Prognostic ability of simplified nuclear grading of renal cell carcinoma

Diagnostic accuracy of percutaneous core biopsy before cryoablation for small-sized renal cell carcinoma

PURPOSE

To retrospectively determine the diagnostic accuracy of a percutaneous core biopsy performed before cryoablation for small-sized renal cell carcinoma.

METHODS

In this study, 216 patients underwent a percutaneous core biopsy for 242 renal lesions suspected to be renal cell carcinoma on image findings before cryoablation at Kyushu University Hospital. We calculated the success rate of the histological diagnosis and investigated factors that may have contributed to the diagnostic success. Complications caused by the biopsy procedure were also evaluated.

RESULTS

The histological diagnosis was successful in 203 lesions (82.8%). The success rate of the histological diagnosis was 65.4% (34/52 cases) for tumors with a diameter of ≤15 mm and 88.9% (169/190 cases) for those >15 mm. Therefore, tumor diameter was a factor contributing to the histological diagnosis success rate in both univariate and multivariable analyses (P < 0.001). For lesions with a tumor diameter ≤15 mm, the histological diagnosis success rates increased from 50.0% to 76.2% in the presence of pre-lipiodol marking and to 85.7% when the biopsy procedure was performed separately from cryoablation; the latter was statistically significant (P = 0.039). Major complications that may have been caused by the biopsy procedure were grade 3 bleeding and tract seeding (one case each).

CONCLUSION

Percutaneous core biopsy in cryoablation for small-sized renal cell carcinoma had a high diagnostic rate and was safely performed. For lesions with a tumor diameter ≤15 mm, a separate biopsy procedure and pre-lipiodol marking may improve the diagnostic accuracy.

Proposal of a grading system for squamous cell carcinoma of the lung - the prognostic importance of tumour budding, single cell invasion, and nuclear diameter

The prognostic markers of lung squamous cell carcinoma (LSCC) are less investigated. The aim of our study was to evaluate tumour budding (TB), minimal cell nest size, nuclear diameter (ND), and spread through air spaces (STAS) among patients with resected LSCC, semi-quantitatively. Furthermore, we aimed to identify a grading system for the best prognostic stratification of LSCC. Patients who underwent surgical resection at the Department of Surgery, University of Szeged between 2010 and 2016 were included. Follow-up data were collected from medical charts. Morphological characteristics were recorded from histologic revision of slides. Kaplan-Meier analysis, log rank test and Cox proportional-hazards model, ROC curve analysis, and intraclass correlation were utilised. Altogether 220 patients were included. In univariate analysis, higher degree of TB, infiltrative tumour border, larger ND, the presence of single cell invasion (SCI) and STAS were associated with adverse prognosis. Based on our results, we proposed an easily applicable grading scheme focusing on TB, ND, and SCI. In multivariate analysis, the proposed grading system (pOS < 0.001, pRFS < 0.001) and STAS (pOS = 0.008, pRFS < 0.001) were independent prognosticators. Compared to the previously introduced grading systems, ROC curve analysis revealed that the proposed grade had the highest AUC values (AUCOS: 0.83, AUCRFS: 0.78). Each category of the proposed grading system has good (ICC: 0.79-0.88) reproducibility. We validated the prognostic impact of TB, SCI, ND, and STAS in LSCC. We recommend a reproducible grading system combining TB, SCI, and ND for proper prognostic stratification of LSCC patients. Further research is required for validation of this grading scheme.

Prognostic value of PD-L1 expression in recurrent renal cell carcinoma after nephrectomy: a secondary analysis of the ARCHERY study

BACKGROUND

Nephrectomy is a curative treatment for localized renal cell carcinoma (RCC), but patients with poor prognostic features may experience relapse. Understanding the prognostic impact of programmed death-ligand 1 (PD-L1) expression in patients who underwent nephrectomy for RCC may aid in future development of adjuvant therapy.

METHODS

Of 770 surgical specimens collected from Japanese patients enrolled in the ARCHERY study, only samples obtained from patients with recurrent RCC after nephrectomy were examined for this secondary analysis. Patients were categorized into low- and high-risk groups based on clinical stage and Fuhrman grade. Time to recurrence (TTR) and overall survival (OS) were analyzed.

RESULTS

Both TTR and OS were shorter in patients with PD-L1-positive than -negative tumors (median TTR 12.1 vs. 21.9 months [HR 1.46, 95% CI 1.17, 1.81]; median OS, 75.8 vs. 97.7 months [HR 1.32, 95% CI 1.00, 1.75]). TTR and OS were shorter in high-risk patients with PD-L1-positive than -negative tumors (median TTR 7.6 vs. 15.3 months [HR 1.49, 95% CI 1.11, 2.00]; median OS, 55.2 vs. 83.5 months [HR 1.53, 95% CI 1.06, 2.21]) but not in low-risk patients.

CONCLUSIONS

This ARCHERY secondary analysis suggests that PD-L1 expression may play a role in predicting OS and risk of recurrence in high-risk patients with localized RCC.

CLINICAL TRIAL REGISTRATION

UMIN000034131.

TMEM27 expression and clinical characteristics and survival in clear cell renal cell carcinoma

BACKGROUND

Transmembrane protein 27 (TMEM27/collectrin), a glycoprotein and homolog of angiotensin-converting enzyme 2 (ACE2), is a regulator of renal amino acid uptake in the proximal tubule and may have a protective role in hypertension. Two previous reports have shown that the absence of TMEM27 expression in clear cell renal cell carcinoma (ccRCC) correlates with poorer cancer-related survival. We report our findings of TMEM27 expression in ccRCC and clinical outcomes in an independent third cohort.

MATERIAL AND METHODS

We conducted a retrospective analysis to identify all 321 cases of ccRCC diagnosed between 2010 and 2015 at the University of Rochester Medical Center. The intensity of TMEM27 immunostaining on tumor tissue was semi-quantitatively graded on a scale of 0, 0.5, 1, 1.5, 2, 2.5, and 3 by a single pathologist, and correlated with tumor characteristics and survival.

RESULTS

There was evidence of metastasis at time of nephrectomy in 36 (11.2%) cases, and at the latest follow-up in 70 (21.8%) cases. As of Spring 2021, 82 (25.5%) had died. TMEM27 staining intensity correlated inversely with various tumor characteristics. Kaplan-Meier survival analysis showed worse overall all-cause mortality (p = 0.02) and disease-free survival (p = 0.028) for tumors without any TMEM27 staining (0) compared to 0.5 or higher by log-rank test.

CONCLUSION

The absence of TMEM27 expression is associated with more aggressive tumor characteristics and poorer all-cause mortality and disease-free survival in ccRCC. TMEM27 may be a useful biomarker to assess cancer prognosis. Further studies are needed to better assess if TMEM27 is protective in RCC, and its potential role in active surveillance and prediction of response to target therapy.

Preoperative red blood cell distribution width as an independent prognostic factor in metastatic renal cell carcinoma

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Patients with higher red blood cell distribution width (RDW) levels had worse OS and PFS.

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Preoperative RDW was independently associated with PFS and OS in patients with metastatic renal cell carcinoma (mRCC).

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Preoperative RDW can be utilized as a novel prognostic biomarker for patients with mRCC.

Objective

This study aimed to explore the prognostic value of preoperative red blood cell distribution width (RDW) in patients with metastatic renal cell carcinoma (mRCC).

Methods

Clinicopathological data of 230 patients with mRCC treated at the First Affiliated Hospital of Chongqing Medical University and the Chinese PLA General Hospital from January 2008 to December 2018 were retrospectively analyzed. Patients were stratified according to the optimal cut-off value of RDW calculated using X-tile software. The prognostic value of RDW was analyzed using the Kaplan-Meier curve with log-rank test and univariate and multivariate Cox proportional hazards models.

Results

A total of 230 patients were included. The optimal cut-off value of RDW obtained using X-tile software was 13.1%. The median Progression-free survival (PFS) and Overall survival (OS) of all populations were 12.06 months (IQR: 4.73–36.9) and 32.20 months (IQR: 13.73–69.46), respectively. Kaplan–Meier curves showed that patients with high RDW had worse PFS and OS than those with low RDW (median PFS of 9.7 months vs. 17.9 months, P = 0.002, and median OS of 27.8 months vs. 45.1 months, P = 0.012, respectively). Multivariate analysis showed that RDW was an independent risk factor for PFS (HR: 1.505; 95% CI: 1.111–2.037; P = 0.008) and OS (HR: 1.626; 95% CI: 1.164–2.272; P = 0.004) in mRCC after cytoreductive nephrectomy.

Conclusion

Preoperative RDW was independently associated with PFS and OS in patients with mRCC and may be a potential predictor of survival outcomes in mRCC.

