EAU guidelines on renal cell carcinoma: 2014 update

Orbital metastasis of renal cell carcinoma masquerading as thyroid ophthalmopathy

Renal cell carcinoma (RCC) is the most common kidney malignancy in adults. However, its presentation with orbital metastasis as the first clinical manifestation is extremely rare and can mimic several other conditions. We report the case of a 72-year-old woman with a history of hyperthyroidism, who presented with symptoms resembling thyroid ophthalmopathy. However, magnetic resonance imaging (MRI) of the orbit revealed orbital metastasis. To find the primary tumor, a surveillance computed tomography (CT) was done which showed a mass in the left kidney suggestive of RCC. Histopathological analysis of the mass confirmed clear cell RCC. Early identification of orbital metastases in RCC is crucial, as it may indicate advanced disease. Misdiagnosis due to similarities with other orbital conditions can lead to delayed treatment and suboptimal outcomes. This case highlights the pivotal role of radiological imaging in guiding the diagnosis and management of orbital metastases from RCC.

Risk factors for renal insufficiency and survival implications after radical nephrectomy and thrombectomy in renal cell carcinoma with tumor thrombus: a systematic review

BACKGROUND

Renal cell carcinoma (RCC) with venous tumor thrombus (VTT) is great burden over world. Radical nephrectomy (RN) with thrombectomy seems to be its gold standard operation, which might cause reduction of renal function. The aim of this systematic review was to provide evidence about the incidence, risk factors, possible reasons and influence of renal insufficiency in RCC patients undergoing RN with thrombectomy.

METHODS

A systematic search using PubMed, Embase, Web of Science, the Cochrane Library and European Urology databases was conducted. Study selection followed the PRISMA guidelines. After screening, eleven articles and abstracted fully compatible with the PICOS were included in this systematic review. The study was registered with PROSPERO, CRD42024516596.

RESULTS

Overall, a total of 1,668 patients who were diagnosed with RCC and VTT and underwent RN (open/laparoscopic/robotic) with thrombectomy were analyzed. The postoperative renal insufficiency was present from 0.7 to 53.9%. Relevant risk factors of postoperative renal insufficiency could be summarized into three aspects: baseline characteristics (male gender, tumor thrombus level), intraoperative procedure (surgical method and inferior vena cava clamping time) and other factors (development of the times). The reason of renal insufficiency could be depletion of circulation volume, alteration in renal hemodynamics and condition of solitary kidney. The overall survival (OS) ranged from 2 months to 98 months. A clear association between survival and renal function could not be established because of the oncological risk on survival. Necessary managements like supplying blood volume, diuretic therapy and renal replacement therapy should be applied.

CONCLUSIONS

The present incidence of postoperative renal insufficiency was underestimated. More possible risk factors should be explored. Large cohort, multi-center, prospective, and well-designed studies would be necessary to corroborate these results and provide high-grade recommendation for clinical practice.

Identification and validation of prognostic biomarkers in ccRCC: immune-stromal score and survival prediction

BACKGROUND

The tumor microenvironment (TME) is integral to tumor progression. However, its prognostic implications and underlying mechanisms in clear cell renal cell carcinoma (ccRCC) are not yet fully elucidated. This study aims to examine the prognostic significance of genes associated with immune-stromal scores and to explore their underlying mechanisms in ccRCC.

METHODS

Data from the Cancer Genome Atlas (TCGA) and International Cancer Genome Consortium (ICGC) were subjected to analysis to compute immune and stromal scores utilizing the ESTIMATE algorithm. The weighted gene co-expression network analysis (WGCNA) was employed to identify gene modules associated with these scores. Differentially expressed genes were assessed using the limma package. Prognostic biomarkers were subsequently identified through univariate, LASSO, and multivariate Cox regression analyses, culminating in the development of a risk score model. Gene expression was confirmed in ccRCC cell lines (786-O, Caki-1) and tumor tissues. Functional assays, such as wound healing and Transwell assays, were employed to evaluate tumor invasion and migration. The prognostic accuracy was assessed through ROC curve analysis, and a nomogram integrating risk scores with clinical variables was constructed. Analyses of immune infiltration, human leukocyte antigen (HLA) expression, immune checkpoint expression, immunophenoscore (IPS), tumor immune dysfunction and exclusion (TIDE) scores, and responses to six targeted therapies were conducted across different risk groups.

RESULTS

Twelve critical prognostic markers, including CAPRIN1, CXCR3, FERMT3, HAPLN3, HBP1, MACF1, MPEG1, OSCAR, STAT1, UBA7, VAMP1, and VSIG4, were identified. The risk score model exhibited a high degree of predictive accuracy for survival outcomes in ccRCC. Immune profiling revealed significant differences in the TME between risk groups, with high-risk patients displaying elevated expression of HLA and immune checkpoints. Drug sensitivity analyses suggested that high-risk patients had a better response to erlotinib, temsirolimus, axitinib, and sunitinib, whereas low-risk patients demonstrated greater sensitivity to pazopanib. Variability in immunotherapy responsiveness between groups was observed based on IPS and TIDE analyses.

CONCLUSION

This study highlights the prognostic value and TME-related mechanisms of immune-stromal score signatures in ccRCC, developing a risk score model and nomogram for predicting patient prognosis.

Inhibition of Renal Cell Carcinoma Growth by 1,3-thiazin-6-one Through Targeting the Inflammatory Reaction

The current study examined the underlying mechanism and the effect of 1,3-thiazin-6-one on the growth of renal cancer. The findings showed that 1,3-thiazin-6-one treatment inhibited the growth of xenograft tumors in a dose-dependent manner in mice model of renal cancer. Furthermore, when 1,3-thiazin-6-one was administered in a dose-dependent manner to mice with renal cancer, the expression of the proteins p-PI3K and p-Akt significantly decreased. In mice model of renal cancer, 1,3-thiazin-6-one treatment also inhibited p-mTOR expression. In a model of renal cancer in mice, the 1,3-thiazin-6-one therapy specifically targeted the expression of nuclear factor κB (NF κB) and signal transducer and activator of transcription 3 (STAT3). Renal cancer cells' vitality was significantly (p < 0.05) reduced in a dose-dependent manner upon exposure to 1,3-thiazin-6-one. It also prevents invasiveness of the renal cancer cells in addition to suppression of colony forming potential. In summary, the 1,3-thiazin-6-one blocks the growth of kidney cancer by focusing on the pathways that trigger the inflammatory cascade. Therefore, 1,3-thiazin-6-one might be developed as a significant medicinal agent to cure renal cancer.

Correlation between cathepsins and the likelihood of renal cancer: a Mendelian randomization study

BACKGROUND

Previous studies have established a relationship between cathepsins and renal cancer. Nonetheless, the specific causal connection between the two factors continues to be ambiguous. The aim of this study is to evaluate the causal relationship between cathepsins and renal cancer via employing Mendelian randomization (MR).

METHODS

The summary data of genome-wide association study were used for univariable MR (UVMR), reverse MR, and multivariable MR (MVMR) analyses. The primary MR method used in this study was Inverse variance weighting.

RESULTS

UVMR analysis showed that cathepsin Z increased the overall risk of renal cancer and cathepsin F were observed increased the risk of clear cell renal cell carcinoma. Furthermore, the concentration of cathepsin S had a significant positive correlation with the risk of papillary renal cell carcinoma (pRCC), whereas that of cathepsin G was negatively correlated with the risk of pRCC. Reverse MR analysis showed that renal cancer reduced the concentration of cathepsin H. MVMR analysis showed that the concentration of cathepsin B had a significant positive correlation with overall risk of renal cancer and pRCC. In addition, a higher concentration of cathepsin S was significantly associated with an increased risk of pRCC.

CONCLUSION

This study confirmed a direct link between cathepsins and the risk of renal cancer. Specifically, cathepsin S has a significant positive correlation with the risk of pRCC. The findings of our research could provide significant contributions to both fundamental and clinical investigations pertaining to renal cancer. Key message What is already known on this topic? - Previous studies have suggested the role of some cathepsins in renal cancer occurrence and progression. However, the causal link between different cathepsins and renal cancer is unknown. What this study adds? - Our Mendelian randomization (MR) study revealed that the effects of different cathepsins on the risk of renal cancer. Remarkably, both univariable MR and multivariable MR demonstrated that the levels of cathepsin S increases the risk of papillary renal cell carcinoma. How this study might affect research, practice or policy? - The findings offer novel insights into the relationship between cathepsins and renal cancer, which may have implications for the prevention and management of renal cancer.

Can parenchymal volume analysis replace nuclear renal scans for split renal function before and after partial nephrectomy with warm ischemia?

BACKGROUND

The assessment of split renal function (SRF) before and after partial nephrectomy (PN) is crucial. While nuclear renal scan (NRS) is a traditional method for evaluating SRF, its extensive use is hindered by concerns regarding radioactivity. Parenchymal volume analysis (PVA) has been employed to assess SRF for kidney donors. Nonetheless, the efficacy of PVA in evaluating SRF in kidneys with renal masses before and after PN with warm ischemia remains uncertain.

AIM

The current study probed into the potential of PVA as a substitute for NRS in assessing SRF before and after PN with warm ischemia.

METHODS

This study included 318 patients who underwent unilateral PN with warm ischemia at Sun Yat-Sen University Cancer Center (SYSUCC) and had a functional contralateral kidney. All patients underwent PVA and NRS assessments both pre-PN and at 1-12 months post-PN. PVA was analyzed using Mimics software in the venous phase. The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation. The correlation between ipsilateral eGFR values derived from SRF assessed via PVA and NRS was examined using Pearson correlation. Concordance between different methods of SRF estimation was analyzed using the Friedman test, Bland-Altman plots, and Kendall's consistency coefficient. Similar study was conducted on a comparable cohort from Sun Yat-Sen Memorial Hospital.

RESULTS

The median tumor size was 3.5cm, and the median warm ischemia time was 25min. Preoperatively, ipsilateral SRF values based on PVA were notably consistent with those derived from NRS (49.4% vs 50.0%, P = .501). A strong correlation was observed between preoperative ipsilateral eGFR based on SRF from PVA and NRS (r = 0.89, P < .0001). Bland-Altman plots indicated minimal bias (-0.36%) between PVA and NRS in assessing SRF. However, post-PN, the median ipsilateral SRF based on PVA was slightly higher than that based on NRS (45.6% vs. 43.6%, P < .0001). Although there was still a strong correlation between post-PN ipsilateral eGFR based on SRF from PVA and NRS (r = 0.87, P < .0001), Bland-Altman plots revealed a non-negligible bias between the 2 methods (2.19 %). External study supported our findings.

