Prognostic Value of Body Mass Index According to Histologic Subtype in Nonmetastatic Renal Cell Carcinoma: A Large Cohort Analysis

Unraveling the BMI paradox in different renal cortical tumors: insights from the INMARC registry

OBJECTIVE

To investigate impact of body mass index (BMI) on survival across different histologies and stages of renal cell carcinoma (RCC).

METHODS

We conducted a retrospective multicenter analysis of clear cell (ccRCC) and non-ccRCC. Obesity was defined according to the WHO criteria (non-Asian BMI >30 Kg/m2, Asian BMI >27.5 Kg/m2). Multivariable analysis (MVA) via Cox regression model was conducted for all-cause (ACM), cancer-specific mortality (CSM) and recurrence.

RESULTS

A total of 3,880 patients with a median follow-up of 31 (IQR 9-64) months were analyzed. Overall, 1,373 (35.3%) were obese; 2,895 (74.6%) were ccRCC and 985 (25.3%) were non-ccRCC (chRCC 246 [24.9%], pRCC 469 [47.6%] and vhRCC 270 [27.4%]). MVA in ccRCC revealed obesity associated with decreased risk of ACM, CSM and recurrence (hazard ratio [HR] 0.80, P = 0.044; HR 0.71, P = 0.039; HR 0.73, P = 0.012, respectively), while in non-ccRCC was not associated with decreased risk of ACM, CSM, and recurrence (P = 0.84, P = 0.53, P = 0.84, respectively). Subset analysis in stage IV ccRCC demonstrated obesity as associated with a decreased risk of ACM, CSM, and recurrence (HR 0.68, P = 0.04; HR 0.59, P = 0.01; HR 0.59, P = 0.01, respectively), while in stage I-III ccRCC was not (P = 0.21; P = 0.30; P = 0.19, respectively).

CONCLUSION

Our findings refute a broad "obesity paradox" for RCC. Obesity was not associated with improved survival in non-ccRCC and in nonmetastatic ccRCC, while metastatic ccRCC patients with obesity had improved survival outcomes.

Markers of local kidney cancer recurrence: A surgeon's mistake or a pattern? Review

The influence of various morphological, anatomical, genetic and other factors on the local recurrence-free survival of patients who have undergone different renal cell cancer (RCC) treatment is still a rather complex, ambiguous and controversial issue for practicing oncourologists. This review evaluates the effect of several factors on both recurrence-free survival and local recurrence-free survival. The review includes articles, clinical cases, literature reviews, and meta-analyses highlighting the analysis of independent and interrelated predisposing factors for developing local recurrence of RCC from 1984 to 2020. The PubMed, Web of Science, and Scopus databases were searched in English, Spanish, and German. A review of the literature showed the role of the following indices in the local recurrence RCC: microvascular invasion (p = 0.001), tumor necrosis (p = 0.0001), high malignancy (Fuhrman III or IV) (HR = 38.3, 95% CI 3.1-467, p = 0.004) as histological factors, tumor size as an anatomical factor. Thus, the authors state that every centimeter of the tumor increases the risk of local recurrence (p < 0.05). A group from the Mayo Clinic showed the equivalence of different treatment methods in local RCC recurrence. Thus, in the group of patients with cT1a stage kidney cancer, the 5-year local recurrence-free survival rates were 97.7% (96.7-98.6), 95.9% (92.3-99.6), and 95.9% (92.3-99.6) for renal resection, RFA, and cryoablation, respectively. Surgical margin status is the most studied and controversial marker of local renal cell carcinoma recurrence. Researchers found a direct effect of PSM on the risk of local RCC recurrence (p < 0.01). The personalized approach with the search and evaluation of predisposing factors for the local recurrence, as well as further selection of the most optimal treatment, will allow oncourologists to improve both the effectiveness of primary treatment and the recurrence-free survival of patients.

