Prognostic significance of diabetes mellitus in localized renal cell carcinoma

Evaluation of prognostic factors for late recurrence in clear cell renal carcinoma: an institutional study

Background and objectives

Following nephrectomy with curative intent, a subset of patients diagnosed with non-metastatic renal cell carcinoma (nmRCC) will present late recurrences, with metastatic relapses after 5 years from the surgical intervention. The aim of this study is to evaluate the prevalence of late recurrences in Romanian patients with nmRCC that have undergone surgery and to assess the clinicopathological characteristics prognostic for late-relapse RCC.

Materials and methods

This is a single-center, retrospective and observational study that analyzed patients with nmRCC with clear cell histology who underwent surgical resection of the primary tumor with curative intent. The patients included in the study were treated and further surveilled according to a personalized follow-up plan between January 2011 and December 2012 in The Oncology Institute "Prof. Dr. Ion Chiricuţă", Cluj-Napoca, Romania. Study endpoints included median disease-free survival (DFS), median overall survival (OS), as well as evaluation of possible prognostic factors indicative of late relapse.

Results

In the study cohort (n=51), the median DFS was 46 months and median OS was 130 months. DFS was significantly correlated with the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) score (p=0.04, HR=2.48; 95% CI [1.02, 6.01]), neutrophil to lymphocyte ratio (NLR) (a higher NLR value was associated with a poorer DFS, p=0.035), tumor size (T4 tumors vs. T1 p<0.05, HR=9,81; 95% CI [2.65, 36.27]) and Fuhrman nuclear grade (Fuhrman grade 1 vs. Fuhrman grade 3 p<0.05, HR=4,16; 95% CI = [1.13,15.22]). Fifty one percent of the patients included experienced disease relapse. From this subgroup, a significant percentage of 42% patients presented disease recurrence after 60 months from nephrectomy. OS was correlated to IMDC score (p=0.049, HR=2.36; 95% CI [1, 5.58]) and Fuhrman nuclear grade (Fuhrman grade 1 vs. Fuhrman grade 3 p<0.05, HR=3,97; 95% CI [1.08, 14.54]).

Conclusions

The results of this study support the previously presented biological behavior of RCC, demonstrating that late recurrences in RCC are not uncommon occurrences and patients with localized RCC should be followed up for a longer interval after the surgery for the primary tumor. In addition, the study strengthens the data supporting certain biomarkers as valuable prognostic factors determining survival outcomes of patients with RCC.

Effect of smoking, hypertension and lifestyle factors on kidney cancer - perspectives for prevention and screening programmes

Renal cell carcinoma (RCC) incidence has doubled over the past few decades. However, death rates have remained stable as the number of incidental renal mass diagnoses peaked. RCC has been recognized as a European health care issue, but to date, no screening programmes have been introduced. Well-known modifiable risk factors for RCC are smoking, obesity and hypertension. A direct association between cigarette consumption and increased RCC incidence and RCC-related death has been reported, but the underlying mechanistic pathways for this association are still unclear. Obesity is associated with an increased risk of RCC, but interestingly, improved survival outcomes have been reported in obese patients, a phenomenon known as the obesity paradox. Data on the association between other modifiable risk factors such as diet, dyslipidaemia and physical activity with RCC incidence are conflicting, and potential mechanisms underlying these associations remain to be elucidated.

Increased kidney cancer risk in diabetes mellitus patients: a population-based cohort study in Lithuania

BACKGROUND

Diabetes is associated with increased risk of various cancers but its association with kidney cancer is unclear. The objective of this study was to evaluate the association between T2DM with or without metformin use and the risk of kidney cancer in a population-based national cohort in Lithuania.

METHODS

The cohort was composed of diabetic patients identified in the NHIF database during 2000-2012. Cancer cases were identified by record linkage with the national Cancer Registry. Standardized incidence ratios (SIRs) for kidney cancer as a ratio of observed number of cancer cases in diabetic patients to the expected number of cancer cases in the underlying general population were calculated.