Prediction of histologic grade and type of small (< 4 cm) papillary renal cell carcinomas using texture and neural network analysis: a feasibility study

OBJECTIVE

To predict the histologic grade and type of small papillary renal cell carcinomas (pRCCs) using texture analysis and machine learning algorithms.

METHODS

This was a retrospective HIPAA-compliant study. 24 noncontrast (NC), 22 corticomedullary (CM) phase, and 24 nephrographic (NG) phase CTs of small (< 4 cm) surgically resected pRCCs were identified. Surgical pathology classified the tumors as low- or high-Fuhrman histologic grade and type 1 or 2. The axial image with the largest cross-sectional tumor area was exported and segmented. Six histogram and 31 texture (20 gray-level co-occurrences and 11 gray-level run-lengths) features were calculated for each tumor in each phase. Feature values in low- versus high-grade and type 1 versus 2 pRCCs were compared. Area under the receiver operating curve (AUC) was calculated for each feature to assess prediction of histologic grade and type of pRCCs in each phase. Histogram, texture, and combined histogram and texture feature sets were used to train and test three classification algorithms (support vector machine (SVM), random forest, and histogram-based gradient boosting decision tree (HGBDT)) with stratified shuffle splits and threefold cross-validation; AUCs were calculated for each algorithm in each phase to assess prediction of histologic grade and type of pRCCs.

RESULTS

Individual histogram and texture features did not have statistically significant differences between low- and high-grade or type 1 and type 2 pRCCs across all phases. Individual features had low predictive power for tumor grade or type in all phases (AUC < 0.70). HGBDT was highly accurate at predicting pRCC histologic grade and type using histogram, texture or combined histogram and texture feature data from the CM phase (AUCs = 0.97-1.0). All algorithms had highest AUCs using CM phase feature data sets; AUCs decreased using feature sets from NC or NG phases.

CONCLUSIONS

The histologic grade and type of small pRCCs can be predicted with classification algorithms using CM histogram and texture features, which outperform NC and NG phase image data. The accurate prediction of pRCC histologic grade and type may be able to further guide management of patients with small (< 4 cm) pRCCs being considered for active surveillance.

Tumor grade estımatıon of clear cell and papıllary renal cell carcınomas usıng contrast-enhanced MDCT and FSE T2 weıghted MR ımagıng: radıology-pathology correlatıon

BACKGROUND

Discrimination of low grade (grade 1-2) renal tumors from high grade (grade 3-4) ones carries crucial importance in terms of the management of these patients and also in the decision-making of appropriate treatment strategies. Our aim was to investigate whether contrast-enhanced multidetector computed tomography (MDCT) and T2 weighted fast spin echo (FSE) magnetic resonance imaging (MRI) could play a specific role in the discrimination of low grade versus high grade tumors in clear cell renal cell carcinoma (ccRCC) and papillary renal cell carcinoma (pRCC) patients.

METHODS

In this study, we retrospectively evaluated 66 RCC patients based on histopathologic findings who had underwent either partial or total nephrectomies. Our cohort consisted of 52 ccRCC and 14 pRCC patients, of whom 50 were male (%76) and 16 were female (%24). Among the 52 ccRCC patients, 18 had both cortico-medullary phase contrast-enhanced CT and MRI, 15 had only cortico-medullary phase CT and 19 had only MRI examination. In the pRCC group, 8 patients had both cortico-medullary phase contrast-enhanced CT and MRI, 3 had only cortico-medullary phase CT and 3 had only MRI. We both calculated mean tumor attenuation values on cortico-medullary phase MDCT images as HU (hounsfield unit) and also tumor mean signal intensity values on FSE T2 weighted MR images, using both region of interest and whole lesion measurements including normal renal cortex. The obtained values were compared with the grading results of the ccRCC and pRCC tumors according to the WHO/International Society of Urological Pathology grading system.

RESULTS

A significant positive correlation was found between the mean attenuation values of both tumor subtypes on cortico-medullary phase contrast-enhanced CT and their grades (p < 0.001). High grade tumors exhibited higher mean attenuation values (74.3 ± 22.3 HU) than the low grade tumors (55.2 ± 23.7 HU) in both subtypes. However, a statistically significant correlation was not found between the mean signal intensity values of the two tumor subtypes on FSE T2 weighted MR images and their grades (p > 0.05). Low grade tumors had a mean signal intensity value of 408.9 ± 44.6, while high grade tumors showed a value of 382.1 ± 44.2. The analysis of the ccRCC group patients, yielded a statistically significant correlation between the mean signal intensity values on T2 weighted images and tumor grading (p < 0.001). Low grade (grade 1-2) ccRCC patients exhibited higher mean signal intensity values (475.7 ± 51.3), as compared to those of high grade (grade 3-4) (418.5 ± 45.7) tumors. On the other hand, analysis of the pRCC group patients revealed that there was a significant correlation between the mean attenuation values of tumors on cortico-medullary phase contrast-enhanced CT and their grades (p < 0.001). High grade papillary subtype tumors (54.2 ± 25.2) showed higher mean attenuation values than the low grade (35.5 ± 18.8) ones.

CONCLUSIONS

Contrast-enhanced MDCT and T2 weighted FSE MRI can play a considerable role in the discrimination of low grade versus high grade tumors of both subtype RCC patients. Thus, these non-invasive evaluation techniques may have positive impact on the determination of the management and treatment strategies of these patients.

Human immunodeficiency virus-related renal cell carcinoma: a retrospective study of 19 cases

PURPOSE

We aimed to investigate basic information, clinical findings, treatments for tumor, pathology, and outcomes of HIV-positive patients diagnosed with renal cell carcinoma (RCC).

PATIENTS AND METHODS

We collected 19 patients from 2012 to 2020 who are diagnosed with RCC with HIV-positive. A retrospective analysis was performed on their hospitalization course and tumor-related parameters, including basic information, clinical findings, HIV-associated data, pathology, treatments for tumor, and outcomes.

RESULTS

In our study, patients were diagnosed with RCC at the median age of 51. Males took a great part (17 males, 89%) in all patients, while only 2 females were diagnosed. The median CD4⁺ T lymphocyte cell count was 462 cells/μl when diagnosed with RCC (range from 111 cells/μl to 1536 cells/μl). Eleven patients diagnosed with RCC and HIV infection at the same time, who may have high viral load and low CD4⁺ T lymphocyte cell count. Eight patients accepted a median HAART for 30 months (range from 11 months to 108 months) prior to diagnosis of RCC. All the patients performed operations successfully, and 4 of them performed partial nephrecotomy. Only 1 patient was identified with chromophobe cell carcinoma, 1 with partially clear cell and partially papillary carcinoma, and 17 with clear cell carcinoma. Two of the patients with Fuhrman grades 2-3 accepted cytokine therapy with IL-2 and IFN-α. Two patients died of lung metastasis 1 year and 6 months after surgery respectively, even though 1 patient accepted full dose targeted therapy (sorafenib) for 3 months, and one refused adjuvant therapy. The remaining 17 patients are still alive at a median follow-up of 34 months; however, 1 patient lives with lung and brain metastases at the last follow-up of 3 years after surgery.

CONCLUSIONS

RCC patients with HIV-positive were similar to the general population in terms of clinical characters, treatment measures, and pathology. RCC patients with HIV-positive seemed like to obey the same clinical practice guideline as in the general population. The outcomes of HIV-positive patients with partial nephrectomy are not inferior to patients with radical nephrectomy. Furthermore, experience in targeted therapy and immunal therapy (PD-1/PD-L1 inhibitors) needs to be learned.

Multiphase Contrast-Enhanced CT-Based Machine Learning Models to Predict the Fuhrman Nuclear Grade of Clear Cell Renal Cell Carcinoma

OBJECTIVE

To investigate the predictive performance of different machine learning models for the discrimination of low and high nuclear grade clear cell renal cell carcinoma (ccRCC) by using multiphase computed tomography (CT)-based radiomic features.

MATERIALS AND METHODS

A total of 137 consecutive patients with pathologically proven ccRCC (including 96 low-grade [grade 1 or 2] and 41 high-grade [grade 3 or 4] ccRCC) from January 2011 to January 2019 were enrolled in this retrospective study. Target region of interest (ROI) delineation followed by texture extraction was performed on a representative slice with the largest section of the tumor on the four-phase (unenhanced phase [UP], corticomedullary phase [CMP], nephrographic phase [NP] and excretory phase [EP]) CT images. Fifteen concatenations of the four-phase features were fed into 176 classification models (built with 8 classifiers and 22 feature selection methods), the classification performances of the 2640 resultant discriminative models were compared, and the top-ranked features were analyzed.

