SEOM clinical guideline for treatment of kidney cancer (2017)

Assessing the methodological strengths and limitations of the Spanish Society of Medical Oncology (SEOM) guidelines: a critical appraisal using AGREE II and AGREE-REX tool

BACKGROUND

The Spanish Society of Medical Oncology (SEOM) has provided open-access guidelines for cancer since 2014. However, no independent assessment of their quality has been conducted to date. This study aimed to critically evaluate the quality of SEOM guidelines on cancer treatment.

METHODS

Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE-REX tool was used to evaluate the qualities of the guidelines.

RESULTS

We assessed 33 guidelines, with 84.8% rated as "high quality". The highest median standardized scores (96.3) were observed in the domain "clarity of presentation", whereas "applicability" was distinctively low (31.4), with only one guideline scoring above 60%. SEOM guidelines did not include the views and preferences of the target population, nor did specify updating methods.

CONCLUSIONS

Although developed with acceptable methodological rigor, SEOM guidelines could be improved in the future, particularly in terms of clinical applicability and patient perspectives.

Localization of spleen and kidney organs from CT scans based on classification of slices in rotational views

This article presents a novel multiple organ localization and tracking technique applied to spleen and kidney regions in computed tomography images. The proposed solution is based on a unique approach to classify regions in different spatial projections (e.g., side projection) using convolutional neural networks. Our procedure merges classification results from different projection resulting in a 3D segmentation. The proposed system is able to recognize the contour of the organ with an accuracy of 88-89% depending on the body organ. Research has shown that the use of a single method can be useful for the detection of different organs: kidney and spleen. Our solution can compete with U-Net based solutions in terms of hardware requirements, as it has significantly lower demands. Additionally, it gives better results in small data sets. Another advantage of our solution is a significantly lower training time on an equally sized data set and more capabilities to parallelize calculations. The proposed system enables visualization, localization and tracking of organs and is therefore a valuable tool in medical diagnostic problems.

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).

A CT-based radiomics model for predicting renal capsule invasion in renal cell carcinoma

Background

Renal cell carcinoma (RCC) is a heterogeneous group of kidney cancers. Renal capsule invasion is an essential factor for RCC staging. To develop radiomics models from CT images for the preoperative prediction of capsule invasion in RCC patients.

Methods

This retrospective study included patients with RCC admitted to the Chongqing University Cancer Hospital (01/2011–05/2019). We built a radiomics model to distinguish patients grouped as capsule invasion versus non-capsule invasion, using preoperative CT scans. We evaluated effects of three imaging phases, i.e., unenhanced phases (UP), corticomedullary phases (CMP), and nephrographic phases (NP). Five different machine learning classifiers were compared. The effects of tumor and tumor margins are also compared. Five-fold cross-validation and the area under the receiver operating characteristic curve (AUC) are used to evaluate model performance.

Results

This study included 126 RCC patients, including 46 (36.5%) with capsule invasion. CMP exhibited the highest AUC (AUC = 0.81) compared to UP and NP, when using the forward neural network (FNN) classifier. The AUCs using features extracted from the tumor region were generally higher than those of the marginal regions in the CMP (0.81 vs. 0.73) and NP phase (AUC = 0.77 vs. 0.76). For UP, the best result was obtained from the marginal region (AUC = 0.80). The robustness analysis on the UP, CMP, and NP achieved the AUC of 0.76, 0.79, and 0.77, respectively.

Conclusions

Radiomics features in renal CT imaging are associated with the renal capsule invasion in RCC patients. Further evaluation of the models is warranted.

Clinical translation of immunomodulatory therapeutics

Immunomodulatory therapeutics represent a unique class of drug products that have tremendous potential to rebalance malfunctioning immune systems and are quickly becoming one of the fastest-growing areas in the pharmaceutical industry. For these drugs to become mainstream medicines, they must provide greater therapeutic benefit than the currently used treatments without causing severe toxicities. Immunomodulators, cell-based therapies, antibodies, and viral therapies have all achieved varying amounts of success in the treatment of cancers and/or autoimmune diseases. However, many challenges related to precision dosing, off-target effects, and manufacturing hurdles will need to be addressed before we see widespread adoption of these therapies in the clinic. This review provides a perspective on the progress of immunostimulatory and immunosuppressive therapies to date and discusses the opportunities and challenges for clinical translation of the next generation of immunomodulatory therapeutics.

