The roaring 2020s: a new decade of systemic therapy for renal cell carcinoma

Diagnostic accuracy and clinical impact of renal biopsy cytology

BACKGROUND

The role of fine needle biopsy cytology in the workup of renal mass lesions remains controversial. With advances in imaging technology and clinical management for renal masses, a critical reevaluation of the role of renal biopsy is needed. This study was designed to provide a comprehensive evaluation of the performance and clinical impact of fine needle biopsy in patients with renal masses.

METHODS

A 5-year retrospective study of ultrasound or computer tomography (CT)-guided fine needle biopsies of renal masses diagnosed via cytopathology was conducted. Overall diagnostic rate, sensitivity, and diagnostic accuracy were calculated. Further analysis of the impact of fine needle biopsy cytology on clinical management was performed.

RESULTS

A total of 227 cases of fine-needle aspiration and/or biopsy (FNA/B) of renal masses were identified, including 76 with subsequent nephrectomies. Complications were rare (<1%). The diagnostic rate and sensitivity of FNA/B were 83.3% and 89.5%, respectively. Diagnostic accuracy was 98.7% at the major categorical level and 94.7% at the tumor subtype level. Subsequent clinical actions were associated with a definitive cytologic diagnosis of malignancy/neoplasia (p < .05) and were affected by tumor subtype (p < .05).

CONCLUSION

This study demonstrates that FNA/B of renal masses is a safe and reliable minimally invasive diagnostic tool with excellent accuracy in confirmation of malignancy and subclassification of tumors. Diagnoses made on FNA/B play a key role in guiding a personalized clinical treatment plan.

Belzutifan: a novel therapeutic for the management of von Hippel-Lindau disease and beyond

The identification of the VHL gene and its role in regulating the hypoxia-inducible factor signaling pathway has helped to revolutionize the treatment of renal cell carcinoma (RCC). Belzutifan is a novel small-molecule inhibitor of hypoxia-inducible factor 2α which has demonstrated efficacy in treating von Hippel-Lindau (VHL) disease, earning regulatory approvals for this indication. There is also early evidence for efficacy in sporadic RCC. Belzutifan has a favorable safety profile. Several clinical trials are currently ongoing, which should help in identifying this promising drug's role in RCC and beyond. This review summarizes the history, pharmacology and clinical evidence for belzutifan use to date, and also explores unanswered questions as they relate to this novel therapeutic agent.

Single-cell analysis reveals ADGRL4+ renal tubule cells as a highly aggressive cell type in clear cell renal cell carcinoma

Clear cell renal cell carcinoma (ccRCC) is a highly heterogeneous cancer that poses great challenge to clinical treatment and prognostic prediction. Characterizing the cellular landscape of ccRCC in a single-cell dimension can help better understand the tumor heterogeneity and molecular mechanisms of ccRCC. This study analyzed single-cell profiles in ccRCC samples and para-tumor samples from Gene Expression Omnibus and identified a highly heterogeneous subcluster of renal tubule cells. Single-cell regulatory network inference and clustering analyses and cell communication analysis were performed to develop transcription factor-target gene regulatory networks and cell-cell interactions. Additionally, the distribution and prognostic risk of renal tubule cells from spatial transcriptome data (GSM6415706) and The Cancer Genome Atlas-Kidney Clear Cell Carcinoma data were analyzed. A total of 10 cell types were identified in ccRCC and para-tumor samples. The ccRCC renal tubule cells showed a high expression of the oncogene nicotinamide N-methyltransferase and a significantly high degree of tumor heterogeneity. We further identified 6 cell subclusters with specific expression of BEX2, PTHLH, SFRP2, KLRB1, ADGRL4, and HGF from the ccRCC renal tubule cells. ADGRL4+ renal tubule cells had highly metastatic and angiogenesis-inducing characteristics, with more ADGRL4+ renal tubule cells indicating a worse survival. ADGRL4+ renal tubule cells regulated the metastasis of other renal tubule cells through metastasis-related receptor-ligand communication. We also found that ADGRL4+ renal tubule cells clustered around the glomeruli but the rest of the renal tubule cell subclusters rarely localized in ccRCC tissues. ETS1 and ELK3 -dominant GRNs were remarkably activated in ADGRL4+ renal tubule cells, functionally, knockdown of ELK3 in A498 significantly disturbedaffected the cell migration and invasion. ADGRL4+ renal tubule cells, which were highly metastatic and invasive, might be an essential cell subcluster for ccRCC, and ADGRL4 could be used a novel therapeutic target.

