Survival and prognostic factors of patients with renal cell cancer with bone metastasis in the era of targeted therapy: A single-institution analysis

Renal cell carcinoma with multiple bone metastases effectively treated by a combination of tyrosine kinase inhibitor, robot-assisted partial nephrectomy, and metastasectomy

Key Clinical Message

Maintaining a disease-free status for a long time in cases of renal cell carcinoma with multiple bone metastases and repeated recurrences is challenging. What matters most in the multidisciplinary approach is the treatment strategy. Although this is a case where multidisciplinary treatment resulted in long-term CR during the TKI era, the treatment strategy is still relevant now that treatment options have increased.

Abstract

Recent advances in medications, such as immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs), have improved metastatic renal cell carcinoma (mRCC) outcomes. We report a case of mRCC with bone metastasis that was successfully treated using a multidisciplinary approach. Here, we present a case of a 56-year-old man with left renal cancer and large and painful bone metastases at the 11th thoracic vertebrae (Th11). Therefore, a metastasectomy of Th11 was performed. Systemic treatment with TKI, robot-assisted partial nephrectomy, and metastasectomy were then administered. No recurrence was observed in >2 years. Long-term disease-free survival with the TKI-era multidisciplinary approach in a patient with mRCC remains significant when considering treatment sequences, especially now that drug treatment options-including ICIs-have increased. Treatment strategy and indication and timing of resection of the primary lesion and metastasectomy should be carefully considered in each case.

The Outcome of Molecularly Targeted Therapy after Surgical Treatment of Spinal Metastasis

The aim of this study was to investigate outcomes of molecularly targeted therapy after surgical treatment of spinal metastasis. Participants comprised 164 patients who underwent surgical treatment of spinal metastasis, divided according to whether molecularly targeted therapy was performed. We compared survival, local recurrence of metastasis detected by imaging, the disease-free interval, relapses of neurological deterioration, and the ability to walk between groups. Molecularly targeted drugs were administered to 39 patients after surgery (TT group) and were not administered to 125 patients (non-TT group). Median survival was significantly longer in the TT group (1027 days) than in the non-TT group (439 days, p < 0.01). Local recurrence occurred in 25 patients in the non-TT group and 10 patients in the TT group. The disease-free interval did not differ between groups. Neurological deterioration was observed in three patients in the non-TT group and no patients in the TT group. The ability to walk was preserved in 97.6% of patients in the TT group and 88% of patients in the non-TT group (p = 0.12). In conclusion, molecularly targeted drugs improve survival in patients with spinal metastasis but do not alter local control of metastatic tumors.

Establishment and Validation of a Machine Learning Prediction Model Based on Big Data for Predicting the Risk of Bone Metastasis in Renal Cell Carcinoma Patients

Purpose

Since the prognosis of renal cell carcinoma (RCC) patients with bone metastasis (BM) is poor, this study is aimed at using big data to build a machine learning (ML) model to predict the risk of BM in RCC patients.

Methods

A retrospective study was conducted on 40,355 RCC patients in the SEER database from 2010 to 2017. LASSO regression and multivariate logistic regression analysis was performed to determine independent risk factors of RCC-BM. Six ML algorithm models, including LR, GBM, XGB, RF, DT, and NBC, were used to establish risk models for predicting RCC-BM. The prediction performance of ML models was weighed by 10-fold cross-validation.

Results

The study investigated 40,355 patients diagnosed with RCC in the SEER database, where 1,811 (4.5%) were BM patients. Independent risk factors for BM were tumor grade, T stage, N stage, liver metastasis, lung metastasis, and brain metastasis. Among the RCC-BM risk prediction models established by six ML algorithms, the XGB model showed the best prediction performance (AUC = 0.891). Therefore, a network calculator based on the XGB model was established to individually assess the risk of BM in patients with RCC.

Conclusion

The XGB risk prediction model based on the ML algorithm performed a good prediction effect on BM in RCC patients.

Role of metastasectomy in the management of renal cell carcinoma

Treatment of metastatic renal cell carcinoma (mRCC) has evolved with the development of a variety of systemic agents; however, these therapies alone rarely lead to a complete response. Complete consolidative surgery with surgical metastasectomy has been associated with improved survival outcomes in well-selected patients in previous reports. No randomized control trial exists to determine the effectiveness of metastasectomy. Therefore, reviewing observational studies is important to best determine which patients are most appropriate for metastasectomy for mRCC and if such treatment continues to be effective with the development of new systemic therapies such as immunotherapy. In this narrative review, we discuss the indications for metastasectomies, outcomes, factors associated with improved survival, and special considerations such as location of metastasis, number of metastases, synchronous metastases, and use of systemic therapy. Additionally, alternative treatment options and trials involving metastasectomy will be reviewed.