RESULTS

Image features extracted from the unenhanced phase (UP) CT images demonstrated a dominant classification performance over features from the other three phases. The discriminative model "Bagging + CMIM" achieved the highest classification AUC of 0.75. The top-ranked features from the UP included one shape-based feature and five first-order statistical features.

CONCLUSION

Image features extracted from the UP are more effective than other CT phases in differentiating low and high nuclear grade ccRCC based on machine learning-based classification modeling.

Validation of the World Health Organization/International Society of Urological Pathology grading for Chinese patients with clear cell renal cell carcinoma

Background

This study aimed to compare the World Health Organization/International Society of Urological Pathology (WHO/ISUP) grading system and the Fuhrman grading system and to verify the WHO/ISUP grade as a prognostic parameter of clear cell renal cell carcinoma (ccRCC) in a Chinese population.

Methods

The study consisted of 753 ccRCC patients treated with curative surgery between 2010 and 2018 at Xiangya Hospital Central South University (Changsha, China). All pathologic data were retrospectively reviewed by two pathologists. Cancer-specific survival (CSS) and recurrence-free survival (RFS) were examined as clinical outcomes.

Results

According to the WHO/ISUP grading system (ISUP group), nephrectomy type, pT stage and WHO/ISUP grade were independent risk factors for CSS (P<0.0001, P=0.0127 and P<0.0001, respectively) and RFS (P<0.0001, P=0.0077, and P<0.0001, respectively). In the Fuhrman group, nephrectomy type, pT stage and Fuhrman grade were independent risk factors for CSS (P<0.0001, P=0.0004, and P<0.0001, respectively) and RFS (P<0.0001, P=0.0001, and P<0.0001, respectively). The C-index for CSS and RFS using the Fuhrman grading system was 0.6323 and 0.6342, respectively, and that using the WHO/ISUP grading system was 0.6983 and 0.7005, respectively, both higher than the former (P=0.0185, and P=0.0172, respectively). In addition, upgrading from Fuhrman grade 2 to ISUP grade 3 resulted in worse CSS and RFS for ccRCC patients (P=0.0033 and P =0.0003, respectively).

Conclusions

We first verified correlations between the postoperative prognosis and WHO/ISUP grade of ccRCC in a Chinese population and confirmed that the ability to predict clinical outcomes with the WHO/ISUP grading system was superior to that with the Fuhrman grading system.

Profiles of overall survival-related gene expression-based risk signature and their prognostic implications in clear cell renal cell carcinoma

The present work aimed to evaluate the prognostic value of overall survival (OS)-related genes in clear cell renal cell carcinoma (ccRCC) and to develop a nomogram for clinical use. Transcriptome data from The Cancer Genome Atlas (TCGA) were collected to screen differentially expressed genes (DEGs) between ccRCC patients with OS > 5 years (149 patients) and those with <1 year (52 patients). In TCGA training set (265 patients), seven DEGs (cytochrome P450 family 3 subfamily A member 7 (CYP3A7), contactin-associated protein family member 5 (CNTNAP5), adenylate cyclase 2 (ADCY2), TOX high mobility group box family member 3 (TOX3), plasminogen (PLG), enamelin (ENAM), and collagen type VII α 1 chain (COL7A1)) were further selected to build a prognostic risk signature by the least absolute shrinkage and selection operator (LASSO) Cox regression model. Survival analysis confirmed that the OS in the high-risk group was dramatically shorter than their low-risk counterparts. Next, univariate and multivariate Cox regression revealed the seven genes-based risk score, age, and Tumor, lymph Node, and Metastasis staging system (TNM) stage were independent prognostic factors to OS, based on which a novel nomogram was constructed and validated in both TCGA validation set (265 patients) and the International Cancer Genome Consortium cohort (ICGC, 84 patients). A decent predictive performance of the nomogram was observed, the C-indices and corresponding 95% confidence intervals of TCGA training set, validation set, and ICGC cohort were 0.78 (0.74–0.82), 0.75 (0.70–0.80), and 0.70 (0.60–0.80), respectively. Moreover, the calibration plots of 3- and 5 years survival probability indicated favorable curve-fitting performance in the above three groups. In conclusion, the proposed seven genes signature-based nomogram is a promising and robust tool for predicting the OS of ccRCC, which may help tailor individualized therapeutic strategies.

Prediction models for clear cell renal cell carcinoma ISUP/WHO grade: comparison between CT radiomics and conventional contrast-enhanced CT

OBJECTIVE

Comparing the prediction models for the ISUP/WHO grade of clear cell renal cell carcinoma (ccRCC) based on CT radiomics and conventional contrast-enhanced CT (CECT).

METHODS

The corticomedullary phase images of 119 cases of low-grade (I and II) and high-grade (III and IV) ccRCC based on 2016 ISUP/WHO pathological grading criteria were analyzed retrospectively. The patients were randomly divided into training and validation set by stratified sampling according to 7:3 ratio. Prediction models of ccRCC differentiation were constructed using CT radiomics and conventional CECT findings in the training setandwere validated using validation set. The discrimination, calibration, net reclassification index (NRI) and integrated discrimination improvement index (IDI) of the two prediction models were further compared. The decision curve was used to analyze the net benefit of patients under different probability thresholds of the two models.

RESULTS

In the training set, the C-statistics of radiomics prediction model was statistically higher than that of CECT (p < 0.05), with NRI of 9.52% and IDI of 21.6%, both with statistical significance (p < 0.01).In the validation set, the C-statistics of radiomics prediction model was also higher but did not show statistical significance (p = 0.07). The NRI and IDI was 14.29 and 33.7%, respectively, both statistically significant (p < 0.01). Validation set decision curve analysis showed the net benefit improvement of CT radiomics prediction model in the range of 3-81% over CECT.

CONCLUSION

The prediction model using CT radiomics in corticomedullary phase is more effective for ccRCC ISUP/WHO grade than conventional CECT.

ADVANCES IN KNOWLEDGE

As a non-invasive analysis method, radiomics can predict the ISUP/WHO grade of ccRCC more effectively than traditional enhanced CT.

Anti-angiogenesis and Immunotherapy: Novel Paradigms to Envision Tailored Approaches in Renal Cell-Carcinoma

Although decision making strategy based on clinico-histopathological criteria is well established, renal cell carcinoma (RCC) represents a spectrum of biological ecosystems characterized by distinct genetic and molecular alterations, diverse clinical courses and potential specific therapeutic vulnerabilities. Given the plethora of drugs available, the subtype-tailored treatment to RCC subtype holds the potential to improve patient outcome, shrinking treatment-related morbidity and cost. The emerging knowledge of the molecular taxonomy of RCC is evolving, whilst the antiangiogenic and immunotherapy landscape maintains and reinforces their potential. Although several prognostic factors of survival in patients with RCC have been described, no reliable predictive biomarkers of treatment individual sensitivity or resistance have been identified. In this review, we summarize the available evidence able to prompt more precise and individualized patient selection in well-designed clinical trials, covering the unmet need of medical choices in the era of next-generation anti-angiogenesis and immunotherapy.

Outcomes of patients with spinal metastases from renal cell carcinoma treated with conventionally-fractionated external beam radiation therapy

Renal cell carcinoma (RCC) has been traditionally thought to be radioresistant. This retrospective cohort study aims to assess the outcomes of patients with spinal metastases from RCC treated with conventionally-fractionated external beam radiation therapy (cEBRT) in our institution.Patients diagnosed with histologically or radiologically-proven RCC who received palliative cEBRT to spinal metastases, using 3-dimensional conformal technique between 2009 and 2018 were reviewed. Local progression-free survival (PFS), overall survival (OS) and common terminology criteria for adverse events version 4.0-graded toxicity were assessed. Univariable and multivariable Cox proportional hazards regression analyses were performed to evaluate for predictors associated with survivals.Thirty-five eligible patients with forty spinal segments were identified, with a median follow-up of 7 months (range, 0-47). The median equivalent dose in 2 Gy fractions (EQD2) was 32.5 Gy 10 (range, 12-39). Thirty-seven percent of patients underwent surgical intervention. At the time of last follow-up, all but 1 patient had died. Seven patients developed local progression, with the median time to local progression of 10.2 months. The median local PFS and OS were 3.3 and 4.8 months. There was no grade 3 or higher toxicity. A higher radiation dose (equivalent dose to 2 Gy fraction <32.5 Gy 10 vs ≥32.5Gy 10) (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.17-3.18; P-value (P) = .68) and spinal surgery (HR, 2.35; 95% CI, 0.53-10.29; P = .26) were not significantly associated with local PFS on univariable analysis. Multivariable analysis showed that higher Tokuhashi score (HR, 0.41; 95% CI, 0.19-0.88; P = .02), lower number of spinal segments irradiated (HR, 1.18; 95% CI, 1.01-1.37; P = .04) and use of targeted therapy (HR, 0.41; 95% CI, 0.18-0.96; P = .04) were independent predictors for improved OS.For an unselected group of patients with RCC, there is no significant association between higher radiation dose and improved local control following cEBRT. This may be due to their short survivals. With the use of more effective systemic therapy, including targeted therapy and immunotherapy, survival will likely be prolonged. A tailored-approach is needed to identify patients with good prognosis who may still benefit from aggressive local treatments.

