European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update

Retroperitoneal laparoscopic radical nephrectomy (RLRN) is associated with poor integrity of Gerota's fascia and perirenal fat: A prospective comparative study

Purpose

To figure out the difference of integrity of Gerota's fascia and perirenal fat between Retroperitoneal Laparoscopic Radical Nephrectomy (RLRN) and Transperitoneal Laparoscopic Radical Nephrectomy (TLRN).

Methods

This is a prospective comparative study of patients with Renal Cell Carcinoma (RCC) from a designated tertiary center in Lanzhou, China. We have developed and propose a scoring tool to quantify the integrity of nephrectomy specimens from both approaches. The integrity score is based on 6 common conditions of nephrectomy specimens. Specimens are scored on a 1 to 6-point scale according to the integrity of Gerota's fascia and perirenal fat. We applied the integrity score to 142 consecutive patients. Integrity scores were compared between RLRN and TLRN groups. Factors associated with low integrity score were assessed by logistic regression.

Results

Among 142 patients, 79 (55.6%) patients and 63 (44.4%) patients, respectively, underwent RLRN and TLRN. There was a significant difference in the distribution of integrity score between the two groups (P < 0.001). RLRN (odds ratio 10.65, 95%CI 4.29-26.45, P < 0.001), tumor size (odds ratio 1.22, 95%CI 1.04-1.42, P = 0.015) and Body Mass Index (BMI) (odds ratio 0.83, 95%CI 0.72-0.96, P = 0.010) were significantly associated with low integrity score. The logistic regression equation showed good power to predict low integrity score.

Conclusion

RLRN has poor integrity of Gerota's fascia and the perirenal fat. The integrity score can be used to evaluate the extent of resection and specimen completeness in LRN. Postoperative evaluation of the integrity score is of great value for urologists to evaluate the risk of tumor residue.

A Retrospective Study of Metastatic Renal Cell Carcinoma Patients With Brain Metastases

Metastatic renal cell carcinoma (mRCC) involving the central nervous system is currently an excluded subgroup of patients in the systemic treatment; for this reason, there is no solid data to support the efficacy of therapies in this subgroup. That is why it is important to describe real-life experiences in order to know if there is a special change in clinical behavior or treatment response in these kinds of patients. Patients and methods A retrospective review was performed to characterize mRCC patients diagnosed with brain metastases (BrM) during treatment at the National Institute of Cancerology of Bogota, Colombia. Descriptive statistics and time-to-event methods are used to evaluate the cohort. For the descriptive measures of quantitative variables, the mean with standard deviation was taken, and the minimum and maximum values were reported. In the case of qualitative variables, absolute and relative frequencies were used. The software used was R - Project v4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Results A total of 16 patients were included with mRCC between January 2017 to August 2022 with a median 35.1-month follow-up, 4/16 (25%) were diagnosed with BrM at the time of screening and 12/16 (75%) during treatment. The International Metastatic RCC Database Consortium risk (IMDC) was favorable for 12.5%, intermediate for 43.7%, and poor for 25%, and not classified for 18.8%, BrM involvement was multifocal in 50% of the population and localized, brain-directed therapy was done in 43.7% of patients, predominantly palliative radiotherapy. Median overall survival (OS) for all the patients regardless of the time of metastatic presentation of the disease in the central nervous system was 53.5 months (0-70.3), and OS for cases with central nervous system involvement was 10.9 months. IMDC risk did not correlate with survival (log-rank, p=0.67). The OS for the subgroup of patients who debut with metastatic disease in the central nervous system is different from the group that developed metastasis in the progression of their disease (OS of 42 vs 3.6 months, respectively). Conclusions This is the largest descriptive study in Latin America and the second in the world from one institution that admits patients with metastasic renal cell carcinoma and central nervous system metastasis. In these kinds of patients with metastatic disease or progression to the central nervous system, there is a hypothesis that shows more aggressive clinical behavior. There is limited data on locoregional intervention to metastatic disease in the nervous system drastically, but trends show this could impact overall survival outcomes.

Safety and efficacy of RFA versus MWA for T1a renal cell carcinoma: a propensity score analysis

OBJECTIVES

Percutaneous radiofrequency ablation (RFA) is stated as a treatment option for renal cell carcinoma (RCC) smaller than 4 cm (T1a). Microwave ablation (MWA) is a newer technique and is still considered experimental in some guidelines. The objective of this study was to compare the safety and efficacy of RFA and MWA for the treatment of RCC.

METHODS

Patients with T1a RCC treated by RFA or MWA in two referral centers were retrospectively analyzed. Patient records were evaluated to generate mRENAL nephrometry scores. Local tumor progression (LTP) was considered when new (recurrence) or residual tumor enhancement within/adjacent to the ablation zone was objectified. Differences in LTP-free interval (residual + recurrence) between ablation techniques were assessed with Cox proportional hazards models and propensity score (PS) methods.

RESULTS

In 164 patients, 87 RFAs and 101 MWAs were performed for 188 RCCs. The primary efficacy rate was 92% (80/87) for RFA and 91% (92/101) for MWA. Sixteen patients had residual disease (RFA (n = 7), MWA (n = 9)) and 9 patients developed recurrence (RFA (n = 7), MWA (n = 2)). LTP-free interval was significantly worse for higher mRENAL nephrometry scores. No difference in LTP-free interval was found between RFA and MWA in a model with inverse probability weighting using PS (HR = 0.99, 95% CI 0.35-2.81, p = 0.98) and in a PS-matched dataset with 110 observations (HR = 0.82, 95% CI 0.16-4.31, p = 0.82). Twenty-eight (14.9%) complications (Clavien-Dindo grade I-IVa) occurred (RFA n = 14, MWA n = 14).

CONCLUSION

Primary efficacy for ablation of RCC is high for both RFA and MWA. No differences in efficacy and safety were observed between RFA and MWA.

KEY POINTS

• Both RFA and MWA are safe and effective ablation techniques in the treatment of T1a renal cell carcinomas. • High modified RENAL nephrometry scores are associated with shorter local tumor progression-free interval. • MWA can be used as heat-based ablation technique comparable to RFA for the treatment of T1a renal cell carcinomas.

Safety and Efficacy of Stereotactic Ablative Radiation Therapy for Renal Cell Cancer: 24-Month Results of the RSR1 Phase 1 Dose Escalation Study

PURPOSE

Stereotactic body radiation therapy (SBRT) has become a new therapeutic option for primary renal cell carcinoma. However, treatment doses lack consistency in the literature. The primary objective of this study was to determine the maximum tolerated dose for renal cancer SBRT.

METHODS AND MATERIALS

This phase 1 multicentric dose-escalation study assessed 4 dose levels: 8 Gy × 4, 8 Gy × 5, 10 Gy × 4, and 12 Gy × 4. The primary objective of this study was to determine the maximal tolerated dose, defined by the occurrence of dose-limiting toxicity was defined as any acute side effect of grade ≥4 based on the Common Terminology Criteria for Averse Events, version 4.0.

RESULTS

From October 2010 to September 2017, 13 patients were enrolled. The median follow-up was 23 months. There was no dose-limiting toxicity in our study, and the highest dose was reached successfully. No acute or late toxic effects above grade 2 were seen. There was no significant alteration of renal function after treatment. At 24 months, 2 patients had partial response and the others had stable disease.

CONCLUSIONS

After 24 months of follow-up, no dose-limiting toxicity was seen at any of the prescribed dose levels in our study. The findings suggest that our last dose level of 48 Gy in 4 12-Gy fractions can be considered safe and can be used in further studies.

The Role of Long Noncoding RNA (lncRNAs) Biomarkers in Renal Cell Carcinoma

Renal cell carcinoma is one of the common cancers whose incidence and mortality are continuously growing worldwide. Initially, this type of tumour is usually asymptomatic. Due to the lack of reliable diagnostic markers, one-third of ccRCC patients already have distant metastases at the time of diagnosis. This underlines the importance of establishing biomarkers that would enable the prediction of the disease's course and the risk of metastasis. LncRNA, which modulates genes at the epigenetic, transcriptional, and post-transcriptional levels, appears promising. The actions of lncRNA involve sponging and sequestering target miRNAs, thus affecting numerous biological processes. Studies have confirmed the involvement of RNAs in various diseases, including RCC. In this review, we focused on MALAT1 (a marker of serious pathological changes and a factor in the promotion of tumorigenesis), RCAT1 (tumour promoter in RCC), DUXAP9 (a plausible marker of localized ccRCC), TCL6 (exerting tumour-suppressive effects in renal cancer), LINC00342 (acting as an oncogene), AGAP2 Antisense1 (plausible predictor of RCC progression), DLEU2 (factor promoting tumours growth via the regulation of epithelial-mesenchymal transition), NNT-AS1 (sponge of miR-22 contributing to tumour progression), LINC00460 (favouring ccRCC development and progression) and Lnc-LSG1 (a factor that may stimulate ccRCC metastasis).

Construction and Validation of a Novel Immune Checkpoint-Related Model in Clear Cell Renal Cell Carcinoma

Background

With the highest mortality and metastasis rate, kidney renal clear cell carcinoma (KIRC) is one of the most common urological malignant tumors and not sensitive to chemotherapy and radiotherapy. Immunotherapy, which proves to be effective and a big progression, such as PD-1/PD-L1 inhibitors, is not sensitive to all KIRC patients. To predict prognosis and immunotherapy response, a novel immune checkpoint gene- (ICG-) related model is essential in clinics.

