No improvement in renal cell carcinoma survival: a population-based study in the Netherlands

Fructose 1,6-Bisphosphatase 1 Expression Reduces 18F-FDG Uptake in Clear Cell Renal Cell Carcinoma

Purpose

To determine the relationship between fructose 1,6-bisphosphatase 1 (FBP1) expression and fluorine 18 (¹⁸F) fluorodeoxyglucose (FDG) uptake in patients with clear cell renal cell carcinoma (ccRCC), and to investigate how ¹⁸F-FDG uptake and FBP1 expression are related to tumor metabolism and tumor differentiation grade.

Materials and Methods

A total of 54 patients with ccRCC underwent ¹⁸F-FDG combined positron emission tomography and computed tomography (PET/CT) before tumor resection. The maximum standardized uptake value (SUVmax) for the primary tumor was calculated from the ¹⁸F-FDG uptake. The relationship between SUVmax of primary tumor and the expression of FBP1, hexokinase 2 (HK2), and glucose transporter 1 (GLUT1) was analyzed via immunohistochemical analysis.

Results

We identified an inverse relationship between FBP1 expression and SUVmax (P=0.031). SUVmax was higher in patients with high-grade ccRCC (mean, 11.6 ± 5.0) than in those with low-grade ccRCC (mean, 3.8 ± 1.6, P < 0.001). FBP1 expression was significantly lower in patients with high-grade ccRCC (mean, 0.23 ± 0.1) than in those with low-grade ccRCC (mean, 0.57 ± 0.08; P=0.018). FBP1 status could be predicted with an accuracy of 66.7% when a SUVmax cutoff value of 3.55 was used. GLUT1 expression in ccRCC was positively correlated with ¹⁸F-FDG uptake and FBP1 status, whereas HK2 expression was not.

Conclusion

SUVmax in patients with ccRCC is inversely associated with the expression of FBP1, and FBP1 may inhibit ¹⁸F-FDG uptake via regulating GLUT1. SUVmax is higher in patients with high-grade ccRCC than in those with low-grade ccRCC, which could be the result of lower FBP1 expression in patients with high-grade ccRCC.

Oncologic Outcomes of Cytoreductive Nephrectomy in Synchronous Metastatic Renal-Cell Carcinoma: A Single-Center Experience

PURPOSE

To evaluate the prognostic role of cytoreductive nephrectomy (CN) in patients with synchronous metastatic renal-cell carcinoma (mRCC).

PATIENTS AND METHODS

We analyzed the electronic medical records of 294 patients with synchronous mRCC treated at Samsung Medical Center from January 2005 to December 2015. Primary and secondary end points were overall survival (OS) and cancer-specific survival (CSS), respectively. OS and CSS were estimated by the Kaplan-Meier method and compared between patients with and without CN, particularly by performing 1:1 propensity score matching. Multivariate Cox regression analysis was used to identify independent predictors of survival outcomes.

RESULTS

Among the overall population of synchronous mRCC patients, 189 patients (64.3%) underwent CN. Compared to mRCC patients without CN, those who underwent CN have a higher proportion of single metastasis (63.0% vs. 32.4%) and clear-cell histology (87.8% vs. 72.4%). In the matched cohort, the patients who underwent CN had better OS and CSS outcomes compared to those who did not undergo CN (median OS, 23.0 months vs. 11.0 months; P < .001; median CSS, 34.0 months vs. 14.0 months; P < .001). On multivariable analysis, undergoing CN, body mass index, and Heng risk score were found as significant predictive factors of both OS and CSS. In subgroup analyses stratified by Heng risk criteria, the patients who received CN had better OS and CSS in all risk groups.

CONCLUSION

CN significantly improved survival outcomes in synchronous mRCC patients treated with targeted therapies and independently associated with prolonged survival, regardless of Heng risk criteria.

Cytoreductive nephrectomy in the modern era: Predictors of use, morbidity, and survival

INTRODUCTION

To determine tumour, patient, and provider factors associated with cytoreductive nephrectomy (CN) use and to identify those factors that predicted short-term and long-term surgical outcomes.

METHODS

We performed a retrospective review (1998-2011) of the National Cancer Database, a U.S. population-based oncology outcomes database. The review included 36 549 patients with metastatic renal cell carcinoma (mRCC). We assessed predictors of CN use, length of stay (LOS), 30-day readmission, and 30-day mortality using multivariable logistic regression. The Cox proportional hazards model assessed predictors of overall survival (OS).

