Surgical management of low-stage renal cell carcinoma: Technology does not supersede biology

Costunolide Induces Autophagy and Apoptosis by Activating ROS/MAPK Signaling Pathways in Renal Cell Carcinoma

Although costunolide (Cos), a natural sesquiterpene compound isolated from various medicinal plants, exhibits antiproliferative and pro-apoptotic effects in diverse types of cancers, the mechanism associated with the anticancer property of Cos has not been elucidated. The present investigation was carried out to study the anticarcinogenic influence of Cos on kidney cancer cells. Several human renal cancer cell lines were used and biological and molecular studies were conducted. It was found that Cos significantly suppressed renal carcinoma cell growth via stimulation of apoptosis and autophagy in a concentration-dependent manner. Further studies revealed that Cos increased Bax/Bcl-2 ratio, decreased mitochondrial transmembrane potential (MMP), and enhanced cytoplasmic levels of cytochrome c, and activation of caspase-9, caspase-3, and cleaved PARP, resulting in cell apoptosis. The autophagy induced by Cos resulted from the formation of GFP-LC3 puncta and upregulation of LC3B II and Beclin-1 proteins. Compared with Cos treatment, the autophagy inhibitor 3-MA or ROS scavenger NAC significantly inhibited apoptosis and autophagy. Moreover, NAC and JNK-specific inhibitor SP600125 attenuated the effect of Cos. Taken together, Cos exerted autophagic and apoptotic effects on renal cancer through the ROS/JNK-dependent signal route. These findings suggest that Cos could be a beneficial anticarcinogenic agent.

Ubenimex enhances the radiosensitivity of renal cell carcinoma cells by inducing autophagic cell death

Renal cell carcinoma (RCC) is resistant to standard radiotherapy. Ubenimex, an aminopeptidase N inhibitor, is widely used as an adjunct therapy after surgery to enhance the function of immunocompetent cells and confer antitumor effects. Our previous study demonstrated that ubenimex induces autophagic cell death in RCC cells. Recently, the molecular mechanism of autophagy induction has been associated with radiosensitivity in RCC cells. In the present study, the ability of ubenimex to enhance RCC cell sensitivity to radiation via the induction of autophagic cell death was determined, and the mechanism of action of this effect was investigated. The 786-O and OS-RC-2 human RCC cell lines were treated with 0.5 mg/ml ubenimex and different doses of irradiation (IR). The cell viability was measured using a colony-formation assay and flow cytometry. Acridine orange (AO)-ethidium bromide (EB) staining was assessed by fluorescence microscopy as an indicator of autophagic cell death. Protein expression was assessed by western blotting. Autophagosomes were evaluated using transmission electron microscopy. RCC cells were used to evaluate the sensitivity to radiation using clonogenic survival and lactate dehydrogenase assays. Furthermore, these parameters were also tested at physiological oxygen levels. The AO-EB staining and flow cytometry of the OS-RC-2 cells indicated that the combined treatment significantly enhanced autophagic cell death compared with ubenimex or IR alone. Therefore, treatment with ubenimex did not significantly alter cell cycle progression but increased cell death when combined with radiation. An Akt agonist could significantly weaken this effect, indicating that ubenimex may act as an Akt inhibitor. Furthermore, the western blot analysis indicated that the combined treatment inhibited the Akt signaling pathway compared with ubenimex treatment or IR alone. Ubenimex may enhance RCC cell sensitivity to radiation by inducing cell autophagy. This induction changes the role of autophagy from protective to lethal in vitro, and this switch is associated with the inhibition of the Akt signaling pathway.

A modified adrenal gland-sparing surgery based on retroperitoneal laparoscopic radical nephrectomy

Background

The objective of this study was to modify the adrenal gland-sparing strategy based on retroperitoneal laparoscopic radical nephrectomy by reviewing the anatomic relationship between the kidney and the adrenal gland.

