Epidemiology of Renal Cell Carcinoma: 2022 Update

Time trend and age-period-cohort effect on kidney cancer mortality in Spain, 1983-2022

OBJECTIVE

This study examines trends and disparities in kidney cancer (KC) mortality in Spain from 1983 to 2022, focusing on gender, birth cohort, and age influences.

METHODS

Data from the Spanish National Institute of Statistics were analyzed using age-standardized mortality rates (ASMRs). Joinpoint regression identified temporal trends and annual percentage changes, while Age-Period-Cohort (A-P-C) analysis assessed the impacts of age, calendar period, and birth cohort on mortality.

RESULTS

KC mortality increased significantly for both sexes, with men experiencing a steeper rise (1.2% annually) compared to women (0.6% annually). Joinpoint analysis revealed distinct phases: a sharp increase until the mid-1990s, followed by stabilization for men and a slight decline for women. Men aged over 50, particularly those above 80, showed pronounced increases. A-P-C analysis confirmed age as a significant risk factor, with consistently higher mortality rates observed among men across all age groups. Men born from the early 20th century until the 1960s faced increasing mortality risks, while women's risk, after an increase in the early 20th century, stabilized after the 1933 birth cohort. For those born after 1960, both sexes show a potential decline in KC mortality, with a slight upturn in men from the 1980s onwards. The period effect exhibited an increase during the 1980s-1990s, followed by stabilization for men and a continuous decrease for women.

CONCLUSION

This study reveals significant disparities in KC mortality trends in Spain across genders, birth cohorts, and age groups. Despite advancements in diagnosis and treatment, substantial public health challenges remain.

Current use of percutaneous ablation in renal tumors: an analysis of the registry of the German Society for Interventional Radiology and Minimally Invasive Therapy

OBJECTIVE

To evaluate the success and complications of thermal ablation (TA) based on the voluntary, prospective registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) with 303 participating centers from Germany, Austria, and Switzerland.

MATERIALS AND METHODS

Registry data from 2018 until 2023 of 1102 patients with small renal tumors (age: 72.5 ± 11.6 years; female: 33.6%, 370/1102) were analyzed. Hospitals with ≥ 20 TAs were considered high-volume centers. Technical success and complication rates between different parameters were compared using the chi-square or Fisher's exact test, p < 0.05 was considered statistically significant.

RESULTS

Patients were most frequently treated with radiofrequency ablation (RFA, 43.6%, 481/1102), then microwave ablation (MWA, 41.9%, 462/1102) or cryoablation (13.3%, 147/1102). Technical success for heat-based TA (RFA&MWA) was 94.3% (893/947), for cryoablation 97.3% (143/147). RFA&MWA was significantly more successful in lesions ≤ 3 cm (96.1%, 567/590) compared to 3-4 cm lesions (89.8%, 97/108; p = 0.005). In patients treated with cryoablation, no significant differences between sizes could be found (≤ 3 cm: 97.9%, 94/96; 3-4 cm: 85.7%, 12/14; p = 0.078). Complication rate was significantly higher in RFA&MWA of lesions 3-4 cm compared to ≤ 3 cm (≤ 3 cm: 3.9%, 23/590; 3-4 cm: 11.1%, 12/108, p = 0.002), while no significant differences were seen regarding cryoablation (≤ 3 cm: 1.0%, 1/96; 3-4 cm: 0.0%, 0/14; p = 1.000).

CONCLUSIONS

In this exploratory analysis of the DeGIR registry, percutaneous TA of small renal masses is technically feasible with low complication rates. Heat-based TAs seem to have lower success rates and higher complication rates in larger tumors. Cryoablation could potentially be a safe alternative for 3- to 4-cm-sized tumors.

KEY POINTS

Question How effective is renal thermal ablation (TA) in terms of treatment success and complication rates? Findings In contrast to cryoablation, heat-based thermal ablation has lower success and higher complication rates in tumors measuring 3-4 cm compared to tumors < 3 cm. Clinical relevance Thermal ablation is not influenced by the need for additional techniques such as cooling, protective organ displacement, or temporary vessel occlusion. For small renal tumors, TA is an effective and safe treatment option. Cryoablation could be beneficial in larger tumors.

Impact of race and payor status on patterns of utilization of partial and radical nephrectomy in patients with renal cell carcinoma in California

BACKGROUND

Prospective trials have shown similar outcomes with partial nephrectomy (PN) in patients with localized renal cell carcinoma (RCC), and multiple studies suggest increasing the use of the technique. We hypothesize that patients who stem from minority groups, as well as Medicare and Medical, have less access to this specialized procedure and, therefore, have a higher rate of radical nephrectomy (RN).

METHODS

We interrogated the California Office of Statewide Health Planning and Development (OSHPD) database, which collects information from all inpatient admissions, emergency room visits and inpatient/outpatient procedures in the state. All patients undergoing nephrectomy for RCC were identified from 2012 to 2018 using CPT and ICD-9/10 codes to identify patients with RCC undergoing RN and PN. Variables of interest included patient demographics, comorbidities, payor status and type of institution where the surgery was performed. We performed univariate and multivariable analysis to explore associations between patient factors and type of nephrectomy performed.

RESULTS

In total, 31,093 patients who had undergone a nephrectomy in the study period were identified. Overall, most were 57% male, with a mean age of 58 years. PN and RN were performed in 15,840 (50.9%) and 15,253 (49.1%) patients, respectively. PN rates differed according to race/ ethnicity, as it was performed in 8576 (53.1%) White, 1124 (55.3%) Black, 1286 (46.0%) Asian, 4107 (47.5%) Hispanic and 747 (50.5%) other race patients (P < 0.001). Use of PN also differed among patients based on payor status, with 6800 (56.4%) private, 5,036 (43.9%) Medicare, 1,817 (38.3%) Medical, and 2,187 (77.7%) other insurance patients (P < 0.001). On multivariate analysis controlling for age, gender, comorbidities, and frailty, race was independently associated with the type of nephrectomy, but payor was not.

CONCLUSIONS

Our study confirms that race and payor status may have an influence on the utilization of partial versus status radical nephrectomy, with the highest rate of partial nephrectomies among Black patients and those with private insurance. Although there are multiple potential confounders (e.g., latency of diagnosis and resulting tumor size/complexity), it is possible access to care is a driver of this phenomenon.

Comparative efficacy and safety of ablative therapies in the management of primary localised renal cell carcinoma: a systematic review and meta-analysis

BACKGROUND

Non-invasive and minimally invasive ablative treatments, including stereotactic body radiotherapy (SBRT), radiofrequency ablation, microwave ablation, and cryoablation, have emerged as key treatment options for managing renal cell carcinoma, especially for patients who are unsuitable for surgery. We aimed to compare the clinical efficacy and safety of these emerging treatment methods in patients with localised renal cell carcinoma.

METHODS

In this systematic review and meta-analysis, we searched PubMed (MEDLINE), Embase, and the Cochrane Library for publications between Jan 1, 2000, and March 1, 2024. Eligible articles were observational studies and randomised controlled trials including at least five adult patients (age ≥18 years) with primary and localised renal cell carcinoma treated with SBRT, radiofrequency ablation, microwave ablation, or cryoablation and that reported on local control outcomes. Two reviewers independently screened titles and abstracts and then full texts of eligible studies were independently evaluated by the same reviewers, with disagreements resolved via discussion or consultation with a third reviewer. Summary estimates were extracted from published reports manually using a standardised data extraction form. The primary endpoint was local control rate at 1 year, 2 years, and 5 years after start of treatment. A meta-analysis was conducted using a DerSimonian and Laird model to summarise local control rates. Publication bias was evaluated using funnel plots and Egger's test. We also recorded the frequency and severity of adverse events after treatment on the basis of the Common Terminology Criteria for Adverse Events (version 5.0) and Clavien-Dindo complication index. The study protocol was prospectively registered with PROSPERO, CRD42024511840.

FINDINGS

We identified 6668 records, of which 330 were assessed via full-text review, and 133 were included in our systematic review and meta-analysis. The eligible studies included data for 8910 patients (mean age 67·9 years [SD 7·3], 2518 [31·4%] of 8018 patients with available data were female and 5500 [68·6%] were male). Local control rates for SBRT were 99% (95% CI 97-100; I2=6%) at 1 year, 97% (95-99; I2=0%) at 2 years, and 95% (89-98; I2=42%) at 5 years; for radiofrequency ablation were 96% (94-98; I2=73%) at 1 year, 95% (92-98; I2=77%) at 2 years, and 92% (88-96; I2=78%) at 5 years; for microwave ablation were 97% (95-99; I2=74%) at 1 year, 95% (92-98; I2=77%) at 2 years, and 86% (75-94; I2=66%) at 5 years; and for cryoablation were 95% (93-96; I2=61%) at 1 year, 94% (91-96; I2=69%) at 2 years, and 90% (87-93; I2=74%) at 5 years. The proportion of patients who reported grade 3-4 adverse events was 3% (121 of 3726) after cryoablation, 2% (39 of 2503) after radiofrequency ablation, 1% (22 of 2069) after microwave ablation, and 2% (11 of 612) after SBRT. Risk of bias was moderate in most studies (70 [53%] of 133) and no publication bias was observed.

INTERPRETATION

All investigated ablative methods continue to represent effective treatment choices in renal cell carcinoma, and these findings support multi-disciplinary discussions of these treatment methods, along with surgery and surveillance, to individualise treatment decisions in these patients. Future research should aim to conduct randomised controlled trials across larger patient populations to further elucidate the long-term oncological and survival outcomes associated with these treatments.

FUNDING

None.

Use of Interactive Three-dimensional Modeling for Partial Nephrectomy in the 3DPN Study

Virtual interactive three-dimensional modeling is a novel visualization tool that could improve preoperative surgery planning and intraoperative navigation. The 3DPN trial seeks to assess its value for robot-assisted partial nephrectomy in comparison to conventional computed tomography imaging in a multicenter randomized controlled setting.