Methods

From the public database-downloaded dataset, a novel ICG-related model for predicting prognosis and immunotherapy response in KIRC patients was built up and verified with R packages and Cox regression analysis. The Kaplan-Meier curve was plotted.

Results

39 ICGs were identified to have different expression in KIRC patients and enriched in immune-related biological pathways and activities. Three ICGs (CTLA4, TNFSF14, and HHLA2) were screened to generate KIRC-ICG model. The KIRC-ICG model was verified to be effective. With conducting KIRC-SYS model, KIRC-ICGscore was verified to be an independent factor regardless of age, gender, stage, grade, and TNM stage. Compared to the ICG-low subgroup, the ICG-high subgroup had more immune activities. KIRC-ICGscore was significantly positively correlated with the expression of Treg markers. KIRC-ICG model could also be reliable to predict immunotherapy response.

Conclusion

The KIRC-ICG model was reliable to predict prognosis and immunotherapy response for KIRC patients and could be an independent factor regardless of clinical characteristics.

Targeting hyaluronic acid synthase-3 (HAS3) for the treatment of advanced renal cell carcinoma

BACKGROUND

Hyaluronic acid (HA) promotes cancer metastasis; however, the currently approved treatments do not target HA. Metastatic renal carcinoma (mRCC) is an incurable disease. Sorafenib (SF) is a modestly effective antiangiogenic drug for mRCC. Although only endothelial cells express known SF targets, SF is cytotoxic to RCC cells at concentrations higher than the pharmacological-dose (5-µM). Using patient cohorts, mRCC models, and SF combination with 4-methylumbelliferone (MU), we discovered an SF target in RCC cells and targeted it for treatment.

METHODS

We analyzed HA-synthase (HAS1, HAS2, HAS3) expression in RCC cells and clinical (n = 129), TCGA-KIRC (n = 542), and TCGA-KIRP (n = 291) cohorts. We evaluated the efficacy of SF and SF plus MU combination in RCC cells, HAS3-transfectants, endothelial-RCC co-cultures, and xenografts.

RESULTS

RCC cells showed increased HAS3 expression. In the clinical and TCGA-KIRC/TCGA-KIRP cohorts, higher HAS3 levels predicted metastasis and shorter survival. At > 10-µM dose, SF inhibited HAS3/HA-synthesis and RCC cell growth. However, at ≤ 5-µM dose SF in combination with MU inhibited HAS3/HA synthesis, growth of RCC cells and endothelial-RCC co-cultures, and induced apoptosis. The combination inhibited motility/invasion and an HA-signaling-related invasive-signature. We previously showed that MU inhibits SF inactivation in RCC cells. While HAS3-knockdown transfectants were sensitive to SF, ectopic-HAS3-expression induced resistance to the combination. In RCC models, the combination inhibited tumor growth and metastasis with little toxicity; however, ectopic-HAS3-expressing tumors were resistant.

CONCLUSION

HAS3 is the first known target of SF in RCC cells. In combination with MU (human equivalent-dose, 0.6-1.1-g/day), SF targets HAS3 and effectively abrogates mRCC.

Trends of kidney cancer burden from 1990 to 2019 in European Union 15 + countries and World Health Organization regions

In recent decades, variability in the incidence and mortality of kidney cancer (KC) has been reported. This study aimed to compare trends in incidence, mortality, and disability-adjusted life years (DALY) of KC between the European Union (EU) 15 + countries and 6 World Health Organization (WHO) regions. The data of KC Age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and age-standardized DALYs were extracted from the Global Burden of Disease database. Joinpoint regression was employed to examine trends. From 1990 to 2019, the ASIR increased in most countries except for Luxembourg (males), the USA (females) and Austria and Sweden (both sexes). ASIR increased across all 6 WHO regions for both sexes except for females in Americas. The ASMR increased in 10/19 countries for males and 9/19 for females as well across most WHO regions. The mortality-to-incidence ratio (MIR) decreased in all countries and WHO regions. Trends in DALYs were variable across countries and WHO regions. While the incidence and mortality from KC rose in most EU15 + countries and WHO regions from 1990 to 2019, the universal drop in MIR suggests an overall improvement in KC outcomes. This is likely multifactorial, including earlier detection of KC and improved treatments.

Impact of Time-To-Surgery on the Prognosis of Patients with T1 Renal Cell Carcinoma: Implications for the COVID-19 Pandemic

Background: During the COVID-19 pandemic, elective surgery has to undergo longer wait times, including nephrectomy for T1 renal cell carcinoma (RCC). This study aimed to investigate the time-to-surgery (TTS) of Chinese T1 RCC patients and its influencing factors, and to illustrate the impact of TTS on the prognosis of T1 RCC. Methods: We retrospectively enrolled 762 Chinese patients with pathological T1 RCC that underwent nephrectomy. To discover the impact of TTS on survival outcomes, we explored the possible delay intervals by week using the Kaplan-Meier method and Log-rank test. Cox proportional hazard models with inverse probability-treatment weighting (IPTW) were used to assess the association between TTS and disease-free survival (DFS) and overall survival (OS). Results: The median TTS of T1 RCC patients was 15 days. The Charlson comorbidity index, the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score, and the maximal tumor diameter on presentation were independent influencing factors for TTS. The cut-off point of TTS was selected as 5 weeks according to the Log-rank analysis. For T1a RCC, patients with TTS > 5 weeks had similar DFS (HR = 2.39; 95% CI, 0.82−6.94; p = 0.109) and OS (HR = 1.28; 95% CI, 0.23−7.16; p = 0.779) compared to patients with TTS ≤ 5 weeks. For T1b RCC, patients with TTS > 5 weeks had shorter DFS (HR = 2.90; 95% CI = 1.46−5.75; p = 0.002) and OS (HR = 2.49, 95% CI = 1.09−5.70; p = 0.030) than patients with TTS ≤ 5 weeks. Conclusions: Prolonged TTS had no impact on the prognosis of T1a RCC while surgery delayed for over 5 weeks may lead to worse survival in T1b RCC.

Renal cell carcinoma: the population, real world, and cost-of-illness

BACKGROUND

The RCC treatment landscape has evolved dramatically over the past decade. The purpose of this study is to present a real-world data estimation of RCC's cost-of-illness for this tumour's clinical pathway.

METHODS

This investigation is a population-based cohort study using real-world data, which considers all RCC incident cases diagnosed in Local Unit 6 of the Province of Padua in 2016 and 2017 as registered by the Veneto Cancer Registry. Data on drug prescriptions, the use of medical devices, hospital admissions, and visits to outpatient clinics and emergency departments were collected by means of administrative databases. We evaluated the costs of all healthcare procedures performed in the 2 years of follow-up post-RCC diagnosis. The overall and annual average real-world costs per patient, both as a whole and by single item, were calculated and stratified by stage of disease at diagnosis.

RESULTS

The analysis involved a population of 148 patients with a median age of 65.8 years, 66.22% of whom were male. Two years after diagnosis, the average total costs amounted to €21,429 per patient. There is a steady increment in costs with increasing stage at diagnosis, with a total amount of €41,494 spent 2 years after diagnosis for stage IV patients, which is 2.44 times higher than the expenditure for stage I patients (€17,037). In the first year, hospitalization appeared to be the most expensive item for both early and advanced disease. In the second year, however, outpatient procedures were the main cost driver in the earlier stages, whereas anticancer drugs accounted for the highest costs in the advanced stages.

CONCLUSIONS

This observational study provides real-world and valuable estimates of RCC's cost-of-illness, which could enable policymakers to construct dynamic economic cost-effectiveness evaluation models based on real world costs' evaluation.

Local Treatment of Recurrent Renal Cell Carcinoma May Have a Significant Survival Effect Across All Risk-of-recurrence Groups

Background

Retrospective comparative studies suggest a survival benefit after complete local treatment of recurrence (LTR) in renal cell carcinoma (RCC), which may be largely due to an indication bias.

Objective

To determine the role of LTR in a homogeneous population characterised by limited and potentially resectable recurrence.

Design setting and participants

RECUR is a protocol-based multicentre European registry capturing patient and tumour characteristics, risk of recurrence (RoR), recurrence patterns, and survival of those curatively treated for nonmetastatic RCC from 2006 to 2011. Per-protocol resectable disease (RD) recurrence was defined as (1) solitary metastases, (2) oligometastases, or (3) renal fossa or renal recurrence after radical or partial nephrectomy, respectively.

Intervention

Local treatment of recurrence.

Outcome measurements and statistical analysis

Overall survival (OS) and cancer-specific survival was compared in the RD population that underwent LTR versus no LTR. We constructed a multivariate model to predict risk factors for overall mortality and analysed the effect of LTR across RoR groups.

Results and limitations

Of 3039 patients with localised RCC treated with curative intent, 505 presented with recurrence, including 176 with RD. Of these patients, 97 underwent LTR and 79 no LTR. Patients in the LTR group were younger (64.3 [40-80] vs 69.2 [45-87] yr; p = 0.001). The median OS was 70.3 mo (95% confidence interval [CI] 58-82.6) versus 27.4 mo (95% CI 23.6-31.15) in the LTR versus no-LTR group (p < 0.001). After a multivariate analysis, having LTR (hazard ratio [HR] 0.37 [95% CI 0.2-0.6]), having low- versus high-risk RoR (HR 0.42 [95% CI [0.20-0.83]), and not having extra-abdominal/thoracic metastasis (HR 1.96 [95% CI 1.02-3.77]) were prognostic factors of longer OS. The LTR effect on survival was consistent across risk groups. OS HR for high, intermediate, and low risks were 0.36 (0.2-0.64), 0.27 (0.11-0.65), and 0.26 (0.08-0.8), respectively. Limitations include retrospective design.