The Combination of Low Skeletal Muscle Mass and High Tumor Interleukin-6 Associates with Decreased Survival in Clear Cell Renal Cell Carcinoma

Clear cell renal carcinoma (ccRCC) is frequently associated with cachexia which is itself associated with decreased survival and quality of life. We examined relationships among body phenotype, tumor gene expression, and survival. Demographic, clinical, computed tomography (CT) scans and tumor RNASeq for 217 ccRCC patients were acquired from the Cancer Imaging Archive and The Cancer Genome Atlas (TCGA). Skeletal muscle and fat masses measured from CT scans and tumor cytokine gene expression were compared with survival by univariate and multivariate analysis. Patients in the lowest skeletal muscle mass (SKM) quartile had significantly shorter overall survival versus the top three SKM quartiles. Patients who fell into the lowest quartiles for visceral adipose mass (VAT) and subcutaneous adipose mass (SCAT) also demonstrated significantly shorter overall survival. Multiple tumor cytokines correlated with mortality, most strongly interleukin-6 (IL-6); high IL-6 expression was associated with significantly decreased survival. The combination of low SKM/high IL-6 was associated with significantly lower overall survival compared to high SKM/low IL-6 expression (26.1 months vs. not reached; p < 0.001) and an increased risk of mortality (HR = 5.95; 95% CI = 2.86–12.38). In conclusion, tumor cytokine expression, body composition, and survival are closely related, with low SKM/high IL-6 expression portending worse prognosis in ccRCC.

Prognostic Implication of Body Mass Index on Survival Outcomes in Surgically Treated Nonmetastatic Renal Cell Carcinoma: A Single-Institutional Retrospective Analysis of a Large Cohort

PURPOSE

Obesity is a well-known risk factor for renal cell carcinoma (RCC). However, the prognostic role of obesity in RCC has not been clearly established thus far. We aim to assess the effect of preoperative body mass index (BMI) on survival outcomes in nonmetastatic RCC patients.

PATIENTS AND METHODS

We retrospectively analyzed data on 2329 patients who underwent curative surgery for RCC between 2000 and 2014 in a single institution. Patients were divided into normal (< 23 kg/m²), overweight (23-24.9 kg/m²), and obese (≥ 25 kg/m²) groups depending on cutoffs for Asian population. Kaplan-Meier analysis with log-rank test was used to estimate and compare survival outcomes, including recurrence-free, overall, and cancer-specific survival, among each BMI group. The influence of BMI on each survival outcome was evaluated using multivariate Cox regression analyses.

RESULTS

Obese patients presented favorable 5-year recurrent-free (90.7% vs 84.9%, p < 0.001), overall (91.8% vs 86.8%, p = 0.002), and cancer-specific (94.8% vs 89.4%, p = 0.002) survival rates than the normal group. Multivariate analyses revealed that increasing BMI was an independent predictor of favorable survival outcomes (all p values < 0.05). In particular, overweight (p = 0.009) and obese (p = 0.009) patients showed better cancer-specific survival compared with normal patients.

CONCLUSIONS

Our data suggest that overweight and obesity defined based on BMI are generally related to favorable survival outcomes after surgery for RCC. Additional basic research is required to find out the biological mechanisms explaining the correlation between BMI and survival outcomes.

Lifestyle in urology: Cancer

The opportunity to prevent, to improve their prognosis, or even to cure uro-oncological diseases by modifying the lifestyle habits is a very modern topical subject and represents a great and fascinating challenge for the future. A PubMed and Web of Science databases search has been performed to review the published knowledge on most important lifestyle habits, such as smoking, physical activity, nutrition, sexual activity, and personal hygiene, highlighting modifiable factors influencing development and progression of urological cancers. Cigarette smoking has been historically established as risk factors for urothelial cancer, and an association with risk of renal cell carcinoma and worse prognosis of prostate cancer has been sufficiently demonstrated. Poor genital hygiene is a recognized risk factor for penile cancer. Furthermore, a convincing evidence has been found on the association between physical activity and both risk and prognosis of bladder and prostate cancer. Obesity is strongly associated with increased risk of developing lethal prostate cancer. An unequivocal evidence of a direct relationship between most of the other lifestyle habits and development of the uro-oncological diseases has not been found.