Association of 5α-reductase inhibitor prescription with immunotherapy efficacy in metastatic renal cell carcinoma: a multicenter retrospective analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of metastatic renal cell carcinoma (mRCC), but response rates remain heterogeneous, and reliable predictive biomarkers are lacking. Recent studies suggest that androgen receptor (AR) signaling plays a role in regulating CD8+ T-cell function, implying that 5α-reductase inhibitors (5-ARIs), which lower androgen activity, could enhance antitumor immunity and improve clinical outcomes in patients receiving immunotherapy. This study retrospectively investigates the impact of a history of 5-ARI use (≥12 months) on the efficacy of ICIs in mRCC.

METHODS

We conducted a multicenter retrospective cohort study of 185 patients with mRCC who received ICIs. Patients were stratified based on their history of 5-ARI use. Baseline characteristics included age, body mass index, International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk group, programmed death-ligand 1 (PD-L1) expression levels, tumor stage, and metastasis sites. The primary endpoints were progression-free survival (PFS) and overall survival (OS), analyzed using Cox proportional hazards models. Secondary endpoints included objective response rate (ORR) and disease control rate (DCR). Key immunological insights were gained through single-cell RNA sequencing analysis of tumor samples.

RESULTS

Patients with a history of 5-ARI use demonstrated improved ORR (59.8% vs 39.8%, p=0.0075) and DCR (87.0% vs 78.7%, p=0.1747) compared with those without. The median PFS and OS were significantly longer in the 5-ARI group, with HRs of 0.64 (95% CI: 0.47 to 0.86, p=0.0085) for PFS and 0.65 (95% CI: 0.47 to 0.90, p=0.0271) for OS. Subgroup analysis further indicated enhanced ICI efficacy with 5-ARI use across age, IMDC risk scores, and PD-L1 expression levels. Single-cell RNA sequencing analysis revealed that 5-ARI treated patients exhibited a reduced presence of regulatory T cells and CD8 T-cell exhaustion (CD8 Tex), and lower programmed cell death protein-1 expression in CD8 Tex cells, suggesting an immunologically favorable modification of the tumor.

CONCLUSION

A history of 5-ARI use is associated with improved responses to ICI therapy in mRCC, potentially through AR-related modulation of CD8+ T-cell activity and favorable alterations in the immune microenvironment. These findings support further investigation into androgen-targeted approaches as adjunctive strategies in immunotherapy for RCC.

Global and regional burden of kidney cancer due to high body index in adults from 1990 to 2021 and predictions to 2036

Monitoring the evolving global and regional burden of kidney cancer attributable to high BMI is vital for informing prevention and healthcare policies. This study aimed to evaluate historical trends in the global and regional burden of kidney cancer attributable to high BMI from 1990 to 2021 and to predict future trends through 2036 for individuals aged 20 years and older. We conducted a retrospective analysis using the Global Burden of Disease 2021 database. We analyzed data on mortality and disability-adjusted life years (DALYs) linked to kidney cancer from high BMI. Stratifications included sociodemographic index (SDI), region, sex, and age. Temporal trends were assessed using joinpoint regression models, while the relationship between SDI and regional burden was examined. Projections were generated using Bayesian age-period-cohort models. In 2021, high BMI contributed to 19.86% of global kidney cancer deaths (0.032 million) and 19.00% of DALYs (0.782 million), representing an increase since 1990. Globally, age-standardized mortality rate and age-standardized disability rate have declined in recent years. However, rates have risen in developing regions such as South Asia and East Asia. Projections indicate stable global rates with slight fluctuations through 2036. The global kidney cancer burden attributable to high BMI shows signs of decline but continues to rise in some developing regions. Addressing this disparity requires strengthening obesity prevention and control strategies tailored to regional needs.

CNPY2 in Solid Tumors: Mechanisms, Biomarker Potential, and Therapeutic Implications

Canopy FGF signaling regulator 2 (CNPY2) has emerged as a crucial player in cancer development by promoting cell proliferation, tissue repair, and angiogenesis. This review synthesizes the current understanding of CNPY2's role in solid tumors, particularly renal cell carcinoma, prostate cancer, hepatocellular carcinoma, and non-small-cell lung cancer. CNPY2 modulates key pathways such as p53, MYLIP, NF-κB, and AKT/GSK3β, thereby driving tumor growth and progression. In renal cell carcinoma, CNPY2 paradoxically promotes tumor growth through p53 upregulation, while in hepatocellular carcinoma, CNPY2 drives cell cycle progression via p53 destabilization. In prostate cancer, it enhances tumor progression by stabilizing androgen receptors through MYLIP interaction, and in non-small-cell lung cancer, it contributes to chemoresistance and metastasis through NF-κB and AKT/GSK3β signaling. Additionally, CNPY2 influences the tumor microenvironment, impacting immune function and metastatic potential. As a potential biomarker, CNPY2 shows promise for cancer detection and prognosis, particularly when used in combination with other markers. Early therapeutic strategies, including siRNA and miRNA approaches, are under exploration, though challenges remain due to CNPY2's expression in normal tissues and potential off-target effects. This review underscores the need for further research to fully elucidate CNPY2's oncogenic mechanisms and develop targeted therapies. Improved understanding of CNPY2's diverse roles may lead to novel diagnostic and therapeutic approaches in solid tumors.

Clear cell renal carcinoma essentially requires CDKL3 for oncogenesis

Clear cell renal cell carcinoma (ccRCC) is the predominant human renal cancer with surging incidence and fatality lately. Hyperactivation of hypoxia-inducible factor (HIF) and mammalian target of rapamycin (mTOR) signaling are the common signatures in ccRCC. Herein, we employed spontaneous ccRCC model to demonstrate the indispensability of an underappreciated Ser/Thr kinase, CDKL3, in the initiation and progression of ccRCC. Ablation of CDKL3 does not affect normal kidney, but abrogates Akt-mTOR hyperactivity and thoroughly prevents the formation and growth of the HIF-agitated ccRCC in vivo. Remarkable clinical correlations also supported the oncogenic role of CDKL3. Mechanism-wise, cytosolic CDKL3 unexpectedly behaves as the adaptor to physically potentiate mTORC2-dependent Akt activation without functioning through kinase activity. And mTORC2 can phosphorylate and stabilize CDKL3 to form a positive feedback loop to sustain the cancer-favored Akt-mTOR overactivation. Together, we revealed the pathological importance and molecular mechanism of CDKL3-mediated Akt-mTOR axis in ccRCC initiation and progression.

Glycogen metabolism genes as a molecular signature for subtyping, prognostic prediction, and immunotherapy selection in clear cell renal cell carcinoma

Glycogen accumulation is a typical feature in clear cell renal cell carcinoma (ccRCC). It has been reported that glycogen metabolism-related genes can promote the progression of ccRCC, but its role in molecular typing, prognosis, immune infiltration, and immunotherapy response has rarely been reported. We applied an unsupervised clustering approach for molecular typing of ccRCC. The least absolute shrinkage and selection operator regression (LASSO) was used for prognostic model construction. The robustness of the model is evaluated by multicenter mutual verification. Weighted gene co-expression network analysis (WGCNA) was used to explore potential biological mechanisms. RT-qPCR was used to identify mRNA relative expression. We found ccRCC can be divided into two subtypes based on glycogen metabolism-related genes, and the prognosis of patients between the two subtypes is significantly different. Furthermore, we constructed a prognostic model for ccRCC patients based on glycogen metabolism-related genes using LASSO algorithm. We found that the model has a strong prognostic effect. Subsequently, we explored the underlying mechanisms through WGCNA and found that the model is associated with immune-related signaling pathways. Finally, we also found that this prognostic model can be used as a marker of response to immunotherapy in patients with advanced ccRCC. In conclusion, glycogen metabolism-related genes have critical value in molecular typing and prognosis evaluation of ccRCC.

Urinary exosomes as promising biomarkers for early kidney disease detection

Kidney injury and disease pose a significant global health burden. Despite existing diagnostic methods, early detection remains challenging due to the lack of specific molecular markers to identify and stage various kidney lesions. Urinary exosomes, extracellular vesicles secreted by kidney cells, offer a promising solution. These vesicles contain a variety of biomolecules, such as proteins, RNA, and DNA. These biomolecules can reflect the unique physiological and pathological states of the kidney. This review explores the potential of urinary exosomes as biomarkers for a range of kidney diseases, including renal failure, diabetic nephropathy, and renal tumors. By analyzing specific protein alterations within these exosomes, we aim to develop more precise and tailored diagnostic tools to detect kidney diseases at an early stage and improve patient outcomes. While challenges persist in isolating, characterizing, and extracting reliable information from urinary exosomes, overcoming these hurdles is crucial for advancing their clinical application. The successful implementation of urinary exosome-based diagnostics could revolutionize early kidney disease detection, enabling more targeted treatment and improved patient outcomes.

HIF2α drives ccRCC metastasis through transcriptional activation of methylation-controlled J protein and enhanced prolegumain secretion

The role of hypoxia-inducible factor 2α (HIF2α) in clear cell Renal Cell Carcinoma (ccRCC) is still not fully understood. In this study, we identified that urinary prolegumain levels positively correlated with the malignant characteristics of ccRCC. In cultured 786-O and OSRC-2 cells, HIF2α downregulation reduced prolegumain secretion. RNA sequencing assay revealed that HIF2α induces methylation-controlled J (MCJ), a negative regulator on the mitochondrial respiratory chain. Silencing MCJ reduced prolegumain secretion, and MCJ overexpression restored prolegumain secretion inhibited by HIF2α downregulation. Chromatin immunoprecipitation and luciferase assay confirmed MCJ as a transcription target of HIF2α. Furthermore, we showed the ectopic MCJ overexpression reversed the improved mitochondrial damage resulting from HIF2α downregulation, as evidenced by electron microscope, ATP level, GSSG/GSH ratio, MitoSOX, and DHE staining. Through mass spectrometry analysis, we identified oxidation site His343 on the legumain sequence as contributing to the prolegumain secretion. Therapeutically, silencing MCJ or HIF2α or using ROS scavengers Vitamin C or MitoQ alleviated MMP2 activation as well as cell migration and tube formation. In a mouse orthotopic xenograft model of ccRCC, silencing MCJ or administration of MitoQ significantly protected against mitochondrial damage and subsequently reduced the lung metastasis of tumors. Overall, our study identified MCJ as a target molecule of HIF2α in ccRCC. Silencing MCJ or using ROS scavengers like MitoQ can suppress oxidation site His343 in legumain, preventing prolegumain secretion and subsequently reducing metastasis of ccRCC.