CONCLUSIONS

PVA shows promise as a substitute for NRS in assessing SRF before PN with warm ischemia. However, this substitution may result in an overestimation of ipsilateral renal function in the post-PN phase.

Is Ablation Suitable For Small Renal Masses? A Meta-Analysis

RATIONALE AND OBJECTIVES

To compare perioperative and oncology outcomes of ablation and partial nephrectomy in small renal masses (SRMs).

METHODS

We conduct this meta-analysis strictly according to the PRISMA standard, and the quality evaluation follows the AMSTAR standard. Four databases, Embase, PubMed, Cochrane Library, and Web of Science, were systematically searched. The search time range is from database creation to November 2023. Stata16 statistical software was used for statistical analysis. Weighted mean difference (WMD) represented continuity variables, odds ratio or relative risk (OR/RR) represented dichotomies variables, and 95% confidence intervals (95%CI) were calculated.

RESULTS

A total of 27 studies, including 6030 patients. Results showed that patients undergoing partial nephrectomy were younger (WMD = -5.45 years, 95%CI [-7.44, -3.46], P < 0.05), had longer operation time (WMD = 64.91 min, 95%CI [44.47, 85.34], P < 0.05), had longer length of stay (WMD = 2.91 days, 95%CI [2.04, 3.78], P < 0.05), and had more estimated blood loss (WMD = 97.76 ml, 95%CI [69.48, 126.04]. P < 0.05), the overall complication rate was higher (OR = 1.84, 95%CI [1.48, 2.29], P < 0.05), the major complication rate was higher (OR = 1.98, 95%CI [1.36, 2.88], P < 0.05), and the recurrence rate was lower (OR = 0.32, 95%Cl [0.20, 0.50], P < 0.05). However, there were no differences between ablation and partial nephrectomy in cancer-specific survival (CSS) (HR = 2.07, 95%CI [0.61, 7.04], P > 0.05), overall survival (OS) (HR = 1.24, 95%CI [0.58, 2.65], P > 0.05), and recurrence-free survival (RFS) (HR = 2.68, 95%CI [0.91, 7.88], P > 0.05).

CONCLUSION

Patients undergoing partial nephrectomy are younger, have longer operation time and length of stay, and have higher complication rate. However, there was no significant difference in CSS, OS, and RFS between partial nephrectomy and ablation, but more well-designed, high-quality studies are needed to confirm this.

Growth kinetics and predictive factors in renal angiomyolipomas

BACKGROUND

Although renal angiomyolipomas (AMLs) are benign lesions, they can grow and cause serious complications. In this study, we aimed to determine the factors affecting the growth of renal AMLs.

METHOD

Patients followed up for AMLs between January 2014 and January 2024 were screened. By accepting 2.5 mm/year as the limit for a significant growth rate, the patients were divided into two groups: those with and without significant growth. Demographic characteristics, tumor characteristics, and laboratory parameters, platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and aspartate aminotransferase-to-alanine aminotransferase (De Ritis) ratio, were compared between the groups.

RESULTS

The study included a total of 98 patients. Of the entire cohort, 78.6% were women. Significant growth was detected in nine (9.2%) patients. Multivariate analysis revealed that the baseline scan tumor size, PLR, and De Ritis ratio were significant independent predictors of significant AML growth (p = 0.011, p = 0.017, and p = 0.030, respectively). In the receiver operating characteristic curve analysis, the cut-off value of PLR in predicting significant growth was 131.85 (sensitivity: 77.8%, specificity: 73%, area under the curve [AUC] 0754), while the cut-off value of the De Ritis ratio was 1.33 (sensitivity: 66.7%, specificity: 95.8%, AUC 0.721).

CONCLUSION

Tumor size at the time of initial diagnosis, as well as PLR and De Ritis ratio, were found to be independent predictors of AML growth rate. The use of these factors in patient follow-up has the potential to assist clinicians in predicting tumor growth and related complications.

Microwave vs radiofrequency ablation for small renal masses: perioperative and oncological outcomes

OBJECTIVE

To conduct a comprehensive comparison of microwave ablation (MWA) vs radiofrequency ablation (RFA) outcomes in the treatment of small renal masses (SRMs), specifically: TRIFECTA ([i] complete ablation, [ii] absence of Clavien-Dindo Grade ≥III complications, and [iii] absence of ≥30% decrease in estimated glomerular filtration rate) achievement, operative time (OT), and local recurrence rate (LRR).

PATIENTS AND METHODS

We retrospectively analysed 531 patients with SRMs (clinical T1a-b) treated with MWA or RFA at a single centre (2008-2022). First, multivariable logistic regression models were used for testing TRIFECTA achievement. Second, multivariable Poisson regression models were used to evaluate variables associated with longer OT. Finally, Kaplan-Meier plots depicted LRR over time. All analyses were repeated after 1:1 propensity score matching (PSM).

RESULTS

Of 531 patients with SRMs, 373/531 (70.2%) underwent MWA and 158/531 (29.8%) RFA. MWA demonstrated superior TRIFECTA achievement (314/373 [84.2%]) compared to RFA (114/158 [72.2%], P = 0.001). These differences were driven by higher rates of complete ablation in MWA- vs RFA-treated patients (348/373 [93.3%] vs 137/158 [86.7%], P < 0.001). In multivariable logistic regression models, MWA was associated with higher TRIFECTA achievement, compared to RFA, before (odds ratio [OR] 1.92, P = 0.008) and after PSM (OR 1.99, P = 0.023). Finally, the median OT was shorter for MWA vs RFA (105 vs 115 min; P = 0.002). At Poisson regression analyses, MWA predicted shorter OT before (incidence rate ratio [IRR] 0.86, P < 0.001) and after PSM (IRR 0.85, P < 0.001). Local recurrence occurred in 17/373 (4.6%) MWA-treated patients and 21/158 (13.3%) RFA-treated patients (P = 0.29) after a median (interquartile range) follow-up of 24 (8-46) months. There were no differences in the LRR in Kaplan-Meier plots before (P = 0.29) and after PSM (P = 0.42).

CONCLUSION

Microwave ablation provides higher TRIFECTA achievement, and shorter OT than RFA. No significant differences were found regarding the LRR.

ACE Loss Drives Renal Cell Carcinoma Growth and Invasion by Modulating AKT-FOXO1

Purpose

Emerging literature links the role of the renin-angiotensin-aldosterone system (RAAS) to the progression of cancers. However, the function of RAAS has not been verified in Clear-cell renal cell carcinoma (ccRCC).

Methods

ACE expression in ccRCC tissues was determined using RT-PCR, Western blot, and immunohistochemistry staining. The clinical significance of ACE was evaluated through Cox regression analysis. To assess the impact of ACE expression on ccRCC cell growth, metastasis, and glucose activity, CCK-8 assays, transwell assays, Seahorse detection, and xenograft models were utilized. The mechanisms of ACE and its upstream and downstream regulatory factors were investigated using RNA-seq, chromatin immunoprecipitation (ChIP), and luciferase reporter assays.

Results

RAAS-related gene Angiotensin-Converting Enzyme (ACE) was significantly under expressed in ccRCC cells and tissues. High ACE expression was positively associated with a favorable prognosis in ccRCC patients. Functional studies showed that ACE overexpression suppressed ccRCC cell line OS-RC-2 and A498 growth, metastasis, and glycolysis activities, while its knockdown had the opposite effect. Mechanistically, ACE inhibited ccRCC progression and epithelial-mesenchymal transition (EMT) by disrupting the AKT-FOXO1 signaling pathway. Furthermore, we provide evidence that ACE could enhance everolimus (approved agent for ccRCC) antitumor effect and ACE expression is transcriptionally regulated by ZBTB26.

Conclusion

Our findings investigated the roles and mechanisms of ACE in ccRCC. ACE inhibits the growth and metastasis of ccRCC cells in vitro and in vivo by promoting FOXO1 expression, which is the downstream target of PI3K-AKT pathway. Thus, this research suggests that ACE may be a promising target for new therapeutic strategy in ccRCC.

Determinants of conventional and contrast-enhanced ultrasound diagnosis of fat-poor angiomyolipoma <5 cm

Purpose

This study aims to assess the diagnostic efficacy of conventional ultrasound (CUS) and contrast-enhanced ultrasound (CEUS) in detecting fat-poor angiomyolipomas(AML) with dimensions less than 5 cm. Additionally, the study seeks to identify independent indicators for predicting the presence of fat-poor AML.

Methods

We conducted a retrospective analysis of patients diagnosed with renal AML and renal cell carcinoma, who were admitted and underwent surgery at Fujian Provincial Hospital from January 2013 to October 2023. A total of 154 renal tumors were included (104 renal cell carcinomas and 50 fat-poor AMLs). Prior to radical or partial nephrectomy, these patients underwent both CUS and CEUS examinations. We systematically analyzed the features observed in CUS and CEUS, identified independent factors through multifactorial regression analysis, and evaluated diagnostic efficacy by calculating the area under the curve (AUC).

Results

Univariate analysis revealed significant distinctions in fat-poor AML concerning gender, age, morphology, internal hyperechoic features (starry-sky sign, crescent sign), enhancement uniformity, and delayed enhancement, all displaying significance compared to renal cell carcinoma (RCC) (p < 0.05). Multivariate analysis demonstrated that internal hyperechoic features (p < 0.01, Odds Ratio [OR] = 0.003, 95% Confidence Interval [CI]: 0.000-0.0028) and enhancement uniformity (p < 0.01, OR = 0.016, 95% CI: 0.001-0.229) independently predicted fat-poor AML. The Receiver Operating Characteristic (ROC) curve's area under the curve (AUC) for internal hyperechoic features (starry-sky sign, crescent sign) was 0.88 (95% CI: 0.80-0.95), with a sensitivity of 78.00%, specificity of 97.12%, positive predictive value of 92.85%, and negative predictive value of 90.18%. Conversely, the ROC curve AUC for enhancement uniformity was 0.70 (95% CI: 0.62-0.78), with a sensitivity of 96.00%, specificity of 44.23%, positive predictive value of 45.28%, and negative predictive value of 95.83%.

Conclusion

This study suggests that both CUS and CEUS possess discriminative value in differentiating fat-poor AMLs from RCCs. Notably, internal hyperechoic features (starry-sky sign, crescent sign) and uniform enhancement within renal tumors emerge as potential independent indicators for predicting fat-poor AML.

Exploring the value of arterial spin labeling and six diffusion MRI models in differentiating solid benign and malignant renal tumors

OBJECTIVE

To explore the value of three-dimensional arterial spin labeling (ASL) and six diffusion magnetic resonance imaging (MRI) models in differentiating solid benign and malignant renal tumors.