Texture analysis and machine learning algorithms accurately predict histologic grade in small (< 4 cm) clear cell renal cell carcinomas: a pilot study

PURPOSE

To predict the histologic grade of small clear cell renal cell carcinomas (ccRCCs) using texture analysis and machine learning algorithms.

METHODS

Fifty-two noncontrast (NC), 26 corticomedullary (CM) phase, and 35 nephrographic (NG) phase CTs of small (< 4 cm) surgically resected ccRCCs were retrospectively identified. Surgical pathology classified the tumors as low- or high-Fuhrman histologic grade. The axial image with the largest cross-sectional tumor area was exported and segmented. Six histogram and 31 texture (gray-level co-occurrences (GLC) and gray-level run-lengths (GLRL)) features were calculated for each tumor in each phase. T testing compared feature values in low- and high-grade ccRCCs, with a (Benjamini-Hochberg) false discovery rate of 10%. Area under the receiver operating curve (AUC) was calculated for each feature to assess prediction of low- and high-grade ccRCCs in each phase. Histogram, texture, and combined histogram and texture data sets were used to train and test four algorithms (k-nearest neighbor (KNN), support vector machine (SVM), random forests, and decision tree) with tenfold cross-validation; AUCs were calculated for each algorithm in each phase to assess prediction of low- and high-grade ccRCCs.

RESULTS

Zero, 23, and 0 features in the NC, CM, and NG phases had statistically significant differences between low and high-grade ccRCCs. CM histogram skewness and GLRL short run emphasis had the highest AUCs (0.82) in predicting histologic grade. All four algorithms had the highest AUCs (0.97) predicting histologic grade using CM histogram features. The algorithms' AUCs decreased using histogram or texture features from NC or NG phases.

CONCLUSION

The histologic grade of small ccRCCs can be accurately predicted with machine learning algorithms using CM histogram features, which outperform NC and NG phase image data.

Expression signature of six-snoRNA serves as novel non-invasive biomarker for diagnosis and prognosis prediction of renal clear cell carcinoma

Increasing evidence has verified that small nucleolar RNAs (snoRNAs) play significant roles in tumorigenesis and exhibit prognostic value in clinical practice. In the study, we analysed the expression profile and clinical relevance of snoRNAs from TCGA database including 530 ccRCC (clear cell renal cell carcinoma) and 72 control cases. By using univariate and multivariate Cox analysis, we established a six‐snoRNA signature and divided patients into high‐risk or low‐risk groups. We found patients in high‐risk group had significantly shorter overall survival and recurrence‐free survival than those in low‐risk group in test series, validation series and entire series by Kaplan‐Meier analysis. We also confirmed this signature had a great accuracy and specificity in 64 clinical tissue cases and 50 serum samples. Then, depending on receiver operating characteristic curve analysis we found the six‐snoRNA signature was an superior indicator better than conventional clinical factors (AUC = 0.732). Furthermore, combining the signature with TNM stage or Fuhrman grade were the optimal indicators (AUC = 0.792; AUC = 0.800) and processed the clinical applied value for ccRCC. Finally, we found the SNORA70B and its hose gene USP34 might directly regulate Wnt signalling pathway to promote tumorigenesis in ccRCC. In general, our study established a six‐snoRNA signature as an independent and superior diagnosis and prognosis indicator for ccRCC.

Automated clear cell renal carcinoma grade classification with prognostic significance

We developed an automated 2-tiered Fuhrman's grading system for clear cell renal cell carcinoma (ccRCC). Whole slide images (WSI) and clinical data were retrieved for 395 The Cancer Genome Atlas (TCGA) ccRCC cases. Pathologist 1 reviewed and selected regions of interests (ROIs). Nuclear segmentation was performed. Quantitative morphological, intensity, and texture features (n = 72) were extracted. Features associated with grade were identified by constructing a Lasso model using data from cases with concordant 2-tiered Fuhrman's grades between TCGA and Pathologist 1 (training set n = 235; held-out test set n = 42). Discordant cases (n = 118) were additionally reviewed by Pathologist 2. Cox proportional hazard model evaluated the prognostic efficacy of the predicted grades in an extended test set which was created by combining the test set and discordant cases (n = 160). The Lasso model consisted of 26 features and predicted grade with 84.6% sensitivity and 81.3% specificity in the test set. In the extended test set, predicted grade was significantly associated with overall survival after adjusting for age and gender (Hazard Ratio 2.05; 95% CI 1.21-3.47); manual grades were not prognostic. Future work can adapt our computational system to predict WHO/ISUP grades, and validating this system on other ccRCC cohorts.

Management of kidney cancer patients: 2018 guidelines of the Italian Medical Oncology Association (AIOM)

In the past two decades, the treatment landscape for patients with metastatic renal cell carcinoma has significantly changed thanks to the approval of several targeted molecular therapies (VEGF and mTOR inhibitors) and recently immune-checkpoint inhibitors. The Italian Association of Medical Oncology (AIOM) Renal Cell Cancer (RCC) Guidelines Panel has developed clinical guidelines to provide evidence-based information and recommendations to oncologists, urologists and all professionals involved in the management of patients with renal cell cancer.

Recurrence of Renal Cell Cancer After Renal Transplantation in a Multicenter French Cohort

BACKGROUND

Renal cancer accounts for 3% of adult malignancies; renal cell carcinoma (RCC) represents 80% of all renal cancers, and is characterized by late recurrences. Recurrences after kidney transplantation are associated with a high mortality rate. We aimed to determine if recurrences are linked to tumor characteristics and to delays between diagnosis and transplantation.

METHODS

We retrospectively analyzed data from French kidney-transplanted patients with medical histories of pretransplant renal cancer, focusing on the most common histological subtypes: clear cell and papillary cancers. Characteristics of the tumors, patients, and kidney transplantations were documented, and posttransplant patient survival was analyzed.

RESULTS

Of 143 patients, 13 experienced cancer recurrence after kidney transplantation. The mean delay in recurrence was 3 ± 2.3 years posttransplantation, and the cumulative incidences of recurrence were 7.7% at 5 years and 14.9% at 10 years. The risk of recurrence was higher in patients with clear cell RCC (13% vs 0%, P = 0.015). There was no correlation between posttransplant recurrence and the interval before transplantation. Factors associated with a higher risk of cancer recurrence were histological clear cell RCC (P = 0.025), tumor stage pT2 (P = 0.002), and Fuhrman grade IV (P < 0.001). Recurrences were associated with a high mortality rate; 76.9% of patients with recurrences had died by the end of the follow-up period.

CONCLUSIONS

Recurrences of clear cell RCC are not uncommon after kidney transplantation and are associated with very poor prognoses. These results should be considered before listing patients with a history of renal cancer for transplantation.

Image-Guided Renal Interventions

Image-guided renal biopsies have an increasing role in clinical practice. Renal mass and renal parenchymal biopsy indications, techniques, and other clinical considerations are reviewed in this article. Image-guided renal mass ablation shows significant promise and increasing clinical usefulness as more studies demonstrate its safety and efficacy. Renal mass ablation indications, techniques, and other considerations are also reviewed.

Correlation of c-MET Expression with PD-L1 Expression in Metastatic Clear Cell Renal Cell Carcinoma Treated by Sunitinib First-Line Therapy

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) is highly metastatic. Cabozantinib, an anti-angiogenic tyrosine kinase inhibitor that targets c-MET, provided interesting results in metastatic ccRCC treatment.

OBJECTIVE

To understand better the role of c-MET in ccRCC, we assessed its status in a population of patients with metastatic ccRCC.

PATIENTS AND METHODS

For this purpose, tumor samples were analyzed for c-MET expression by immunohistochemistry (IHC), for c-MET copy number alterations by fluorescence in situ hybridization (FISH), and for c-MET mutations by next generation sequencing (NGS) in a retrospective cohort of 90 primary ccRCC of patients with metastases treated by first-line sunitinib. The expression of c-MET was correlated with pathological, immunohistochemical (VEGFA, CAIX, PD-L1), clinical, and molecular criteria (VHL status) by univariate and multivariate analyses and to clinical outcome using Kaplan-Meier curves compared by log-rank test.