Conclusions

This is the first study assessing the effectiveness of LTR in RCC in a comparable population with RD. This study supports the role of LTR across all RoR groups.

Patient summary

We assessed the effectiveness of local treatment of resectable recurrent renal cell carcinoma after surgical treatment of the primary kidney tumour. Local treatment of recurrence was associated with longer survival across groups with a risk of recurrence.

Eosinophilic solid and cystic renal cell carcinoma: a single Indian tertiary center experience of three cases of a newly described entity

Background

Among adult malignant tumors, renal cell carcinoma accounts for 2–3% and has the worst prognosis among common urologic tumors. Recently, an eosinophilic, solid and cystic (ESC) renal cell carcinoma (RCC) histological subtype has been described and proposed as an entity separate than the 16 subtypes described in the 2016 WHO classification. The aim of the present study is to share our experience of three such cases of this newly described entity.

Methods

We retrospectively reviewed our cases of renal cell carcinoma and describe the presentation, diagnosis and management with follow-up details of ESC RCC.

Results

Our three patients presented at an advanced stage with flank pain or mass, and one patient had metastasis. All patients underwent radical nephrectomy, diagnosis proved by histopathological examination with immunohistochemistry (IHC), with abundant eosinophilic cytoplasm in all three cases. On IHC, CK 20 was positive in two cases and one patient with CK 20, CK 7 negative and PAX 8 positive.

Conclusions

ESC RCC is a newly described entity, with increasing incidence probably due to better diagnosis. Previously, 66 such cases are described, with female predominance, lower stage and indolent behavior. Only four cases with metastasis are described.

Partial Versus Radical Nephrectomy: Complexity of Decision-Making and Utility of AUA Guidelines

INTRODUCTION

The American-Urological-Association(AUA) Guidelines for renal cancer(2017) recommend consideration for radical-nephrectomy(RN) over partial(PN) whenever there is increased oncologic-risk; and RN should be prioritized if three other criteria are all also met: 1) increased tumor-complexity; 2) no preexisting chronic-kidney-disease/ proteinuria, and 3) normal contralateral kidney that will likely provide estimated glomerular-filtration-rate (eGFR) >45ml/min/1.73m² even if RN is performed. Our objective was to assess the complexity of decision-making about RN/PN and utility of AUA Guidelines statements regarding this issue.

PATIENTS AND METHODS

Retrospective review of 267 consecutive RN/PN from 2019(100-RN/167-PN). High tumor-complexity was defined as R.E.N.A.L.≥9. Increased oncologic-risk was defined as tumor >7cm, locally-advanced or infiltrative-features on imaging, or high-risk pathology on biopsy, if obtained. New-baseline GFR after RN was estimated using global-GFR, split-renal-function_{contralateral}, and presuming 25% renal-functional-compensation.

RESULTS

163 patients(61%) fit scenarios that are well-defined in the Guidelines. Of these, 34 had strong indications for RN, and all had RN. Twelve of 129 patients(9.3%) underwent RN despite Guidelines generally favoring PN. The remaining 104 patients(39%) did not fit within situations where the Guidelines provide specific recommendations. In these patients, RN was often performed despite functional-considerations favoring PN due to overriding concerns about oncologic-risk and/or tumor-complexity.

CONCLUSION

Our data demonstrate complexity of decision-making about PN/RN as almost 40% of patients did not fit well-described AUA Guidelines descriptors. Compliance was generally strong although occasional overutilization of RN remains a concern in our series, and will be addressed with additional education. Further studies will be required to assess the generalizability of our findings in other institutions/settings.

Stereotactic Body Radiotherapy for Localized Kidney Cancer

PURPOSE OF REVIEW

Stereotactic body radiation therapy (SBRT) is increasingly utilized in the management of localized kidney cancers, particularly for patients who are not surgical candidates. Herein, we provide a narrative review of SBRT in the management of localized kidney cancers.

RECENT FINDINGS

Recent prospective studies and multi-institutional retrospective studies highlight the safety and efficacy of SBRT in the management of renal tumors, a disease previously thought to be radioresistant. Studies have shown that local control is greater than 90% with rare grade 3 or 4 toxicity and no grade 5 toxicity. SBRT can be utilized successfully in the treatment of large kidney tumors (> 5 cm). New techniques such as MRI-guided radiation therapy may further improve the therapeutic ratio. However, randomized clinical trials are necessary to confirm the optimal dosing schedule and compare outcomes with nephrectomy, which remains the standard of care in suitable patients. Advances in SBRT have made this modality a safe and effective treatment option in the management of localized kidney cancers.

Three-dimensional Model-assisted Minimally Invasive Partial Nephrectomy: A Systematic Review with Meta-analysis of Comparative Studies

CONTEXT

Use of three-dimensional (3D) guidance for nephron-sparing surgery (NSS) has increased in popularity, especially for laparoscopic and robotic approaches. Different 3D visualization modalities have been developed as promising new tools for surgical planning and intraoperative navigation.

OBJECTIVES

To summarize and evaluate the impact of 3D models on minimally invasive NSS in terms of perioperative, functional, and oncological outcomes.

EVIDENCE ACQUISITION

A systematic literature search was conducted in December 2021 using the Medline (PubMed), Embase (Ovid), Scopus, and Web of Science databases. The protocol was registered on PROSPERO (CRD42022300948). The search strategy used the PICOS (Population, Intervention, Comparison, Outcome, Study design) criteria and article selection was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Meta-analysis was performed using the Mantel-Haenszel method for binary outcomes, with results summarized as the odds ratio (OR), and the inverse variance method for continuous data, with results reported as the mean difference (MD). All effect estimates are reported with the 95% confidence interval (CI) and p ≤ 0.05 was considered statistically significant. All analyses were performed using R software and the meta package.

EVIDENCE SYNTHESIS

The initial electronic search identified 450 papers, of which 17 met the inclusion criteria and were included in the analysis. Use of 3D technology led to a significant reduction in the global ischemia rate (OR 0.22, 95% CI 0.07-0.76; p = 0.02) and facilitated more frequent enucleation (OR 2.54, 95% CI 1.36-4.74; p < 0.01) and less frequent opening of the collecting system (OR 0.36, 95% CI 0.15-0.89; p = 0.03) and was associated with less blood loss (MD 23.1 ml, 95% CI 31.8-14.4; p < 0.01). 3D guidance for NSS was associated with a significant reduction in the transfusion rate (OR 0.20, 95% CI 0.07-0.56; p < 0.01). There were no significant differences in rates of conversion to radical nephrectomy, minor and major complications, change in glomerular filtration rate, or surgical margins (all p > 0.05).

CONCLUSIONS

3D guidance for NSS is associated with lower rates of detriment and surgical injury to the kidney. Specifically, a lower amount of nontumor renal parenchyma is exposed to ischemia or sacrificed during resection, and opening of the collecting system is less frequent. However, use of 3D technology does not lead to significant improvements in oncological or functional outcomes.

PATIENT SUMMARY

We reviewed the use of three-dimensional tools for minimally invasive surgery for partial removal of the kidney in patients with kidney cancer. The evidence suggests that these tools have benefits during surgery, but do not lead to significant improvements in cancer control or functional outcomes for patients.

Management and Health Resource Use of Patients With Metastatic Renal Cell Carcinoma treated With Systemic Therapy Over 2014-2017 in France: A National Real-World Study

BACKGROUND

The introduction of novel systemic therapies for metastatic renal cell carcinoma (mRCC) over the last decade has significantly improved patient outcomes. Little information is available on treatment modalities and outcomes in everyday practice. The objective of this study was to describe patient characteristics, treatment patterns, and healthcare resource use in mRCC patients receiving systemic therapy in France (2014-2017), using the nationwide claims database.

PATIENTS AND METHODS

Patients with a diagnosis of RCC (ICD-10: C64) between 2009 and 2017 and receiving a first systemic treatment for mRCC between 2014 and 2017 were eligible. Patients were divided into two groups at diagnosis, Group A: metastatic RCC and Group B: localized RCC.

RESULTS

4,929 eligible patients were identified (Group A: 2638 patients, 53.5%; Group B: 2,291 patients,46.5%). Median age was 66 years and 73% were men. In patients with incident RCC (N = 3,425), 62.3% underwent nephrectomy (94.4% in Group B). Within the year following mRCC diagnosis, 86.5% were hospitalized at least once; among them 58.1% for RCC. Nearly 31% of patients underwent radiotherapy. First line treatment was sunitinib for 65% of patients and pazopanib for 24%. Twenty five percent and 10% of patients received 2 and 3 lines of systemic treatment, respectively. The 2-year survival rate after mRCC diagnosis was 44%, with median overall survival of 20 [95%CI: 19-21] months (14 and 28 in Group A and B).

CONCLUSION

This study documented patient characteristics, treatment patterns and survival outcomes in mRCC patients receiving systemic therapy in France (2014-2017). Estimated survival rates were consistent with real-world studies from other countries.

Diagnostic performance and prognostic value of preoperative 18F-FDG PET/CT in renal cell carcinoma patients with venous tumor thrombus

Background

To observe the diagnostic efficacy of preoperative fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) upon venous tumor thrombus (VTT) in patients with renal cell carcinoma (RCC), and investigate the prognostic value of imaging parameters integrated with clinicopathological characteristics in patients with VTT after nephrectomy with tumor thrombectomy.