An unusual case of post-menopausal bleeding

BACKGROUND

Metastasis from Renal cell carcinoma at presentation is seen in nearly one fifth of the patients and commonly occur to lung, bone and liver. Synchronous vaginal and cervical metastasis is extremely rare. Several pathways have been proposed of which blood reflux from left renal vein to ovarian vein is most plausible. The prognosis is usually very poor as they are often associated with disseminated metastasis.

CASE PRESENTATION

A 55-year-old women presented with post-menopausal vaginal bleeding, on examination a smooth mass occupying the vagina and obscuring the view of cervix with normal mucosa was found. Biopsy and Immunohistochemistry showed it to be renal cell carcinoma. Further investigations lead to identification of left renal mass with pulmonary, vaginal and cervical metastasis. Patient was started on Pazopanib 800 mg PO per day, and was lost to follow-up.

CONCLUSION

Vaginal metastasis presenting as post-menopausal bleeding is one of the rarest presentation of renal cell carcinoma with only 3 cases reported in literature before this. Metastatic tumors to the vagina are more common than primary tumors and are mostly from cervix, endometrium and ovary. A high index of suspicion and through examination and investigation is the key to correct diagnosis and management.

Silencing of APEX1 triggers ferroptosis in clear cell renal cell carcinoma via APP-mediated activation of p53/xCT signaling

BACKGROUND

Apurinic/apyrimidinic endodeoxyribonuclease 1 (APEX1) is involved in regulating the proliferation, invasion, migration, and other malignant progression of various cancer cells. However, its mechanism in clear cell renal cell carcinoma (ccRCC) remains unclear.

METHODS

UALCAN database was performed to predict APEX1 expression in ccRCC. CCK-8, colony formation, EdU, wound healing, transwell, and flow cytometry assays were used to assess cell proliferation, migration, invasion, and cell cycle. Expressions of cell cycle proteins and ferroptosis biomarkers were detected by Western blot. The levels of Fe2+, ROS, MDA, SOD, and GSH in cells were detected by assay kits. Fluorescent probe was used to monitor the intracellular lipid peroxidation level. The binding of APEX1 and amyloid precursor protein (APP) was validated by Co-IP. The expressions of p53/xCT pathway proteins were examined by Western blot.

RESULTS

The results showed that APEX1 was highly expressed in ccRCC tissues and positively correlated with poor prognosis. Silencing of APEX1 inhibited the proliferation, invasion, and migration of Caki-1 cells and induced cell cycle arrest. This silencing also led to increased levels of intracellular Fe2+, lipid peroxidation, and ROS, thereby inducing cell ferroptosis. APEX1 could bind to APP, and their expressions were negatively correlated. Silencing of APP reversed the inhibition effects of APEX1 silencing on proliferation, invasion, migration, and cell cycle in Caki-1 cells. Moreover, silencing of APEX1 up-regulated the p53/xCT signaling by binding to APP, thereby promoting ferroptosis.

CONCLUSION

In summary, silencing of APEX1 promotes ferroptosis and inhibits the malignant progression of ccRCC, potentially through APP-mediated activation of p53/AKT signaling, providing a novel therapeutic strategy for ccRCC treatment.

GXYLT2: an emerging therapeutic target and predictive biomarker for anti-PD-1 efficacy in clear cell renal cell carcinoma

There are studies reporting that glucoside xylosyltransferase 2 (GXYLT2) has a role in promoting tumor progression, but its role in clear cell renal cell carcinoma (ccRCC) remains unclear. In this study, RT-qPCR and western blotting were employed to detect the expression level of GXYLT2. RNA interference assays were used to knock down GXYLT2. CCK-8, wound healing assays, clone formation assays, and Transwell assays were utilized to investigate the function of GXYLT2. Bioinformatics analysis was used to explore the tumor microenvironment and potential biological mechanisms. We found that the expression level of GXYLT2 in ccRCC was higher than that in adjacent normal renal tissues. Patients with high GXYLT2 expression have worse clinical outcomes. Knockdown of GXYLT2 inhibits the proliferation, invasion, migration, and clone formation ability of ccRCC cells. Enrichment analysis uncovered that GXYLT2 participates in Wnt, cell cycle, and actin cytoskeleton regulation signaling pathways. After receiving anti-PD-1 therapy, patients with high GXYLT2 expression had longer progression-free survival compared with those with low GXYLT2 expression. In conclusion, GXYLT2 is a novel potential therapeutic target for ccRCC. Meanwhile, GXYLT2 can be used as a novel marker for predicting immunotherapeutic response.

CDC20-Mediated Selective Autophagy Degradation of PBRM1 Affects Immunotherapy for Renal Cell Carcinoma

Polybromo 1 (PBRM1) inactivating mutations are associated with clinical benefit from immune checkpoint inhibitor treatments in clear cell renal cell carcinoma (ccRCC). However, whether targeting PBRM1 has the potential to enhance immunotherapy efficacy in patients with wild-type PBRM1 and the upstream pathways that regulate PBRM1 protein stability remain unclear. Here, it is demonstrated that PBRM1 knockdown induced M1 macrophage polarization and infiltration, which enhanced the efficacy of anti-PD-1 immunotherapy in RCC. Meanwhile, CDC20 catalyzes K27 ubiquitination of PBRM1 and promotes its degradation via p62-mediated selective autophagy. A bicyclic peptide (PB1-p62) is designed and constructed to target PBRM1 and p62, thereby promoting the degradation of PBRM1. As a result, the efficacy of anti-PD-1 immunotherapy is enhanced, leading to improved overall survival rates in syngeneic mouse tumor models. Overall, this finding suggest the clinical application of PB1-p62 and provide a novel approach for enhancing the effectiveness of immunotherapy in RCC patients with wild-type PBRM1.

Efficacy and Safety of Nivolumab Plus Ipilimumab for Metastatic Renal Cell Carcinoma in Patients 75 Years and Older: Multicenter Retrospective Study

BACKGROUND/OBJECTIVES

The efficacy and safety of nivolumab plus ipilimumab (NIVO + IPI) for elderly patients with metastatic renal cell carcinoma have not been reported with sufficient evidence. Our study therefore aimed to compare the efficacy and safety of NIVO + IPI between patients ≥75 years and patients <75 years with metastatic renal cell carcinoma.

METHODS

We retrospectively analyzed a multi-center cohort of the 156 patients that received NIVO + IPI treatment at eight institutions. Among them, 33 patients were ≥75 years old, and the remainder were <75 years old.

RESULTS

Patient demographics and tumor characteristics were not significantly different between the two groups except for age. The objective response rate, disease control rate, progression-free survival, or cancer-specific survival were not significantly different between the groups. However, overall survival in the patients ≥75 years was significantly shorter than that in the patients <75 years (median: 18 months vs. 46 months, p = 0.01). In addition, an age ≥75 years was shown in multivariable analysis to be a significant independent predictor of poor overall survival. Toxicity did not show any significant variation between the groups.

CONCLUSIONS

Although the clinical efficacy and safety of NIVO + IPI was demonstrated in patients ≥75 years old, it is suggested that the indication for NIVO + IPI in this age group should be carefully considered, taking into account patients' expected life expectancy.

Overexpression of PLCG2 and TMEM38A inhibit tumor progression in clear cell renal cell carcinoma

Clear cell renal cell carcinoma is a prevalent urological malignancy, imposing substantial burdens on both patients and society. In our study, we used bioinformatics methods to select four putative target genes associated with EMT and prognosis and developed a nomogram model which could accurately predicting 5-year patient survival rates. We further analyzed proteome and single-cell data and selected PLCG2 and TMEM38A for the following experiments. Overexpression models of PLCG2 and TMEM38A were generated in Caki-1 and 786-O cell lines using plasmids. The in vitro experiments demonstrated that both of them exerted pro-apoptotic effects on Caki-1 and 786-O cells, inducing G2/M phase arrest, inhibiting proliferation, and suppressing EMT. In summary, we identified potential tumor suppressor factors and stratified ccRCC patients into high-risk and low-risk groups based on these factors. Furthermore, we elucidated the impact of PLCG2 and TMEM38A in Caki-1 and 786-O cell lines, offering novel avenues for therapeutic target exploration.

miR-9-5p/HMMR regulates the tumorigenesis and progression of clear cell renal cell carcinoma through EMT and JAK1/STAT1 signaling pathway

BACKGROUND

The most common malignant type of kidney cancer is clear cell renal cell carcinoma (ccRCC). The expression levels of hyaluronan-mediated motility receptor (HMMR) in many tumor types are significantly elevated. HMMR is closely associated with tumor-related progression, treatment resistance, and poor prognosis, and has yet to be fully investigated in terms of its expression patterns and molecular mechanisms of action in ccRCC. Further research is imperative to elucidate these aspects.

METHODS

We used The Cancer Genome Atlas (TCGA) database to preliminarily investigate HMMR expression and function in ccRCC and the data for 19 samples from the NCBI GEO database (GSE207493) for single-cell analysis. We assessed the differential expression level of HMMR between ccRCC cancerous tissues and their matched non-tumor tissues. Subsequently, a series of in vivo and in vitro experiments were designed to elucidate the biological function of HMMR in ccRCC, including Transwell assays, CCK-8 assays, clone formation assays and subcutaneous xenograft experiments in nude mice. Through bioinformatics analysis, we identified potential microRNAs (miRNAs) that may regulate HMMR, as well as the possible signaling pathways involved. Finally, we conducted a series of cellular functional experiments to validate our hypotheses regarding the HMMR axis.

RESULTS

HMMR expression was significantly up-regulated in tumor tissues of ccRCC patients, and elevated HMMR expression level showed a strong correlation with ccRCC progression and adverse prognoses of patients. Knocking down HMMR inhibited the proliferative and migratory abilities of ccRCC cells, while its overexpression amplified these oncogenic properties. In nude mice model, reduced HMMR expression inhibited ccRCC tumor proliferation in vivo. Furthermore, overexpression of an upstream transcriptional regulator, miR-9-5p, effectively downregulated HMMR expression and thus impeded ccRCC cells proliferation and migration. HMMR might influence ccRCC growth via the Epithelial-Mesenchymal Transition (EMT) pathway and the Janus Kinase 1/Signal Transducer and Activator of Transcription 1 (JAK1/STAT1) pathway.