METHODS

This retrospective study included 89 patients with renal tumors. All patients underwent ASL and ZOOMit diffusion-weighted imaging (DWI) examinations and were divided into three groups: clear cell renal cell carcinoma (ccRCC), non-ccRCC, and benign renal tumors (BRT). The mean and peak renal blood flow (RBFmean and RBFpeak) from ASL and fourteen diffusion parameters from mono-exponential DWI (Mono_DWI), intravoxel incoherent motion (IVIM), diffusion kurtosis imaging (DKI), stretched exponential model (SEM), fractional order calculus (FROC), and continuous-time random-walk (CTRW) model were analyzed. Binary logistic regression was used to determine the optimal parameter combinations. The diagnostic performance of various MRI-derived parameters and their combinations was compared.

RESULTS

Among the six diffusion models, the SEM model achieved the highest performance in differentiating ccRCC from non-ccRCC (area under the receiver operating characteristic curve [AUC] 0.880) and from BRT (AUC 0.891). IVIM model achieved the highest AUC (0.818) in differentiating non-ccRCC from BRT. Among all the MRI-derived parameters, RBFpeak combined with DKI_MK yielded the highest AUC (0.970) in differentiating ccRCC from non-ccRCC, and the combination of RBFpeak, SEM_DDC, and FROC_μ yielded the highest AUC (0.992) for differentiating ccRCC from BRT.

CONCLUSION

ASL and all diffusion models showed similar diagnostic performance in differentiating ccRCC from non-ccRCC or BRT, while the IVIM model performed better in distinguishing non-ccRCC from BRT. Combining ASL with diffusion models can provide additional value in predicting ccRCC.

RELEVANCE STATEMENT

Considering the increasing detection rate of incidental renal masses, accurate discrimination of benign and malignant renal tumors is crucial for decision-making. Combining ASL with diffusion MRI models offers a promising solution to this clinical issue.

KEY POINTS

All assessed models were effective for differentiating ccRCC from non-ccRCC or BRT. ASL and all diffusion models showed similar performance in differentiating ccRCC from non-ccRCC or BRT. Combining ASL with diffusion models significantly improved diagnostic efficacy in predicting ccRCC. IVIM model could better differentiate non-ccRCC from BRT.

Deep learning-based diagnosis and survival prediction of patients with renal cell carcinoma from primary whole slide images

There is an urgent clinical demand to explore novel diagnostic and prognostic biomarkers for renal cell carcinoma (RCC). We proposed deep learning-based artificial intelligence strategies. The study included 1752 whole slide images from multiple centres. Based on the pixel-level of RCC segmentation, the diagnosis diagnostic model achieved an area under the receiver operating characteristic curve (AUC) of 0.977 (95% CI 0.969-0.984) in the external validation cohort. In addition, our diagnostic model exhibited excellent performance in the differential diagnosis of RCC from renal oncocytoma, which achieved an AUC of 0.951 (0.922-0.972). The graderisk for the recognition of high-grade tumour achieved AUCs of 0.840 (0.805-0.871) in the Cancer Genome Atlas (TCGA) cohort, 0.857 (0.813-0.894) in the Shanghai General Hospital (General) cohort, and 0.894 (0.842-0.933) in the Clinical Proteomic Tumor Analysis Consortium (CPTAC) cohort, for the recognition of high-grade tumour. The OSrisk for predicting 5-year survival status achieved an AUC of 0.784 (0.746-0.819) in the TCGA cohort, which was further verified in the independent general cohort and the CPTAC cohort, with AUCs of 0.774 (0.723-0.820) and 0.702 (0.632-0.765), respectively. Moreover, the competing-risk nomogram (CRN) showed its potential to be a prognostic indicator, with a hazard ratio (HR) of 5.664 (3.893-8.239, p<0.0001), outperforming other traditional clinical prognostic indicators. Kaplan-Meier survival analysis further illustrated that our CRN could significantly distinguish patients with high survival risk. Deep learning-based artificial intelligence could be a useful tool for clinicians to diagnose and predict the prognosis of RCC patients, thus improving the process of individualised treatment.

Insights into virtual reality-based training for unexplained disease outbreaks: A qualitative exploration of Chinese standardized training nurses' experiences

BACKGROUND

An unexplained disease outbreak refers to a scenario wherein a group of individuals encounters similar health issues within a short timeframe, yet healthcare professionals find it challenging to promptly identify the specific cause or pathogenic factors triggering the outbreak. Emerging as a vital force in China, standardized training nurses can significantly mitigate the impact of unforeseen events.

OBJECTIVE

This study aims to illuminate the experiences of Chinese standardized training nurses engaged in training for unexplained disease outbreaks utilizing virtual reality (VR) technology.

DESIGN

A qualitative descriptive research design was employed.

PARTICIPANTS

Thirty Chinese standardized training nurses participated in semi-structured interviews.

METHODS

Data were collected through semi-structured interviews conducted from April 2023 to June 2023. Braun and Clark's thematic analysis method was applied for data analysis.

RESULTS

The study revealed five prominent themes: Surpassing Expectations, Enjoyable Learning, Self-challenge, Reflective Learning, and Promotion-Worthy. In essence, Chinese standardized training nurses perceived VR training as effective, meaningful, and conducive to reflective opportunities. Nevertheless, they expressed challenges in composing epidemiological reports, particularly when lacking expertise in epidemiology and having limited exposure to simulated training.

CONCLUSION

Virtual Reality (VR) technology plays a crucial role in continuing education after graduation (standardized training for nurses) in China, contributing to the enhancement of clinical practice standards and the promotion of teamwork collaboration. Its broader application is considered worthy of promotion.

Tumor morphology evaluation using 3D-morphometric features of renal masses

OBJECTIVE

To assess the correlation between the general (gender, age, and maximum tumor size) and 3D morphotopometric features of the renal tumor node, following the MSCT data post-processing, and the tumor histological structure; to propose an equation allowing for kidney malignancy assessment based on general and morphometric features.

MATERIALS AND METHODS

In total, 304 patients with unilateral solitary renal neoplasms underwent laparoscopic (retroperitoneoscopic) or robotic partial or radical nephrectomy. Before the procedure, kidney contrast-enhanced MSCT followed by the tumor 3D-modeling was performed. 3D model of the kidney tumor, and its morphotopometric features, and histological structure were analyzed. The morphotopometric ones include the side of the lesion, location by segments, the surface where the tumor, the depth of the tumor invasion into the kidney, and the shape of tumor.

RESULTS

Out of 304 patients, 254 (83.6%) had malignant kidney tumors and 50 (16.4%) benign kidney tumors. In total, 231 patients, out of 254 (90.9%) were assessed for the degree of malignant tumor differentiation. Malignant tumors were more frequent in men than in women (p < 0.001). Mushroom-shaped tumors were the most common shapes among benign renal masses (35.2%). The most common malignant kidney tumors had spherical with a partially uneven surface (27.6%), multinodular (tuberous (27.2%)), and spherical with a conical base (24.8%) shapes. Logistic regression model enabled the development of prognostic equation for tumor malignancy prediction ("low" or "high"). The univariate analysis revealed the correlation only between high differentiation (G1) and a spherical tumor with a conical base (p = 0.029).

CONCLUSION

The resulting logistic model, based on the analysis of such predictors as gender and form of kidney lesions, demonstrated a large share (87.6%) of correct predictions of the kidney tumor malignancy.

The effect of 11th rib excision on perioperative outcomes in patients undergoing partial nephrectomy for upper pole renal tumors

INTRODUCTION

We aimed to evaluate the effect of eleven11th rib resection.on the perioperative period TRIFECTA criteria in patients who underwent retroperitoneal partial nephrectomy (PN) with the diagnosis of upper pole kidney tumors.

MATERIALS AND METHODS

We conducted a retrospective analysis of the data of the patients who underwent Open PN for upper pole renal masses between 2018 and 2023. The patients were divided into two groups: PN with rib resection and PN without rib resection. The demographic characteristics, tumor sizes, PADUA scores, warm-cold renal ischemia times, mass excision and tumor bed suturing times, histopathological tumor type and surgical margin positivity of the patients were examined. Both groups were evaluated comparatively based on this data.

RESULTS

The renal nephrometry scores of the two groups were similar. The total renal ischemia time was significantly shorter in the patients who underwent a rib resection than in those who did not (p < 0.001). Both the tumor excision and tumor bed suturing times were significantly shorter in the group that underwent a rib resection than in the group that did not (p < 0.001). The Clavien-Dindo complication grades were statistically similar between the two groups.

CONCLUSION

Complex in nature and high-risk renal masses located in the upper pole of the kidney, partial nephrectomy performed with an 11th rib resection can be considered a reliable surgical option with a shorter ischemia time, supporting the preservation of long-term renal function.

Successful diaphragm repair following radiofrequency ablation for renal cell carcinoma: A case report

INTRODUCTION AND IMPORTANCE

This study aimed to assess the effectiveness of surgical intervention in treating traumatic diaphragmatic rupture accompanied by pleural empyema resulting from radiofrequency ablation for renal cell carcinoma.

CASE PRESENTATION

A 72-year-old female patient underwent radiofrequency ablation at our institution's urology department to address a 4-cm tumor in the left upper kidney detected during routine health screening. Subsequently, the patient experienced persistent fever from the 5th day post- procedure. Chest radiography revealed increased opacity in the left lower lung, prompting further evaluation with contrast-enhanced chest computed tomography. Examination revealed multiple loculated effusions and discernible diaphragmatic defects. Consequently, the patient was referred to the department of thoracic surgery, where an emergency surgery was performed. The surgical procedure was performed under general anesthesia the following day, revealing a 4-centimeter defect in the diaphragm along with damaged surrounding tissue and multiple loculated empyema sacs within the thoracic cavity. The intervention included excision of the empyema sacs, extensive irrigation, and reconstruction of the diaphragm using a 2-mm Gore- Tex membrane. One week postoperatively, the patient was discharged without any complications related to the procedure.

CLINICAL DISCUSSION

Although radiofrequency ablation is considered a relatively safe procedure with low complication rates, vigilant post-procedural monitoring is essential for detecting potentially serious complications.

CONCLUSION

Surgical intervention remains the preferred approach for the repair of traumatic diaphragmatic ruptures and is typically performed via thoracotomy.

French AFU Cancer Committee Guidelines - Update 2024-2026: Management of kidney cancer

OBJECTIVE

To update the French recommendations for the management of kidney cancer.

METHODS

A systematic review of the literature was conducted for the period from 2014 to 2024. The most relevant articles concerning the diagnosis, classification, surgical treatment, medical treatment, and follow-up of kidney cancer were selected and incorporated into the recommendations. The recommendations have been updated specifying the level of evidence (strong or weak).

