Postoperative surveillance imaging for patients undergoing nephrectomy for renal cell carcinoma

A Real-World, Population-Based Retrospective Analysis of Therapeutic Survival for Recurrent Localized Renal Cell Carcinoma After Nephrectomy

We retrospectively analyzed therapeutic strategies and risk factors for overall survival (OS) in disease recurrence following curative nephrectomy for localized renal cell carcinoma (loRCC) using the Korean National Cancer Registry Database. We selected 1295 recurrent loRCC patients who underwent either partial or radical nephrectomy from 2007-2013. Patients were excluded for age <19 years, secondary RCC, multiple primary tumors, other SEER stages except for a localized or regional stage, postoperative recurrence within 3-month, and non-nephrectomized cases. Four therapeutic groups were statistically analyzed for OS and risk factors: surgery (OP, 12.0%), other systemic therapy (OST, 59.5%), radiotherapy (RT, 2.8%), and targeted therapy (TT, 25.8%). The overall mortality rate for recurrent loRCC was 32.5%, including 82.4% for RCC-related deaths. The baseline comparison among groups showed statistical differences for the diagnostic age of cancer and the SEER stage (p<0.05). Multivariate analysis of OS showed significance for the TT (hazard ratio [HR]: 6.27), OST (HR: 7.05), and RT (HR: 7.47) groups compared with the OP group, along with significance for the sex, SEER stage, and the time from nephrectomy to treatment for disease recurrence (p<0.05). The median OS curve showed a significantly better OS in the OP group (54.9 months) compared with the TT, OST, and RT groups (41.7, 42.9, and 38.0 months, respectively; p<0.001). In conclusion, the surgery-treated group had the best OS among the different therapeutic strategies for recurrent loRCC after nephrectomy, and the importance of the time from nephrectomy to secondary treatment was a significant prognostic factor.

Recurrence Risk of Renal Cell Carcinoma Lingers Even Decades After Nephrectomy

Renal cell carcinoma (RCC) is a common malignancy in elderly males. Metastatic spread of this cancer is not an uncommon occurrence, even after nephrectomy. Lung, bone, liver, and brain are the most frequently involved sites. Such a type of presentation mostly occurs within five years after nephrectomy however, cases have been reported later as well. Here, we report a case of metastatic renal cell carcinoma that presented in the form of a lung growth 28 years after nephrectomy. This highlights the importance to consider relapsed metastatic renal cancer in the differential, even decades after its surgical removal.

Role of F-18 FDG PET/CT in the follow-up of asymptomatic renal cell carcinoma patients for postoperative surveillance: based on conditional survival analysis

PURPOSE

This study investigated the clinical usefulness of F-18 fluorodeoxylucose (FDG) positron emission tomography/computed tomography (PET/CT) for postoperative surveillance in the RCC patients in terms of detectability of recurrence and radiation exposure.

METHODS

Three-hundred-and-forty- three RCC patients who underwent surgery and postoperative surveillance were retrospectively included. Conditional recurrent free survival (CRFS) was investigated and diagnostic performance of conventional imaging (CI) which include abdominopelvic CT or/and chest CT was compared to the FDG PET/CT.

RESULTS

At a median follow-up of 4.3 years (0.5-13.0 years), thirty-nine patients (11.4%) developed recurrence. CRFS of the patients increased over time with greater increment in advanced stage. The sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy of FDG PET/CT were 92.3%, 97%, 80%, 99.0%, and 96.5% in detecting recurrence, while those values for CI were 89.7%, 97.7%, 83.3%, 98.7%, and 96.8%, respectively. There were no significant differences in these values between FDG PET/CT and CI (McNemar test, p = 0.581). The average radiation dose from FDG PET/CT was around 16.9 ± 3.08 mSv at each follow-up time point. For early stage patients, the average radiation dose from CI was around 26.5 ± 8.57 mSv at each follow-up time point, while this was about 33.0 ± 9.76 mSv for advanced stage patients.