RESULTS

Overall, 10 809 (29.6%) patients received CN, increasing from 15.2% to 36.1% over time. Private insurance (odds ratio [OR] 1.26; 95% confidence interval [CI] 1.16-1.37) and academic facilities (OR 1.83; 95% CI 1.68-1.99) were associated with receiving CN (p<0.0001). Charlson score ≥2 and older age group were less likely to undergo surgery (p<0.0001). Median LOS was five days (inter-quartile range [IQR] 3-7), while 30-day readmission and 30-day mortality were 5.3% and 3.3%, respectively. Undergoing CN (hazard ratio [HR] 0.48; 95% CI 0.44-0.52; p<0.0001) and treatment at academic centres (HR 0.88; 95% CI 0.81-0.95; p=0.001) were independently associated with improved OS. Limitation includes retrospective design with possible selection bias.

CONCLUSIONS

Increased CN use continues in the modern era, with relatively low surgical morbidity. Further study is required to determine if the finding of lower all-cause mortality in patients treated at academic centres is due to improved care or unmeasured confounders.

Description of the EuroTARGET cohort: A European collaborative project on TArgeted therapy in renal cell cancer-GEnetic- and tumor-related biomarkers for response and toxicity

OBJECTIVE

For patients with metastatic renal cell cancer (mRCC), treatment choice is mainly based on clinical parameters. With many treatments available and the limited response to treatment and associated toxicities, there is much interest in identifying better biomarkers for personalized treatment. EuroTARGET aims to identify and characterize host- and tumor-related biomarkers for prediction of response to tyrosine kinase inhibitor therapy in mRCC. Here, we describe the EuroTARGET mRCC patient cohort.

METHODS AND MATERIALS

EuroTARGET is a European collaborative project designed as an observational study for which patients with mRCC were recruited prospectively in 62 centers. In addition, 462 patients with mRCC from previous studies were included. Detailed clinical information (baseline and follow-up) from all patients was entered in web-based case record forms. Blood was collected for germline DNA and pharmacokinetic/pharmacodynamic analyses and, where available, fresh-frozen tumor material was collected to perform tumor DNA, RNA, kinome, and methylome analyses.

RESULTS

In total, 1,210 patients with mRCC were included. Of these, 920 received a tyrosine kinase inhibitor as first-line targeted treatment (sunitinib [N = 713, 78%], sorafenib [N = 41, 4%], or pazopanib [N = 166, 18%]) and had at least 6 months of outcome assessment (median follow-up 15.3 months [interquartile range: 8.5-30.2 months]). Germline DNA samples were available from 824 of these patients, fresh-frozen tumor material from 142 patients, fresh-frozen normal kidney tissue from 95 patients, and tissue microarrays created from formalin-fixed paraffin-embedded tumor material from 247 patients. Of the 920 patients, germline DNA variant chip data were successfully generated for 811 patients (Illumina HumanOmniExpress BeadChip). For 80 patients, next-generation exome sequencing of germline and tumor DNA was performed, tumor RNA sequencing was performed for 124 patients, kinome activity measured and processed for 121 patients (PamChip), and methylome data (Illumina Infinium HumanMethylation450 BeadChip) were created for 116 RCC tissues (and 23 normal kidney tissues). For 73 out of the 920 patients, all platform data types were generated. In addition, 40 patients were included in a pharmacokinetic/pharmacodynamic phase IV substudy.

CONCLUSIONS

Analysis of EuroTARGET cohort data will contribute to personalization of therapy for patients with mRCC. The extensive clinical data and multiplatform EuroTARGET data will be freely available.

Better survival of renal cell carcinoma in patients with inflammatory bowel disease

Background

Immunosuppressive therapy may impact cancer risk in inflammatory bowel disease (IBD). Cancer specific data regarding risk and outcome are scarce and data for renal cell carcinoma (RCC) are lacking. We aimed(1) to identify risk factors for RCC development in IBD patients (2) to compare RCC characteristics, outcome and survival between IBD patients and the general population.

Methods

A PALGA (Dutch Pathology Registry) search was performed to establish a case group consisting of all IBD patients with incident RCC in The Netherlands (1991–2013). Cases were compared with two separate control groups: (A) with a population-based IBD cohort for identification of risk factors (B) with a RCC cohort from the general population to compare RCC characteristics and outcomes.