Methods

Patients with newly diagnosed RCC who underwent 18F-FDG PET/CT were reviewed retrospectively. The diagnostic efficacy of 18F-FDG PET/CT in VTT was analyzed. Logistic regression analysis was carried out to identify the clinical variables and PET/CT variables (including maximum standardized uptake value (SUVmax) of primary tumor, VTT SUVmax and primary tumor size) for differentiating early VTT (Mayo 0-II) from advanced VTT (Mayo III-IV). Cox proportional hazard analyses were used to evaluate clinicopathological factors and PET/CT factors (including distant metastasis, primary tumor SUVmax, VTT SUVmax and primary tumor size) for disease-free survival (DFS) in patients with VTT after operation.

Results

A total of 174 eligible patients were included in this study, including 114 men (65.5%) and 60 women (34.5%), with a median age of 58 years (range, 16–81 years). The distribution of pathological tumor stage (T stage) was 56 (T1), 17 (T2), 95 (T3), and 6 cases (T4), respectively. According to WHO/ISUP grade, except for 4 cases of chromophobe cell RCC, there were 14 patients (8.0%) of grade 1, 59 patients (33.9%) of grade 2, 74 patients (42.5%) of grade 3 and 23 patients (13.2%) of grade 4. The median maximum diameter of the primary tumor on PET/CT was 7.3 cm (5.0–9.5 cm). The distal metastasis was observed in 46 patients (26.4%). Sixty-one cases (35.1%) were confirmed with VTT by pathology. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 18F-FDG PET/CT imaging were 96.7, 99.1, 98.3, 98.3, and 98.2%, in detecting VTT, respectively, and 70.0, 100.0, 94.9, 100.0, and 94.2%, in evaluating the level of VTT, respectively. Elevated VTT SUVmax (≥5.20) could significantly distinguish the early VTT group and advanced VTT group (P = 0.010). In the prognosis analysis, elevated VTT SUVmax (≥4.30) (P = 0.018, HR 3.123, 95% CI 1.212–8.044) and distant metastasis (P = 0.013, HR 3.344, 95% CI 1.293–8.649) were significantly independent predictors for DFS.

Conclusion

Preoperative 18F-FDG PET/CT has a high diagnostic efficacy in detecting VTT and evaluating its level in RCC patients. Those patients with elevated VTT SUVmax should be carefully monitored to detect the possibility of disease progression after operation.

Improved overall survival of metastatic renal cell carcinoma patients in the era of modern tyrosine kinase inhibitors and immune checkpoint inhibitors: results from a real-life, population-based Austrian study comprising three decades of follow-up

BACKGROUND

The treatment landscape of metastatic renal cell carcinoma (mRCC) has substantially advanced over the last three decades, whereby data from controlled clinical trials indicate significant improvements regarding patients' overall survival (OS) in highly selected patient cohorts. The aim of this study is to evaluate the impact of potentially game changing drugs on patients' outcomes by comparing three different historical mRCC treatment eras.

METHODS

In all, 914 mRCC patients who were diagnosed between July 1985 and September 2020 were included into this observational study and assigned to three different treatment eras ['cytokine', 'first-generation tyrosine kinase inhibitors (TKIs)', and 'modern TKIs/immunotherapy'] based on the EMA approval dates of sunitinib (July 2006) and nivolumab (June 2015) in mRCC treatment. OS was considered the primary study endpoint. Kaplan-Meier analyses, log-rank tests, and uni- and multivariable Cox regression models were performed.

RESULTS

OS was significantly longer in patients of the modern TKIs/immunotherapy era (median OS not reached) as compared to the cytokine (2.4 years) and first-generation TKIs era (1.7 years, all p < 0.001). Moreover, patients of the modern TKIs/immunotherapy era demonstrated a significantly better prognosis [hazard ratio (HR): 0.41, 95% confidence interval (CI): 0.32-0.55, p < 0.001] compared to those of the cytokine era, while no statistically significant difference was observed between the cytokine and the first-generation TKIs era cohort (HR: 1.12, 95% CI: 0.89-1.41, p = 0.341). Subgroup analyses stratified by the International Metastatic RCC Database Consortium (IMDC) risk groups showed a significantly longer OS in the modern TKIs/immunotherapy era as compared to first-generation TKIs and cytokines across all IMDC risk groups.

CONCLUSION

Significant advances in the systemic medical treatment of mRCC during the recent decade and the introduction of immunotherapy exerted a major impact on patient outcomes in terms of OS in a real-life population.

Can Pre-Operative Neutrophil-to-Lymphocyte Ratio (NLR) Help Predict Non-Metastatic Renal Carcinoma Recurrence after Nephrectomy? (UroCCR-61 Study)

Recent studies suggested that the neutrophil-to-lymphocyte ratio (NLR) could play a key role in tumor initiation, progression and response to treatments. The main objective was to assess the prognostic value of the pre-operative NLR on recurrence-free survival (RFS) in patients with non-hereditary localized renal cell carcinoma. From the UroCCR database (NCT03293563), factors influencing the disease recurrence of consecutive patients who underwent nephrectomy for cT1-T4 N0M0 were analyzed using multi-variate cox regression and log-rank methods. We included 786 patients, among which 135 (17.2%) experienced a recurrence at a median time of 23.7 [8.5-48.6] months. RFS for patients with a pre-operative NLR of <2.7 was 94% and 88% at 3 and 5 years, respectively, versus 76% and 63% for patients with a NLR of ≥2.7 (p < 0.001, log-rank test). To predict the risk of post-operative recurrence, the NLR was combined with the UCLA integrated staging system (UISS), and we defined four groups of the UroCCR-61 predictive model. The RFS rates at 3 and 5 years were 100% and 97% in the very-low-risk group, 93% and 86% in the low-risk group, 78% and 68% in the intermediate-risk group and 63% and 46% in the high-risk group (p < 0.0001). The pre-operative NLR seems to be an inexpensive and easily accessible prognostic bio-marker for non-metastatic RCCs.

Hypoxia increases RCC stem cell phenotype via altering the androgen receptor (AR)-lncTCFL5-2-YBX1-SOX2 signaling axis

Background

Early studies indicated that the androgen receptor (AR) could promote renal cell carcinoma (RCC) development and metastasis, but its linkage to RCC progression under hypoxia, remains unclear.

Results

Here we found AR expression in RCC cells decreased in response to hypoxia, which might then lead to increase the cancer stem cells (CSC) phenotype through the lncTCFL5-2-modulated YBX1/SOX2 signals. The consequences of such hypoxia-modulated AR/lncTCFL5-2/YBX1/SOX2 signals ablity to alter the CSC phenotype might render RCC cells more resistant to targeted therapy with Sunitinib. Mechanism dissection revealed that AR might alter the lncTCFL5-2/YBX1/SOX2 signaling through transcriptional suppression of the lncTCFL5-2 expression via the AR-response-elements (AREs) on the lncTCFL5-2 promoter. The lncTCFL5-2 interacts with YBX1 to increase its stability, which in turn increases SOX2 expression at a transcriptional level via the YBX1-response-elements (YBX1Es) on the SOX2 promoter. The in vivo mouse model with orthotopic xenografts of RCC cells also validates the in vitro data, and a human RCC sample survey demonstrated the clinical significance of the AR/lncTCFL5-2/YBX1/SOX2 signaling axis for the RCC prognosis, likely as a result of regulating CSC phenotypes.

Conclusions

Together, these findings suggest that hypoxia may increase the RCC CSC phenotype via altering the AR/lncTCFL5-2/YBX1/SOX2 signaling axis and a potential therapy to target this newly identified signal perhaps may help improve the targeted therapy with Sunitinib to better suppress RCC progression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13578-022-00912-5.

Comparison of open and robotic-assisted partial nephrectomy approaches using multicentric data (UroCCR-47 study)

We compared the outcomes of robotic-assisted partial nephrectomy (RPN) and open partial nephrectomy (OPN) using contemporary data to respond to unmet clinical needs. Data from patients included in the registry who underwent partial nephrectomy between January 01, 2014 and June 30, 2017 within 20 centres of the French Network for Research on Kidney Cancer UroCCR were collected (NCT03293563). Statistical methods included adjusted multivariable analyses. Rates of peri- and post-operative transfusion, and of surgical revision, were lower in the RPN (n = 1434) than the OPN (n = 571) group (2.9% vs. 6.0%, p = 0.0012; 3.8% vs. 11.5%, p < 0.0001; 2.4% vs. 6.7%, p < 0.0001, respectively). In multivariable analyses, RPN was independently associated with fewer early post-operative complications than OPN (overall: odds-ratio [95% confidence interval, CI] = 0.48 [0.35-0.66]; severe: 0.29 [0.16-0.54], p < 0.0001 for both) and shorter hospital stays (34% [30%; 37%], p < 0.0001). RPN was also a significantly associated with a decresedrisk of post-operative acute renal failure, and new-onset chronic kidney disease at 3 and 12 months post-surgery. There were no between-group differences in oncological outcomes. In comparison with OPN, RPN was associated with improved peri- and post-operative morbidity, better functional outcomes, and shorter hospital stays. Our results support the use of RPN, even for large and complex tumours.