RESULTS

Of ccRCC, 31.1% had low c-MET expression (absent to weak intensity by IHC) versus 68.9% with high expression (moderate to strong intensity). High expression of c-MET was associated with a gain in FISH analysis (p=0.0284) without amplification. No mutations were detected in NGS. Moreover, high c-MET expression was associated with lymph node metastases (p=0.004), sarcomatoid component (p=0.029), VEGFA (p=0.037), and PD-L1 (p=0.001) overexpression, the only factor that remained independently associated (p<0.001) after logistic regression. No difference was observed in clinical outcomes.

CONCLUSION

This study is the first to analyse c-MET status in metastatic ccRCC. The high expression of c-MET in the majority of ccRCC and its independent association with PD-L1 expression, may suggest a potential benefit from combining c-MET inhibitors and targeted immunotherapy.

Prognostic factors and prognostic models for renal cell carcinoma: a literature review

PURPOSE

Following curative treatment for localised renal cell carcinoma (RCC), up to 30% of patients develop tumour recurrence. Prognostic scores are essential to guide individualised surveillance protocols, patient counselling and potentially in the future to guide adjuvant therapy. In metastatic RCC, prognostic scores are routinely used for treatment selection in clinical practice as well as in all major trials.

METHODS

We performed a literature review on the current evidence based on prognostic factors and models for localised and metastatic RCC.

RESULTS

A number of prognostic factors have been identified, of which tumour node metastasis classification remains the most important. Multiple prognostic models and nomograms have been developed for localised disease, based on a combination of tumour stage, grade, subtype, clinical features, and performance status. However, there is poor level of evidence for their routine use. Prognostic scores for patients with metastatic RCC receiving targeted treatments are used routinely, but have limited accuracy. Molecular markers can improve the accuracy of established prognostic models, but frequently lack external, independent validation.

CONCLUSION

Several factors and models predict prognosis of localised and metastatic RCC. They represent valuable tools to provide estimates of clinically important endpoints, but their accuracy should be improved further. Validation of molecular markers is a future research priority.

Image-guided biopsy of small (≤4 cm) renal masses: the effect of size and anatomical location on biopsy success rate and complications

OBJECTIVE

To study the influence of tumour diameter and anatomy on the success and complication rates of small renal mass (SRM, ≤4 cm) core biopsy.

METHODS

Retrospective analysis of SRMs that underwent ultrasound or CT-guided biopsy. Diagnostic and complication rates were compared according to tumour size (subcategorised as axial diameter ≤2 cm, >2 to- ≤3 cm, >3-≤4 cm) and anatomical disposition (exophytic/endophytic, centrality, polar location and anterior/posterior).

RESULTS

94 patients (54 male; age range 21.8-84.3 years) with 95 SRMs underwent biopsy. The first biopsy was diagnostic in 81/95 (85.3%). Seven patients underwent repeat biopsy (6/7 diagnostic), to give an overall diagnostic rate of 91.5%. The primary diagnostic rates in the ≤2, >2-≤3 , >3-≤4 cm groups were 21/25 (84%); 38/44 (86.4%) and 22/26 (84.6%) respectively and were similar (p = 1.00). Anterior and upper pole SRMs were more likely to fail initial biopsy (odds ratio 13.8, p < 0.01; and odds ratio 4.35, p = 0.04) respectively, but other anatomical factors were not relevant. Complications occurred in 14% (all conservatively managed perinephric haematomas; Clavien-Dindo Grade 1) and size or location were not relevant.

CONCLUSION

Image-guided biopsy of SRMs has a high diagnostic rate irrespective of tumour size. Anterior and upper pole location had lower diagnostic rates. Biopsy should be considered for all patients with SRMs, if the result will impact on management and we list specific scenarios where an SRM biopsy may be helpful. Advances in knowledge: SRM size does not affect the likelihood of a diagnostic biopsy.

Tumor Microvessel Density as a Prognostic Marker in High-Risk Renal Cell Carcinoma Patients Treated on ECOG-ACRIN E2805

Purpose: Increased vascularity is a hallmark of renal cell carcinoma (RCC). Microvessel density (MVD) is one measurement of tumor angiogenesis; however, its utility as a biomarker of outcome is unknown. ECOG-ACRIN 2805 (E2805) enrolled 1,943 resected high-risk RCC patients randomized to adjuvant sunitinib, sorafenib, or placebo. We aimed to determine the prognostic and predictive role of MVD in RCC.Experimental Design: We obtained pretreatment primary RCC nephrectomy tissues from 822 patients on E2805 and constructed tissue microarrays. Using quantitative immunofluorescence, we measured tumor MVD as the area of CD34-expressing cells. We determined the association with disease-free survival (DFS), overall survival (OS), treatment arm, and clinicopathologic variables.Results: High MVD (above the median) was associated with prolonged OS for the entire cohort (P = 0.021) and for patients treated with placebo (P = 0.028). The association between high MVD and OS was weaker in patients treated with sunitinib or sorafenib (P = 0.060). MVD was not associated with DFS (P = 1.00). On multivariable analysis, MVD remained independently associated with improved OS (P = 0.013). High MVD correlated with Fuhrman grade 1-2 (P < 0.001), clear cell histology (P < 0.001), and absence of necrosis (P < 0.001) but not with gender, age, sarcomatoid features, lymphovascular invasion, or tumor size.Conclusions: High MVD in resected high-risk RCC patients is an independent prognostic, rather than predictive, biomarker of improved OS. Further studies should assess whether incorporating MVD into clinical models will enhance our ability to predict outcome and if low MVD can be used for selection of high-risk patients for adjuvant therapy trials. Clin Cancer Res; 24(1); 217-23. ©2017 AACR.

Clear cell renal cell carcinoma: validation of World Health Organization/International Society of Urological Pathology grading

AIMS

In 2012, the International Society of Urological Pathology (ISUP) introduced a novel grading system for clear cell renal cell carcinoma (ccRCC) and papillary renal cell carcinoma. This system is incorporated into the latest World Health Organization renal tumour classification, being designated WHO/ISUP grading. This study was undertaken to compare WHO/ISUP and Fuhrman grading and to validate WHO/ISUP grading as a prognostic parameter in a series of clear cell RCC.

METHODS AND RESULTS

Analysis of 681 cases of ccRCC showed that 144 tumours could not be assigned a Fuhrman grade on the basis of ambiguous grading features. The application of WHO/ISUP grading resulted in a general down-grading of cases when compared with Fuhrman grading. In a sub-group of 374 cases, for which outcome data were available, 9.3% were WHO/ISUP grade 1, 50.3% were grade 2, 24.1% grade 3 and 16.3% grade 4, while the distribution of Fuhrman grades was 0.4% grade 1, 48.7% grade 2, 29.4% grade 3 and 21.5% grade 4. There were no recurrence/metastases amongst patients with WHO/ISUP grade 1 tumours and there was a significant difference in outcome for WHO/ISUP grades 2, 3 and 4. For Fuhrman grading the cancer-free survival was not significantly different for grade 2 and grade 3 tumours. On multivariate analysis WHO/ISUP grade and pT staging category were found to retain prognostic significance.

CONCLUSIONS

The study demonstrates that FG cannot be applied in >20% of cases of ccRCC and the WHO/ISUP provides superior prognostic information.

A Grading System Combining Tumor Budding and Nuclear Diameter Predicts Prognosis in Resected Lung Squamous Cell Carcinoma

For lung squamous cell carcinomas, there are no histologic findings that have been universally accepted as prognostic factors. Tumor budding and nuclear grade have been recognized as prognostic factors in other carcinomas. In this study, we investigated whether pathologic findings could determine clinical outcome in Japanese patients with lung squamous cell carcinomas. Tumor slides from surgically resected lung squamous cell carcinomas (1999 to 2012) were reviewed (n=216). Tumors were evaluated for histologic subtypes, differentiation, tumor budding, nuclear diameter, and mitosis. Recurrence-free survival (RFS) and overall survival (OS) were analyzed using the log-rank test and the Cox proportional hazards model. Tumor budding and large nuclei were independent prognostic factors of a worse RFS (P<0.001 and P=0.002, respectively) and a worse OS (P<0.001 and P=0.038, respectively) on multivariate analysis after adjustment for pathologic stage and lymphatic invasion. However, histologic subtypes, differentiation, and mitotic count did not correlate with prognosis. A grading system combining tumor budding and nuclear diameter was an independent prognostic factors of a worse RFS (grade 2 vs. 1, hazard ratio [HR]=2.91; P<0.001, and grade 3 vs. 1, HR=7.60, P<0.001) and a worse OS (grade 2 vs. 1, HR=2.15; P=0.014, and grade 3 vs. 1, HR=4.54, P<0.001). We found that a grading system combining tumor budding and nuclear diameter was a significant prognostic factor among Japanese patients with resected lung squamous cell carcinoma.