RESULTS

Kidney cancer following prolonged occupational exposure to trichloroethylene should be considered an occupational disease. The reference examination for the diagnosis and staging of kidney cancer is the contrast-enhanced thoraco-abdominal CT scan. PET scans are not indicated in the staging of kidney cancer. Percutaneous biopsy is recommended in situations where its results will influence therapeutic decisions. It should be used to reduce the number of surgeries for benign tumors, particularly avoiding unnecessary radical nephrectomies. Kidney tumors should be classified according to the pTNM 2017 classification, the WHO 2022 classification, and the ISUP nucleolar grade. Metastatic kidney cancers should be classified according to IMDC criteria. Surveillance of tumors smaller than 2cm should be prioritized and can be offered regardless of patient age. Robot-assisted laparoscopic partial nephrectomy is the reference surgical treatment for T1 tumors. Ablative therapies and surveillance are options for elderly patients with comorbidities for tumors larger than 2cm. Stereotactic radiotherapy is an option to discuss for treating localized kidney tumors in patients not eligible for other treatments. Radical nephrectomy is the first-line treatment for locally advanced localized cancers. Pembrolizumab is recommended for patients at high risk of recurrence after surgery for localized kidney cancer. In metastatic patients, cytoreductive nephrectomy can be immediate in cases of good prognosis, delayed in cases of intermediate or poor prognosis for patients stabilized by medical treatment, or as "consolidation" in patients with complete or major partial response at metastatic sites after systemic treatment. Surgical or local treatment of metastases can be proposed for single lesions or oligometastases. Recommended first-line drugs for metastatic clear cell renal carcinoma are combinations of axitinib/pembrolizumab, nivolumab/ipilimumab, nivolumab/cabozantinib, and lenvatinib/pembrolizumab. Patients with non-clear cell metastatic kidney cancer should be presented to the CARARE Network and prioritized for inclusion in clinical trials.

CONCLUSION

These updated recommendations are a reference that will enable French and French-speaking practitioners to optimize their management of kidney cancer.

Nivolumab plus ipilimumab versus sunitinib for first-line treatment of advanced renal cell carcinoma: extended 8-year follow-up results of efficacy and safety from the phase III CheckMate 214 trial

BACKGROUND

Nivolumab plus ipilimumab (NIVO+IPI) has demonstrated superior overall survival (OS) and durable response benefits versus sunitinib (SUN) with long-term follow-up in patients with advanced renal cell carcinoma (aRCC). We report updated analyses with 8 years of median follow-up from CheckMate 214.

PATIENTS AND METHODS

Patients with aRCC (N = 1096) were randomized to NIVO 3 mg/kg plus IPI 1 mg/kg Q3W × four doses, followed by NIVO (3 mg/kg or 240 mg Q2W or 480 mg Q4W); or SUN (50 mg) once daily for 4 weeks on, 2 weeks off. The endpoints included OS, independent radiology review committee (IRRC)-assessed progression-free survival (PFS), and IRRC-assessed objective response rate (ORR) in intermediate/poor-risk (I/P; primary), intent-to-treat (ITT; secondary), and favorable-risk (FAV; exploratory) patients.

RESULTS

With 8 years (99.1 months) of median follow-up, the hazard ratio [HR; 95% confidence interval (CI)] for OS with NIVO+IPI versus SUN was 0.72 (0.62-0.83) in ITT patients, 0.69 (0.59-0.81) in I/P patients, and 0.82 (0.60-1.13) in FAV patients. PFS probabilities at 90 months were 22.8% versus 10.8% (ITT), 25.4% versus 8.5% (I/P), and 12.7% versus 17.0% (FAV), respectively. ORR with NIVO+IPI versus SUN was 39.5% versus 33.0% (ITT), 42.4% versus 27.5% (I/P), and 29.6% versus 51.6% (FAV). Rates of complete response were higher with NIVO+IPI versus SUN in all International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk groups (ITT, 12.0% versus 3.5%; I/P, 11.8% versus 2.6%; FAV, 12.8% versus 6.5%). The median duration of response (95% CI) with NIVO+IPI versus SUN was 76.2 versus 25.1 months [59.1 months-not estimable (NE) versus 19.8-33.2 months] in ITT patients, 82.8 versus 19.8 months (54.1 months-NE versus 16.4-26.4 months) in I/P patients, and 61.5 versus 33.2 months (27.8 months-NE versus 24.8-51.4 months) in FAV patients. The incidence of treatment-related adverse events was consistent with previous reports. Exploratory post hoc analyses are reported for FAV patients, those receiving subsequent therapy based on their response status, clinical subpopulations, and adverse events over time.

CONCLUSIONS

Superior survival, durable response benefits, and a manageable safety profile were maintained with NIVO+IPI versus SUN at 8 years, the longest phase III follow-up for a first-line checkpoint inhibitor combination therapy in aRCC.

Implementation of surgical rehearsal utilizing patient specific hydrogel kidney phantoms prior to complex renal cancer surgery: a pilot study

INTRODUCTION

With the advancement of surgical technology, the opportunity to integrate novel surgical preparation is imperative to improve patient outcomes and enhance safety.

METHODS

Patient specific perfused kidney phantoms including the tumor, parenchyma, artery, vein, and calyx were fabricated using 3D-printing and hydrogel injection molding from scans of 25 patients scheduled for robotic partial-nephrectomy (RAPN). Models are validated for anatomical accuracy, mechanical, functional properties and surrounded by the other models of relevant anatomy in a body cast for a simulated surgical rehearsal. We investigated the impact of these preoperative rehearsals preceding complex RAPN by analyzing changes in surgeons' decisions following review of both axial-imaging and following rehearsal simulation. Predictive ability of these rehearsal platforms was compared to live surgery outcomes and trifecta of cases as an outcome was calculated.

RESULTS

25 patients with complex renal tumors, average 9.8 nephrometry score and 4.9 cm mean tumor diameter were consented. Mean blood loss and WIT were 193.2 ml and 19.8 min. Two Clavien 2 complications were reported at 30-day postoperative. Trifecta was achieved in 17 (68%) of surgical cases. Surgeons' confidence in their ability to complete a partial nephrectomy and ability to predict WIT significantly increased from initial viewing the axial imaging to after the rehearsal. The correlation coefficient between the procedural clinical data collected during the rehearsals and live surgery were calculated.

CONCLUSION

The application of this versatile method for creating authentic perfused kidney phantoms can result in increased confidence in surgical plan and thus improved surgical performance and outcomes.

Identification of exosomal ceRNA networks as prognostic markers in clear cell renal cell carcinoma

Aggressive clear cell renal cell carcinoma (ccRCC) has a bad prognosis. We seek new ccRCC biomarkers for diagnosis and treatment. We used exoRBase and The Cancer Genome Atlas Database to compare DEmRNAs, DEmiRNAs, DElncRNAs, and DEcircRNAs in ccRCC and normal renal tissues. CircRNAs and circRNAs targeting microRNAs (miRNAs) were anticipated and taken intersections, and several databases assessed the targeted link between common miRNAs and messenger RNAs (mRNAs). The Cancer Genome Atlas database was used to create a predictive mRNA signature that was validated in E-MTAB-1980. Finally, we examined competing endogenous RNA network miRNAs and long noncoding RNAs for ccRCC predictive biomarkers using overall survival analysis. We built the first competing endogenous RNA regulation network of circRNA-lncRNA-miRNA-mRNA and found that it substantially correlates with ccRCC prognosis. We unveiled ccRCC's posttranscriptional regulation mechanism in greater detail. Our findings identified novel biomarkers for ccRCC diagnosis, therapy, and prognosis.

Long non-coding RNAs: regulators of autophagy and potential biomarkers in therapy resistance and urological cancers

The non-coding RNAs (ncRNAs) comprise a large part of human genome that mainly do not code for proteins. Although ncRNAs were first believed to be non-functional, the more investigations highlighted tthe possibility of ncRNAs in controlling vital biological processes. The length of long non-coding RNAs (lncRNAs) exceeds 200 nucleotidesand can be present in nucleus and cytoplasm. LncRNAs do not translate to proteins and they have been implicated in the regulation of tumorigenesis. On the other hand, One way cells die is by a process called autophagy, which breaks down proteins and other components in the cytoplasm., while the aberrant activation of autophagy allegedly involved in the pathogenesis of diseases. The autophagy exerts anti-cancer activity in pre-cancerous lesions, while it has oncogenic function in advanced stages of cancers. The current overview focuses on the connection between lncRNAs and autophagy in urological cancers is discussed. Notably, one possible role for lncRNAs is as diagnostic and prognostic variablesin urological cancers. The proliferation, metastasis, apoptosis and therapy response in prostate, bladder and renal cancers are regulated by lncRNAs. The changes in autophagy levels can also influence the apoptosis, proliferation and therapy response in urological tumors. Since lncRNAs have modulatory functions, they can affect autophagy mechanism to determine progression of urological cancers.

Qualitative and quantitative analysis of solid renal tumors by high-frame-rate contrast-enhanced ultrasound

OBJECTIVE

To analyze the characteristics of high-frame-rate contrast-enhanced ultrasound (H-CEUS) in solid renal tumors using qualitative and quantitative methods.

METHODS

Seventy-five patients who underwent preoperative conventional ultrasound (US), conventional contrast-enhanced ultrasound (C-CEUS), and H-CEUS examination of renal tumors were retrospectively analyzed, with a total of 89 renal masses. The masses were divided into the benign (30 masses) and malignant groups (59 masses) based on the results of enhanced computer tomography and pathology. The location, diameter, shape, border, calcification, and color doppler blood flow imaging (CDFI) of the lesions were observed by US, and the characteristics of the C-CEUS and H-CEUS images were qualitatively and quantitatively analyzed. The χ² test or Fisher's exact probability method was used to compare the US image characteristics between the benign and malignant groups, and the image characteristics of C-CEUS and H-CEUS between the benign and malignant groups. Moreover, the nonparametric Mann-Whitney test was used to compare the differences in C-CEUS and H-CEUS time-intensity curve (TIC) parameters.

RESULTS

Significant differences in gender, surgical approach, echogenicity, and CDFI were observed between the malignant and benign groups (p = 0.003, < 0.001, < 0.001, = 0003). Qualitative analysis also revealed significant differences in the mode of wash-out and fill-in direction between C-CEUS and H-CEUS in the malignant group (p = 0.041, 0.002). In addition, the homogeneity of enhancement showed significant differences between the two contrast models in the benign group (p = 0.009). Quantitative analysis indicated that the TIC parameters peak intensity (PI), deceleration time (DT) /2, area under the curve (AUC), and mean transition time (MTT) were significantly lower in the H-CEUS model compared to the C-CEUS model in both the benign and malignant groups. (all p < 0.001). In contrast, ascending slope of rise curve (AS) was significantly higher in the H-CEUS model compared to the C-CEUS model in the malignant group (p = 0.048).

