Prognostic Factors and Survival of Renal Clear Cell Carcinoma Patients with Bone Metastases

A dynamic visualization clinical tool constructed and validated based on the SEER database for screening the optimal surgical candidates for bone metastasis in primary kidney cancer

The implementation of primary tumor resection (PTR) in the treatment of kidney cancer patients (KC) with bone metastases (BM) has been controversial. This study aims to construct the first tool that can accurately predict the likelihood of PTR benefit in KC patients with BM (KCBM) and select the optimal surgical candidates. This study acquired data on all patients diagnosed with KCBM during 2010-2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was utilized to achieve balanced matching of PTR and non-PTR groups to eliminate selection bias and confounding factors. The median overall survival (OS) of the non-PTR group was used as the threshold to categorize the PTR group into PTR-beneficial and PTR-Nonbeneficial subgroups. Kaplan-Meier (K-M) survival analysis was used for comparison of survival differences and median OS between groups. Risk factors associated with PTR-beneficial were identified using univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC), area under the curve (AUC), calibration curves, and decision curve analysis (DCA) were used to validate the predictive performance and clinical utility of the nomogram. Ultimately, 1963 KCBM patients meeting screening criteria were recruited. Of these, 962 patients received PTR and the remaining 1061 patients did not receive PTR. After 1:1 PSM, there were 308 patients in both PTR and non-PTR groups. The K-M survival analysis results showed noteworthy survival disparities between PTR and non-PTR groups, both before and after PSM (p < 0.001). In the logistic regression results of the PTR group, histological type, T/N stage and lung metastasis were shown to be independent risk factors associated with PTR-beneficial. The web-based nomogram allows clinicians to enter risk variables directly and quickly obtain PTR beneficial probabilities. The validation results showed the excellent predictive performance and clinical utility of the nomograms for accurate screening of optimal surgical candidates for KCBM. This study constructed an easy-to-use nomogram based on conventional clinicopathologic variables to accurately select the optimal surgical candidates for KCBM patients.

Surgical treatment for pelvic bone metastatic disease from renal cell carcinoma

INTRODUCTION

Pelvic bone metastases from renal cell carcinoma (RCC) are challenging due to their destructive pattern, poor response to radiotherapy and hypervascularity. The purpose of our study was to review a series of patients undergoing surgical treatment with the aim to investigate: 1) survival; 2) local disease control; and 3) complications.

METHODS

A series of 16 patients was reviewed. A curettage procedure was performed on 12 patients. In eight the lesion involved the acetabulum; a cemented hip arthroplasty with cage was performed in seven; a flail hip in one. Four patients received a resection; in two cases with acetabular involvement, reconstruction was performed with a custom-made prosthesis and with an allograft and prosthesis.

RESULTS

Disease-specific survival accounted for 70% at 3 years and 41% at 5 years. Only one local tumor progression after curettage occurred. Revision surgery (flail hip) was necessary for deep infection of the custom-made prosthesis.

CONCLUSION

A prolonged survival in patients affected by bone metastatic disease from RCC can justify also major surgical procedures. Due to a low local progression rate after intralesional procedures, curettage, cement and a total hip arthroplasty with cage, when feasible, should be considered as an alternative to more demanding surgeries like resections and reconstructions.

LEVEL OF EVIDENCE (OXFORD)

Level 4.

Outcomes of palliative surgery for bone metastasis of metastatic renal cell carcinoma in the era of targeted therapy

INTRODUCTION

The introduction of tyrosine kinase inhibitors has revolutionized treatment strategies for metastatic renal cell carcinoma (RCC) and has improved survival rates. The number of patients with bone metastases from RCC requiring surgery will increase as survival rates improve. However, there is insufficient evidence to standardize the treatment of bone metastases after the introduction of targeted therapy for metastatic RCC. We aimed to determine the outcomes of palliative surgical treatment of bone metastases in the extremities of patients with metastatic RCC.

MATERIALS AND METHODS

We retrospectively reviewed 26 lesions from 17 patients who underwent surgery for extremity and acetabular bone metastases and were treated with targeted therapies for advanced RCC between 2008 and 2020. The median follow-up duration was 19 months (range, 4-76). We assessed the patients' activities of daily living, quality of life, and pain and analyzed their postoperative values relative to preoperative values. Postoperative overall survival (OS), local progression-free survival (LPFS), and the factors affecting them were evaluated using the Kaplan-Meier method and log-rank test.