Hilar fat infiltration: A new prognostic factor in metastatic clear cell renal cell carcinoma with first-line sunitinib treatment

INTRODUCTION

The selection of patients with metastatic clear cell renal cell carcinoma (ccRCC) who may benefit from targeted tyrosine kinase inhibitors has been a challenge, even more so now with the advent of new therapies. Hilar fat infiltration (HFI) is a validated prognostic factor in nonmetastatic ccRCC (TNM 2009 staging system) but has never been studied in metastatic patients. We aimed to assess its phenotype and prognostic effect in patients with metastatic ccRCC treated with first-line sunitinib.

MATERIALS AND METHODS

In a multicentric study, we retrospectively included 90 patients and studied the corresponding ccRCC at the pathological, immunohistochemical, and molecular levels. Patient and tumor characteristics were compared using univariate and multivariate analysis. All the features were then studied by Cox models for prognostic effect.

RESULTS

HFI was found in 42 patients (46.7%), who had worse prognosis (Heng criteria) (P = 0.003), liver metastases (P = 0.036), and progressive diseases at first radiological evaluation (P = 0.024). The corresponding ccRCC was associated with poor pathological prognostic factors that are well known in nonmetastatic ccRCC. For these patients, median progression-free survival was 4 months vs. 13 months (P = 0.02), and median overall survival was 14 months vs. 29 months (P = 0.006). In a multivariate Cox model integrating all the variables, only poor prognosis, according to the Heng criteria and HFI, remained independently associated with both progression-free survival and overall survival.

CONCLUSION

HFI was demonstrated for the first time to be an independent poor prognostic factor. Its potential role in predicting resistance to antiangiogenic therapy warrants further investigation.

Histological features of malignancy correlate with growth patterns and patient outcome in lung adenocarcinoma

AIMS

Until the launch of the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society adenocarcinoma classification in 2011, there were no uniform histological grading criteria for pulmonary adenocarcinomas. The current classification highlights the prognostic importance of the various histological growth patterns observed in these morphologically heterogeneous neoplasias. In this study, we aimed to evaluate the classic histological parameters of malignancy in correlation with the growth patterns and patient outcomes in a series of 112 surgically operated stage I-IV lung adenocarcinomas.

METHODS AND RESULTS

Architectural growth pattern analysis was performed according to the current adenocarcinoma classification. Histological features including, for example, nuclear atypia, mitotic activity, tumour necrosis, and different patterns of invasion were assessed and correlated statistically with the architecture and the clinical data. A solid predominant histology was associated with increased levels of atypia (P = 0.027), mitotic activity (P < 0.001), necrosis (P < 0.001), and lymphovascular invasion (P = 0.001), and a non-predominant solid pattern was associated with intra-alveolar tumour spread (P = 0.004). The presence of a non-predominant lepidic tumour component showed inverse correlations with atypia (P = 0.002), mitotic rate (P = 0.009), and tumour necrosis (P < 0.001). Tumour size (P < 0.001), mitotic activity (P = 0.019), tumour necrosis (P = 0.002), lymphovascular invasion (P = 0.001) and visceral pleural involvement (P = 0.001) were all associated with reduced disease-specific survival.

CONCLUSIONS

The classic histological features of malignancy correlate with tumour architecture and patient outcome, confirming the prognostic value of the growth pattern analysis and questioning the need for a parallel grading system in pulmonary adenocarcinoma.

Update on Renal Mass Biopsy

Renal masses are diagnosed with an increasing frequency. However, a significant proportion of these masses are benign, and the majority of malignant tumors are biologically indolent. Furthermore, renal tumors are often harbored by the elderly and comorbid patients. As such, matching of renal tumor biology to appropriate treatment intensity is an urgent clinical need. Renal mass biopsy is currently a very useful clinical tool that can assist with critical clinical decision-making in patients with renal mass. Yet, renal mass biopsy is associated with limitations and, as such, may not be appropriate for all patients.

Current Role of Renal Biopsy in Urologic Practice

Most small renal masses (SRMs) are indolent. In fact, only approximately 80% of SRMs are malignant. Furthermore, SRMs are commonly detected in elderly and comorbid patients. Therefore, opportunities for better care intensity calibration exist. Renal mass biopsy (RMB), when appropriately used, is a valuable clinical tool to help with critical clinical decision-making in patients with SRM. This article summarizes the role of modern RMB in helping gauge care for patients with SRM.

Clinicopathological and prognostic factors for long-term survival in Chinese patients with metastatic renal cell carcinoma treated with sorafenib: a single-center retrospective study

Data on long-term survival and prognostic significance of demographic factors and adverse events (AEs) associated with sorafenib, an orally administered multikinase inhibitor in Chinese population with advanced renal cell carcinoma (RCC) are limited. Outcome data from adult patients (n = 256) with advanced RCC who received sorafenib (400 mg twice daily) either as first-line or second-line therapy between April 2006 and May 2013 were analyzed retrospectively. The primary endpoint was median overall survival (OS), determined to be 22.2 (95% CI: 17.1–27.4) months, and the secondary endpoint was overall median progression-free survival (PFS), determined to be 13.6 (95% CI: 10.7–16.4) months at a median follow-up time of 61.8 (95% CI: 16.2–97.4) months. Analysis of the incidence of AEs revealed the most common side effect as hand-foot skin reactions (60.5%) followed by diarrhea (38.7%), fatigue (35.5%), alopecia (34.0%), rash (24.6%), hypertension (21.5%) and gingival hemorrhage (21.1%). Multivariate regression analysis revealed older age (≥ 58 years), lower Memorial Sloan-Kettering Cancer Center score, time from nephrectomy to sorafenib treatment, number of metastatic tumors and best response as significant and independent demographic predictors for improved PFS and/or OS (p ≤ 0.05). Alopecia was identified as a significant and independent predictor of increased OS, whereas vomiting and weight loss were identified as significant predictors of decreased OS (p ≤ 0.05). Sorafenib significantly improved OS and PFS in Chinese patients with advanced RCC. Considering the identified significant prognostic demographic factors along with the advocated prognostic manageable AEs while identifying treatment strategy may help clinicians select the best treatment modality and better predict survival in these patients.

Correlation of CT imaging features and tumor size with Fuhrman grade of clear cell renal cell carcinoma

Background Identification of clinical features to determine the aggressive potential of tumors is highly warranted to stratify patients for adequate treatment. Computed tomography (CT) imaging features of clear cell renal cell carcinoma (ccRCC) may contribute to personalized risk assessment. Purpose To assess the correlation between CT imaging features and Fuhrman grade of ccRCC, and to identify the predictors of high Fuhrman grade in conjunction with tumor size. Material and Methods CT scans of 169 patients with 173 pathologically proven ccRCCs were retrospectively reviewed in consensus by two radiologists for the presence of intratumoral necrosis and intratumoral cyst and tumor size. Histologic grade was classified as either low (Fuhrman grade I or II) or high (Fuhrman grade III or IV). Statistical significance was evaluated by using univariate, multivariate regression, receiver operating characteristic (ROC) curve, and Spearman correlation analyses. Results On CT, 20 of the 173 tumors had intratumoral cysts, 60 had intratumoral necrosis, and 93 showed entirely solid tumors. The odds of high grade were higher with intratumoral necrosis and entirely solid tumor than with intratumoral cyst ( P < 0.03). Intratumoral necrosis showed a significantly high odds ratio of 25.73 for high Fuhrman grade. The ROC curve showed a threshold tumor size of 36 mm to predict high Fuhrman grade for overall tumors (area under the ROC curve, 0.70). In ccRCCs with intratumoral necrosis or cyst, tumor size did not significantly correlate with Fuhrman grade. Conclusion Intratumoral necrosis on CT was a strong and independent predictor of biologically aggressive ccRCCs, irrespective of tumor size.

Molecular Subtypes Improve Prognostic Value of International Metastatic Renal Cell Carcinoma Database Consortium Prognostic Model

INTRODUCTION

Gene-expression signatures for prognosis have been reported in localized renal cell carcinoma (RCC). The aim of this study was to test the predictive power of two different signatures, ClearCode34, a 34-gene signature model [Eur Urol 2014;66:77-84], and an 8-gene signature model [Eur Urol 2015;67:17-20], in the setting of systemic therapy for metastatic disease.

