Sarcomatoid renal cell carcinoma: Biology and treatment advances

Special populations in metastatic renal cell carcinoma

PURPOSE OF REVIEW

This review focuses on special populations poorly represented in current evidence-based practice for metastatic renal cell carcinoma (mRCC). This includes the elderly and frail, patients on immunosuppression or with autoimmune diseases, patients with brain, liver, and/or bone metastases, and RCC with sarcomatoid features.

RECENT FINDINGS

Certain populations are poorly represented in current trials for mRCC. Patients with central nervous system (CNS) metastases are often excluded from first-line therapy trials. Modern doublet systemic therapy appears to benefit patients with bone or liver metastases, but data supporting this conclusion is not robust. Post-hoc analyses on patients with sarcomatoid differentiation have shown improved response to modern doublet therapy over historical treatments. The elderly are underrepresented in current clinical trials, and most trials exclude all but high-performing (nonfrail) patients, though true frailty is likely poorly captured using the current widely adopted indices. It is difficult to make conclusions about the efficacy of modern therapy in these populations from subgroup analyses. Data from trials on other malignancies in patients with autoimmune diseases or solid organ transplant recipients on immunosuppression suggest that immune checkpoint inhibitors (ICIs) may still have benefit, though at the risk of disease flare or organ rejection. The efficacy of ICIs has not been demonstrated specifically for RCC in this group of patients.

SUMMARY

The elderly, frail, and immunosuppressed, those with tumors having aggressive histologic features, and patients with brain, bone, and/or liver metastases represent the populations least understood in the modern era of RCC treatment.

Demographic Patterns and Clinicopathological Analysis of Sarcomatoid Renal Cell Carcinoma in US Population

BACKGROUND

Sarcomatoid renal cell carcinoma (RCC) is defined by the presence of any amount of sarcomatoid components admixed with other RCC histologic subtypes. Our investigation utilizes a large, diverse set of sarcomatoid RCC patients to summarize clinical, demographic, and pathological factors along with demographic disparities that may affect the prognosis and survival of sarcomatoid RCC patients.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was employed to compile data from 2000 to 2018 from 2695 patients diagnosed with sarcomatoid RCC.

RESULTS

The mean age for sarcomatoid RCC diagnosis is 62.8 years. Males (68.2%) and White patients (82.6%) were more likely to be diagnosed with sarcomatoid RCC. Among the 64.4% of tumors with known size, 35.4% were less than 7 cm, 27.6% were 7.1 to 10 cm, and 36.4% were larger than 10 cm. Among the 95.8% of patients with known stage, 15.3% were localized, 28.9% were regionalized, and 55.8% were found in distant sites. Among the 44.2% of cases with known metastases site, lung was found to be the most common metastatic site.. Surgery was the most common treatment (70.9%). While the overall 5-year survival was 18.1%, it was 27.1% among patients who underwent surgery. Independent risk factors for mortality include age > 60 years, distant stage, and tumor size > 10 cm, per our multivariate analysis.

CONCLUSION

Sarcomatoid RCC most commonly affects White males in their seventh decade. Increased age, distant stage, and size > 10 cm tumor size have associations with unfavorable prognosis. Surgery is associated with better survival outcomes in localized disease and multimodal therapy (surgery with adjuvant chemoradiation was associated with better survival.).

A novel immune-related model to predict prognosis and responsiveness to checkpoint and angiogenesis blockade therapy in advanced renal cancer

Background

Immune checkpoint blockade (ICB) and anti-angiogenic drug combination has prolonged the survival of patients with advanced renal cell carcinoma (RCC). However, not all patients receive clinical benefits from this intervention. In this study, we aimed to establish a promising immune-related prognostic model to stratify the patients responding to ICB and anti-angiogenic drug combination and facilitate the development of personalized therapies for patients with RCC.

Materials and methods

Based on clinical annotations and RNA-sequencing (RNA-seq) data of 407 patients with advanced RCC from the IMmotion151 cohort, nine immune-associated differentially expressed genes (DEGs) between responders and non-responders to atezolizumab (anti-programmed death-ligand 1 antibody) plus bevacizumab (anti-vascular endothelial growth factor antibody) treatment were identified via weighted gene co-expression network analysis. We also conducted single-sample gene set enrichment analysis to develop a novel immune-related risk score (IRS) model and further estimate the prognosis of patients with RCC by predicting their sensitivity to chemotherapy and responsiveness to immunotherapy. IRS model was further validated using the JAVELIN Renal 101 cohort, the E-MTAB-3218 cohort, the IMvigor210 and GSE78220 cohort. Predictive significance of the IRS model for advanced RCC was assessed using receiver operating characteristic curves.

Results

The IRS model was constructed using nine immune-associated DEGs: SPINK5, SEMA3E, ROBO2, BMP5, ORM1, CRP, CTSE, PMCH and CCL3L1. Advanced RCC patients with high IRS had a high risk of undesirable clinical outcomes (hazard ratio = 1.91; 95% confidence interval = 1.43–2.55; P < 0.0001). Transcriptome analysis revealed that the IRS-low group exhibited significantly high expression levels of CD8+ T effectors, antigen-processing machinery, and immune checkpoints, whereas the epithelial–mesenchymal transition pathway was enriched in the IRS-high group. IRS model effectively differentiated the responders from non-responders to ICB combined with angiogenesis blockade therapy or immunotherapy alone, with area under the curve values of 0.822 in the IMmotion151 cohort, 0.751 in the JAVELIN Renal 101 cohort, and 0.776 in the E-MTAB-3218 cohort.

Conclusion

IRS model is a reliable and robust immune signature that can be used for patient selection to optimize the efficacy of ICB plus anti-angiogenic drug therapies in patients with advanced RCC.

Sarcomatoid renal cell carcinoma: MRI features and their association with survival

OBJECTIVE

To evaluate MRI features of sarcomatoid renal cell carcinoma (RCC) and their association with survival.

METHODS

This retrospective single-center study included 59 patients with sarcomatoid RCC who underwent MRI before nephrectomy during July 2003-December 2019. Three radiologists reviewed MRI findings of tumor size, non-enhancing areas, lymphadenopathy, and volume (and percentage) of T2 low signal intensity areas (T2LIA). Clinicopathological factors of age, gender, ethnicity, baseline metastatic status, pathological details (subtype and extent of sarcomatoid differentiation), treatment type, and follow-up were extracted. Survival was estimated using Kaplan-Meier method and Cox proportional-hazards regression model was used to identify factors associated with survival.