RESULTS

T2DM patients (11,592) between 2000 and 2012 were identified. Overall, 598 cases of primary kidney cancer were identified versus 393.95 expected yielding an overall SIR of 1.52 (95% CI: 1.40-1.64). Significantly higher risk was found in males and females. Significantly higher risk of kidney cancer was also found in both metformin users and never-users' groups (SIRs 1.45, 95% CI: 1.33-1.60 and 1.78 95% CI: 1.50-2.12, respectively).

CONCLUSIONS

The patients with T2DM have higher risk for kidney cancer compared with the general Lithuanian population.

The Role of Metabolic Factors in Renal Cancers

An increasing number of evidence indicates that metabolic factors may play an important role in the development and progression of certain types of cancers, including renal cell carcinoma (RCC). This tumour is the most common kidney cancer which accounts for approximately 3-5% of malignant tumours in adults. Numerous studies indicated that concomitant diseases, including diabetes mellitus (DM) and hypertension, as well as obesity, insulin resistance, and lipid disorders, may also influence the prognosis and cancer-specific overall survival. However, the results of studies concerning the impact of metabolic factors on RCC are controversial. It appears that obesity increases the risk of RCC development; however, it may be a favourable factor in terms of prognosis. Obesity is closely related to insulin resistance and the development of diabetes mellitus type 2 (DM2T) since the adipocytes in visceral tissue secrete substances responsible for insulin resistance, e.g., free fatty acids. Interactions between insulin and insulin-like growth factor (IGF) system appear to be of key importance in the development and progression of RCC; however, the exact role of insulin and IGFs in RCC pathophysiology remains elusive. Studies indicated that diabetes increased the risk of RCC, but it might not alter cancer-related survival. The risk associated with a lipid profile is most mysterious, as numerous studies provided conflicting results. Even though large studies unravelling pathomechanisms involved in cancer growth are required to finally establish the impact of metabolic factors on the development, progression, and prognosis of renal cancers, it seems that the monitoring of health conditions, such as diabetes, low body mass index (BMI), and lipid disorders is of high importance in clear-cell RCC.

Pre-existing type 2 diabetes is an adverse prognostic factor in patients with renal cell carcinoma

BACKGROUND

Diabetes is a risk factor for various cancers, but its prognostic role in renal cell carcinoma (RCC) is controversial and understudied. This study investigated the prognostic value of type 2 diabetes (T2D) in RCC patients.

METHODS

The clinicopathological and follow-up data of 451 RCC patients undergoing radical or partial nephrectomy at the First Hospital of Shanxi Medical University from 2013 to 2018 were reviewed. Associations of T2D with clinicopathological parameters of RCC were evaluated using the Kaplan-Meier method for survival estimates and Cox regression univariate and multivariate analyses.

RESULTS

Of 451 patients, 74 (16.4%) had T2D. These patients were older, had a higher body mass index, higher incidence rates of hypertension and cardiovascular morbidity, a higher rate of laparoscopic surgery, and smaller neoplasms (all P < .05). Patients with T2D exhibited shorter overall survival (OS; P = .009), cancer-specific survival (CSS; P = .043), and recurrence-free survival (RFS; P = .008) than patients without T2D. Fuhrman grade (hazard ratio [HR] 2.542, 95% confidence interval [CI] 1.115-5.795, P = .026) and T2D (HR 3.391, CI 1.458-7.886, P = .005) were independent predictors of OS; T2D was an independent predictor of CSS (HR = 4.637, 95% CI 1.420-15.139, P = .011) and RFS (HR 3.492, 95% CI 1.516-8.044, P = .003).

CONCLUSIONS

Renal cell carcinoma patients with T2D have a shorter OS and higher recurrence rate and mortality risk than those without T2D.

Type 2 Diabetes in Relation to the Risk of Renal Cell Carcinoma Among Men and Women in Two Large Prospective Cohort Studies

OBJECTIVE

We assessed whether type 2 diabetes is associated with renal cell carcinoma (RCC), independent of key potential confounders, in two large prospective cohorts with biennially updated covariate data.

RESEARCH DESIGN AND METHODS

A total of 117,570 women from the Nurses' Health Study (NHS) and 48,866 men from the Health Professionals Follow-Up Study (HPFS) were followed from 1976 and 1986, respectively, through 2014. Multivariable Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% CIs for associations between type 2 diabetes and pathology-confirmed RCC, overall and by stage, grade, and histologic subtype.