Prognostic biomarkers in renal cell carcinoma: is there a relationship with obesity?

Obesity is a recognized risk factor for renal cell carcinoma (RCC) the commonest form of kidney cancer. Both obesity and RCC are serious diseases with increasing incidence yearly. This review examined certain obesity associated measurements and adipokines as detection/prognostic indicators for RCC. The obesity related measurements such as body mass index (BMI), waist circumstance (WC), waist-hip ratio (WHR) in predicting RCC are valid when used in conjunction with other risk factors such as age and sex or with histological findings. The adipokine adiponectin holds promising outcomes as a predictive marker in assessing the risk of developing RCC. In addition, tissue leptin/leptin receptor may be a distinguishing marker for RCC subtypes. However, circulating leptin may not be a suitable detection or prognostic biomarker for RCC. The other less investigated adipokines; omentin, visfatin, apelin and resistin are also expressed in RCC but their prognostic capabilities are still inconclusive. BMI, WC and adipokines may be useful additions in a nomogram which includes TNM staging and pathological grading system to detect, confirm and follow-up RCC cases.

Age-dependent prognostic value of body mass index for non-metastatic clear cell renal cell carcinoma: A large multicenter retrospective analysis

BACKGROUND AND OBJECTIVES

The prognostic value of obesity is unestablished for renal cell carcinoma. We assessed the age-dependent prognostic value of body mass index (BMI) in a large multicenter cohort of patients with non-metastatic clear cell renal cell carcinoma (nm-cRCC).

METHODS

This study evaluated 2092 patients with nm-cRCC who underwent surgery with curative intent at five Korean institutions between 2001 and 2014.

RESULTS

There was no significant difference in BMI between the young (<45 years) and older patients (≥45 years) (P = 0.398). Among older patients, high BMI (≥25 kg/m² ) was associated with better 5-year rates of recurrence-free survival (RFS) and cancer-specific survival (CSS) (P = 0.003 and 0.004, respectively), and multivariate analysis confirmed that high BMI was independently associated with better RFS and CSS (RFS hazard ratio [HR]: 0.617, P = 0.005; CSS HR: 0.588, P = 0.024). However, among young patients, there were no significant BMI-related differences in the 5-year RFS and CSS rates (P = 0.457 and 0.420, respectively), and high BMI was not independently associated with RFS or CSS (P = 0.822 and 0.749, respectively).

CONCLUSIONS

Among patients with nm-cRCC, high BMI was associated with a favorable prognosis among older patients but not among young patients. Therefore, the relationship between obesity and nm-cRCC prognosis might vary according to age.

Excessive Pretreatment Weight Loss Is a Risk Factor for the Survival Outcome of Esophageal Carcinoma Patients Undergoing Radical Surgery and Postoperative Adjuvant Chemotherapy

BACKGROUND

The prognostic values of weight loss and body mass index (BMI) in esophageal carcinoma remain controversial. This study aimed to evaluate the impacts of weight loss on the survival of patients undergoing radical surgery and adjuvant chemotherapy.

METHODS

The medical records of 189 consecutive patients with nonmetastatic esophageal carcinoma treated in our hospital between January 2012 and December 2013 were reviewed, and 121 patients were included for analysis.

RESULTS

Kaplan-Meier analysis revealed that the 3-year overall survival rate was significantly higher in the low pretreatment weight loss (pre-LWL) group than in the high pretreatment weight loss (pre-HWL) group (P < 0.001). In addition, the 3-year overall survival rate of normal weight group was higher than that of overweight and underweight groups (P = 0.007). Multivariate Cox proportional hazards analysis showed that pre-LWL group had a significantly better 3-year overall survival than pre-HWL group (P = 0.027, HR = 1.89, and 95% CI = 1.07-3.32). pN stage and age were also the survival prognostic factors.

CONCLUSIONS

Our study showed that low pretreatment weight loss predicted a better survival outcome in the esophageal carcinoma patients with radical surgery and adjuvant chemotherapy. However, BMI and weight loss during treatment had no impact on the survival outcome.