RESULTS

Forty-one males and eighteen females (median age 62 years; interquartile range 51-68) were included. T2LIAs were present in 43 (72.9%) patients. At univariate analysis, clinicopathological factors associated with shorter survival were: greater tumor size (> 10 cm; HR [hazard ratio] = 2.44, 95% CI 1.15-5.21; p = 0.02), metastatic lymph nodes (present; HR = 2.10, 95% CI 1.01-4.37; p = 0.04), extent of sarcomatoid differentiation (non-focal; HR = 3.30, 95% CI 1.55-7.01; p < 0.01), subtypes other than clear cell, papillary, or chromophobe (HR = 3.25, 95% CI 1.28-8.20; p = 0.01), and metastasis at baseline (HR = 5.04, 95% CI 2.40-10.59; p < 0.01). MRI features associated with shorter survival were: lymphadenopathy (HR = 2.24, 95% CI 1.16-4.71; p = 0.01) and volume of T2LIA (> 3.2 mL, HR = 4.22, 95% CI 1.92-9.29); p < 0.01). At multivariate analysis, metastatic disease (HR = 6.89, 95% CI 2.79-16.97; p < 0.01), other subtypes (HR = 9.50, 95% CI 2.81-32.13; p < 0.01), and greater volume of T2LIA (HR = 2.51, 95% CI 1.04-6.05; p = 0.04) remained independently associated with worse survival.

CONCLUSION

T2LIAs were present in approximately two thirds of sarcomatoid RCCs. Volume of T2LIA along with clinicopathological factors were associated with survival.

Long-term outcomes with nivolumab plus ipilimumab versus sunitinib in first-line treatment of patients with advanced sarcomatoid renal cell carcinoma

BACKGROUND

Patients with advanced renal cell carcinoma with sarcomatoid features (sRCC) have a poor prognosis and limited therapeutic options. First-line nivolumab plus ipilimumab (NIVO+IPI) provided efficacy benefits over sunitinib (SUN) in patients with intermediate/poor-risk sRCC at 42 months minimum follow-up in the phase 3 CheckMate 214 trial. In this exploratory post hoc analysis, we report clinical efficacy of NIVO+IPI in sRCC after a minimum follow-up of 5 years.

METHODS

In CheckMate 214, patients with clear cell advanced RCC were randomized to NIVO 3 mg/kg plus IPI 1 mg/kg every 3 weeks (four doses), then NIVO 3 mg/kg every 2 weeks versus SUN 50 mg once daily (4 weeks; 6-week cycles). Randomized patients with sRCC were identified via independent central pathology review of archival tumor tissue or histological classification per local pathology report. Overall survival (OS), as well as progression-free survival (PFS) and objective response rate (ORR) per independent radiology review using Response Evaluation Criteria in Solid Tumors V.1.1, were evaluated in all International Metastatic Renal Cell Carcinoma Database Consortium intermediate/poor-risk sRCC patients and by baseline tumor PD-L1 expression level (≥1% vs <1%). Safety outcomes are reported using descriptive statistics.

RESULTS

In total, 139 patients with intermediate/poor-risk sRCC were identified (NIVO+IPI, n=74; SUN, n=65). At 5 years minimum follow-up, more patients remained on treatment with NIVO+IPI versus SUN (12% vs zero). Efficacy benefits with NIVO+IPI versus SUN were maintained with median OS of 48.6 vs 14.2 months (HR 0.46), median PFS of 26.5 vs 5.5 months (HR 0.50), and ORR 60.8% vs 23.1%. In addition, median duration of response was longer (not reached vs 25.1 months), and more patients had complete responses (23.0% vs 6.2%) with NIVO+IPI versus SUN, respectively. Efficacy was better with NIVO+IPI versus SUN regardless of tumor PD-L1 expression, but the magnitude of OS, PFS, and ORR benefits with NIVO+IPI was greater for sRCC patients with tumor PD-L1 ≥1%. No new safety signals emerged in either arm with longer follow-up.

CONCLUSIONS

Among patients with intermediate/poor-risk sRCC, NIVO+IPI maintained long-term survival benefits and demonstrated durable and deep responses over SUN at minimum follow-up of 5 years, supporting NIVO+IPI as a preferred first-line therapy in this population.

TRIAL REGISTRATION NUMBER

NCT02231749.

Clinicopathologic factors linked to oncologic outcomes for renal cell carcinoma with sarcomatoid dedifferentiation: A PRISMA-compliant systematic review and meta-analysis

Background

There are still differences in the prognostic factors of renal cell carcinoma with sarcomatoid dedifferentiation (sRCC). The aim of this study was to evaluate important predictors of survival in patients with sRCC.

Patients and methods

A comprehensive search of PubMed, Embase, and Cochrane Library was conducted to identify eligible studies. The endpoints embraced overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS). Hazard ratios (HRs) and related 95% confidence intervals (CIs) were extracted.

Results

A total of 13 studies were included for analyses. The pooled results showed that high European Cooperative Oncology Group performance score (HR 2.39, 95% CI 1.32–4.30; P = 0.004), high T stage (HR 2.18, 95% CI 1.66–2.86; P < 0.001), positive lymph node (HR 1.54, 95% CI 1.40–1.69; P < 0.001), distant metastasis (HR 2.52, 95% CI 1.99–3.21; P < 0.001), lung metastases (HR 1.45, 95% CI 1.16–1.80; P < 0.001), liver metastases (HR 1.71, 95% CI 1.30–2.25; P < 0.001), tumor necrosis (HR 1.78, 95% CI 1.14–2.80; P = 0.010), and percentage sarcomatoid ≥50% (HR 2.35, 95% CI 1.57–3.52; P < 0.001) were associated with unfavorable OS. Positive lymph node (HR 1.57, 95% CI 1.33–1.85; P < 0.001) and high neutrophil to lymphocyte ratio (HR 1.16, 95% CI 1.04–1.29; P = 0.008) were associated with unfavorable CSS. High T stage (HR 1.93 95% CI 1.44–2.58; P < 0.001) was associated with unfavorable progression-free survival.

Conclusions

A meta-analysis of available data identified important prognostic factors for CSS, OS, and PFS of sRCC, which should be systematically evaluated for patient counseling, risk stratification, and treatment selection.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=249449.