CONCLUSION

FDG PET/CT exhibited good diagnostic performance in asymptomatic RCC patients after surgery, of a level comparable to that of CI, but with a lower radiation dose.

Baseline perfusion CT parameters as potential biomarkers in predicting long-term prognosis of localized clear cell renal cell carcinoma

PURPOSE

We aimed to explore the relationship among baseline perfusion CT parameters, clinical, and pathological factors with post-nephrectomy long-term progression-free survival in localized clear cell renal cell carcinoma.

MATERIALS AND METHODS

This study retrospectively collected 127 patients from March 2005 to May 2007 who undertook perfusion CT. 61 patients were confirmed of pT1N0M0 or pT2N0M0 ccRCC. The mean follow-up time is 118.8 months (± 13.1 m, range 72-135 m). We compared clinical, pathological factors (gender, T stage, age, Fuhrmann grade, VEGF level, and MVD), and perfusion parameters before treatment [blood flow (BF), blood volume, mean transition time, and permeability surface-area product] between groups with post-nephrectomy metastasis and without metastasis. Association between covariates and progression-free survival (PFS) were analyzed using Cox proportional regression.

RESULTS

Among 61 patients, 11 developed distant metastasis (10 in the lung, one in the bone). BF in metastatic group [429.1 (233.8, 570.1) ml/min/100 g] was significantly higher than non-metastatic group [214.3 (153.3, 376.5) ml/min/100 g] (p = 0.011). Metastatic group also had more patients with higher Fuhrmann grade. Multi-covariant Cox regression demonstrated T staging, Fuhrmann grade, and BF were significantly associated with PFS [hazard ratio (HR) 3.35, 3.08, and 1.006]. In another model, BF > 230 ml/min/100 g was associated with PFS (HR 12.90), along with T staging and Fuhrmann grade (HR 4.73, 3.69).

CONCLUSION

Baseline tumor BF is a potential biomarker in prediction long-term metastasis of localized ccRCC and may help screening for higher risk localized ccRCC patients who need personalized surveillance strategy after nephrectomy.

Methods for the evaluation of biomarkers in patients with kidney and liver diseases: multicentre research programme including ELUCIDATE RCT

Background

Protein biomarkers with associations with the activity and outcomes of diseases are being identified by modern proteomic technologies. They may be simple, accessible, cheap and safe tests that can inform diagnosis, prognosis, treatment selection, monitoring of disease activity and therapy and may substitute for complex, invasive and expensive tests. However, their potential is not yet being realised.

Design and methods

The study consisted of three workstreams to create a framework for research: workstream 1, methodology – to define current practice and explore methodology innovations for biomarkers for monitoring disease; workstream 2, clinical translation – to create a framework of research practice, high-quality samples and related clinical data to evaluate the validity and clinical utility of protein biomarkers; and workstream 3, the ELF to Uncover Cirrhosis as an Indication for Diagnosis and Action for Treatable Event (ELUCIDATE) randomised controlled trial (RCT) – an exemplar RCT of an established test, the ADVIA Centaur® Enhanced Liver Fibrosis (ELF) test (Siemens Healthcare Diagnostics Ltd, Camberley, UK) [consisting of a panel of three markers – (1) serum hyaluronic acid, (2) amino-terminal propeptide of type III procollagen and (3) tissue inhibitor of metalloproteinase 1], for liver cirrhosis to determine its impact on diagnostic timing and the management of cirrhosis and the process of care and improving outcomes.

