Prognostic models and algorithms in renal cell carcinoma

A three miRNAs panel in paraffin tissue serves as tool for predicting prognosis of renal cell carcinoma

Background

Renal cell carcinoma (RCC) stands as the most prevalent form of urogenital cancer. However, there is currently no universally accepted method for predicting the prognosis of RCC. MiRNA holds great potential as a prognostic biomarker for RCC.

Methods

A total of 100 cases with complete paraffin specimens and over 5-year follow-up data meeting the requirements were collected. Utilizing the clinical information and follow-up data of the specimens, an information model was developed. The expression levels of eight microRNAs were identified using RT-qPCR. Finally, determine and analyze the clinical application value of these microRNAs as prognostic markers for RCC.

Results

Significant differences were observed in the expression of two types of miRNAs (miR-378a-5p, miR-23a-5p) in RCC tissue, and three types of miRNAs (miR-378a-5p, miR-642a-5p, miR-23a-5p) were found to be linked to the prognosis of RCC. Establish biomarker combinations of miR-378a-5p, miR-642a-5p, and miR-23a-5p to evaluate RCC prognosis.

Conclusion

The combination of three microRNA groups (miR-378a-5p, miR-642a-5p, and miR-23a-5p) identified in paraffin section specimens of RCC in this study holds significant potential as biomarkers for assessing RCC prognosis.

NAA10 gene expression is associated with mesenchymal transition, dedifferentiation, and progression of clear cell renal cell carcinoma

INTRODUCTION

We aimed to investigate the expression and prognostic role of NAA10 in clear cell renal cell carcinoma (ccRCC).

MATERIAL AND METHODS

We performed a gene expression and survival analysis based on the human cancer genome atlas database of ccRCC patients (TCGA-KIRC).

RESULTS

The patients in the TCGA-KIRC (n = 537) were divided into two subgroups: NAA10-low and NAA10-high expression groups. NAA10-high ccRCC exhibited higher T stages (p = 0.002), a higher frequency of distant metastasis (p = 0.018), more advanced AJCC stages (p < 0.001), a lower overall survival time (p = 0.036), and a lower survival rate (p < 0.001). NAA10-high ccRCC was associated with increased activity of non-specific oncogenic pathways, including oxidative phosphorylation (p < 0.001) and cell cycle progression [G2 to M phase transition (p = 0.045) and E2F targets (p < 0.001)]. Additionally, the NAA10-high tumors showed reduced apoptosis via TRIAL pathways (p < 0.001) and increased levels of activity that promoted epithelial-mesenchymal transition (p = 0.026) or undifferentiation (p = 0.01). In ccRCC, NAA10 expression was found to be a negative prognostic factor in both non-metastatic (p < 0.001) and metastatic tumors (p = 0.032).

CONCLUSIONS

In ccRCC, NAA10 expression was shown to be a negative prognostic factor related to tumor progression rather than tumor initiation, and high NAA10 expression promoted epithelial-mesenchymal transition and undifferentiation.

2018 Leibovich prognostic model for renal cell carcinoma: Performance in a large population with special consideration of Black race

BACKGROUND

The 2018 Leibovich prognostic model for nonmetastatic renal cell carcinoma (RCC) combines clinical, surgical, and pathologic factors to predict progression-free survival (PFS) and cancer-specific survival (CSS) for patients with clear cell (ccRCC), papillary (pRCC), and chromophobe (chRCC) histology. Despite high accuracy, <1% of the original cohort was Black. Here, the authors examined this model in a large population with greater Black patient representation.

METHODS

By using a prospectively maintained RCC institutional database, patients were assigned Leibovich model risk scores. Survival outcomes included 5-year and 10-year PFS and CSS. Prognostic accuracy was determined using area under the curve (AUC) analysis and calibration plots. Black patient subanalyses were conducted.

RESULTS

In total, 657 (29%) of 2295 patients analyzed identified as Black. Declines in PFS and CSS were observed as scores increased. Discrimination for ccRCC was strong for PFS (AUC: 5-year PFS, 0.81; 10-year PFS, 0.78) and for CSS (AUC: 5-year CSS, 0.82; 10-year CSS, 0.74). The pRCC AUC for PFS was 0.74 at 5 years and 0.71 at 10 years; and the AUC for CSS was 0.74 at 5 years and 0.70 at 10 years. In chRCC, better performance was observed for CSS (AUC at 5 years, 0.75) than for PFS (AUC: 0.66 at 5 years; 0.55 at 10 years). Black patient subanalysis revealed similar-to-improved performance for ccRCC at 5 years (AUC: PFS, 0.79; CSS, 0.87). For pRCC, performance was lower for PFS (AUC at 5 years, 0.63) and was similar for CSS (AUC at 5 years, 0.77). Sample size limited Black patient 10-year and chRCC analyses.

CONCLUSIONS

The authors externally validated the 2018 Leibovich RCC prognostic model and found optimal performance for ccRCC, followed by pRCC, and then chRCC. Importantly, the results were consistent in this large representation of Black patients.

PLAIN LANGUAGE SUMMARY

In 2018, a model to predict survival in patients with renal cell carcinoma (kidney cancer) was introduced by Leibovich et al. This model has performed well; however, Black patients have been under-represented in examination of its performance. In this study, 657 Black patients (29%) were included, and the results were consistent. This work is important for making sure the model can be applied to all patient populations.

STING is a prognostic factor related to tumor necrosis, sarcomatoid dedifferentiation, and distant metastasis in clear cell renal cell carcinoma

STING is a molecule involved in immune reactions against double-stranded DNA fragments, released in infective and neoplastic diseases, whose role in the interactions between immune and neoplastic cells in clear cell renal cell carcinoma has not been studied yet. We investigated the immunohistochemical expression of STING in a series of 146 clear-cell renal cell carcinomas and correlated it with the main pathological prognostic factors. Furthermore, tumoral inflammatory infiltrate was evaluated and studied for the subpopulations of lymphocytes. Expression of STING was observed in 36% (53/146) of the samples, more frequently in high-grade (G3-G4) tumors (48%,43/90) and recurrent/metastatic ones (75%, 24/32) than in low grade (G1-G2) and indolent neoplasms (16%, 9/55). STING staining correlated with parameters of aggressive behavior, including coagulative granular necrosis (p = 0.001), stage (p < 0.001), and development of metastases (p < 0.001). Among prognostic parameters, STING immune expression reached an independent statistical significance (p = 0.029) in multivariable analysis, along with the stage and the presence of coagulative granular necrosis. About tumor immune-environment, no significant statistical association has been demonstrated between tumor-infiltrating lymphocytes and STING. Our results provide novel insights regarding the role of STING in aggressive clear cell renal cell carcinomas, suggesting its adoption as a prognostic marker and a potentially targetable molecule for specific immunotherapies.

Imaging Recommendations for Diagnosis, Staging, and Management of Renal Tumors

Renal cell carcinomas accounts for 2% of all the cancers globally. Most of the renal tumors are detected incidentally. Ultrasound remains the main screening modality to evaluate the renal masses. A multi -phase contrast enhanced computer tomography is must for characterizing the renal lesions. Imaging plays an important role in staging, treatment planning and follow up of renal cancers. In this review , we discuss the imaging guidelines for the management of renal tumors.

Construction of a ferroptosis-related signature based on seven lncRNAs for prognosis and immune landscape in clear cell renal cell carcinoma

BACKGROUND

Recent studies have demonstrated that long non-coding RNAs (lncRNAs) are involved in regulating tumor cell ferroptosis. However, prognostic signatures based on ferroptosis-related lncRNAs (FRLs) and their relationship to the immune microenvironment have not been comprehensively explored in clear cell renal cell carcinoma (ccRCC).

METHODS

In the present study, the expression profiles of ccRCC were acquired from The Cancer Genome Atlas (TCGA) database; 459 patient specimens and 69 adjacent normal tissues were randomly separated into training or validation cohorts at a 7:3 ratio. We identified 7 FRLs that constitute a prognostic signature according to the differential analysis, correlation analysis, univariate regression, and least absolute shrinkage and selection operator (LASSO) Cox analysis. To identify the independence of risk score as a prognostic factor, univariate and multivariate regression analyses were also performed. Furthermore, CIBERSORT was conducted to analyze the immune infiltration of patients in the high-risk and low-risk groups. Subsequently, the differential expression of immune checkpoint and m6A genes was analyzed in the two risk groups.

