Risk-adjusted proposal for >60 months follow up after surgical treatment of organ-confined renal cell carcinoma according to life expectancy

Can Cytoreductive Nephrectomy Improve Outcomes of Nivolumab Treatment in Patients with Metastatic Clear-Cell Renal Carcinoma?

Background: This study aimed to investigate the effect of cytoreductive nephrectomy (CN) on the survival outcomes of nivolumab used as a subsequent therapy after the failure of at least one anti-vascular endothelial growth factor (VEGF) agent in patients with metastatic clear-cell renal-cell carcinoma (ccRCC). Methods: We included 106 de novo metastatic ccRCC patients who received nivolumab after progression on at least one anti-VEGF agent. Multivariate Cox regression analysis was performed to investigate the factors affecting survival in patients receiving nivolumab. Results: Of the 106 de novo metastatic ccRCC patients, 83 (78.3%) underwent CN. There were no statistical differences between the two groups in terms of age, gender, Eastern Cooperative Oncology Group (ECOG) score, tumor size, International Metastatic RCC Database Consortium (IMDC) risk group, number of previous treatment lines, first-line anti-VEGF therapy, or metastasis sites (p = 0.137, p = 0.608, p = 0.100, p = 0.376, p = 0.185, p = 0.776, p = 0.350, and p = 0.608, respectively). The patients who received nivolumab with CN had a longer time to treatment discontinuation (TTD) [14.5 months, 95% confidence interval (CI): 8.6-20.3] than did those without CN 6.7 months (95% CI: 3.9-9.5) (p = 0.001). The median overall survival (OS) was 22.7 months (95% CI: 16.1-29.4). The patients with CN had a median OS of 22.9 months (95% CI: 16.3-29.4), while those without CN had a median OS of 8.1 months (95% CI: 5.6-10.5) (p = 0.104). In the multivariate analysis, CN [hazard ratio (HR): 0.521; 95% CI: 0.297-0.916; p = 0.024] and the IMDC risk score (p = 0.011) were statistically significant factors affecting TTD; however, the IMDC risk score (p = 0.006) was the only significant factor for overall survival. Conclusions: Our study showed that the TTD of nivolumab was longer in metastatic ccRCC patients who underwent cytoreductive nephrectomy.

Retrospective Multicenter Analysis of Prognostic Risk Factors for One Year Recurrence in Patient With Renal Cell Carcinoma After Partial or Radical Nephrectomy: Results of Korean Renal Cancer Study Group (KRoCS) Database

BACKGROUND

We sought to identify prognostic risk factors for one year recurrence in patient with renal cell carcinoma (RCC) after partial or radical nephrectomy.

METHODS

We performed a retrospective study of 1,269 patients with RCC after partial or radical nephrectomy and diagnosed recurrence using Korean Renal Cancer Study Group (KRoCS) database between January 1991 and March 2017. Recurrence-free survival (RFS), and overall survival (OS) were calculated using the Kaplan-Meier method and multivariate Cox regression analysis were performed to evaluate independent prognostic factors for recurrence.

RESULTS

The median patient age was 56 years and median follow-up period was 67 months. Multivariable analysis demonstrated BMI greater than or equal to 23 and less than 30 (vs. BMI less than 23, hazard ratio [HR]: 0.707, P = 0.020) reduced recurrence one year postoperatively. Eastern Cooperative Oncology Group performance status (ECOG PS) greater than or equal to 1 (vs. ECOG PS 0, HR: 1.548, P = 0.007), high pathological T stage (pT2 vs. pT1, HR: 2.622, P < 0.001; pT3 vs. pT1, HR: 4.256, P < 0.001; pT4 vs. pT1, HR: 4.558, P < 0.001), and tumor necrosis (vs. no tumor necrosis, HR: 2.822, P < 0.001) were independent predictive factors for early recurrence within one year in patients with RCC. Statistically significant differences on RFS and OS were found among pathological T stages (pT2 vs. pT1; pT3 vs. pT1; pT4 vs. pT1, all P < 0.001).

