Epidemiologic and socioeconomic burden of metastatic renal cell carcinoma (mRCC): a literature review

MicroRNA-21 is overexpressed in renal cell carcinoma

OBJECTIVE

To identify microRNAs (miRNAs) that are overexpressed in renal cell carcinoma (RCC) and characterize the functional role of miR-21.

MATERIALS AND METHODS

The miRNA expression profiles between RCC tissue and adjacent normal tissue were compared using microarray analysis. The differential expression of miR-21 was validated by real-time polymerase chain reaction (RT-PCR). 786-O RCC cells were transfected with miR-21 mimic, miR-21 inhibitor, or negative controls and cell proliferation, apoptosis and cell cycle were examined by MTT assay and flow cytometry. The expression of programmed cell death 4 (PDCD4) and tropomyosin 1 (TPM1) was detected by RT-PCR and Western blot analysis.

RESULTS

Compared to adjacent normal tissue, 10 human miRNAs were significantly upregulated and 7 were downregulated in RCC tissue. RT-PCR confirmed that miR-21 was significantly overexpressed in RCC tissue. In vitro expression of miR-21 mimic promoted the growth of 786-O cells, whereas miR-21 inhibitor inhibited cell growth by inducing apoptosis and cell cycle arrest at S phase. Furthermore, miR-21 mimic or inhibitor significantly reduced or increased the expression of PDCD4 and TPM1.

CONCLUSIONS

MiR-21 is overexpressed in RCC tissue and modulates the growth, apoptosis and cell cycle progression of RCC cells and regulates the expression of PDCD4 and TPM1.

Down-Regulated miR-30a in Clear Cell Renal Cell Carcinoma Correlated with Tumor Hematogenous Metastasis by Targeting Angiogenesis-Specific DLL4

Background

Endothelial DLL4 plays an important role in controlling of tumor angiogenesis, which is required for tumor invasive growth and metastasis. However, the regulation of DLL4 in clear cell renal cell carcinoma (ccRCC) has not yet been systematically elucidated.

Methodology

We performed bioinformatical analysis to explore miRNAs targeting DLL4. miR-30a was selected as a representative to validate its functional association in endothelial cell. Then, the expressions of DLL4 and mature miR-30a from 90 cases of ccRCC and 28 cases of nonmatched adjacent non-tumor tissues were measured by quantitative real-time PCR. Finally, the expression of miR-30a was correlated with DLL4 expression, tumor features (metastatic condition and microvessel density), and patient metastasis-free survival. The univariate and multivariate analyses were performed to select the risk factors associated with hematogenous metastasis, respectively.

Principal Findings

miR-30a negatively regulated DLL4 and inhibited the proliferation and migration of endothelial cells. DLL4 was up-regulated in ccRCC and further increased in hematogenous metastatic cases, while miR-30a was down-regulated in tumor tissues and further decreased in hematogenous metastatic ccRCC (student t test, all p<0.05). Additionally, expression of miR-30a was inversely correlated with expression of DLL4 and microvessel density (linear correlation analysis, both p<0.05). Low-level miR-30a also indicated a higher probability of developing metastasis (log-rank test, p = 0.010). Most importantly, miR-30a expression was an independent predictor of ccRCC hematogenous metastasis by the univariate analysis and binary logistic regression model (both p<0.05).

Conclusions

Down-regulated miR-30a in ccRCC was associated with tumor hematogenous metastasis through increasing microvessel density by targeting angiogenesis-specific DLL4.

Tumour-associated macrophages might represent a favourable prognostic indicator in patients with papillary renal cell carcinoma

AIMS

Tumour-associated macrophages (TAM) have been reported to be regulators of progression in various human cancers. We evaluated the prognostic relevance of TAM in a large series of patients with papillary renal cell carcinoma (PRCC).

METHODS AND RESULTS

The impact of TAM on cancer-specific survival (CSS) in 177 patients with PRCC was assessed using the Kaplan-Meier method and log-rank test. A multivariate Cox regression analysis was performed with respect to CSS. The presence of TAM was noted in 112 of 177 (63%) tumours and was associated statistically significantly with favourable pathological parameters, including low pathological T stage, node-negative tumours, low tumour grade, absence of vascular invasion and papillary subtype (all P < 0.05), respectively. Five-year CSS probabilities for patients with TAM-positive tumours were 93.5%, compared with 72.5% in patients with TAM-negative tumours, respectively (P < 0.001). Multivariate analysis revealed node-positive tumours, distant metastases and UICC stage (I versus II-IV) as independent predictors of death from PRCC, whereas the presence of TAM was associated independently with favourable outcome (hazard ratio = 0.45, 95% confidence interval 0.24-0.84, P = 0.012).

CONCLUSIONS

The presence of TAM was shown independently to reduce the risk of death from cancer by 55%. The presence of TAM should therefore become part of routine pathology reporting in PRCC.

Evaluating the expression of CARMA3 as a prognostic tumor marker in renal cell carcinoma

Increased expression of CARMA3 has been reported to be involved in tumorigenesis and tumor progression of several cancer types. The aim of our study is to investigate the prognostic role of CARMA3 expression in patients with renal cell carcinoma (RCC). Real-time quantitative PCR was performed to detect CARMA3 mRNA expression level in 31 paired samples of RCC and adjacent noncancerous renal tissues. Subsequently, extensive immunohistochemistry was performed to detect CARMA3 protein expression in 114 RCC cases. Clinicopathological data for these patients were evaluated. The prognostic significance was assessed using the Kaplan-Meier survival estimates and log-rank tests. CARMA3 mRNA expression was significantly higher in RCC tissues compared with adjacent noncancerous renal tissues (3.525 ± 1.233 vs. 1.512 ± 0.784, P < 0.001). In addition, high CARMA3 expression in RCC tissues was significantly associated with tumor size (P = 0.026), histological differentiation (P = 0.039), tumor stage (P = 0.006), and the presence of metastasis (P < 0.001). Moreover, Kaplan-Meier analysis showed that patients with high CARMA3 expression also had a significantly poorer prognosis than those with low CARMA3 expression (log-rank test, P < 0.001). Furthermore, multivariate analysis illustrated that CARMA3 overexpression might be an independent prognostic indicator for the survival of patients with RCC. In conclusion, this work shows that CARMA3 may serve as a novel and prognostic marker for RCC and play a role during the development and progression of the disease.

Tumor-infiltrating PD1-Positive Lymphocytes and FoxP3-Positive Regulatory T Cells Predict Distant Metastatic Relapse and Survival of Clear Cell Renal Cell Carcinoma

BACKGROUND

Clear cell renal cell carcinoma (CRCC) is the most common malignant tumor of the kidney, and the clinical outcome of CRCC is related with the metastatic potential of CRCC. A significant proportion of metastatic CRCC remains incurable. Recently, immunotherapy against specific targets such as programmed death 1 (PD1) has been adapted for fatal cases of CRCC.

MATERIALS AND METHODS

In this study, we aimed to evaluate the potential of tumor-infiltrating PD1-positive lymphocytes or FoxP3-positive regulatory T cells (Tregs) as predictors of the metastatic potential or prognosis of CRCC and investigate possible correlations with Epstein-Barr virus (EBV) infection in 199 cases of CRCC.

RESULTS

PD1 positivity, high Treg number, and EBV infection all predicted poor overall survival (OS) by univariate analysis. PD1 positivity and high Treg numbers were also significantly correlated with more distant metastatic relapse (DMR) and poor relapse-free survival (RFS) by univariate analysis. PD1 positivity and high Treg number were independent prognostic indicators for OS. In addition, PD1 positivity was an independent predictor of RFS and DMR. EBV infection was an independent predictor of OS of CRCC.