Methods

From June 2010 to October 2012, a total of 68 patients (45 males and 23 females) with localized renal cell carcinoma were treated at our hospital. The study included 35 cases that were right side and 33 cases that were left, and average patient age was 54.06 years. The average tumor size was 4.7 cm. Tumors were classified via the TNM staging system. All patients underwent adrenal gland-sparing surgery based on retroperitoneal laparoscopic radical nephrectomy.

Results

For each patient, surgery was successful without conversion to open surgery. The average operative time was 56.65 ± 26.60 min, and the mean blood loss was 70.61 ± 60.96 ml. All patients were discharged from the hospital 3 to 8 days after surgery. During surgery, the adrenal gland was slightly lacerated in three cases and the peritoneum showed perforation in six cases. Only one case recurred during the study follow-up.

Conclusions

Based on retroperitoneal laparoscopy radical nephrectomy, this effective adrenal gland-sparing surgery showed direct exposure of tissue and little interference of the upper pole of the kidney. Elevation of the adrenal gland could help with the complete dissection of the adrenal gland from the kidney. The separation of the kidney was rapid, simple and accurate. The probability of adrenal gland damage was reduced. This strategy is recommended for widespread use in T1-2 renal neoplasms.

Radiosensitization of renal cell carcinoma in vitro through the induction of autophagy

BACKGROUND AND PURPOSE

For patients diagnosed with advanced renal cell carcinoma (RCC), there are few therapeutic options. Radiation therapy is predominantly used to treat metastasis and has not proven effective in the adjuvant setting for renal cancer. Furthermore, RCC is resistant to standard cytotoxic chemotherapies. Targeted anti-angiogenics are the standard of care for RCC but are not curative. Newer agents, such as mTOR inhibitors and others that induce autophagy, have shown great promise for treating RCC. Here, we investigate the potential use of the small molecule STF-62247 to modulate radiation.

MATERIALS AND METHODS

Using RCC cell lines, we evaluate sensitivity to radiation in addition to agents that induce autophagic cell death by clonogenic survival assays. Furthermore, these were also tested under physiological oxygen levels.

RESULTS

STF-62247 specifically induces autophagic cell death in cells that have lost VHL, an essential mutation in the development of RCC. Treatment with STF-62247 did not alter cell cycle progression but when combined with radiation increased cell killing under oxic and hypoxic/physiological conditions.

CONCLUSIONS

This study highlights the possibility of combining targeted therapeutics such as STF-62247 or temsirolimus with radiation to reduce the reliance on partial or full nephrectomy and improve patient prognosis.

Complications and failure to rescue after laparoscopic versus open radical nephrectomy

PURPOSE

Since to our knowledge the population level impact of laparoscopy on post-radical nephrectomy morbidity and mortality remains unknown, we compared the rates of postoperative complications and failure to rescue (the fatality rate in patients with a complication) in patients treated with laparoscopic vs open radical nephrectomy.

MATERIALS AND METHODS

Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data we identified patients with kidney cancer who were treated with laparoscopic or open radical nephrectomy from 2000 through 2005. After measuring the frequency of postoperative complications and failure to rescue we fit multivariate logistic regression models to estimate the association of these outcomes with surgical approach, adjusting for patient characteristics, cancer severity and surgery year. We also assessed the relationship between case volume, complications and failure to rescue.

RESULTS

We identified 2,108 (26%) and 5,895 patients (74%) treated with laparoscopic and open radical nephrectomy, respectively. The overall rates of complications and failure to rescue were 36.9% and 5.3%, respectively. The predicted probability of any, major, medical and surgical complications was 15%, 12%, 13% and 23% lower, respectively, after laparoscopic than after open radical nephrectomy (each p <0.05). Despite less frequent complications patients treated with laparoscopic radical nephrectomy had a greater probability of failure to rescue (7.6% vs 4.6%, p = 0.010). Higher volume surgeons and hospitals had a lower rate of failure to rescue in patients treated with radical nephrectomy (each p <0.05) but not with open radical nephrectomy.

CONCLUSIONS

Supporting the decreased morbidity of laparoscopy, patients treated with radical nephrectomy had fewer complications than those who underwent open radical nephrectomy. However, failure to rescue was more common in patients with a complication after radical nephrectomy, suggesting that these events may be more difficult to recognize and manage successfully, especially among less experienced surgeons and hospitals.