CONCLUSION

This large multicenter study demonstrated ECOG PS greater than or equal to 1, high pathological T stage, tumor necrosis and BMI less than 23 were significant prognostic risk factors of early recurrence within one year in patients with RCC who underwent nephrectomy.

NUDT1 Could Be a Prognostic Biomarker and Correlated with Immune Infiltration in Clear Cell Renal Cell Carcinoma

Background

Clear cell renal cell carcinoma (ccRCC) is a malignant tumor with high morbidity and mortality. As a member of the Nudix hydrolase superfamily, Nudix (nucleoside diphosphate-linked moiety X)-type motif 1 (NUDT1) is closely related to the occurrence and development of cancer. Our study aims to explore the role of NUDT1 in ccRCC and its relationship with immune infiltration.

Methods

The NUDT1 expression matrix and corresponding clinical information were obtained from The Cancer Genome Atlas (TCGA) database. The expression difference of NUDT1 in ccRCC and its relationship with the clinical characteristics were investigated using R software. Kaplan-Meier (K-M) analysis, univariate Cox regression, multivariate Cox regression, receiver operating characteristic (ROC) curve, and nomogram were utilized to evaluate the survival and prognosis of patients. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were utilized to explore the function of differential genes in low- or high-expression group of NUDT1. TCGA dataset and Tumor IMmune Estimation Resource (TIMER) database were utilized to explore the relationship between NUDT1 and immune infiltration. Finally, TCGA dataset was utilized for gene set enrichment analysis (GSEA).

Results

NUDT1 was not only overexpressed in ccRCC but also significantly correlated with clinicopathological features (P < 0.05). K-M survival analysis showed that upregulated NUDT1 was closely related to the decrease of overall survival (OS) and progression-free survival (PFS) in ccRCC patients. Multivariate Cox regression revealed that NUDT1 was a independent prognostic indicator (HR = 1.437, 95% CI: 1.065-1.939, P=0.018). The ROC curve showed that NUDT1 had a certain accuracy in predicting the outcome of ccRCC patiens. Furthermore, a total of 150 coexpressed genes and 1,886 differentially expressed genes (DEGs) were identified. GO/KEGG and GSEA results suggested that NUDT1 and its DEGs were involved in the immune-related pathways. NUDT1 expression was positively correlated with infiltrating levels of regulatory T cells (Tregs), CD8⁺ T cells, follicular helper T cells, and M0 macrophages. In addition, NUDT1 was positively related to immune checkpoints, such as PD-1, LAG3, CTLA4, and CD70, in ccRCC.

Conclusion

NUDT1 plays a key role in the prognosis and immune cell infiltration of ccRCC patients, indicating its potential use as a prognostic biomarker and therapeutic target.

A clinical investigation of recurrence and lost follow-up after renal cell carcinoma surgery: a single-center, long-term, large cohort, retrospective study

BACKGROUND

Late recurrence of renal cell carcinoma (RCC) is observed in some postoperative patients. In addition, some of these patients are lost to long-term postoperative follow-up. We reviewed the treatment results and prognosis of postoperative patients with RCC at Chiba University Hospital, with the aim of clarifying the proportion and background of patients lost to follow-up.

METHODS

This retrospective study included 1176 RCC patients who underwent radical or/and partial nephrectomy. Overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), and lost follow-up free survival (LFFS) were evaluated and the risk factors for LFFS identified.

RESULTS

The median RFS for stage II and II cases was 188.3 and 104.0 months, respectively. Even in stage I, recurrence was observed in about 20% of patients 20 years after surgery. The Kaplan-Meier curve for LFFS showed a linear descent over time, with 50% of patients lost to follow-up within 25 years. Older age (≥ 62 years), histological type (clear cell RCC), and no recurrence were significant risk factors for lost follow-up.

CONCLUSIONS

Long-term follow-up is necessary after RCC surgery because late recurrence cases are not uncommon. We believe that lifelong follow-up with imaging studies is recommended for postoperative RCC patients. Early detection of recurrence in postoperative patients is a very important issue, and it may be worthwhile for improving the prognosis of postoperative patients to focus on patients lost to follow-up who may have been overlooked.