A Rare Case of Sarcomatoid Renal Cell Carcinoma in a Young Adult Patient

Background

Sarcomatoid differentiation is a rare condition that could present in different subtypes of renal cell carcinomas (RCCs) and is associated with a significantly poor prognosis. Sarcomatoid renal cell carcinoma (SRCC) patients are typically aged between 54 and 63, with a male-to-female ratio ranging from 1.3:1 to 2:1. Here, we report a case of SRCC in a 29-year-old female patient.

Case Presentation

A 29-year-old female presented with left flank pain. A large lump was palpated on left flank and there was costovertebral angle tenderness. The lump was enlarged, and the patient also suffered from anemia. Abdominopelvic CT demonstrated solid mass with an internal gliosis in the left part of the renal cortex and the solid component was enhanced with contrast admission. Then, the patient underwent left radical nephrectomy with wide perirenal excision and paraaortic lymph nodes resection. Histopathological examination revealed SRCC with no lymphovascular invasion.

Conclusion

The scarcity of data on SRCCs emphasizes the need for ongoing research into the biology, diagnostics, and effective treatment options for patients with this disease, as responses to conventional therapies have been disappointing, leaving patients with few options. Cytoreductive nephrectomy for SRCC patients with metastatic disease is debatable, although some research suggests resection at any stage in patients with good performance status. In this case, radical nephrectomy was performed and there was no evidence of metastasis.

The Role of Cytoreductive Nephrectomy and Targeted Therapy on Outcomes of Patients With Metastatic Sarcomatoid Renal Cell Carcinoma: A Population-Based Analysis

Sarcomatoid renal cell carcinoma (sRCC) is a rare but aggressive form of kidney cancer with a poor prognosis. Despite recent advances in therapies for kidney cancers, an effective management strategy for sRCC is uncertain. We evaluated the impact of targeted therapy and cytoreductive nephrectomy (CN) on survival outcomes of patients with metastatic sRCC. We identified patients diagnosed with sRCC between January 1, 1973, and December 31, 2014, within the Surveillance, Epidemiology and End Results (SEER) database. Patients with metastatic sRCC were stratified based on the era of diagnosis (before or after the introduction of targeted systemic therapy in 2006) and the status of CN. Cancer-specific survival (CSS) and overall survival (OS) were analyzed. Data of 993 patients with metastatic sRCC were available for analysis. The median age was 62 years. Most patients were male (69%), Caucasian (71%), and were diagnosed in the targeted therapy era (83%); 53% of patients underwent CN. CSS and OS of the whole cohort were 5.0 months and 4.0 months, respectively. While the introduction of targeted therapy did not improve outcomes, CN improved CSS and OS in both pre-targeted therapy and targeted therapy era. On multivariable analysis, CN was a predictor of an improved CSS (hazard ratio [HR] 0.54, p < 0.0001) and OS (HR 0.51, p < 0.0001). Among other factors, older age at diagnosis, higher T stages, and node positivity were associated with worse outcomes. Our results showed that the introduction of targeted therapy did not improve outcomes in patients with metastatic sRCC. CN improved survival in both pre-targeted and targeted therapy eras.

Reviewing Treatment Options for Advanced Renal Cell Carcinoma: Is There Still a Place for Tyrosine Kinase Inhibitor (TKI) Monotherapy?

Renal cell carcinoma (RCC) comprises a highly heterogeneous group of kidney tumours built upon distinct genetic- and epigenetic-driven mechanisms and molecular pathways. Therefore, responsiveness to treatment is considerably variable across patients, adding an extra layer of complexity to the already challenging therapeutic decision process. The last decade brought an unprecedented shift in the medical approach to advanced or metastatic RCC; in fact, immunotherapy-based combinations have significantly transformed the therapeutic arsenal and clinical outcomes of these patients. These strategies were quickly adopted by international guidelines committees as the new standards of care. However, this enhanced efficacy comes at the expense of tolerability, with a predictable negative impact on patients’ quality of life. Moreover, subgroup and post hoc analyses of the major clinical trials have shown that not all patients benefit equally from these innovative approaches. In this context, a group of experts on kidney cancer met and discussed the state of the art in the field, with a special emphasis on the appropriateness of using monotherapy with an anti-angiogenesis tyrosine kinase inhibitor (TKI) to treat specific subgroups of patients with RCC. This article reviews the main topics that were considered to be pertinent for that discussion and establishes the profile of patients for whom TKI monotherapy remains a sensible frontline option by avoiding overtreatment and an unnecessary exposure to treatment-related toxicity.

Sarcomatoid Renal Cell Carcinoma: The Present and Future of Treatment Paradigms

Sarcomatoid renal cell carcinoma (sRCC) is an aggressive form of kidney cancer that is associated with poor prognosis. It can arise from any histologic type of renal cell carcinoma. The majority of cases will present with advanced or metastatic disease requiring systemic therapy. Nephrectomy is the treatment of choice in locally resectable disease. The therapeutic options for sRCC have evolved in the past decade. Cytotoxic chemotherapy and monotherapy with targeted therapy (VEGF and mTOR) have historically shown poor response rates and survival in the treatment of metastatic sRCC. The use of checkpoint inhibitors and their combination with targeted therapy against VEGF has changed the landscape and outcomes for renal cell carcinoma. Given the rarity of sRCC most of the data on treatment is from small cohorts or extrapolation from larger clinical trials. The benefit from the combination of checkpoint inhibitors and targeted therapy to VEGF has shown promise in the sRCC population in post hoc analysis of large clinical trials. Future research focusing on further characterizing the unique biologic and clinical features of sRCC is critical in advancing the knowledge and developing effective therapy to improve clinical outcomes and survival.

Pathology and systemic therapy of non-clear cell renal cell carcinoma: an overview

Introduction: Non-clear cell renal cell carcinoma (nccRCC) represents a highly heterogenous group of kidney cancer entities. As most clinical trials predominantly include patients with clear cell RCC (ccRCC), nccRCC treatment guidelines are mainly extrapolated from recommendations in ccRCC. Here, we review and elucidate current data on the pathologic classification and treatment of nccRCC.Areas covered: This article gives an overview of the WHO classification of RCC, showing the histological diversity of nccRCC and focusing particularly on entities first characterized since 2016, their specific molecular behavior and their role as indicators for hereditary cancer syndromes. In this context, we discuss the available data on nccRCC treatment oprtions such as tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors, cytotoxic chemotherapy, and immune checkpoint inhibitors.Expert opinion: Although nccRCCs are relatively uncommon, entities of this type account for a subgroup of up to 20-25% of all RCCs. Advances in histopathology and molecular genetics, together with evidence gained from retrospective and prospective clinical data, have improved understanding of these tumors in recent years. Nevertheless, selective trials of current and novel therapies including new targeted agents in patients with nccRCC are urgently needed to further improve treatment guidelines.