CONCLUSION

This study demonstrates that intratumoral infiltration of PD1-positive or FoxP3-positive lymphocytes can be used as significant prognostic indicators of CRCC and PD1 positivity could be very helpful in the prediction of latent distant metastasis of CRCCs. Therefore, evaluation of the infiltration of PD-positive cells or Tregs in CRCC may be useful diagnostic tools for the selection of patients who could benefit from PD1- or Treg-based immunotherapy.

Down-regulation of human leukocyte antigen class I (HLA-I) is associated with poor prognosis in patients with clear cell renal cell carcinoma

Human leukocyte antigen class I (HLA-I) molecules are transmembrane glycoproteins that have been reported to be down-regulated in multiple types of human malignancies, including clear cell renal cell carcinoma (CCRCC). However, only one study has investigated its prognostic value in CCRCC. In the present study, HLA-I protein expression was analyzed in 120 archived, paraffin-embedded CCRCC samples and 10 adjacent normal tissues using immunohistochemistry. The correlation between HLA-I expression and clinicopathological factors was evaluated by the χ(2) test. Patients' overall survival was analyzed by the Kaplan-Meier method. HLA-I down-regulation was observed in 38.3% (46/120) of renal tumor samples, but only in 10% (1/10) of adjacent normal tissues. Statistical analysis showed a significant correlation of HLA-I expression with TNM stage, lymph node metastasis, and Fuhrman grade. Patients with tumors displaying down-regulation of HLA-I showed significantly shorter overall survival (P=0.021, log-rank test). More importantly, multivariate analysis indicated that down-regulation of HLA-I was an independent prognostic factor for CCRCC patients (P=0.033). Overall, our data suggest that HLA-I down-regulation is associated with tumor progression and a poor prognosis in CCRCC patients, and emphasize the importance of HLA-I in natural and therapeutic immune surveillance of patients with CCRCC.

Development and characterization of a novel mAb against bilitranslocase - a new biomarker of renal carcinoma

Background

Bilitranslocase (TC 2.A.65.1.1) is a bilirubin-specific membrane transporter, found on absorptive (stomach and intestine) and excretory (kidney and liver) epithelia and in vascular endothelium. Polyclonal antibodies have been raised in rabbits in the past, using a synthetic peptide corresponding to AA65-77 of rat liver bilitranslocase, as an antigen. Affinity-purified antibodies from immune sera have been found to inhibit various membrane transport functions, including the bilirubin uptake into human hepatocytes and the uptake of some flavonoids into human vascular endothelial cells. It was described by means of immunohistochemistry using polyclonal antibodies that bilitranslocase expression is severely down-regulated in clear cell renal carcinoma. The aim of our work was development and characterization of high-affinity, specific mAbs against bilitranslocase, which can be used as a potential diagnostic tool in renal cell carcinoma as well as in a wide variety of biological assays on different human tissues.

Materials and methods

Mice were immunized with a multi-antigen peptide corresponding to segment 65–75 of predicted primary structure of the bilitranslocase protein. By a sequence of cloning, immune- and functional tests, we aimed at obtaining a specific monoclonal antibody which recognizes a 37 kDa membrane protein, and influences the transport activity of bilitranslocase.

Results

On the basis of previous results, specific IgM monoclonal antibodies were produced in BALB/c mice, in order to further improve and extend the immunological approach to the study of bilitranslocase in renal cancer cells as well as to develop its potential diagnostics use.

Conclusions

In this article we show an immunological approach, based on newly developed monoclonal antibodies, to a detailed biochemical and functional characterization of a protein whose gene and protein structure is still unknown. We were able to demonstrate our novel mAb as a tumor marker candidate of renal cell carcinoma, which may prove useful in the diagnostic procedures.

Sunitinib induces cellular senescence via p53/Dec1 activation in renal cell carcinoma cells

Although multitargeted tyrosine kinase inhibitor sunitinib has been used as first-line therapeutic agent against metastatic renal cell carcinoma (mRCC), the molecular mechanism and functional role per se for its therapeutic performance remains obscure. Our present study revealed that sunitinib-treated RCC cells exhibit senescence characteristics including increased SA-β-gal activity, DcR2 and Dec1 expression, and senescence-associated secretary phenotype (SASP) such as proinflammatory cytokines interleukin (IL)-1α, IL-6 and IL-8 secretion. Moreover, sunitinib administration also led to cell growth inhibition, G1-S cell cycle arrest and DNA damage response in RCC cells, suggesting therapeutic significance of sunitinib-induced RCC cellular senescence. Mechanistic investigations indicated that therapy-induced senescence (TIS) following sunitinib treatment mainly attributed to p53/Dec1 signaling activation mediated by Raf-1/NF-κB inhibition in vitro. Importantly, in vivo study showed tumor growth inhibition and prolonged overall survival were associated with increased p53 and Dec1 expression, decreased Raf-1 and Ki67 staining, and upregulated SA-β-gal activity after sunitinib treatment. Immunohistochemistry analysis of tumor tissues from RCC patients receiving sunitinib neoadjuvant therapy confirmed the similar treating phenotype. Taken together, our findings suggested that sunitinib treatment performance could be attributable to TIS, depending on p53/Dec1 activation via inhibited Raf-1/nuclear factor (NF)-κB activity. These data indicated potential insights into therapeutic improvement with reinforcing TIS-related performance or overcoming SASP-induced resistance.

Immunohistochemical expression of CD44s in renal cell carcinoma lacks independent prognostic significance

PURPOSE

To analyze the immunohistochemical expression of the standard isoform of CD44 (CD44s) adhesion molecule in clear cell renal cell carcinoma (CCRCC) and its impact on clinical outcomes.

MATERIALS AND METHODS

Ninety-nine consecutive patients treated surgically for RCC between 1992 and 2009 were selected. A single pathologist reviewed all cases to effect a uniform reclassification and determine the most representative tumor areas for construction of a tissue microarray. The same pathologist, who was blinded to the outcome of the cases, semi-quantitatively scored the staining intensity of CD44s in all specimens. The counting was done using the H-Score algorithm.

RESULTS

Of the 99 immunostained RCC specimens, 57(57.7 %) showed low expression, and 42(42.4 %) showed high expression levels of CD44s. The expression of CD44s was directly associated with tumor size (p = 0.03), clinical stage (p = 0.02) and Fuhrman grade (p = 0.02). Disease specifi c survival (DSS) rates for patients whose specimens expressed low and high levels of CD44s was 88.1 % and 67.5 %, respectively (p = 0.009). Progression free survival (PFS) rates in patients with low and high expression of CD44s were 78.8 % and 61.7 %, respectively (p = 0.05). Classical features such as the presence of metastasis and clinical stage remained isolated predictors of survival.

CONCLUSIONS

Immunohistochemical expression of CD44s was associated with important clinical variables such as stage and Fuhrman grade. However, it was not an independent predictor of survival. Therefore, we believe it has a limited role as a prognostic marker in patients with CCRCC.

Dendritic cell-based vaccination for renal cell carcinoma: challenges in clinical trials

After decades of research, dendritic cell (DC)-based vaccines for renal cell carcinoma have progressed from preclinical rodent models and safety assessments to Phase I/II clinical trials. DC vaccines represent a promising therapy that has produced measurable immunological responses and prolonged survival rates. However, there is still much room to improve in terms of therapeutic efficacy. The key issues that affect the efficiency and reliability of DC therapy include the selection of patients who will respond best to treatment, the proper preparation and administration of DC vaccines, and a combination of DC vaccination with other immune-enhancing therapies (e.g., removal of Tregs, CTLA-4 blockade and lymphodepletion). Additional antiangiogenic agents will hopefully lead to greater survival benefits for patients in early disease stages. This review focuses on the different approaches of DC-based vaccination against renal cell carcinoma and potential strategies to enhance the efficacy of DC vaccination.