Papillary Renal Cell Carcinoma: Demographics, Survival Analysis, Racial Disparities, and Genomic Landscape

Papillary renal cell carcinoma (PRCC) is the second most common histological subtype of renal cell cancer. This research aims to present a large database study highlighting the demographic, clinical, and pathological factors, racial disparities, prognosis, and survival of PRCC. The clinical and demographic data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database, and molecular data was cured from the Catalogue Of Somatic Mutations in Cancer (COSMIC) database. PRCC had a median age of diagnosis at 64 years, with a higher incidence in men (77%), and Whites (68%). 70.3% of cases were Grades I-IV (13, 53, 31, and 3%, respectively). In patients with known data, 85% were localized to the kidney, and 84% of cases were 7 cm in size. No metastasis occurred in 97% of the known data. The most common treatment offered was surgical resection (9%). The 5-year overall survival was 79%, with patients undergoing surgery having a 90.6% 5-year survival. Multivariable analysis revealed age > 60 years, Black race, poor histologic differentiation, distant metastases, and tumor size > 10 cm as independent risk factors for mortality. The most common mutations identified from the COSMIC database were MET, KMT2D, KMT2C, ARID1A, and SPEN. PRCC affects male individuals in the sixth decade of life. Increased age, Black race, distant metastases, and tumors > 10 cm are associated with a worse prognosis. Surgical resection offers a favorable survival outcome. Next-generation sequencing (NGS) could identify potentially targetable alterations and future personalized therapeutic approaches.

A Delphi Study of Core Patient-Reported Outcomes for Advanced Renal Cell Carcinoma and Advanced Hepatocellular Carcinoma

OBJECTIVES

There is little research to help health care professionals understand what patient outcomes are considered a priority in advanced liver or kidney cancer. Knowing what is important to patients can help promote person-centered approaches to treatment and disease management. The aim of this study was to identify those patient-reported outcomes (PROs) that patients, carers, and health care professionals consider as "core" when providing care to those with advanced liver or kidney cancer.

DATA SOURCES

A three-round Delphi study was undertaken to ask experts by profession or experience to rank PROs identified from a previous literature review. Fifty-four experts, including people living with advanced liver or kidney cancer (44.4%), family members and caregivers (9.3%), and health care professionals (46.8%), reached consensus on 49 PROs including 12 new items (eg, palpitations, hopefulness, or social isolation). Items with the highest rate of consensus included quality of life, pain, mental health, and capacity to do daily activities.

CONCLUSION

People living with advanced liver or kidney cancer experience complex health care needs. Some important outcomes were not actually captured in practice in this population and were suggested as part of this study. There are discrepancies between the views of health care professionals, patients, and family in what is important, highlighting the need of using measures to facilitate communication.

IMPLICATIONS FOR NURSING PRACTICE

Identification of priority PROs reported here will be key to facilitate more focused patient assessments. The actual use of measures in cancer nursing practice to allow monitoring of PROs must be tested for feasibility and usability.

Immune regulation and prognosis indicating ability of a newly constructed multi-genes containing signature in clear cell renal cell carcinoma

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) is the most common renal malignancy, although newly developing targeted therapy and immunotherapy have been showing promising effects in clinical treatment, the effective biomarkers for immune response prediction are still lacking. The study is to construct a gene signature according to ccRCC immune cells infiltration landscape, thus aiding clinical prediction of patients response to immunotherapy.

METHODS

Firstly, ccRCC transcriptome expression profiles from Gene Expression Omnibus (GEO) database as well as immune related genes information from IMMPORT database were combine applied to identify the differently expressed meanwhile immune related candidate genes in ccRCC comparing to normal control samples. Then, based on protein-protein interaction network (PPI) and following module analysis of the candidate genes, a hub gene cluster was further identified for survival analysis. Further, LASSO analysis was applied to construct a signature which was in succession assessed with Kaplan-Meier survival, Cox regression and ROC curve analysis. Moreover, ccRCC patients were divided as high and low-risk groups based on the gene signature followed by the difference estimation of immune treatment response and exploration of related immune cells infiltration by TIDE and Cibersort analysis respectively among the two groups of patients.

RESULTS

Based on GEO and IMMPORT databases, a total of 269 differently expressed meanwhile immune related genes in ccRCC were identified, further PPI network and module analysis of the 269 genes highlighted a 46 genes cluster. Next step, Kaplan-Meier and Cox regression analysis of the 46 genes identified 4 genes that were supported to be independent prognosis indicators, and a gene signature was constructed based on the 4 genes. Furthermore, after assessing its prognosis indicating ability by both Kaplan-Meier and Cox regression analysis, immune relation of the signature was evaluated including its association with environment immune score, Immune checkpoint inhibitors expression as well as immune cells infiltration. Together, immune predicting ability of the signature was preliminary explored.