RESULTS

The 5-year OS and LPFS rates were 39.5% and 65.6%, respectively. The factors affecting OS were sex, Katagiri score, visceral metastases, and preoperative targeted therapy, while the factors affecting LPFS were pathologic fractures and surgical technique.

CONCLUSION

In this study, the postoperative outcomes of palliative surgery for bone metastases from metastatic RCC were good. We suggest that systemic treatment should be prioritized over local control for advanced bone metastasis in RCC and surgery before pathological fracture should be performed for local control.

Bone metastasis risk and prognosis assessment models for kidney cancer based on machine learning

Background

Bone metastasis is a common adverse event in kidney cancer, often resulting in poor survival. However, tools for predicting KCBM and assessing survival after KCBM have not performed well.

Methods

The study uses machine learning to build models for assessing kidney cancer bone metastasis risk, prognosis, and performance evaluation. We selected 71,414 kidney cancer patients from SEER database between 2010 and 2016. Additionally, 963 patients with kidney cancer from an independent medical center were chosen to validate the performance. In the next step, eight different machine learning methods were applied to develop KCBM diagnosis and prognosis models while the risk factors were identified from univariate and multivariate logistic regression and the prognosis factors were analyzed through Kaplan-Meier survival curve and Cox proportional hazards regression. The performance of the models was compared with current models, including the logistic regression model and the AJCC TNM staging model, applying receiver operating characteristics, decision curve analysis, and the calculation of accuracy and sensitivity in both internal and independent external cohorts.

Results

Our prognosis model achieved an AUC of 0.8269 (95%CI: 0.8083-0.8425) in the internal validation cohort and 0.9123 (95%CI: 0.8979-0.9261) in the external validation cohort. In addition, we tested the performance of the extreme gradient boosting model through decision curve analysis curve, Precision-Recall curve, and Brier score and two models exhibited excellent performance.

Conclusion

Our developed models can accurately predict the risk and prognosis of KCBM and contribute to helping improve decision-making.

Mid and long-term overall survival after carcinologic resections of thyroid cancer bone metastases

Background

Bone metastases in thyroid cancer impair the patient's quality of life and prognosis. Interestingly, wide margins resection as the surgical treatment of bone metastases might improve the overall survival (OS). Nonetheless, data are lacking regarding the potential benefits of this strategy.

Methods

In order to assess the OS of patients with thyroid cancer after a bone metastases carcinologic resection, a retrospective multicentric study was performed, evaluating the 1, 5, 10 and 15 years-OS along with the potential prognosis associated factors.

Results

40 patients have been included in this multicentric study, with a mean follow-up after surgery of 46.6 ± 58 months. We observed 25 (62.5%) unimestastatic patients and 15 multimetastatic patients (37.5%). The median overall survival after resection was 48 ± 57.3 months. OS at 1, 5, 10, and 15 years was respectively 76.2%, 63.6%, 63.6%, and 31.8%. Survival for patients with a single bone metastasis at 15 year was 82.3%, compared with 0.0% (Log Rank, p = 0.022) for multi-metastatic bone patients.

Conclusions

This study advocates for an increased long term 10-year OS in patients with thyroid cancer, after resection of a single bone metastasis, suggesting the benefits of this strategy in this population.

Risk Factors, Prognostic Factors, and Nomograms for Bone Metastasis in Patients with Newly Diagnosed Clear Cell Renal Cell Carcinoma: A Large Population-Based Study

Background

This study aimed to investigate risk factors and prognostic factors in patients with clear cell renal cell carcinoma (ccRCC) with bone metastasis (BM) and establish nomograms to provide a quantitative prediction of the risk of BM and survival probability.

Methods

The clinicopathological characteristics of patients with ccRCC between January 2010 and December 2015 were obtained from the Surveillance, Epidemiology and End Results (SEER) database. Independent factors for BM in ccRCC patients were identified using univariate and multivariate logistic regression analyses. Prognostic factors for predicting cancer-specific death were evaluated using univariate and multivariate analyses based on a competing risk regression model. We then constructed a diagnostic nomogram and a prognostic nomogram. The two nomograms were evaluated using calibration curves, receiver operating characteristic curves, and decision curve analysis.