Immune Checkpoint Inhibitor Therapy for Bone Metastases: Specific Microenvironment and Current Situation

The treatment of bone metastases is a thorny issue. Immunotherapy may be one of the few hopes for patients with unresectable bone metastases. Immune checkpoint inhibitors are the most commonly used immunotherapy drugs currently. In this review, the characteristics and interaction of bone metastases and their immune microenvironment were systematically discussed, and the relevant research progress of the immunological mechanism of tumor bone metastasis was reviewed. On this basis, we expounded the clinical application of immune checkpoint inhibitors for bone metastasis of common tumors, including non-small-cell lung cancer, renal cell carcinoma, prostate cancer, melanoma, and breast cancer. Then, the deficiencies and limitations in current researches were summarized. In-depth basic research on bone metastases and optimization of clinical treatment is needed.

Clinical Characteristics and Prognosis of Renal Cell Carcinoma With Spinal Bone Metastases

Background

The prognosis of renal cell carcinoma (RCC) with spinal bone metastasis (sBM) varies greatly. In this study, we aimed to define the clinical characteristics and prognostic factors of RCC with spinal bone metastasis (sBM) in our center.

Methods

The clinical and medical records of RCC patients with sBMs were collected. The gender, age, time of BM, the extent of BM, the number of BMs, the presence or absence of visceral metastasis, and the pathological type of BM were investigated. All patients were followed up regularly. Overall survival (OS) was calculated from the date of BMs diagnosis to death or last follow-up using Kaplan-Meier method and modelled with Cox regression analysis.

Results

Forty-three RCC patients with sBM were collected. sBM was found synchronously in 30 patients (70%) and metachronously in 13 patients (30%). The median survival time was 30 months in 13 patients (30%) with solitary sBM and 19 months in 30 patients (70%) with multiple sBMs (P = 0.002). Visceral metastasis occurred in 12 patients (28%) with the median survival time of 17 months, while the other 31 patients (72%) had no visceral metastasis with the median survival time of 29 months (P<0.001). En-block resection was done in 10 patients with median survival time of 40.1 months. Non-en-block resection were done in 33 patients with median survival time of 19.7 months (P<0.001). Multivariate COX regression analysis showed that MSKCC score, number of BM, visceral metastasis, and en-block resection are the independent prognosis factors of RCC patients with sBM.

Conclusions

MSKCC risk stratification, number of sBM, visceral metastasis and en-block resection are significant prognostic factors for OS in RCC patients with spinal BM. Therefore, for selected patients who has solitary spinal BM with no visceral metastasis, en-block resection of spinal BM can potentially prolong survival and is the treatment of choice.

Clinical outcomes and prognostic factors following the surgical resection of renal cell carcinoma spinal metastases

The efficacy of surgical resection in metastatic renal cell carcinoma is an active and important research field in the postcytokine era. Bone metastases, especially in the spine, compromise patient performance status. Metastasectomy is indicated, if feasible, because it helps to achieve the best clinical outcomes possible compared with other treatments. This study examined the postoperative survival and prognostic factors in patients who underwent metastasectomy of spinal lesions. The retrospective study included 65 consecutive patients with metastatic renal cell carcinomas who were operated on by spinal metastasectomy between 1995 and 2017 at our institution. The cancer‐specific survival times from the first spinal metastasectomy to death or the last follow‐up (≥3 years) were determined using Kaplan‐Meier analysis. Potential factors influencing survival were analyzed using Cox proportional hazard models. Planned surgical resection of all the spine tumors was achieved in all patients. Of these, 38 had complete metastasectomy of all visible metastases, including extraspinal lesions. In all patients, the estimated median cancer‐specific survival time was 100 months. The 3‐, 5‐, and 10‐year cancer‐specific survival rates were 77%, 62%, and 48%, respectively. The survival times after spinal metastasectomy were similar in both cytokine and postcytokine groups. In multivariate analyses, postoperative disability, the coexistence of liver metastases, multiple spinal metastases, and incomplete metastasectomy were significant risk factors associated with short‐term survival. Complete metastasectomy, including extraspinal metastases, was associated with improved cancer‐specific survival. Proper patient selection and complete metastasectomy provide a better prognosis in metastatic renal cell carcinoma patients.

Survival nomogram for patients with bone metastatic renal cell carcinoma: A population-based study

Purpose:

Increased attention has been focused on the survival of renal cell carcinoma (RCC) patients with bone metastasis. This study proposed to establish and evaluate a nomogram for predicting the overall survival (OS) and cancer-specific survival (CSS) of RCC patients with bone metastasis.