CONCLUSIONS

Based on ccRCC genes expression profiles and multiple bioinformatic analysis, a 4 genes containing signature was constructed and the immune regulation of the signature was preliminary explored. Although more detailed experiments and clinical trials are needed before potential clinical use of the signature, the results shall provide meaningful insight into further ccRCC immune researches.

Integrating Surgery in the Multidisciplinary Care of Advanced Renal Cell Carcinoma

The role of surgery for patients with locally advanced and metastatic renal cell carcinoma (RCC) is not precisely defined in our contemporary era of systemic therapies. Research in this field is focused on the role of regional lymphadenectomy, along with indications and timing of cytoreductive nephrectomy and metastasectomy. As our understanding of the molecular and immunological basis of RCC continues to develop along with the advent of novel systemic therapies, prospective clinical trials will be critical in defining how surgery should be integrated into the treatment paradigm of advanced RCC.

Two is company, is three a crowd? Triplet therapy, novel molecular targets, and updates on the management of advanced renal cell carcinoma

PURPOSE OF REVIEW

The purpose of this review is to highlight the most recent changes in the management of advanced renal cell carcinoma, a complicated and ever-changing field of research.

RECENT FINDINGS

A recent meta-analysis examining combination therapy favors nivolumab plus cabozantinib as the overall survival leader in doublet therapy. Initial results on the first ever trial of triplet therapy have demonstrated improved progression-free survival over current standard of care. The hypoxia-inducible factor-2α (HIF-2α) inhibitor belzutifan is FDA approved for patients with von Hippel-Lindau disease and is currently being investigated in patients with nonhereditary renal cell carcinoma. The new glutamate synthesis inhibitor, telaglenastat, perhaps confers synergistic benefit when combined with everolimus, but combination with cabozantinib was not so effective. Dual mammalian target of rapamycin (mTOR) inhibition with sapanisertib does not appear to be an effective therapeutic option. New biomarkers and targets are actively being investigated. Four recent trials examining alternative agents to pembrolizumab in the adjuvant setting did not demonstrate an improvement in recurrence-free survival. Cytoreductive nephrectomy in the combination therapy era is supported by retrospective data; clinical trials are recruiting patients.

SUMMARY

The last year ushered in novel approaches of varying success for managing advanced renal cell carcinoma, including triplet therapy, HIF-2α inhibitors, metabolic pathway inhibitors, and dual mTOR inhibitors. Pembrolizumab remains the only modern therapy available in the adjuvant setting, and the waters surrounding cytoreductive nephrectomy are still murky.

Endosialin-positive tumor-derived pericytes promote tumor progression through impeding the infiltration of CD8+ T cells in clear cell renal cell carcinoma

BACKGROUND

Immune checkpoint blockade (ICB) therapy can be effective against clear cell renal cell carcinoma (ccRCC), but many patients show no benefit. Tumor-derived pericytes (TDPs) may promote tumor progression by influencing T cells and are an immunotherapy target; however, they may comprise functionally distinct subtypes. We aimed to identify markers of tumor-promoting TDPs and develop TDP-targeting strategies to enhance ICB therapy effectiveness against ccRCC.

METHODS

We analyzed the relationship between endosialin (EN) expression and cytotoxic T-lymphocyte (CTL) infiltration in ccRCC tumor samples using flow cytometry and in a ccRCC-bearing mice inhibited for EN via knockout or antibody-mediated blockade. The function of EN^high TDPs in CTL infiltration and tumor progression was analyzed using RNA-sequencing (RNA-seq) data from ccRCC tissue-derived TDPs and single-cell RNA-seq (scRNA-seq) data from an online database. The role of EN in TDP proliferation and migration and in CTL infiltration was examined in vitro. Finally, we examined the anti-tumor effect of combined anti-EN and anti-programmed death 1 (PD-1) antibodies in ccRCC-bearing mice.

RESULTS

High EN expression was associated with low CTL infiltration in ccRCC tissues, and inhibition of EN significantly increased CTL infiltration in ccRCC-bearing mice. RNA-seq and scRNA-seq analyses indicated that high EN expression represented the TDP activation state. EN promoted TDP proliferation and migration and impeded CTL infiltration in vitro. Finally, combined treatment with anti-EN and anti-PD-1 antibodies synergistically enhanced anti-tumor efficacy.