Long-term outcomes of CT-guided percutaneous cryoablation of T1a and T1b renal cell carcinoma

PURPOSE

We aimed to evaluate the long-term outcomes of computed tomography-guided percutaneous cryoablation (PCA) for biopsy-confirmed renal cell carcinoma (RCC).

METHODS

This was a single-center, retrospective study investigating all patients treated with PCA between January 2010 and February 2019 for RCC tumors. Primary outcome measures included overall survival (OS), disease-free survival (DFS), progression-free survival (PFS) and cancer-specific survival (CSS). Secondary outcome measures included kidney function, complications, technical success, hospital stay, procedural time, and the identification of factors affecting the primary outcomes.

RESULTS

Fifty-three consecutive patients with 54 lesions (T1a: 49/54; T1b: 5/54) were included. Mean tumor diameter was 28.0±8.5 mm and mean R.E.N.A.L. score was 7.2±2.0. Technical success was 100% (54/54 lesions) after two reinterventions for incomplete ablation. Mean follow-up time was 46.7±28.6 months (range, 3-122 months). Local recurrence was noted in 5 patients (9.2%). According to Kaplan-Meyer analysis, OS was 98.2%, 94.2%, 71.2%, and 58.2% at 1, 3, 5, and 8 years. One patient (1.9%) died of cancer and CSS was 95.8% at 8 years. DFS was 100.0%, 95.5%, and 88.6%, and PFS was 100%, 94.3%, and 91.0%, at 1, 2, and 5 years. Clavien-Dindo grade II complication rate was 7.8% (5/64 procedures). There were no complications classified as grade III or greater. Mean creatinine increase was 7.1±6.3 μm/L (p = 0.31). No patient advanced to dialysis during follow up. Mean procedural time was 163±45 min. Median hospital stay was 2.0 days (IQR, 1-2.5 days). Diabetes was the only independent predictor of decreased OS (hazard ratio 4.3, 95% CI 0.043-0.914; p = 0.038).

CONCLUSION

PCA for stage T1a and T1b RCC provides favorable long-term oncological and renal function preservation outcomes, with acceptable complication rates.

Analysis of expression, epigenetic, and genetic changes of HNF1B in 130 kidney tumours

Hepatocyte nuclear factor 1 beta (HNF1B) is a transcription factor which plays a crucial role in nephronogenesis, and its germline mutations have been associated with kidney developmental disorders. However, the effects of HNF1B somatic exonic mutations and its role in the pathogenesis of kidney tumours has not yet been elucidated. Depending on the type of the tumour HNF1B may act as a tumour suppressor or oncogene, although the exact mechanism by which HNF1B participates in the process of cancerogenesis is unknown. Using an immunohistochemical approach, and methylation and mutation analysis, we have investigated the expression, epigenetic, and genetic changes of HNF1B in 130 cases of renal tumours (121 renal cell carcinomas, 9 oncocytomas). In the subset of clear cell renal cell carcinoma (ccRCC), decreased HNF1B expression was associated with a higher tumour grade and higher T stage. The mutation analysis revealed no mutations in the analysed samples. Promoter methylation was detected in two ccRCCs and one oncocytoma. The results of our work on a limited sample set suggest that while in papillary renal cell carcinoma HNF1B functions as an oncogene, in ccRCC and chRCC it may act in a tumour suppressive fashion.