The Non-Interventional PAZOREAL Study to Assess the Effectiveness and Safety of Pazopanib in a Real-Life Setting: Reflecting a Changing mRCC Treatment Landscape

The approval of tyrosine kinase inhibitors and checkpoint inhibitors represented a remarkable progression in the therapeutic landscape for the treatment of metastatic renal cell carcinoma (mRCC). Yet, in the ever-evolving landscape of mRCC treatment, real-world data on these agents, including pazopanib, are scarce. The non-interventional PAZOREAL study investigated the effectiveness and safety of pazopanib (first-line), nivolumab (second-line), and everolimus (second- and third-line) in a real-life setting. The multicentric study included 376 mRCC patients who received first-line treatment with pazopanib and assessed time on the drug (primary endpoint), overall survival, best responses, disease control rates, as well as safety signals and health-related quality of life. The median overall time on the drug was 10.0 months, with first-line pazopanib having a median time on drug of 6.3 months. The median overall survival was 35.9 months. The disease control rate for first-line pazopanib was 56.9%. No new safety signals were detected. PAZOREAL provides valuable real-world data for first-line treatment with pazopanib.

Exploration of the role of Cuproptosis genes and their related long non-coding RNA in clear cell renal cell carcinoma: a comprehensive bioinformatics study

Clear cell renal cell carcinoma is a common malignant tumor of the urinary system. The mechanism of its occurrence and development is unknown, and there is currently few effective comprehensive predictive markers for prognosis and treatment response. With the discovery of a new cell death process - cuproptosis drew the attention of researchers. We constructed a model for the prediction of clinical prognosis and immunotherapy response through integrative analysis of gene expression datasets from KIRC samples in The Cancer Genome Atlas (TCGA) database. During the course of the study, we found that cuproptosis genes are significantly differentially expressed between clear cell renal cell carcinoma samples and normal samples. Based on this, we put forward the prognostic model for cuproptosis gene related-long non-coding RNA. And through various statistic and external independent cohorts, we proved that the model is accurate and stable, worthy of clinical application and further exploration and validation.

Contrast-Enhanced Ultrasound Features of Adult Xp11.2 Translocation Renal Cell Carcinoma: Differential Diagnosis With Three Main Renal Cell Carcinoma Subtypes

OBJECTIVES

To investigate the sonographic features in Xp11.2 translocation renal cell carcinoma (Xp11.2 tRCC) using both conventional ultrasound (US) and contrast-enhanced US (CEUS) and evaluate the usefulness of sonographic imaging characteristics to differentiate between Xp11.2 tRCC and the three common RCC subtypes.

METHODS

Thirty-four adult Xp11.2 tRCC patients who preoperatively underwent both conventional US and CEUS and had solitary renal lesions and pathological confirmation after surgery were enrolled. Control matched patients included 131 with clear cell RCC (ccRCC), 48 with papillary RCC (pRCC), and 35 with chromophobe RCC (chRCC). Conventional US and CEUS data of all patients were retrospectively analyzed and compared.

RESULTS

Xp11.2 tRCC was more common in young women. The echogenicity of Xp11.2 tRCC lesions was hypo- and isoechoic relative to the adjacent renal cortex. A higher frequency of calcification within tumors was detected in Xp11.2 tRCC, but the presence of color flow signal (26.5%, 9/34) was much lower. Regarding CEUS features relative to the adjacent renal cortex, synchronous wash-in (61.8%, 21/34), iso-enhancement at peak (55.9%, 19/34), and fast wash-out (50.0%, 17/34) were more common in Xp11.2 tRCC. Moreover, an integrated variables model based on these features could differentiate Xp11.2 tRCC from ccRCC, pRCC, and chRCC (area under the curve, sensitivity, and specificity: 0.934, 92.0%, and 86.0%; 0.907, 88.0%, and 87.0%; and 0.808, 65.0%, and 99.0%, respectively).

CONCLUSIONS

Combining conventional US and CEUS lesion features with clinical information may provide a feasible and effective method to differentiate Xp11.2 tRCC from ccRCC, pRCC, and chRCC.

Epigenetically-regulated miR-30a/c-5p directly target TWF1 and hamper ccRCC cell aggressiveness

Clear cell renal cell carcinoma (ccRCC) is highly prone to metastasize and displays an extremely low 5-year survival rate. Not only miRNAs (miRs) are key gene expression regulators but can also be epigenetically modified. Abnormal miR expression has been linked with epithelial-mesenchymal transition (EMT)-driven ccRCC progression. MiR-30a/c-5p were found downregulated in ccRCC and associated with aggressiveness. Herein, we sought to unravel miR-30a/c-5p mechanistic role in ccRCC. RNA sequencing and genome-wide methylome data of ccRCC and normal tissue samples from The Cancer Genome Atlas database were integrated to identify candidate miRs cytosine-phosphate-guanine (CpG) loci deregulated in ccRCC. TargetScan was searched to identify miR putative targets. MiR-30a/c-5p expression and promoter methylation was evaluated in vitro, by PCR. Western blot, functional and luciferase assays were performed after cell transfection with either pre-miR, antimiR, or siRNA against twinfilin-1 (TWF1). Immunohistochemistry (IHC) was performed in ccRCC tissues. We found miR-30c-5p downregulation and aberrant promoter methylation in ccRCC tissues. In vitro studies revealed concomitant miR-30a/c-5p downregulation and increased promoter methylation, as well as a significant re-expression following decitabine treatment. Functional assays demonstrated that both miRs significantly decreased cell aggressiveness and the protein levels of EMT-promoting players, while upregulating epithelial markers, namely Claudin-1 and ZO-1. Importantly, we confirmed TWF1 as a direct target of both miRs, and its potential involvement in epithelial-mesenchymal transition/mesenchymal-epithelial transition regulation. IHC analysis revealed higher TWF1 expression in primary tissues from patients that developed metastases, after surgical treatment. Our results implicate miR-30a/c-5p in ccRCC cells' aggressiveness attenuation by directly targeting TWF1 and hampering EMT.

Positive surgical margin's impact on short-term oncological prognosis after robot-assisted partial nephrectomy (MARGINS study: UroCCR no 96)

The oncological impact of positive surgical margins (PSM) after robot-assisted partial nephrectomy (RAPN) is still under debate. We compared PSM and Negative Surgical Margins (NSM) in terms of recurrence-free survival (RFS), metastasis-free survival (MFS) and overall survival (OS) after RAPN, and we identified predictive factors of PSM. Multi-institutional study using the UroCCR database, which prospectively included 2166 RAPN between April 2010 and February 2021 (CNIL DR 2013-206; NCT03293563). Two groups were retrospectively compared: PSM versus NSM. Prognostic factors were assessed using Kaplan-Meyer curves with log-Rank test, cox hazard proportional risk model and logistic regression after univariate comparison. 136 patients had PSM (6.3%) and 2030 (93.7%) had NSM. During a median follow-up of 19 (9-36) months after RAPN, 160 (7.4%) recurrences were reported. Kaplan-Meier curves and analysis suggested that RFS, MFS and OS were not affected by a PSM (p = 0.68; 0.71; 0.88, respectively). In multivariate analysis predictors of PSM were a lower RENAL score (p = 0.001), longer warm ischemia time (WIT) (p = 0.003) and Chromophobe Renal Cell Carcinoma (chrRCC) (p = 0.043). This study found no impact of PSM on RFS, MFS or OS, and predictors of PSM were the RENAL score, WIT and chrRCC.

Comprehensive analysis of a homeobox family gene signature in clear cell renal cell carcinoma with regard to prognosis and immune significance

The homeobox (HOX) family genes have been linked to multiple types of tumors, while their effect on malignant behaviors of clear cell renal cell carcinoma (ccRCC) and clinical significance remains largely unknown. Here, we comprehensively analyzed the expression profiles and prognostic value of HOX genes in ccRCC using datasets from The Cancer Genome Atlas (TCGA) and International Cancer Genome Consortium (ICGC) databases. We developed a prognostic signature comprising eight HOX genes (HOXB1, HOXA7, HOXB5, HOXD8, HOXD9, HOXB9, HOXA9, and HOXA11) for overall survival prediction in ccRCC and it allowed patients to be subdivided into high- and low-risk groups. Kaplan-Meier survival analysis in all the internal and external cohorts revealed significant difference in clinical outcome of patients in different risk groups, indicating the satisfactory predictive power of the signature. Additionally, we constructed a prognostic nomogram by integrating signature-derived risk score and clinical factors such as gender, age, T and M status, which might be helpful for clinical decision-making and designing tailored management schedules. Immunological analysis revealed that the regulatory T cells (Tregs) infiltrated differently between the two subgroups in both TCGA and ICGC cohorts. ssGSEA method showed that the enrichment scores for mast cells were significantly lower in high-risk group compared with the low-risk group, which was consistent in both TCGA and ICGC cohorts. As for the related immune function, the enrichment scores of APC co-inhibition, para-inflammation, and type II IFN response were consistently lower in high-risk group in both cohorts. Of the eight HOX genes, the mRNA and protein levels of HOXD8 were downregulated in ccRCC than that in normal tissues, and decreased expression of HOXD8 was associated with increased tumor grade and stage, and lymph node metastasis. Survival analysis revealed that lower expression of HOXD8 predicted worse overall survival in ccRCC. In conclusion, our HOX gene-based signature was a favorable indicator to predict the prognosis of ccRCC cases and associated with immune cell infiltration. HOXD8 might be a tumor suppressor gene in ccRCC and a potential predictor of tumor progression.