Nephron-Sparing Surgery for Renal Cell Carcinoma with Tumor Thrombus

OBJECTIVE

The aim of the study was to describe our experience in patients who underwent nephron-sparing surgery (NSS) with tumor thrombectomy.

PATIENTS AND METHODS

Three consecutive patients who underwent NSS and tumor thrombectomy for localized single/multifocal renal cell carcinomas (RCCs) in conjunction with tumor thrombus between 2007 and 2011 were included. Open partial nephrectomy and thrombectomy was performed. Reconstruction included main renal vein, collecting system, and remaining parenchymal closure. One of the cases required additional artery repair and flushing with preservation solution.

RESULTS

Ischemic time was kept for 30-40 min. Mean estimated blood loss was 183.3 cc (range:100-300). One patient required the transfusion of 1 packed red blood cells unit. One of the patients developed a urinary fistula requiring double-J stenting. Hospital staying ranged between 5 and 8 days. None of the patients required renal replacement therapy either postoperatively or in the follow-up. Serum creatinine level at last follow-up (mean 83 months) ranged from 0.8 to 2.8 mg/dL.

CONCLUSION

Our experience supports the feasibility of imperative partial nephrectomy and tumor thrombectomy for cases of RCC with renal vein involvement by tumor thrombus. In experienced hands, this approach may offer the patient a low morbidity postoperative course and long-term freedom from disease while maintaining the renal function, thus avoiding the need of renal replacement therapy.

A Retrospective, Multicenter, Long-Term Follow-Up Analysis of the Prognostic Characteristics of Recurring Non-Metastatic Renal Cell Carcinoma After Partial or Radical Nephrectomy

This study aimed to compare the cancer-specific survival (CSS) and overall survival (OS) of nephrectomized patients with non-metastatic renal cell carcinoma (nmRCC) and local recurrence without distant metastasis (LR group), those with metastasis without local recurrence (MET group), and those with both local recurrence and metastasis (BOTH group). This retrospective multicenter study included 464 curatively nephrectomized patients with nmRCC and disease recurrence between 2000 and 2012; the follow-up period was until 2017. After adjusting for significant clinicopathological factors using Cox proportional hazard models, CSS and OS were compared between the MET (n = 50, 10.7%), BOTH (n = 95, 20.5%), and LR (n = 319, 68.8%) groups. The CSS and OS rates were 34.7 and 6.5% after a median follow-up of 43.9 months, respectively. After adjusting for significant prognostic factors of OS and CSS, the MET group had hazard ratios (HRs) of 0.51 and 0.57 for OS and CSS (p = 0.039 and 0.103), respectively, whereas the BOTH group had HRs of 0.51 and 0.60 for OS and CSS (p < 0.05), respectively; LR was taken as a reference. The 2-year OS and CSS rates from the date of nephrectomy and disease recurrence were 86.9% and 88.9% and 63.5% and 67.8%, respectively, for the LR group; 89.5% and 89.5% and 48.06% and 52.43%, respectively, for the MET group; and 96.8% and 96.8% and 86.6% and 82.6%, respectively, for the BOTH group. Only the LR and BOTH groups had significant differences in the 2-year OS and CSS rates (p < 0.05). In conclusion, our study showed that the LR group had worse survival prognoses than any other group in nephrectomized patients with nmRCC.

The Choice of Candidates in Survival Markers Based on Coordinated Gene Expression in Renal Cancer

We aimed to identify and investigate genes that are essential for the development of clear cell renal cell carcinoma (ccRCC) and sought to shed light on the mechanisms of its progression and create prognostic markers for the disease. We used real-time PCR to study the expression of 20 genes that were preliminarily selected based on their differential expression in ccRCC, in 68 paired tumor/normal samples. Upon ccRCC progression, seven genes that showed an initial increase in expression showed decreased expression. The genes whose expression levels did not significantly change during progression were associated mainly with metabolic and inflammatory processes. The first group included CA9, NDUFA4L2, EGLN3, BHLHE41, VWF, IGFBP3, and ANGPTL4, whose expression levels were coordinately decreased during tumor progression. This expression coordination and gene function is related to the needs of tumor development at different stages. Specifically, the high correlation coefficient of EGLN3 and NDUFA4L2 expression may indicate the importance of the coordinated regulation of glycolysis and mitochondrial metabolism. A panel of CA9, EGLN3, BHLHE41, and VWF enabled the prediction of survival for more than 3.5 years in patients with ccRCC, with a probability close to 90%. Therefore, a coordinated change in the expression of a gene group during ccRCC progression was detected, and a new panel of markers for individual survival prognosis was identified.

