory to conventional hormone therapy, chemotherapy or radiotherapy, renal cell carcinoma has become a model tumor for the development and evaluation of diverse novel targeted drugs. This review highlights currently available agents and summarizes evidence-based data regarding their effectiveness in metastatic renal cell carcinoma. Furthermore, the role of debulking tumor nephrectomy followed by systemic therapy as part of an optimum treatment algorithm is being elucidated.

Urinary collecting system invasion is no independent prognostic factor in renal cell carcinoma

OBJECTIVES

To assess the specific impact of urinary collecting system (UCS) invasion on the long-term prognosis of patients with renal cell carcinoma (RCC).

METHODS

We evaluated 1,678 patients with complete information about UCS invasion of their primary RCC who had undergone renal surgery between 1990 and 2005 in two high volume centers (MH Hannover and Marburg, Germany); the mean follow-up was 5.4 years.

RESULTS

Hundred and forty-nine (8.9%) patients demonstrated collecting system invasion. These patients incurred a significant increase in the likelihood of cancer-related death (HR 1.7, 95% CI: 1.4-2.0; P < 0.001), their median 5-year tumor-specific survival rate was 45% as opposed to 73% for patients without UCS invasion (P < 0.001). UCS invasion was significantly associated with tumor stage, grade, lymph node, and visceral metastasis at diagnosis but not with age, gender, histologic subtype, or body mass index. However, using multivariate analysis, UCS invasion disqualified as individual prognostic factor for RCC, neither for localized nor for advanced disease.

CONCLUSION

Facing the results of this large trial, we do not support the inclusion of UCS invasion into upcoming TNM staging systems. In contrast, future research should focus on novel molecular markers expressed by the tumor and/or specific immunological characteristics of patients with RCC which could improve prediction of RCC-associated prognosis.

[Pelvic lymphadenitis after total hip arthroplasty : Mimicking of lymph node metastases in a patient with prostate cancer]

This report describes the case of a 65-year-old patient who underwent radical prostatectomy in our department. Intraoperatively we detected suspicious lymph nodes on the left side. The histopathological examination revealed histiocytosis and foreign body giant cells but no sign of tumor. The enlarged lymph nodes were ascribed to an ipsilateral total hip arthroplasty performed 14 years previously because of progressive coxarthrosis. Lymphadenitis after total hip arthroplasty is frequently observed. Histopathologically and with the use of polarized light microscopy, histiocytosis and wear particles such as titanium, polyethylene, and polyethylene-methylacrylate may be detected. When operating on patients with arthroplasty of a lower limb, particularly those with a total endoprosthesis, the surgeon should bear in mind that changes in lymph node consistency and size do not necessarily indicate tumor involvement or metastases.

[Gender-specific characteristics and survival of renal cell carcinoma]

BACKGROUND

Renal cell carcinoma (RCC) occurs twice as often in men as in women; however, the influence of gender on stage, grade, subtype and prognosis has not been studied in detail.

METHODS

This study included 780 patients treated by (partial) nephrectomy at our institution in Marburg between 1990 and 2005. The mean follow-up was 5.44 years.

RESULTS

Of the 780 patients, 486 (62%) were men and 294 (38%) were women. Women were significantly older (mean, 65.3 vs. 62.2 years; p<0.001, t-test), presented at lower T stages (p=0.046, chi(2)) and suffered metastasis less frequently at diagnosis (p=0.026, chi(2)). In addition, women more frequently had clear cell tumours (85.2% vs. 78.3%) and less frequently papillary tumours (11.0% vs. 18.8%) than men (p=0.026, chi(2)). In contrast, men had an increased risk of death from RCC (HR 1.23, CI 0.92-1.63); Kaplan-Meier curves revealed a significant difference in tumour-specific survival between men and women (p=0.033, log rank; 5-year survival 74% vs. 83%). However, unlike tumour stage and tumour grade, gender could not be retained as a significant independent prognostic marker in multivariate analysis.

CONCLUSION

In general, RCC in men is characterized by higher tumour stages and more frequent metastasis at diagnosis along with inferior tumour-specific survival. However, as gender failed to qualify as an independent prognostic marker for tumour-specific survival, delayed diagnosis due to insufficient routine medical check-up and/or a more aggressive tumour biology might be be a concurrent cause. Thorough regular medical check-ups for men, also with regard to RCC, are thus mandatory.

[Selective cervical lymph node dissection for primary, node-negative, oral squamous cell carcinoma: oncologic assessment and clinical relevance of prognostic factors for secondary local metastasis]

BACKGROUND

The aim of this retrospective study was to evaluate prognostic factors for the development of secondary local lymph node metastases in patients with oral squamous cell carcinoma who had undergone selective neck dissection for primary node-negative disease.

PATIENTS AND METHODS

The study included 331 patients with primary squamous cell carcinoma of the oral cavity who underwent 431 selective neck dissections between January 1986 and December 2002 in Germany at the Hannover Medical School's Department of Oral and Maxillofacial Surgery. Several potential prognostic factors were evaluated for their influence on the development of secondary metastases following primary neck dissection.