Results

Our study included 34,659 patients diagnosed with ccRCC in the SEER database, with 1,415 patients who presented with bone metastasis. Risk factors for BM in patients with ccRCC included age, stage T, stage N, brain metastasis, liver metastasis, lung metastasis, tumor size, and laterality. Independent prognostic factors for patients with ccRCC patients with BM were Fuhrman grade, tumor size, T stage, N stage, brain metastases, lung metastasis, and surgery. For the diagnostic nomogram, the area under the curve values in the training and testing cohorts were 0.863 (95% CI, 0.851–0.875) and 0.859 (95% CI, 0.839–0.878), respectively. In the prognostic cohort, the area under the curve values for 1-, 2-, and 3-year cancer-specific survival rates in the training cohort were 0.747, 0.774, and 0.780, respectively, and 0.671, 0.706, and 0.696, respectively, in the testing cohort. Through calibration curves and decision curve analyses, the nomograms displayed excellent performance.

Conclusions

Several factors related to the development and prognosis of BM in patients with ccRCC were identified. The nomograms constructed in this study are expected to become effective and precise tools for clinicians to improve cancer management.

Surgical management of renal cancer metastasis in the humerus: novel use of a trabecular metal spacer

Humeral metastases from renal cell carcinoma are not uncommon. Current surgical practice centres around adequate tumour resection, but often at the expense of functional outcome. The use of trabecular metal (TM) implants is well described in spine and joint surgery. However, their use as a reconstruction device in osseous tumour surgery has yet to be reported. We present our experience in using a TM vertebral body replacement device (VBR) in treating a patient with painful bilateral diaphyseal humeral metastases. Resection of the tumour resulted in defects which the TM-VBR was able to fill. The defect was then bridged with a locking plate and cables. At 2-year clinical and radiographic review, bony integration and a return to pain free, near-normal function was achieved.

Imaging and its Impact on Defining the Oligometastatic State

Successful treatment of oligometastatic disease (OMD) is facilitated through timely detection and localization of disease, both at the time of initial diagnosis (synchronous OMD) and following the initial therapy (metachronous OMD). Hence, imaging plays an indispensable role in management of patients with OMD. However, the challenges and complexities of OMD management are also reflected in the imaging of this entity. While innovations and advances in imaging technology have made a tremendous impact in disease detection and management, there remain substantial and unaddressed challenges for earlier and more accurate establishment of OMD state. This review will provide an overview of the available imaging modalities and their inherent strengths and weaknesses, with a focus on their role and potential in detection and evaluation of OMD in different organ systems. Furthermore, we will review the role of imaging in evaluation of OMD for malignancies of various primary organs, such as the lung, prostate, colon/rectum, breast, kidney, as well as neuroendocrine tumors and gynecologic malignancies. We aim to provide a practical overview about the utilization of imaging for clinicians who play a role in the care of those with, or at risk for OMD.

Survival nomogram for patients with bone metastatic renal cell carcinoma: A population-based study

Purpose:

Increased attention has been focused on the survival of renal cell carcinoma (RCC) patients with bone metastasis. This study proposed to establish and evaluate a nomogram for predicting the overall survival (OS) and cancer-specific survival (CSS) of RCC patients with bone metastasis.

Materials and Methods:

RCC patients with bone metastasis between 2010 and 2015 were captured from the surveillance, epidemiology and end results (SEER) database. Univariate and multivariate cox regressions were performed to assess the effects of clinical variables on OS and CSS. The nomogram based on the Cox hazards regression model was developed. Concordance index (C-index) and calibration curve were performed to evaluate the accuracy of nomogram models, receiver operating characteristic (ROC) curves and decision curve analysis (DCA) were conducted to assess the predict performance.

Results:

A total of 2.471 eligible patients were enrolled in this study. The patients were assigned to primary (n=1.672) and validation (n=799) cohorts randomly. The 1-, 2-, and 3-year OS and CSS nomogram models were constructed based on age at diagnosis, sex, marital status, pathological grade, T-stage, N-stage, brain/liver/lung metastasis, surgery, radiotherapy and chemotherapy. The c for OS and CSS prediction was 0.730 (95% confidence interval [CI]: 0.719-0.741) and 0.714 (95%CI:0.702-0.726). The calibration curves showed significant agreement between nomogram models and actual observations. ROC and DCA indicated nomograms had better predict performance.

Conclusions:

The nomograms for predicting prognosis provided an accurate prediction of OS and CSS in RCC patients with bone metastasis, and contributed clinicians to optimize individualized treatment plans.

En bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases

PURPOSE

To evaluate the short-term clinical efficacy and complications of en bloc resection and intercalary prosthesis implantation for the treatment of humeral diaphyseal bone metastases.

METHODS

A total of 21 patients with humeral diaphyseal bone metastases treated with en bloc resection and intercalary prosthesis implantation from August 2014 to August 2019 were retrospectively analysed. The visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) scale, International Society of Limb Salvage (ISOLS) scoring system, Karnofsky Performance Status (KPS) scale, and Nottingham Health Profile (NHP) scale were used to assess pain, limb function, and quality of life. Survival of the patients was analysed using the Kaplan-Meier method.

RESULTS

The patients were followed up for 12-57 months (mean: 22 months); the operative time was 68-114 minutes (mean: 76.24 min); the osteotomy length was 6.5-10 cm (mean: 8.02 cm); and the intra-operative blood loss was 95-125 ml (mean: 104.71 ml). At three, six and 12 months after surgery, the VAS and NHP scores were lower, whereas the MSTS, ISOLS, and KPS scores were higher than those before surgery, and the differences were statistically significant (P < 0.05). The survival time was four to 24 months (mean: 19.46 months). Thesix month and one year survival rates were 80.95% and 52.38%, respectively. During the follow-up period, no complications occurred except for aseptic prosthesis loosening in one patient.

CONCLUSIONS

En bloc resection and intercalary prosthesis implantation can reduce pain, improve limb function, prolong survival time, and improve quality of life in patients with humeral diaphyseal bone metastases.

Personal Medicine and Bone Metastases: Biomarkers, Micro-RNAs and Bone Metastases

Bone metastasis is a major cause of morbidity within solid tumours of the breast, prostate, lung and kidney. Metastasis to the skeleton is associated with a wide range of complications including bone fractures, spinal cord compression, hypercalcaemia and increased bone pain. Improved treatments for bone metastasis, such as the use of anti-bone resorptive bisphosphonate agents, within post-menopausal women have improved disease-free survival; however, these treatments are not without side effects. There is thus a need for biomarkers, which will predict the risk of developing the spread to bone within these cancers. The application of molecular profiling techniques, together with animal model systems and engineered cell-lines has enabled the identification of a series of potential bone-metastasis biomarker molecules predictive of bone metastasis risk. Some of these biomarker candidates have been validated within patient-derived samples providing a step towards clinical utility. Recent developments in multiplex biomarker quantification now enable the simultaneous measurement of up to 96 micro-RNA/protein molecules in a spatially defined manner with single-cell resolution, thus enabling the characterisation of the key molecules active at the sites of pre-metastatic niche formation as well as tumour-stroma signalling. These technologies have considerable potential to inform biomarker discovery. Additionally, a potential future extension of these discoveries could also be the identification of novel drug targets within cancer spread to bone. This chapter summarises recent findings in biomarker discovery within the key bone metastatic cancers (breast, prostate, lung and renal cell carcinoma). Tissue-based and circulating blood-based biomarkers are discussed from the fields of genomics, epigenetic regulation (micro-RNAs) and protein/cell-signalling together with a discussion of the potential future development of these markers towards clinical development.

Establishment of predictive model for patients with kidney cancer bone metastasis: a study based on SEER database

Background

Bone is a common metastatic tissue of kidney cancer. Accurate prediction of the prognosis of patients with kidney cancer bone metastasis (KCBM) can help doctors and patients choose a further appropriate treatment.

Methods

During the period from January 1, 2010 to December 31, 2015, screening patients with kidney cancer diagnosed with bone metastases from the SEER database. Summary of demographic, pathology, number of other metastatic organs, and treatment for KCBM patients. All prognostic factors were plotted for Kaplan-Meier survival curves and log-rank test. Prognostic factors of P<0.001 in the log-rank test were chosen and used to establish nomograms of OS and KCSS. We used C-index, ROC curve, and calibration plot to test the prediction accuracy of two nomograms.

Results

A total of 4,234 KCBM patients were included in the study, and patients were diagnosed between January 1, 2010 and December 31, 2015. The model establishment group included 2,966 KCBM patients and the validation group included 1,268 KCBM patients. We have established nomograms for OS and KCSS respectively. These two nomograms included factors such as age, marital status, insurance status, histological type, grade, T stage, N stage, number of extra-bone metastatic organs, surgery, RT, and CT. The C-index of nomograms of OS and KCSS was 0.733 and 0.752, respectively. In all ROC curves, all AUC values were greater than 0.7, proving that the nomograms of both OS and KCSS have achieved medium prediction accuracy. The calibration plots of the model establishment group and the validation group showed good consistency between the predicted nomograms of OS and KCSS.