RESULTS

A 7-FRLs prognostic signature of ccRCC was developed to distinguish patients into high-risk and low-risk groups with significant survival differences. This signature has great prognostic performance, with the area under the curve (AUC) for 1, 3, and 5 years of 0.713, 0.700, 0.726 in the training set and 0.727, 0.667, and 0.736 in the testing set, respectively. Moreover, this signature was significantly associated with immune infiltration. Correlation analysis showed that risk score was positively correlated with regulatory T cells (Tregs), activated CD4 memory T cells, CD8 T cells and follicular helper T cells, whereas it was inversely correlated with monocytes and M2 macrophages. In addition, the expression of fourteen immune checkpoint genes and nine m6A-related genes varied significantly between the two risk groups.

CONCLUSION

We established a novel FRLs-based prognostic signature for patients with ccRCC, containing seven lncRNAs with precise predictive performance. The FRLs prognostic signature may play a significant role in antitumor immunity and provide a promising idea for individualized targeted therapy for patients with ccRCC.

Heterogeneity of Hippo signalling activity in different histopathologic subtypes of renal cell carcinoma

This study aimed to reveal the prognostic role of the Hippo pathway in different histopathological subtypes of renal cell carcinoma (RCC). The TCGA-KIRC (n = 537), TCGA-KIRP (n = 291) and TCGA-KICH (n = 113), which contain data about clear cell (ccRCC), papillary (pRCC) and chromophobe RCC (chRCC), respectively, were investigated. Gene Set Variation Analysis was used to compare the activity of many pathways within a single sample. Oncogenic pathway-related expression differed between cases of ccRCC involving low and high Hippo pathway activity. There were two subsets of ccRCC, in which the cancer exhibited lower and higher Hippo signalling activity, respectively, compared with normal tissue. In the ccRCC cohort, lower Hippo pathway activity was associated with a higher clinical stage (p < 0.001). The Hippo pathway (HR = 0.29; 95% CI = 0.17-0.50, p < 0.001), apoptosis (HR = 6.02; 95% CI = 1.47-24.61; p = 0.013) and the p53 pathway (HR = 0.09; 95% CI = 0.02-0.36; p < 0.001) were identified as independent prognostic factors for ccRCC. The 5-year overall survival of the ccRCC patients with low and high Hippo pathway activity were 51.9% (95% CI = 45.0-59.9) and 73.6% (95% CI = 67.8-79.9), respectively. In conclusion, the Hippo pathway plays an important role in the progression of ccRCC. Low Hippo pathway activity is associated with poor outcomes in ccRCC, indicating the tumour suppressor function of this pathway.

Novel plasma glycoprotein biomarkers predict progression-free survival in surgically resected clear cell renal cell carcinoma

INTRODUCTION

Limited data exists on utilization of protein post-translational modifications as biomarkers for clear cell renal cell carcinoma (ccRCC). We employed high-throughput glycoproteomics to evaluate differential expression of glycoprotein-isoforms as novel markers for ccRCC progression-free survival (PFS).

METHODS

Plasma samples were obtained from 77 patients treated surgically for ccRCC. Glycoproteomic analyses were carried out after liquid chromatography tandem mass spectrometry. Age-adjusted Cox proportional hazard models were constructed to evaluate PFS. Optimized Harrell's C-index was employed to dichotomize the collective for the construction of Kaplan-Meier curves.

RESULTS

The average length of follow-up was 3.4 (range: 0.04-9.83) years. Glycoproteomic analysis identified 39 glycopeptides and 14 non-glycosylated peptides that showed statistically significant (false discovery rate P ≤ 0.05) differential expression associated with PFS. Five of the glycosylated peptides conferred continuous hazard ratio (HR) of > 6 (range 6.3-11.6). These included prothrombin A2G2S glycan motif (HR = 6.47, P = 9.53E-05), immunoglobulin J chain FA2G2S2 motif (HR = 10.69, P = 0.001), clusterin A2G2 motif (HR = 7.38, P = 0.002), complement component C8A A2G2S2 motif (HR = 11.59, P = 0.002), and apolipoprotein M glycopeptide with non-fucosylated and non-sialylated hybrid-type glycan (HR = 6.30, P = 0.003). Kaplan-Meier curves based on dichotomous expression of these five glycopeptides resulted in hazard ratios of 3.9 to 10.7, all with P-value < 0.03. Kaplan-Meyer plot using the multivariable model comprising 3 of the markers yielded HR of 11.96 (P < 0.0001).

CONCLUSION

Differential glyco-isoform abundance of plasma proteins may be a useful source of biomarkers for the clinical course and prognosis of ccRCC.

An Integrative Analysis Framework for Identifying the Prognostic Markers from Multidimensional RNA Data of Clear Cell Renal Cell Carcinoma

The altered regulatory status of long noncoding RNA (lncRNA), miRNA, and mRNA and their interactions play critical roles in tumor proliferation, metastasis, and progression, which ultimately influence cancer prognosis. However, there are limited studies of comprehensive identification of prognostic biomarkers from combined data sets of the three RNA types in the highly metastatic clear cell renal cell carcinoma (ccRCC). The current study employed an integrative analysis framework of functional genomics approaches and machine learning methods to the lncRNA, miRNA, and mRNA data and identified 16 RNAs (3 lncRNAs, 6 miRNAs, and 7 mRNAs) of prognostic value, with 9 of them novel. A 16 RNA-based score was established for prognosis prediction of ccRCC with significance (P < 0.0001). The area under the curve for the score model was 0.868 to 0.870 in the training cohort and 0.714 to 0.778 in the validation cohort. Construction of the lncRNA-miRNA-mRNA interaction network showed that the downstream mRNAs and upstream lncRNAs in the network initiated from the miRNA or lncRNA markers exhibit significant enrichment in functional classifications associated with cancer metastasis, proliferation, progression, or prognosis. The functional analysis provided clear support for the role of the RNA biomarkers in predicting cancer prognosis. This study provides promising biomarkers for predicting prognosis of ccRCC using multidimensional RNA data, and these findings are expected to facilitate potential clinical applications of the biomarkers.

Potential Clinical Value of Pretreatment De Ritis Ratio as a Prognostic Biomarker for Renal Cell Carcinoma

Background

We performed this study to explore the prognostic value of the pretreatment aspartate transaminase to alanine transaminase (De Ritis) ratio in patients with renal cell carcinoma (RCC).

Methods

PubMed, EMBASE, Web of Science, and Cochrane Library were searched to identify all studies. The hazard ratio (HR) with a 95% confidence interval (CI) for overall survival (OS) and cancer-specific survival (CSS) were extracted to evaluate their correlation.

Results

A total of 6,528 patients from 11 studies were included in the pooled analysis. Patients with a higher pretreatment De Ritis ratio had worse OS (HR = 1.41, p < 0.001) and CSS (HR = 1.59, p < 0.001). Subgroup analysis according to ethnicity, disease stage, cutoff value, and sample size revealed that the De Ritis ratio had a significant prognostic value for OS and CSS in all subgroups.

Conclusions

The present study suggests that an elevated pretreatment De Ritis ratio is significantly correlated with worse survival in patients with RCC. The pretreatment De Ritis ratio may serve as a potential prognostic biomarker in patients with RCC, but further studies are warranted to support these results.

Long non-coding RNA SNHG3 promotes the progression of clear cell renal cell carcinoma via regulating BIRC5 expression

Background

Research has shown that the progression of clear cell renal cell carcinoma (ccRCC) is modulated by long non-coding RNAs (lncRNAs). However, the roles of specific lncRNAs in the malignancy of ccRCC are still unknown.

Methods

TCGA and GSE66272 datasets were used to predict differentially expressed genes (DEGs) in ccRCC. ENCORI database was employed to display BIRC5 miRNA network and potential lncRNA interactions for miRNAs. KM plotter and correlation analyses were performed to identify the overall survival (OS)- and BIRC5-related miRNAs. Quantitative real-time PCR (qRT-PCR) was used to verify the BIRC5 mRNA in the seventy paired clinical samples of ccRCC tissues. The ccRCC A498 and 786-O were individually transfected with lncRNA SNHG3 and LINC00997 and then western blotting was used to detect the BIRC5 protein expression. The Dual-luciferase reporter assay was used to examine the regulatory interaction between lncRNA SNHG3 and microRNA (miRNA/miR)-10b-5p.

Results

BICR5 is associated with the progression of ccRCC. The two novel lncRNAs (LINC00997, SNHG3) were up-regulated in ccRCC tissues and positively with the BICR5 protein expression. However, Suppressing SNHG3 expression reduced BIRC5 protein expression compared with the LINC00997, most importantly, Suppressing SNHG3 expression suppressed tumor progression in vitro. In addition, SNHG3 promotes the expression of BIRC5 protein by sponging microRNA-10b-5p.