Determinants of treatment for first-line immune-based combinations in metastatic renal cell carcinoma: a critical overview of recent evidence

The last three decades have witnessed a revolution in the therapeutic scenario of metastatic renal cell carcinoma (mRCC), due to the advent of novel agents including tyrosine kinase inhibitors, immune checkpoint inhibitors and the combination of both treatments. These strategies have reported unprecedented response rates, thus improving the clinical outcomes of mRCC patients, and current international guidelines support the use of immune-based combinations as first-line treatment in patients with metastatic disease. However, more data are awaited to help clinicians in the decision-making process. Herein, we provide an overview of recently published results regarding immune-based combinations as first-line treatment in mRCC patients, critically discussing available data that could help in suggesting determinants of treatment in this setting.

Adjuvant therapy in renal cell carcinoma: is it the right strategy to inhibit VEGF?

Despite several clinical trials have assessed different agents in the adjuvant setting, renal cell carcinoma (RCC) still remains a disease orphan of an effective adjuvant treatment. In fact, systemic therapies targeting angiogenesis that have been observed to be effective in metastatic setting failed to show an improvement in terms of clinical outcomes when used ad adjuvant treatments. In this study, we performed a meta-analysis of 5 randomized clinical trials to assess the impact of tyrosine kinase inhibitors (TKIs) targeting angiogenesis after surgery: ASSURE, S-TRAC, PROTECT, ATLAS, SORCE. Among the 6,531 patients assessed, we confirmed the lack of efficacy of adjuvant treatments in terms of disease-free survival (DFS) (pooled-HR 0.93, 95% CI, 0.84–1.02, P=0.16) and overall survival (OS) (pooled-HR 0.98, 95% CI, 0.88–1.09, P=0.54). To the best of our knowledge, we still ignore why some treatments active in the metastatic setting do not show similar efficacy as adjuvant treatment. Exploring possible reasons of this apparently conflicting results is important as it may offer new insights that should be evaluated in next generation adjuvant trials. Immune checkpoint inhibitors (ICIs) have reported significant results—as monotherapy or in combinations with other anticancer agents—in metastatic setting, and the results of trials evaluating these agents in the adjuvant setting are awaited.

Development and validation of prognostic nomograms and a web-based survival rate calculator for sarcomatoid renal cell carcinoma in pre- and post-treatment patients

Background

To develop a clinical prediction model and web-based survival rate calculator to predict the overall survival (OS) and cancer-specific survival (CSS) of sarcomatoid renal cell carcinoma (SRCC) for clinical diagnosis and treatment.

Methods

SRCC patient data were retrieved from Surveillance, Epidemiology, and End Results (SEER) database. Factors independently associated with survival were identified by a Cox regression analysis. Nomograms of the prediction model were constructed using a SEER training cohort and validated with a SEER validation cohort. At the same time, the decision analysis curve, receiver operating characteristic curve, and calibration curve were also used to examine and evaluate the model. A web-based survival rate calculator was constructed to help assist in the assessment of the disease condition and clinical prognosis.

Results

The records of 2,742 SRCC cases were retrieved from SEER, while 1,921 cases with a median OS of 14 and CSS of 32 months were used as the training cohort. The developed nomograms were more accurate than that of the American Joint Committee on Cancer staging (C-indexes of 0.767 versus 0.725 for OS and 0.775 versus 0.715 for CSS), with better discrimination than that of the American Joint Committee on Cancer (AJCC) stage model and the calibration was validated in the SEER validation cohort. The model's 3- and 5-year OS and CSS were superior to AJCC and T staging on the analysis decision curve. The prognosis prediction of SRCC established by the prediction model could be evaluated through the web-based survival rate calculator, which plays a guiding role in clinical treatment.

Conclusions

Nomograms and a web-based survival rate calculator predicting the OS and CSS of SRCC patients with better discrimination and calibration were developed.

Molecular Subsets in Renal Cancer Determine Outcome to Checkpoint and Angiogenesis Blockade

Integrated multi-omics evaluation of 823 tumors from advanced renal cell carcinoma (RCC) patients identifies molecular subsets associated with differential clinical outcomes to angiogenesis blockade alone or with a checkpoint inhibitor. Unsupervised transcriptomic analysis reveals seven molecular subsets with distinct angiogenesis, immune, cell-cycle, metabolism, and stromal programs. While sunitinib and atezolizumab + bevacizumab are effective in subsets with high angiogenesis, atezolizumab + bevacizumab improves clinical benefit in tumors with high T-effector and/or cell-cycle transcription. Somatic mutations in PBRM1 and KDM5C associate with high angiogenesis and AMPK/fatty acid oxidation gene expression, while CDKN2A/B and TP53 alterations associate with increased cell-cycle and anabolic metabolism. Sarcomatoid tumors exhibit lower prevalence of PBRM1 mutations and angiogenesis markers, frequent CDKN2A/B alterations, and increased PD-L1 expression. These findings can be applied to molecularly stratify patients, explain improved outcomes of sarcomatoid tumors to checkpoint blockade versus antiangiogenics alone, and develop personalized therapies in RCC and other indications.

Immunotherapy in metastatic sarcomatoid renal cell carcinoma: A single institution experience

INTRODUCTION

Immune checkpoint inhibitors (CPIs) were recently approved in advanced clear cell renal cell carcinoma (RCC) and could be a promising option for metastatic RCC with sarcomatoid differentiation (sRCC) which otherwise carry a poor prognosis. We sought to compare outcomes between patients who received immunotherapy (IO) including CPIs or high dose interleukin-2 (HD IL2) for metastatic sRCC versus those who did not.

PATIENTS AND METHODS

We performed a single-center retrospective data analysis of 44 consecutive sRCC patients with any percentage of sarcomatoid differentiation from our institutional RCC database of whom 34 received IO and 10 patients did not.