RESULTS

During 38 years of follow-up in the NHS, we confirmed 418 RCC case subjects, including 120 fatal cases. Over 28 years in the HPFS, we confirmed 302 RCC case subjects, including 87 fatal cases. Women with type 2 diabetes had a significantly increased risk of RCC compared with women without type 2 diabetes (multivariable HR 1.53; 95% CI 1.14-2.04), with some evidence that the association was stronger for ≤5 (HR 2.15; 95% CI 1.44-3.23) than >5 (HR 1.22; 95% CI 0.84-1.78) years' duration of type 2 diabetes (P_difference 0.03). Among men, type 2 diabetes was not associated with total RCC (HR 0.89; 95% CI 0.56-1.41) or with RCC defined by stage, grade, or subtype. Sample sizes for analyses by stage, grade, and subtype were limited.

CONCLUSIONS

We found that type 2 diabetes was independently associated with a greater risk of RCC in women but not in men.

The impact of metformin use on survival in kidney cancer patients with diabetes: a meta-analysis

PURPOSE

The effects of metformin on the prognosis of kidney cancer patients with diabetes are in controversial. The present study is conducted to classify the association of metformin use with the survival of patients with kidney cancer.

METHODS

Electronic databases, namely PubMed and Web of Science, were used to search the eligible studies up to December, 2016. Pooled hazard ratio (HR) and its corresponding 95% confidence interval (95% CI) were calculated. It was considered as statistically significant when P value was <0.05.

RESULTS

Eight cohorts were eligible for the present meta-analysis, including 254,329 kidney cancer patients. The combined HR suggested that the use of metformin could improve the overall survival (OS) (HR 0.643, 95% CI 0.520-0.795, P < 0.001) and cancer-specific survival (CSS) (HR 0.618, 95% CI 0.446-0.858, P = 0.004) in kidney cancer patients. In subgroup analysis, positive associations were found between metformin use and OS/CSS of localized renal cell carcinoma patients (OS: HR 0.634, 95% CI 0.440-0.913, P = 0.014; CSS: HR 0.476, 95% CI 0.295-0.768, P = 0.002). Moreover, we also found that the use of metformin could reduce the risk of death in kidney cancer patients (HR 0.711, 95% CI 0.562-0.899, P = 0.004).

CONCLUSION

Our findings suggest that the use of metformin is in favor of the prognosis of patients with kidney cancers. Further investigations are needed to evaluate the prognostic value of metformin on kidney cancer patients.

Metabolic Syndrome Negatively Impacts the Outcome of Localized Renal Cell Carcinoma

The aim of this study was to analyze the impact of metabolic syndrome (MetS) on outcome of patients with localized renal cell carcinoma (RCC). A retrospective database was compiled consisting of 646 patients who underwent surgery for localized RCC between 2005 and 2014. A total of 439 patients were eligible for final analysis. For diagnosis of MetS, the WHO criteria of 1998 were used. Median follow-up was 32 months (ranging from 2 to 119). Kaplan-Meier and log-rank analyses were performed to compare patients with and without MetS or its components. Univariate and multivariate logistic regression identified prognostic factors for progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). In our cohort, 9.8% (n = 43) of patients were diagnosed with MetS. There were no differences between patients with and without MetS regarding clinicopathological parameters with the exception of patients' age (p = 0.002). Kaplan-Meier and log-rank analyses revealed a shorter PFS for patients with MetS (p = 0.018), whereas no differences were found for each of the single components of MetS, namely, diabetes mellitus (DM) (p = 0.332), BMI >30 kg/m² (p = 0.753), hypertension (p = 0.451), and hypertriglyceridemia (p = 0.891). Logistic regression identified age (HR = 1.92, p = 0.03), tumor stage (HR = 4.37, p < 0.001), grading (HR = 4.57, p < 0.001), nodal status (HR = 3.73, p = 0.04), surgical margin (HR = 1.96, p = 0.04), concomitant sarcomatoid differentiation (HR = 5.06, p < 0.001), and MetS (HR = 1.98, p = 0.04) as independent factors for PFS. For CSS, only age (HR = 2.62, p = 0.035), tumor stage (HR = 3.06, p < 0.02), and grading (HR = 6.83, p < 0.001) were significant. In conclusion, patients with localized RCC and MetS show significantly reduced PFS and might profit from specific consultation and follow-up.