CONCLUSIONS

HMMR is overexpressed in ccRCC, and there is a significant link between high HMMR expression and tumor progression, as well as poor patient prognosis. Specifically, HMMR could be targeted and inhibited by miR-9-5p and might modulate the tumorigenesis and progression of ccRCC through both EMT and JAK1/STAT1 signaling pathway.

Genetic Variations in MDM2 Gene Contribute to Renal Cell Carcinoma Susceptibility: A Genotype-Phenotype Correlation Study

BACKGROUND

This study aimed to investigate the polymorphic genotypes of MDM2 rs937282, rs937283, rs2279744, and rs769412, as well as the combined effects of MDM2 genotypes and environmental factors on RCC susceptibility.

METHODS

A total of 135 RCC patients and 590 controls were recruited for MDM2 genotyping using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Quantitative PCR was performed to assess MDM2 mRNA levels among 30 healthy individuals and 22 RCC patients.

RESULTS

MDM2 rs2279744, but not other polymorphisms, was significantly associated with an increased RCC risk (p = 0.0133). The MDM2 rs2279744 G allele was identified as a risk factor for RCC (odds ratio [OR] = 1.49, 95% confidence interval [CI] = 1.14-1.96, p = 0.0047). Among smokers (p = 0.0070), alcohol drinkers (p = 0.0233), individuals with hypertension (p = 0.0041), diabetes (p = 0.0225), and those with a family history of cancer (p = 0.0020), the MDM2 rs2279744 GT and GG genotypes exhibited increased RCC risks. However, this risk effect was not observed in non-smokers, non-drinkers, or individuals without hypertension, diabetes, or a family cancer history (all p > 0.05). Moreover, MDM2 mRNA levels were significantly higher in RCC patients compared to controls and varied among the rs2279744 genotypes, with GG genotype exhibiting the highest expression levels among both RCC patients and controls.

CONCLUSIONS

This study highlights the association between MDM2 rs2279744 genotypes and RCC risk, suggesting that genotype-associated MDM2 mRNA levels could contribute to early RCC detection. Further studies are warranted to elucidate the detailed mechanisms underlying the role of MDM2 in RCC development.

circASAP1 induces renal clear cell carcinoma ferroptosis by binding to HNRNPC and thereby regulating GPX4

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) represents the most prevalent subtype, accounting for nearly 80% of all RCC cases. Recent research has shown that high expression of circular non-coding RNA (circRNA) is associated with poor prognosis in patients with renal clear cell carcinoma (ccRCC), however, the underlying mechanism remains unclear.

METHODS

After analysing self-sequenced renal cancer and paracancer circRNA sequencing data and comparing it with the GEO public database, we discovered that circASAP1 expression was significantly up-regulated in renal cancers. We also tested circASAP1 levels in 102 renal cancer patients and found that high expression of circASAP1 was associated with poor prognosis and metastasis. The interaction between circASAP1, HNRNPC and their downstream target genes was confirmed through experiments such as RNA pull-down, RIP and fluorescence in situ hybridisation. A series of in vitro and in vivo functional experiments were performed to verify the effects of circASAP1 on RCC proliferation and metastasis.

RESULTS

Circular RNA sequencing analysis revealed that circASAP1 expression was markedly elevated in ccRCC, with a significant association observed between elevated circASAP1 expression and poor prognosis and metastasis. Actinomycin D, RNase R, as well as fluorescence in situ hybridization (FISH) analyses revealed the ring structure and cytoplasmic localization of circASAP1. High circASAP1 expression was associated with ccRCC cell proliferative viability, invasion, and metastasis in CCK-8, transwell, plate cloning, and EdU experiments. Interaction of circASAP1 with HNRNPC and their downstream target genes was confirmed by RNA pull-down, RNA immunoprecipitation, FISH, silver staining, and mass spectrometry. Experiments using truncated isoforms demonstrated that amino acids 16-87 of HNRNPC bound circASAP1. Proteins altered by circASAP1 were enriched in the ferroptosis pathway on the Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis.

CONCLUSIONS

The relationship between circRNA and the ASAP1/HNRNPC/GPX4 axis was demonstrated by experimental data, which was further confirmed by rescue experiments. circASAP1 influenced tumor growth and ferroptosis in animal experiments and predicted the prognosis of patients with ccRCC. The circASAP1/HNRNPC/GPX4 axis provides novel directions and potential targets for RCC treatment.

An Interesting Case of Vitamin D-Mediated Severe Hypercalcemia in a Patient With Renal Mass

Hypercalcemia of malignancy (HCM) is the most common cause of hypercalcemia in hospitalized patients. The pathogenesis of HCM is often multifactorial. One of the rare causes of HCM is extra-renal production of 1,25-dihydroxyvitamin D (or calcitriol), which is often seen in patients with lymphoproliferative malignancies. Here we report an interesting case of a 77-year-old female with severe hypercalcemia and renal mass. Initially, she was presumed to have humoral hypercalcemia of malignancy. However, her renal mass turned out to be diffuse large B cell lymphoma upon removal. Her severe hypercalcemia was attributed to a combination of ectopic calcitriol production from the tumor and probable iatrogenic vitamin D intoxication. This case highlights the need to consider multiple concurrent etiologies in patients with severe hypercalcemia.

Cardiovascular Disease and Other Competing Causes of Death in Older Kidney Cancer Patients

Background

To study the risk of cardiovascular disease (CVD) and other competing causes of death in older kidney cancer patients.

Methods

Data on older patients (aged 65 and above) diagnosed with kidney cancer between 1975 and 2018 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. We delved into the distribution of CVD and other competing causes of death across the entire cohort and in various patient subgroups. The competing risk analysis was used to produce cumulative mortality curves based on cumulative mortality for the primary outcomes by follow-up period. Utilizing the standardized mortality ratios (SMRs) and absolute excess risks (AERs), we contrasted the risk of CVD and other competing causes of death in older kidney cancer patients to that observed in the general population.

Results

The analysis included 29,349 older kidney cancer patients, of which included 4563 CVD deaths. As survival time extended, the proportion of non-cancer deaths increased in older kidney cancer patients, with CVD accounting for the largest share of non-cancer deaths. At 10-15 years after diagnosis, cumulative non-cancer mortality exceeded primary kidney cancer as the predominant cause of death, and cumulative CVD mortality is higher among all non-cancer causes. Older kidney cancer patients exhibited a greater risk of CVD and other non-cancer deaths than their counterparts in the general older population did (SMR: 1.38-2.81; AER: 1.1-143.69).

Conclusions

As survival time increases, the risk of non-cancer death in older kidney cancer patients gradually surpassed that of primary cancer, and CVD death accounted for the majority of non-cancer deaths. Among older kidney cancer patients, the risk of CVD mortality was higher than in the general population. Managing non-cancer deaths, especially CVD deaths, should be a focus in the care of older kidney cancer patients.

Renal cell cancer treatment: the Latin American Cooperative Oncology Group (LACOG) and the Latin American Renal Cancer Group (LARCG) surgery-focused consensus update

Renal cell carcinoma (RCC) represents 2.2% of all malignancies worldwide; however, its mortality rate is not negligible. Surgery is the primary treatment for most nonadvanced cases, with its indications and techniques evolving over the years. To provide an update on RCC management in Brazil, focusing on surgery. The Latin American Cooperative Oncology Group-Genitourinary Section and the Latin American Renal Cancer Group gathered a panel of Brazilian urologists and clinical oncologists to vote on and discuss the best management of surgically resectable RCC. The experts compared the results with the literature and graded them according to the level of evidence. For small renal masses (SRMs; less than 4 cm), biopsy is indicated for specific/select cases, and when intervention is needed, partial nephrectomy should be prioritized. Radical nephrectomy and ablative techniques are exceptions for managing SRMs. Patients with small tumors (less than 3 cm), slow tumor growth, or a risk for surgery may benefit from active surveillance. Localized carcinoma up to 7 cm in diameter should be treated preferably with partial nephrectomy. Lymphadenectomy and adrenalectomy should be performed in locally advanced cases if involvement is suspected by imaging exams. Patients with venous tumor thrombi usually require surgical intervention depending on the extent of the thrombus. Neoadjuvant therapy should be considered for unresectable cases. Even in the era of targeted therapy, cytoreductive nephrectomy still has a role in metastatic disease. Metastasectomy is indicated for most patients with resectable disease. This consensus presents recommendations for surgical treatment of RCC based on expert opinions and evidence from the medical literature. Surgery remains the best curative option for nonadvanced cases, and it still has a role for select patients with metastatic disease.

CRYAB is upregulated and predicts clinical prognosis in kidney renal clear cell carcinoma

Clear cell renal cell carcinoma (KIRC) is the most prevalent subtype of renal cell carcinoma (RCC), accounting for 70% to 80% of all RCC cases. The CRYAB (αB-crystallin) gene is broadly expressed across various human tissues, yet its role in KIRC progression remains unclear. This study aims to elucidate the function of CRYAB in KIRC progression and to assess its potential as a biomarker for early diagnosis, therapeutic targeting, and prognosis. In our report, we found that CRYAB was dramatically upregulated in KIRC, and its expression was associated with TNM stage, pathological stage, and age. Also, patients with higher CRYAB expression exhibited poor survival and prognosis. CRYAB overexpression led to enhanced tumor cell proliferation. Vice versa, CRYAB downregulation resulted in decreased cell proliferation in vitro. Mechanistically, Gene set enrichment analysis plots showed the enrichment of cell survival. Consistently, these effects were associated with increased AKT signaling and BCL-2 expression. Furthermore, we also observed that CRYAB expression levels were negatively correlated with immunocyte infiltration. In conclusion, these findings suggested that CRYAB could be regarded as a latent biomarker for early diagnosis, therapeutic targeting, and prognosis.

The 7-Methylguanosine (m7G) methylation METTL1 acts as a potential biomarker of clear cell renal cell carcinoma progression

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) is the most common subtype of renal cancer. 7-Methylguanosine (m7G), one of the most prevalent RNA modifications, has been reported to play an important role in ccRCC progression; however, the specific regulators of m7G modification that are involved in this function remain unclear. This study aimed to explore the correlation between regulators of m7G methylation and ccRCC progression using unsupervised machine learning methods.