Results

180 IBD patients with RCC were identified. Pancolitis (OR 1.8–2.5), penetrating Crohn's disease (OR 2.8), IBD related surgery (OR 3.7–4.5), male gender (OR 3.2–5.0) and older age at IBD onset (OR 1.0–1.1) were identified as independent risk factors for RCC development. IBD patients had a significantly lower age at RCC diagnosis (p < 0.001), lower N-stage (p = 0.025), lower M-stage (p = 0.020) and underwent more frequently surgical treatment for RCC (p < 0.001) compared to the general population. This translated into a better survival (p = 0.026; HR 0.7) independent of immunosuppression.

Conclusions

IBD patients with a complex phenotype are at increased risk to develop RCC. They are diagnosed with RCC at a younger age and at an earlier disease stage compared to the general population. This translates into a better survival independent of immunosuppressive or anti-TNFα therapy.

Higher circulating expression levels of miR-221 associated with poor overall survival in renal cell carcinoma patients

The mechanisms involved in renal cell carcinoma (RCC) development and progression remain unclear, and new biomarkers for early detection, follow-up of the disease and prognosis are needed in routine practice to improve the diagnostic and/or prognostic accuracy. There is increasing evidence that microRNAs (miRNAs) are involved in cancer development and progression. The up-regulation of miR-221/222 has been described in several human cancers, and during RCC development, this up-regulation can modulate the metastatic process. Our purpose was to investigate the circulating expression levels of miR-221/222 as potential biomarkers for RCC detection and their influence in patients' overall survival. The circulating miR-221/222 was studied by relative quantification in 77 plasma samples. A follow-up study was undertaken to evaluate the overall survival. We observed that RCC patients presented higher circulating expression levels of miR-221 and miR-222 than healthy individuals (2(-ΔΔCt) = 2.8, P = 0.028; 2(-ΔΔCt) = 2.2, P = 0.044, respectively). The RCC patients with metastasis at diagnosis also presented higher circulating expression levels of miR-221 than patients with no metastasis (2(-ΔΔCt) = 10.9, P = 0.001). We also observed a significantly lower overall survival in patients with higher expression levels of miR-221 (48 vs 116 months, respectively; P = 0.024). Furthermore, multivariate Cox regression analysis using the tumour, nodes and metastasis stage (TNM stage); Fuhrman nuclear grade and age (≥60 years) as covariants demonstrated a higher risk of specific death by cancer in patients who presented higher expression levels of miR-221 (hazard ratio (HR) = 10.7, 95% confidence interval 1.33-85.65, P = 0.026). The concordance (c) index showed that the definition of profiles that contain information regarding tumour characteristics associated with circulating miR-221 expression information presents an increased capacity to predict the risk of death by RCC (c index model 1, 0.800 vs model 2, 0.961). Our results, which identified the plasma miR-221/222 at variable levels during RCC development, suggest that these miRNAs may have a potential as noninvasive biomarkers of RCC development.

A GWAS-identified susceptibility locus on chromosome 11q13.3 and its putative molecular target for prediction of postoperative prognosis of human renal cell carcinoma

Genome-wide association studies have been used to identify single nucleotide polymorphisms (SNPs) associated with renal cell carcinoma (RCC) in European individuals. The current study aimed to evaluate the correlation between significant SNPs identified in European individuals and the occurrence and postoperative prognosis of RCC in Chinese individuals. A total of 400 cases and 806 controls were involved in the current study. rs4765623, rs7105934, rs7579899 and rs1867785 were genotyped using qPCR, and the expression of cyclin D1 in renal tissue and RCCs was determined via western blotting and immunohistochemistry. The correlation between the SNPs/cyclin D1 expression and overall survival was evaluated using multivariate Cox regression analyses. Of the four SNPs, only rs7105934 was found to significantly correlate with RCC risk in Chinese individuals. The rs7105934 GA + AA genotype was correlated with a reduced risk of RCC with an odds ratio of 0.64 (95% confidence interval [CI], 0.43–0.96), following adjustment for age. This genotype was found to independently predict an improved postoperative prognosis in the multivariate analysis, with a hazard ratio (HR) of 0.12 (95% CI, 0.02–0.93). Expression of cyclin D1, a putative regulated protein of rs7105934, did not vary in adjacent renal tissue and tumors when compared with that of various rs7105934 genotypes. However, cyclin D1 expression in RCCs inversely correlated with advanced tumor stage, and moderate to high expression of cyclin D1 in RCCs independently predicted improved postoperative prognosis, with an HR of 0.13 (95% CI, 0.02–0.96). Observations of the present study indicate that the rs7105934 A allele is associated with reduced risk and improved postoperative prognosis of RCC; however, this effect is unlikely to be caused by cyclin D1 expression.