Association of body mass index with mortality and postoperative survival in renal cell cancer patients, a meta-analysis

Obesity is one of the major risk factors of cancer. However, how body mass index (BMI) influences the prognosis of renal cell cancer (RCC) patient is unclear. In this work, we have performed a meta-analysis to elucidate the role of abnormal weight in RCC mortality and postoperative survival. Articles related to BMI and RCC mortality as well as postoperative survival has been identified by searching PUBMED and ENBASE. Totally, 19 articles have been selected for this meta-analysis, 5 articles for RCC mortality and 14 for postoperative survival. Compared to normal weight, the estimated relative risks of RCC mortality are 0.71 (95% CI: 0.34–1.49), 1.19 (95% CI: 1.05–1.35) and 1.71 (95% CI: 1.27–2.00) respectively for the underweight, overweight and obesity patients. The risk of RCC mortality increase 5% for each 1 kg/m² increment of BMI. However, the estimated hazard ratios of cancer specific postoperative survival are 2.62 (95% CI: 1.67–4.11), 0.72 (95% CI: 0.63–0.83) and 0.66 (95% CI: 0.49–0.89) respectively for underweight, overweight and obesity RCC patients. The risk of hazard ratio decrease 5% for each 1 kg/m² increment of BMI. In addition, the hazard ratios of postoperative overall survival show a similar tendency. These results indicate an opposite association of BMI with mortality and postoperative survival in renal cell cancer patients.

Diet, Physical Activity, and Body Weight in Cancer Survivorship

Diet, physical activity, and body weight have been shown to play an important role in cancer survivorship. The impact of each of these lifestyle factors differs slightly among cancer types, and adherence to recommended diet and physical activity guidelines has been associated with positive outcomes, including decrease in the risk of cancer recurrence and improvement of quality of life. Although there are compelling data that appropriate diet, physical activity, and body weight have beneficial effects in cancer survivorship, additional trials are needed to understand the relationship.

Sex-Specific Prognostic Significance of Obesity in Nonmetastatic Clear-Cell Renal-Cell Carcinoma in Korea: A Large Multicenter Cohort Analysis

INTRODUCTION

We assessed the prognostic significance of obesity in relation to sex in patients with nonmetastatic clear-cell renal-cell carcinoma (nm-cRCC) in a large multicenter setting in Korea.

PATIENTS AND METHODS

A total of 2097 patients with nm-cRCC who underwent surgery with curative intent were enrolled from 6 institutions in Korea between April 2000 and February 2014. Obesity was determined by body mass index (BMI) before surgery. BMI was used as a continuous variable and was categorized as normal (≥ 18.5 to < 25.0 kg/m2, normal BMI) and overweight or obese (≥ 25 kg/m2, high BMI). The relationships between BMI, sex, recurrence-free survival (RFS), and cancer-specific survival (CSS) were evaluated.

RESULTS

Male patients had a greater high BMI ratio than female patients (P = .030). In men, the 5-year RFS and CSS rates in the high BMI group were greater than those in the normal BMI group (P = .003 and .006, respectively). Multivariate analyses revealed that in men, a high BMI was associated with greater RFS or CSS rates (hazard ratio: RFS, 0.901, P = .001; CSS, 0.822, P < .001). In women, there were no significant differences in the 5-year RFS and CSS rates according to BMI (P = .531 and .323, respectively), and high BMI was not associated with RFS or CSS (P = .250 and .180, respectively).

CONCLUSION

In patients with nm-cRCC, obesity was a favorable prognosticator in male but not female patients. Therefore, the association between obesity and nm-cRCC prognosis might differ by sex.

Obesity and Other Cancers

Purpose

Evidence on overweight, obesity, and an increased risk of cancer continues to accumulate and was updated in the 2016 handbook on weight control from the International Agency for Research on Cancer (IARC). The underlying primary data, together with dose-response meta-analysis and, finally, pooled analysis of individual participant data, add insight into the relation between obesity and cancer risk and prognosis. We summarize the evidence for mortality from prostate cancer, hematologic malignancies, and kidney cancer.