RESULTS

Baseline variables between the two groups were not significantly different except for a greater percentage of patients with ≥40% sarcomatoid differentiation in the non-IO cohort. At a median follow-up of 27.6 months, patients treated with IO had a median overall survival of 57.6 months compared to 6.6 months in patients not treated with IO (p = 0.0002). Overall response rates (ORR) between the IO and non-IO group were 35.3% and 0% respectively (p = 0.06). When IO was given in the 1st line setting, the ORR was 25.0%, as compared to 44.4% in the 2nd line setting and beyond though limitations of small sample sizes apply. Immune-related adverse events (IRAE) occurred in 38.2% of patients in the IO group, with grade 3 events (mostly gastrointestinal) in 20.6% with no grade 4 or 5 events. IRAEs led to interruption or discontinuation of immunotherapy in 26.5%.

CONCLUSION

Our results support IO as an effective therapeutic option for patients with metastatic sarcomatoid RCC. Further study of various IO regimens, including those affecting the interleukin-2 signaling pathway, and their efficacy in neoadjuvant and adjuvant settings are warranted in sRCC.

Prognostic Significance of Sarcomatoid Differentiation in Patients With Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

Background

To date, the prognostic value of sarcomatoid differentiation in patients having metastatic renal cell carcinoma (mRCC) remains inconclusive. A systematic review and meta-analysis were conducted.

Materials and Methods

Relevant literatures were obtained from PubMed, Embase, and Cochrane Library published prior to May, 2020. All patients were diagnosed with mRCC and treated with surgery, cytokine therapy, targeted therapy, and immunotherapy. Sarcomatoid differentiation in the pathological specimens was identified. Each endpoint [overall survival (OS), progression-free survival (PFS), and cancer-specific survival (CSS)] was assessed using a multivariable adjusted hazard ratio (HR) and 95% confidence interval (CI).

Results

Fifteen observational studies having 5,828 patients with mRCC were included. The merged results showed that patients presenting sarcomatoid differentiation had a significantly inferior OS (HR: 2.26, 95% CI: 1.82-2.81; P < 0.001), PFS (HR: 2.28, 95% CI: 1.63-3.19; P < 0.001), and CSS (HR: 2.27, 95% CI: 1.51-3.40; P < 0.001) compared to those without sarcomatoid differentiation. Subgroup analysis based on publication year, patient population, country, number of cases, and NOS score did not change the direction of results. A significant publication bias was identified for OS, but no publication bias was identified for PFS. Moreover, sensitivity analysis also verified the robustness of the results.

Conclusion

This study suggested that sarcomatoid differentiation was correlated to unfavorable clinical outcomes in mRCC and may be a poor prognostic factor incorporating to prognostic models for mRCC patients.

LINC02738 Participates in the Development of Kidney Cancer Through the miR-20b/Sox4 Axis

Background

Long non-coding RNAs (lncRNAs) can affect tumorigenesis. Data from The Cancer Genome Atlas (TCAG) suggest that LINC02783 is highly expressed in renal cell carcinoma (RCC) and is expected to be a potential biological target. We conducted this study to verify this.

Patients and Methods

We conducted this study to verify the opinion that "LINC02783 is highly expressed in renal cell carcinoma (RCC) and is expected to be a potential biological target". We employed quantitative real-time polymerase chain reaction (qRT-PCR) to test LINC02783 expression in RCC tissues, CKK-8 assay and transwell assay to assess the viability and invasion of RCC cells, Western blot to quantify Sox-4 expression, dual-luciferase reporter (DLR) assay and RNA immunoprecipitation (RIP) assay to analyze the interaction between LINC02783 and miR-20b, in vivo experiments to test tumor formation.

Results

We detected high LINC02783 expression in RCC patients. Patients with higher LINC02783 levels had a markedly poorer prognosis. In vitro and in vivo, the down-regulation of LINC02783 suppressed the viability and invasion of RCC cells. The DLR assay results revealed that LINC02783 enhanced Sox-4 expression by regulating miR-20b. LINC02783 can act as a sponge for miR-20b to inhibit Sox-4 expression.

Conclusion

LINC02783 is highly expressed in RCC patients and indicates a poor prognosis. LINC02783 can affect the occurrence and progression of RCC through the miR-20b/Sox-4 axis, making it a promising target for the treatment of RCC.

Prognostic and Predictive Factors in Metastatic Renal Cell Carcinoma: Current Perspective and a Look Into the Future

Metastatic renal cell carcinoma (mRCC) comprises a highly heterogeneous group of diseases with varied clinical outcomes. As a result, models to estimate prognosis were developed in an attempt to aid patient counseling, treatment selection, and clinical trial design. Contemporary prognostic models have been mostly generated based on clinical factors because of their ease of use. Recent advances in molecular techniques have allowed unprecedented molecular profiling of RCC and the discovery of genomic and proteotranscriptomic factors that may contribute to disease trajectory. With the advent of multiple systemic therapies in mRCC in recent years, predictive biomarkers have become increasingly relevant in treatment selection. In this review, we discuss the existing staging systems and prognostic models in mRCC. We also highlight various promising molecular biomarkers according to the subtypes of RCC and explore their integration into the traditional prognostic models. In addition, we discuss emerging predictive biomarkers in the era of immuno-oncology. Lastly, we explore future directions with a focus on liquid biopsies and composite biomarkers.

Fatal hyperprogression induced by nivolumab in metastatic renal cell carcinoma with sarcomatoid features: a case report

In the past few years, the immune checkpoint inhibitor (ICI) nivolumab has become standard of care in the treatment of metastatic renal cell carcinoma (mRCC) progressing after antiangiogenic agents. To date, neither expression of programmed death ligand-1 (PD-L1) nor any other biomarker can be used to predict responses to ICIs, although intermediate-poor International Metastatic Database of Renal Carcinoma (IMDC) risk patients and those with sarcomatoid tumors appear to achieve superior benefit from immunotherapy. Paradoxically, ICIs may sometimes increase the speed of tumor growth. This rare phenomenon, called hyperprogression, has first been described in patients with melanoma and lung cancer treated with ICIs and is associated with poor survival. Here, we present the case of a patient affected by an intermediate IMDC risk mRCC with diffuse sarcomatoid features who achieved long disease control with first-line sunitinib and then started a second-line treatment with nivolumab. Unexpectedly, he experienced a dramatic acceleration of tumor growth and died soon after the third infusion of nivolumab. Then, we review the frequency of hyperprogression in mRCC and discuss the biological peculiarity of sarcomatoid RCC in terms of different responses to ICIs and antiangiogenic agents.