Epithelial-mesenchymal transition-related microRNA-200s regulate molecular targets and pathways in renal cell carcinoma

Our recent studies of microRNA (miRNA) expression signatures demonstrated that the epithelial-mesenchymal transition (EMT)-related microRNA-200 family (miR-200s: miR-200a/b/c, miR-141 and miR-429) were significantly downregulated in renal cell carcinoma (RCC) and putative tumor-suppressive miRNAs in RCC. In this study, our aim was to investigate the functional significance of the miR-200s in cancer cells and to identify novel miR-200s-regulated molecular targets and pathways in RCC. Expression levels of all the miR-200s members were significantly downregulated in human RCC tissues compared with normal renal tissues. Restoration of mature miR-200s in RCC cell line resulted in significant inhibition of cell proliferation and migration, suggesting that miR-200s function as tumor suppressors in RCC. Furthermore, we utilized gene expression analysis and in silico database analysis to identify miR-200s-regulated molecular targets and pathways in RCC. The miR-200s was categorized into two groups, according to their seed sequences, miR-200b/c/429 and miR-200a/141. Our data demonstrated that the 'Focal adhesion' and 'ErbB signaling' pathways were significantly regulated by miR-200b/c/429 and miR-200a/141, respectively. The identification of novel tumor-suppressive miR-200s-regulated molecular targets and pathways has provided new insights into RCC oncogenesis and metastasis.

Efficacy and safety of axitinib versus sorafenib in metastatic renal cell carcinoma: subgroup analysis of Japanese patients from the global randomized Phase 3 AXIS trial

OBJECTIVE

Axitinib is a potent and selective second-generation inhibitor of vascular endothelial growth factor receptors 1, 2 and 3. The efficacy and safety of axitinib in Japanese patients with metastatic renal cell carcinoma were evaluated.

METHODS

A subgroup analysis was conducted in Japanese patients enrolled in the randomized Phase III trial of axitinib versus sorafenib after failure of one prior systemic therapy for metastatic renal cell carcinoma.

RESULTS

Twenty-five (of 361) and 29 (of 362) patients randomized to the axitinib and sorafenib arms, respectively, were Japanese and included in this analysis. Median progression-free survival in Japanese patients was 12.1 months (95% confidence interval 8.6 to not estimable) for axitinib and 4.9 months (95% confidence interval 2.8-6.6) for sorafenib (hazard ratio 0.390; 95% confidence interval 0.130-1.173; stratified one-sided P = 0.0401). The objective response rate was 52.0% for axitinib and 3.4% for sorafenib (P = 0.0001). The common all-causality adverse events (all grades) in Japanese patients were dysphonia (68%), hypertension (64%), hand-foot syndrome (64%) and diarrhea (56%) for axitinib, and hand-foot syndrome (86%), hypertension (62%) and diarrhea (52%) for sorafenib. The safety profiles of axitinib and sorafenib in Japanese patients were generally similar to those observed in the overall population, with the exceptions of higher incidences of hypertension, dysphonia, hand-foot syndrome, hypothyroidism and stomatitis.

CONCLUSIONS

Axitinib is efficacious and well tolerated in Japanese patients with previously treated metastatic renal cell carcinoma, consistent with the results in the overall population, providing a new targeted therapy for these Japanese patients.

Pelvic and muscular metastasis of a renal cell carcinoma: A case report

We report a case of an uncommon site of metastasis of a renal cell carcinoma. The most common sites of renal cell carcinoma metastasis are the lung, lymph nodes, liver, bone and adrenal glands; skeletal muscle metastasis is a rare occurrence. We report the case of a 75-year-old female who underwent a laparoscopic left radical nephrectomy for a renal neoplasm in 2011. The histological examination revealed the presence of a renal cell carcinoma, Fuhrman grade 2, with extensive necrosis and phlogosis areas (TNM 2009 RCC pT2a). Ten months later, the patient noted an indolent swelling on the proximal third of the right thigh and underwent a ultrasonographic and CT evaluation, documenting the presence of a pathological, solid bulk in the front of the right iliac vessels and in the rectus femoris muscle. The fine needle biopsy revealed a metastasis of renal cell carcinoma. The patient underwent 4 cycles of sunitinib therapy, followed by 3 cycles of salvage therapy with sorafenib, which were well tolerated. This unpredictable behaviour of RCC suggests the need to perform a thorough follow-up of patients.

Human telomerase reverse-transcriptase promoter-controlled and herpes simplex virus thymidine kinase-armed adenoviruses for renal cell carcinoma treatment

New treatment strategies are required for renal cell carcinoma (RCC) due to its relative insensitivity to conventional radio- and chemotherapies. The promising strategy of tumor inhibition using human telomerase reverse transcriptase (hTERT)-controlled herpes simplex virus thymidine kinase/ganciclovir (HSV-TK/GCV) in the hTERT promoter-driven HSV-TK/GCV suicide gene system was investigated. Tumor volume, weight, relative proliferation rate, and cell-apoptosis levels were examined in mice injected with adenovirus (Ad)-hTERT-HSV-TK and GCV. Increased cell death occurred following treatment with Ads carrying hTERT-HSV-TK/GCV or cytomegalovirus promoter-controlled (CMV)-HSV-TK/GCV for human RCC 786-0 and fibroblast MRC-5 cells. In mice, Ad-hTERT-HSV-TK/GCV more specifically inhibited tumor and RCC xenograft growth than Ad-CMV-HSV-TK/GCV (P < 0.05). Furthermore, Ad-hTERT-HSV-TK/GCV did not significantly damage normal fibroblasts or organ systems (heart, lung, liver, brain, kidney, and spleen). Thus, Ad-hTERT-HSV-TK/GCV is an effective RCC inhibitor in human cells in vitro and in vivo mouse models, indicating potential usefulness in RCC-targeted gene therapy.

Patient-reported outcomes for axitinib vs sorafenib in metastatic renal cell carcinoma: phase III (AXIS) trial

Background:

Axitinib demonstrated greater progression-free survival vs sorafenib in a phase III study of previously treated patients with metastatic renal cell carcinoma. Here, we report patient-reported kidney-specific symptoms and health status, measured by the Functional Assessment of Cancer Therapy (FACT) Kidney Cancer Symptom Index (FKSI) and the European Quality of Life self-report questionnaire (EQ-5D).

Methods:

In all, 723 patients received axitinib (starting dose 5 mg twice daily (b.i.d.)) or sorafenib (400 mg b.i.d.). The FKSI-15, including the disease-related symptoms (FKSI-DRS) subscale, was administered on day 1 before dosing, every 4 weeks and at end of treatment (EOT)/withdrawal. Statistical methods included a mixed-effects repeated-measures model.

Results:

At baseline, patients in both arms had relatively high mean FSKI-15 and FKSI-DRS scores, comparable to the general US population. Subsequent on-treatment overall mean scores were similar between axitinib and sorafenib, and there was no substantial decline during treatment. Scores substantially worsened at EOT, mainly due to disease progression.

Conclusion:

Patient-reported outcomes were comparable for second-line axitinib and sorafenib and were maintained at relatively high levels while on treatment, but worsened at EOT. As duration of treatment was longer with axitinib than sorafenib, time to worsening of symptoms can be delayed longer with axitinib.

Sarcopenia and body mass index predict sunitinib-induced early dose-limiting toxicities in renal cancer patients

BACKGROUND

Little is known on factors predicting sunitinib toxicity. Recently, the condition of low muscle mass, named sarcopenia, was identified as a significant predictor of toxicity in metastatic renal cell cancer (mRCC) patients treated with sorafenib. We investigated whether sarcopenia could predict early dose-limiting toxicities (DLTs) occurrence in mRCC patients treated with sunitinib.