Conclusions

In this study, nomograms of OS and KCSS were established based on the published data of KCBM patients in the SEER database, and the model was validated internally and externally. The prediction accuracy of nomograms of OS and KCSS achieved satisfactory results. At present, this model has the ability to predict the prognosis of KCBM patients and can be used in clinical work.

Long-term patient survival after the surgical treatment of bone and soft-tissue metastases from renal cell carcinoma

Aims

The aims of this study were to evaluate the long-term outcome of surgery for bone or soft-tissue metastases from renal cell carcinoma (RCC) and to determine factors that affect prognosis.

Patients and Methods

Between 1993 and 2014, 58 patients underwent surgery for bone or soft-tissue metastases from RCC at our hospital. There were 46 men and 12 women with a mean age of 60 years (25 to 84). The mean follow-up period was 52 months (1 to 257). The surgical sites included the spine (33 patients), appendicular skeleton (ten patients), pelvis (eight patients), thorax (four patients), and soft tissue (three patients). The surgical procedures were en bloc metastasectomy in 46 patients (including 33 patients of total en bloc spondylectomy (TES)) and intralesional curettage in 12 patients. These patients were retrospectively evaluated for factors associated with prognosis.

Results

The one-, three-, five-, ten-, and 15-year overall survival (OS) rates were 89%, 75%, 62%, 48%, and 25%, respectively. The median survival time (MST) was 127 months for en bloc metastasectomy and 54 months for intralesional curettage and bone grafting. The median survival time was 127 months for the spine, 140 months for lesions of the appendicular skeleton, and 54 months for the pelvis. Multivariate analysis showed that non-clear cell type RCC and metastases to more than two sites were independent risk factors for a poor prognosis.

Conclusion

Patients with bone or soft-tissue metastases from a RCC have a reasonable prognosis, making surgical resection a viable option even in patients in whom the metastases are advanced. Cite this article: Bone Joint J 2018;100-B:1241-8.

Humeral metastasis of renal cancer: Surgical options and review of literature

INTRODUCTION

The humerus is the second most common long bone site of metastatic disease from renal cell carcinomas (RCC) after femur. Surgery has an important role in the treatment of these lesions due to renal cell tumor's resistance to chemotherapy and radiotherapy.

HYPOTHESIS

Prosthetic replacement is an effective and safe solution in treatment of renal humeral metastasis.

MATERIAL AND METHODS

Fifty-six patients affected by RCC bone metastases of the humerus that underwent a surgical reconstruction were rewised. Thirty-five lesions were localized on proximal third, 12 on the shaft, 9 on distal third. Among proximal 29 were treated with resection and endoprosthetic replacement and 6 with plate and cement. Six diaphyseal lesions were stabilized with intramedullary nailing, 5 with plate and cement and 1 with an intercalary prosthesis. Regarding distal lesions, 7 elbow prostheses and 2 plates and cement were used.

RESULTS

The average age was 63years. Metastasis was single in 55% of cases, and in 45% metachronous. A pathologic fracture (PF) occurred in 64% of cases. Only 9% of patients had a mechanical complication, 7% an infection and 5% neurological deficit. A local recurrence occurred in 14% of patients. An implant failure has been observed in 10 patients, 5 for mechanical complications, 2 for infections and 3 for local recurrence; of these 7 were treated with a prosthesis and 3 with plate and cement. The mean value of MSTS score was 64%, 63% and 59% respectively in patients with proximal, diaphyseal and distal humerus metastases.

DISCUSSION

Solitary and metachronous bone metastases have a longer survival. Disease-free interval>2years is another important prognostic factor. Reconstruction with a modular prosthesis is recommended in proximal and distal third. Instead in diaphyseal lesions a closed reduction and fixation with intramedullary locked nailing are preferred. When surgical indications are correctly followed, good oncologic and functional outcomes are obtained, leading to markedly improvement of patients' quality of life.

RETROSPECTIVE STUDY

Level of evidence: IV.