Conclusions

Our findings suggest that SNHG3 plays a vital role in promoting ccRCC via the microRNA-10b-5p/BIRC5 axis and may serve as a novel therapeutic target for the treatment of patients with ccRCC.

Partial nephrectomy provides equivalent oncologic outcomes and better renal function preservation than radical nephrectomy for pathological T3a renal cell carcinoma: A meta-analysis

Purpose:

Radical nephrectomy (RN) is the standard surgical type for pathological stage T3a (pT3a) renal cell carcinoma (RCC). Recently, some studies have suggested equivalence between partial nephrectomy (PN) and RN for oncologic control and have shown the benefits of PN for better renal function. We conducted this meta-analysis to assess oncologic outcomes, perioperative outcomes and renal function between two groups among patients with pT3a RCC.

Materials and methods:

PubMed, Scopus, Web of Science, Science Direct, Ovid MEDLINE, The Cochrane Library, Embase and Google Scholar were searched for eligible articles. The endpoints of the final analysis included overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), surgical complications, operative time, estimated blood loss (EBL), serum creatinine and estimated glomerular filtration rate (eGFR).

Results:

Twelve studies of moderate to high quality, including 14.152 patients, were examined. PN showed superiority for renal functional preservation, providing higher eGFR (WMD=12.48mL/min; 95%CI: 10.28 to 14.67; P <0.00001) and lower serum creatinine (WMD=-0.31mg/dL; 95%CI: −0.40 to −0.21; P <0.00001). There were no significant differences between PN and RN regarding operative time, EBL, surgical complications, OS, RFS and CSS. Despite inherent selection bias, most pooled estimates were consistent in sensitivity analysis and subgroup analysis. More positive margins were found in the PN group (RR=2.42; 95%CI: 1.25-4.68; P=0.009).

Conclusions:

PN may be more suitable for treating pT3a RCC than RN because it provides a similar survival time (OS or RFS) and superior renal function. Nevertheless, this result is still disputed, and more high-quality studies are required.

Association of beta-catenin and CD44 in the development of renal cell carcinoma

INTRODUCTION AND OBJECTIVE

Renal cell carcinoma (RCC) accounts for approximately 3% of all cancers. Approximately 25%-30% of patients present with metastatic disease at the time of diagnosis, and metastatic RCC is a treatment-resistant malignancy. Altered expression of cell adhesion molecules such as CD44 on tumor cells suggests a pathogenetic mechanism for tumor metastasis and may provide prognostic information for particular tumors. These cell matrix interactions of CD44 play a role in tumor cell invasion and metastasis. The Wnt/beta-catenin pathway turned out to be a promising target as it is involved in the regulation of cell proliferation, differentiation and apoptosis induction.

METHOD

In this study, the expression of beta-catenin and CD44 was analyzed in primary renal cell carcinoma (RCC) samples to understand their association with development of the disease. For this purpose, immunohistochemical expression analysis of beta-catenin and CD44 was performed in 30 primary RCC histological samples and normal kidney tissues in different subtypes at different clinical stages of Indian patients (year: 2017-2019).

RESULT

Most of the patients who presented were diagnosed as clear cell carcinoma and it was observed that expression of CD44 was high in patients with high stage tumors. Also beta-catenin was increased in advanced grade tumors, but there was insignificant correlation between high expression of molecules and survival or recurrence of disease.

CONCLUSION

Both cd44 and beta-catenin activation was noted in patients with clear cell carcinoma, more in advanced tumors. Both can be promising targets for treatment in clear cell RCCs.

Identification of the miRNA-mRNA regulatory pathways and a miR-21-5p based nomogram model in clear cell renal cell carcinoma

Background

The purpose of this study was to determine the key microRNAs (miRNAs) and their regulatory networks in clear cell renal cell carcinoma (ccRCC).

Methods

Five mRNA and three microRNA microarray datasets were downloaded from the Gene Expression Omnibus database and used to screen the differentially expressed miRNAs (DEMs) and differentially expressed genes (DEGs). Gene ontology enrichment analysis and Kyoto Encyclopedia of Genes and Genomes pathway analysis were performed with Metascape. A miRNA-mRNA network was mapped with the Cytoscape tool. The results were validated with data from The Cancer Genome Atlas (TCGA) and qRT-PCR. A nomogram model based on independent prognostic key DEMs, stage and grade was constructed for further investigation.

Results

A total of 26 key DEMs and 307 DEGs were identified. Dysregulation of four key DEMs (miR-21-5p, miR-142-3p, miR-155-5p and miR-342-5p) was identified to correlate with overall survival. The results were validated with TCGA data and qRT-PCR. The nomogram model showed high accuracy in predicting the prognosis of patients with ccRCC.

Conclusion

We identified 26 DEMs that may play vital roles in the regulatory networks of ccRCC. Four miRNAs (miR-21-5p, miR-142-3p, miR-155-5p and miR-342-5p) were considered as potential biomarkers in the prognosis of ccRCC, among which only miR-21-5p was found to be an independent prognostic factor. A nomogram model was then created on the basis of independent factors for better prediction of prognosis for patients with ccRCC. Our results suggest a need for further experimental validation studies.

Transcriptomic characterization and innovative molecular classification of clear cell renal cell carcinoma in the Chinese population

Background

Large-scale initiatives like The Cancer Genome Atlas (TCGA) performed genomics studies on predominantly Caucasian kidney cancer. In this study, we aimed to investigate genomics of Chinese clear cell renal cell carcinoma (ccRCC).

Methods

We performed whole-transcriptomic sequencing on 55 tumor tissues and 11 matched normal tissues from Chinese ccRCC patients. We systematically analyzed the data from our cohort and comprehensively compared with the TCGA ccRCC cohort.

Results

It found that PBRM1 mutates with a frequency of 11% in our cohort, much lower than that in TCGA Caucasians (33%). Besides, 31 gene fusions including 5 recurrent ones, that associated with apoptosis, tumor suppression and metastasis were identified. We classified our cohort into three classes by gene expression. Class 1 shows significantly elevated gene expression in the VEGF pathway, while Class 3 has comparably suppressed expression of this pathway. Class 2 is characterized by increased expression of extracellular matrix organization genes and is associated with high-grade tumors. Applying the classification to TCGA ccRCC patients revealed better distinction of tumor prognosis than reported classifications. Class 2 shows worst survival and Class 3 is a rare subtype ccRCC in the TCGA cohort. Furthermore, computational analysis on the immune microenvironment of ccRCC identified immune-active and tolerant tumors with significant increased macrophages and depleted CD4 positive T-cells, thus some patients may benefit from immunotherapies.

Conclusion

In summary, results presented in this study shed light into distinct genomic expression profiles in Chinese population, modified the stratification patterns by new molecular classification, and gave practical guidelines on clinical treatment of ccRCC patients.

mRNA overexpression of prolyl hydroxylase PHD3 is inversely related to nuclear grade in renal cell carcinoma

The aim of the present study was to evaluate the relative mRNA expression levels of genes involved in the hypoxia inducible factor (HIF) signalling pathway in renal cell carcinoma (RCC) and to analyse their associations with clinicopathological parameters and survival outcomes. Reverse transcription-quantitative PCR was used to quantify the mRNA expression levels of HIF-1α, HIF-2α, prolyl hydroxylase (PHD)1, PHD2 and PHD3 in formalin-fixed paraffin-embedded (FFPE) tumour tissue samples from 41 patients with RCC, including 33 cases of clear cell RCC (ccRCC). FFPE samples of corresponding adjacent normal kidney tissues were used as a comparison. mRNA expression levels were analysed in regard to clinical parameters, histological type, stage, nuclear grade, cancer specific survival and overall survival. Compared with adjacent normal kidney tissue, HIF-1α levels were lower in 16/33 ccRCC samples (48.48%), while HIF-2α, PHD1 and PHD2 levels did not exhibit a specific expression pattern. By contrast, the PHD3 mRNA level was higher in 29/33 (87.87%) of the tumour samples. HIF-1α was positively associated with HIF-2α, PHD1 and PHD2. HIF-2α levels were associated with PHD1, PHD2 and PHD3, while PHD3 was strongly associated with PHD2. PHD3 mRNA levels were inversely associated with nuclear grade (P=0.015). However, in univariate analysis, PHD3 was not associated with cancer-specific or overall survival rates. The present findings suggest an important involvement of PHD3 in ccRCC, since PHD3 mRNA expression was inversely associated with nuclear grade. However, PHD3 mRNA levels did not have an independent prognostic value. Further studies are required to investigate whether PHD3 could be used as either a therapeutic target or prognostic marker.