Increased expression of the RNA-binding protein Musashi-2 is associated with immune infiltration and predicts better outcomes in ccRCC patients

RNA-binding proteins (RBPs) mainly contribute to abnormalities in posttranscriptional gene regulation. The RBP Musashi-2, an evolutionarily conserved protein, has been characterized as an oncoprotein in various tumors. However, the prognostic value and potential roles of Musashi-2 in clear cell renal cell carcinoma (ccRCC) have not yet been elucidated. In this study, we found that Musashi-2 was mainly expressed in the normal distal tubular cells and collecting duct cells of the kidneys, while its expression was significantly decreased in ccRCC. And higher expression levels of Musashi-2 indicated better overall survival (OS) in ccRCC. Furthermore, immunohistochemistry demonstrated that PD-L1 expression was negatively correlated with Musashi-2 expression, and Musashi-2 was found to be remarkably correlated with multiple immune cells and immune inhibitors, including CD8+ T cells, CD4+ T cells, regulatory T (Treg) cells, PDCD1, CTLA4, Foxp3, and LAG3. Functional enrichment analysis revealed that Musashi-2 might be involved in ccRCC metabolic reprogramming and immune infiltration and further predicted the therapeutic sensitivity of ccRCC. Taken together, Musashi-2 is a prognostic biomarker for ccRCC patients that may provide novel insights into individualized treatment strategies and guide effective immunotherapy.

3D renal model for surgical planning of partial nephrectomy: A way to improve surgical outcomes

OBJECTIVE

to evaluate the impact of 3D model for a comprehensive assessment of surgical planning and quality of partial nephrectomy (PN).

MATERIALS AND METHODS

195 patients with cT1-T2 renal mass scheduled for PN were enrolled in two groups: Study Group (n= 100), including patients referred to PN with revision of both 2D computed tomography (CT) imaging and 3D model; Control group (n= 95), including patients referred to PN with revision of 2D CT imaging. Overall, 20 individuals were switched to radical nephrectomy (RN). The primary outcome was the impact of 3D models-based surgical planning on Trifecta achievement (defined as the contemporary absence of positive surgical margin, major complications and ≤30% postoperative eGFR reduction). The secondary outcome was the impact of 3D models on surgical planning of PN. Multivariate logistic regressions were used to identify predictors of selective clamping and Trifecta's achievement in patients treated with PN (n=175).

RESULTS

Overall, 73 (80.2%) patients in Study group and 53 (63.1%) patients in Control group achieved the Trifecta (p=0.01). The preoperative plan of arterial clamping was recorded as clampless, main artery and selective in 22 (24.2%), 22 (24.2%) and 47 (51.6%) cases in Study group vs. 31 (36.9%), 46 (54.8%) and 7 (8.3%) cases in Control group, respectively (p<0.001). At multivariate logistic regressions, the use of 3D model was found to be independent predictor of both selective or super-selective clamping and Trifecta's achievement.

CONCLUSION

3D-guided approach to PN increase the adoption of selective clamping and better predict the achievement of Trifecta.

Establishment and validation of a polygene prognostic model for clear cell renal cell carcinoma

Purpose: To establish an effective prognostic model for patients with clear cell renal cell carcinoma (ccRCC). Methods: We identified four hub differentially expressed genes (DEGs) in Gene Expression Omnibus (GEO) database and verified them in the Cancer Gene Atlas (TCGA), STRING, UALCAN, TIMER, and Gene Expression Profiling Interactive Analysis (GEPIA) databases. We then used TCGA and International Cancer Genome Consortium (ICGC) to identify tumor pathway molecules highly correlated with hub DEGs. And by further LASSO and Cox regression analysis, we successfully identified five genes as prognostic factors. Results: We successfully identified a risk prediction model consisting of five genes: IGF2BP3, CDKN1A, GSDMB, FABP5, RBMX. We next distributed patients into low-risk and high-risk groups using the median as a cutoff. The low-risk group obviously had better survival than those in the predicted high-risk group. The results showed discrepancies in tumor-associated immune cell infiltration between risk groups. We also combined the risk model with clinical variables to create a nomogram. Conclusion: Our model has a satisfactory predictive effect on the prognosis of ccRCC patients and may provide new ideas for future immune therapy.

Cabozantinib-Loaded PLGA Nanoparticles: A Potential Adjuvant Strategy for Surgically Resected High-Risk Non-Metastatic Renal Cell Carcinoma

Patients with high-risk non-metastatic renal cell carcinoma (RCC) are at risk of metastatic relapse following nephrectomy. Cabozantinib (CZ), a potent multitarget tyrosine kinase inhibitor, interferes with angiogenesis and immunosuppression associated with surgery-induced metastasis. Here, we explored the therapeutic potential of CZ-loaded poly(lactic-co-glycolic acid) (PLGA) nanoparticles (CZ-PLGA-NPs) as an adjuvant strategy for targeting post-nephrectomy metastasis. A clinically relevant subline recapitulating post-nephrectomy lung metastasis of high-risk human RCC, namely Renca-SRLu5-Luc, was established through in vivo serial selection of luciferase-expressing murine RCC Renca-Luc cells. CZ was encapsulated into PLGA-NPs via the conventional single emulsion technique. The multifaceted preclinical antimetastatic efficacy of CZ-PLGA-NPs was assessed in Renca-SRLu5-Luc cells. CZ-PLGA-NPs with a smooth surface displayed desirable physicochemical properties, good CZ encapsulation efficiency, as well as controlled and sustained CZ release. CZ-PLGA-NPs exhibited remarkable dose-dependent toxicity against Renca-SRLu5-Luc cells by inducing G2/M cell cycle arrest and apoptosis. CZ-PLGA-NPs attenuated in vitro colony formation, migration, and invasion by abrogating AKT and ERK1/2 activation. An intravenous injection of CZ-PLGA-NPs markedly reduced lung metastatic burden and prolonged lifespan with favorable safety in the Renca-SRLu5-Luc experimental lung metastasis model. The novel CZ-PLGA-NPs system with multifaceted antimetastatic effects and alleviating off-target toxicity potential is a promising adjunctive agent for patients with surgically resected high-risk RCC.

Bosniak classification of cystic renal masses, version 2019: Is it helpful to incorporate the diffusion weighted imaging characteristic of lesions into the guideline?

Objective

To improve understanding of diffusion weighted imaging (DWI) characteristic of MRI and clinical variables, further optimize the Bosniak classification for diagnosis of cystic renal masses (CRMs).

Methods

This study retrospectively analyzed 130 CRMs in 125 patients with CT or MRI, including 87 patients with DWI (b = 600, 1000 s/mm2). Clinical variables and histopathological results were recorded. Two radiologists in consensus analyzed images of each lesion for the size, thickness of wall, number of septum, enhancement of wall/septum, wall nodule, signal intensity on DWI, calcification, and cyst content. Clinical variables, CT and MRI image characteristics were compared with pathology or follow-up results to evaluate the diagnostic performance for CRMs.

Results

Of the 130 lesions in 125 patients, histological analysis reported that 36 were malignant, 38 were benign, and no change was found in 56 followed-up lesions (mean follow-up of 24 months). The incidences of cystic wall thickened, more septa, measurable enhancement of wall/septum, nodule(s) on CT/MRI, and high signal intensity on DWI were significantly higher in malignant than in benign CRMs (CT: p = 0.005, p < 0.001, p < 0.001, p < 0.001, p < 0.001; MRI: p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001). Combination of MRI including DWI features with CT findings showed the highest area under ROC curve (0.973) in distinguishing benign and malignant CRMs.

Conclusions

Incorporating DWI characteristic of CRMs into Bosniak classification helps to improve diagnostic efficiency.

The Role of Focal Therapy and Active Surveillance for Small Renal Mass Therapy

Small and low-grade renal cell carcinomas have little potential for metastasis and disease-related mortality. As a consequence, the main problem remains the use of appropriately tailored treatment for each individual patient. Surgery still remains the gold standard, but many clinicians are questioning this approach and present the advantages of focal therapy. The choice of treatment regimen remains a matter of debate. This article summarizes the current treatment options in the management of small renal masses.

Perioperative outcomes following robot-assisted partial nephrectomy in elderly patients

OBJECTIVE

To compare perioperative outcomes following robot-assisted partial nephrectomy (RAPN) in patients with age ≥ 70 years to age < 70 years.

METHODS

Using Vattikuti Collective quality initiative (VCQI) database for RAPN we compared perioperative outcomes following RAPN between the two age groups. Primary outcome of the study was to compare trifecta outcomes between the two groups. Propensity matching using nearest neighbourhood method was performed with trifecta as primary outcome for sex, body mass index (BMI), solitary kidney, tumor size and Renal nephrometery score (RNS).

RESULTS

Group A (age ≥ 70 years) included 461 patients whereas group B included 1932 patients. Before matching the two groups were statistically different for RNS and solitary kidney rates. After propensity matching, the two groups were comparable for baselines characteristics such as BMI, tumor size, clinical symptoms, tumor side, face of tumor, solitary kidney and tumor complexity. Among the perioperative outcome parameters there was no difference between two groups for operative time, blood loss, intraoperative transfusion, intraoperative complications, need for radical nephrectomy, positive margins and trifecta rates. Warm ischemia time was significantly longer in the younger age group (18.1 min vs. 16.3 min, p = 0.003). Perioperative complications were significantly higher in the older age group (11.8% vs. 7.7%, p = 0.041). However, there was no difference between the two groups for major complications.