METHODS

Consecutive mRCC patients treated with sunitinib were retrospectively reviewed. A DLT was defined as any toxicity leading to dose reduction or treatment discontinuation. Body composition was evaluated using CT scan obtained within 1 month before treatment initiation.

RESULTS

Among 61 patients eligible for analysis, 52.5% were sarcopenic and 32.8% had both sarcopenia and a body mass index (BMI)<25 kg m(-2). Eighteen patients (29.5%) experienced a DLT during the first cycle. Sarcopenic patients with a BMI<25 kg m(-2) experienced more DLTs (P=0.01; odds ratio=4.1; 95% CI: (1.3-13.3)), more cumulative grade 2 or 3 toxicities (P=0.008), more grade 3 toxicities (P=0.04) and more acute vascular toxicities (P=0.009).

CONCLUSION

Patients with sarcopenia and a BMI<25 kg m(-2) experienced significantly more DLTs during the first cycle of treatment.

Emerging immunotherapies for renal cell carcinoma

In recent years, an improved understanding of renal cell carcinoma (RCC) tumour biology has resulted in major advances in the treatment of patients with metastatic RCC (mRCC). Although immunotherapy with interleukin-2 and interferon-α was once the standard of care for mRCC, the introduction of novel agents targeting angiogenesis and signal transduction pathways has markedly improved patient outcomes. However, targeted agents rarely induce complete responses, and patients eventually develop resistance to therapy, prompting consideration of novel therapeutic approaches and a resurgence of interest in immunotherapy for RCC. Phase I/II trials of vaccination with allogeneic dendritic cell/tumour fusions in patients with mRCC have demonstrated immunological and clinical responses in some patients, and T-cell modulating agents (e.g. antibodies against programmed death 1 and cytotoxic T lymphocyte-associated antigen-4, or soluble lymphocyte activation gene-3) and dendritic cell-activating toll-like receptor agonists have also shown encouraging evidence of efficacy in early-phase clinical trials. These early studies suggest that immunotherapy may continue to be an effective approach for patients with mRCC. As such, a number of other strategies are currently under investigation, including adoptive cell transfer (ACT) with T cells modified to target proteins expressed by renal tumours such as MAGE-A3/12, DR4 and TRAIL, and ACT with autologous natural killer cells. Results from trials of novel immunotherapies are encouraging, with data from other indications helping to facilitate development. To realise the full benefit for patients, it is likely that immunotherapy will need to be combined with targeted agents or other agents. Novel therapies used in combination or sequentially have the potential to improve outcomes in mRCC, and results from ongoing/planned trials will shape future therapy.

The epidemiology and risk factors for renal cancer

BACKGROUND

Renal cancer is a frequently occurring malignancy with over 270,000 new cases diagnosed and it being responsible for 110,000 deaths annually on a global basis. Incidence rates have gradually increased whilst mortality rates are starting to plateau.

OBJECTIVE

To review epidemiology and risk factors for renal cancer.

METHODS

The current data is based on a thorough review of available original and review articles on epidemiology and risk factors for renal cancer with a systemic literature search utilising Medline.

RESULTS

The prevalence of associated risk factors such as genetic susceptibility, smoking, hypertension and obesity are changing and could account for the changes in incidence whilst the role of diet and occupational exposure to carcinogens requires further investigation.

CONCLUSION

Despite the evidence of various associated risk factors, further work is required from well designed studies to gain a greater understanding of the etiology of renal cancer.

The expression of Eg5 predicts a poor outcome for patients with renal cell carcinoma

Eg5 is a member of the kinesin family of proteins, which associates with bipolar spindle formation in dividing tumor cells during mitosis. The aim of our study is to investigate the prognostic role of Eg5 expression in patients with renal cell carcinoma (RCC). RCC tissue specimens from 164 consecutively treated patients who underwent surgery between 2005 and 2011 were evaluated. The Eg5 expression was determined by immunohistochemistry, and correlated with clinicopathological parameters. The prognostic significance of Eg5 expression was explored using the univariate and multivariate survival analysis of 164 patients who were followed; one hundred and sixty-four tissue specimens "of patients" who were regularly followed with the mean 35.8 months (from 5 to 80 months). The expression of Eg5 was significantly associated with tumor nuclear grade (P = 0.019) and stage (P = 0.007), as well as tumor size (P = 0.033). In univariate analysis, Eg5 overexpression showed unfavorable influence on recurrence-free survival with statistical significance (P = 0.003). Clinical stage, nuclear grade and tumor size also showed strong statistical relation with adverse recurrence-free survival (P < 0.001). Multivariate analysis revealed that tumor stage, nuclear grade and Eg5 reactivity (P < 0.001, P = 0.002, P = 0.032) were identified as independent prognostic factors for recurrence-free survival in patients with RCC. In our opinion, the result of this study proved the relationship between Eg5 expression and worse clinical outcome in RCC. This finding suggested that Eg5 served as a prognostic factor, which could be useful to predict cancer evolution and provide appropriate treatments for RCC patients.

Axitinib Induced Recurrent Pneumothorax following Near-Complete Response of Renal Cell Carcinoma Lung Metastasis: An Unexpected Complication

We report a case of a Caucasian male with a history of renal cell carcinoma metastatic (mRCC) to the lungs refractory despite aggressive treatment with several lines of targeted therapy. He was started on axitinib palliative targeted therapy with a good clinical and radiological response; however one month after treatment initiation he presented to the emergency department with severe dyspnea and hypoxemia. Physical exam and chest X-ray revealed left-sided tension pneumothorax which required emergent thoracostomy with subsequent improvement; however it recurred requiring video assisted thoracoscopy. A left-sided 4 × 3 cm cavitated necrotic lesion was found at the level of the main pulmonary artery. Repair with pericardial fat flap was performed. Surgical biopsies from this lesion revealed mRCC with extensive necrosis. Imaging studies before and after axitinib use showed an initial 4 × 3 cm mass seen in the same location of this large cavitated necrotic tumor. Pneumothorax has not been described as a potential major complication from the use of axitinib. Complete or near-complete responses of mRCC to axitinib targeted therapy may lead to this potential life-threatening complication, particularly if the metastatic lesions are located near to pleural structures. We also review pertinent clinical trial data on axitinib.

Single-fraction stereotactic body radiotherapy for spinal metastases from renal cell carcinoma

Object

Stereotactic body radiotherapy (SBRT) has emerged as an important treatment option for spinal metastases from renal cell carcinoma (RCC) as a means to overcome RCC's inherent radioresistance. The authors reviewed the outcomes of SBRT for the treatment of RCC metastases to the spine at their institution, and they identified factors associated with treatment failure.

Methods

Fifty-seven patients (88 treatment sites) with RCC metastases to the spine received single-fraction SBRT. Pain relief was based on the Brief Pain Inventory and was adjusted for narcotic use according to the Radiation Therapy Oncology Group protocol 0631. Toxicity was scored according to Common Toxicity Criteria for Adverse Events version 4.0. Radiographic failure was defined as infield or adjacent (within 1 vertebral body [VB]) failure on follow-up MRI. Multivariate analyses were performed to correlate outcomes with the following variables: epidural, paraspinal, single-level, or multilevel disease (2–5 sites); neural foramen involvement; and VB fracture prior to SBRT. Kaplan-Meier analysis and Cox proportional hazards modeling were used for statistical analysis.

Results

The median follow-up and survival periods were 5.4 months (range 0.3–38 months) and 8.3 months (range 1.5–38 months), respectively. The median time to radiographic failure and unadjusted pain progression were 26.5 and 26.0 months, respectively. The median time to pain relief (from date of simulation) and duration of pain relief (from date of treatment) were 0.9 months (range 0.1–4.4 months) and 5.4 months (range 0.1–37.4 months), respectively. Multivariate analyses demonstrated that multilevel disease (hazard ratio [HR] 3.5, p = 0.02) and neural foramen involvement (HR 3.4, p = 0.02) were correlated with radiographic failure; multilevel disease (HR 2.3, p = 0.056) and VB fracture (HR 2.4, p = 0.046) were correlated with unadjusted pain progression. One patient experienced Grade 3 nausea and vomiting; no other Grade 3 or 4 toxicities were observed. Twelve treatment sites (14%) were complicated by subsequent vertebral fractures.