CONCLUSIONS

In renal tumors, H-CEUS shows clearer internal enhancement of the mass and the changes in the wash-out period. The quantitative TIC parameters PI, DT/2, AUC, and MTT were lower in H-CEUS compared to C-CEUS. Both the quantitative and qualitative analyses indicated that H-CEUS better displays the characteristics of solid renal masses compared with C-CEUS.

Ultrasound-guided renal artery balloon catheter occluded hybrid partial nephrectomy (UBo-HPN) with branch renal artery occlusion: a single arm trial

BACKGROUND

One key focus of partial nephrectomy is preserving renal function. Segmental renal artery occlusion with microdissection at the renal hilum confines ischemia, effectively reducing warm ischemic injury. Ultrasound-Guided Renal Artery Balloon Catheter Occluded Hybrid Partial Nephrectomy (UBo-HPN) can achieve branch occlusion without the need for dissecting the renal hilum.

OBJECTIVE

To investigate the feasibility and safety of UBo-HPN of branch renal artery occlusion in the treatment of localized renal tumors.

SUBJECT AND METHODS

A prospective single-arm analysis involving 20 patients with renal localized tumors underwent robot assisted UBo-HPN with branch renal artery occlusion from August 2021 to July 2023, with an average follow-up of 12 months.

RESULTS

All patient was successfully operated on without conversion to conventional arterial clamping or radical nephrectomy. One case (5%) of minor complication occurred in the whole cohort, which was bruising around the puncture site. The mean total operative time was 95.8 min, with a mean operative time of 21.25 min for vascular intervention. The mean warm ischemia time was 20.35 min, and the median estimated blood loss was 50 ml. The median eGFR preservation percentage at postoperative 48 h, 30 days, and the latest follow-up were 87.52%, 91.47%, and 92.2%, respectively. After a median follow-up of 10.2 (2.3-19.2) months, no patients had radiological tumor recurrence or died from tumor-related causes.

CONCLUSIONS

UBo-HPN with renal artery branch occlusion emerges as an efficient alternative to partial nephrectomy (PN), which achieved branch artery occlusion without dissecting the renal hilum. Long-term follow-up is expected for functional outcomes.

Machine learning analysis for detecting late recurrence and loss to follow-up after renal cell carcinoma surgery

Objectives

Renal cell carcinoma (RCC) is shown to have a tendency for late recurrence, occurring 5 or more years after curative surgery. Imaging diagnosis is required for follow-up, and there is no definitive answer as to how long this should continue. Some patients discontinue follow-up visits at their own discretion. How best to predict late recurrence and loss to follow-up (LF) remains unclear.

Patients and methods

This study targeted patients diagnosed with non-metastatic RCC who underwent either radical or partial nephrectomy at Chiba University Hospital between 1988 and 2021. Follow-up for patients with RCC is typically lifelong. We used random survival forests (RSFs), a machine learning-based survival analysis method, to predict late recurrence and LF. For verification of prediction accuracy, we applied the time-dependent area under the receiver operating characteristic curve (t-AUC). To analyse the risks of late recurrence and LF, SurvSHAP(t) and partial dependence plots were used.

Results

We analysed 1051 cases in this study. Median follow-up was 58.5 (range: 0-376) months. The predictive accuracy of recurrence using RSF was t-AUC 0.806, 0.761, 0.674 and 0.566 at 60, 120, 180 and 240 months postoperatively, respectively. The recurrence risk impact showed a time-dependent increase up to approximately 50 months postoperatively. Beyond 50 months, there were no distinct risk factors characteristic of late recurrence. The predictive accuracy of LF using RSF was t-AUC 0.542, 0.699, 0.685, 0.628 and 0.674 at 60, 120, 180, 240 and 300 months postoperatively, respectively. The risk of LF increased with advancing age beyond 70 years.

Conclusion

It is difficult to identify factors that predict late recurrence. For long-term follow-up observation, it is essential to pay particular attention to patients with RCC aged 70 years and above. Establishing frameworks to facilitate collaboration with local hospitals near patients' residences and providing care within the community is necessary.

Meta-analysis of clinical outcomes of robot-assisted partial nephrectomy and classical open partial nephrectomy

BACKGROUND

Robotic-assisted partial nephrectomy (RAPN) has emerged as a promising alternative to classical partial nephrectomy (CPN).

AIM

This study aimed to compare the outcomes of RAPN and CPN for treating localized renal tumors through a meta-analysis of available literature.

METHODS

Chinese databases, such as CNKI, Chinese Science and Technology Periodicals Database (VIP), and Wanfang Full-text Database, were searched using Chinese search terms, and all published articles on PubMed and Web of Science were searched using English search terms. Articles on Localized Renal Tumors were included. RevMan5.3 software was used for meta-analysis. The funnel plots were drawn using Stata software to assess publication bias.

OUTCOMES

This study aimed to identify the differences between robotic-assisted partial nephrectomy and classic partial nephrectomy in patients with localized renal tumors.

RESULTS

In total, 67 articles with 17 677 patients were included. The results demonstrate the advantages of RAPN over CPN for localized renal tumors. Compared to CPN and RAPN had significant differences in intraoperative blood loss, hospital stay duration, incidence of perioperative complications, and proportion of patients requiring blood transfusion. Regarding surgical outcomes, RAPN showed more favorable results regarding the incidence of positive resection margins, postoperative decline in glomerular filtration rate (GFR), postoperative local recurrence rate, and proportion of Trifecta achieved. However, there was no significant difference between RAPN and CPN regarding 5-year tumor-specific survival rates.

CLINICAL IMPLICATIONS

The study suggests that robotic-assisted partial nephrectomy is a viable alternative to classic surgery for renal tumors.

STRENGTHS AND LIMITATIONS

The strengths of this study are the use of a comprehensive search strategy and the inclusion of studies published in both English and Chinese. The limitations of this study are the small sample size and the need for long-term follow-up data.

CONCLUSION

RAPN and CPN have similar overall survival outcomes for treating localized renal tumors. However, RAPN may offer advantages in terms of perioperative outcomes and preservation of renal function. Further studies are needed to confirm these findings and to identify the optimal surgical approach for individual patients.

Lipid metabolism reprogramming in renal cell carcinomas

This study investigates the intricate mechanisms underlying the correlation between elevated consumption of harmful fats and the onset of kidney malignancies. The rise in global obesity rates has been accompanied by an increased prevalence of renal cancers, prompting an exploration into the molecular pathways and biological processes linking these phenomena. Through an extensive review of current literature and clinical studies, we identify potential key factors contributing to the carcinogenic influence of harmful fats on renal tissues. Our analysis highlights the role of adipose tissue-derived factors, inflammatory mediators, and lipid metabolism dysregulation in fostering a microenvironment conducive to renal tumorigenesis. Furthermore, we delve into the impact of harmful fats on signaling pathways associated with cell proliferation, apoptosis evasion, and angiogenesis within the renal parenchyma. This review underscores the importance of elucidating the molecular intricacies linking lipid metabolism and kidney malignancies, offering a foundation for future research and the development of targeted preventive and therapeutic interventions. The findings discussed herein contribute to our understanding of the complex relationship between lipid mediators and renal cancer, providing a basis for public health strategies aimed at mitigating the impact of harmful fats on kidney health.

Role of Systematic Biopsy in the Era of Targeted Biopsy: A Review

Prostate cancer (PCa) is a major public health issue, as the second most common cancer and the fifth leading cause of cancer-related deaths among men. Many PCa cases are indolent and pose minimal risk, making active surveillance a suitable management approach. However, clinically significant prostate carcinoma (csPCa) can lead to serious health issues, including progression, metastasis, and death. Differentiating between insignificant prostate cancer (inPCa) and csPCa is crucial for determining appropriate treatment. Diagnosis of PCa primarily involves trans-perineal and transrectal systematic biopsies. Systematic transrectal prostate biopsy, which typically collects 10-12 tissue samples, is a standard method, but it can miss csPCa and is associated with some complications. Recent advancements, such as magnetic resonance imaging (MRI)-targeted biopsies, have been suggested to improve risk stratification and reduce overtreatment of inPCa and undertreatment of csPCa, thereby enhancing patient quality of life and treatment outcomes. Guided biopsies are increasingly recommended for their ability to better detect high-risk cancers while reducing identification of low-risk cases. MRI-targeted biopsies, especially when used as an initial biopsy in biopsy-naïve patients and those under active surveillance, have become more common. Utilization of MRI-TB alone can decrease septic complications; however, the combining of targeted biopsies with perilesional sampling is recommended for optimal detection of csPCa. Future advancements in imaging and biopsy techniques, including AI-augmented lesion detection and robotic-assisted sampling, promise to further improve the accuracy and effectiveness of PCa detection.

Cost-Effectiveness Analysis Comparing Biopsy in Advance of Ablation with Concurrent Biopsy and Ablation for Small Renal Masses Measuring 1-3 cm

PURPOSE

To analyze the cost effectiveness of performing a renal mass biopsy in advance of ablation or concurrently with a percutaneous ablation procedure for the management of small renal masses (SRMs).

MATERIALS AND METHODS

A decision-analytic model was developed with a cohort of 65-year-old male patients with an incidental, unilateral 1-3 cm SRM. A decision tree modeled the first year of clinical intervention, after which patients entered a Markov model with a lifetime horizon. Patients were assumed to be treated in accordance with established clinical practice guidelines, including surveillance, repeat ablation for recurrence, and systemic therapy for metastasis. Healthcare cost and utility values were determined from published literature or local hospital estimates, discounted at 1.5%. Total lifetime costs were calculated from the perspective of a Canadian healthcare payer and converted to 2022 Canadian dollars (C$). The primary outcome was incremental cost-effectiveness ratio (ICER) at a willingness-to-pay threshold of C$50,000 per quality-adjusted life year (QALY) gained. The secondary outcome was ICER at a willingness-to-pay threshold of C$50,000 per life year (LY) gained.

RESULTS

Concurrent biopsy and ablation resulted in a gain of 16.4 quality-adjusted days, at an incremental cost of $386, with an ICER of C$8,494/QALY. The concurrent strategy was the dominant strategy for a prevalence of benign mass of <5%. Sequential biopsy and ablation was only cost-effective when LYs were not quality-adjusted and ablation cost was >C$4,300 or benign mass prevalence was >28%.

CONCLUSIONS

Concurrent biopsy and ablation is cost-effective relative to pretreatment diagnostic biopsy for management of incidental SRMs.