FDG PET/CT and CT Findings of Renal Cell Carcinoma With Sarcomatoid Differentiation

OBJECTIVE. The purpose of this article is to investigate the value of ¹⁸F-FDG PET/CT and enhanced CT in the diagnosis of renal cell carcinoma (RCC) with sarcomatoid differentiation and the differential diagnosis of clear cell renal cell carcinoma (ccRCC). MATERIALS AND METHODS. Among patients with renal tumors confirmed by pathologic examination from September 2010 to August 2019, 29 patients with RCC with sarcomatoid differentiation and 82 patients with ccRCC who underwent FDG PET/CT, renal contrast-enhanced CT examination, or both, before surgery were studied. Features of the two groups on CT and PET/CT were retrospectively reviewed. RESULTS. The tumor size of RCC with sarcomatoid differentiation was larger than that of ccRCC (p = 0.0086). Cystic necrosis, peritumoral neovascularity, and metastasis were more common in RCC with sarcomatoid differentiation (p = 0.0052, p = 0.0008, p < 0.0001, respectively). The ratio of necrotic area to tumor diameter of RCC with sarcomatoid differentiation was statistically significantly larger than that of ccRCC (p = 0.0032). Three cases of RCC with sarcomatoid differentiation showed a large central necrotic area and dense intratu-moral neovascularity in the surrounding parenchyma, defined as the ring-of-fire sign, which was not found in ccRCC. The maximum standardized uptake value (SUV_max), mean standardized uptake value (SUV_mean), and peak standardized uptake value (SUV_peak) of RCC with sarcomatoid differentiation were statistically significantly higher than those for ccRCC (all p < 0.0001), and the SUV_max, SUV_mean, and SUV_peak cutoff values of 5.4, 4.2, and 5.0, respectively, were helpful for discrimination. CONCLUSION. Imaging features including higher SUV_max, SUV_mean, and SUV_peak; a larger ratio of necrotic area to tumor diameter; the presence of peritumoral neovascularity; and metastasis are more commonly associated with RCC with sarcomatoid differentiation than with ccRCC. The ring-of-fire sign and SUV_max, SUV_mean, SUV_peak cutoff values of 5.4, 4.2, 5.0, respectively, may be helpful to indicate RCC with sarcomatoid differentiation.

Construction and validation of a novel prognostic nomogram for patients with sarcomatoid renal cell carcinoma: a SEER-based study

OBJECTIVE

The only one established prognostic nomogram for patients with sarcomatoid renal cell carcinoma (sRCC) was based on a small sample-sized study without external validation, and a nomogram can be applied to western sRCC patients has not yet been developed. Therefore, our study aimed to construct and validate an effective nomogram to predict overall survival (OS) for these patients.

METHODS

The independent predictors for OS were identified and the nomogram was constructed on the basis of a retrospective study of a training cohort consisted of 428 non-Hispanic white sRCC patients registered in the Surveillance, Epidemiology and End Results (SEER) database from January 2010 to December 2015. Then, the discriminative performance of the nomogram was assessed by the concordance index (C-index). OS calibrations of the nomogram were also performed by comparing the nomogram-predicted probability to the observed survival rate. Furthermore, our nomogram was externally validated using two independent cohorts consisted of 71 non-Hispanic black patients and 82 Hispanic patients, respectively.

RESULTS

Age at diagnosis, T stage, N stage, bone metastases, liver metastases, lung metastases and nephrectomy were identified as independent predictors for OS. In the training cohort and two validation cohorts, the C-indexes of the nomogram were 0.737, 0.801 and 0.764, respectively. Besides, excellent agreements between the nomogram prediction and the actual observation were achieved in all cohorts.

CONCLUSIONS

The current study constructed and validated an effective prognostic nomogram for patients with sRCC, which can be used to perform accurate predictions of the 0.5-, 1-, and 2-year possibilities of OS.

Impact of sarcomatoid differentiation and rhabdoid differentiation on prognosis for renal cell carcinoma with vena caval tumour thrombus treated surgically

Background

Sarcomatoid differentiation in renal cell carcinoma (RCC) with vena caval tumour thrombus has been shown to be associated with aggressive behaviours and poor prognosis; however, evidence of the impact of rhabdoid differentiation on prognosis is lacking. This study evaluated the impact of sarcomatoid differentiation and rhabdoid differentiation on oncological outcomes for RCC with vena caval tumour thrombus treated surgically.

Methods

We retrospectively analysed patients treated surgically for RCC with vena caval tumour thrombus at our institute from Jan 2015 to Nov 2018. Prognostic variables were evaluated for associations with progression-free survival (PFS) and cancer-specific survival (CSS) by Kaplan–Meier survival analysis and log-rank test. Univariate and multivariate analyses were performed to determine independent prognostic variables.

Results

We identified 125 patients with RCC and vena caval tumour thrombus, including 17 (13.6%) with sarcomatoid differentiation alone, 8 (6.4%) with rhabdoid differentiation alone and 3 (2.4%) with both sarcomatoid and rhabdoid differentiation. Compared to pure RCC, patients with sarcomatoid differentiation but not rhabdoid differentiation have worse PFS (p = 0.018 and p = 0.095, respectively). The univariate and multivariate analyses both showed sarcomatoid differentiation as a significant predictor of PFS. Compared to pure RCC, patients with sarcomatoid differentiation (p = 0.002) and rhabdoid differentiation (p = 0.001) both had significantly worse CSS. The univariate analysis showed sarcomatoid differentiation, rhabdoid differentiation, metastasis and blood transfusion as significant predictors of CSS (All, p < 0.05). In the multivariate analysis, sarcomatoid differentiation (HR 3.90, p = 0.008), rhabdoid differentiation (HR 3.01, p = 0.042), metastasis (HR 3.87, p = 0.004) and blood transfusion (HR 1.34, p = 0.041) all remained independent predictors of CSS.

Conclusions

Sarcomatoid differentiation and rhabdoid differentiation are both independent predictors of poor prognosis in RCC with vena caval tumour thrombus treated surgically.