Methods

We reviewed pooled analysis of rare end points across cohorts, regardless of primary results reported from the individual studies, further reducing risk of publication bias. Of these cancer sites, only kidney cancer was included in the IARC 2002 report, although mortality from prostate cancer and hematologic malignancies was noted in the American Cancer Society prospective cohort study in 2003. The 2016 update from the IARC added details for prostate and hematologic malignancies, classifying the evidence as sufficient to conclude that avoiding excess body fatness lowers the risk of multiple myeloma but found that the evidence for it lowering the risk of prostate cancer mortality or diffuse large B-cell lymphoma was limited.

Results

A higher body mass index is associated with an increased risk of advanced prostate cancer and prostate cancer mortality and is associated with worse survival in most subtypes of hematologic malignancies, in a dose-response fashion. Evidence for kidney cancer is built mostly on retrospective data, which supports an obesity paradox in patients with the clear cell variant; however, population-based cohort data indicate that a higher cohort-entry body mass index is associated with worse kidney cancer–specific survival.

Conclusion

Together, these data add support to the evidence for a growing cancer burden caused by adiposity in both early adult and later adult life, yet leave open the question of the means of weight management after diagnosis as a strategy to improve survival.

Obesity and Kidney Cancer

Renal cell cancer (RCC) is the major type of kidney cancer with increasing incidence. Obesity is one of the well-established risk factors for RCC. Meta-analyses including multiple cohort and case-control studies have found a consistent positive association between obesity and RCC. The association appeared to be independent of other RCC risk factors including hypertension and has been often stronger in women, although a positive association has also been observed in men. Obesity has been largely measured as body mass index (BMI). Studies which evaluated other measures of obesity including waist circumference (WC), waist-to-hip ratio (WHR) as well as increase in weight have reported similar positive associations with RCC. Although the mechanisms by which obesity influences renal carcinogenesis have been under-explored, insulin resistance and certain growth factors including insulin-like growth factor (IGF-1), sex steroid hormones, and biochemical markers such as adiponectin may be involved. The positive association with obesity has been observed with the clear cell type of RCC, which is the major histological subtype. On the other hand, the association between obesity and RCC survival appears to be much more complex. An apparent inverse association between obesity at time of diagnosis and RCC survival has been observed in some studies' generating speculation of an "obesity paradox" hypothesis. However, this "paradox" may be due to reverse causation, selection bias, or other forms of bias rather than a true biological association.

Visceral adipose tissue is prognostic for survival of diffuse large B cell lymphoma treated with frontline R-CHOP

The potential role of visceral adipose tissue (VAT) as a prognostic factor in patients with diffuse large B cell lymphoma (DLBCL) treated with frontline rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) immunochemotherapy was explored. Total adipose tissue and VAT were measured by analyzing positron emission tomography (PET)/computed tomography (CT) images obtained during the initial staging of patients with DLBCL. The VAT ratio was calculated as follows: VAT ratio = VAT area/total adipose tissue area. Body mass index (BMI), sex, and International Prognostic Index (IPI) were also incorporated as co-variates in the final model of multivariate Cox regression analysis for survival. A total of 156 patients with DLBCL, who were treated with frontline R-CHOP, were enrolled in our study. The median patient age was 61 years, and 81 patients were male (51.9 %). The median cycle of R-CHOP was six. The IPI risk group was a strong prognostic factor for progression-free survival (PFS) and overall survival (OS) (p < 0.001). Obese BMIs were an independent prognostic factor for PFS, but not for OS in multivariate analyses, compared to patients with normal BMIs (HR = 0.43, 95 % CI = 0.19-0.98, and p = 0.046 for PFS). A high VAT ratio (third tertile) was an independent adverse prognostic factor for PFS and OS in multivariate analyses (HR = 2.87 and 2.66, 95 % CI = 1.30-6.32 and 1.30-5.44, and p = 0.009 and 0.007 for PFS and OS, respectively). VAT ratio was an independent prognostic factor for patients with DLBCL treated with first-line R-CHOP; thus, additional large prospective studies are warranted.