A comprehensive review and meta-analysis comparing robot-assisted and laparoscopic adrenalectomy in individuals with obesity

This meta-analysis aimed to compare the efficacy of robot-assisted vs. laparoscopic adrenalectomy in individuals with obesity. We performed an extensive review of the PubMed, Embase, and Cochrane Library databases for research on adrenalectomy in individuals with obesity up to August 2024. Only studies comparing robot-assisted surgery with laparoscopic surgery were included. Only articles written in English were included. We utilized established criteria for inclusion and exclusion, concentrating on randomized controlled trials and cohort studies. The ROBINS-I instrument was employed to assess the bias risk in non-randomized control studies. Review Manager 5.4.1 was utilized to conduct the meta-analysis. The final analysis incorporated four retrospective cohort studies with a total of 492 individuals with obesity (261 receiving RA and 231 undergoing LA). The results showed that RA was linked to a shorter duration of hospitalization and less estimated blood loss in comparison to LA. Nonetheless, there were no notable distinctions between the two surgical methods in terms of OT, laparotomy conversion rates, overall postoperative complications, or death rates after surgery. In conclusion, RA is a reliable and safe choice for individuals with obesity. It offers notable advantages over LA in terms of LOHS and EBL.

Treatment Preferences Among Patients with Renal Cell Carcinoma: Results from a Discrete Choice Experiment

Introduction

The treatment landscape for advanced/metastatic renal cell carcinoma (aRCC) has evolved quickly with the introduction of immunotherapies as a first-line treatment option. This study examined the preferences of patients with aRCC to better understand the characteristics of preferred treatments and the tradeoffs patients are willing to make when choosing treatment.

Methods and Materials

An online, cross-sectional survey was conducted in the US from May to August 2022 with adult patients with aRCC. A discrete-choice experiment assessed treatment preferences for aRCC. Attributes were identified through literature review and qualitative interviews and included progression-free survival, survival time, objective response rate, duration of response, risk of serious side effects, quality of life (QoL), and treatment regimen.

Results

Survey results from 299 patients with aRCC were analyzed. Patients had a mean age of 55.7 years, were primarily White (50.5%) and were evenly representative of males (49.8%) and females (48.8%). Improvements in all attributes influenced treatment choice. On average, increasing survival time from 10% to 55% was most important, followed by improvements in QoL (ie, from worsens a lot to improves) and improvements to treatment regimen convenience (ie, less frequent infusions). Risk of serious adverse events and increased progression-free time, objective response rate (ORR), and duration of response (DOR) were of lesser importance.

Conclusion

In this study, patients highlighted that improving survival time was the most important and that QoL is also an important consideration. Discussions during treatment decision-making may benefit from broader conversations around treatment characteristics, including impacts on QoL and convenience of the regimen.

Perioperative, functional and oncologic outcomes of percutaneous ablation versus minimally invasive partial nephrectomy for clinical T1 renal tumors: outcomes from a pooled analysis

The objective of this study was to perform a comprehensive pooled analysis aimed at comparing the efficacy and safety of percutaneous ablation (PCA) versus minimally invasive partial nephrectomy (MIPN), including robotic and laparoscopic approaches, in patients diagnosed with cT1 renal tumors. We conducted a comprehensive search across four major electronic databases: PubMed, Embase, Web of Science, and the Cochrane Library, targeting studies published in English up to April 2024. The primary outcomes evaluated in this analysis included perioperative outcomes, functional outcomes, and oncological outcomes. A total of 2449 patients across 17 studies were included in the analysis. PCA demonstrated superior outcomes compared to MIPN in terms of shorter hospital stays (WMD: - 2.13 days; 95% Confidence Interval [CI]: - 3.29, - 0.97; p = 0.0003), reduced operative times (WMD: - 109.99 min; 95% CI: - 141.40, - 78.59; p < 0.00001), and lower overall complication rates (OR: 0.54; 95% CI: 0.40, 0.74; p = 0.0001). However, PCA was associated with a higher rate of local recurrence when compared to MIPN (OR: 3.81; 95% CI: 2.45, 5.92; p < 0.00001). Additionally, no significant differences were observed in major complications, estimated glomerular filtration rate decline, creatinine variation, overall survival, recurrence-free survival, and disease-free survival between the two treatment modalities. PCA presents a notable disadvantage regarding local recurrence rates in comparison to MIPN. However, PCA offers several advantages over MIPN, including shorter durations of hospital stay, reduced operative times, and lower complication rates, while achieving similar outcomes in other oncologic metrics.

Evaluation of the suitability of using ArtiSential in various renal surgery: IDEAL stage 1 study

BACKGROUND

ArtiSential, a new articulating laparoscopic instruments, addresses the limited movement associated with conventional laparoscopic instruments. This study was conducted to assess the clinical effectiveness of ArtiSential in detailed steps of various renal surgery.

METHODS

This study was approved by the Institutional Review Board of our institution and registered on the Clinical Research Information Service site of the Korea Disease Control and Prevention Agency. Participants meeting all inclusion and exclusion criteria were included in the clinical trial and underwent renal surgery. The clinical effectiveness of ArtiSential was assessed in terms of the feasibility and objective and subjective parameters across 9 detailed steps.

RESULTS

Of the 15 potential candidates enrolled from October 2021 to November 2021, 1 patient dropped out due to anaphylaxis from an anesthetic agent, and 14 patients underwent laparoscopic surgery using ArtiSential. Of the 14 patients, 2 patients were converted to laparoscopic surgery using straight-shaped instruments due to the ischemia time exceeding 30 min, and 1 patient due to excessive bleeding. The feasibility for most steps was more than 90%, except the renorrhaphy step. The median total operation time and ischemia time were 161 and 23 min, respectively. The median estimated blood loss was 58.5 mL. Two cases of venous injury occurred during renal pedicle dissection step. The accuracy of the procedure judged by reviewers and usability judged by the operator were acceptable in all steps. The surgeon's quantitatively measured stress score was the highest during renorrhaphy step.

CONCLUSIONS

Laparoscopic surgery using ArtiSential is feasible for most steps except the renorrhaphy step. The difficulty of performing renorrhaphy is attributed to prolonged ischemia time, which could be addressed by overcoming the learning curve.

TRIAL REGISTRATION

Clinical Research Information Service site of the Korea Disease Control and Prevention Agency, KCT0006532. Registered 03/09/2021, https://cris.nih.go.kr/cris/search/detailSearch.do?seq=24071 .

Network analysis of histopathological image features and genomics data improving prognosis performance in clear cell renal cell carcinoma

INTRODUCTION

Clear cell renal cell carcinoma is the most common type of kidney cancer, but the prediction of prognosis remains a challenge.

METHODS

We collected whole-slide histopathological images, corresponding clinical and genetic information from the The Cancer Imaging Archive and The Cancer Genome Atlas databases and randomly divided patients into training (n = 197) and validation (n = 84) cohorts. After feature extraction by CellProfiler, we used 2 different machine learning techniques (Least Absolute Shrinkage and Selector Operation-regularized Cox and Support Vector Machine-Recursive Feature Elimination) and weighted gene co-expression network analysis to select prognosis-related image features and genes, respectively. These features and genes were integrated into a joint model using random forest and used to create a nomogram that combines other predictive indicators.

RESULTS

A total of 4 overlapped features were identified, represented by the computed histopathological risk score in the random forest model, and showed predictive value for overall survival (test set: 1-year area under the curves (AUC) = 0.726, 3-year AUC = 0.727, and 5-year AUC = 0.764). The histopathological-genetic risk score (HGRS) integrating the genetic information computed performed better than the model that used image features only (test set: 1-year AUC = 0.682, 3-year AUC = 0.734, and 5-year AUC = 0.78). The nomogram (gender, stage, and HGRS) achieved the highest net benefit according to decision curve analysis compared to HGRS or clinical model.

CONCLUSION

This study developed a histopathological-genetic-related nomogram by combining histopathological features and clinical predictors, providing a more comprehensive prognostic assessment for clear cell renal cell carcinoma patients.

Percutaneous ablation versus robotic‑assisted partial nephrectomy for cT1 renal cell carcinoma: an evidence-based analysis of comparative outcomes

This investigation sought to conduct a comprehensive meta-analysis to assess the comparative effectiveness and safety of percutaneous ablation (PCA) versus robotic-assisted partial nephrectomy (RAPN) among individuals diagnosed with cT1 renal tumors. This study rigorously followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct a systematic review and meta-analysis. A systematic search was carried out in the PubMed, Embase, Web of Science, and Cochrane Library databases, focusing on studies published in English through February 2024. We focused on evaluating primary outcomes, specifically perioperative outcomes, functional outcomes, and oncological outcomes. In this analysis, data from 1534 patients across 13 studies were evaluated. PCA was found to have advantageous outcomes in comparison to RAPN regarding hospital stay durations, with a Weighted Mean Difference (WMD) of - 2.03 days (95% Confidence Interval [CI]: -3.78 to - 0.27; p = 0.02), operative times (WMD: -106.75 min; 95% CI: - 170.78 to - 42.72; p = 0.001), and overall complication rates (Odds Ratio [OR]: 0.61; 95% CI: 0.42 to 0.89; p = 0.01). Conversely, PCA showed a higher incidence of local recurrence compared to RAPN, with an OR of 3.20 (95% CI: 1.91 to 5.35; p < 0.00001). Moreover, there were no statistically significant differences between the two treatments in terms of major complications, declines in estimated glomerular filtration rates (eGFR), variations in creatinine levels, overall survival rates, and recurrence-free survival. While PCA exhibits higher local recurrence rates than RAPN, it also presents significant advantages, such as shorter hospital stays, decreased operative durations, and lower complication rates. This juxtaposition underscores the urgent need for further, more rigorous research to substantiate these findings.