METHODS

Transcriptome and clinical data of ccRCC were retrieved from The Cancer Genome Atlas (TCGA) database to identify differentially expressed m7G-related genes associated with the overall survival of patients with ccRCC. To construct and validate a prognostic risk model, TCGA dataset samples were divided into training and test sets. A multiple-gene risk signature was constructed using least absolute shrinkage and selection operator Cox regression analysis, and its prognostic significance was assessed using Cox regression and survival analyses. Finally, immunohistochemistry was performed to verify the prognostic significance of this signature.

RESULTS

In total, 537 patients with ccRCC were included in this study. We found that 26 m7G RNA methylation regulators that were significantly differentially expressed. Univariate and multifactorial Cox regression analyses revealed that METTL1 expression was associated with ccRCC progression.

CONCLUSIONS

METTL1 associated with m7G may serve as a potential biomarker for ccRCC prognosis and diagnosis. Moreover, it may affect the prognosis of ccRCC by regulating the tumor immune microenvironment, providing a potential therapeutic target for immunotherapy. These results provide a new perspective on the role of M7G-related RNAs in ccRCC pathogenesis.

The role of cytoreductive nephrectomy in the era of immune checkpoint inhibitors: A review of current evidence and ongoing trials

Renal cell carcinoma (RCC) was diagnosed in over 400 000 individuals globally in 2020, making it a significant global health concern. The incidence of RCC varies by region and overall mortality rates have been declining. This decline is attributed in part to advancements in early cancer detection through imaging and the development of more effective systemic therapies. Cytoreductive nephrectomy (CN) was adopted as a standard treatment for metastatic RCC (mRCC) based on clinical experience and early clinical trials. However, the treatment landscape has shifted with the introduction of tyrosine kinase inhibitors (TKI) in 2007 and, more recently, immune checkpoint inhibitors (ICIs). Dual ICI therapy and combinations of ICIs with TKIs are collectively referred to as immuno-combination therapies and have become standard first-line treatments. This review examines the evolving role of CN in the era of immuno-combination therapies, with a focus on patient selection and the timing of surgery. The immunogenic nature of RCC, characterized by spontaneous tumor regression and immune cell infiltration, suggests a potential benefit from combining CN with ICI therapy to enhance treatment outcomes. This is supported by several clinical studies that reported improved outcomes; however, these were limited by their retrospective nature. Ongoing clinical trials, such as NORDIC-SUN, PROBE, and SEVURO-CN, are expected to provide critical insights into the role of CN in the ICI era. Their findings will ultimately guide future clinical decision-making and further refine treatment strategies for mRCC.

[Precision Medicine for Patients with Renal Cell Carcinoma Based on Drug-metabolizing Enzyme Expression Levels]

Notable advances have recently been achieved in drug therapies for renal cell carcinoma (RCC). Several tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) have been approved for metastatic RCC (mRCC). The current first-line treatment for mRCC involves combination therapies using TKIs and ICIs. However, there is no consensus on which TKI+ICI therapy is best or how to select the appropriate therapy for individual patients with RCC. The kidney expresses various metabolic enzymes, including CYP and uridine diphosphate glucose (UDP)-glucuronosyltransferase (UGT). Although information on CYP and UGT expression in the kidney is limited compared to our understanding of liver expression, the main CYP and UGT subtypes expressed at high levels in the kidney are estimated to be CYP2B6, CYP3A5, CYP4A11, CYP4F2, UGT1A6, UGT1A9, and UGT2B7. In RCC, the expression profiles and levels of these enzymes are somewhat altered compared with normal kidney. The main known subtypes of CYP and UGT in RCC are CYP1B1, CYP3A5, CYP4A11, UGT1A6, UGT1A9, UGT1A10, and UGT2B7. High CYP expression has been reported in several cancers, possibly conferring resistance to anti-cancer drugs including TKIs, due to extensive drug metabolism. Additionally, CYP and UGT expression levels may possibly affect cancer prognosis by metabolizing endogenous substrates, regardless of their role in anti-cancer drug metabolism. In this review, I discuss CYP and UGT expression level profiles in RCC based on previously published papers, including ours, and examine possible relationships between these enzyme expression profiles and treatment outcomes for patients with RCC.

Stereotactic ablative radiotherapy for primary kidney cancer - An international patterns of practice survey

Purpose

To conduct an international survey of radiation oncologists treating primary renal cell carcinoma (RCC) with SABR to ascertain the general patterns of SABR use, common dose/treatment/follow-up details, and expected outcomes.

Materials and methods

A 51-question survey was created containing the following themes: prevalence and clinical scenarios in which RCC SABR is used, dose-fractionation schedules, treatment delivery details, follow-up/outcome assessments, and implementation barriers. The survey was distributed widely across multiple influential radiation oncology societies and social media, and ran from January to April 2023.

Results

A total of 255 respondents participated, mostly from academic centers within Europe/North America. Of these, 40 % (n = 102) currently offer SABR (50 % having begun within the last 3 years). Common barriers in non-users included lack of referrals by urologists and lack of supportive practice guidelines. Of respondents who do offer SABR, 77 % treat both small (4 cm or less) and large (>4 cm) renal masses. Dose-fractionation strategies varied from 27-52 Gy (3-5 fractions) for multifraction regimens, and 15-34 Gy for single fractions. Apart from treatment for medically inoperable disease, scenarios in which SABR was likely to be offered were for recurrence post surgery/thermal ablation and for oligometastatic kidney lesions. Uncommon scenarios included RCC with renal vein/inferior vena cava thrombosis, and as cytoreductive therapy in metastatic RCC. Expected local control outcomes were generally above 70 %, higher for small versus large renal masses.

Conclusions

SABR is a relatively newer indication for primary RCC, offered by less than 50% of respondents, with both consistent and variable practice patterns observed.

Rural Versus Urban Genitourinary Cancer Incidence and Mortality in Pennsylvania: 1990-2019

Our aim was to describe the incidence and mortality of genitourinary (GU) cancers in rural and urban Pennsylvania counties. We calculated age-adjusted incidence and mortality rates of GU (prostate, bladder, and kidney) cancers from 1990 to 2019 in the Pennsylvania Cancer Registry. We defined rurality using the Center for Rural Pennsylvania's population density-based definition. We modeled average annual percent changes (AAPC) in age-adjusted incidence and mortality rates using joinpoint regression. Overall GU cancer incidence decreased in rural and urban counties (AAPC -7.5%, p = 0.04 and AAPC -6.6%, p = 0.02, respectively). Prostate cancer incidence decreased in rural and urban counties by -10.5% (p = 0.02) and -9.1% (p = 0.01), respectively. Kidney cancer incidence increased in both rural and urban counties, respectively (AAPC = +11.2, p = 0.002 and +9.3%, p = 0.01). GU cancer mortality decreased in rural and urban counties (AAPC = -11.6, p = 0.047 and AAPC -12.2, p = 0.01, respectively). Prostate cancer mortality decreased at similar rates in rural and urban counties (AAPC -15.5, p = 0.03 and -15.4, p = 0.02, respectively). Kidney cancer mortality decreased in urban (AAPC -6.9% p = 0.03) but remained stable in rural counties. Bladder cancer incidence and mortality were unchanged in both types of counties. Over three decades, GU cancer incidence and mortality decreased across Pennsylvania counties.

The long-term survival outcome of sporadic bilateral renal cell carcinoma and optimization of surgical treatment: a large-scale population-based cohort study

Sporadic bilateral renal cell carcinoma (BRCC) is a rare situation of RCC. The treatment for BRCC is controversial and there is a lack of authoritative guidelines about the management of BRCC. Patients diagnosed with sporadic BRCC between 2004 and 2020 were identified from Surveillance, Epidemiology, and End Results (SEER) database. The primary outcome was overall survival (OS). Kaplan-Meier survival analysis, Cox regression analysis, and competing risk regression models were used to compare survival outcomes and identify prognostic factors. A total of 20,523 patients (16,534 unilateral RCC [URCC] patients and 3989 BRCC patients) were included. The prognosis of BRCC patients is between metastatic and non-metastatic URCC patients. 3677 patients were diagnosed with localized BRCC (2180 synchronous BRCC patients and 1497 metachronous BRCC patients). Compared with metachronous BRCC, synchronous BRCC patients had relatively poor OS. However, the CSS was similar. Partial nephrectomy (PN) leads to the best OS and provides equivalent oncological outcomes to radical nephrectomy. Local tumor destruction (LTD) could also achieve an acceptable cancer-control effect. Then we developed treatment flowchart for localized BRCC patients. Additionally, we identified the prognostic factors, and analyzed the association between factors using the multivariable Cox regression method. PN should be the initial treatment for sporadic localized BRCC patients if feasible. LTD could be considered as an effective treatment alternative. This study could provide evidence for the optimization of individualized treatment for sporadic BRCC patients.Trial registration: The trial was registered on the ClinicalTrials.gov (NCT06369519).

Integrated machine learning reveals the role of tryptophan metabolism in clear cell renal cell carcinoma and its association with patient prognosis

BACKGROUND

Precision oncology's implementation in clinical practice faces significant constraints due to the inadequacies in tools for detailed patient stratification and personalized treatment methodologies. Dysregulated tryptophan metabolism has emerged as a crucial factor in tumor progression, encompassing immune suppression, proliferation, metastasis, and metabolic reprogramming. However, its precise role in clear cell renal cell carcinoma (ccRCC) remains unclear, and predictive models or signatures based on tryptophan metabolism are conspicuously lacking.

METHODS

The influence of tryptophan metabolism on tumor cells was explored using single-cell RNA sequencing data. Genes involved in tryptophan metabolism were identified across both single-cell and bulk-cell dimensions through weighted gene co-expression network analysis (WGCNA) and its single-cell data variant (hdWGCNA). Subsequently, a tryptophan metabolism-related signature was developed using an integrated machine-learning approach. This signature was then examined in multi-omics data to assess its associations with patient clinical features, prognosis, cancer malignancy-related pathways, immune microenvironment, genomic characteristics, and responses to immunotherapy and targeted therapy. Finally, the genes within the signature were validated through experiments including qRT-PCR, Western blot, CCK8 assay, and transwell assay.

