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Bekku K, Kawada T, Yanagisawa T, Karakiewicz PI, Shariat SF. Role of lymphadenectomy during primary surgery for kidney cancer. Curr Opin Urol 2023; 33:294-301. [PMID: 37014778 PMCID: PMC10256307 DOI: 10.1097/mou.0000000000001095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
PURPOSE OF REVIEW Lymph node dissection (LND) during radical nephrectomy (RN) for renal cell carcinoma (RCC) is not considered as a standard. The emergence of robot-assisted surgery and effective immune checkpoint inhibitors (ICI) in recent years may change this and lymph node (LN) staging has become easier and has a clinical impact. In this review, we aimed to reconsider the role of LND today. RECENT FINDINGS Although the extent of LND has still not been well established, removal of more LN seems to provide better oncologic outcomes for a select group of patients with high-risk factors such as clinical T3-4. Adjuvant therapy using pembrolizumab has been shown to improve disease free survival if complete resection of metastatic lesions as well as the primary site is obtained in combination. Robot assisted RN for localized RCC has been widespread and the studies regarding LND for RCC has been recently appeared. SUMMARY The staging and surgical benefits and its extent of LND during RN for RCC remains unclear, but it is becoming increasingly important. Technologies that allow an easier LND and adjuvant ICI that improve survival in LN-positive patients are engaging the role of LND, a procedure that was needed, but almost never done, is now indicated sometimes. Now, the goal is to identify the clinical and molecular imaging tools that can help identify with sufficient accuracy who needs a LND and which LNs to remove in a targeted personalized approach.
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Affiliation(s)
- Kensuke Bekku
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Tatsushi Kawada
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Pierre I. Karakiewicz
- Cancer Prognostic and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Canada
| | - Shahrokh F. Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
- Division of Urology, Department of Special Surgery, The University of Jordan, Amman, Jordan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Urology, Weill Cornell Medical College, New York, New York, USA
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
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Chakiryan NH, Gore LR, Reich RR, Dunn RL, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain RK, Chahoud J, Spiess PE, Manley BJ, Sexton WJ, Hollenbeck BK, Gilbert SM. Survival Outcomes Associated With Cytoreductive Nephrectomy in Patients With Metastatic Clear Cell Renal Cell Carcinoma. JAMA Netw Open 2022; 5:e2212347. [PMID: 35576003 PMCID: PMC9112069 DOI: 10.1001/jamanetworkopen.2022.12347] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Level I evidence has failed to demonstrate an overall survival (OS) advantage for cytoreductive nephrectomy in patients with metastatic clear cell renal cell carcinoma (ccRCC) in the modern era, which is at odds with observational studies reporting a marked OS benefit associated with these operations. These observational studies were not designed to adjust for unmeasured confounding. OBJECTIVE To assess whether cytoreductive nephrectomy is associated with improved OS in patients with metastatic ccRCC. DESIGN, SETTING, AND PARTICIPANTS This cohort study identified patients with metastatic ccRCC in the National Cancer Database from January 1, 2006, to December 31, 2016, who received systemic targeted therapy. The analysis was finalized on July 23, 2021. EXPOSURES Receipt of cytoreductive nephrectomy. MAIN OUTCOMES AND MEASURES The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. Distance from the patients' zip code of residence to the treating facility was identified as a valid instrument and was used in a 2-stage residual inclusion instrumental variable analysis. Conventional adjustments for selection bias, multivariable Cox proportional hazards regression, and propensity score matching were performed for comparison. Measured covariates adjusted for in all analyses included age, sex, race, Charlson-Deyo score, facility type, year of diagnosis, clinical T stage, and clinical N stage. RESULTS The final study population included 12 766 patients (median age, 63 years; IQR, 56-70 years; 8744 [68%] male; 11 206 [88%] White). Cytoreductive nephrectomy was performed in 5005 patients (39%). Conventional adjustments for selection bias demonstrated a significant OS benefit associated with cytoreductive nephrectomy (multivariable Cox proportional hazards regression: hazard ratio [HR], 0.49; 95% CI, 0.47-0.51; propensity score matching: HR, 0.48; 95% CI, 0.46-0.50). Instrumental variable estimates did not demonstrate an association between cytoreductive nephrectomy and OS (HR, 0.92; 95% CI, 0.78-1.09). CONCLUSIONS AND RELEVANCE Instrumental variable analysis did not demonstrate a survival advantage associated with cytoreductive nephrectomy for patients with metastatic ccRCC. This discrepancy likely reflects the fact that surgical indication for cytoreductive nephrectomy is primarily driven by factors that are not commonly measured or available in observational data sets.