Retroperitoneoscopic radical nephrectomy with a small incision for renal cell carcinoma: comparison with the conventional method

purpose

When retroperitoneoscopic radical nephrectomy for renal cell carcinoma was introduced into our institution, we performed a combined small skin incision method. In this method, a small incision was made to approach the retroperitoneal space prior to setting trockers and thereafter a LAPDISC was placed in the incision to start the retroperitoneoscopic procedure. In this study, we compared the outcomes between the combined small skin incision method ("A method" hereinafter) and the conventional method ("B method" hereinafter).

material and methods

Among the cases of T1N0M0 suspicious renal cell carcinoma treated at Yokohama City University between May 2003 and June 2009, the A method was performed in 51 cases and the B method was performed in 33 cases. The factors in the outcomes compared between the A and B methods were the duration of procedure, volume of bleeding, volume of transfusion, weight of the specimen, incidence of peritoneal injury, rate of conversion to open surgery, and perioperative complications.

results

The duration of the procedure was 214.4 ± 46.9 minutes in the A method group and 208.1 ± 36.4 minutes in the B method group (p = 0.518). The volume of bleeding and the weight of the specimen were 105.5 ± 283.2 ml and 335.1 ± 137.4 g in the A method group and 44.8 ± 116 ml (p = 0.247) and 309.2 ± 126 g (p = 0.385) in the B method group. There was no significant difference in all factors analyzed.

conclusion

The A method would be highly possible to produce stable results, even during the introduction period when the staff and the institution are still unfamiliar with the retroperitoneoscopic surgery.

Neoadjuvant and adjuvant strategies in renal cell carcinoma: more questions than answers

The current standard treatment for early stage (I-III) renal cell cancer (RCC) is surgery. While the prognosis of stage I tumors is excellent, stage II and particularly stage III have a high risk of relapse. The adjuvant treatment of patients with RCC remains an area of investigation, with patient selection being a key aspect. There are currently two prognostic nomograms to establish the risk of relapse in patients with resected RCC. The results of earlier studies of adjuvant therapy, including the use chemotherapy and/or immunotherapy after nephrectomy have failed to show any benefit in the outcome of patients at risk of developing local recurrence or distant metastases. Two recent phase III trials with vaccines (autologous tumor cell vaccine and autologous tumor-derived heat shock protein peptide complex-96) have shown promising, albeit still preliminary, results. In the metastatic RCC setting, recent advances in the molecular understanding of oncogenic pathways have led to the development of new therapeutic strategies with the use of targeted therapies in the adjuvant setting. Neoadjuvant treatment is another treatment modality currently being evaluated for patients with early disease and in patients with metastatic RCC with inoperable primary tumors. The questions that remain unanswered include activity of these agents in early stages of the disease, patient selection, optimal start time of the adjuvant treatment, and finally, the optimal length of treatment.

Decreasing size at diagnosis of stage 1 renal cell carcinoma: analysis from the National Cancer Data Base, 1993 to 2004

PURPOSE

The proportion of renal cell carcinoma cases diagnosed at stage I is known to be increasing significantly. We characterized stage I tumors further in terms of tumor size at diagnosis using a large national cancer registry.

MATERIALS AND METHODS

The National Cancer Data Base captures approximately 75% of all newly diagnosed cancer cases in the United States. The database was queried for all adults who were diagnosed between 1993 and 2004 with stage I renal cell carcinoma. Trends were assessed in mean size with time as well as in the proportion of stage I tumors diagnosed at less than 2.0, less than 2.5 and less than 3.0 cm.

RESULTS

There were 104,150 patients in the National Cancer Data Base diagnosed with stage I renal cell carcinoma during the study period. A total of 10,279 stage I tumors (9.9%) were less than 2.0 cm, 26,621 (25.6%) were 2.5 cm or less and 39,879 (38.3%) were 3.0 cm or less. Analysis of stage I renal cell carcinoma diagnoses with time demonstrated a statistically significant increase in the proportion of renal masses 3.0 cm or less between 1993 and 2004 (32.5% vs 43.4%). Of tumors 3.0 cm or less the proportion smaller than 2.0 cm increased significantly during the study period from 24.1% in 1993 to 29.4% in 2004. Mean tumor size decreased from 4.1 to 3.6 cm between 1993 and 2004 (p <0.001).