RESULTS

Dysregulated tryptophan metabolism was identified as a potential driver of the malignant transformation of normal epithelial cells. The tryptophan metabolism-related signature (TMRS) demonstrated robust predictive capability for overall survival (OS) and progression-free survival (PFS) across multiple datasets. Moreover, a high TMRS risk score correlated with increased tumor malignancy, significant metabolic reprogramming, an inflamed yet dysfunctional immune microenvironment, heightened genomic instability, resistance to immunotherapy, and increased sensitivity to certain targeted therapeutics. Experimental validation revealed differential expression of genes within the signature between RCC and adjacent normal tissues, with reduced expression of DDAH1 linked to enhanced proliferation and metastasis of tumor cells.

CONCLUSION

This study investigated the potential impact of dysregulated tryptophan metabolism on clear cell renal cell carcinoma, leading to the development of a tryptophan metabolism-related signature that may provide insights into patient prognosis, tumor biological status, and personalized treatment strategies. This signature serves as a valuable reference for further exploring the role of tryptophan metabolism in renal cell carcinoma and for the development of clinical applications based on this metabolic pathway.

Exploring prognostic implications of miRNA signatures and telomere maintenance genes in kidney cancer

Kidney cancer, particularly clear cell renal cell carcinoma (KIRC), presents significant challenges in disease-specific survival. This study investigates the prognostic potential of microRNAs (miRNAs) in kidney cancers, including KIRC and kidney papillary cell carcinoma (KIRP), focusing on their interplay with telomere maintenance genes. Utilizing data from The Cancer Genome Atlas, miRNA expression profiles of 166 KIRC and 168 KIRP patients were analyzed. An evolutionary learning-based kidney survival estimator identified robust miRNA signatures predictive of 5-year survival for both cancer types. For KIRC, a 37-miRNA signature showed a correlation coefficient (R) of 0.82 and mean absolute error (MAE) of 0.65 years. Similarly, for KIRP, a 23-miRNA signature exhibited an R of 0.82 and MAE of 0.64 years, demonstrating comparable predictive accuracy. These signatures also displayed diagnostic potential with receiver operating characteristic curve values between 0.70 and 0.94. Bioinformatics analysis revealed targeting of key telomere-associated genes such as TERT, DKC1, CTC1, and RTEL1 by these miRNAs, implicating crucial pathways such as cellular senescence and proteoglycans in cancer. This study highlights the significant link between miRNAs and telomere genes in kidney cancer survival, offering insights for therapeutic targets and improved prognostic markers.

Nrf2 Signaling in Renal Cell Carcinoma: A Potential Candidate for the Development of Novel Therapeutic Strategies

Renal cell carcinoma (RCC) is the most common type of kidney cancer arising from renal tubular epithelial cells and is characterized by a high aggressive behavior and invasiveness that lead to poor prognosis and high mortality rate. Diagnosis of RCC is generally incidental and occurs when the stage is advanced and the disease is already metastatic. The management of RCC is further complicated by an intrinsic resistance of this malignancy to chemotherapy and radiotherapy, which aggravates the prognosis. For these reasons, there is intense research focused on identifying novel biomarkers which may be useful for a better prognostic assessment, as well as molecular markers which could be utilized for targeted therapy. Nuclear factor erythroid 2-related factor 2 (Nrf2) is a transcriptional factor that has been identified as a key modulator of oxidative stress response, and its overexpression is considered a negative prognostic feature in several types of cancers including RCC, since it is involved in various key cancer-promoting functions such as proliferation, anabolic metabolism and resistance to chemotherapy. Given the key role of Nrf2 in promoting tumor progression, this enzyme could be a promising biomarker for a more accurate prediction of RCC course and it can also represent a valuable therapeutic target. In this review, we provide a comprehensive literature analysis of studies that have explored the role of Nrf2 in RCC, underlining the possible implications for targeted therapy.

Exploring the value of arterial spin labeling and six diffusion MRI models in differentiating solid benign and malignant renal tumors

OBJECTIVE

To explore the value of three-dimensional arterial spin labeling (ASL) and six diffusion magnetic resonance imaging (MRI) models in differentiating solid benign and malignant renal tumors.

METHODS

This retrospective study included 89 patients with renal tumors. All patients underwent ASL and ZOOMit diffusion-weighted imaging (DWI) examinations and were divided into three groups: clear cell renal cell carcinoma (ccRCC), non-ccRCC, and benign renal tumors (BRT). The mean and peak renal blood flow (RBFmean and RBFpeak) from ASL and fourteen diffusion parameters from mono-exponential DWI (Mono_DWI), intravoxel incoherent motion (IVIM), diffusion kurtosis imaging (DKI), stretched exponential model (SEM), fractional order calculus (FROC), and continuous-time random-walk (CTRW) model were analyzed. Binary logistic regression was used to determine the optimal parameter combinations. The diagnostic performance of various MRI-derived parameters and their combinations was compared.

RESULTS

Among the six diffusion models, the SEM model achieved the highest performance in differentiating ccRCC from non-ccRCC (area under the receiver operating characteristic curve [AUC] 0.880) and from BRT (AUC 0.891). IVIM model achieved the highest AUC (0.818) in differentiating non-ccRCC from BRT. Among all the MRI-derived parameters, RBFpeak combined with DKI_MK yielded the highest AUC (0.970) in differentiating ccRCC from non-ccRCC, and the combination of RBFpeak, SEM_DDC, and FROC_μ yielded the highest AUC (0.992) for differentiating ccRCC from BRT.

CONCLUSION

ASL and all diffusion models showed similar diagnostic performance in differentiating ccRCC from non-ccRCC or BRT, while the IVIM model performed better in distinguishing non-ccRCC from BRT. Combining ASL with diffusion models can provide additional value in predicting ccRCC.

RELEVANCE STATEMENT

Considering the increasing detection rate of incidental renal masses, accurate discrimination of benign and malignant renal tumors is crucial for decision-making. Combining ASL with diffusion MRI models offers a promising solution to this clinical issue.

KEY POINTS

All assessed models were effective for differentiating ccRCC from non-ccRCC or BRT. ASL and all diffusion models showed similar performance in differentiating ccRCC from non-ccRCC or BRT. Combining ASL with diffusion models significantly improved diagnostic efficacy in predicting ccRCC. IVIM model could better differentiate non-ccRCC from BRT.

Predictive nomogram for ischemic stroke risk in clear cell renal cell carcinoma patients

Clear cell renal cell carcinoma (ccRCC) and ischemic stroke are critical global health challenges with a notable association. This study explores the correlation between tumor-related factors and ischemic stroke risk, aiming to construct a predictive nomogram model for ischemic stroke in ccRCC patients. We retrospectively analyzed data from ccRCC patients who underwent nephrectomy at the First Hospital of Shanxi Medical University between January 1, 2013, and May 31, 2022. The data were randomly divided into a training cohort (70%) and a validation cohort (30%). Predictive factors were identified using univariate logistic regression, least absolute shrinkage and selection operator regression, and multivariate logistic regression. A nomogram and a Shiny local calculator were developed using these predictors. We identified six predictors for the nomogram: WHO/ISUP grade, diabetes, hypertension, LDL-C, age, and D-dimer. The nomogram showed good discrimination, with an area under the ROC curve of 0.816 in the training cohort and 0.775 in the validation cohort. The optimal cutoff value was 53.7%. The model demonstrated excellent calibration and clinical applicability. WHO/ISUP grade correlates with ischemic stroke risk, offering insights into cancer-related ischemic stroke mechanisms. This nomogram aids in identifying high-risk individuals among ccRCC patients, facilitating early management and improved outcomes.

CD70-Targeted Immuno-PET/CT Imaging of Clear Cell Renal Cell Carcinoma: A Translational Study

The diagnosis and surveillance of clear cell renal cell carcinoma (ccRCC) remains a clinical challenge. The high and specific expression of the cluster of differentiation 70 (CD70) in ccRCC makes it a potential diagnostic and therapeutic target. Methods: We detected and analyzed CD70 expression in various renal cell carcinomas (RCCs) and normal kidneys using immunohistochemical staining. Two novel CD70-specific single-domain antibodies, RCCB3 and RCCB6, were produced and labeled with 68Ga to develop radiotracers. We performed immuno-PET/CT imaging with [68Ga]Ga-NOTA-RCCB3 and [68Ga]Ga-NOTA-RCCB6 in subcutaneous ccRCC patient-derived xenograft models. We recruited 8 RCC patients in a pilot clinical trial (ClinicalTrials.gov identifier: NCT06148220) to evaluate the diagnostic utility of [68Ga]Ga-NOTA-RCCB3 and [68Ga]Ga-NOTA-RCCB6 immuno-PET/CT. Results: Expression of CD70 is associated with sex, tumor differentiation, tumor thrombus, necrosis, distant metastasis, and overall survival of RCC patients. RCCB3 and RCCB6 had high affinities for recombinant human CD70. Immuno-PET/CT imaging with [68Ga]Ga-NOTA-RCCB3 and [68Ga]Ga-NOTA-RCCB6 rapidly visualized subcutaneous ccRCC with clarity. Tumor uptake of [68Ga]Ga-NOTA-RCCB6 was significantly reduced after the blockade of CD70. [68Ga]Ga-NOTA-RCCB6 PET/CT in ccRCC patients outperformed traditional 18F-FDG PET/CT in specifically identifying CD70-positive ccRCC metastases. Conclusion: CD70-targeted immuno-PET/CT imaging with [68Ga]Ga-NOTA-RCCB6 or [68Ga]Ga-NOTA-RCCB3 is a precise and superior method for evaluating tumor burden and suspected metastases in ccRCC patients. This advancement in imaging technology has the potential to improve the clinical decision-making process for this patient cohort significantly.

Organoids as Sophisticated Tools for Renal Cancer Research: Extensive Applications and Promising Prospects

Background

Kidney cancer is a significant global health problem that affects nearly 1 in 25 of cancer patients. Prevalence, morbidity and mortality data associated with kidney cancer continue to increase every year, revealing a heavy economic and social burden. Organoid culture is a new research tool with great potential for many applications, particularly in cancer research. The integration of organoids with other emerging technologies has simultaneously expanded their potential applications. However, there is no thorough assessment of organoids in the field of renal cancer research.