Identification of a three-m6A related gene risk score model as a potential prognostic biomarker in clear cell renal cell carcinoma

Background

Clear cell renal cell carcinoma (ccRCC) is one of the most prevalent malignancies worldwide, N6-methyladenosine (m6A) has been shown to play important roles in regulating gene expression and phenotypes in both health and disease. Here, our purpose is to construct a m6A-regulrator-based risk score (RS) for prediction of the prognosis of ccRCC.

Methods

We used clinical and expression data of m6A related genes from The Cancer Genome Atlas (TCGA) dataset and the Least Absolute Shrinkage and Selection Operator (LASSO) Cox regression analysis to develop an RS to predict survival of patients with ccRCC, and analyzed correlations between RS and other clinical indicators such as age, grade and stage. Validation of this RS was then engaged in another cohort, E-MTAB-1980 from the ArrayExpress dataset. Finally, we used quantitative real-time PCR to analyze the expression profile of genes consists of the RS.

Results

A three-gene RS including METTL3, METTL14 and HNRNPA2B1 which can predict overall survival (OS) of ccRCC patients from TCGA. After applying this RS into the validation cohort from Arrayexpress, we found that it successfully reproduced the result; furthermore, the results of PCR validation were in line with our analysis.

Conclusion

To sum up, our study has identified an RS composed of m6A related genes that may predict the prognosis of ccRCC patients, which might be helpful for future therapeutic strategies. Our results call for further experimental studies for validations.

Curative-intent pancreas resection for pancreatic metastases: surgical and oncological results

Background

Pancreatic metastasis is a rare cause for pancreas surgery and often a sign of advanced disease no chance of curative-intent treatment. However, surgery for metastasis might be a promising approach to improve patients’ survival. The aim of this study was to analyze the surgical and oncological outcome after pancreatic resection of pancreatic metastasis.

Methods

This is a retrospective cohort analysis of a prospectively-managed database of patients undergoing pancreatic resection at the University of Freiburg Pancreatic Center from 2005 to 2017.

Results

In total, 29 of 1297 (2%) patients underwent pancreatic resection due to pancreatic metastasis. 20 (69%) patients showed metastasis of renal cell carcinoma (mRCC), followed by metastasis of melanoma (n = 5, 17%), colon cancer (n = 2, 7%), ovarian cancer (n = 1, 3%) and neuroendocrine tumor of small intestine (n = 1, 3%). Two (7%) patients died perioperatively. Median follow-up was 76.4 (range 21–132) months. 5-year and overall survival rates were 82% (mRCC 89% vs. non-mRCC 67%) and 70% (mRCC 78% vs. non-mRCC 57%), respectively. Patients with mRCC had shorter disease-free survival (14 vs. 22 months) than patients with other primary tumor entities.

Conclusion

Despite malignant disease, overall survival of patients after metastasectomy for pancreatic metastasis is acceptable. Better survival appears to be associated with the primary tumor entity. Further research should focus on molecular markers to elucidate the mechanisms of pancreatic metastasis to choose the suitable therapeutic approach for the individual patient.

Overexpression of PPT2 Represses the Clear Cell Renal Cell Carcinoma Progression by Reducing Epithelial-to-mesenchymal Transition

Clear cell renal cell carcinoma (ccRCC) is one of the most common malignant tumors of the urinary system and has a poor response to radiotherapy and chemotherapy. To date, it is urgent to find effective biomarkers for the prevention and treatment of ccRCC. The occurrence and development of ccRCC is closely related to metabolic disturbances. Palmitoyl protein thioesterase 2 (PPT2) is a lysosomal thioesterase which is highly associated with metabolism, and it has never been studied in ccRCC. In this study, we first revealed PPT2 is significantly downregulated in ccRCC, and its expression level is highly correlated with clinicopathological parameters of ccRCC patients. Our ROC curve analyses evaluated the potential of PPT2 as a novel diagnostic marker and prognostic factor. Functional experiment results showed overexpression of PPT2 represses the proliferation, migration and invasion of ccRCC cells in vitro. Mechanistic investigations demonstrated that overexpression of PPT2 represses the ccRCC progression by reducing epithelial-to-mesenchymal transition (EMT). In conclusion, PPT2 is downregulated in ccRCC. Decreased PPT2 expression may be considered as a novel diagnostic marker and prognostic factor and serve as a therapeutic target for ccRCC.

Prognostic analysis of postoperative clinically nonmetastatic renal cell carcinoma

Objectives

To investigate the survival characteristics of postoperative nonmetastatic renal cell carcinoma (RCC) patients, and the predictive value of a prognostic model.

Materials and Methods

We retrospectively evaluated data from 1202 postoperative nonmetastatic RCC patients who were treated between 1999 and 2012 at West China Hospital, Sichuan University (Chengdu, China). In addition, we also evaluated data relating to 53 205 cases acquired from the Surveillance, Epidemiology, and End Results (SEER) program. Survival analysis was performed on the cases, and subgroups, using the Kaplan‐Meier and Cox regression methods. The concordance index of the Stage Size Grade Necrosis (SSIGN), Leibovich, and the UCLA integrated staging system, scores was determined to evaluate the accuracy of these outcome prediction models.

Results

The 5‐year overall survival rate for RCC cases in West China Hospital was 87.6%; this was higher than that observed for SEER cases. Survival analysis identified several factors that exerted significant influence over prognosis, including the time of surgery, Eastern Cooperative Oncology Group performance status, tumor stage, size, nuclear differentiation, pathological subtypes, along with necrotic and sarcomatoid differentiation. Moreover tumor stage, size, and nuclear grade were all identified as independent predictors for both our cases and those from the SEER program. Patient groups with advanced RCC, and poorly differentiated RCC subgroups, were both determined to have a poor prognosis. The SSIGN model yielded the best predictive value as a prognostic model, followed by the Leibovich, and UCLA integrated staging system; this was the case for our patients, and for sub‐groups with a poor prognosis.

Conclusion

The prognosis of RCC was mostly influenced by tumor stage, size, and nuclear differentiation. SSIGN may represent the most suitable prognostic model for the Chinese population.

Development of Nomograms to Predict the Recovery of Erectile Function Following Radical Prostatectomy

INTRODUCTION

Given the number of confounders in predicting erectile function recovery after radical prostatectomy (RP), a nomogram predicting the chance to be functional after RP would be useful to patients' and clinicians' discussions.

AIM

To develop preoperative and postoperative nomograms to aid in the prediction of erectile function recovery after RP.

MAIN OUTCOME MEASURES

International Index of Erectile Function (IIEF) erectile function domain score-based erectile function.

METHODS

A prospective quality-of-life database was used to develop a series of nomograms using multivariable ordinal logistic regression models. Standard preoperative and postoperative factors were included.

MAIN OUTCOME MEASURES

The nomograms predicted the probability of recovering functional erections (erectile function domain scores ≥24) and severe erectile dysfunction (≤10) 2 years after RP.

RESULTS

3 nomograms have been developed, including a preoperative, an early postoperative, and a 12-month postoperative version. The concordance indexes for all 3 exceeded 0.78, and the calibration was good.

CLINICAL IMPLICATIONS

These nomograms may aid clinicians in discussing erectile function recovery with patients undergoing RP.

STRENGTHS & LIMITATIONS

Strengths of this study included a large population, validated instrument, nerve-sparing grading, and nomograms that are well calibrated with excellent discrimination ability. Limitations include current absence of external validation and an overall low comorbidity index.

CONCLUSIONS

It is hoped that these nomograms will allow for a more accurate discussion between patients and clinicians regarding erectile function recovery after RP. Mulhall JP, Kattan MW, Bennett NE, et al. Development of Nomograms to Predict the Recovery of Erectile Function Following Radical Prostatectomy J Sex Med 2019;16:1796-1802.

Role of PDL1 as a prognostic marker in renal cell carcinoma: a prospective observational study in eastern India

Background:

Renal cell carcinoma (RCC) is one of the most common genitourinary malignancies. Programmed death ligand-1 (PDL1) is an immune checkpoint inhibitor, instrumental in ‘T cell escape’ of malignant cells. PDL1 has been shown to be associated with poor prognosis in multiple small studies. In this study, we want to study the role of PDL1 as a prognostic marker in RCC in an Indian population.

Methods:

A total of 30 patients who underwent radical or partial nephrectomy, with histopathological findings of RCC, were included in the study. PDL1 expression was studied in tumour tissue with immunohistochemistry. Patients were followed up for a period of 2 years for disease recurrence and cancer-specific mortality.