Comprehensive investigation of malignant epithelial cell-related genes in clear cell renal cell carcinoma: development of a prognostic signature and exploration of tumor microenvironment interactions

Clear cell renal cell carcinoma (ccRCC) is a prevalent malignancy with complex heterogeneity within epithelial cells, which plays a crucial role in tumor progression and immune regulation. Yet, the clinical importance of the malignant epithelial cell-related genes (MECRGs) in ccRCC remains insufficiently understood. This research aims to undertake a comprehensive investigation into the functions and clinical relevance of malignant epithelial cell-related genes in ccRCC, providing valuable understanding of the molecular mechanisms and offering potential targets for treatment strategies. Using data from single-cell sequencing, we successfully identified 219 MECRGs and established a prognostic model MECRGS (MECRGs' signature) by synergistically analyzing 101 machine-learning models using 10 different algorithms. Remarkably, the MECRGS demonstrated superior predictive performance compared to traditional clinical features and 92 previously published signatures across six cohorts, showcasing its independence and accuracy. Upon stratifying patients into high- and low-MECRGS subgroups using the specified cut-off threshold, we noted that patients with elevated MECRGS scores displayed characteristics of an immune suppressive tumor microenvironment (TME) and showed worse outcomes after immunotherapy. Additionally, we discovered a distinct ccRCC tumor cell subtype characterized by the high expressions of PLOD2 (procollagen-lysine,2-oxoglutarate 5-dioxygenase 2) and SAA1 (Serum Amyloid A1), which we further validated in the Renji tissue microarray (TMA) cohort. Lastly, 'Cellchat' revealed potential crosstalk patterns between these cells and other cell types, indicating their potential role in recruiting CD163 + macrophages and regulatory T cells (Tregs), thereby establishing an immunosuppressive TME. PLOD2 + SAA1 + cancer cells with intricate crosstalk patterns indeed show promise for potential therapeutic interventions.

Al-Shammari Y, Soliman Y, Rezq H, Abdelazeem B, Kunadi A. The efficacy and safety of cabozantinib in patients with metastatic or advanced renal cell carcinoma: a systematic review and meta-analysis

Background

Cabozantinib, a new first-line treatment for advanced renal cell carcinoma (aRCC), targets essential tyrosine kinases and outperforms the established comparator (sunitinib) in various efficacy outcomes. This systematic review and meta-analysis aimed to assess the efficacy and safety of cabozantinib compared to other aRCC treatments.

Methods

Following PRISMA and Cochrane guidelines, our protocol was registered in PROSPERO. A systematic search, without date limits, was conducted on PubMed, Cochrane, Web of Science, and EMBASE until October 8, 2023. Data extraction encompassed study details, baseline information, and outcomes. Hazard ratios (HR) and risk ratios (RR) with 95% confidence intervals were employed for each outcome, and a random-effects model was applied to account for expected heterogeneity.

Results

Three studies, encompassing 967 patients, were included in our analysis. In terms of efficacy, the pooled rate for overall survival significantly favored cabozantinib. However, in subgroup analyses, cabozantinib was only statistically superior to everolimus. For progression-free survival and tumor objective response rate, cabozantinib outperformed both everolimus and sunitinib. In adverse events, compared to sunitinib, cabozantinib exhibited inferiority in nearly all evaluated aspects, except for nausea and stomatitis, which showed no difference between the two groups. Conversely, it demonstrated a comparable risk profile with everolimus across various side effects.

Conclusion

Cabozantinib shows significant efficacy in extending overall survival, progression-free survival, and tumor objective response rate despite a potentially higher risk of adverse events compared to sunitinib. These findings support cabozantinib as a first-line therapy for aRCC, either as an initial treatment or after prior VEGFR-targeted therapies.

High peripheral neutrophil and monocyte count distinguishes renal cell carcinoma from renal angiomyolipoma and predicts poor prognosis of renal cell carcinoma

Background

The presence of peripheral inflammatory cells has been linked to the prognosis of cancer. This study aims to investigate the distinct roles of absolute neutrophil count (ANC) and absolute monocyte count (AMC) in differentiating renal cell carcinoma (RCC) from renal angiomyolipoma (RAML), as well as their prognostic significance in RCC.

Methods

We conducted a comprehensive analysis of peripheral immune cell data, clinicopathological data, and tumor characteristics in patients diagnosed with RCC or RAML from January 2015 to December 2021. Receiver operating characteristic (ROC) curves, as well as univariate and multivariate analyses, were employed to assess the diagnostic utility of AMC and ANC in differentiating between RCC and RAML. Kaplan-Meier curve analysis was used to study the survival of RCC patients with different AMC and ANC. The prognostic value of AMC and ANC in RCC was investigated using COX univariate and multivariate analysis. The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases were used for bioinformatic correlation analysis.

Results

A total of 1120 eligible patients were included in the study. The mean preoperative AMC and ANC in patients with RCC were found to be significantly higher compared to those in patients with RAML (P = 0.001 and P < 0.001, respectively). High preoperative AMC and ANC significantly correlated with smoking history, tumor length, gross hematuria, and high T Stage, N stage, and pathological grade. In multivariate analyses, an ANC> 3.205 *10^9/L was identified to be independently associated with the presence of RCC (HR = 1.618, P = 0.008). High AMC and ANC were significantly associated with reduced OS and PFS (P < 0.05), and ANC may be an independent prognostic factor. Public database analysis showed that signature genes of tumor-associated macrophages (TAMs) and tumor-associated neutrophils (TANs) were highly expressed in ccRCC.

Conclusions

Elevated preoperative ANC and AMC can distinguish RCC from RAML and predict poor prognosis in patients with RCC. Furthermore, the signature genes of TAMs and TANs exhibit high expression levels in clear cell RCC.

Deep learning-based pathological prediction of lymph node metastasis for patient with renal cell carcinoma from primary whole slide images

BACKGROUND

Metastasis renal cell carcinoma (RCC) patients have extremely high mortality rate. A predictive model for RCC micrometastasis based on pathomics could be beneficial for clinicians to make treatment decisions.

METHODS

A total of 895 formalin-fixed and paraffin-embedded whole slide images (WSIs) derived from three cohorts, including Shanghai General Hospital (SGH), Clinical Proteomic Tumor Analysis Consortium (CPTAC) and Cancer Genome Atlas (TCGA) cohorts, and another 588 frozen section WSIs from TCGA dataset were involved in the study. The deep learning-based strategy for predicting lymphatic metastasis was developed based on WSIs through clustering-constrained-attention multiple-instance learning method and verified among the three cohorts. The performance of the model was further verified in frozen-pathological sections. In addition, the model was also tested the prognosis prediction of patients with RCC in multi-source patient cohorts.

RESULTS

The AUC of the lymphatic metastasis prediction performance was 0.836, 0.865 and 0.812 in TCGA, SGH and CPTAC cohorts, respectively. The performance on frozen section WSIs was with the AUC of 0.801. Patients with high deep learning-based prediction of lymph node metastasis values showed worse prognosis.

CONCLUSIONS

In this study, we developed and verified a deep learning-based strategy for predicting lymphatic metastasis from primary RCC WSIs, which could be applied in frozen-pathological sections and act as a prognostic factor for RCC to distinguished patients with worse survival outcomes.

Tracing the evolving dynamics and research hotspots in the kidney neoplasm and nephron sparing surgery field from the past to the new era

BACKGROUND

With increasing detection of small renal masses and accumulating evidence that nephron sparing surgery (NSS) could achieve oncological equivalence and functional superiority compared with radical nephrectomy (RN), NSS has become first-line therapy for some patients with localized renal masses.

OBJECTIVE

This study aims to review the publications in the kidney neoplasm and NSS field, exploring the research hotspots.

METHOD

Kidney neoplasm and NSS related publications before July 3th 2023 were obtained from the Web of Science Core Collection database. We then used bibliometric analysis to conduct performance analysis, citation analysis and co-citation network of publications, together with keyword co-occurrence analysis.

RESULTS

Seven thousand five hundred and sixty-four documents were finally retrieved, and the annual publications increased exponentially. The most productive authors were "KAOUK JH" and "GILL IS", while USA, and 12 American affiliations such as CLEVELAND CLINIC FOUNDATION and MAYO CLINIC were far leading in this field. Journal of Urology and European Urology were journals with the highest citations and h-index.

DISCUSSION

Through literature reviewing plus co-occurrence and clustering analysis, the therapeutic effects of partial nephrectomy (PN) versus RN on patients with localized renal cell carcinoma, different operative approaches of PN, and conservative NSS methods were deemed as the most focused topics.

CONCLUSION

Three aspects were the most important hotspots in this field. Firstly, how to provide the optimal management choices for different patients. Secondly, therapeutic effects of different management options and surgical techniques needed more prospective and randomized studies. Finally, more novel technologies and surgical techniques were required.

LASSO regression and WGCNA-based telomerase-associated lncRNA signaling predicts clear cell renal cell carcinoma prognosis and immunotherapy response

OBJECTIVE

To investigate whether telomerase-associated lncRNA expression affects the prognosis and anti-tumor immunity of patients with renal clear cell carcinoma (ccRCC).

METHODS

A series of analyses were performed to establish a prognostic risk model and validate its accuracy. Immune-related analyses were performed to assess further the association between immune status, tumor microenvironment, and prognostic risk models.

RESULTS

Eight telomerase-associated lncRNAs associated with prognosis were identified and applied to establish a prognostic risk model. Overall survival was higher in the low-risk group.

CONCLUSION

The established prognostic risk model has a good predictive ability for the prognosis of ccRCC patients and provides a new possible therapeutic target for ccRCC.

Molecular subtypes of clear cell renal carcinoma based on PCD-related long non-coding RNAs expression: insights into the underlying mechanisms and therapeutic strategies

BACKGROUND

PCD-related long non-coding RNAs (PRLs) are rarely investigated in relation to clear cell renal carcinoma (ccRCC). As part of this study, we evaluated the immunological potential of PRL signatures as a biomarker for ccRCC prognosis and immunological function.

MATERIALS AND METHODS

Data were downloaded from the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA) databases. A Pearson correlation analysis was conducted on the 27 PCD-associated genes to determine whether lncRNAs were significantly associated with PCD. Kaplan-Meier analysis, biological function identification, immune infiltration analysis, estimation of efficacy of immunotherapy and targeted drug screening, and exploration of the landscape of mutation status were conducted by analyzing the risk scores.

RESULTS

Seven PRLs, LINC02747, AP001636.3, AC022126.1, LINC02657, LINC02609, LINC02154, and ZNNT1, were used to divide patients with ccRCC into groups with high and low risk. High-risk patients had a worse prognosis than low-risk patients, according to the results, and the PRL signature showed promising predictive ability. More immune cells were clustered in the high-risk group, whereas the immune cell function of the low-risk group was significantly suppressed. The high-risk group was less sensitive to immunotherapy, whereas the low-risk group had positive responses to most drugs.

CONCLUSIONS

Collectively, we established and verified a PRL signature that could competently guide the prognostic survival and immunotherapy of ccRCC. In addition, molecular subtypes were determined for ccRCC based on PRL expression, which may help elucidate the underlying molecular mechanism of ccRCC and develop targeted treatments.