CONCLUSION

RAPN in well-selected elderly patients is associated with comparable trifecta outcomes with acceptable perioperative morbidity.

A novel nomogram and risk classification system predicting the overall survival of patients with papillary renal cell carcinoma after nephrectomy: A population-based study

Background

Papillary renal cell carcinoma (pRCC) is the largest histologic subtype of non-clear-cell RCC. To date, there is no reliable nomogram to predict the prognosis of patients with pRCC after nephrectomy. We aimed to first establish an effective nomogram to predict the overall survival (OS) of patients with pRCC after nephrectomy.

Methods

A total of 3,528 eligible patients with pRCC after nephrectomy were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The patients were randomized into the training cohort (n = 2,472) and the validation cohort (n = 1,056) at a 7:3 ratio. In total, 122 real-world samples from our institute (titled the AHMU-pRCC cohort) were used as the external validation cohort. Univariate and subsequent multivariate Cox regression analyses were conducted to identify OS-related prognostic factors, which were further used to establish a prognostic nomogram for predicting 1-, 3-, and 5-year OS probabilities. The performance of the nomogram was evaluated by using the concordance index (C-index), receiver operating characteristic curve (ROC), calibration plot, and decision curve analysis (DCA).

Results

Multivariate Cox analysis showed that age, race, marital status, TNM stage, tumor size, and surgery were significant OS-related prognostic factors. A prognostic model consisting of these clinical parameters was developed and virtualized by a nomogram. High C-index and area under the ROC curve (AUC) values of the nomogram at 1, 3, and 5 years were found in the training, validation, and AHMU-pRCC cohorts. The calibration plot and DCA also showed that the nomogram had a satisfactory clinical application value. A risk classification system was established to risk-stratify patients with pRCC.

Conclusion

Based on a large cohort from the public SEER database, a reliable nomogram predicting the OS of patients with pRCC after nephrectomy was constructed, which could optimize the survival assessment and clinical treatment.

Emerging photodynamic/sonodynamic therapies for urological cancers: progress and challenges

Photodynamic therapy (PDT), and sonodynamic therapy (SDT) that developed from PDT, have been studied for decades to treat solid tumors. Compared with other deep tumors, the accessibility of urological tumors (e.g., bladder tumor and prostate tumor) makes them more suitable for PDT/SDT that requires exogenous stimulation. Due to the introduction of nanobiotechnology, emerging photo/sonosensitizers modified with different functional components and improved physicochemical properties have many outstanding advantages in cancer treatment compared with traditional photo/sonosensitizers, such as alleviating hypoxia to improve quantum yield, passive/active tumor targeting to increase drug accumulation, and combination with other therapeutic modalities (e.g., chemotherapy, immunotherapy and targeted therapy) to achieve synergistic therapy. As WST11 (TOOKAD® soluble) is currently clinically approved for the treatment of prostate cancer, emerging photo/sonosensitizers have great potential for clinical translation, which requires multidisciplinary participation and extensive clinical trials. Herein, the latest research advances of newly developed photo/sonosensitizers for the treatment of urological cancers, and the efficacy, as well as potential biological effects, are highlighted. In addition, the clinical status of PDT/SDT for urological cancers is presented, and the optimization of the photo/sonosensitizer development procedure for clinical translation is discussed.

Artificial intelligence to predict oncological outcome directly from hematoxylin and eosin-stained slides in urology

INTRODUCTION

Artificial intelligence (AI) has been successfully applied for automatic tumor detection and grading in histopathological image analysis in urologic oncology. The aim of this review was to assess the applicability of these approaches in image-based oncological outcome prediction.

EVIDENCE ACQUISITION

A systematic literature search was conducted using the databases MEDLINE through PubMed and Web of Science up to April 20, 2021. Studies investigating AI approaches to determine the risk of recurrence, metastasis, or survival directly from H&E-stained tissue sections in prostate, renal cell or urothelial carcinoma were included. Characteristics of the AI approach and performance metrics were extracted and summarized. Risk of bias (RoB) was assessed using the PROBAST tool.

EVIDENCE SYNTHESIS

16 studies yielding a total of 6658 patients and reporting on 17 outcome predictions were included. Six studies focused on renal cell, six on prostate and three on urothelial carcinoma while one study investigated renal cell and urothelial carcinoma. Handcrafted feature extraction was used in five, a convolutional neural network (CNN) in six and a deep feature extraction in four studies. One study compared a CNN with handcrafted feature extraction. In seven outcome predictions, a multivariable comparison with clinicopathological parameters was reported. Five of them showed statistically significant hazard ratios for the AI's model's-prediction. However, RoB was high in 15 outcome predictions and unclear in two.

CONCLUSIONS

The included studies are promising but predominantly early pilot studies, therefore primarily highlighting the potential of AI approaches. Additional well-designed studies are needed to assess the actual clinical applicability.

Impact of Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography in the Management of Oligometastatic Renal Cell Carcinoma

Background

Prostate-specific membrane antigen (PSMA) is overexpressed in the neovasculature of renal cell carcinoma (RCC). However, there remains limited evidence regarding the use of PSMA positron emission tomography/computed tomography (PET/CT) in RCC.

Objective

To assess the impact of PSMA PET/CT in the management of metastatic RCC.

Design, setting, and participants

This was a retrospective review of patients who underwent PSMA PET/CT from 2014 to 2020 for restaging or suspected metastatic RCC in a tertiary academic setting.

Outcome measurements and statistical analysis

Management plans before and after PSMA PET/CT were recorded. Impact was classified as high (change of treatment intent, modality, or site), medium (change in treatment method), or low. Secondary outcomes included the patient-level detection rate, PSMA PET/CT parameters, sensitivity, and comparison to CT and, if available, fluorodeoxyglucose (FDG) PET/CT.

Results and limitations

Sixty-one patients met the inclusion criteria, of whom 54 (89%) had clear cell RCC. PSMA-positive disease was detected in 51 patients (84%). For 30 patients (49%) there was a change in management due to PSMA PET/CT (high impact, 29 patients, 48%). In 15 patients (25%), more metastases were detected on PSMA PET/CT than on CT. The sensitivity of combined PSMA PET/CT and diagnostic CT was 91% (95% confidence interval 77–98%). In a subcohort of 40 patients, the detection rate was 88% for PSMA and 75% for FDG PET/CT (p = 0.17). The maximum standardised uptake value (SUV_max) was higher for PSMA than for FDG PET/CT (15.2 vs 8.0; p = 0.02). Limitations include selection bias due to the retrospective design, and a lack of corresponding histopathology for all patients.

Conclusions

PSMA PET/CT is a promising imaging modality in metastatic RCC and led to a change in management in 49% of patients. PSMA PET/CT detected additional metastases compared to CT in 25% of patients and registered a significantly higher SUV_max than FDG PET/CT. Prospective studies are required to further define its role.

Patient summary

We report on a group of patients undergoing a new type of imaging for suspected advanced kidney cancer, called PSMA PET/CT. This imaging changed the management plan in 49% of the patients. PSMA PET/CT detected metastases in 84% of our patients and detected more metastases than computed tomography imaging in 25%.

Volumetric Quantitative Contrast-enhanced Ultrasonography Evaluation of Complex Renal Cysts: An Adjunctive Metric to the Bosniak Classification System to Predict Malignancy

BACKGROUND

Management of complex renal cysts is guided by the Bosniak classification system, which may be inadequate for risk stratification of patients for intervention. Fractional tumor vascularity (FV) calculated from volumetric contrast-enhanced ultrasound (CEUS) images may provide additional useful information.

OBJECTIVE

To evaluate CEUS and FV calculation for risk stratification of patients with complex renal cysts.

DESIGN, SETTING, AND PARTICIPANTS

This was a pilot prospective study with institutional review board approval involving patients undergoing surgery for Bosniak IIF-IV complex renal cysts. CEUS was performed preoperatively on the day of surgery with two-dimensional (2D) and three-dimensional (3D) imaging and sulfur hexafluoride lipid-type A microspheres as the ultrasound contrast agent.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A custom MATLAB program was used to select regions of interest on CEUS scans. FV was calculated according to FV = 1 - (total nonenhancing area/total lesion area). We assessed the ability of 2D- and 3D-derived percentage FV (2DFV%, and 3DFV%) and Bosniak classification schemes (pre-2019 [P2019B] and post-2019 [B2019]) to predict malignancy, aggressive histology, and upstaging on surgical pathology. Performance was assessed as area under the receiver operating characteristic curve (AUC).

RESULTS AND LIMITATIONS

Twenty eligible patients were included in final analysis, of whom 85% (n = 17) had Bosniak IV cysts and 85% (n = 17) had malignant disease on final pathology. Four (24%) of the malignant lesions were International Society of Urological Pathology grade 3-4. The AUC for predicting malignancy was 0.980, 0.824, 0.863, and 0.824 with P2019B, B2019, 2DFV%, and 3DFV%, respectively. When the Bosniak classification was combined with FV%, three models had an AUC of 1, while the combined 2DFV% + B2019 model had AUC of 0.980.

CONCLUSIONS

FV is a novel metric for evaluating complex cystic renal masses and enhances the ability of the Bosniak classification system to predict malignancy. This metric may serve as an adjunct in risk stratification for surgical intervention. Further prospective evaluation is warranted.