Conclusions

Stereotactic body radiotherapy for RCC metastases to the spine offers fast and durable pain relief with minimal toxicity. Stereotactic body radiotherapy seems optimal for patients who have solitary or few spinal metastases. Patients with neural foramen involvement are at an increased risk for failure.

Treatment for liver metastasis from renal cell carcinoma with computed-tomography-guided high-dose-rate brachytherapy (CT-HDRBT): a case series

PURPOSE

To retrospectively analyze the clinical outcome of patients with hepatic metastases from renal cell carcinoma who were treated with computed-tomography-guided high-dose-rate brachytherapy (CT-HDRBT).

METHODS

Ten patients (7 men and 3 women; median age 72 ± 7.9 years) with a total number of 16 hepatic metastases from histologically proven renal cell carcinoma were treated with CT-HDRBT after discussing the case in an interdisciplinary tumor conference. All patients had underwent nephrectomy before CT-HDRBT. Three patients had extrahepatic manifestations (2 lung and 1 bone). Six patients had received immunotherapy or targeted therapy before CT-HDRBT. Follow-up included gadoxetic acid (Gd-EOB-DTPA) enhanced MRI two times within 6-8 weeks and after that every 3 months after treatment to evaluate treatment efficacy.

RESULTS

Mean follow-up time was 21.6 ± 13.7 months. One patient developed local and systemic (pulmonary and osseous) progression after 10.8 months which was treated with targeted therapy and died 20.3 months after CT-HDRBT. None of the remaining nine patients developed local progression or died during the follow-up period. Five patients developed systemic progression (3 pulmonary, 1 osseous and 1 locally at the site of nephrectomy) after an average of 19.7 ± 5.5 months.

CONCLUSIONS

CT-HDRBT is a viable alternative to hepatic resection of liver metastases from renal cell carcinoma in selected patients.

Constitutional genetic variants as predictors of antiangiogenic therapy outcome in renal cell carcinoma

The development of specific angiogenesis inhibitors has drastically improved renal cancer treatment in recent years. Currently, four VEGF receptor inhibitors (sorafenib, sunitinib, pazopanib and axitinib), one anti-VEGF monoclonal antibody (bevacizumab) and two inhibitors of the mTOR pathway (temsirolimus and everolimus) have been approved to treat renal cell carcinoma (RCC), and several other molecules are under investigation. However, lack of response to antiangiogenic drugs and adverse drug reactions leading to treatment suspension are critical clinical problems that need to be solved. Because antiangiogenic drugs act on nonmalignant endothelial cells, the genetic background of the patient may play a crucial role determining the efficacy of these drugs. This article focuses on the identification of polymorphisms associated with antiangiogenic drugs outcome in RCC patients. It reviews and summarizes our current knowledge on this area and discusses future strategies to identify new biomarkers that could be used to personalize RCC management.

Novel immunotherapeutic strategies in development for renal cell carcinoma

CONTEXT

The purpose of this report is to review immunotherapies under investigation for patients with renal cell carcinoma (RCC), the most common form of kidney cancer, for which the incidence and mortality rate continue to increase.

OBJECTIVE

To summarize and evaluate current data on immunotherapies for RCC and discuss issues to be resolved before integration into the RCC treatment paradigm.

EVIDENCE ACQUISITION

A search of Medline, clinicaltrials.gov, and congress abstracts/treatment guidelines was performed in May 2012 using the following terms (and variations): metastatic renal cell carcinoma, practice guidelines, response/resistance to current treatments, immunotherapy, novel immunotherapeutic strategies, T-cell modulation, immune priming, innate immunity, and combination therapy.

EVIDENCE SYNTHESIS

Prior to the advent of novel agents targeting the vascular endothelial growth factor and mechanistic target of rapamycin pathways, interleukin-2 (IL-2) and interferon-α were the mainstays of RCC treatment. IL-2 remains one of the only treatments capable of curing advanced RCC, albeit in few patients. Despite recent advances, unmet need still exists for patients in the adjuvant setting, those with poor prognostic factors, and those who have progressed on prior targeted therapies. Improved understanding of host-tumor immune interactions has led to development of novel immunotherapeutic agents, including antibodies against immune checkpoint proteins (eg, programmed death-1 and cytotoxic T-lymphocyte antigen-4), and various vaccines. Because many of these compounds are in development, clinical experience with them is limited, although some have demonstrated activity in preliminary studies.

CONCLUSIONS

It is not yet clear where these new immunotherapies will fit into RCC treatment paradigms, but they may provide new options for patients whose current choices are limited. Furthermore, predictive biomarkers are needed to identify patients who will derive the greatest benefit from immunotherapy.

Systemic adjuvant therapies in renal cell carcinoma

Renal cell carcinoma (RCC) is one of the ten most frequent solid tumors worldwide. Recent innovations in the treatment of metastatic disease have led to new therapeutic approaches being investigated in the adjuvant setting. Observation is the only current standard of care after radical nephrectomy, although there is evidence of efficacy of adjuvant use of vaccine among all the strategies used. This article aims to collect published experiences with systemic adjuvant approaches in RCC and to describe the results of past and ongoing phase III clinical trials in this field. We explored all the systemic treatments, including chemotherapy, immunotherapy and targeted drugs while alternative approaches have also been described. Appropriate selection of patients who would benefit from adjuvant therapies remains a crucial dilemma. Although the international guidelines do not actually recommend any adjuvant treatment after radical surgery for RCC, no conclusions have yet been drawn pending the results of the promising ongoing clinical trials with the target therapies. The significant changes that these new drugs have made on advanced disease outcome could represent the key to innovation in terms of preventing recurrence, delaying relapse and prolonging survival after radical surgery for RCC.

Potential role of genetic markers in the management of kidney cancer

CONTEXT

Kidney cancer is not a single entity but comprises a number of different types of cancer that occur in the kidney including renal cell tumours as the most common type. Four major renal cell tumour subtypes can be distinguished based on morphologic and genetic characteristics. To individualise therapy and to improve the prognosis in patients with renal cell tumours, accurate subtyping, definition of individual course of disease, and the prediction of therapy response are necessary.

OBJECTIVE

To discuss the potential role of genetic markers in the management of kidney cancer.

EVIDENCE ACQUISITION

A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of genetic alterations in kidney cancer management. Keywords included kidney neoplasms, genetics, SNP, gene expression, miRNA, classification, diagnosis, drug therapy, prognosis, and therapy. The articles with the highest level of evidence were identified and critically reviewed. This review is the result of an interactive peer-reviewing process by an expert panel of co-authors.

EVIDENCE SYNTHESIS

Each subtype is characterised by specific genetic, epigenetic, and expression patterns that potentially can be used to subclassify renal cell tumours in cases of ambivalent histopathology. Molecular signatures and single alterations in primary tumours are associated with aggressiveness and prognosis. Germline polymorphisms in specific genes encoding for metabolizing enzymes, efflux transporters, and drug targets seem to be associated with toxicity and response in patients receiving targeted therapy.

CONCLUSIONS

Significant advances have been achieved in the molecular analysis of renal cancer. Validation of findings is greatly needed to implement genetic markers in the management of renal cancer. This should lead to improved diagnosis, prognosis, and personalised therapy in this heterogeneous disease.