Outcomes Associated with First-Line anti-PD-1/ PD-L1 agents vs. Sunitinib in Patients with Sarcomatoid Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

Immunotherapy based on anti PD-1/PD-L1 inhibitors has proven to be more effective than sunitinib in the first-line setting of advanced renal cell carcinoma (RCC). RCC patients with sarcomatoid histology (sRCC) have a poor prognosis and limited therapeutic options. We performed a systematic review and a meta-analysis of randomized-controlled trials (RCTs) of first-line anti PD-1/PDL-1 agents vs. sunitinib, presenting efficacy data in the sub-group of sRCC patients. The systematic research was conducted on Google Scholar, Cochrane Library, PubMed and Embase and updated until 31th January, 2020. Abstracts from ESMO and ASCO (2010–2019) were also reviewed. Full texts and abstracts reporting about RCTs testing first-line anti-PD-1/ PD-L1 agents vs. sunitinib in RCC were included if sRCC sub-group analyses of either PFS (progression-free survival), OS (overall survival) or radiological response rate were available. Pooled data from 3814 RCC patients in the ITT (intention-to-treat) population and from 512 sRCC patients were included in the quantitative synthesis. In the sRCC sub-group vs. the ITT population, pooled estimates of the PFS-HRs were 0.57 (95%: 0.45–0.74) vs. 0.79 (95% CI: 0.70–0.89), respectively, with a statistically meaningful interaction favoring the sRCC sub-group (pooled ratio of the PFS-HRs = 0.64; 95% CI: 0.50–0.82; p < 0.001). Pooled estimates of the difference in CR-R (complete response-rate) achieved with anti-PD-1/PDL-1 agents vs. sunitinib were + 0.10 (95% CI: 0.04–0.16) vs. + 0.04 (95% CI: 0.00–0.07) in the sRCC vs. the non-sRCC sub groups, with a statistically meaningful difference of + 0.06 (95% CI: 0.02–0.10; p = 0.007) favoring the sRCC sub-group. Sarcomatoid histology may be associated with improved efficacy of anti PD-1/PDL-1 agents vs. sunitinib in terms of PFS and CR-R.

Real-world evidence on first-line treatment for metastatic renal cell carcinoma with non-clear cell and sarcomatoid histologies: are sunitinib and pazopanib interchangeable?

Introduction

Non-clear cell renal cell carcinoma (nccRCC) and sarcomatoid renal cell carcinoma (sRCC) are underrepresented in clinical trials. Treatment approaches are frequently extrapolated from data of clear cell renal cell carcinoma, in which pazopanib is non-inferior to sunitinib. We aim to compare the effectiveness of first-line sunitinib and pazopanib for nccRCC and sRCC.

Methods

We evaluated a retrospective cohort of patients with metastatic nccRCC and sRCC treated with first-line sunitinib or pazopanib at an academic cancer centre. Overall survival (OS), progression-free survival (PFS) and response rate were measured. Kaplan–Meier and log-rank analyses were used for time-to-event data. Cox regression was used for prognostic factors.

Results

Fifty-three patients were included; 16 (30.1%) treated with sunitinib and 37 (69.9%) with pazopanib. Forty-six (86.8%) patients had nccRCC and 7 (13.2%) had sRCC. The majority had intermediate or poor International Metastatic Renal-Cell Carcinoma Database Consortium risk (93%).

Median PFS was 6.6 months with sunitinib and 4.9 months with pazopanib (HR 1.75; P = 0.078). Treatment with pazopanib was associated with inferior OS in comparison with sunitinib (median OS: 30.4 months versus 8.7 months; HR 2.71, 95% CI 1.31–5.58, P = 0.007). These results were confirmed in subgroup analysis of patients with papillary, chromophobe and MiT family translocation histologies (median OS: 38.7 months versus 14.7 months; HR 3.16, 95% CI 1.20–8.29, P = 0.019). Unclassified and sarcomatoid histologies had inferior OS (median: 6.9 and 1.1 months, respectively) regardless of the treatment used.

Conclusion

In this patient cohort, pazopanib was associated with inferior OS in comparison with sunitinib for metastatic nccRCC. Larger trials are ideally warranted to confirm these results.

Immune Checkpoint Inhibitors in the Treatment of Renal Cell Carcinoma

Immune checkpoint inhibitors have quickly become a critical component to the management of advanced renal cell carcinoma. These therapies have been approved for patients who are treatment-naive and who have progressed on antiangiogenesis agents. Combinations of immune checkpoint inhibitors with antiangiogenesis agents show significant response rates and prolong survival. Adverse events associated with the use of checkpoint inhibition present unique challenges in the management of patients, and careful considerations are needed when checkpoint inhibitors are combined with antiangiogenesis agents. Nevertheless, the improvement in overall survival associated with these agents indicates that they will remain a vital component of kidney cancer treatment.

Molecular and histological correlations in liver cancer

Hepatocellular carcinoma (HCC) is a highly heterogeneous cancer, both at the molecular and histological level. High-throughput sequencing and gene expression profiling have identified distinct transcriptomic subclasses and numerous recurrent genetic alterations; several HCC subtypes characterised by histological features have also been identified. HCC phenotype appears to be closely related to particular gene mutations, tumour subgroups and/or oncogenic pathways. Non-proliferative tumours display a well-differentiated phenotype. Among this molecular subgroup, CTNNB1-mutated HCCs constitute a homogeneous subtype, exhibiting cholestasis and microtrabecular and pseudoglandular architectural patterns. Another non-proliferative subtype has a gene expression pattern similar to that of mature hepatocytes (G4) and displays a steatohepatitic phenotype. In contrast, proliferative HCCs are most often poorly differentiated, and notably include tumours with progenitor features. A novel morphological variant of proliferative HCC - designated "macrotrabecular-massive" - was recently shown to be associated with angiogenesis activation and poor prognosis. Altogether, these findings may help to translate our knowledge of HCC biology into clinical practice, resulting in improved precision medicine for patients with this highly aggressive malignancy. This manuscript reviews the most recent data in this exciting field, discussing future directions and challenges.

A Case of Sarcomatoid Renal Cell Carcinoma With Osseous Metaplasia and Papillary Renal Cell Carcinoma Metastasis

Sarcomatoid renal cell carcinoma is an uncommon and aggressive renal tumor with rapid disease progression. A median survival time is only 4-9 months after diagnosis. Osteogenic differentiation is a rare feature of the tumor. Here, we present a case of renal cell carcinoma with sarcomatoid feature and osteoid differentiation, and papillary renal cell carcinoma metastasis in a 58 year-old African-American male. This is the first reported renal cell carcinoma case with the combination of sarcomatoid feature, osteoid differentiation, and papillary renal cell carcinoma metastasis.