Tumor-suppressive microRNA-135a inhibits cancer cell proliferation by targeting the c-MYC oncogene in renal cell carcinoma

Recently, many studies have suggested that microRNAs (miRNAs) are involved in cancer cell development, invasion, and metastasis of various types of human cancers. In a previous study, miRNA expression signatures from renal cell carcinoma (RCC) revealed that expression of microRNA-135a (miR-135a) was significantly reduced in cancerous tissues. The aim of this study was to investigate the functional significance of miR-135a and to identify miR-135a-mediated molecular pathways in RCC cells. Restoration of mature miR-135a significantly inhibited cancer cell proliferation and induced G0 /G1 arrest in the RCC cell lines caki2 and A498, suggesting that miR-135a functioned as a potential tumor suppressor. We then examined miR-135a-mediated molecular pathways using genome-wide gene expression analysis and in silico analysis. A total of 570 downregulated genes were identified in miR-135a transfected RCC cell lines. To investigate the biological significance of potential miR-135a-mediated pathways, we classified putative miR-135a-regulated genes according to the Kyoto Encyclopedia of Genes and Genomics pathway database. From our in silico analysis, 25 pathways, including the cell cycle, pathways in cancer, DNA replication, and focal adhesion, were significantly regulated by miR-135a in RCC cells. Moreover, based on the results of this analysis, we investigated whether miR-135a targeted the c-MYC gene in RCC. Gain-of-function and luciferase reporter assays showed that c-MYC was directly regulated by miR-135a in RCC cells. Furthermore, c-MYC expression was significantly upregulated in RCC clinical specimens. Our data suggest that elucidation of tumor-suppressive miR-135a-mediated molecular pathways could reveal potential therapeutic targets in RCC.

Tumor suppressive microRNA-1285 regulates novel molecular targets: aberrant expression and functional significance in renal cell carcinoma

MicroRNAs (miRNA) are non-coding RNAs, approximately 22 nucleotides in length, which function as post-transcriptional regulators. A large body of evidence indicates that miRNAs regulate the expression of cancer-related genes involved in proliferation, migration, invasion, and metastasis. The aim of this study was to identify novel cancer networks in renal cell carcinoma (RCC) based on miRNA expression signatures obtained from RCC clinical specimens. Expression signatures revealed that 103 miRNAs were significantly downregulated (< 0.5-fold change) in RCC specimens. Functional screening (cell proliferation assays) was performed to identify tumor suppressive activities of 20 downregulated miRNAs. Restoration of mature miRNAs in cancer cells showed that 14 miRNAs (miR-1285, miR-206, miR-1, miR-135a, miR-429, miR-200c, miR-1291, miR-133b, miR-508-3p, miR-360-3p, miR-509-5p, miR-218, miR-335, miR-1255b and miR-1285) markedly inhibited cancer cell proliferation, suggesting that these miRNAs were candidate tumor suppressive miRNAs in RCC. We focused on miR-1285 because it significantly inhibited cancer cell proliferation, invasion, and migration following its transfection. We addressed miR-1285-regulated cancer networks by using genome-wide gene expression analysis and bioinformatics. The data showed that transglutaminase 2 (TGM2) was directly regulated by miR-1285. Silencing of the target gene demonstrated significant inhibition of cell proliferation and invasion in the RCC cells. Furthermore, immunohistochemistry showed that TGM2 expression levels in RCC specimens were significantly higher than those in normal renal tissues. Downregulation of tumor suppressive miR-1285, which targets oncogenic genes including TGM2, might contribute to RCC development. Thus, miR-1285 modulates a novel molecular target and provides new insights into potential mechanisms of RCC oncogenesis.

The functional significance of miR-1 and miR-133a in renal cell carcinoma

PURPOSE

The aim of this study was to find a novel molecular network involved in renal cell carcinoma (RCC) development through investigating the functions of miR-1 and miR-133a and their target genes.