MATERIALS AND METHODS

Metastatic RCC (mRCC) patients from five institutions who were part of TCGA were identified and clinical data were retrieved. We trained and implemented each gene model as described by the original study. The latter was demonstrated by faithful regeneration of a figure and results from the original study. mRCC patients were dichotomized to good or poor prognostic risk groups using each gene model. Cox proportional hazard regression and concordance index (C-Index) analysis were used to investigate an association between each prognostic risk model and overall survival (OS) from first-line therapy.

RESULTS

Overall, 54 patients were included in the final analysis. The primary endpoint was OS. Applying the ClearCode34 model, median survival for the low-risk-ccA (n = 17)-and the high-risk-ccB (n = 37)-subtypes were 27.6 and 22.3 months (hazard ratio (HR): 2.33; p = .039), respectively. ClearCode34 ccA/ccB and International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) classifications appear to represent distinct risk criteria in mRCC, and we observed no significant overlap in classification (p > .05, chi-square test). On multivariable analyses and adjusting for IMDC groups, ccB remained independently associated with a worse OS (p = .044); the joint model of ccA/ccB and IMDC was significantly more accurate in predicting OS than a model with IMDC alone (p = .045, F-test). This was also observed in C-Index analysis; a model with both ccA and ccB subtypes had higher accuracy (C-Index 0.63, 95% confidence interval [CI] = 0.51-0.75) and 95% CIs of the C-Index that did not include the null value of 0.5 in contrast to a model with IMDC alone (0.60, CI = 0.47-0.72). The 8-gene signature molecular subtype model was a weak but insignificant predictor of survival in this cohort (p = .13). A model that included both the 8-gene signature and IMDC (C-Index 0.62, CI = 0.49-0.76) was more prognostic than IMDC alone but did not reach significance, as the 95% CI included the null value of 0.5. These two genomic signatures share no genes in common and are enriched in different biological pathways. The ClearCode34 included genes ARNT and EPAS1 (also known as HIF2a), which are involved in regulation of gene expression by hypoxia-inducible factor.

CONCLUSION

The ClearCode34 but not the 8-gene molecular model improved the prognostic predictive power of the IMDC model in this cohort of 54 patients with metastatic clear cell RCC. The Oncologist 2017;22:286-292 IMPLICATIONS FOR PRACTICE: The clinical and laboratory factors included in the International Metastatic Renal Cell Carcinoma Database Consortium model provide prognostic information in metastatic renal cell carcinoma (mRCC). The present study shows that genomic signatures, originally validated in localized RCC, may add further complementary prognostic information in the metastatic setting. This study may provide new insights into the molecular basis of certain mRCC subgroups. The integration of clinical and molecular data has the potential to redefine mRCC classification, enhance the understanding of mRCC biology, and potentially predict response to treatment in the future.

Safety, reliability and accuracy of small renal tumour biopsies: results from a multi-institution registry

OBJECTIVE

To validate, in a multi-institution review, the safety, accuracy and reliability of renal tumour biopsy (RTB) and its role in decreasing unnecessary treatment.

MATERIALS AND METHODS

We conducted a multi-institution retrospective study of patients who underwent RTB to characterize a small renal mass (SRM) between 2011 and May 2015. Patients were identified using the prospectively maintained Canadian Kidney Cancer information system. Diagnostic and concordance rates were presented using proportions, whereas factors associated with a diagnostic RTB were identified using a logistic regression model.

RESULTS

Of the 373 biopsied SRMs, the initial biopsy was diagnostic in 87% of cases. Of the 47 non-diagnostic biopsies, 15 had a repeat biopsy of which, 80% were diagnostic. When both were combined, therefore, a diagnosis was obtained in 91% of SRMs. Of these, 18% were benign. Size was the only factor found to be associated with achieving a diagnostic biopsy. RTB histology and nuclear grade (high or low) were found to be highly concordant with surgical pathology (86 and 81%, respectively). Of the discordant tumours (n = 16), all were upgraded from low to high grade on surgical pathology. Adverse events were rare (<1% of cases).

CONCLUSION

The present multi-institution study confirms that RTB of SRMs is safe, accurate and reliable across institutions, while decreasing unnecessary treatment. Given our findings, RTBs may be a helpful tool with which to triage SRMs and guide appropriate management.

Preoperative evaluation of renal cell carcinoma by using 18F-FDG PET/CT

PURPOSE

This study aimed to characterize the FDG uptake of renal cell carcinoma (RCC) by the pathological subtype and nuclear grade.

PATIENTS AND METHODS

We retrospectively identified patients who underwent F-FDG PET and subsequent partial or radical nephrectomy for renal tumors. The relationships of the SUV of renal tumor with subtypes, nuclear grade, and clinicopathological variables were investigated.

RESULTS

Ninety-two tumors were analyzed, including 52 low-grade (G1 and G2) and 18 high-grade (G3 and G4) clear cell RCC; 7 chromophobe, 5 papillary, and 1 unclassified RCC; and 9 benign tumors (7 angiomyolipoma and 2 oncocytoma). The SUVs of high-grade clear cell RCC (mean ± SD, 6.8 ± 5.1) and papillary RCC (6.6 ± 3.7) were significantly higher than that of the controls (2.2 ± 0.3). The SUV of high-grade clear cell RCC was higher than that of low-grade tumors (median, 4.0 vs. 2.2; P < 0.001). The optimal SUV cutoff value of 3.0 helped to differentiate high-grade from low-grade clear cell RCC, with 89% sensitivity and 87% specificity. On multiple regression analysis, a high grade was the most significant predictor of SUV for clear cell RCC.

CONCLUSIONS

FDG uptake higher than that observed in normal kidney tissues suggests a high-grade clear cell RCC or papillary RCC subtype. FDG-PET using SUV may have a role in prediction of pathological grade of renal tumor.

Nestin expression on tumour vessels and tumour-infiltrating macrophages define a poor prognosis subgroup of pt1 clear cell renal cell carcinoma

The behaviour of clear cell renal cell carcinoma (CCRCC) is highly unpredictable. Despite adequate initial surgery, 20 to 30 % of patients will develop local recurrence or metastasis during follow-up. Usual clinical and pathology parameters tend to classify most patients in an intermediate prognosis group, and molecular markers to determine prognosis more accurately are needed. A key feature of CCRCC is its abundant vascularization. Factors that upregulate angiogenesis, such as hypoxia and the presence of immune cells including macrophages, also modulate tumour proliferation and metastasis. We studied angiogenesis, as defined by nestin-positive capillaries, and tumour infiltration by macrophages especially in the good prognosis pT1 subgroup of CCRCC. We assessed whether these parameters are associated with metastatic extension and survival in CCRCC. The expression of HIF1α, CAIX, nestin, CD68 and CD163 was assessed by immunohistochemistry on a tissue microarray (TMA) containing tissue samples from 257 consecutive patients with sporadic CCRCC. Factors associated with progression-free (PFS) and overall survival (OS) were analysed. The presence of nestin-positive tumour vessels was independently associated with shorter PFS in the whole cohort and in the pT1 subgroup. The presence of tumour-infiltrating macrophages was independently associated with shorter OS in the whole cohort and in the pT1 subgroup. The presence of nestin-positive endothelial cells is associated with early relapse, especially in the pT1 subgroup and may help to select patients for antiangiogenic treatment. The presence of tumour-infiltrating M2-type macrophages is a strong predictor of short survival and may be used to adapt treatment strategy.

Clinical evaluation of microRNA-145 expression in renal cell carcinoma: a promising molecular marker for discriminating and staging the clear cell histological subtype

The vast majority of malignancies detected in renal parenchyma are diagnosed as renal cell carcinoma (RCC), whose subtype discrimination and determination of prognosis may contribute to the selection of the adequate therapy. Recently, a new class of small non-coding RNAs, known as microRNAs, has proven to be among the most promising biomarkers for providing this information. Herein, we sought to add up to this knowledge by evaluating the expression levels of microRNA-145 (miR-145) in RCC. For that purpose, total RNA from 58 cancerous and 44 adjacent non-cancerous renal tissues was firstly extracted and then polyadenylated and reverse transcribed to cDNA. MiR-145 levels were finally analyzed by developing and applying a highly sensitive real-time PCR protocol, while their clinical significance was determined via comprehensive statistical analysis. Our data showed that miR-145 was significantly downregulated in cancerous samples and could discriminate between clear cell and non-clear cell subtypes. Moreover, miR-145 expression was found to be correlated with primary tumor staging of cancerous samples, something also noticed in the clear cell RCC subset, in which miR-145 levels were negatively correlated with tumor size as well. Overall, these results indicate that miR-145 might constitute a promising molecular marker for RCC classification and staging.