PATIENT SUMMARY

Cysts in the kidney are currently classified using a scheme called the Bosniak system. We assessed measurement of the percentage of vascular tissue (called fractional vascularity) in cysts on a special type of ultrasound scan. This promising test adds information when combined with the Bosniak system and can help in guiding appropriate treatment.

Construction and Characterization of n6-Methyladenosine-Related lncRNA Prognostic Signature and Immune Cell Infiltration in Kidney Renal Clear Cell Carcinoma

Background. Kidney renal clear cell carcinoma (KIRC) lacks effective prognostic biomarkers and the role and mechanism of N6-methyladenosine (m6A) modification of long noncoding RNAs (lncRNAs) in KIRC remain unclear. Methods. We extracted standard mRNA-sequencing and clinical data from the TCGA database. The prognostic risk model was obtained by Lasso regression and Cox regression. We randomly divided the samples into training and test sets, each taking half of the cases. Based on Lasso regression and Cox regression for training set, the prognostic risk signature was constructed; risk scores were calculated with the R package “glmnet.” Based on the median value of the prognostic risk score, risk scores were calculated for each patient and we divided all KIRC samples into high-risk and low-risk groups. Then, high- and low-risk subtypes were established and their prognosis, clinical features, and immune infiltration microenvironment were evaluated in test set and the entire sampled data set. The reliability of the prognostic model was confirmed by receiver operating characteristic curve analysis. Results. We found 28 prognostic m6A-related lncRNAs and established a m6A-related lncRNAs prognostic signature. $\text{Risk\hspace{0.17em}score}=AC015813.1\ast \left(0.0086\right)+EMX2OS\ast \left(-0.0101\right)+LINC00173\ast \left(0.0309\right)+PWAR5\ast \left(-0.0146\right)+SNHG1\ast \left(0.0043\right).$ The signature showed a better predictive ability than other clinical indicators, including tumor node metastasis classification (TNM), histological, and pathological stages. In the high-risk group, M0 macrophages, CD8+ T cells, and regulatory T cells had significantly higher scores. Contrarily, in the low-risk group, activated dendritic cells, M1 macrophages, mast resting cells, and monocytes had significantly higher scores. In the high-risk group, LSECtin was overexpressed. In the low-risk group, PD-L1 was overexpressed. Moreover, high-risk patients may benefit more from AZ628. Conclusions. In conclusion, prognosis prediction of patients with KIRC and new insights for immunotherapy are provided by the m6A-related lncRNA prognostic signature.

CT-based transformer model for non-invasively predicting the Fuhrman nuclear grade of clear cell renal cell carcinoma

Background

Clear cell Renal Cell Carcinoma (ccRCC) is the most common malignant tumor in the urinary system and the predominant subtype of malignant renal tumors with high mortality. Biopsy is the main examination to determine ccRCC grade, but it can lead to unavoidable complications and sampling bias. Therefore, non-invasive technology (e.g., CT examination) for ccRCC grading is attracting more and more attention. However, noise labels on CT images containing multiple grades but only one label make prediction difficult. However, noise labels exist in CT images, which contain multiple grades but only one label, making prediction difficult.

Aim

We proposed a Transformer-based deep learning algorithm with CT images to improve the diagnostic accuracy of grading prediction and to improve the diagnostic accuracy of ccRCC grading.

Methods

We integrate different training models to improve robustness and predict Fuhrman nuclear grade. Then, we conducted experiments on a collected ccRCC dataset containing 759 patients and used average classification accuracy, sensitivity, specificity, and AreaUnderCurve as indicators to evaluate the quality of research. In the comparative experiments, we further performed various current deep learning algorithms to show the advantages of the proposed method. We collected patients with pathologically proven ccRCC diagnosed from April 2010 to December 2018 as the training and internal test dataset, containing 759 patients. We propose a transformer-based network architecture that efficiently employs convolutional neural networks (CNNs) and self-attention mechanisms to extract a persuasive feature automatically. And then, a nonlinear classifier is applied to classify. We integrate different training models to improve the accuracy and robustness of the model. The average classification accuracy, sensitivity, specificity, and area under curve are used as indicators to evaluate the quality of a model.

Results

The mean accuracy, sensitivity, specificity, and Area Under Curve achieved by CNN were 82.3%, 89.4%, 83.2%, and 85.7%, respectively. In contrast, the proposed Transformer-based model obtains a mean accuracy of 87.1% with a sensitivity of 91.3%, a specificity of 85.3%, and an Area Under Curve (AUC) of 90.3%. The integrated model acquires a better performance (86.5% ACC and an AUC of 91.2%).

Conclusion

A transformer-based network performs better than traditional deep learning algorithms in terms of the accuracy of ccRCC prediction. Meanwhile, the transformer has a certain advantage in dealing with noise labels existing in CT images of ccRCC. This method is promising to be applied to other medical tasks (e.g., the grade of neurogliomas and meningiomas).

A pyroptosis-associated signature plays a role in prognosis prediction in clear cell renal cell carcinoma

Background

Approximately 90% of renal malignancies are RCCs (renal cell carcinomas), and the primary subtype in histology is ccRCC (clear cell RCC). In recent years, pyroptosis has been considered a kind of inflammation-related programmed cell death that participates in the invasion, metastasis, and proliferation of tumour cells, thereby influencing tumour prognosis. Nonetheless, the expression level of pyroptosis-associated genes in RCCs and their relationship with prognosis remain obscure.

Results

In our research, 44 regulators of pyroptosis that were differentially expressed between normal kidney and ccRCC tissues were identified. ccRCC cases were categorized into 2 subgroups according to prognostic-related DEGs (differentially expressed genes), and there was a significant difference in OS (overall survival) between them. The prognostic value of pyroptosis-associated genes was assessed as a signature based on a cohort from TCGA (The Cancer Genome Atlas). Following Cox regression with DEGs and LASSO (least absolute shrinkage and selection operator), a 6-gene signature was established, and all ccRCC cases in the cohort from TCGA were categorized into an LR (low-risk) or HR (high-risk) group (P < 0.001). In combination with clinical features, risk scores were considered a predictive factor of OS in ccRCC. KEGG (Kyoto Encyclopedia of Genes and Genomes) and GO (Gene Ontology) analyses suggest increased immunity and enrichment of genes related to immunity in the HR group.

Conclusions

Our findings indicate that genes related to pyroptosis have an important role in tumour immunity and may be used to predict the prognosis of ccRCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12920-022-01339-0.

Alternative use of endocavitary probe to guide minimally invasive partial nephrectomy: is it reasonable?

Purpose:

To describe the use of endocavitary ultrasound probe as an auxiliary tool when performing partial nephrectomy in cases of endophytic renal tumors, to standardize the method, and to report the preliminary results achieved with this technique.

Methods:

Fifteen patients diagnosed with completely endophytic underwent partial nephrectomy with the use of an endocavitary ultrasound probe. This article describes the technique involved in partial nephrectomy and details the preparation of the endocavitary ultrasound probe to ensure its safe use.

Results:

All the patients had a RENAL score between 8 and 11. The median time of warm ischemia was 26 and 18 minutes for laparoscopic or robot-assisted surgery, respectively. The median duration of surgery was 150 minutes, and the median console time was 145 minutes for the laparoscopic and robot-assisted surgery groups, respectively. The median estimate of blood loss was 200 mL. Only three patients in the laparoscopic group had focal positive surgical margins. There were no cases of infection at the site of probe entry.

Conclusions:

Intraoperative use of an endocavitary ultrasound probe for partial nephrectomy is possible and a safe alternative to the excision of endophytic tumors when neither robotic probes nor laparoscopic probes are available.

Cuproptosis-related modification patterns depict the tumor microenvironment, precision immunotherapy, and prognosis of kidney renal clear cell carcinoma

Background

Due to the different infiltration abundance of immune cells in tumor, the efficacy of immunotherapy varies widely among individuals. Recently, growing evidence suggested that cuproptosis has impact on cancer immunity profoundly. However, the comprehensive roles of cuproptosis-related genes in tumor microenvironment (TME) and in response to immunotherapy are still unclear.

Methods

Based on 43 cuproptosis-related genes, we employed unsupervised clustering to identify cuproptosis-related patterns and single-sample gene set enrichment analysis algorithm to build a cuproptosis signature for individual patient's immune cell infiltration and efficacy of immune checkpoint blockade (ICB) evaluation. Then, the cuproptosis-related genes were narrowed down using univariate Cox regression model and least absolute shrinkage and selection operator algorithm. Finally, a cuproptosis risk score was built by random survival forest based on these narrowed-down genes.

Results

Two distinct cuproptosis-related patterns were developed, with cuproptosis cluster 1 showing better prognosis and higher enrichment of immune-related pathways and infiltration of immune cells. For individual evaluation, the cuproptosis signature that we built could be used not only for predicting immune cell infiltration in TME but also for evaluating an individual's sensitivity to ICBs. Patients with higher cuproptosis signature scores exhibited more activated cancer immune processes, higher immune cell infiltration, and better curative efficacy of ICBs. Furthermore, a robust cuproptosis risk score indicated that patients with higher risk scores showed worse survival outcomes, which could be validated in internal and external validation cohorts. Ultimately, a nomogram which combined the risk score with the prognostic clinical factors was developed, and it showed excellent prediction accuracy for survival outcomes.

Conclusion

Distinct cuproptosis-related patterns have significant differences on prognosis and immune cell infiltration in kidney renal clear cell carcinoma (KIRC). Cuproptosis signature and risk score are able to provide guidance for precision therapy and accurate prognosis prediction for patients with KIRC.