New Treatments in Renal Cancer: The AhR Ligands

Kidney cancer rapidly acquires resistance to antiangiogenic agents, such as sunitinib, developing an aggressive migratory phenotype (facilitated by c-Metsignal transduction). The Aryl hydrocarbon receptor (AhR) has recently been postulated as a molecular target for cancer treatment. Currently, there are two antitumor agent AhR ligands, with activity against renal cancer, that have been tested clinically: aminoflavone (AFP 464, NSC710464) and the benzothiazole (5F 203) prodrug Phortress. Our studies investigated the action of AFP 464, the aminoflavone pro-drug currently used in clinical trials, and 5F 203 on renal cancer cells, specifically examining their effects on cell cycle progression, apoptosis and cell migration. Both compounds caused cell cycle arrest and apoptosis but only 5F 203 potently inhibited the migration of TK-10, Caki-1 and SN12C cells as well as the migration signal transduction cascade, involving c-Met signaling, in TK-10 cells. Current investigations are focused on the development of nano-delivery vehicles, apoferritin-encapsulated benzothiazoles 5F 203 and GW610, for the treatment of renal cancer. These compounds have shown improved antitumor effects against TK-10 cells in vitro at lower concentrations compared with a naked agent.

Upregulation of lncRNA AGAP2-AS1 is an independent predictor of poor survival in patients with clear cell renal carcinoma

Long non-coding RNA (lncRNA) AGAP2-AS1 has been reported to be a potential biomarker for a variety of cancer types, while its function in clear cell renal carcinoma (ccRCC) has not yet been fully determined. The current study aimed to determine the value of lncRNA AGAP2-AS1 in ccRCC based on The Cancer Genome Atlas (TCGA) database. The association between AGAP2-AS1 expression and associated clinical characters were analyzed using the Wilcoxon signed-rank test and logistic regression. The diagnostic value of AGAP2-AS1 expression in ccRCC tissue was assessed using receiver operating characteristic (ROC) curve analysis. Clinicopathological characteristics associated with overall survival in patients with TCGA were analyzed using Cox regression and the Kaplan-Meier method. Gene set enrichment analysis (GSEA) was also performed to assess the biological function of AGAP2-AS1. The results demonstrated that increased expression of AGAP2-AS1 in ccRCC was significantly associated with male, T3/T4, lymph node metastasis, distant metastasis and high tumor stage (III/IV; all, P<0.05). The area under the ROC curve (normal vs. all tumors) was revealed to be 0.891. Kaplan-Meier survival analysis indicated that ccRCC with high lncRNA AGAP2-AS1 exhibited a worse prognosis compared with low AGAP2-AS1 (P<0.001). The univariate analysis revealed that high expression of AGAP2-AS1 was significantly associated with poor overall survival [hazard ratio (HR). 1.85; 95% confidence interval (CI), 1.48-2.33; P<0.001). Multivariate analysis revealed that AGAP2-AS1 remained independently associated with overall survival, with a HR of 1.57 (CI, 1.21-2.03; P<0.01). GSEA outcome demonstrated that stromal stimulation, angiogenesis, epithelial to mesenchymal transition, basal cell carcinoma, ECM receptor interaction and the Notch signaling pathway were differentially enriched in the AGAP2-AS1 high expression phenotype. Therefore, the high expression of AGAP2-AS1 may be an independent predictor of poor survival in patients with ccRCC.

Complex surgery and perioperative systemic therapy for genitourinary cancer of the retroperitoneum

Objective

The purpose of the present guideline is to recommend surgical or systemic treatment for metastatic testicular cancer; T3b or T4, or node-positive, and metastatic renal cell cancer (rcc); and T3, T4, or node-positive upper tract urothelial (utuc) cancer.

Methods

Draft recommendations were formulated based on evidence obtained through a systematic review of randomized controlled trials, comparative retrospective studies, and guideline endorsement. The draft recommendations underwent an internal review by clinical and methodology experts, and an external review by clinical practitioners.

Results

The primary literature search yielded eight guidelines, five systematic reviews, and twenty-seven primary studies that met the eligibility criteria.

