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Patel VM, Elias R, Asokan A, Sharma A, Christie A, Pedrosa I, Chiu H, Reznik S, Hannan R, Timmerman R, Brugarolas J. Life-threatening hemoptysis in patients with metastatic kidney cancer. Clin Genitourin Cancer 2023; 21:497-506. [PMID: 37045713 PMCID: PMC10510952 DOI: 10.1016/j.clgc.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
Hemoptysis is a complication of intrathoracic tumors, both primary and metastatic, and the risk may be increased by procedural interventions as well as Stereotactic Ablative Radiation (SAbR). The risk of hemoptysis with SAbR for lung cancer is well characterized, but there is a paucity of data about intrathoracic metastases. Here, we sought to evaluate the incidence of life-threatening/fatal hemoptysis (LTH) in patients with renal cell carcinoma (RCC) chest metastases with a focus on SAbR. We systematically evaluated patients with RCC at UT Southwestern Medical Center (UTSW) Kidney Cancer Program (KCP) from July 2005 to March 2020. We queried Kidney Cancer Explorer (KCE), a data portal with clinical, pathological, and experimental genomic data. Patients were included in the study based on mention of "hemoptysis" in clinical documentation, if they had a previous bronchoscopy, or had undergone SAbR to any site within the chest. Two hundred and thirty four patients met query criteria and their records were individually reviewed. We identified 10 patients who developed LTH. Of these, 4 had LTH as an immediate procedural complication whilst the remaining 6 had prior SAbR to ultra-central (UC; abutting the central bronchial tree) metastases. These 6 patients had a total of 10 lung lesions irradiated (UC, 8; central 1, peripheral 1), with a median total cumulative SAbR dose of 38 Gray (Gy/ lesion) (range: 25-50 Gy). Other risk factors included intrathoracic disease progression (n = 4, 67%), concurrent anticoagulant therapy (n = 1, 17%) and concurrent systemic therapy (n = 4, 67%). Median time to LTH from first SAbR was 26 months (range: 8-61 months). Considering that 130 patients received SAbR to a chest lesion during the study period, the overall incidence of LTH following SAbR was 4.6% (6/130). The patient population that received SAbR (n = 130) was at particularly high risk for complications, with 67 (52%) having two or more chest metastaes treated, and 29 (22%) receiving SAbR to three or more lesions. Overall, the risk of LTH following SAbR to a central or UC lesion was 10.5% (6/57). In conclusion, SAbR of RCC metastases located near the central bronchial tree may increase the risk of LTH.
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Affiliation(s)
- Viral M Patel
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Roy Elias
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Annapoorani Asokan
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Akanksha Sharma
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alana Christie
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Biostatistics Shared Resource, Simmons Comprehensive Cancer Center, University of Texas Southwestern, Dallas, TX, USA
| | - Ivan Pedrosa
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hsienchang Chiu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pulmonary Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Scott Reznik
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Raquibul Hannan
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Timmerman
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Brugarolas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Narayan V, Jonasch E. Systemic Therapy Development in Von Hippel-Lindau Disease: An Outsized Contribution from an Orphan Disease. Cancers (Basel) 2022; 14:5313. [PMID: 36358730 PMCID: PMC9658616 DOI: 10.3390/cancers14215313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/20/2022] [Accepted: 10/28/2022] [Indexed: 11/20/2023] Open
Abstract
Over the last several decades, an improved understanding of von Hippel-Lindau disease and its underlying biology has informed the successful development of numerous anti-cancer agents, particularly for the treatment of advanced renal cell carcinoma. Most recently, this has culminated in the first regulatory approval for a systemic therapy for VHL disease-associated neoplasms. This review will trace the clinical development of systemic therapies for VHL disease and additionally highlight anticipated challenges and opportunities for future VHL systemic therapy.
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Affiliation(s)
- Vivek Narayan
- Division of Hematology/Medical Oncology, University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA 19104, USA
| | - Eric Jonasch
- Genitourinary Medical Oncology, MD Anderson Cancer Center, Houston, TX 77030, USA
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Molecular characterization of renal cell carcinoma tumors from a phase III anti-angiogenic adjuvant therapy trial. Nat Commun 2022; 13:5959. [PMID: 36216827 PMCID: PMC9550765 DOI: 10.1038/s41467-022-33555-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/22/2022] [Indexed: 12/02/2022] Open
Abstract
Multigene assays can provide insight into key biological processes and prognostic information to guide development and selection of adjuvant cancer therapy. We report a comprehensive genomic and transcriptomic analysis of tumor samples from 171 patients at high risk for recurrent renal cell carcinoma post nephrectomy from the S-TRAC trial (NCT00375674). We identify gene expression signatures, including STRAC11 (derived from the sunitinib-treated population). The overlap in key elements captured in these gene expression signatures, which include genes representative of the tumor stroma microenvironment, regulatory T cell, and myeloid cells, suggests they are likely to be both prognostic and predictive of the anti-angiogenic effect in the adjuvant setting. These signatures also point to the identification of potential therapeutic targets for development in adjuvant renal cell carcinoma, such as MERTK and TDO2. Finally, our findings suggest that while anti-angiogenic adjuvant therapy might be important, it may not be sufficient to prevent recurrence and that other factors such as immune response and tumor environment may be of greater importance. Based on the S-TRAC results, sunitinib is approved as adjuvant treatment for adult patients at high risk of recurrent RCC following nephrectomy. Here, the authors report the results of an integrated multi-omics tumor analysis of 171 patients from the trial and identify specific molecular subtypes as well as potential new targets.