METHODS

We checked the expression levels of miR-1 and miR-133a in RCC cell lines and specimens (N=40) using real time RT-PCR. MiR-1 and miR-133a transfectants were subjected to a gain-of-function study to identify the functions of the miRNAs. To find the target genes of the miRNAs, we analysed the gene expression profile of their transfectants and performed a luciferase reporter assay. mRNA expression levels of the candidate target gene in the clinical specimens were examined, and loss-of-function studies were performed.

RESULTS

The expression levels of miR-1 and miR-133a were significantly suppressed in RCC cell lines and specimens. Ectopic restoration of miR-1 and miR-133a showed significant inhibition of cell proliferation and invasion, and moreover, revealed induction of apoptosis and cell cycle arrest. The luciferase assay revealed transgelin-2 (TAGLN2), selected as a target gene for miR-1 and miR-133a on the basis of the gene expression profile, to be directly regulated by both miR-1 and miR-133a. The loss-of-function studies showed significant inhibitions of cell proliferation and invasion in the si-TAGLN2 transfectant. The expression level of TAGLN2 mRNA was significantly up-regulated in the RCC specimens; in addition, there was a statistically significant inverse correlation between TAGLN2 and miR-1 and miR-133a expression.

CONCLUSIONS

Our data indicate that up-regulation of the oncogenic TAGLN2 was due to down-regulation of tumour-suppressive miR-1 and miR-133a in human RCC.

Modest improvement in 20 years of kidney cancer care in the Netherlands

AIM

For an evaluation of the progress achieved in the field of kidney cancer care in the Netherlands in the last decades, we described trends in incidence, treatment, mortality and relative survival.

METHODS

All adult patients newly diagnosed with kidney cancer between 1989 and 2009 (N=32,545) were selected from the Netherlands Cancer Registry. Age-standardised incidence and mortality rates were calculated. Follow-up was completed until January 2010. In order to assess trends estimated annual percentages of change (EAPC) were estimated.

RESULTS

The incidence of kidney cancer has been fairly stable between 1989 and 2001 with a European Standardised Rate of approximately 11 per 100,000 person years (PY). Since 2001 the incidence increased to 13 per 100,000 PY in 2009 (EAPC: 2.4%; 95%confidence interval (CI): 1.5 to 3.4%). The mortality rate decreased slightly over time, from 6.2 per 100,000 PY in 1989 to 5.6 in 2010. No changes in treatment were observed, except for the introduction of targeted therapies for stage IV disease, since 2005. The 5-year relative survival improved from 51% in 1989-1994 to 58% in 2005-2009 (EAPC: 0.9%; 95%CI 0.7 to 1.2%). Improvement in survival was especially seen in males, younger age groups and low stages.

CONCLUSIONS

The incidence of kidney cancer has increased slightly, and survival improved modestly, resulting in a decreasing mortality. A positive effect of the introduction of targeted therapies for metastatic kidney cancer was observed in 1-year relative survival. For progress in kidney cancer care, effective prevention strategies and new therapies remain warranted.

Better survival in patients with metastasised kidney cancer after nephrectomy: a population-based study in the Netherlands

AIM

Cytoreductive nephrectomy is considered beneficial in patients with metastasised kidney cancer but only a minority of these patients undergo cytoreductive surgery. Factors associated with nephrectomy and the independent effect of nephrectomy on survival were evaluated in this study.

METHODS

Patients were selected from the population-based cancer registry and detailed data were retrieved from clinical files. Factors associated with nephrectomy were evaluated by logistic regression analyses. Cox proportional hazard regression analysis was performed to evaluate factors associated with survival; a propensity score reflecting the probability of being treated surgically was included in order to adjust for confounding by indication.

RESULTS

37.5% of 328 patients diagnosed with metastatic kidney cancer between 1999 and 2005 underwent nephrectomy. Patients with a low performance score, high age, ≥2 comorbid conditions, ≥2 metastases, low or high BMI, weight loss, elevated lactate dehydrogenase, elevated alkaline phosphatase, female gender and liver or bone metastases were less likely to be treated surgically. Three year survival was 25% and 4% for patients with and without nephrectomy, respectively (p<0.001). After adjustment for other prognostic factors including the propensity score, nephrectomy remained significantly associated with better survival (Hazard ratio: 0.52, 95% Confidence interval: 0.37-0.73).

CONCLUSIONS

Even after accounting for prognostic profile, patients still benefit from a nephrectomy; an approximately 50% reduction in mortality was observed. It is, therefore, recommended that patients with metastasised disease receive cytoreductive surgery when there is no contraindication. Trial results on cytoreductive surgery combined with targeted molecular therapeutics are awaited for.