Objectives

This paper presents a comprehensive review of the current development of renal cancer organoids and discusses the corresponding solutions and future directions of renal cancer organoids.

Methods

In this study, we have compared the operating procedures of different organoid culture protocols and proposed a summary of constituents in culture media. Extensive discussions of renal cancer organoids, including generation and maintenance approaches, application scenarios, current challenges and prospects, have also been made. The information required for this study is extracted from literature databases such as PubMed, SCOPUS and Web of Science.

Results

In this article, we systematically review thirteen successful methods for generating organoids to kidney cancer and provide practical guidelines for their construction as a reference. In addition, we also elucidate the clinical application of organoids, address the existing challenges and limitations, and highlight promising prospects.

Conclusion

Ultimately, we firmly believe that as kidney tumour organoids continue to develop and improve, they will become a crucial tool for treating kidney cancer.

Exploring the Prognostic Value of Tumour-Associated Genes in Clear Cell Renal Cell Carcinoma Through Single-Cell RNA Sequencing Insights

Clear cell renal cell carcinoma (ccRCC) characterised by its diversity and a tendency to defy standard therapeutic approaches. Amidst the advent of immunotherapy, it has become imperative to pinpoint prognostic indicators of the tumour microenvironment (TME) influence the efficacy of treatments. Employing single-cell RNA sequencing (scRNA-seq), this research delved into the diverse landscape of ccRCC, uncovering its complex underpinnings and pinpointing molecular avenues for therapeutic intervention. We constructed a prognostic model using 101 machine learning algorithms and integrated data from multiple cohorts, including TCGA, ICGC, and microarray datasets. The model's efficacy was assessed using the Concordance Index (C-index), and further analyses included pseudotime analysis of tumour cells, mutation analysis and correlation analysis between the prognostic model and tumour immunity. The prognostic model, combining Lasso regression and survival Support Vector Machine (SVM), demonstrated robust discrimination with a C-index of 0.650. Investigation into the TME uncovered pronounced associations between the presence of immune cell infiltrates and patient outcomes, with a notable emphasis on the impact of CCL2-expressing neoplastic cells. The GO Biological Processes (GOBP) encompass the regulation of endothelial cell maturation, the formation of endothelial layers, the enhancement of gene expression controlled by Notch receptors, and the development of endothelial barriers. The research effectively pinpointed critical prognostic markers and crafted a forecasting model that achieved a C-index of 0.650, highlighting the significant impact of immune cell infiltration, especially CCL2+ neoplastic cells, on ccRCC patient prognosis.

Prognostic significance of CD3+ and CD8+ T-cells immunoscore in renal cell carcinoma: A comparison between two simple models for assessment

The immunoscore (ISc) has been extensively investigated as a prognostic indicator for numerous solid tumors. In renal cell carcinoma (RCC), its prognostic significance has been evaluated in a small number of studies. This study was designed to ascertain the prognostic value of ISc based on CD3+ and CD8+ T cells in patients with RCC. This study included 115 non-metastatic RCC patients who underwent nephrectomy. The ISc was obtained by estimating the densities of CD3+ and CD8+ cells at the invasive margin and center of the tumor using two methods: cell count per square millimeter (cell count/mm2) and percentage of cells per square millimeter (% of cells/mm2). The patients were categorized into low and high groups according to the ISc. The associations between the ISc and clinicopathological characters, including survival, were analyzed statistically. Adverse clinicopathologic factors were significantly associated with high ISc. Patients with high ISc had significantly worse overall survival (OS) and disease-free survival (DFS) rates over three years (p < 0.001). High ISc was considered a predictor of shortened DFS in univariate analysis (p < 0.001). However, in multivariate analysis, it was a dependent predictor. High ISc could help identify individuals more likely to develop recurrence and may impact treatment strategy for more effective personalized care. Moreover, establishing a modified objective, automated, digital quantification method of immune cells (% of cells/mm2 instead of cell count/mm2) is expected to be simple to implement in routine, highly affordable, time efficient, clinically meaningful, and will improve assay performance.

Role of apoptosis repressor with caspase recruitment domain in human health and chronic diseases

Apoptosis repressor with caspase recruitment domain (ARC) is a highly potent and multifunctional suppressor of various types of programmed cell death (PCD) (e.g. apoptosis, necroptosis, and pyroptosis) and plays a key role in determining cell fate. Under physiological conditions, ARC is predominantly expressed in terminally differentiated cells, such as cardiomyocytes and skeletal muscle cells. Its expression and activity are tightly controlled by a complicated system consisting of transcription factor (TF), non-coding RNA (ncRNA), and post-translational modification (PTM). ARC dysregulation has been shown to be closely associated with many chronic diseases, including cardiovascular disease, cancer, diabetes, and neurodegenerative disease. However, the detailed mechanisms of ARC involved in the progression of these diseases remain unclear to a large extent. In this review, we mainly focus on the regulatory mechanisms of ARC expression and activity and its role in PCD. We also discuss the underlying mechanisms of ARC in health and disease and highlight the potential implications of ARC in the clinical treatment of patients with chronic diseases. This information may assist in developing ARC-based therapeutic strategies for patients with chronic diseases and expand researchers' understanding of ARC.

Protection from injury to organs adjacent to a renal tumor during Imaging-guided thermal ablation with hydrodissection and pyeloperfusion

PURPOSE

The treatment of renal tumors is dictated by the results acquired from renal imaging, which play a crucial role in determining the appropriate strategy and surgical plan. Radiofrequency ablation, microwave ablation, and cryoablation are established percutaneous thermal ablation procedures that have widespread recognition. The objective of this scholarly article is to present a comprehensive summary of the application of the primary thermal protection strategies of the structures adjacent to renal tumors, in particular the effectiveness in terms of safety of hydrodissection and pyeloperfusion, in the context of percutaneous thermal ablation for renal tumors.

METHODS

A literature search was conducted in PubMed in April 2023 using the keywords "hydrodissection", "hydrodisplacement", "renal", "kidney", "percutaneous ablation", "cryoablation", "microwave", "radiofrequency", and "pyeloperfusion". No language restriction was applied.

RESULTS

Our study yielded a total of 676 cases describing the use of either hydrodissection or pyeloperfusion in conjunction with percutaneous thermal ablation. The fluids employed for displacing the neighboring structures encompassed saline solution, a mixture of saline solution and iodinated contrast, 5% dextrose in water, iodinated contrast in dextrose solution, lactated singer solution, and iodinated contrast.

CONCLUSIONS

By using these procedures effectively, a greater number of ablations could be performed on anterior or lower polar renal tumors, sometimes excluded from these treatments due to the high risk of causing damage to adjacent anatomical structures.

Targeting Hypoxia and Autophagy Inhibition via Delivering Sonodynamic Nanoparticles With HIF-2α Inhibitor for Enhancing Immunotherapy in Renal Cell Carcinoma

Immune checkpoint blockers (ICBs) therapy stands as the first-line treatment option for advanced renal cell carcinoma (RCC). However, its effectiveness is hindered by the immunosuppressive tumor microenvironment (TME). Sonodynamic therapy (SDT) generates tumor cell fragments that can prime the host's antitumor immunity. Nevertheless, the hypoxic microenvironment and upregulated autophagy following SDT often lead to cancer cell resistance. In response to these challenges, a hypoxia-responsive polymer (Poly(4,4'-azobisbenzenemethanol-PMDA)-mPEG5k, P-APm) encapsulating both a HIF-2α inhibitor (belzutifan) and the ultrasonic sensitize (Chlorin e6, Ce6) is designed, to create the nanoparticle APm/Ce6/HIF. APm/Ce6/HIF combined with ultrasound (US) significantly suppresses tumor growth and activates antitumor immunity in vivo. Moreover, this treatment effectively transforms the immunosuppressive microenvironment from "immune-cold" to "immune-hot", thereby enhancing the response to ICBs therapy. The findings indicate that APm/Ce6/HIF offers a synergistic approach combining targeted therapy with immunotherapy, providing new possibilities for treating RCC.

Integrative analysis of bulk and single-cell RNA sequencing reveals sphingolipid metabolism and immune landscape in clear cell renal cell carcinoma

Clear cell renal cell carcinoma (ccRCC) is characterized by its aggressive behavior and complex molecular heterogeneity, posing significant challenges for treatment and prognostication. This study offers a comprehensive analysis of ccRCC by leveraging both bulk and single-cell RNA sequencing data, with a specific aim to unravel the complexities of sphingolipid metabolism and the intricate dynamics within the tumor microenvironment (TME). By examining ccRCC samples sourced from public databases, our investigation delves deep into the genetic and transcriptomic landscape of this cancer type. Employing advanced analytical techniques, we have identified pivotal patterns in gene expression and cellular heterogeneity, with a special focus on the roles and interactions of various immune cells within the TME. Significantly, our research has unearthed insights into the dynamics of sphingolipid metabolism in ccRCC, shedding light on its potential implications for tumor progression and strategies for immune evasion. A novel aspect of this study is the development of a risk score model designed to enhance prognostic predictions for ccRCC patients, which is currently pending external validation to ascertain its clinical utility. Despite its contributions, the study is mindful of its limitations, including a reliance on observational data from public sources and a primary focus on RNA sequencing data, which may constrain the depth and generalizability of the findings. The study does not encompass critical aspects, such as protein expression, posttranslational modifications, and comprehensive metabolic profiles. Moreover, its retrospective design underscores the necessity for future prospective studies to solidify these preliminary conclusions. Our findings illuminate the intricate interplay between genetic alterations, sphingolipid metabolism, and immune responses in ccRCC. This research not only enhances our understanding of the molecular foundations of ccRCC but also paves the way for the development of targeted therapies and personalized treatment modalities. The study underlines the importance of cautious interpretation of results and champions ongoing research using diverse methodologies to thoroughly comprehend and effectively combat this formidable cancer type.