RESULTS

No statistically significant relationship to the appearance of secondary local metastasis following selective neck dissection was detected concerning: patient age or sex, histopathologic tumor stage, primary tumor grade, or adjuvant therapies such as pre- or postoperative radiotherapy and radiochemotherapy. The only study factor with a statistically significant influence was the extent of lymphadenectomy, in which particularly the region of the carotid bifurcation played a decisive role.

CONCLUSION

Significantly fewer secondary metastases occurred following neck dissections that included the carotid trigone. In light of these results, we recommend that neck dissection for primary oral squamous cell cancer always include the region of the carotid bifurcation, regardless of the above mentioned associated patient and tumor factors.

Metastatic non-clear cell renal cell carcinoma: current therapeutic options

Non-clear cell (ncc) renal cell carcinoma (RCC) accounts for approximately 25% of all patients with metastatic RCC. It is refractory to standard immuno(chemo)therapy and, to date, no specific trials have been reported to evaluate the efficacy of novel targeted drugs in the different subtypes of metastatic nccRCC. We review all available data from subgroup analyses of the global sorafenib and sunitinib expanded access programmes, current phase-III trials, and smaller multi- and single-centre studies focusing on the activity of targeted agents in these specific and rare RCC subtypes. Both sorafenib and sunitinib have significant activity in metastatic nccRCC, but the efficacy of each agent seems to vary between different nccRCC forms. Preliminary clinical data for temsirolimus appear to be promising but more extensive and long-term data are awaited. With the advent of novel therapeutic options, specific controlled multicentre trials are urgently needed to define their exact value and efficacy for treating the historically resistant nccRCC forms. The medium-term aim should be to tailor the most advantageous therapy for each patient with respect to his/her individual RCC subtype and physical condition.

Pre- and perioperative predictors of short-term clinical outcomes in patients undergoing percutaneous nephrolitholapaxy

Percutaneous nephrolitholapaxy (PCNL) with modern stone disintegration technologies is the treatment of choice for patients with extensive stone burden or stones refractory to extracorporeal shock wave lithotripsy. However, little is known about factors predicting unfavourable outcome in terms of perioperative complications, residual stone burden or prolonged hospitalization. The aim of this study was to evaluate preoperative, patient- and stone-related parameters that might influence the perioperative course and short-term clinical outcomes. In a prospective study, age, sex, body mass index (BMI), bidimensional size, side, pre-existent urinary tract infection, pre-existent hydronephrosis and previous kidney surgery were used as independent variables in both univariate and multiple regression models in 109 PCNL patients in order to predict the partition of patients rendered stone free at hospital discharge, duration of surgery, length of inpatient hospital stay and the occurrence of major complications. Univariate and multiple regression analysis revealed that stone size was the only factor influencing duration of surgery (P < 0.001) and hospitalization (P = 0.02), but had no predictive potential for major complications. Univariate analysis showed a trend towards longer inpatient hospital stay and clinically relevant residuals in patients with lower BMI (P = 0.05 and 0.06); however, after controlling for the other confounding variables, this was only reproducible for residual stone burden. The other patient- and stone-related factors did not adversely affect the outcome measures. In our patient sample treated with PCNL by LithoClast Master/Ultra we found evidence that large stone burden is a prognostic factor predicting longer surgery and prolonged hospitalization. In addition, patients with lower BMIs might be at higher risk of not being stone free at hospital discharge accompanied by prolonged inpatient treatment.

Clinical impact of MDR1-expression in testicular germ cell cancer

AIM

The multidrug resistance protein 1 (MDR1, P-gp, p-170) is a membrane glycoprotein that acts as an energy-dependent drug efflux pump. In various malignancies its expression is associated with resistance to diverse cytostatic drugs, and therefore predicts resistance to systemic treatment. The aim of this study was to investigate the prognostic value of MDR1 expression in primary tumor tissue to predict necrosis or viable cancer in residual tumor masses after systemic chemotherapy for advanced testicular germ cell cancer.

MATERIALS AND METHODS

Out of 77 patients, histopathological characteristics of primary testicular cancer specimens and retroperitoneal lymph node dissection (RPLND) samples following chemotherapy were available from 72 and all 77 patients, respectively. Moreover, MDR1 expression was determined by immunohistochemistry in 47 primary tumors and corresponding 73 RPLND sections.

RESULTS

After chemotherapy and subsequent RPLND, the examination of residual tumor masses revealed that mature teratoma and active viable tumor were predominantly found in patients with non-seminoma (NSGCT; p=0.048), especially in those with containing mature teratoma (p=0.001). Moreover, using univariate analysis the expression of MDR1 in the primary testicular tumor predicted viable tumor/teratoma residues in RPLND sections (p=0.003). However, in multivariate analysis including the tumors' histological subtype, MDR1 expression alone failed to reach statistical significance as an independent prognostic marker for residual vital tumor (p>or=0.16).

CONCLUSIONS

With the limited number of patients given, the correlation between MDR1 expression in primary testis cancer and active residual retroperitoneal disease after chemotherapy failed to reach statistical significance as in independent marker. Therefore, up to now routine MDR1 staining of testicular germ cell cancer samples should not be performed in clinical practice. However, as there was a clear trend, a larger number of patients suffering from metastatic non-seminomas should be studied, as MDR1 expression might have significant prognostic value in this particular subgroup of patients.