Skeletal metastasis in renal cell carcinoma: A review

Background

Renal cell carcinoma account for 3% of all cancers, with peak incidence between 60 and 70 years of age predominantly affecting male population. Renal carcinoma is the most common malignancy of kidney constitutes for 80–90% of renal neoplasm with an overall 45% five years survival rate. Majority are diagnosed incidentally during investigation for other disease process of abdomen. Classical triad of gross hematuria, pain and palpable mass in abdomen is rare accounting to only 6–10%. Treatment of early stages of disease i.e. localized disease is partial or radical nephrectomy. Most common metastasis in RCC occurs to lung, followed by bone involvement in 20–35%, lymph nodes, liver, adrenal gland and brain. In metastatic disease median survival rate of patient is about eight months with 50% mortality rate within first year of life, five years survival rate is 10%. Skeletal metastasis are very destructive in patients with renal cell carcinoma compromising bone integrity leading to skeletal related events including pains, impending fractures, nerve compressions, hypercalcemia and even pathological fractures which may require surgical interventions and other therapy. In addition to skeletal complications, presence of bone metastases in RCC has negative impact on progression free survival and overall survival of patients treated with systemic therapies.

Objective

In this review we discuss pathophysiology of tumor metastasis, diagnosis, management and Case examples of metastatic renal cell carcinoma.

Conclusion

Incidence of metastatic renal carcinoma is increasing. Overall prognosis of patient with advanced RCC is poor, emphasizing the importance of early detection and prompt treatment of primary lesion in its early stage. Advancement in targeted therapy in recent decades had made some improvement in treatment of SREs and has helped in improving patent's quality of life but still we are in need of further improvement in treatment modalities to cure disease thereby decreasing morbidity and mortality.

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Renal cell carcinoma account for 3% of all cancers.

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It is a very destructive that may compromise bone integrity.

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Most common metastasis in renal cell carcinoma occurs to lung, followed by bone , lymph nodes, liver, adrenal gland and brain.

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Most common metastasis in renal cell carcinoma occurs to lung, followed by bone involvement in 20–35%, lymph nodes, liver, adrenal gland and brain.

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In metastatic disease median survival rate of patient is about eight months with 50% mortality rate within first year of life, five years survival rate is 10.

Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma

INTRODUCTION

Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.

Opposite prognostic roles of HIF1α and HIF2α expressions in bone metastatic clear cell renal cell cancer

BACKGROUND

Prognostic markers of bone metastatic clear cell renal cell cancer (ccRCC) are poorly established. We tested prognostic value of HIF1α/HIF2α and their selected target genes in primary tumors and corresponding bone metastases.

RESULTS

Expression of HIF2α was lower in mRCC both at mRNA and protein levels (p/mRNA/=0.011, p/protein/=0.001) while HIF1α was similar to nmRCC. At the protein level, CAIX, GAPDH and GLUT1 were increased in mRCC. In all primary RCCs, low HIF2α and high HIF1α as well as CAIX, GAPDH and GLUT1 expressions correlated with adverse prognosis, while VEGFR2 and EPOR gene expressions were associated with favorable prognosis. Multivariate analysis confirmed high HIF2α protein expression as an independent risk factor. Prognostic validation of HIFs, LDH, EPOR and VEGFR2 in RNA-Seq data confirmed higher HIF1α gene expression in primary RCC as an adverse (p=0.07), whereas higher HIF2α and VEGFR2 expressions as favorable prognostic factors. HIF1α/HIF2α-index (HIF-index) proved to be an independent prognostic factor in both the discovery and the TCGA cohort.

PATIENTS AND METHODS

Expressions of HIF1α and HIF2α as well as their 7 target genes were analysed on the mRNA and protein level in 59 non-metastatic ccRCCs (nmRCC), 40 bone metastatic primary ccRCCs (mRCC) and 55 corresponding bone metastases. Results were validated in 399 ccRCCs from the TCGA project.

CONCLUSIONS

We identified HIF2α protein as an independent marker of the metastatic potential of ccRCC, however, unlike HIF1α, increased HIF2α expression is a favorable prognostic factor. The HIF-index incorporated these two markers into a strong prognostic biomarker of ccRCC.

Diagnostic algorithm, prognostic factors and surgical treatment of metastatic cancer diseases of the long bones and spine

Oncological management of skeletal metastases has changed dramatically in the last few decades. A significant number of patients survive for many years with their metastases.

Surgeons are more active and the technical repertoire is broader, from plates to intramedullary devices to (tumour) endoprostheses.