Results:

Expression of PDL1 was seen to be associated with higher grade and stage at presentation. PDL1 expression was also associated with statistically significant increased incidence of disease recurrence. Although cancer-specific mortality was higher in patients with positive PDL1 expression, it was seen to be statistically insignificant.

Conclusions:

PDL1 is a novel prognostic marker for RCC and is associated with poor prognosis. More studies with larger patient pool and multicentric studies will establish the role of PDL1 with certainty. This can be the torchbearer for the future management of RCC.

Integrated analysis of long noncoding RNA associated-competing endogenous RNA as prognostic biomarkers in clear cell renal carcinoma

Clear cell renal cell carcinoma (ccRCC) is one of the most common malignant carcinomas and its molecular mechanisms remain unclear. Long noncoding RNA (lncRNA) could bind sites of miRNA which affect the expression of mRNA according to the competing endogenous (ceRNA) theory. The aim of the present study was to construct a ceRNA network and to identify key lncRNA to predict survival prognosis. We identified differentially expressed mRNA, lncRNA and miRNA between tumor tissues and normal tissues from The Cancer Genome Atlas database. Then, using bioinformatics tools, we explored the connection of 89 lncRNA, 10 miRNA and 22 mRNA, and we constructed the ceRNA network. Furthermore, we analyzed the functions and pathways of 22 differentially expressed mRNA. Then, univariate and multivariate Cox regression analyses of these 89 lncRNA and overall survival were explored. Nine lncRNA were finally screened out in the training group. The patients were divided into high‐risk and low‐risk groups according to the 9 lncRNA and low‐risk scores having better clinical overall survival (P < .01). Furthermore, the receiver operating characteristic curve demonstrates the predicted role of the 9 lncRNA. The 9‐lncRNA signature was successfully proved in the testing group and the entire group. Finally, multivariate Cox regression analysis and stratification analysis further proved that the 9‐lncRNA signature was an independent factor to predict survival. In summary, the present study provides a deeper understanding of the lncRNA‐related ceRNA network in ccRCC and suggests that the 9‐lncRNA signature could serve as an independent biomarker to predict survival in ccRCC patients.

Oncologic Outcomes of Partial Nephrectomy for Stage T3a Renal Cell Cancer

BACKGROUND

Partial nephrectomy (PN) for clinical stage T3 tumors is controversial. Radical nephrectomy (RN) has been associated with a greater rate of chronic kidney disease, an increased risk of cardiovascular disease, and increased mortality compared with PN. We present our long-term 2-center experience with PN for stage pT3a tumors and compare the oncologic outcomes with those of similar patients treated with RN.

MATERIALS AND METHODS

We reviewed the data from all patients who had undergone nephrectomy for renal cell carcinoma from 1987 to 2015 in 2 medical centers. The study included 134 patients with pathologic stage T3a tumors, of whom 48 and 86 underwent PN and RN, respectively. We compared the 2 groups (PN and RN) using univariate and multivariate analyses.

RESULTS

The tumors of all patients with pathologic stage T3a who had undergone PN had been pathologically upstaged from clinical stage T1 or T2. Univariate and multivariate analyses revealed tumor size was significantly different statistically between the study groups (median, 7.0 cm in RN group vs. 4.0 cm in PN group; P < .001). Surgery type was not a predictor of local recurrence (P = .978), metastatic progression (P = .972), death from renal cancer (P = .626), or death from all causes (P = .974) at the 5-year follow-up point.

CONCLUSION

The results of the present study have shown similar oncologic outcomes between 48 patients with stage pT3a renal cancer who underwent PN and 86 patients who underwent RN. Although PN was not performed on clinical T3a tumors, our findings suggest that PN can also be considered for these tumors and, thus, avoid the long-term complications of RN. However, strict follow-up protocols are mandatory.

J. Risk models for patients with localised renal cell carcinoma

INTRODUCTION

We conducted a retrospective analysis of our series to assess the factors that influenced disease-free survival (DFS) and cancer-specific survival (CSS) for patients with localised renal cell carcinoma (RCC). We also created our own risk groups.

MATERIAL AND METHODS

Between January 1990 and December 2012, 596 patients underwent surgery for localised RCC (clear cell, papillary or chromophobe). Using Cox regression models, we analysed the clinical-pathological variables that influenced DFS and CSS and designed risk groups for DFS and CSS with the variables.

RESULTS

The median follow-up for the series was 5.96 years. By the end of the study, 112 patients (18.8%) had a recurrence of the disease, with DFS rates of 82%, 77% and 72% at 5, 10 and 15 years, respectively. The independent factors that influenced DFS in the multivariate study were the following: A Furhman grade of 3-4, haematuria, lymphocytic or vascular invasion, the presence of tumour necrosis and a disease stage pT3-pT4. Furthermore, by the end of the study, 57 patients (9.6%) died due to renal cancer, with CSS rates of 92%, 86% and 83% at 5, 10 and 15 years, respectively. The independent factors that influenced CSS in the multivariate study were the following: A Furhman grade of 3-4, perinephric fat invasion and the presence of tumour necrosis.

CONCLUSIONS

Factors in addition to the disease stage pT3-pT4 in patients with localised RCC are important, such as the presence of haematuria and lymphocytic or vascular invasion for DFS. A Furhman grade of 3-4 and the presence of tumour necrosis are especially relevant for DFS and CSS.

Increasing trends in kidney cancer over the last 2 decades in Saudi Arabia

Objectives:

To examine the trends of kidney cancer over the last 2 decades in a subset of a Saudi Arabian population.

Methods:

We conducted a retrospective study in a tertiary care center including all adult patients with primary kidney cancer who presented and were managed between 1990 and 2010. The time period was split into 4 quartiles, and variables tested and compared using chi-square, T-test, and Kaplan-Meier curves for survival.

Results:

The total was 215 patients with a mean age of 57.8 years. There was an increase in the number of kidney cancer cases over the last 2 decades. There was no significant difference in the mode of presentation or stage distribution between quartiles. A significant change was observed in the management towards minimally invasive and nephron-sparing surgeries (p<0.001). There was no change in recurrence-free and disease-specific survival over the last 20 years.

Conclusions:

There have been an increasing number of kidney cancer patients over the last 2 decades with no observed migration towards more incidental and low stage tumors as compared with developed countries.

An Empiric Evaluation of the Effect of Variation in Intensity of Followup for Surgically Treated Renal Neoplasms on Cancer Specific Survival

PURPOSE

Followup protocols after the surgical management of renal cell carcinoma lack clear evidence linking the intensity of imaging surveillance to improved outcomes. In this context we characterized the relationship between surveillance imaging intensity and cancer specific survival.

MATERIALS AND METHODS

Using SEER-Medicare data we identified 7,603 men with renal cell carcinoma treated surgically between 2004 and 2009. Multivariable negative binomial regression analysis was performed to assess the relationship between patient level characteristics and the variation in imaging intensity. We modeled the association between kidney cancer specific mortality and imaging intensity using Fine and Gray proportional subdistribution hazards regression with other cause death treated as a competing risk for 2 separate followup periods (15 and 36 months).

RESULTS

More than 40% of patients in the short interval cohort and more than 50% in the intermediate interval group underwent no chest imaging during the evaluated survivorship period. More than 30% of patients in both followup periods had no abdominal imaging tests performed. Overall, followup imaging did not appear to confer an improvement in disease specific survival compared to undergoing no imaging in the 2 survivorship periods.

CONCLUSIONS

There remains considerable variation in the posttreatment surveillance regimen for patients with renal cell carcinoma in the United States. More importantly, this study raises important questions regarding the link between posttreatment surveillance imaging and survival.

Positive Surgical Margins Increase Risk of Recurrence after Partial Nephrectomy for High Risk Renal Tumors

PURPOSE

The clinical significance of a positive surgical margin after partial nephrectomy remains controversial. The association between positive margin and risk of disease recurrence in patients with clinically localized renal neoplasms undergoing partial nephrectomy was evaluated.

MATERIALS AND METHODS

A retrospective multi-institutional review of 1,240 patients undergoing partial nephrectomy for clinically localized renal cell carcinoma between 2006 and 2013 was performed. Recurrence-free survival was estimated using the Kaplan-Meier method and evaluated as a function of positive surgical margin with the log rank test and Cox models adjusting for tumor size, grade, histology, pathological stage, focality and laterality. The relationship between positive margin and risk of relapse was evaluated independently for pathological high risk (pT2-3a or Fuhrman grades III-IV) and low risk (pT1 and Fuhrman grades I-II) groups.