Overexpression of FoxM1 is associated with tumor progression in patients with clear cell renal cell carcinoma

Background

Fork head box M1 (FoxM1) is a proliferation-associated transcription factor essential for cell cycle progression. Numerous studies have documented that FoxM1 has multiple functions in tumorigenesis and its elevated levels are frequently associated with cancer progression. The present study was conducted to investigate the expression of FoxM1 and its prognostic significance in clear cell renal cell carcinoma (ccRCC). Meanwhile, the function of FoxM1 in human ccRCC was further investigated in cell culture models.

Methods

Real-time quantitative PCR, western blot and immunohistochemistry were used to explore FoxM1 expression in ccRCC cell lines and primary ccRCC clinical specimens. FoxM1 expression was knocked down by small interfering RNA (siRNA) in Caki-1 and 786-O cells; proliferation, colony formation, cell cycle, migration, invasion, and angiogenesis were assayed.

Results

FoxM1 expression was up-regulated in the majority of the ccRCC clinical tissue specimens at both mRNA and protein levels. Clinic pathological analysis showed that FoxM1 expression was significantly correlated with primary tumor stage (P <0.001), lymph node metastasis (P = 0.01), distant metastasis (P = 0.01), TNM stage (P < 0.001) and histological grade (P = 0.003). The Kaplan–Meier survival curves revealed that high FoxM1 expression was associated with poor prognosis in ccRCC patients (P < 0.001). FoxM1 expression was an independent prognostic marker of overall ccRCC patient survival in a multivariate analysis (P = 0.008). Experimentally, we found that down-regulation of FoxM1 inhibited cell proliferation and induced cell cycle arrest with reduced expression of cyclin B1, cyclin D1, and Cdk2, and increased expression of p21 and p27. Also, down-regulation of FoxM1 reduced expression and activity of matrix metalloproteinase-2 (MMP-2), MMP-9 and vascular endothelial growth factor (VEGF), resulting in the inhibition of migration, invasion, and angiogenesis.

Conclusions

These results suggest that FoxM1 expression is likely to play important roles in ccRCC development and progression, and that FoxM1 is a prognostic biomarker and a promising therapeutic target for ccRCC.

TGF-β - an excellent servant but a bad master

The transforming growth factor (TGF-β) family of growth factors controls an immense number of cellular responses and figures prominently in development and homeostasis of most human tissues. Work over the past decades has revealed significant insight into the TGF-β signal transduction network, such as activation of serine/threonine receptors through ligand binding, activation of SMAD proteins through phosphorylation, regulation of target genes expression in association with DNA-binding partners and regulation of SMAD activity and degradation. Disruption of the TGF-β pathway has been implicated in many human diseases, including solid and hematopoietic tumors. As a potent inhibitor of cell proliferation, TGF-β acts as a tumor suppressor; however in tumor cells, TGF-β looses anti-proliferative response and become an oncogenic factor. This article reviews current understanding of TGF-β signaling and different mechanisms that lead to its impairment in various solid tumors and hematological malignancies.

Management of favorable-risk patients with metastatic renal cell carcinoma: when to start and when to stop targeted therapy

Targeted therapy has changed the treatment of metastatic renal cell carcinoma (mRCC). However, it is unclear if patients need to start systemic therapy immediately or if treatment can be deferred. Identification of the appropriate time to discontinue therapy is also uncertain. We reviewed treatment guidelines and trials evaluating targeted agents for mRCC to assess the evidence regarding commencing and discontinuing therapy for mRCC. Guidelines recommend that patients with mRCC receive targeted agents; however, they do not address when therapy should start. Risk factors based on Memorial Sloan-Kettering Cancer Center (MSKCC) or Heng criteria can be used to stratify patients. MSKCC prognostic factors include Karnofsky performance status (< 80%), high lactate dehydrogenase levels, low hemoglobin levels, high serum calcium levels, and time from diagnosis to start of therapy < 1 year. In patients with poor and intermediate risk (≥ 3 and 1-2 factors, respectively) and/or with high tumor burden, targeted therapy should commence as soon as possible. In patients with MSKCC good-risk disease and few disease symptoms, active surveillance may be appropriate. Regular monitoring is required so that treatment can be initiated upon evidence of active disease. Second-line therapy is usually commenced after disease progression; however, because of the limitations of radiologic assessment of response to targeted therapies, other factors may need to be considered to guide decisions regarding stopping or switching therapy. These include scenarios such as a mixed response to therapy. For selected patients at favorable risk, active surveillance may be feasible; however, strict monitoring is required.

New tools for assessing the individual risk of metastasis in renal cell carcinoma

Localized renal cell carcinoma (RCC) progresses to metastatic disease in 20-40 % after surgical resection. Affected patients might benefit from adjuvant treatment and have to be reliably identified for treatment indication. However, existing molecular markers and classification nomograms lack sufficient validity for clinical application so far. Therefore, in order to improve diagnostic tools for the identification of patients at risk, we tested invasiveness and the capability to activate vascular endothelium of primary RCC cells as tumor specific functional parameters. As a parameter for cell invasiveness the ability of RCC cells to break-down transepithelial electrical resistance (TEER) of an epithelial cell monolayer was tested. Loss of resistance, calculated as invasivity index, resembled the degree of cell invasiveness. In addition, secretion of Von Willebrand Factor by endothelial cells incubated with RCC cell supernatant was measured as a surrogate marker for endothelial cell activation. TEER-assay results matched clinical status of disease in 9 out of 12 cases. Metastatic tumors and less differentiated tumors had a significant increase of invasivity index (p = 0.007; p = 0.034). Endothelial cell activation and clinical outcome matched in 5 out of 9 samples. In addition, tumor cell induced endothelial cell activation significantly correlated to the pathologic T classification status of RCC tumors (p = 0.009). Taken together, our study validated endothelial cell activation analysis and cell invasiveness as solitary prognostic markers for tumor dissemination. TEER-analysis has proven to be a useful functional assay giving highly relevant individual information on functional tumor cell characteristics that add to pathologic evaluation.

Novel agents and approaches for advanced renal cell carcinoma

PURPOSE

Targeted agents have changed the treatment paradigm for advanced renal cell carcinoma. Approved agents with demonstrated efficacy are sunitinib, sorafenib, pazopanib, bevacizumab, temsirolimus and everolimus. However, there is an unmet need for new agents to improve the clinical outcome in treatment naïve patients and in those who are disease refractory or intolerant to traditional and targeted therapies. Many novel targeted agents, of which some have different mechanisms of action than approved agents, and immunomodulatory agents are currently in development for renal cell carcinoma.

MATERIALS AND METHODS

We searched ClinicalTrials.gov to identify novel agents for advanced renal cell carcinoma in ongoing phase II/III clinical trials. Using the relevant agents as search terms we reviewed the medical literature for mechanisms of action and efficacy, and safety results to date, including data from recent major oncology meetings.

RESULTS

A total of 11 novel targeted agents, including next generation tyrosine kinase inhibitors, and inhibitors of vascular endothelial growth factor ligand binding, Akt and endothelial cell proliferation, and 3 novel immunomodulatory agents, are under evaluation for renal cell carcinoma. In addition to ongoing phase II/III trials of emerging agents, head-to-head, crossover and combination trials of approved targeted agents are under way.

CONCLUSIONS

Although many agents are approved or in development for renal cell carcinoma, comparative effectiveness data are lacking. Ongoing and future head-to-head trials using appropriate comparators are essential to update renal cell carcinoma treatment guidelines. Future research should be aimed at identifying agents that improve patient outcomes and have decreased toxicity compared with currently approved agents with the goal of complete remission.