Results

The methodology workstream evaluated the quality of recommendations for using prostate-specific antigen to monitor patients, systematically reviewed RCTs of monitoring strategies and reviewed the monitoring biomarker literature and how monitoring can have an impact on outcomes. Simulation studies were conducted to evaluate monitoring and improve the merits of health care. The monitoring biomarker literature is modest and robust conclusions are infrequent. We recommend improvements in research practice. Patients strongly endorsed the need for robust and conclusive research in this area. The clinical translation workstream focused on analytical and clinical validity. Cohorts were established for renal cell carcinoma (RCC) and renal transplantation (RT), with samples and patient data from multiple centres, as a rapid-access resource to evaluate the validity of biomarkers. Candidate biomarkers for RCC and RT were identified from the literature and their quality was evaluated and selected biomarkers were prioritised. The duration of follow-up was a limitation but biomarkers were identified that may be taken forward for clinical utility. In the third workstream, the ELUCIDATE trial registered 1303 patients and randomised 878 patients out of a target of 1000. The trial started late and recruited slowly initially but ultimately recruited with good statistical power to answer the key questions. ELF monitoring altered the patient process of care and may show benefits from the early introduction of interventions with further follow-up. The ELUCIDATE trial was an ‘exemplar’ trial that has demonstrated the challenges of evaluating biomarker strategies in ‘end-to-end’ RCTs and will inform future study designs.

Conclusions

The limitations in the programme were principally that, during the collection and curation of the cohorts of patients with RCC and RT, the pace of discovery of new biomarkers in commercial and non-commercial research was slower than anticipated and so conclusive evaluations using the cohorts are few; however, access to the cohorts will be sustained for future new biomarkers. The ELUCIDATE trial was slow to start and recruit to, with a late surge of recruitment, and so final conclusions about the impact of the ELF test on long-term outcomes await further follow-up. The findings from the three workstreams were used to synthesise a strategy and framework for future biomarker evaluations incorporating innovations in study design, health economics and health informatics.

Trial registration

Current Controlled Trials ISRCTN74815110, UKCRN ID 9954 and UKCRN ID 11930.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 3. See the NIHR Journals Library website for further project information.

Surveillance following surgery for nonmetastatic renal cell carcinoma

PURPOSE OF REVEIW

Approximately one in three patients with nonmetastatic renal cell carcinoma (RCC) at the time of surgery will subsequently develop local or metastatic recurrence. The purpose of this review is to examine the current rationale for surveillance, describe sites of RCC metastasis, evaluate the existing guidelines for postsurgical follow-up studies, and analyze the risk stratification systems following RCC surgery.

RECENT FINDINGS

Although 75% of recurrences will be identified during the first 5 years following surgery, late recurrences are not uncommon. The risk of recurrence can be predicted from the tumor stage, grade, and other pathologic features. Advanced risk stratification will likely be possible in the future with increased use of molecular classification and serum biomarkers. Patient comorbidities, age, and individual recurrence risk should also be considered when designing individualized surveillance protocols.

SUMMARY

Follow-up after surgery for RCC should focus on imaging of the chest and abdomen to detect common sites of recurrence. Patients should be stratified for risk, and surveillance imaging should be more frequent and intensive in healthy patients with higher risk. Future research is needed to define an optimal individualized surveillance strategy that balances the potential benefits of early cancer detection with the risks and cost of surveillance.

Prognostic role of myoferlin expression in patients with clear cell renal cell carcinoma

OBJECTIVES

In patients with cancer, myoferlin protein hyperexpression has been correlated with poor patient prognosis. Here, we evaluated myoferlin expression in patients with clear cell renal cell carcinoma (ccRCC) and investigated the prognostic significance of myoferlin expression in these patients.

MATERIALS AND METHODS

One hundred and fifty-two patients with ccRCC who underwent treatment at Gyeongsang National University Hospital, Korea, between January 2000 and December 2009 were enrolled. Immunohistochemical analysis was performed on tissue microarray blocks produced from surgical specimens. Surgical specimen cancerous cells were graded as showing myoferlin hyperexpression or hypoexpression by comparison with intratumoral endothelial cells. Disease-free survival was evaluated using Kaplan-Meier analysis. Cox regression analysis was used to determine the relationships between myoferlin expression levels, risk factors, and prognosis.