RESULTS

A positive surgical margin was encountered in 97 (7.8%) patients. Recurrence developed in 69 (5.6%) patients during a median followup of 33 months, including 37 (10.3%) with high risk disease (eg pT2-pT3a or Fuhrman grade III-IV). A positive margin was associated with an increased risk of relapse on multivariable analysis (HR 2.08, 95% CI 1.09-3.97, p=0.03) but not with site of recurrence. In a stratified analysis based on pathological features, a positive surgical margin was significantly associated with a higher risk of recurrence in cases considered high risk (HR 7.48, 95% CI 2.75-20.34, p <0.001) but not low risk (HR 0.62, 95% CI 0.08-4.75, p=0.647).

CONCLUSIONS

Positive surgical margins after partial nephrectomy increase the risk of disease recurrence, primarily in patients with adverse pathological features.

Role of dose exposure and inflammatory status in a single center, real-world analysis of sunitinib in patients with metastatic renal cell carcinoma

AIM, PATIENTS & METHODS: To evaluate the real-world setting use of sunitinib, we reviewed data of our patients from January 2007 to December 2014.

RESULTS

In 114 patients, sunitinib was used as first-line TKI. Out of 110 evaluable patients, 5 complete responses, 37 partial responses, 42 stabilizations were reported. Median progression-free survival and overall survival (OS) were 14.3 and 28.4 months. Patients who received ≥ 4 full-dose cycles had a better OS (p = 0.02). A neutrophil-lymphocyte ratio <3 was associated both with OS and progression-free survival (50.4 vs 8.4 and 20.0 vs 3.3 months).

CONCLUSION

Sunitinib is active and feasible. Patients receiving <4 full-dose cycles or having increased neutrophil-lymphocyte ratio achieved worse outcomes: therefore, these are present potential predictive factors.

Urine aquaporin 1 and perilipin 2 differentiate renal carcinomas from other imaged renal masses and bladder and prostate cancer

OBJECTIVE

To evaluate the sensitivity and specificity of urine aquaporin 1 (AQP1) and perilipin 2 (PLIN2) concentrations to diagnose clear cell or papillary renal cell carcinoma (RCC) by comparing urine concentrations of these unique biomarkers in patients with RCC, noncancer renal masses, bladder cancer, and prostate cancer.

METHODS

From February 1, 2012, through October 31, 2012, preoperative urine samples were obtained from patients with a presumptive diagnosis of RCC based on an imaged renal mass, prostate cancer, or transitional cell bladder cancer. Imaged renal masses were diagnosed postnephrectomy—as malignant or benign—by histology. Urine AQP1 and PLIN2 concentrations were measured by using a sensitive and specific Western blot and normalized to urine creatinine concentration.

RESULTS

Median concentrations of urine AQP1 and PLIN2 in patients with clear cell and papillary RCC (n=47) were 29 and 36 relative absorbance units/mg urine creatinine, respectively. In contrast, median concentrations in patients with bladder cancer (n=22) and prostate cancer (n=27), patients with chromophobe tumors (n=7), and patients with benign renal oncocytomas (n=9) and angiomyolipomas (n=7) were all less than 10 relative absorbance units/mg urine creatinine (Kruskal-Wallis test, P<.001 vs RCC for both biomarkers) and comparable with those in healthy controls. The area under the receiver operating characteristic curve ranged from 0.99 to 1.00 for both biomarkers.

CONCLUSION

These results support the specificity and sensitivity of urine AQP1 and PLIN2 concentrations for RCC. These novel tumor-specific proteins have high clinical validity and high potential as specific screening biomarkers for clear cell and papillary RCC as well as in the differential diagnosis of imaged renal masses.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00851994.

Nomograms incorporating serum C-reactive protein effectively predict mortality before and after surgical treatment of renal cell carcinoma

OBJECTIVES

To incorporate C-reactive protein into nomograms estimating survival in patients with renal cell carcinoma.

METHODS

Patients undergoing surgery for renal cell carcinoma from 2005-2012 were studied retrospectively. Multivariable Cox proportional hazards regression and competing risks regression models including stage, grade, C-reactive protein levels and presence of metastatic disease were constructed. Outcomes analyzed include overall mortality overall mortality and renal cell carcinoma-specific mortality.

RESULTS

The cohort included 516 patients with a mean follow up of 1.7 years (SD 1.4 years). One- and 3-year renal cell carcinoma-specific mortality was 8.8% and 13.5%, respectively. Four nomograms were generated using overall mortality and renal cell carcinoma-specific mortality as end-points, two each for pre- and postoperative counseling. The factor with the largest effect on all nomograms was preoperative C-reactive protein. Based on the internal validation with bootstrapping, the concordance indices for renal cell carcinoma-specific mortality in the preoperative nomogram, postoperative nomogram, and the Mayo Clinic stage, size, grade and necrosis score were 0.889, 0.893, and 0.832, respectively (P = 0.005 and 0.002 comparing with stage, size, grade and necrosis scores for preoperative or postoperative nomograms). For overall mortality, the preoperative nomogram, postoperative nomogram, and stage, size, grade and necrosis score showed concordance indices of 0.866, 0.897, and 0.828, respectively (P = 0.123 and 0.008 compared with stage, size, grade and necrosis score for preoperative or postoperative nomograms).

CONCLUSIONS

We have generated nomograms incorporating serum C-reactive protein levels that effectively predict overall mortality and renal cell carcinoma specific mortality. Our findings warrant external validation.

Renal cell carcinoma

The treatment of renal cell carcinoma (RCC) has changed greatly over the past 15 years. Progress in the surgical management of the primary tumor and increased understanding of the molecular biology and genomics of the disease have led to the development of new therapeutic agents. The management of the primary tumor has changed owing to the realization that clean margins around the primary lesion are sufficient to prevent local recurrence, as well as the development of more sophisticated tools and techniques that increase the safety of partial nephrectomy. The management of advanced disease has altered even more dramatically as a result of new agents that target the tumor vasculature or that attenuate the activation of intracellular oncogenic pathways. This review summarizes data from prospective randomized phase III studies on the surgical management and systemic treatment of RCC, and provides an up to date summary of the histology, genomics, staging, and prognosis of RCC. It describes the management of the primary tumor and offers an overview of systemic agents that form the mainstay of treatment for advanced disease. The review concludes with an introduction to the exciting new class of immunomodulatory agents that are currently in clinical trials and may form the basis of a new therapeutic approach for patients with advanced RCC.

Pathological characteristics and radiographic correlates of complex renal cysts

OBJECTIVES

To characterize pathological and cancer-specific outcomes of surgically resected cystic renal tumors and to identify clinical or radiographic features associated with these outcomes.

METHODS AND MATERIALS

All patients at our institution who underwent radical or partial nephrectomy for complex renal cystic masses between 2004 and 2011 with available computed tomographic imaging were included. The Bosniak score was determined, as were 10 specific radiographic characteristics of renal cysts in patients with preoperative imaging available for review. These characteristics were correlated with cystic mass histopathology. Recurrence-free survival after surgery was determined.

RESULTS

Overall, 133 patients underwent renal surgery for complex cystic lesions, 89 (67%) of whom had malignant lesions. Malignancy risk increased with Bosniak score (P≤0.01) and presence of mural nodules (P = 0.01). Most (63%) malignancies demonstrated clear cell histology. The papillary renal cell carcinomas (25%) exhibited lower enhancement levels (P = 0.04) and were less often septated (P<0.01). Of the malignancies, 79% were low stage (pT1), and 73% were Fuhrman grade 1 or 2. Large cyst size was associated with advanced tumor stage (P = 0.05). Neither Bosniak score nor any other radiographic parameter was associated with Fuhrman grade. In 70 patients with a median follow-up of 43 months, only 1 (1.4%) developed disease recurrence.

CONCLUSIONS

Most cystic renal malignancies are low-stage, low-grade lesions. Papillary renal cell carcinomas account for nearly a quarter of cystic renal malignancies and have unique radiographic characteristics. Disease recurrence after surgical resection is rare. These findings suggest an indolent behavior for cystic renal tumors, and these lesions may be amenable to active surveillance.