The philosophy of treatment should be different in the case of a trauma-related fracture and a pathological fracture. A proper algorithm for establishing a diagnosis and evaluation of prognostic factors helps in planning the surgical intervention.

The aim of palliative surgery is usually to eliminate pain and to allow the patient to regain his/her mobility as well as to improve the quality of life through minimally invasive techniques using life-long durable devices.

In a selected group of patients with an oncologically controlled primary tumour site and a solitary bone metastasis with positive prognostic factors, which meet the criteria for radical excision (approximately 10% to 15% of the cases), a promising three to five years of survival may be achieved, especially in cases of metastases from breast and kidney cancer.

Spinal metastases require meticulous evaluation because decisions on treatment mostly depend on the tumour type, segmental stability, the patient’s symptoms and general state of health.

Advanced radiotherapy combined with minimally invasive surgical techniques (minimally invasive stabilisation and separation surgery) provides durable local control with a low complication rate in a number of patients.

Cite this article: EFORT Open Rev 2017;2:372-381.

Relationship between LINC00341 expression and cancer prognosis

LINC00341 is a novel long intergenic non-protein coding RNA with unknown functions. In our report, we investigated LINC00341 expression and its prognostic value in cancer patients. DNA over-methylation triggered low expression of LINC00341 and that was associated with poor prognosis in cancers. A meta-analysis further confirmed that high expression of LINC00341 was associated with a better prognosis in cancer patients. Both gene set enrichment analysis and meta-analysis showed that LINC00341 inhibited cancer metastasis. Finally, a large-scale multicentre analysis supported a prognostic value of LINC00341 in cancers.

Metastatic bone disease: A review of survival, prognostic factors and outcomes following surgical treatment of the appendicular skeleton

Survival data and prognostic factors may help to provide insight when deciding on the appropriate orthopaedic treatment for patients presenting with metastatic bone disease. This review was conducted to look at the outcomes following orthopaedic surgery for metastatic lesions in the extremities. The literature was identified through the Medline and Embase database and further refined via a set of inclusion and exclusion criteria. Overall, patients presenting with metastatic bone disease from renal cell cancer or breast cancer had the longest survival rate. Important factors found to predict prognosis was the presence of visceral metastasis, multiple metastases, pathological fracture and the type of primary tumour involved. These prognostic factors may help to direct future inquiry into metastatic bone disease and help determine the type of surgery to use in a metastatic setting in order to avoid complications and unnecessary revisions as well as provide durability.

Extracranial oligometastatic renal cell carcinoma: current management and future directions

The term 'oligometastases' was formulated to describe an intermediate state between widespread metastases and locally confined disease. The standard of care in metastatic renal cell carcinoma is systemic therapy; however, in patients with solitary or limited metastases, aggressive local therapies may potentially prolong survival. The literature suggests a survival benefit with surgical metastasectomy, with a reported 5-year survival as high as 45% in those who achieve complete resection. More recently, an expanding body of evidence supports the role of stereotactic ablative body radiation therapy for the treatment of oligometastatic renal cell carcinoma and early results demonstrate comparable local control rates with surgery. There is also increasing interest in the abscopal and immunologic effects of localized radiation. With the proliferation of newer targeted agents and immunomodulatory agents, current work is addressing the optimization of patient selection and avenues towards sequencing and combining the various treatment options.

Natural history of malignant bone disease in renal cancer: final results of an Italian bone metastasis survey

Background

Bone metastasis represents an increasing clinical problem in advanced renal cell carcinoma (RCC) as disease-related survival improves. There are few data on the natural history of bone disease in RCC.

Patients and methods

Data on clinicopathology, survival, skeletal-related events (SREs), and bone-directed therapies for 398 deceased RCC patients (286 male, 112 female) with evidence of bone metastasis were statistically analyzed.

Results

Median time to bone metastasis was 25 months for patients without bone metastasis at diagnosis. Median time to diagnosis of bone metastasis by MSKCC risk was 24 months for good, 5 months for intermediate, and 0 months for poor risk. Median number of SREs/patient was one, and 71% of patients experienced at least one SRE. Median times to first, second, and third SRE were 2, 5, and 12 months, respectively. Median survival was 12 months after bone metastasis diagnosis and 10 months after first SRE. Among 181 patients who received zoledronic acid (ZOL), median time to first SRE was significantly prolonged versus control (n = 186) (3 months vs 1 month for control; P<0.05).