Local Recurrence After Curative Surgical Treatment of Renal Cell Cancer: A Study of 91 Patients

BACKGROUND

Local recurrence (LR) after curative therapy for renal cell cancer is a rare event, and surgery is still the primary treatment option.

PATIENTS AND METHODS

This was a single-institution, single-arm retrospective study from a prospectively conducted database. A total of 91 patients with a median age of 63.0 years (interquartile range, 57.5-68.3), who had undergone LR resection after initial curative treatment of RCC were enrolled. The time to LR (TTLR) was defined as the interval from primary curative surgery to LR. Cancer-specific survival, overall survival, and progression-free survival were evaluated after LR resection. Statistical analyses of the clinical and pathologic variables were performed using Cox regression analysis and the Kaplan-Meier method.

RESULTS

The median time to LR was 29.8 months (interquartile range, 10.8-64.3). On multivariate analysis, age > 65 years, T3/T4 stage, Fuhrman grade 3/4, major venous infiltration, and positive surgical margins were related to early LR after primary curative surgery. LR size of ≤ 7 cm and TTLR of > 24 months were associated with longer cancer-specific survival. Furthermore, patients with a TTLR of > 24 months had better overall survival and progression-free survival. Of the entire cohort, intraoperative radiation therapy and targeted therapy were used in 17 (18.7%) and 15 (16.5%) patients, respectively.

CONCLUSION

Advanced age, T3/T4 stage, Fuhrman grade 3 or 4, major venous infiltration, and positive surgical margins at primary tumor resection were related to a greater risk of early LR. An LR size of ≤ 7 cm and TTLR of > 24 months were associated with favorable oncologic outcomes after LR resection. Thus, patients who present with a longer TTLR and smaller LR size, along with favorable features at primary tumor resection, will benefit from surgical treatment.

Prediction of renal mass aggressiveness using clinical and radiographic features: a global, multicentre prospective study

OBJECTIVE

To examine the ability of preoperative clinical characteristics to predict histological features of renal masses (RMs).

PATIENTS AND METHODS

Data from consecutive patients with clinical stage I RMs treated surgically between 2010 and 2011 in the Clinical Research Office of Endourology Society (CROES) Renal Mass Registry were collected. Based on surgical histology, tumours were categorised as benign, low- or high-aggressiveness cancer. Multivariate logistic regression was used to estimate the probability of the histological group by clinical and radiographic features in the entire cohort and a subcohort of cT1a tumours. The performance of the models was studied by calibration, Nagelkerke's R(2) , and discrimination (area under the receiver operating characteristic curve).

RESULTS

The study cohort included 2 224 patients with a clinical stage I RM, of which 1 367 (61%) were cT1a. Benign lesions were found in 369 (16.6%), low-aggressiveness tumours in 1 156 (52%) and high-aggressiveness tumours in 699 (31.4%). Male gender, smoking history, increased tumour size, and lower exophytic rate were associated with malignancy and high-aggressiveness features (all P < 0.05). Models developed based on these characteristics had the ability to discriminate benign from malignant (bootstrap corrected c-index of 0.64) and high-aggressiveness tumours from benign and low-aggressiveness tumours (bootstrap corrected c-index of 0.66). Similar results were achieved in the cT1a subgroup. The c-index of tumour diameter as a single predictor of malignancy and high-aggressiveness tumours in the entire cohort was 0.6 and 0.63, respectively.

CONCLUSION

Although older age, male gender, smoking history, increased tumour diameter, and reduced exophytic rate are associated with malignancy and high aggressiveness of clinical stage I RMs, models incorporating these characteristics have modest discriminating power, being only slightly better than the predictive ability of tumour size alone.

Critical analysis of a simplified Fuhrman grading scheme for prediction of cancer specific mortality in patients with clear cell renal cell carcinoma--Impact on prognosis

INTRODUCTION AND OBJECTIVES

The traditional 4-tiered Fuhrman grading system (FGS) is widely accepted as histopathological classification for clear cell renal cell carcinoma (ccRCC) and has shown prognostic value. As intra- and inter-observer agreement are sub-optimal, simplified 2- or 3-tiered FGSs have been proposed. We aimed to validate these simplified 2- or 3-tiered FGSs for prediction of cancer-specific mortality (CSM) in a large study population from 2 European tertiary care centers.

METHODS

We identified and followed-up 2415 patients with ccRCC who underwent radical or partial nephrectomy in 2 European tertiary care centers. Univariable and multivariable analyses and prognostic accuracy analyses were performed to evaluate the ability of several simplified FGSs (i.e. grades I + II vs., grades III + IV, grades I + II vs. grade III and grade IV) to predict CSM.

RESULTS

Independent predictor status in multivariate analyses was proved for the simplified 2-tiered FGS (high-grade vs. low-grade), for the simplified 3-tiered FGS (grades I + II vs. grade III and grade IV) as well as for the traditional 4-tiered FGS. The prognostic accuracy of multivariable models of 77% was identical for all tested models. Prognostic accuracy of the model without FG was 75%.

CONCLUSIONS

A simplified 2- or 3-tiered FGS could predict CSM as accurate as the traditional 4-tiered FGS in a large European study population. Application of new simplified 2- or 3-tiered FGS may reduce inter-observer-variability and facilitate clinical practice without compromising the ability to predict CSM in ccRCC patients after radical or partial nephrectomy.

Growth Pattern of Clear Cell Renal Cell Carcinoma in Patients with Delayed Surgical Intervention: Fast Growth Rate Correlates with High Grade and May Result in Poor Prognosis

Objectives. Previous studies revealed an unclear correlation between the growth rate of renal cell carcinoma (RCC) and tumor grade and did not focus on certain histological subtype. This report investigated the correlation between the growth rate and tumor grade in clear cell RCC (ccRCC). Methods. We reviewed 60 patients with 61 ccRCC confirmed by delayed surgeries after at least 12 months of active surveillance. The linear growth rate (LGR), volumetric growth rate (VGR), and volume doubling time (VDT) were calculated, and their correlations with clinicopathologic characteristics were analyzed. Results. The mean LGR, VGR, and VDT were 0.86 (range 0–4.74) cm/year, 20.96 (range 0.31–211.93) cm³/year, and 667 (range 33–3321) days, respectively. ccRCCs with high grade had greater LGR (P < 0.001) and VGR (P = 0.001) and lower VDT (P = 0.017) than ccRCCs with low grade. Grade (OR = 5.185, P = 0.004) was the only independent risk factor of LGR >0.5 cm/year, and grade (OR = 3.006, P = 0.046) and initial size (OR = 0.392, P = 0.004) were independent risk factors of VDT <1 year. Five patients developed metastasis after surgery with LGR >0.5 cm/yr altogether; of them, four had cancer-related death by the last follow-up. Conclusions. Fast growth rate of ccRCC is significantly correlated with high tumor grade and may result in poor prognosis, especially for those with LGR >0.5 cm/yr.

Comprehensive pathological analyses in lung squamous cell carcinoma: single cell invasion, nuclear diameter, and tumor budding are independent prognostic factors for worse outcomes

INTRODUCTION

For lung squamous cell carcinomas, there are no pathological findings that have been universally accepted as prognostic factors, with the exception of pathological stage. Tumor budding and nuclear grade have been recognized as a poor prognostic factor in other carcinomas. In this study, we investigated whether pathological findings could determine prognosis in lung squamous cell carcinomas.

METHODS

All available tumor slides from patients with surgically resected, solitary lung squamous cell carcinomas (1999-2009) were reviewed (n = 485; stage I/II/III, 281/136/68). Tumors were evaluated for differentiation, subtypes (keratinizing, nonkeratinizing, basaloid pattern, papillary growth, and clear cell feature), tumor nest size (tumor budding and single cell invasion), and nuclear grade (nuclear diameter and mitosis). Overall survival (OS) was estimated using the Kaplan-Meier method (stratified by pathological stage), and group differences were investigated using the stratified log-rank test and the Cox proportional hazards model.

RESULTS

OS was significantly decreased in patients with versus without single cell invasion (p = 0.002 for the entire tumor and p = 0.001 for tumor edge), with large versus small nuclei (p = 0.011), and with high versus low grade tumor budding (p < 0.001 for maximum and p = 0.007 for total). In multivariate analyses, single cell invasion (hazard ratio [HR], 1.47-1.49), nuclear diameter (HR, 1.09-1.33), and tumor budding (HR, 1.04) were independent prognostic factors of OS. However, histologic subtyping including keratinizing, nonkeratinizing, basaloid, and clear cell subtypes did not show prognostic significance.

CONCLUSIONS

Pathological factors can help stratify prognosis in patients with lung squamous cell carcinomas.