Atezolizumab plus bevacizumab versus sunitinib in patients with previously untreated metastatic renal cell carcinoma (IMmotion151): a multicentre, open-label, phase 3, randomised controlled trial

BACKGROUND

A phase 2 trial showed improved progression-free survival for atezolizumab plus bevacizumab versus sunitinib in patients with metastatic renal cell carcinoma who express programmed death-ligand 1 (PD-L1). Here, we report results of IMmotion151, a phase 3 trial comparing atezolizumab plus bevacizumab versus sunitinib in first-line metastatic renal cell carcinoma.

METHODS

In this multicentre, open-label, phase 3, randomised controlled trial, patients with a component of clear cell or sarcomatoid histology and who were previously untreated, were recruited from 152 academic medical centres and community oncology practices in 21 countries, mainly in Europe, North America, and the Asia-Pacific region, and were randomly assigned 1:1 to either atezolizumab 1200 mg plus bevacizumab 15 mg/kg intravenously once every 3 weeks or sunitinib 50 mg orally once daily for 4 weeks on, 2 weeks off. A permuted-block randomisation (block size of 4) was applied to obtain a balanced assignment to each treatment group with respect to the stratification factors. Study investigators and participants were not masked to treatment allocation. Patients, investigators, independent radiology committee members, and the sponsor were masked to PD-L1 expression status. Co-primary endpoints were investigator-assessed progression-free survival in the PD-L1 positive population and overall survival in the intention-to-treat (ITT) population. This trial is registered with ClinicalTrials.gov, number NCT02420821.

FINDINGS

Of 915 patients enrolled between May 20, 2015, and Oct 12, 2016, 454 were randomly assigned to the atezolizumab plus bevacizumab group and 461 to the sunitinib group. 362 (40%) of 915 patients had PD-L1 positive disease. Median follow-up was 15 months at the primary progression-free survival analysis and 24 months at the overall survival interim analysis. In the PD-L1 positive population, the median progression-free survival was 11·2 months in the atezolizumab plus bevacizumab group versus 7·7 months in the sunitinib group (hazard ratio [HR] 0·74 [95% CI 0·57-0·96]; p=0·0217). In the ITT population, median overall survival had an HR of 0·93 (0·76-1·14) and the results did not cross the significance boundary at the interim analysis. 182 (40%) of 451 patients in the atezolizumab plus bevacizumab group and 240 (54%) of 446 patients in the sunitinib group had treatment-related grade 3-4 adverse events: 24 (5%) in the atezolizumab plus bevacizumab group and 37 (8%) in the sunitinib group had treatment-related all-grade adverse events, which led to treatment-regimen discontinuation.

INTERPRETATION

Atezolizumab plus bevacizumab prolonged progression-free survival versus sunitinib in patients with metastatic renal cell carcinoma and showed a favourable safety profile. Longer-term follow-up is necessary to establish whether a survival benefit will emerge. These study results support atezolizumab plus bevacizumab as a first-line treatment option for selected patients with advanced renal cell carcinoma.

FUNDING

F Hoffmann-La Roche Ltd and Genentech Inc.

Sarcomatoid Renal Cell Carcinoma: Population-Based Study of 879 Patients

BACKGROUND

Sarcomatoid renal cell carcinoma (sRCC) constitutes a rare and aggressive subtype of renal cell carcinoma. We aimed to investigate its clinicopathologic characteristics and outcomes at a national level.

PATIENTS AND METHODS

We accessed the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010-2015) and extracted data on patients with sRCC. We estimated median, 1-, 3-, and 5-year disease-specific survival (DSS) probabilities after generation of Kaplan-Meier curves and used multivariable regression to evaluate variables associated with nephrectomy and DSS.

RESULTS

A total of 879 patients with sRCC were identified; 60.9% patients had stage IV disease at diagnosis, and the median tumor size was 8.3 cm (interquartile range, 5.5-12 cm). The 5-year DSS were 77.7%, 67.8%, 35.4%, and 3.5% for patients with stage I, II, III, and IV disease at diagnosis, respectively; median DSS was 9 months (interquartile range, 4-42 months) for the entire cohort. Older age (hazard ratio [HR] = 1.01; 95% confidence interval [CI], 1.00-1.02), higher tumor stage (stage III vs. I: HR = 3.81; 95% CI, 2.18-6.67; stage IV vs. I: HR = 9.89; 95% CI, 5.80-16.98), and performance of nephrectomy (HR = 0.53; 95% CI, 0.43-0.66) were found to independently affect DSS.

CONCLUSION

In the largest sRCC cohort to date, we found that most patients present with metastatic disease, and the prognosis for this disease remains extremely poor. Nephrectomy should be considered in all patients with acceptable surgical risk, including cytoreductive nephrectomy in carefully selected patients with metastatic disease.

Long Non-Coding RNA DUXAP8 Enhances Renal Cell Carcinoma Progression via Downregulating miR-126

Background

Renal cell carcinoma (RCC) is one of the common malignant tumors in the urinary system, which endangers human health for a long time. The past decade, the molecular biology of renal cell carcinoma has made considerable progress, so that we have a more profound understanding of renal cell carcinoma. Molecular biological mechanism of renal cell carcinoma remains to be explored. Evidence indicates that long non-coding RNAs (lncRNAs) may be important players in human cancer progression, including RCC. In this study, we found that a newly discovered pseudogene-derived lncRNA named DUXAP8, a 2107-bp RNA, was remarkably upregulated in RCC.

Material/Methods

Expression of lncRNA DUXAP8 was determined by a qRT-PCR assay in RCC tissues. The proliferation and invasion of RCC cell were measured by a cell proliferation assay and a Transwell invasion assay. Expression of miR-126 was detected by real-time PCR. Interactions between lncRNA DUXAP8 and miR-126 were measured by a luciferase reporter assay and an RNA-pull down assay. In vivo experiments were used to detect tumor formation.

Results

Together, our study not only identifies lncRNA DUXAP8 as a negative regulator of renal cancer with potential clinical value, but also reveals a regulatory mechanism by long non-coding RNAs to control tumor development.

Conclusions

Results from this study provide evidence that lncRNA DUXAP8 enhances renal cell carcinoma progression via downregulating of miR-126, which offers a new approach for the treatment of RCC.