Renal Cell Carcinoma with or without Tumor Thrombus Invading the Liver, Pancreas and Duodenum

Simple Summary

Renal cell carcinoma rarely invades the surrounding visceral structures. While surgical extirpation has been the mainstay of treatment for the localized disease, the role of surgery in cases of venous involvement, adjacent invasion or distant metastasis remains controversial. Furthermore, the surgical option may represent a challenge. A large series of locally advanced renal cancer with involvement of the liver, pancreas, and/or duodenum, sometimes in conjunction with tumor thrombus extending inside the inferior vena cava is herein reported. Our series establishes the technical feasibility of this complex surgical procedure with acceptable complication rates, no perioperative death, and potential for durable response. With the use of new systemic therapy schedules, these patients will probably have a better opportunity of survival extension.

Abstract

Background: The purpose of this study is to report the outcomes of a series of patients with locally advanced renal cell carcinoma (RCC) who underwent radical nephrectomy, tumor thrombectomy, and visceral resection. Patients and methods: 18 consecutive patients who underwent surgical treatment in the period 2003-2019 were included. Neoplastic extension was found extending into the pancreas, duodenum, and liver in 9(50%), 2(11.1%), and 7(38.8%) patients, respectively. Seven patients (38.8%) presented also inferior vena cava tumor thrombus level I (n = 3), II (n = 2), or III (n = 2). The resection was tailored according to the degree of invasiveness. Demographics, clinical presentation, disease characteristics, surgical details, 30-day postoperative complications, and overall survival (OS) were analyzed. Results: Median age was 56 years (range: 40–76). Median tumor size was 14.5 cm (range, 8.8–22), and 10 cm (range: 4–15) for those cases with pancreatico-duodenal and liver involvement, respectively. Median estimated blood loss (EBL) was 475 mL (range: 100–4000) and resulted higher for those cases requiring thrombectomy (300 mL vs. 750 mL). Nine patients (50%) required transfusions with a median requirement of 4 units (range: 2–8). No perioperative deaths were registered in the first 30 days. Overall complication rate was 44.4%. Major complications were detected in 6/18 patients (33.3%). Overall median follow-up was 24 months (range: 0–108). Five-year OS (actuarial) rate was 89.9% and 75%, for 9/11 patients with pancreatico-duodenal involvement and 6/7 patients with liver invasion, respectively. Conclusion: Our series establishes the technical feasibility of this procedure with acceptable complication rates, no deaths, and potential for durable response.

Prognostic significance of pathologic nodal positivity in non-metastatic patients with renal cell carcinoma who underwent radical or partial nephrectomy

This retrospective, five-multicenter study was aimed to evaluate the prognostic impact of pathologic nodal positivity on recurrence-free (RFS), metastasis-free (MFS), overall (OS), and cancer-specific (CSS) survivals in patients with non-metastatic renal cell carcinoma (nmRCC) who underwent either radical or partial nephrectomy with/without LN dissection. A total of 4236 nmRCC patients was enrolled between 2000 and 2012, and followed up through the end of 2017. Survival measures were compared between 52 (1.2%) stage pT1-4N1 (LN+) patients and 4184 (98.8%) stage pT1-4N0 (LN-) patients using Kaplan-Meier analysis with the log-rank test and Cox regression analysis to determine the prognostic risk factors for each survival measure. During the median 43.8-month follow-up, 410 (9.7%) recurrences, 141 (3.3%) metastases, and 351 (8.3%) deaths, including 212 (5.0%) cancer-specific deaths, were reported. The risk factor analyses showed that predictive factors for RFS, CSS, and OS were similar, whereas those of MFS were not. After adjusting for significant clinical factors affecting survival outcomes considering the hazard ratios (HR) of each group, the LN+ group, even those with low pT stage, had similar to or worse survival outcomes than the pT3N0 (LN-) group in multivariable analysis and had significantly more relationship with RFS than MFS. All survival measures were significantly worse in pT1-2N1 patients (MFS/RFS/OS/CSS; HR 4.12/HR 3.19/HR 4.41/HR 7.22) than in pT3-4N0 patients (HR 3.08/HR 2.92/HR 2.09/HR 3.73). Therefore, LN+ had an impact on survival outcomes worse than pT3-4N0 and significantly affected local recurrence rather than distant metastasis compared to LN- in nmRCC after radical or partial nephrectomy.