Assessing the role of programmed cell death signatures and related gene TOP2A in progression and prognostic prediction of clear cell renal cell carcinoma

Kidney Clear Cell Carcinoma (KIRC), the predominant form of kidney cancer, exhibits a diverse therapeutic response to Immune Checkpoint Inhibitors (ICIs), highlighting the need for predictive models of ICI efficacy. Our study has constructed a prognostic model based on 13 types of Programmed Cell Death (PCD), which are intertwined with tumor progression and the immune microenvironment. Validated by analyses of comprehensive datasets, this model identifies seven key PCD genes that delineate two subtypes with distinct immune profiles and sensitivities to anti-PD-1 therapy. The high-PCD group demonstrates a more immune-suppressive environment, while the low-PCD group shows better responses to PD-1 treatment. In particular, TOP2A emerged as crucial, with its inhibition markedly reducing KIRC cell growth and mobility. These findings underscore the relevance of PCDs in predicting KIRC outcomes and immunotherapy response, with implications for enhancing clinical decision-making.

Comparing Sonazoid contrast-enhanced ultrasound to contrast-enhanced CT and MRI for differentially diagnosing renal lesions: a prospective multicenter study

PURPOSE

To evaluate the diagnostic performance of contrast-enhanced (CE) ultrasound using Sonazoid (SNZ-CEUS) by comparing with contrast-enhanced computed tomography (CE-CT) and contrast-enhanced magnetic resonance imaging (CE-MRI) for differentiating benign and malignant renal masses.

MATERIALS AND METHODS

306 consecutive patients (from 7 centers) with renal masses (40 benign tumors, 266 malignant tumors) diagnosed by both SNZ-CEUS, CE-CT or CE-MRI were enrolled between September 2020 and February 2021. The examinations were performed within 7 days, but the sequence was not fixed. Histologic results were available for 301 of 306 (98.37%) lesions and 5 lesions were considered benign after at least 2 year follow-up without change in size and image characteristics. The diagnostic performances were evaluated by sensitivity, specificity, positive predictive value, negative predictive value, and compared by McNemar's test.

RESULTS

In the head-to-head comparison, SNZ-CEUS and CE-MRI had comparable sensitivity (95.60 vs. 94.51%, P = 0.997), specificity (65.22 vs. 73.91%, P = 0.752), positive predictive value (91.58 vs. 93.48%) and negative predictive value (78.95 vs. 77.27%); SNZ-CEUS and CE-CT showed similar sensitivity (97.31 vs. 96.24%, P = 0.724); however, SNZ-CEUS had relatively lower than specificity than CE-CT (59.09 vs. 68.18%, P = 0.683). For nodules > 4 cm, CE-MRI demonstrated higher specificity than SNZ-CEUS (90.91 vs. 72.73%, P = 0.617) without compromise the sensitivity.

CONCLUSIONS

SNZ-CEUS, CE-CT, and CE-MRI demonstrate desirable and comparable sensitivity for the differentiation of renal mass. However, the specificity of all three imaging modalities is not satisfactory. SNZ-CEUS may be a suitable alternative modality for patients with renal dysfunction and those allergic to gadolinium or iodine-based agents.

ctDNA predicts clinical T1a to pathological T3a upstaging after partial nephrectomy

Most patients diagnosed with clear cell renal cell carcinoma (ccRCC) are also detected with small and organ-confined tumors, and the majority of these are classified as clinical tumor stage 1a (cT1a). A considerable proportion of patients with cT1 RCC shows tumor upstaging to pathological stage 3a (pT3a), and these patients have worse oncological outcomes. The role of circulating tumor DNA (ctDNA) in RCC has been limited to monitoring treatment response and resistance. Therefore, the present study aimed to evaluate the potential of ctDNA in predicting pT3a upstaging in cT1a ccRCC. We sequenced plasma samples preoperatively collected from 48 patients who had undergone partial nephrectomy for cT1a ccRCC using data from a prospective cohort RCC. The ctDNA were profiled and compared with clinicopathological ccRCC features to predict pT3a upstaging. Associations between ctDNA, tumor complexity, and pT3a upstaging were evaluated. Tumor complexity was assessed using the anatomical classification system. Univariate analysis used chi-squared and Student's t-tests; multivariate analysis considered significant factors from univariate analyses. Of the 48 patients with cT1a ccRCC, 12 (25%) were upstaged to pT3a, with ctDNA detected in 10 (20.8%), predominantly in patients with renal sinus fat invasion (SFI; n = 8). Among the pT3a group, ctDNA was detected in 75%, contrasting with only 2.8% in patients with pT1a (1/36). Detection of ctDNA was the only significant preoperative predictor of pT3a upstaging, especially in SFI. This study is the first to suggest ctDNA as a preoperative predictor of pT3a RCC upstaging from cT1a based on preoperative radiological images.

Transforming growth factors β and their signaling pathway in renal cell carcinoma and peritumoral space-transcriptome analysis

PURPOSE

The aim of the study was to verify hypotheses: Are transforming growth factors TGFβ1-3, their receptors TGFβI-III, and intracellular messenger proteins Smad1-7 involved in the pathogenesis of kidney cancer? What is the expression of genes of the TGFβ/Smads pathway in renal cell carcinoma (RCC) tissues, peritumoral tissues (TME; tumor microenvironment), and in normal kidney (NK) tissue?.

METHODS

Twenty patients with RCC who underwent total nephrectomy were included into the molecular analysis. The mRNA expression of the genes was quantified by RT-qPCR.

RESULTS

The study showed that the expression of the genes of TGFβ/Smads pathway is dysregulated in both RCC and the TME: TGFβ1, TGFβ3 expression is increased in the TME in comparison to the NK tissues; TGFβ2, TGFβ3, TGFβRI, TGFβRIII, Smad1, Smad2, Smad3, and Smad6 are underexpressed in RCC comparing to the TME tissues; TGFβRI, TGFβRIII, and Smad2 are underexpressed in RCC in comparison to the NK tissues.

CONCLUSION

On the one hand, the underexpression of the TGFβ signaling pathway genes within the malignant tumor may result in the loss of the antiproliferative and pro-apoptotic activity of this cytokine. On the other hand, the overexpression of the TGFβ/Smads pathway genes in the TME than in tumor or NK tissues most probably results in an immunosuppressive effect in the space surrounding the tumor and may have an antiproliferative and pro-apoptotic effect on non-neoplastic cells present in the TME. The functional and morphological consistency of this area may determine the aggressiveness of the tumor and the time in which the neoplastic process will spread.

Dose-response of localized renal cell carcinoma after stereotactic body radiation therapy: A meta-analysis

BACKGROUND

Stereotactic ablative radiation therapy (SBRT) is an emerging treatment option for primary renal cell carcinoma (RCC), particularly in patients who are unsuitable for surgery. The aim of this review is to assess the effect of increasing the biologically equivalent dose (BED) via various radiation fractionation regimens on clinical outcomes.

METHODS

A literature search was conducted in PubMed (Medline), EMBASE, and the Cochrane Library for studies published up to October 2023. Studies reporting on patients with localized RCC receiving SBRT were included to determine its effectiveness on local control, progression-free survival, and overall survival. A random effects model was used to meta-regress clinical outcomes relative to the BED for each study and heterogeneity was assessed by I2.

RESULTS

A total of 724 patients with RCC from 22 studies were included, with a mean age of 72.7 years (range: 44.0-81.0). Local control was excellent with an estimate of 99 % (95 %CI: 97-100 %, I2 = 19 %), 98 % (95 %CI: 96-99 %, I2 = 8 %), and 94 % (95 %CI: 90-97 %, I2 = 11 %) at one year, two years, and five years respectively. No definitive association between increasing BED and local control, progression-free survival and overall survival was observed. No publication bias was observed.

CONCLUSIONS

A significant dose response relationship between oncological outcomes and was not identified, and excellent local control outcomes were observed at the full range of doses. Until new evidence points otherwise, we support current recommendations against routine dose escalation beyond 25-26 Gy in one fraction or 42-48 Gy in three fractions, and to consider de-escalation or compromising target coverage if required to achieve safe organ at risk doses.

Time trends in surgical provision and cancer-specific outcomes in patients with stage T2-3 kidney cancer: a SEER-based study

Background and objective

Surgery is the primary therapy that crucially affects the survival of patients with kidney cancer (KC). However, pertinent surgical decision criteria for individuals with stage T2-3 KC are lacking. This study aimed to display the practical choices and evolving trends of surgical procedures and elucidate their implied value.

Methods

Through the Surveillance, Epidemiology, and End Results (SEER) dataset, the levels and evolving trends of different surgical methods were examined to determine cancer-specific risk of death (CSRD). Additionally, stratification analysis and survival rate analysis were performed to explore the effectiveness of partial nephrectomy (PN).

Results

In this study, 9.27% of patients opted for PN. Interestingly, an upward trend was observed in its decision, with an average annual percentage change (AAPC) of 7.0 (95% CI: 4.8-9.3, P < 0.05). Patients who underwent PN and were in a relatively less severe condition exhibited more favorable CSRD levels (0.17-0.36 vs. 0.50-0.67) and an improvement trend compared with those who underwent radical nephrectomy (RN) (AAPC: -1.9 vs. -0.8). Further analysis showed that the levels of CSRD and survival rates for patients opting for different surgical methods followed a similar pattern.

Conclusions

This study showed that RN was still the most common surgical method. Patients with stage T2-3 KC had an increasing preference for PN and exhibited more favorable cancer-related survival outcomes, which underscores the need for further investigation and validation.

MED15 is upregulated by HIF-2α and promotes proliferation and metastasis in clear cell renal cell carcinoma via activation of SREBP-dependent fatty acid synthesis

Emerging evidence has highlighted that dysregulation of lipid metabolism in clear cell renal cell carcinoma (ccRCC) is associated with tumor development and progression. HIF-2α plays an oncogenic role in ccRCC and is involved in abnormal lipid accumulation. However, the underlying mechanisms between these two phenomena remain unknown. Here, MED15 was demonstrated to be a dominant factor for HIF-2α-dependent lipid accumulation and tumor progression. HIF-2α promoted MED15 transcriptional activation by directly binding the MED15 promoter region, and MED15 overexpression significantly alleviated the lipid deposition inhibition and malignant tumor behavior phenotypes induced by HIF-2α knockdown. MED15 was upregulated in ccRCC and predicted poor prognosis. MED15 promoted lipid deposition and tumor progression in ccRCC. Mechanistic investigations demonstrated that MED15 acts as SREBP coactivator directly interacting with SREBPs to promote SREBP-dependent lipid biosynthesis enzyme expression, and promotes SREBP1 and SREBP2 activation through the PLK1/AKT axis. Overall, we describe a molecular regulatory network that links MED15 to lipid metabolism induced by the SREBP pathway and the classic HIF-2α pathway in ccRCC. Efforts to target MED15 or inhibit MED15 binding to SREBPs as a novel therapeutic strategy for ccRCC may be warranted.