Materials and Methods:

RCC patients with bone metastasis between 2010 and 2015 were captured from the surveillance, epidemiology and end results (SEER) database. Univariate and multivariate cox regressions were performed to assess the effects of clinical variables on OS and CSS. The nomogram based on the Cox hazards regression model was developed. Concordance index (C-index) and calibration curve were performed to evaluate the accuracy of nomogram models, receiver operating characteristic (ROC) curves and decision curve analysis (DCA) were conducted to assess the predict performance.

Results:

A total of 2.471 eligible patients were enrolled in this study. The patients were assigned to primary (n=1.672) and validation (n=799) cohorts randomly. The 1-, 2-, and 3-year OS and CSS nomogram models were constructed based on age at diagnosis, sex, marital status, pathological grade, T-stage, N-stage, brain/liver/lung metastasis, surgery, radiotherapy and chemotherapy. The c for OS and CSS prediction was 0.730 (95% confidence interval [CI]: 0.719-0.741) and 0.714 (95%CI:0.702-0.726). The calibration curves showed significant agreement between nomogram models and actual observations. ROC and DCA indicated nomograms had better predict performance.

Conclusions:

The nomograms for predicting prognosis provided an accurate prediction of OS and CSS in RCC patients with bone metastasis, and contributed clinicians to optimize individualized treatment plans.

Transdiaphragmatic nephrectomy with synchronous pulmonary and anterior thoracic wall mass metastasectomy in a young male with metastatic renal cell carcinoma; a single-incision approach

Renal cell carcinoma represents approximately 3% of all cancers, with the highest incidence occurring in the western world. Around 33% of the patients experience metastatic disease at diagnosis. Since the approval of the first targeted therapy, the treatment of metastatic renal cell carcinoma (mRCC) has positively changed, but the surgical treatment of the primary tumor, and metastases if possible, is sometimes crucial in selected patients controlling the burden of cancer sites with the intention to improve survival. We, herein, report on a case of a young male patient presented in the emergency room with gross hematuria which underwent transdiaphragmatic nephrectomy with synchronous pulmonary and anterior thoracic wall mass metastasectomy with a single thoracic incision due to mRCC. Achieving a full response in patients with mRCC is extremely rare only with medical treatment. The role of complete surgical metastasectomy is questioned, but there are several studies that support its efficacy in achieving metastases free status prolonged overall survival and better quality of life. The therapeutic treatment plan for these patients should be discussed within dedicated multidisciplinary cancer centers and focus on each patient individually and they should be offered a closed follow-up strategy.

Radiographical efficacy of systemic treatment for bone metastasis from renal cell carcinoma

Enlarged bone metastasis from renal cell carcinoma (RCC) can cause skeletal-related events, and thus treatment to inhibit the growth of bone metastases is often required. Although radiotherapy for RCC bone metastases can achieve a certain degree of local control, evidence is lacking regarding the effects of systemic therapy to improve bone metastasis. The present study aimed to assess the treatment efficacy of targeted therapy and immune checkpoint inhibitors, and to determine whether systemic therapy without radiotherapy can shrink bone metastases of RCC. The present study retrospectively reviewed 44 patients with RCC with bone metastases treated via systemic therapy, including targeted therapy or immune checkpoint inhibitors. Patients were divided into two groups: Those who underwent systemic therapy with radiotherapy for bone lesions (n=29); and those who underwent systemic therapy without radiotherapy for bone lesions (n=15). The radiographical efficacy of systemic therapy and the time to progression of bone metastases were compared between groups. The overall response rate of systemic therapy with radiotherapy was 44%, and in total, 13 patients demonstrated a partial response. Only one patient (6%) had a partial response among those who were treated via systemic therapy without radiotherapy. The time to progression of bone metastasis was 9.5 and 2.1 months in patients treated with and without radiotherapy, respectively (P<0.0001). Collectively, the present results suggested that targeted therapy or immune checkpoint inhibitors without radiotherapy had only a slight effect on bone metastasis control.

The Evolving Role of Metastasectomy for Patients with Metastatic Renal Cell Carcinoma

Surgical metastasectomy continues to be utilized for patients with solitary or low-volume metastatic renal cell carcinoma (mRCC). Although few high-quality data are available to evaluate outcomes, local treatment is recommended when feasible because it may allow a subset of patients to delay or avoid systemic treatments. With the development of improved mRCC therapies, utilization of metastasectomy has increased because most patients have incomplete responses to systemic treatment of their metastases. This review discusses the rationale and history of metastasectomy, trends in utilization, prognostic factors for patient selection, site-specific considerations, alternatives for nonsurgical local treatment, and risk of morbidity associated with metastasectomy.