Development of pathological diagnostics of human kidney cancer by multiple staining using new fluorescent Fluolid dyes

New fluorescent Fluolid dyes have advantages over others such as stability against heat, dryness, and excess light. Here, we performed simultaneous immunostaining of renal tumors, clear cell renal cell carcinoma (RCC), papillary RCC, chromophobe RCC, acquired cystic disease-associated RCC (ACD-RCC), and renal angiomyolipoma (AML), with primary antibodies against Kank1, cytokeratin 7 (CK7), and CD10, which were detected with secondary antibodies labeled with Fluolid-Orange, Fluolid-Green, and Alexa Fluor 647, respectively. Kank1 was stained in normal renal tubules, papillary RCC, and ACD-RCC, and weakly or negatively in all other tumors. CK7 was positive in normal renal tubules, papillary RCC, and ACD-RCC. In contrast, CD10 was expressed in renal tubules and clear cell RCC, papillary RCC, AML, and AC-RCC, and weakly in chromophobe RCC. These results may contribute to differentiating renal tumors and subtypes of RCCs. We also examined the stability of fluorescence and found that fluorescent images of Fluolid dyes were identical between a tissue section and the same section after it was stored for almost three years at room temperature. This indicates that tissue sections can be stored at room temperature for a relatively long time after they are stained with multiple fluorescent markers, which could open a door for pathological diagnostics.

Prognostic factors of overall survival in renal cancer patients - single oncological center study

INTRODUCTION

The clinical course of renal cancer remains difficult to predict. Attempts to appoint new independent prognostic factors (IPFs) and comparisons of already identified ones among populations are inevitable to develop more effective prognostic instruments. The aim of this study was to evaluate IPFs of overall survival in a given population of patients with renal cancer.

MATERIALS AND METHODS

Retrospective analysis of 148 patients with renal cancer treated at the Oncological Institute in Cracow from 2000 to 2007 was performed. Mean follow-up was 51 months. Using the log-rang test, a group of clinicopathological and biochemical features was analyzed in respect to their influence on overall survival. Results were presented as Kaplan-Meier curves. Final identification of IPFs was made by multivariate Cox regression analysis.

RESULTS

Overall survival rate at 1, 2, and 5-year follow-up was 58.8%, 38.2%, and 21.4%, respectively. The set of identified IPFs consisted of performance status, smoking history, hemoglobin concentration, anatomical staging, tumor grade, and the presence of microvascular invasion. It was confirmed that only nephrectomy increases significantly overall survival.

CONCLUSIONS

Apart from smoking history, the role of all other IPFs identified in our study is well documented in the literature. Smoking history seems to be a new IPF with strong negative impact on survival in patients with RCC.

Factors affecting the time to recurrence after radical nephrectomy for localized renal cell carcinoma

Purpose

The objective of this study was to determine the factors affecting the time to recurrence after radical nephrectomy for localized renal cell carcinoma.

Materials and Methods

We retrospectively evaluated 321 patients who received radical nephrectomies for localized renal cell carcinoma (pT1a-pT2b N0M0). Of 29 patients with disease recurrence, 9 had recurrence more than 5 years after radical nephrectomy. We evaluated the clinicopathological factors, with the use of a retrospective study design.

Results

Tumor necrosis was statistically different between the late recurrence group and the recurrence free group (Fisher exact test, p=0.046). Hematuria at diagnosis (chi-square test, p=0.045) was statistically significant in early recurrence. In the univariate logistic regression analysis, tumor necrosis (odds ratio [OR], 4.629; 95% confidence interval [CI], 1.106 to 19.379; p=0.036) and pT stage>1 (OR, 7.232; 95% CI, 1.727 to 30.280; p=0.007) were risk factors of late recurrence. In the multivariable logistic regression analysis, pT stage>1 (OR, 7.143; 5% CI 1.706 to 29.912, p=0.007) was associated with late recurrence. Regarding early recurrence, initial symptoms at diagnosis and pathologic T stage>1 were statistically significant in both univariate and multivariable logistic regression analysis. In terms of recurrence site, patients with late recurrence tended to have unusual metastasis sites other than lung, liver or bone (chi-square test, p=0.012).

Conclusions

These data suggest that tumor necrosis may affect late disease recurrence. Patients with initial symptoms and hematuria at diagnosis are vulnerable to recurrence in a shorter period after nephrectomy. Patients with late recurrence showed a tendency to have unusual metastasis site other than lung, liver or bone.

Growth pattern, an important pathologic prognostic parameter for clear cell renal cell carcinoma

OBJECTIVES

To assess the validity of growth pattern as a unique prognostic parameter for clear cell renal cell carcinoma (ccRCC).

METHODS

In total, 561 patients with pathologic tumor stage 1 (pT1), pT2, and pT3a ccRCC without preoperative metastasis were evaluated. Clinicopathologic parameters, including pathologic tumor stage, Fuhrman grade, tumor necrosis, lymphovascular invasion, and growth pattern, were analyzed to predict disease-free survival (DFS) and cancer-specific survival (CSS).

RESULTS

Growth patterns were defined as follows: expansive included tumors with well-circumscribed margins without normal renal tissue in the tumor, and infiltrative involved tumors with ill-circumscribed margins or normal renal tissue in the tumors. In multivariate analysis, Fuhrman grade, tumor necrosis, and growth pattern were useful predictors of DFS, whereas Fuhrman grade and growth pattern were useful predictors of CSS, although only 30 cases showed the infiltrative pattern.

CONCLUSIONS

Growth pattern can be considered a new prognostic parameter for ccRCC.

Oncological and renal medical importance of kidney-sparing surgery

In the past decade, the medical and oncological rationale for kidney-sparing surgical approaches for small renal masses has been clarified. Although radical nephrectomy is still necessary for many patients diagnosed with large renal tumours, accumulating evidence indicates that partial nephrectomy provides equivalent oncological outcomes while also preserving renal function and preventing the adverse cardiovascular effects of chronic kidney disease. Furthermore, approximately 45% of resected small renal tumours are benign or indolent, with limited--if any--metastatic potential. Patients who develop kidney cancer often have medical comorbidities that can affect kidney function, such as diabetes and hypertension, and histological examination of the non-tumour-bearing elements of the kidney demonstrate significant pathological changes in the vast majority of patients. For elderly patients or patients with comorbidities, active surveillance provides an alternative kidney-sparing approach, and is associated with extremely low rates of clinical disease progression and metastases. Despite these important advances in understanding, which support the use of partial nephrectomy for the treatment of small renal masses, the technique remains underused.

Integration of surgery and systemic therapy for renal cell carcinoma

Proper integration of surgery and systemic therapy is essential for improving outcomes in renal cell carcinoma (RCC). There is no current role for adjuvant therapy after nephrectomy for clinically localized disease. The potential benefits of neoadjuvant therapy for locally advanced nonmetastatic disease are in need of further study. In metastatic disease, the proper integration of cytoreductive surgery and systemic therapy remains to be elucidated. Presurgical targeted therapy is feasible and may be beneficial. Pending the results of randomized controlled trials, upfront cytoreductive nephrectomy in appropriate patients will likely continue as the paradigm of choice in metastatic RCC.

Emerging critical role of molecular testing in diagnostic genitourinary pathology

CONTEXT

The unprecedented advances in cancer genetics and genomics are rapidly affecting clinical management and diagnostics in solid tumor oncology. Molecular diagnostics is now an integral part of routine clinical management in patients with lung, colon, and breast cancer. In sharp contrast, molecular biomarkers have been largely excluded from current management algorithms of urologic malignancies.

OBJECTIVE

To discuss promising candidate biomarkers that may soon make their transition to the realm of clinical management of genitourologic malignancies. The need for new treatment alternatives that can improve upon the modest outcome so far in patients with several types of urologic cancer is evident. Well-validated prognostic molecular biomarkers that can help clinicians identify patients in need of early aggressive management are lacking. Identifying robust predictive biomarkers that will stratify response to emerging targeted therapeutics is another crucially needed development. A compiled review of salient studies addressing the topic could be helpful in focusing future efforts.

DATA SOURCES

A PubMed (US National Library of Medicine) search for published studies with the following search terms was conducted: molecular , prognostic , targeted therapy , genomics , theranostics and urinary bladder cancer , prostate adenocarcinoma , and renal cell carcinoma . Articles with large cohorts and multivariate analyses were given preference.

CONCLUSIONS

Our recent understanding of the complex molecular alterations involved in the development and progression of urologic malignancies is yielding novel diagnostic and prognostic molecular tools and opening the doors for experimental targeted therapies for these prevalent, frequently lethal solid tumors.

Oncological outcomes of partial nephrectomy for renal carcinoma greater than 4 cm

PURPOSE OF REVIEW

To provide the clinical evidence and benefits of performing partial nephrectomy for renal tumors greater than 4 cm.