The Genes-Candidates for Prognostic Markers of Metastasis by Expression Level in Clear Cell Renal Cell Cancer

The molecular prognostic markers of metastasis are important for personalized approaches to clear cell renal cell carcinoma (ccRCC) treatment but markers for practical use are still missing. To address this gap we studied the expression of ten genes—CA9, NDUFA4L2, VWF, IGFBP3, BHLHE41, EGLN3, SAA1, CSF1R, C1QA, and FN1—through RT-PCR, in 56 ccRCC patients without metastases and with metastases. All of these, excluding CSF1R, showed differential and increased (besides SAA1) expression in non-metastasis tumors. The gene expression levels in metastasis tumors were decreased, besides CSF1R, FN1 (not changed), and SAA1 (increased). There were significant associations of the differentially expressed genes with ccRCC metastasis by ROC analysis and the Fisher exact test. The association of the NDUFA4L2, VWF, EGLN3, SAA1, and C1QA expression with ccRCC metastasis is shown for the first time. The CA9, NDUFA4L2, BHLHE4, and EGLN3 were distinguished as the strongest candidates for ccRCC metastasis biomarkers. We used an approach that presupposed that the metastasis marker was the expression levels of any three genes from the selected panel and received sensitivity (88%) and specificity (73%) levels with a relative risk of RR > 3. In conclusion, a panel of selected genes—the candidates in biomarkers of ccRCC metastasis—was created for the first time. The results might shed some light on the ccRCC metastasis processes.

Retrospective Multicenter Long-Term Follow-up Analysis of Prognostic Risk Factors for Recurrence-Free, Metastasis-Free, Cancer-Specific, and Overall Survival After Curative Nephrectomy in Non-metastatic Renal Cell Carcinoma

We evaluated prognostic risk factors of recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS) outcomes in patients with non-metastatic renal cell carcinoma (nmRCC) after curative nephrectomy during long-term follow-up. The medical records of 4,260 patients with nmRCC who underwent curative nephrectomy between 2000 and 2012 from five Korean institutions and follow-up after postoperative 1 month until December 2017 were retrospectively analyzed for RFS, MFS, OS, and CSS. During the median 43.86 months of follow-up, 342 recurrences, 127 metastases, and 361 deaths, including 222 cancer-specific deaths, were reported. In addition to the unreached median survival of RFS and MFS, the median OS and CSS times were 176.75 and 227.47 months, respectively. Multivariable analyses showed that nephrectomy type (laparoscopy vs. open), pathological T stages, and nuclear grade were common significant risk factors for survival, and the baseline ASA, hemoglobin, and pathological N stage were common factors only for RFS, OS, and CSS (p < 0.05). Further, tumor necrosis for MFS; platelet count, extent (partial vs. radical) of surgery, and lymphovascular invasion for RFS; baseline diabetes, hypertension, age, body mass index, extent of surgery, and pathological sarcomatoid differentiation for OS; and baseline diabetes, hypertension, body mass index, and pathological sarcomatoid differentiation for CSS were additionally significant risk factors (p < 0.05). RFS, MFS, OS, and CSS were significantly different depending on the pathological T stages (p < 0.05). In conclusion, this large-numbered, long-term follow-up study revealed significant factors affecting the survival of patients with nephrectomized nmRCC.