Global histone acetylation levels: prognostic relevance in patients with renal cell carcinoma

Epigenetic alterations play an important role in carcinogenesis. Recent studies have suggested that global histone modifications are predictors of cancer recurrence in various tumor entities. Global histone acetylation levels (histone H3 lysine 9 acetylation [H3K9Ac], histone H3 lysine 18 acetylation [H3K18Ac], total histone H3 acetylation [H3Ac] and total histone H4 acetylation [H4Ac]) were determined in patients with renal cell carcinoma (RCC) using immunohistochemistry in a tissue micro array with 193 RCC and 10 oncocytoma specimens. The histone acetylation pattern was not different among the diverse histological subtypes of RCC or oncocytoma samples. The H3Ac levels were inversely correlated with pT-stage (P = 0.005), distant metastasis (P = 0.036), Fuhrman grading (P = 0.001) and RCC progression (P = 0.029, hazard ratio 0.87). H4Ac deacetylation was correlated with pT-stage (P = 0.011) and grading (P = 0.029). H3K18Ac levels were an independent predictor of cancer-progression following surgery for localized RCC in the univariate (P = 0.001, hazard ratio 0.78) and multivariate (P = 0.005, hazard ratio 0.82) analysis. In conclusion, our study supports the concept of global histone modification levels as a universal cancer prognosis marker, and provides evidence for the use of histone deacetylases inhibitors as future drugs in the therapy of RCC.

Accurate molecular classification of renal tumors using microRNA expression

Subtypes of renal tumors have different genetic backgrounds, prognoses, and responses to surgical and medical treatment, and their differential diagnosis is a frequent challenge for pathologists. New biomarkers can help improve the diagnosis and hence the management of renal cancer patients. We extracted RNA from 71 formalin-fixed paraffin-embedded (FFPE) renal tumor samples and measured expression of more than 900 microRNAs using custom microarrays. Clustering revealed similarity in microRNA expression between oncocytoma and chromophobe subtypes as well as between conventional (clear-cell) and papillary tumors. By basing a classification algorithm on this structure, we followed inherent biological correlations and could achieve accurate classification using few microRNAs markers. We defined a two-step decision-tree classifier that uses expression levels of six microRNAs: the first step uses expression levels of hsa-miR-210 and hsa-miR-221 to distinguish between the two pairs of subtypes; the second step uses either hsa-miR-200c with hsa-miR-139-5p to identify oncocytoma from chromophobe, or hsa-miR-31 with hsa-miR-126 to identify conventional from papillary tumors. The classifier was tested on an independent set of FFPE tumor samples from 54 additional patients, and identified correctly 93% of the cases. Validation on qRT-PCR platform demonstrated high correlation with microarray results and accurate classification. MicroRNA expression profiling is a very effective molecular bioassay for classification of renal tumors and can offer a quantitative standardized complement to current methods of tumor classification.

Caratterizzazione Biologica del Carcinoma Renale Metastatico

Renal cell carcinoma is the sixth leading cause of death for cancer in industrialized countries and one third of patients has metastases at the time of diagnosis. The three most common histological types of renal cell carcinoma are: clear cell carcinoma (70–80%), papillary carcinoma (10–15%) and chromophobe cell carcinoma (5%). The location of metastases vary according to histotype: lung metastases are found in 53.6% of cases in patients with clear cell carcinoma, whereas in patients with papillary carcinoma or chromophobe cell carcinoma in 33.3% and 28.2% of cases, respectively. In contrast, chromophobe cell carcinoma is more often associated with liver metastases (33.3%), compared with clear cell carcinoma (9.7%) or papillary carcinoma (18%). Patients with renal cell carcinoma metastatic to a single organ have a better prognosis than patients with metastases in multiple organs and the overall survival of patients with localized lung metastases is similar to that of patients with exclusive bone metastases. The overall survival, therefore, is related more to the number of organs involved by metastasis rather than by the location of metastases. The widespread use of abdominal non-invasive diagnostic procedures, with an incidental finding of renal cell carcinomas still in a low stage of development, and the refinement of surgical techniques for resection of metastatic disease (metastasectomy) have led to only a slight improvement in overall survival in the last 30 years for the resistance of the tumor to common chemo-radiotherapy Surgery remains the best therapeutic option and a rising in cutting-edge molecular therapies is strongly needed.