Characterization of N-diethylnitrosamine-initiated and ferric nitrilotriacetate-promoted renal cell carcinoma experimental model and effect of a tamarind seed extract against acute nephrotoxicity and carcinogenesis

Renal cell carcinoma (RCC), the commonest malignancy in adult kidney, lacks of early signs, resulting often in metastasis at first diagnosis. N-Diethylnitrosamine (DEN)-initiated and ferric nitrilotriacetate (FeNTA)-promoted RCC may be a useful experimental model, but it is not well characterized. In this study, histological alterations and oxidative stress markers were analyzed at different times throughout RCC development, histological subtype was re-evaluated in the light of current classification, and a tamarind seed extract (TSE) effect was examined. Male Wistar rats experimental groups were control, TSE, DEN, DEN+FeNTA, and TSE+DEN+FeNTA. TSE was given 2 weeks before DEN administration (200 mg/kg) and throughout the experiment. Fourteen days after DEN treatment, two FeNTA doses (9 mg Fe/kg) for acute nephrotoxicity study, and increasing FeNTA doses (3-9 mg Fe/kg) twice a week for 16 weeks for carcinogenesis protocol, were administered. In acute study, necrosis and renal failure were observed and TSE ameliorated them. Throughout carcinogenesis protocol, preneoplastic lesions were observed since 1 month of FeNTA treatment, which were more evident at 2 months, when also renal cysts and RCC were already detected. RCC tumors were obtained without changes in renal function, and clear cell histological subtype was identified in all cases. 4-Hydroxy-2-nonenal and 3-nitro-L: -tyrosine levels increased progressively throughout protocol. TSE decreased both oxidative stress markers and, although there was no statistical difference, it delayed RCC progress and decreased its incidence (21 %). This study brings an insight of the time course events in this carcinogenesis model, identifies clear cell subtype and establishes TSE renoprotective effects.

[Metastasectomy for renal cell cancer]

BACKGROUND

Metastasectomy prior to or after systemic medical cancer treatment is performed within a multimodal therapeutic approach in metastatic renal cell cancer (mRCC) to improve the prognosis. The role of metastasectomy in mRCC is controversially discussed and the potential therapeutic benefit is unquantifiable. The purpose of the current review is to critically discuss the available data.

METHODS

A systematic literature search was carried out in the MedLinedatabase to identify original publications, review articles and editorials with respect to metastasectomy in mRCC and the current European guidelines were also taken into consideration.

RESULTS

Metastasectomy is one of the approaches for mRCC recommended in the guidelines in cases of stable disease for at least 3 months, complete resectability of all metastatic lesions independent of the anatomic localization and a good performance status of the patient. The median survival time varies between 35 and 55 months.

CONCLUSIONS

In mRCC metastasectomy is an indiviudal therapeutic approach which might be considered for limited metastatic disease and the presence of good prognostic risk factors to improve average survival time. Especially in renal cell cancer metastasectomy should be considered early.

Identification of a 4-microRNA signature for clear cell renal cell carcinoma metastasis and prognosis

Renal cell carcinoma (RCC) metastasis portends a poor prognosis and cannot be reliably predicted. Early determination of the metastatic potential of RCC may help guide proper treatment. We analyzed microRNA (miRNA) expression in clear cell RCC (ccRCC) for the purpose of developing a miRNA expression signature to determine the risk of metastasis and prognosis. We used the microarray technology to profile miRNA expression of 78 benign kidney and ccRCC samples. Using 28 localized and metastatic ccRCC specimens as the training cohort and the univariate logistic regression and risk score methods, we developed a miRNA signature model in which the expression levels of miR-10b, miR-139-5p, miR-130b and miR-199b-5p were used to determine the status of ccRCC metastasis. We validated the signature in an independent 40-sample testing cohort of different stages of primary ccRCCs using the microarray data. Within the testing cohort patients who had at least 5 years follow-up if no metastasis developed, the signature showed a high sensitivity and specificity. The risk status was proven to be associated with the cancer-specific survival. Using the most stably expressed miRNA among benign and tumorous kidney tissue as the internal reference for normalization, we successfully converted his signature to be a quantitative PCR (qPCR)-based assay, which showed the same high sensitivity and specificity. The 4-miRNA is associated with ccRCC metastasis and prognosis. The signature is ready for and will benefit from further large clinical cohort validation and has the potential for clinical application.

MicroRNA target site polymorphisms in the VHL-HIF1α pathway predict renal cell carcinoma risk

Renal cell carcinoma (RCC) accounts for ∼4% of all human malignancies and is the 9th leading cause of male cancer death in the United States. The purpose of this study was to determine the effect of variation within microRNA (miRNA)-binding sites of genes in the VHL-HIF1α pathway on RCC risk. We identified 429 miRNA-binding site single-nucleotide polymorphisms (SNPs) in 102 pathway genes and assessed 53 tagging-SNPs for 31 of these genes for risk in a case-control study consisting of 894 RCC cases and 1,516 controls. Results showed that five SNPs were significantly associated with RCC risk. The most significant finding was rs743409 in MAPK1. Under the additive model, the variant was associated with a 10% risk reduction (OR: 0.90, 95% CI, 0.77-0.98). Other significant findings were for SNPs in CDCP1, TFRC, and DEC1. Cumulative effects analysis showed that subjects carrying four or five unfavorable genotypes had a 2.14-fold increase in risk (95% CI, 1.03-4.43, P = 0.04) than those with no unfavorable genotypes. Potential higher-order gene-gene interactions were identified and categorized subjects into different risk groups. The OR of the high-risk group defined by two SNPs: CDCP1:rs6773576 (GG) and DEC1:rs10982724 (GG) was 4.46 times higher than that of low-risk reference group (95% CI, 1.31-15.08). Overall, our study provides the first evidence supporting a connection between miRNA-binding site SNPs within the VHL-HIF1α pathway and RCC risk. These novel genetic risk factors might help identify individuals at high risk to enable detection of tumors at an early, curable stage.

Renal cell carcinoma stage migration in a single European centre over 25 years: effects on 5- and 10-year metastasis-free survival

PURPOSE

To assess renal cell carcinoma (RCC) stage migration in a large European academic centre series over 25 years and its possible impact on patients' metastasis-free survival.

METHODS

The pathology reports of 2,333 consecutive patients with RCC who underwent nephrectomy from 1984 to 2006 at our institution were systematically re-evaluated. Patients were pooled into four groups according to the date of surgery: group 1: 1984-1989, group 2: 1990-1995, group 3: 1996-2001 and group 4: 2002-2006, respectively. Changes in pT-categories over time and the impact on 5- and 10-year metastasis-free survival were evaluated.

RESULTS

Organ-confined (pT1 and pT2) tumours were found in 191/502 (38.0 %) and 372/535 (69.5 %) surgical specimens in groups 1 and 4, respectively (p < 0.001). This stage migration was mainly the result of an increase in pT1a tumours (overall: 32.6 %) from 12.5 % in group 1 to 45.8 % in group 4 and a decrease in pT3a tumours (overall: 24.1 %) from 46.6 % in group 1 to 11.0 % in group 4 (p < 0.001). The mean tumour size decreased from 6.7 cm in group 1 to 4.8 cm in group 4 (p < 0.001). In 2,152 patients with non-metastatic RCC, median follow-up was 76.2 (interquartile range: 36.2-133.9) months. Five- and 10-year metastasis-free survival probabilities were 78.7 and 71.9 % in group 1, 85.3 and 80.0 % in group 2, and 86.9 and 82.7 % in group 3, respectively. Five-year metastasis-free survival in group 4 was 90.3 % (p < 0.001).

CONCLUSION

A statistically significant stage migration towards organ-confined RCC was observed in the cohort studied. This stage migration was accompanied by a significant improvement in metastasis-free survival comparing the period 1984-1989 and following time periods.

Phase II escalation study of sorafenib in patients with metastatic renal cell carcinoma who have been previously treated with anti-angiogenic treatment

OBJECTIVE

To assess both clinical and biological efficacy and toxicity of sorafenib in patients with metastatic renal cell carcinoma (mRCC) previously treated with an anti-angiogenic vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitor.