Knockdown of PIK3R6 impedes the onset and advancement of clear cell renal cell carcinoma

In this research, we investigated the role of PIK3R6, a regulatory subunit of PI3Kγ, known for its tumor-promoting properties, in clear cell renal cell carcinoma (CCRCC). Utilizing the UALCAN website, we found PIK3R6 upregulated in CCRCC, correlating with lower survival rates. We compared PIK3R6 expression in CCRCC tumor tissues and adjacent normal tissues using immunohistochemistry. Post RNA interference-induced knockdown of PIK3R6 in 786-O and ACHN cell lines, we performed CCK-8, colony formation, Edu staining, flow cytometry, wound healing, and transwell assays. Results showed that PIK3R6 silencing reduced cell proliferation, migration, and invasion, and induced G0/G1 phase arrest and apoptosis. Molecular analysis revealed decreased CDK4, Cyclin D1, N-cadherin, Vimentin, Bcl-2, p-PI3K and p-AKT, with increased cleaved caspase-3, Bax, and E-cadherin levels in CCRCC cells. Moreover, inhibiting PIK3R6 hindered tumor growth. These findings suggest a significant role for PIK3R6 in CCRCC cell proliferation and metastasis, presenting it as a potential therapeutic target.

Long-Term Temporal Trends of Real-World Healthcare Costs Associated with Nivolumab Plus Ipilimumab and Pembrolizumab Plus Axitinib as First-Line Treatment for Advanced or Metastatic Renal Cell Carcinoma

INTRODUCTION

Nivolumab plus ipilimumab (NIVO + IPI) and pembrolizumab plus axitinib (PEM + AXI) are first-line (1L) treatments for advanced or metastatic renal cell carcinoma (aRCC), although the long-term trends in their associated real-world healthcare costs are not well defined. We compared the real-world healthcare costs of patients with aRCC who received 1L NIVO + IPI or PEM + AXI over 24 months.

METHODS

Adults with RCC and secondary malignancy who initiated 1L NIVO + IPI or PEM + AXI were identified in the Merative MarketScan Commercial and Medicare Supplemental Databases (01/01/2004 to 09/30/2021). All-cause and RCC-related healthcare costs (unadjusted and adjusted) were assessed per patient per month (PPPM) at 6-month intervals post-treatment initiation (index date) up to 24 months, and differences between the NIVO + IPI and PEM + AXI cohorts were compared.

RESULTS

Of 325 patients with aRCC, 219 received NIVO + IPI and 106 received PEM + AXI as the 1L treatment. According to patients' follow-up length, the analyses for months 7-12 included 210 patients in the NIVO + IPI cohort and 103 in the PEM + AXI cohort; months 13-18 included 119 and 48 patients, respectively; and months 19-24 included 81 and 25 patients. PPPM unadjusted all-cause total costs were $46,348 for NIVO + IPI and $38,097 for PEM + AXI in months 1-6; $26,840 versus $27,983, respectively, in months 7-12; $22,899 versus $25,137 in months 13-18; and $22,279 versus $27,947 in months 19-24. PPPM unadjusted RCC-related costs were $44,059 for NIVO + IPI and $36,456 for PEM + AXI in months 1-6; $25,144 versus $26,692, respectively, in months 7-12; $21,645 versus $23,709 in months 13-18; and $20,486 versus $25,515 in months 19-24. PPPM costs declined more rapidly for patients receiving NIVO + IPI compared to those receiving PEM + AXI, resulting in significantly lower all-cause costs associated with NIVO + IPI during months 19-24 (difference - $10,914 [95% confidence interval - $21,436, - $1091]) and RCC-related costs during months 7-12 (- $4747 [(- $8929, - $512]) and 19-24 (- $10,261 [- $20,842, - $421]) after adjustment. Cost savings for NIVO + IPI versus PEM + AXI were driven by differences in drug costs which, after adjustment, were significantly lower in months 7-12 (difference - $5555 [all-cause], - $5689 [RCC-related]); 13-18 (- $7217 and - $6870, respectively); and 19-24 (- $16,682 and - $16,125).

CONCLUSION

Although the real-world PPPM healthcare costs of 1L NIVO + IPI were higher compared with PEM + AXI in the first 6 months of treatment, the costs associated with NIVO + IPI rapidly declined thereafter, resulting in significantly lower costs vs. PEM + AXI from months 7 to 24.

Beyond Index Conditions: Applying a Multimorbidity Approach to Renal Cancer Nursing

OBJECTIVE

This article aims to describe the key components of renal cancer nursing and multimorbidity nursing, and reflects on how adopting a multimorbidity approach to renal cancer nursing can help nurses provide holistic patient care.

METHODS

This is a discussion paper drawing on relevant evidence and theory.

RESULTS

Renal cancer nurses have a highly specialised knowledge base and are able to use this expertise to deliver excellent care to people with cancer. However, lots of people with cancer have other conditions as well. Adopting a multimorbidity approach to nursing care provides a more holistic framework for care delivery.

CONCLUSIONS

Cancer nurses are ideally placed to support patients in this way, so they are able to deliver care which accounts for factors such as treatment burden and how this impacts on patients and carers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses who care for people with renal cancer should view their patients through the lens of multimorbidity. This involves screening for other chronic conditions, considering polypharmacy, providing emotional support and continuity of care, and coordinating care in a way that accounts for the potentially burdensome nature of the patient's interactions with health care.

NODESAFE Nomogram: A Novel Score System to Predict Lymph Node Involvement at the Time of Nephrectomy or Nodal Recurrence in Nonmetastatic Renal Cell Carcinoma

OBJECTIVE

We sought to develop a preoperative nomogram called NODESAFE (NODE SAFEty) to predict nodal involvement (NI) at time of surgery or subsequent follow up in localized renal cell carcinoma (RCC), as the role of lymphadenectomy in localized RCC remains controversial.

METHODS

We conducted a multicenter retrospective analysis of RCC patients who underwent primary surgical resection. Patients with clinical metastasis at presentation were excluded. NI was defined as presence of histological RCC with lymphadenectomy at time of surgery, or subsequent development histologically proven NI. The dataset was divided into training (70%) and testing subsets to facilitate model evaluation which was constructed through a stepwise multivariable logistic regression (MLR) model. Accuracy was tested with receiver operator characteristic estimated area under the curve (AUC).

RESULTS

Total 3308 patients (2221 [67.1%] male) met inclusion criteria. During follow-up 25 patients (0.76 %) experienced nodal recurrence, and 22/25 were preoperatively classified as cN0. In our cohort, 112 (3.4%) patients had clinical lymphadenopathy preoperatively (cN1), and 34/112 were pN1. The following covariates were found to be statically significant on a MLR model: hypertension (Odds ratio [OR] 3.35, < .001), Charlson Comorbidity Index ≥ 5 (OR 1.93 P = .025), tumor size ≥ 6 cm (OR 2.63, P = .001), tumor necrosis at CT scan (OR 1.83, P = .036), cN1 (OR 5.59, P < .001) and CRP ≥ 8.5 mg/L (1.96, P = .018). Testing the prediction performance of the model in the validation set AUC of the model was 0.89. NODESAFE demonstrated a sensitivity of 83.9%, specificity of 86.1% and 99.1% negative predictive values using a 4% threshold probability.

CONCLUSION

Combining clinical features, serum biomarkers and radiographic findings, we developed a model capable of predicting NI with high degree of accuracy. NODESAFE may refine clinical decision making with respect to the performance of lymphadenectomy at the time of surgery, postsurgical surveillance, and spur consideration for adjuvant therapy.

Financial Distress in Genitourinary Cancer: Insights From CDC National Health Interview Survey

PURPOSE

This study leverages CDC National Health Interview Survey data to examine Financial Distress (FD) among genitourinary (GU) cancer survivors, specifically prostate cancer (PC), kidney cancer (KC), and bladder cancer (BC). It investigates the economic impacts faced by these patients, especially in relation to disparities in insurance coverage and its effects on material, psychological, and behavioral aspects of FD.

METHODS

We retrospectively analyzed responses from GU cancer survivors, stratifying by cancer status and age (18-64 years, ≥65 years). Medical financial hardship was divided into three domains: material, psychological, and behavioral. Associations between cancer history, hardship, and clinical factors were assessed using generalized ordinal logistic regressions.

RESULTS

Significant health care access disparities were found, particularly for mental health services, with 25% of younger BC survivors and 4.7% of younger KC survivors reporting affordability issues, in contrast to 2.7% of noncancer individuals. Dental care was also problematic, with higher avoidance rates among younger BC (27%) and KC (15%) survivors compared with the general population. Surprisingly, noncancer individuals reported more difficulty in affording prescriptions than BC survivors across both age groups. PC survivors, however, showed lower FD across all domains versus noncancer controls, indicating fewer concerns about medical bills and a lesser tendency to forgo care.

CONCLUSION

The study underscores significant gaps in the financial support system for GU cancer survivors, with urgent needs in mental and dental health care access. Policy interventions, including comprehensive insurance reforms, are imperative to alleviate the financial burdens on these individuals.

m6Am Methyltransferase PCIF1 Promotes LPP3 Mediated Phosphatidic Acid Metabolism and Renal Cell Carcinoma Progression

N6-methyl-2'-O-methyladenosine (m6Am), occurring adjacent to the 7-methylguanosine (m7G) cap structure and catalyzed by the newly identified writer PCIF1 (phosphorylated CTD interacting factor 1), has been implicated in the pathogenesis of various diseases. However, its involvement in renal cell carcinoma (RCC) remains unexplored. Here, significant upregulation of PCIF1 and m6Am levels in RCC tissues are identified, unveiling their oncogenic roles both in vitro and in vivo. Mechanically, employing m6Am-Exo-Seq, LPP3 (phospholipid phosphatase 3) mRNA is identified as a key downstream target whose translation is enhanced by m6Am modification. Furthermore, LPP3 is revealed as a key regulator of phosphatidic acid metabolism, critical for preventing its accumulation in mitochondria and facilitating mitochondrial fission. Consequently, Inhibition of the PCIF1/LPP3 axis significantly altered mitochondrial morphology and reduced RCC tumor progression. In addition, depletion of PCIF1 sensitizes RCC to sunitinib treatment. This study highlights the intricate interplay between m6Am modification, phosphatidic acid metabolism, and mitochondrial dynamics, offering a promising therapeutic avenue for RCC.