Insulin and IGFs in renal cancer risk and progression

Insulin and IGFs play a significant role in cancer development and progression, including renal cell carcinoma (RCC). RCC is the most frequent type of kidney cancer in adults and the tenth most common malignancy worldwide. Insulin is normally associated with metabolism control, whereas IGFs are defined as proliferation regulators. Today, there is convincing evidence of an association between obesity and the risk of RCC. Indicated risk factors together with type 2 diabetes are irreversibly connected with circulating insulin and IGF levels. The interplay between these molecules, their receptors, and IGF-binding proteins might be crucial for RCC cell biology and RCC progression. Given the potent activity IGF/IGF receptor 1 (IGF1R) inhibitors demonstrate against RCC in basic research, some type of combination therapy may prove to be beneficial clinically in the management of RCC. This review addresses not only molecular but also clinical associations between insulin and IGF1 signaling pathways and both RCC biology and clinical course. Revealing these interactions may improve our understanding of basic molecular oncology processes in RCC and improve treatment strategies.

The Impact of Diabetes Mellitus on Renal Cell Carcinoma Prognosis: A Meta-Analysis of Cohort Studies

Previous studies that investigated the relationship between DM and survival in renal cell carcinoma (RCC) patients reported inconsistent findings. Hence, we conducted a meta-analysis to obtain a more precise evaluation of the prognostic significance of DM in RCC. A systematic review was conducted with PubMed, Embase, and Web of Science to identify relevant articles that evaluated the effect of DM on RCC patients. Based on the inclusion and quality assessment criteria, 18 studies were eligible for the meta-analysis. Pooled hazard ratios (HR) and corresponding 95% confidence intervals (CI) for overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were calculated by standard meta-analysis techniques. The results suggested that DM was associated with poor OS (HR 1.56, 95% CI, 1.35-1.81, P < 0.001), poor CSS (HR 2.03, 95% CI, 1.37-3.01, P < 0.001), and poor RFS (HR 1.73, 95% CI, 1.25-2.39, P = 0.012). In addition, for patients with localized RCC, patients with clear cell RCC, or patients receiving nephrectomy, DM was associated with both poor OS and CSS by subgroup analyses. Our study revealed that there was a significant negative impact of DM on OS, CSS, and RFS in RCC patients. Therefore, more attention should be paid to RCC patients with preexisting DM because of their poor prognosis.

The impact of type 2 diabetes on the outcome of localized renal cell carcinoma

PURPOSE

To evaluate the influence of type 2 diabetes on cancer-specific outcome in patients undergoing surgery for localized renal cell carcinoma (RCC).

METHODS

A total of 1,140 patients with localized RCC undergoing radical or partial nephrectomy were enrolled into this retrospective case-control study. Primary outcome was the cancer-specific survival comparing patients with and without type 2 diabetes at the time of surgery. Secondary outcomes were recurrence-free survival and metastases-free survival comparing the same groups. Additionally, the influence of accompanying factors on cancer-specific survival and overall survival of patients was evaluated in a multivariate analysis. Among 1,140 patients included in the analyses, 202 had diabetes at the time of surgery and 938 patients without diabetes served as control.

RESULTS

The univariate comparisons between patients with and without diabetes regarding recurrence-free, metastases-free, and cancer-specific survival revealed no significant differences. Multivariate results demonstrate that age, BMI, and diabetes had no significant effect on cancer-specific hazard among participants. After adjustment of the factors in terms of overall survival, however, increased age, increased BMI, and type 2 diabetes at the time of surgery were independent risk factors for the occurrence of the event death.

CONCLUSIONS

Type 2 diabetes and obesity at the time of surgery have no significant impact on cancer-specific and recurrence-free survival in patients with localized renal cancer.