METHODS

Sorafenib is an orally active multikinase inhibitor approved for the treatment of mRCC. Drug-focused translational research on tissues (i.e. B-RAF) and plasma (VEGFR-α, circulating endothelial cells, endothelial progenitor cells) was performed to define biological predictive and prognostic markers and their related kinetics. Patients with mRCC pretreated with an anti-angiogenic treatment, an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0-2 and adequate organ function were eligible. Patients received sorafenib 400 mg twice a day continuously in 4-week cycles. Patients with no progressive disease at 12 weeks continued to receive sorafenib at the standard dose, whereas progressing patients received an increased dose (600 mg twice a day) with early disease restaging after 4 weeks. Patients who progressed at 600 mg twice a day went off study. Efficacy (overall tumour control) was assessed by Response Evaluation Criteria in Solid Tumors.

RESULTS

In all, 19 patients were entered. The baseline characteristics were as follows: ECOG PS 0-1 94.8%; median (range) age 62 (41-81) years; nephrectomy 100%; surgery for metastatic disease 26.4%; clear cell 79.1%; papillary cell 15.7%; sarcomatoid/high grade 5.2%; two or more metastatic sites 84%. Overall, 11 patients (58%) had disease control at 6 months without significant correlation between response to prior therapy and hypertension. Progression-free survival (PFS) of 8.3 months was observed. Of six patients for whom the dose was escalated due to early progression, three benefitted with PFS of >3 months. Three (15.7%) of 19 patients had a V600E mutation and one had a K601E mutation; PFS appeared to be substantially shorter in these patients compared with 15 patients with wild-type B-RAF (2.5 vs 9.1 month, P < 0.05). The most common toxicity (National Cancer Institute Common Toxicity Criteria, NCIC 3.0, all patients) was grade ≥1 diarrhoea and grade 2-3 hand-foot syndrome in 11 patients. Grade 3 mucositis was observed in one patient.

CONCLUSIONS

Sorafenib at doses of 400-600 mg twice a day continuously results in acceptable and well tolerated salvage treatment after VEGFR tyrosine kinase inhibitor failure. In progressive patients, treatment with a higher dose could be a valid option and B-RAF mutations may be an interesting predictive marker to be studied in a larger randomized trial.

Validation of serum amyloid α as an independent biomarker for progression-free and overall survival in metastatic renal cell cancer patients

BACKGROUND

We recently identified apolipoprotein A2 (ApoA2) and serum amyloid α (SAA) as independent prognosticators in metastatic renal cell carcinoma (mRCC) patients, thereby improving the accuracy of the Memorial-Sloan Kettering Cancer Center (MSKCC) model.

OBJECTIVE

Validate these results prospectively in a separate cohort of mRCC patients treated with tyrosine kinase inhibitors (TKIs).

DESIGN, SETTING, AND PARTICIPANTS

For training we used 114 interferon-treated mRCC patients (inclusion 2001-2006). For validation we studied 151 TKI-treated mRCC patients (inclusion 2003-2009).

MEASUREMENTS

Using Cox proportional hazards regression analysis, SAA and ApoA2 were associated with progression-free survival (PFS) and overall survival (OS). In 72 TKI-treated patients, SAA levels were analyzed longitudinally as a potential early marker for treatment effect.

RESULTS AND LIMITATIONS

Baseline ApoA2 and SAA levels significantly predicted PFS and OS in the training and validation cohorts. Multivariate analysis identified SAA in both separate patient sets as a robust and independent prognosticator for PFS and OS. In contrast to our previous findings, ApoA2 interacted with SAA in the validation cohort and did not contribute to a better predictive accuracy than SAA alone and was therefore excluded from further analysis. According to the tertiles of SAA levels, patients were categorized in three risk groups, demonstrating accurate risk prognostication. SAA as a single biomarker showed equal prognostic accuracy when compared with the multifactorial MSKCC risk mode. Using receiver operating characteristic analysis, SAA levels >71 ng/ml were designated as the optimal cut-off value in the training cohort, which was confirmed for its significant sensitivity and specificity in the validation cohort. Applying SAA >71 ng/ml as an additional risk factor significantly improved the predictive accuracy of the MSKCC model in both independent cohorts. Changes in SAA levels after 6-8 wk of TKI treatment had no value in predicting treatment outcome.

CONCLUSIONS

SAA but not ApoA2 was shown to be a robust and independent prognosticator for PFS and OS in mRCC patients. When incorporated in the MSKCC model, SAA showed additional prognostic value for patient management.

[Renal cell carcinoma of patients younger than 40 years old]

CONTEXT

Clinical and pathological characteristics of renal cell carcinoma (RCC) of patients younger than 40 years old are not well known. The objective of this study was to analyze these characteristics by comparison to a group of patients aged 58 to 62.

METHODS

Retrospective study of a group of patients aged less than 40 years old (group 1, n=44) and a group of patients aged 58 to 62 years old (group 2; n=106) treated surgically for a renal mass from January 2000 to July 2009. A comparative analysis of clinical, pathological characteristics and of cancer-specific survival was performed. Specific survival was calculated with the Kaplan-Meier method and compared with the Log-Rank test. Univariate and multivariable analysis were performed to assess and quantify the effect of age on cancer-specific survival. Covariates were gender, age group, tumor size, pT stage, histological sub-type and Fuhrman grade.

RESULTS

Clinical and pathological characteristics were similar in both groups (P>0.05) except for histological sub-type (56% of clear cell RCC for group 1 versus 82% for group 2). In the group of patients younger than 40 years, translocation RCC represented 23% of all RCCs. Cancer-specific survival at five years was similar in both groups (80% and 76% for group 1 and 2 respectively, P>0.58). Fuhrman grade was the only independent prognostic factor of cancer-specific survival (P=0.001).

CONCLUSION

Patients younger than 40 years were more likely to have a translocation RCC than their older counterparts for who clear cell RCC represented the main histological sub-type. Cancer-specific survival was similar between both groups. Only a systematic specific immunostaining for TFE3 or TFEB will allow to assess the exact incidence and prognosis of this entity.

Cardiovascular magnetic resonance imaging in assessment of intracaval and intracardiac extension of renal cell carcinoma

OBJECTIVES

About 1 in 5 patients with renal cell carcinoma have intravascular tumoral extension at presentation. Level of tumoral extension within inferior vena cava determines surgical approach, with higher extension requiring cardiopulmonary bypass. Tumoral invasion of inferior vena caval wall is associated with poor prognosis. We evaluated accuracy of magnetic resonance imaging (MRI) in assessing level of intravascular extension of renal cell carcinoma and predicting vessel wall invasion.

METHODS

MRIs and surgical database were reviewed from January 1999 to December 2008. Sixty-four patients with suspected intravascular extension of renal cell carcinoma underwent MRI. Forty-one underwent curative or palliative surgery at our institution and were included in final analysis. MRI scans were reviewed to determine intravascular extension and tumoral adherence to the vessel wall, as assessed by circumferential flow around the intravascular tumor and its mobility during different phases of cardiac cycle. MRI findings were correlated with surgical findings to assess accuracy.

RESULTS

There was 87.8% agreement (P < .001; κ = 0.82) between MRI and surgical findings regarding level of intravascular extension of tumor. MRI was highly sensitive and specific (93%) in assessing supradiaphragmatic extension (negative predictive value, 96%). Depending on sign used, sensitivities and negative predictive values in assessing tumoral adherence to vessel wall ranged from 86% to 95% and 81% to 91%, respectively.

CONCLUSIONS

MRI is highly accurate in staging intravascular and intracardiac extension, aiding in accurate preoperative surgical planning. MRI may help determine prognosis of renal cell carcinoma by accurately assessing tumoral adherence to the vessel wall.