CONCLUSION

EN^high TDPs are in an activated state and inhibit CTL infiltration into ccRCC tissues. Combined treatment with anti-EN and anti-PD-1 antibodies may improve ICB therapy effectiveness against ccRCC.

The chromosomal instability 25 gene signature is identified in clear cell renal cell carcinoma and serves as a predictor for survival and Sunitinib response

Background

Chromosomal instability (CIN) is a cancer hallmark and it is difficult to directly measure its phenotype, while a CIN25 gene signature was established to do so in several cancer types. However, it is currently unclear whether there exists this signature in clear cell renal cell carcinoma (ccRCC), and if so, which biological and clinical implications it has.

Methods

Transcriptomic profiling was performed on 10 ccRCC tumors and matched renal non-tumorous tissues (NTs) for CIN25 signature analyses. TCGA and E-MBAT1980 ccRCC cohorts were analyzed for the presence of CIN25 signature, CIN25 score-based ccRCC classification, and association with molecular alterations and overall or progression-free survival (OS or PFS). IMmotion150 and 151 cohorts of ccRCC patients treated with Sunitinib were analyzed for the CIN25 impact on Sunitinib response and survival.

Results

The transcriptomic analysis of 10 patient samples showed robustly upregulated expression of the CIN25 signature genes in ccRCC tumors, which were further confirmed in TCGA and E-MBAT1980 ccRCC cohorts. Based on their expression heterogeneity, ccRCC tumors were categorized into CIN25-C1 (low) and C2 (high) subtypes. The CIN25-C2 subtype was associated with significantly shorter patient OS and PFS, and characterized by increased telomerase activity, proliferation, stemness and EMT. The CIN25 signature reflects not only a CIN phenotype, but also levels of the whole genomic instability including mutation burden, microsatellite instability and homologous recombination deficiency (HRD). Importantly, the CIN25 score was significantly associated with Sunitinib response and survival. In IMmotion151 cohort, patients in the CIN25-C1 group exhibited 2-fold higher remission rate than those in the CIN25-C2 group (P = 0.0004) and median PFS in these two groups was 11.2 and 5.6 months, respectively (P = 7.78E-08). Similar results were obtained from the IMmotion150 cohort analysis. Higher EZH2 expression and poor angiogenesis, well characterized factors leading to Sunitinib resistance, were enriched in the CIN25-C2 tumors.

Conclusion

The CIN25 signature identified in ccRCC serves as a biomarker for CIN and other genome instability phenotypes and predicts patient outcomes and response to Sunitinib treatment. A PCR quantification is enough for the CIN25-based ccRCC classification, which holds great promises in clinical routine application.

Prognostic Model for Clear-cell Renal Cell Carcinoma Based on Natural Killer Cell-related Genes

BACKGROUND

Natural killer (NK) cells are a key factor affecting progression and immune surveillance of clear-cell renal cell carcinoma (ccRCC). This study sought to construct a natural killer cell-related prognostic signature (NKRPS) to predict the outcome of ccRCC patients and to furnish guidance for finding appropriate treatment strategies.

METHODS

From the TCGA and ArrayExpress databases, transcriptomic profiles and relevant clinical information of ccRCC patients were downloaded for the TCGA cohort (n = 515) and the E-MTAB-1980 cohort (n = 101). With the univariate Cox analysis and LASSO-Cox regression algorithm, a NKRPS was built to evaluate patients' prognosis. Receiver operating characteristic (ROC) curves and calibration curves were drawn to estimate the predictive power of the prognostic model. Then, tumor microenvironment (TME), tumor mutational burden (TMB), sensitization to immune checkpoint inhibitors (ICIs) therapy and targeted drug treatment were analyzed in ccRCC patients.

RESULTS

Nine genes (BID, CCL7, CSF2, IL23A, KNSTRN, RHBDD3, PIK3R3, RNF19B and VAV3) were identified to construct a NKRPS. High-risk group displayed undesirable survival compared to low-risk group (P < .05). Moreover, the area under the curve (AUC) of ROC at 1-, 3- and 5-year were 0.766, 0.755, and 0.757, respectively. High-risk group was characterized by superior immune infiltration, higher TMB, and higher expression of 5 ICI-related genes. Additionally, this model enabled to predict the sensitivity of patients to chemotherapy drugs.

CONCLUSION

NKRPS had a strong predictive power on prognosis of ccRCC patients, which may facilitate individualized treatment and medical decision making.