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Shulman M, Shi R, Zhang Q. Von Hippel-Lindau tumor suppressor pathways & corresponding therapeutics in kidney cancer. J Genet Genomics 2021; 48:552-559. [PMID: 34376376 PMCID: PMC8453047 DOI: 10.1016/j.jgg.2021.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 11/20/2022]
Abstract
The identification and application of the Von Hippel-Lindau (VHL) gene is a seminal breakthrough in kidney cancer research. VHL and its protein pVHL are the root cause of most kidney cancers, and the cascading pathway below them is crucial for understanding hypoxia, in addition to the aforementioned tumorigenesis routes and treatments. We reviewed the history and functions of VHL/pVHL and Hypoxia-inducible factor (HIF), their well-known activities under low-oxygen environments as an E3 ubiquitin ligase and as a transcription factor, respectively, as well as their non-canonical functions revealed recently. Additionally, we discussed how their dysregulation promotes tumorigenesis: beginning with chromosome 3 p-arm (3p) loss/epigenetic methylation, followed by two-allele knockout, before the loss of complimentary tumor suppressor genes leads cells down predictable oncological paths. These different pathways can ultimately determine the grade, outcome, and severity of the deadliest genitourinary cancer. We finished by investigating current and proposed schemes to therapeutically treat clear cell renal cell carcinoma (ccRCC) by manipulating the hypoxic pathway utilizing Vascular Endothelial Growth Factor (VEGF) inhibitors, mammalian target of rapamycin complex 1 (mTORC1) inhibitors, small molecule HIF inhibitors, immune checkpoint blockade therapy, and synthetic lethality.
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Affiliation(s)
- Maxwell Shulman
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rachel Shi
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Qing Zhang
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Lin P, Lin YQ, Gao RZ, Wen R, Qin H, He Y, Yang H. Radiomic profiling of clear cell renal cell carcinoma reveals subtypes with distinct prognoses and molecular pathways. Transl Oncol 2021; 14:101078. [PMID: 33862522 PMCID: PMC8065300 DOI: 10.1016/j.tranon.2021.101078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022] Open
Abstract
Radiomics profile of clear cell renal cell carcinoma is heterogeneity. Multi-scale Radiogenomics could link molecular features and images. Radiomic subtypes could be used for risk stratification.
Background To identify radiomic subtypes of clear cell renal cell carcinoma (ccRCC) patients with distinct clinical significance and molecular characteristics reflective of the heterogeneity of ccRCC. Methods Quantitative radiomic features of ccRCC were extracted from preoperative CT images of 160 ccRCC patients. Unsupervised consensus cluster analysis was performed to identify robust radiomic subtypes based on these features. The Kaplan–Meier method and chi-square test were used to assess the different clinicopathological characteristics and gene mutations among the radiomic subtypes. Subtype-specific marker genes were identified, and gene set enrichment analyses were performed to reveal the specific molecular characteristics of each subtype. Moreover, a gene expression-based classifier of radiomic subtypes was developed using the random forest algorithm and tested in another independent cohort (n = 101). Results Radiomic profiling revealed three ccRCC subtypes with distinct clinicopathological features and prognoses. VHL, MUC16, FBN2, and FLG were found to have different mutation frequencies in these radiomic subtypes. In addition, transcriptome analysis revealed that the dysregulation of cell cycle-related pathways may be responsible for the distinct clinical significance of the obtained subtypes. The prognostic value of the radiomic subtypes was further validated in another independent cohort (log-rank P = 0.015). Conclusion In the present multi-scale radiogenomic analysis of ccRCC, radiomics played a central role. Radiomic subtypes could help discern genomic alterations and non-invasively stratify ccRCC patients.
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Affiliation(s)
- Peng Lin
- Department of Medical Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, China
| | - Yi-Qun Lin
- Department of Radiology, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, Fujian Province 363020, China
| | - Rui-Zhi Gao
- Department of Medical Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, China
| | - Rong Wen
- Department of Medical Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, China
| | - Hui Qin
- Department of Medical Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, China
| | - Yun He
- Department of Medical Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, China
| | - Hong Yang
- Department of Medical Ultrasound, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, China.
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