Conclusions

Cytoreductive nephrectomy should no longer be considered the standard of care in patients with T3b or T4, or node-positive, and metastatic rcc. Eligible patients should be treated with systemic therapy and have their primary tumour removed only after review at a multidisciplinary case conference (mcc). Adjuvant sunitinib after surgery is not recommended. Patients with venous tumour thrombus should be considered for surgical intervention. Patients with T3, T4, or node-positive utuc should have their tumour removed without delay. Decisions concerning lymph node dissection should be done at a mcc and be based on stage, expertise, and imaging. Adjuvant systemic treatment is recommended for resected high-risk utuc. Patients with metastasis-positive testicular cancer with residual tumour after systemic treatment should be treated at specialized centres. For all complex retroperitoneal surgeries, the evidence shows that higher-volume centres are associated with lower rates of procedure-related mortality, and patients should be referred to higher-volume centres for surgical resection.

Quality assessment of kidney cancer clinical practice guidelines using AGREE II instrument: A critical review

BACKGROUND

Evidence-based guidelines are expected to provide clinicians with explicit recommendations on how to manage health conditions and bridge the gap between research and clinical practice. However, the existing practice guidelines(CPGs) vary in quality. This study aimed to evaluate the quality of CPGs of kidney cancer.

METHODS

We systematically searched PubMed, Embase, China Biology Medicine disc, and relevant guideline websites from their inception to April, 2018. We identified CGPs that provided recommendations on kidney cancer; 4 independent reviewers assessed the eligible CGPs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. The consistency of evaluations was calculated using intraclass correlation coefficients (ICC).

RESULTS

A total of 13 kidney cancer CGPs were included. The mean scores for each AGREEII domain were as follows: scope and purpose-76.9%; clarity and presentation-76.4%; stakeholder involvement-62.8%; rigor of development-58.7%; editorial independence-53.7%; and applicability-49.4%. Two CPGs were rated as "recommended"; 8 as "recommended with modifications"; and 3 as "not recommended." Seven grading systems were used by kidney cancer CGPs to rate the level of evidence and the strength of recommendation.

CONCLUSIONS

Overall, the quality of CPGs of kidney cancer is suboptimal. AGREE II assessment results highlight the need to improve CPG development processes, editorial independence, and applicability in this field. It is necessary to develop a standardized grading system to provide clear information about the level of evidence and the strength of recommendation for future kidney cancer CGPs.

MicroRNA-375 inhibits the proliferation, migration and invasion of kidney cancer cells by triggering apoptosis and modulation of PDK1 expression

Kidney cancer is one of the deadly cancers and is the cause of significant number of deaths worldwide. The treatments used for the treatment of kidney cancer are limited and associated with number of side effects. Therefore, there is need for the development of new drug options or to identify novel therapeutic targets for the treatment of kidney cancer. In this study we investigated the potential of miR-375 as the therapeutic target for the treatment of Kidney cancer. The results revealed that miR-375 is significantly downregulated in the Kidney cancer cells. To investigate the role therapeutic potential of miR-375, one kidney cancer cell line (A-498) was selected for further experimentation. It was observed that overexpression of miR-375 inhibits A-498 kidney cancer proliferation by induction of apoptosis. In addition, overexpression of miR-375 causes suppression of migration and invasion of the A-498 kidney cancers cells. Bioinformatic analysis revealed PDK1 to be putative target of miR-375 in Kidney cancer cells. The western blot analysis revealed the expression of PDK1 to be significantly upregulated in Kidney cancer cells and overexpression of miR-375 in A-498 cells caused inhibition of PDK1 preventing the phosphorylation of AKT (Thr³⁰⁸ and Ser⁴⁷³). Additionally, inhibition of PDK1 had similar effects as that of miR-375 overexpression on cell proliferation of A-498 kidney cancer cells. The inhibition of miR-375 expression could not rescue the effects of PDK-1 suppression on A-498 cell proliferation. In contrary, overexpression of PKD1 in A-498 cells transfected with miR-375 mimics could nullify the effects of miR-375 on proliferation of the A-498 cells. Taken together, we conclude that miR-375 regulates cell proliferation, migration and invasion of A-498 kidney cancer cells and may prove to be an important therapeutic target.