Development and validation of a novel necroptosis-related score to improve the outcomes of clear cell renal cell carcinoma

Necroptosis has been indicated as a key regulator of tumor progression. However, the prognostic regulatory role of necroptosis in clear cell renal cell carcinoma (ccRCC) needs to be further investigated. In this study, necroptosis-related subtypes were identified by mining the public cohort (n = 530) obtained from The Cancer Genome Atlas. By applying Principal Component Analysis (PCA), the necroptosis-related scores (N-Score) were developed to assess the prognosis procession of ccRCC. The results were further validated by an external clinical cohort (n = 116) obtained from the First Affiliated Hospital of Wenzhou Medical University. It has been found that N-Score could precisely distinguish the prognostic outcomes of patients as an independent risk factor (Hazard ratio = 4.990, 95% confidence interval (CI) = 2.007–12.403, p < 0.001). In addition, changes in N-Score were associated with differences in tumor mutational burden as well as immune infiltration characterization. Moreover, higher N-Scores were also correlated significantly molecular drug sensitivity and stronger immune checkpoint activity. Notably, the prognosis of ccRCC could be effectively guided by combining the N-Scores and external clinical indicators. In conclusion, N-Scores could be served as a robust and effective biomarker to improve the prognosis outcomes and targeted therapy of ccRCC.

The cuproptosis-associated 13 gene signature as a robust predictor for outcome and response to immune- and targeted-therapies in clear cell renal cell carcinoma

Cuproptosis, the newly identified form of regulatory cell death (RCD), results from mitochondrial proteotoxic stress mediated by copper and FDX1. Little is known about significances of cuproptosis in oncogenesis. Here we determined clinical implications of cuproptosis in clear cell renal cell carcinoma (ccRCC). Based on the correlation and survival analyses of cuproptosis-correlated genes in TCGA ccRCC cohort, we constructed a cuproptosis-associated 13 gene signature (CuAGS-13) score system. In both TCGA training and two validation cohorts, when patients were categorized into high- and low-risk groups according to a median score as the cutoff, the CuAGS-13 high-risk group was significantly associated with shorter overall survival (OS) and/or progression-free survival (PFS) independently (P<0.001 for all). The CuAGS-13 score assessment could also predict recurrence and recurrence-free survival of patients at stage I - III with a high accuracy, which outperformed the ccAccB/ClearCode34 model, a well-established molecular predictor for ccRCC prognosis. Moreover, patients treated with immune checkpoint inhibitors (ICIs) acquired complete/partial remissions up to 3-time higher coupled with significantly longer PFS in the CuAGS-13 low- than high-risk groups in both training and validation cohorts of ccRCCs (7.2 - 14.1 vs. 2.1 - 3.0 months, P<0.001). The combination of ICI with anti-angiogenic agent Bevacizumab doubled remission rates in CuAGS-13 high-risk patients while did not improve the efficacy in the low-risk group. Further analyses showed a positive correlation between CuAGS-13 and TIDE scores. We also observed that the CuAGS-13 score assessment accurately predicted patient response to Sunitinib, and higher remission rates in the low-risk group led to longer PFS (Low- vs. high-risk, 13.9 vs. 5.8 months, P = 5.0e-12). Taken together, the CuAGS-13 score assessment serves as a robust predictor for survival, recurrence, and response to ICIs, ICI plus anti-angiogenic drugs and Sunitinib in ccRCC patients, which significantly improves patient stratifications for precision medicine of ccRCC.

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.

Effects of TP53 Mutations and miRs on Immune Responses in the Tumor Microenvironment Important in Pancreatic Cancer Progression

Approximately 90% of pancreatic cancers are pancreatic ductal adenocarcinomas (PDAC). PDAC is the fourth leading cause of cancer death world-wide. Therapies for PDAC are largely ineffective due to the dense desmoplastic tumor microenvironment which prevents chemotherapeutic drugs and small molecule inhibitors from exerting effective anti-cancer effects. In this review, we will discuss the roles of TP53 and miRs on the PDAC tumor microenvironment and how loss of the normal functions of TP53 promote tumor progression. The TP53 gene is mutated in approximately 50% of pancreatic cancers. Often, these TP53 mutations are point mutations which confer additional functions for the TP53 proteins. These are called gain of function (GOF) mutations (mut). Another class of TP53 mutations are deletions which result in loss of the TP53 protein; these are referred to TP53-null mutations. We have organized this review into various components/properties of the PDAC microenvironment and how they may be altered in the presence of mutant TP53 and loss of certain miR expression.