Conclusions

RCC patients with bone metastasis are at continuous risk of SREs, and in this survey ZOL effectively reduced this risk.

Renal carcinoma relapse presenting as a peripheral nerve sheath tumor: A case report and brief review of the literature

We report a rare case of renal carcinoma metastasis involving a lumbar nerve root. Metastases to nerve roots are rare occurrences, and to our knowledge, only six cases have been reported so far in the literature. The patient in this report presented with weakness in the right lower limb and intractable pain irradiating along the L5 dermatome. MRI findings revealed a right-sided L5 nerve root mass, suggestive of a schwannoma, involving the spinal ganglion and its extraforaminal region. Complete macroscopic resection of this mass was performed, and histopathologic analysis confirmed the lesion to be a metastasis of a renal clear cell carcinoma. Local radiotherapy was given and tyrosine kinase inhibitors administered. At 5 months, the patient was pain-free and his right limb weakness had completely resolved. A tumoral recurrence could be observed on the control MRI 5 months after surgery. This report presents the first case of a patient with a renal clear cell carcinoma metastasis to a L5 nerve root, as well as a brief review of previous cases of metastases to peripheral nerve roots.

Skeletal metastasis in renal cell carcinoma: current and future management options

Metastasis to the skeleton is common in advanced renal cancer and leads to debilitating skeletal complications including severe pain, increased fracture rate and spinal cord compression. The incidence of renal cell carcinoma is increasing by around 2% per year and recent advances in targeted anti-angiogenic therapy for advanced disease are expected to lead to longer survival times. The clinical management of metastatic bone disease in renal cell carcinoma therefore merits greater focus than hitherto. Bone metastases arising from renal cancer are highly osteolytic and particularly destructive. Fortunately, the continuing development of anti-resorptive drugs is revolutionising the medical management of metastatic bone disease across many tumour types and making a major impact on quality of life. The bisphosphonate zoledronic acid is now licensed for use in advanced renal cell carcinoma and appears to yield a greater benefit in terms of reduction in skeletal related events than in bone metastases arising from other tumour types. Drugs which are directed at specific targets in the bone metastasis pathway are in development, including denosumab, a fully human monoclonal antibody against receptor activator of nuclear factor kappa B ligand, which has recently been licensed in the United States for use in renal cell carcinoma, with European licensing expected soon. This review examines the increasing options for treatment of metastatic bone disease in renal cell carcinoma, with a focus on drug-based advances and progress in the development of existing and new biomarkers to support clinical management.

Skeletal complications and survival in renal cancer patients with bone metastases

Skeletal metastases occur in around one third of patients with advanced or metastatic renal cell carcinoma (RCC). Skeletal involvement is commonly an aggressive, lytic process which causes substantial morbidity through skeletal complications and occurrence of skeletal related events (SREs). However, compared with bone metastases in breast and prostate cancer, there is a paucity of data relating to the demographics of bone metastases in RCC and their sequelae in terms of SREs and survival. The study population included all patients (N=803) with advanced or metastatic RCC treated in a tertiary centre serving a regional population of 2.6 million between 1998 and 2007. Demographic and survival data and information relating to metastatic disease were extracted from electronic records. Thirty-two percent (N=254) of the study population presented with (N=131) or later developed (N=123) bone metastases and 83% of these (N=210) also developed metastases elsewhere. The mean number of SREs experienced by the bone metastatic patients over the course of their disease was 2.4 and only 37 patients experienced no SRE. A high proportion of patients (80%) received radiotherapy for bone pain and there was a surprising and strikingly high incidence of spinal cord/nerve root compression, which was experienced by 28% patients. Although bisphosphonate use increased following the availability of zoledronic acid in 2004, approximately 50% patients with bone metastases did not receive bisphosphonate treatment. The skeletal morbidity rate (number of SREs per patient years at risk) was 1.0 and 1.4 for patients who received or did not receive bisphosphonates, respectively. The median survival following diagnosis of RCC was similar in patients who developed bone metastases (20.4 months) and those who did not (20.9 months). Median survival from diagnosis of metastases was 13.3 months for those who never developed bone metastases, 10.6 months for those who presented with them, 19.6 months for those who developed them later and 22.6 months for patients who had bone only metastases. This is the largest study to date focusing specifically on skeletal complications in RCC. A striking finding was the high incidence of spinal cord/nerve root compression and more research into this area is needed. Clearer, internationally accepted guidelines are recommended for the management of this patient group.