RESULTS

Seventy-one of 304 cores exhibited myoferlin hyperexpression. T stage was not associated with myoferlin hyperexpression, whereas a high Fuhrman nuclear grade was significantly associated with myoferlin hyperexpression. Kaplan-Meier analysis revealed that patients with T stage >2, Fuhrman nuclear grade >2, and those with myoferlin hyperexpression had poorer disease-free survival compared to those with lower T stage, lower Fuhrman nuclear grade, and myoferlin hypoexpression (all p <0.001). Furthermore, myoferlin hyperexpression was significantly associated with disease-free survival on Cox regression analysis (hazard ratio, 4.604; 95% confidence interval, 1.893-11.199; p = 0.001).

CONCLUSION

Myoferlin expression could be a potential prognosticator in patients with ccRCC, and might be a useful marker for oncologic surveillance in such patients.

Selective effects of a fiber chimeric conditionally replicative adenovirus armed with hep27 gene on renal cancer cell

ASBTARCT Adenoviruses mediated cancer gene therapies are widely investigated and show a promising effect on cancer treatment. However, efficient gene transfer varies among different cancer cell lines based on the expression of coxsakie adenovirus receptor (CAR). Hep27, a member of dehydrogenase/reductase (SDR) family, can bind to Mdm2, resulting in the attenuation of Mdm2-mediated p53 degradation. Here we constructed a fiber chimeric adenovirus carrying hep27 gene (F5/35-ZD55-Hep27), in which the fiber protein of 5-serotype adenovirus (Ad5) was substituted by that of 35-serotype adenovirus (Ad35), aiming to facilitate the infection for renal cancer cells and develop the role of hep27 in cancer therapy. We evaluated the CAR and CD46 (a membrane cofactor protein for Ad35) expression in four kinds of renal cancer cells and assessed the relationship between receptors and infection efficiency. 5/35 fiber-modified adenovirus had a much promising infectivity compared with Ad5-based vector in renal cancer cells. F5/35-ZD55-Hep27 had enhanced antitumor activity against human renal cancer cells compared to the other groups. Further, hep27 mediated p53 and cleaved-PARP upregulation and mdm2 downregulation was involved and caused increased apoptosis. Moreover, F5/35-ZD55-Hep27 significantly suppressed tumor growth in subcutaneous renal cancer cell xenograft models. Our data demonstrated that 5/35 fiber-modified adenovirus F5/35-ZD55-Hep27 transferred into renal cancers efficiently and increased p53 to induce cancer cell apoptosis. Thus 5/35 fiber-modified adenoviral vector F5/35-ZD55-Hep27 might a promising vector and antitumor reagent for renal cancer gene therapy.

Comparison of Renal Cell Carcinoma Surveillance Guidelines: Competing Trade-Offs

PURPOSE

We estimated the differences in intensity, cost, radiation exposure and cancer control of published surveillance guidelines screening for secondary renal cell carcinoma in patients treated with partial nephrectomy.

MATERIALS AND METHODS

We developed a Monte Carlo simulation model to contrast the existing guidelines in terms of cost, radiation exposure and cancer control. Model inputs were extrapolated from the existing literature. Surveillance guidelines were analyzed from the AUA, CUA, EAU and NCCN®. Risk stratification among patients treated with partial nephrectomy was based on tumor characteristics.

RESULTS

Expected costs during the 5 years after partial nephrectomy were $587 (CUA), $1,076 (AUA), $1,705 (EAU) and $1,768 (NCCN) for low risk patients, and $903 (CUA), $2,525 (EAU) and $3,904 (AUA and NCCN) for high risk patients. Radiation exposure ranged from 31.41 mSv (CUA) to 104.34 mSv (NCCN) for low risk patients and 46.88 mSv (CUA) to 231.61 mSv (AUA and NCCN) for high risk patients. The EAU and CUA guidelines led to the diagnosis of the highest percentage of low risk patients (more than 95%) while all guidelines diagnosed more than 92% of high risk patients with recurrence.

CONCLUSIONS

Renal cell carcinoma surveillance guidelines differ greatly in terms of intensity, cost and radiation exposure. It is important for clinicians to adopt standardized surveillance strategies that limit unnecessary cost and radiation exposure without compromising cancer control.