CONCLUSIONS

Tumor size at diagnosis is decreasing with time in patients with stage I renal cell carcinoma. These data likely underestimate the proportion of all enhancing renal masses diagnosed at a small size. Patients with small masses may be appropriate candidates for nephron sparing surgery, energy based ablative therapy or active surveillance. Better technologies are needed to determine the diagnosis and prognosis of small enhancing renal masses.

Diffusion of surgical innovation among patients with kidney cancer

BACKGROUND

Despite their potential benefits to patients with kidney cancer, the adoption of partial nephrectomy and laparoscopy has been gradual and asymmetric. To clarify whether this trend reflects differences in kidney cancer patients or differences in surgeon practice styles, the authors compared the magnitude of surgeon-attributable variance in the use of partial nephrectomy and laparoscopic radical nephrectomy with that attributable to patient and tumor characteristics.

METHODS

By using linked Surveillance, Epidemiology, and End Results-Medicare data, the authors identified a cohort of 5483 Medicare beneficiaries who underwent surgery for kidney cancer between 1997 and 2002. Two primary outcomes were defined: 1) the use of partial nephrectomy and (2) the use of laparoscopy among patients undergoing radical nephrectomy. By using multilevel models, surgeon- and patient-level contributions to observed variations in the use of partial nephrectomy and laparoscopic radical nephrectomy were estimated.

RESULTS

Of the 5483 cases identified, 611 (11.1%) underwent partial nephrectomy (43 performed laparoscopically), and 4872 (88.9%) underwent radical nephrectomy (515 performed laparoscopically). After adjusting for patient demographics, comorbidity, tumor size, and surgeon volume, the surgeon-attributable variance was 18.1% for partial nephrectomy and 37.4% for laparoscopy. For both outcomes, the percentage of total variance attributable to surgeon factors was consistently higher than that attributable to patient characteristics.

CONCLUSIONS

For many patients with kidney cancer, the surgery provided depends more on their surgeon's practice style than on the characteristics of the patient and his or her disease. Consequently, dismantling barriers to surgeon adoption of partial nephrectomy and laparoscopy is an important step toward improving the quality of care for patients with early-stage kidney cancer.

Renal epithelial neoplasms: diagnostic applications of gene expression profiling

Renal cell carcinoma (RCC) is the most common form of kidney cancer in adults. RCC is a significant challenge for pathologic diagnosis and clinical management. The primary approach to diagnosis is by light microscopy, using the World Health Organization (WHO) classification system, which defines histopathologic tumor subtypes with distinct clinical behavior and underlying genetic mutations. However, light microscopic diagnosis of RCC subtypes can be difficult due to variable histology, morphologic features shared by tumor subtypes, and a growing frequency of small tumor biopsies with limited morphologic information. In addition to these diagnostic problems, the clinical behavior of RCC is highly variable, and therapeutic response rates are poor. Few clinical assays are available to predict outcome in RCC or correlate behavior with histology. Therefore, novel RCC classification systems based on gene expression should be useful for diagnosis, prognosis, and treatment. Recent microarray studies have shown that renal tumors are characterized by distinct gene expression profiles, which can be used to discover novel diagnostic and prognostic biomarkers. Here, we review clinical features of kidney cancer, the WHO classification system, and the growing role of molecular classification for diagnosis, prognosis, and therapy of this disease.

Laparoscopic partial nephrectomy: how far have we gone?

PURPOSE OF REVIEW

Several technical modifications of laparoscopic partial nephrectomy have resulted in a reduction of complications and warm ischemia time. The most recent results are reviewed with a focus on oncologic outcome and postoperative renal function.