RECENT FINDINGS

Partial nephrectomy was historically performed only for the essential indications of a tumor in a functional or anatomical solitary kidney or in the face of bilateral renal tumors. Partial nephrectomy has now emerged as an oncologically equivalent operation to radical nephrectomy for T1a tumors (<4 cm) with the added benefit of renal functional preservation which can prevent or delay the onset of chronic kidney disease (CKD). CKD is an independent risk factor for hospitalization events, cardiovascular disease, and worse overall survival. Recent evidence has demonstrated that partial nephrectomy also provides equivalent oncological results for larger renal tumors including those of 4-7 cm and even for greater than 7 cm, whenever technically feasible with the continued added benefit of renal functional preservation. Partial nephrectomy is effectively performed using both open surgical techniques and increasingly by minimally invasive approaches although the latter is technically challenging.

SUMMARY

Despite the mounting clinical evidence that partial nephrectomy is an effective and preferable approach to the T1 renal mass, it remains markedly underutilized in the USA and abroad. The overzealous use of radical nephrectomy for the T1 renal mass, by whatever surgical approach, must now be considered detrimental to the long-term health of the kidney tumor patient.

Adjuvant and neoadjuvant therapies in high-risk renal cell carcinoma

The standard of care for renal cell carcinoma (RCC) is surgical resection as a monotherapy or as part of a multimodal approach. A significant number of patients undergoing surgery for localized RCC experience recurrence, suggesting that there are some individuals in whom surgical excision is necessary but insufficient because of the presence of micrometastatic disease at diagnosis. This review summarizes current algorithms used to identify patients at high risk for disease recurrence following the surgical resection of RCC, the outcomes of contemporary adjuvant systemic therapy trials, and the rationale supporting the use of neoadjuvant therapy.

Vascular endothelial growth factor-targeted therapy for the treatment of renal cell carcinoma

Vascular endothelial growth factor (VEGF)-targeted agents have rapidly been adopted into standard-of-care treatment for renal cell carcinoma (RCC). However, a substantial proportion of patients fail to respond to these agents or experience considerable toxicity. This article reviews the benefits and limitations of currently approved anti-VEGF agents in advanced and metastatic RCC, and the role for newly approved and developmental agents. Sunitinib and bevacizumab plus interferon (IFN)-α have demonstrated significant improvements in progression-free survival (PFS) compared with IFNα in treatment-naïve patients. A PFS benefit has also been shown with sorafenib versus placebo second-line to cytokine therapy. However, no anti-VEGF agent has shown a significant overall survival benefit. Anti-VEGF therapy is generally well tolerated, but a number of key adverse events, including dermatological, mucosal and constitutional symptoms, may limit treatment compliance and success. Pazopanib is a recently approved, highly selective anti-VEGF agent that shows benefit in PFS over IFNα, with low rates of treatment-related adverse events and, therefore, may be better tolerated than other currently approved agents. The advent of VEGF-targeted therapy for RCC has greatly improved prospects for patients with advanced or metastatic disease, but more efficacious agents are required that demonstrate a clear survival advantage. Ongoing trials evaluating novel anti-VEGF therapies could establish whether the increased potency and selectivity of these agents results in improved efficacy and tolerability in RCC patients, further improving their prognosis.

Active surveillance: a potential strategy for select patients with small renal masses

Increased abdominal imaging has led to the significant incidental detection of clinically localized renal masses. While the gold standard remains surgical excision, mortality rates from kidney cancer remain relatively unchanged implying that a proportion of small renal masses may be indolent tumors that do not require surgical intervention. As a result, active surveillance has emerged as an alternative management strategy in select patients with significant competing risks. Although the contemporary literature characterizing the natural history of untreated small renal masses is limited, recent data demonstrate that many incidental renal masses demonstrate slow growth kinetics with a low rate of progression to metastatic disease over an intermediate time period. Prospective trials are necessary to define entry and intervention criteria for active surveillance protocols.

Molecular diagnostics in urologic malignancies: a work in progress

CONTEXT

Molecular diagnostic applications are now an integral part of the management algorithms of several solid tumors, such as breast, colon, and lung. In stark contrast, the current clinical management of urologic malignancies is lagging behind. Clinically robust molecular tests that can identify patients who are more likely to respond to a given targeted agent or even those in need of a more aggressive treatment based on well-validated molecular prognosticators are still lacking. Several promising biomarkers for detection, prognosis, and targeted therapeutics are being evaluated.

OBJECTIVE

To discuss candidate biomarkers that may soon make the transition to clinical assay for patients in urologic oncology.

DATA SOURCES

Selected original articles published in the PubMed service of the US National Library of Medicine.

CONCLUSIONS

Recent understanding of the complex molecular alterations involved in the development and progression of urologic malignancies is yielding novel diagnostic and prognostic molecular tools and opening the doors for experimental targeted therapies in these prevalent, frequently lethal solid tumors.

The role of surgery in the management of early-stage renal cancer

There were an estimated 58,240 new cases and 13,040 deaths from kidney cancer in the United States in 2010. The increased treatment and cure of small, incidentally discovered renal tumors, most of which are nonlethal in nature, has not offset the increased mortality caused by advanced and metastatic tumors. In this article, the optimum approach to the surgical management of localized renal tumors and its impact on renal function are discussed.

The Karakiewicz nomogram is the most useful clinical predictor for survival outcomes in patients with localized renal cell carcinoma

BACKGROUND

Outcomes after surgical removal of localized renal cell carcinoma (RCC) are variable. There have been multiple prognostic nomograms and risk groups developed for estimation of survival outcomes, with different models in use for evaluating patient eligibility in ongoing trials of adjuvant therapy. The authors aimed to establish the most useful prognostic model for patients with localized RCC to guide trial design, biomarker research, and clinical counseling.

METHODS

A total of 390 consecutive patients who underwent nephrectomy for sporadic localized RCC in a tertiary institution (1990-2006) with 65 months median follow-up were retrospectively evaluated. The Karakiewicz nomogram, the Kattan nomogram, the Sorbellini nomogram, and the Leibovich model were compared in predicting survival outcomes (overall survival, cancer-specific survival, and freedom from recurrence) using likelihood analysis, adequacy indices, decision curve analysis, calibration, and concordance indices.

RESULTS

Overall, the Karakiewicz nomogram outperformed the Kattan nomogram, the Sorbellini nomogram, and the Leibovich model. Highly improved accuracy was seen using the Karakiewicz nomogram in survival prediction, using likelihood ratio analysis in bivariate models including the competing prognostic models. The Karakiewicz nomogram showed higher adequacy and concordance indices and improved clinical benefit relative to all other nomograms. All 4 models were reasonably calibrated. Exploratory comparisons of prespecified discretized Karakiewicz nomograms and the SORCE trial recruitment criteria (a discretized Leibovich model) of high-risk patients favored the discretized Karakiewicz nomograms.

CONCLUSIONS

The Karakiewicz nomogram was shown to be superior to the other tested nomograms and risk groups in predicting survival outcomes in localized RCC. Routine integration of this model into trial design and biomarker research should be considered.

Preoperative nutritional status is an important predictor of survival in patients undergoing surgery for renal cell carcinoma

BACKGROUND

The role of malnutrition has not been well studied in patients undergoing surgery for renal cell carcinoma (RCC).

OBJECTIVE

Our aim was to evaluate whether nutritional deficiency (ND) is an important determinant of survival following surgery for RCC.

DESIGN, SETTING, AND PARTICIPANTS

A total of 369 consecutive patients underwent surgery for locoregional RCC from 2003 to 2008. ND was defined as meeting one of the following criteria: body mass index <18.5 kg/m(2), albumin <3.5 g/dl, or preoperative weight loss ≥ 5% of body weight.

INTERVENTION

All patients underwent radical or partial nephrectomy.

MEASUREMENTS

Primary outcomes were overall and disease-specific mortality. Covariates included age, Charlson comorbidity index (CCI), preoperative anemia, tumor stage, Fuhrman grade, and lymph node status. Multivariate analysis was performed using a Cox proportional hazards model. Mortality rates were estimated using the Kaplan-Meier product-limit method.

RESULTS AND LIMITATIONS

Eighty-five patients (23%) were categorized as ND. Three-year overall and disease-specific survival were 58.5% and 80.4% in the ND cohort compared with 85.4% and 94.7% in controls, respectively (p<0.001). ND remained a significant predictor of overall mortality (hazard ratio [HR]: 2.41, 95% confidence interval [CI], 1.40-4.18) and disease-specific mortality (HR: 2.76; 95% CI, 1.17-6.50) after correcting for age, CCI, preoperative anemia, stage, grade, and nodal status. This study is limited by its retrospective nature.

CONCLUSIONS

ND is associated with higher mortality in patients undergoing surgery for locoregional RCC, independent of key clinical and pathologic factors. Given this mortality risk, it may be important to address nutritional status preoperatively and counsel patients appropriately.