A 17-Gene Signature Predicted Prognosis in Renal Cell Carcinoma

Renal cell carcinoma (RCC), which was one of the most common malignant tumors in urinary system, had gradually increased incidence and mortality in recent years. Although significant advances had been made in molecular and biology research on the pathogenesis of RCC, effective treatments and prognostic indicators were still lacking. In order to predict the prognosis of RCC better, we identified 17 genes that were associated with the overall survival (OS) of RCC patients from The Cancer Genome Atlas (TCGA) dataset and a 17-gene signature was developed. Through SurvExpress, we analyzed the expression differences of the 17 genes and their correlation with the survival of RCC patients in five datasets (ZHAO, TCGA, KIPAN, KIRC, and KIRP), and then evaluated the survival prognostic significance of the 17-gene signature for RCC. Our results showed that the 17-gene signature had a predictive prognostic value not only in single pathologic RCC, but also in multiple pathologic types of RCC. In conclusion, the 17-gene signature model was related to the survival of RCC patients and could help predict the prognosis with significant clinical implications.

Clinical analysis of bone metastasis of gastric cancer: incidence, clinicopathological features and survival

Aim: We evaluated the incidence, clinicopathological features, prognostic factors and survival of gastric cancer (GC) with bone metastasis in a single large cancer center in China. Patients & methods: Patients with bone metastasis of GC were retrospectively analyzed. Overall survival was estimated using the Kaplan-Meier method. Clinicopathological factors, which were associated with prognostic factors for survival, were evaluated. Results: The incidence of bone metastasis was 11.3% for metastatic GC patients. Median overall survival time was 6.5 months. Multivariate analysis revealed two independent poor prognostic factors: Eastern Cooperative Oncology Group ≥2 (p = 0.023) and lack of palliative chemotherapy (p = 0.018). Conclusion: The incidence of bone metastasis from metastatic GC was underestimated. The prognosis of GC with bone metastasis was poor.

TUSC3 as a potential biomarker for prognosis in clear cell renal cell carcinoma

The aim of the present study was to explore the expression levels of tumor suppressor candidate 3 (TUSC3) in human clear cell renal cell carcinoma (ccRCC) and its clinical value. Immunohistochemical staining, western blotting and reverse transcription-quantitative polymerase chain reaction were used to detect TUSC3 expression in paracancerous normal tissues and ccRCC tissues. The tissues were derived from the pathological specimens of 54 patients with ccRCC. Additionally, associations among TUSC3 expression and histological grade and clinicopathological staging of ccRCC were investigated. The results of these comparisons revealed that TUSC3 expression in ccRCC tissues was significantly lower than that in paracancerous tissues (P<0.05). TUSC3 expression in the high differentiation group was higher than that in the median and low differentiation groups (P<0.05). Expression levels of TUSC3 in stage I and II tissues were higher than those in stage III and IV tissues (P<0.05). The expression levels of TUSC3 in the lymph node metastasis group were lower than those in the non-lymph node metastasis group (P<0.05). In conclusion, the expression levels of TUSC3 in human ccRCC tissues were downregulated compared with those found in normal human renal tissue, and TUSC3 may inhibit the progression of ccRCC. Furthermore, the TUSC3 gene may be used as a promising tumor marker for the early diagnosis and prognosis of ccRCC.

Surgical Metastasectomy in Renal Cell Carcinoma: A Systematic Review

CONTEXT

The benefit of surgical metastasectomy (SM) for patients with metastatic renal cell carcinoma (mRCC) remains controversial because of the lack of high-level evidence on the role of SM in terms of survival benefit in the era of systemic therapy.

OBJECTIVE

To perform a systematic review of the literature on the role of SM in the treatment of mRCC and discuss key issues in the SM decision-making process.

EVIDENCE ACQUISITION

A systematic search of the Embase and Medline databases was carried out and a systematic review of the role of SM in mRCC was performed. A total of 56 studies were finally included in the evidence synthesis.

EVIDENCE SYNTHESIS

All the studies included were retrospective and mostly noncomparative. Median overall survival (OS) ranged from 36 to 142mo for those undergoing SM, compared to 8-27mo for no SM. SM was associated with a lower risk of all-cause mortality compared to no SM (pooled adjusted hazard ratio 2.37, 95% confidence interval 2.03-2.87; p<0.001). Morbidity and mortality were similar for SM and primary tumor surgery. The most important prognostic factor for OS was complete resection of metastases. Other prognostic factors included disease free-survival from nephrectomy, primary tumor features (T stage ≥3, high grade, sarcomatoid features, and pathological nodal status), the number of metastases, and performance status. Lung metastasectomy seemed to show the best survival benefit.

CONCLUSIONS

Although no randomized clinical data are available, published studies support the role of SM in selected patients in the modern era. Complete SM allows sustained survival free of systemic treatment. Integration of SM and systemic therapy in a multimodal approach remains a valid option for some patients.

PATIENT SUMMARY

Surgical resection of metastases originating from renal cell carcinoma may play a role in prolonging survival and avoiding systemic therapy when complete resection is achievable. This strategy is an option for selected patients with a limited number of metastases who still have good general health status.