RECENT FINDINGS

The indications for laparoscopic partial nephrectomy are the same as for open surgery. All tumors up to 4 cm should be included and selected tumors up to 7 cm may be considered as well. In experienced hands, the complication rate is considerably low. Oncologic outcome is comparable with open partial nephrectomy and 5-year survival data have been published recently. Long warm ischemia time may be of some concern. The published functional results are excellent. Cost should not be the main argument in favor of a method. Laparoscopic partial nephrectomy, however, combines advantages for the patient with lower cost as shown by two studies.

SUMMARY

Laparoscopic partial nephrectomy duplicates the principles of open surgery and has been standardized to a great extent. It is technically difficult and is being performed by a small number of centers only; however, the interest of the urologists and patient demand is growing quickly. At the present time, laparoscopic partial nephrectomy cannot be considered a standard of care, but excellent results have been reported when performed by experienced laparoscopists.

Laparoscopy for Renal Cell Carcinoma: Diffusion Versus Regionalization?

PURPOSE

Recognizing the emergence of laparoscopy as a standard of care for surgical treatment in many patients with organ confined renal cell carcinoma, we explored the diffusion of this technology by examining temporal trends in the nationwide use of laparoscopic total and partial nephrectomy in patients with renal cell carcinoma.

MATERIALS AND METHODS

Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample were abstracted for 1991 through 2003. International Classification of Diseases-Ninth Revision, Clinical Modification 9 codes were used to identify patients undergoing open and laparoscopic total and partial nephrectomy for renal cell carcinoma. Using hospital sampling weights we calculated annual incidence rates for open and laparoscopic nephrectomy, thereby estimating the diffusion of laparoscopy. Bivariate and multivariate analyses were used to identify patient and hospital characteristics associated with the more frequent use of laparoscopic techniques.

RESULTS

Data on 63,812 patients were abstracted from the Nationwide Inpatient Sample, yielding a weighted national estimate of 323,979 who underwent laparoscopic (4.9%) or open (95.1%) nephrectomy (total or partial) for renal cell carcinoma between 1991 and 2003. Although it is still infrequent, the use of laparoscopy has increased steadily since 1998 with a utilization peak in 2003 of 1.7 laparoscopic nephrectomies per 100,000 American population, representing 16% of all total and partial nephrectomies for renal cell carcinoma in 2003. Treatment year, overall hospital nephrectomy volume and teaching hospital status were the most robust determinants of increased laparoscopic use (each p <0.001).

CONCLUSIONS

Although its use has increased progressively in the last decade, the dissemination of laparoscopy for renal cell carcinoma has been generally slow and limited in scope. The next step in this body of work is to identify specific technical, educational and policy interventions that will influence the diffusion of this alternative standard of care.

Cost Trends for Oncological Renal Surgery: Support for a Laparoscopic Standard of Care

PURPOSE

There may be inherent costs associated with the cultivation of laparoscopic expertise. We compared the cost trends for laparoscopy during the development of our program with that of open surgery for renal neoplasms.

MATERIALS AND METHODS

We retrospectively reviewed the records of 381 patients treated surgically for renal cortical neoplasms from 1998 to 2003. Demographic information and cancer specific data were recorded on each subject. Direct variable costs, which are directly traceable to the patient care service provided and vary with patient volume, were used to analyze cost. Temporal trends were assessed using multivariate models developed to determine smoothed mean costs by year.

RESULTS

Although it was initially more expensive, by 2003 mean costs were lower for laparoscopic than for open radical nephrectomy ($5,157 vs $5,808). This reflected a significantly lower annual increase in direct variable costs for laparoscopy vs open surgery even after adjustment for patient age, sex, race and clinical stage (p = 0.013). Although a similar trend was observed when comparing nephron sparing procedures vs open surgery, this did not attain statistical significance. In addition to surgical technique, only higher clinical stage was independently associated with increased direct variable costs after adjustment for operative year (p <0.0001).

CONCLUSIONS

Relative to their open counterparts the costs of laparoscopic treatment of renal cortical neoplasms have increased at a lower rate in the last 6 years. When considered in the context of the well established benefits of laparoscopy, our findings lend additional support in favor of laparoscopy as the standard of care.