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Affiliation(s)
| | - L. Robert Gore
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Richard R. Reich
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Rodney L. Dunn
- Department of Urology, University of Michigan Medical School, Ann Arbor
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kyle A. Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City
| | - Elizabeth Green
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Lee Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Rohit K. Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Wade J. Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | | | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida
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Wu K, Zheng X, Yao Z, Zheng Z, Huang W, Mu X, Sun F, Liu Z, Zheng J. Accumulation of CD45RO+CD8+ T cells is a diagnostic and prognostic biomarker for clear cell renal cell carcinoma. Aging (Albany NY) 2021; 13:14304-14321. [PMID: 34016791 PMCID: PMC8202838 DOI: 10.18632/aging.203045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/09/2021] [Indexed: 01/18/2023]
Abstract
Renal cell carcinoma is characterized by high immunogenicity and infiltration of immune cells. CD45RO+CD8+ T cells are well known as a critical role in host defense of the immune environment. However, their role in clear cell renal carcinoma (ccRCC) remains unknown. To elucidate the clinical importance of CD45RO+CD8+ T cells in ccRCC as well as its underlying mechanism, we analyzed several types of peripheral immune cells from 274 patients with ccRCC who have received radical or partial nephrectomy and 350 healthy people. Flow cytomety assays showed there was no significant difference in the proportions of CD8+ T cells and its subtypes other than CD45RO+/CD45RA+CD8+ cells. Both gene and protein expression levels of CD45RO in ccRCC tissues were decreased. CD45RO+CD8+ T cells showed increased proliferative abilities but decreased apoptotic abilities through MAPK signaling activation in ccRCC. High expression level of CD45RO+CD8+ T cells inhibited ccRCC progression, including proliferation, invasion, as well as autophagy of ccRCC through many signaling pathways. Bioinformatics and immunohistochemical chip analysis measured gene and protein levels of CD45RO and other related proteins. The combination of UCHL1, HMGB3, and CD36 has diagnostic value in ccRCC and is able to predict prognosis. Collectively, CD45RO+CD8+ T cells play a critical role in ccRCC progression and may be regarded as clinical indicators.
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Affiliation(s)
- Ke Wu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Xinyi Zheng
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zhixian Yao
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Zhong Zheng
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Wenjie Huang
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Xingyu Mu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Feng Sun
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Zhihong Liu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Junhua Zheng
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
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Chakiryan NH, Jiang DD, Gillis KA, Green E, Hajiran A, Hugar L, Zemp L, Zhang J, Jain RK, Chahoud J, Spiess PE, Sexton W, Gilbert SM, Manley BJ. Real-World Survival Outcomes Associated With First-Line Immunotherapy, Targeted Therapy, and Combination Therapy for Metastatic Clear Cell Renal Cell Carcinoma. JAMA Netw Open 2021; 4:e2111329. [PMID: 34032854 PMCID: PMC8150693 DOI: 10.1001/jamanetworkopen.2021.11329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Clinical trials have shown an overall survival (OS) benefit associated with first-line immunotherapy (IT) and combination targeted therapy (TT) and IT regimens compared with TT among patients with metastatic clear cell renal cell carcinoma (RCC). Generalizability of these findings in a real-world cohort outside of a clinical trial setting is unclear. OBJECTIVE To assess the association of first-line TT, IT, and combination TT and IT regimens with OS in a real-world cohort of patients with metastatic clear cell RCC. DESIGN, SETTING, AND PARTICIPANTS This retrospective propensity-matched cohort study identified 5872 patients with metastatic clear cell RCC in the National Cancer Database from January 1, 2015, to December 31, 2017, who received first-line TT, IT, or combination TT and IT and were not treated on a clinical trial protocol. Patients were stratified by first-line systemic treatment. Statistical analysis was conducted from October 1 to December 1, 2020. MAIN OUTCOMES AND MEASURES The primary outcome was OS from the date of diagnosis to death or censoring at last follow-up. After 1:1:1 nearest-neighbor caliper matching of propensity scores, survival analyses were conducted using Cox proportional hazards regression and Kaplan-Meier estimates. RESULTS The final study population included 5872 patients (TT group: n = 4755 [81%]; 3332 men [70%]; median age, 64 years [interquartile range, 57-71 years]; IT group: n = 638 [11%]; 475 men [74%]; median age, 61 years [interquartile range, 54-69 years]; and combination TT and IT group: n = 479 [8%]; 321 men [67%]; median age, 62 years [interquartile range, 55-69 years]), and the matched cohort included 1437 patients (479 per treatment group). Patients in the IT and combination TT and IT groups were younger than those in the TT group, had fewer comorbid conditions (Charlson-Deyo score of 0, 480 of 638 [75%] in the TT group, 356 of 479 [74%] in the IT group, and 3273 of 4755 [69%] in the combination TT and IT group), and were more often treated at academic centers (315 of 638 [49%], 216 of 479 [45%], and 1935 of 4755 [41%], respectively). Both first-line IT and combination TT and IT were associated with improved OS compared with first-line TT for patients with metastatic clear cell RCC (IT group: hazard ratio [HR], 0.60 [95% CI, 0.48-0.75]; P < .001; combination TT and IT group: HR, 0.74 [95% CI, 0.60-0.91]; P = .005). No survival difference was seen between the IT and combination TT and IT groups (combination TT and IT: HR, 1.24 [95% CI, 0.98-1.56]; P = .08). CONCLUSIONS AND RELEVANCE This study suggests that both first-line IT and combination TT and IT were associated with improved OS compared with first-line TT for patients with metastatic clear cell RCC. These findings are similar to those identified in recently reported clinical trials, lending confidence to the broader applicability of these findings outside of a clinical trial setting.
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Affiliation(s)
- Nicholas H. Chakiryan
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Da David Jiang
- Department of Urology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kyle A. Gillis
- Department of Urology, University of Iowa Hospitals & Clinics, Iowa City
| | - Elizabeth Green
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ali Hajiran
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Lee Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Logan Zemp
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rohit K. Jain
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Philippe E. Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Wade Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Scott M. Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Brandon J. Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Bensalah K, Bigot P, Albiges L, Bernhard J, Bodin T, Boissier R, Correas J, Gimel P, Hetet J, Long J, Nouhaud F, Ouzaïd I, Rioux-Leclercq N, Méjean A. Recommandations françaises du Comité de cancérologie de l’AFU – actualisation 2020–2022 : prise en charge du cancer du rein. Prog Urol 2020; 30:S2-S51. [DOI: 10.1016/s1166-7087(20)30749-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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