Prognostic factors for renal cell carcinoma: a multivariate analysis of 320 cases

C-Reactive Protein Is an Important Biomarker for Prognosis Tumor Recurrence and Treatment Response in Adult Solid Tumors: A Systematic Review

PURPOSE

A systematic literature review was done to determine the relationship between elevated CRP and prognosis in people with solid tumors. C-reactive protein (CRP) is a serum acute phase reactant and a well-established inflammatory marker. We also examined the role of CRP to predict treatment response and tumor recurrence.

METHODS

MeSH (Medical Subject Heading) terms were used to search multiple electronic databases (PubMed, EMBASE, Web of Science, SCOPUS, EBM-Cochrane). Two independent reviewers selected research papers. We also included a quality Assessment (QA) score. Reports with QA scores <50% were excluded. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology was utilized for this review (S1 PRISMA Checklist).

RESULTS

271 articles were identified for final review. There were 45% prospective studies and 52% retrospective. 264 had intermediate QA score (≥50% but <80%); Seven were adequate (80% -100%); A high CRP was predictive of prognosis in 90% (245/271) of studies-80% of the 245 studies by multivariate analysis, 20% by univariate analysis. Many (52%) of the articles were about gastrointestinal malignancies (GI) or kidney malignancies. A high CRP was prognostic in 90% (127 of 141) of the reports in those groups of tumors. CRP was also prognostic in most reports in other solid tumors primary sites.

CONCLUSIONS

A high CRP was associated with higher mortality in 90% of reports in people with solid tumors primary sites. This was particularly notable in GI malignancies and kidney malignancies. In other solid tumors (lung, pancreas, hepatocellular cancer, and bladder) an elevated CRP also predicted prognosis. In addition there is also evidence to support the use of CRP to help decide treatment response and identify tumor recurrence. Better designed large scale studies should be conducted to examine these issues more comprehensively.

C-reactive protein in urologic cancers

C-reactive protein is an acute-phase reactant that is elevated in the setting of systemic infections, trauma, and malignancies. Urologic cancers have been shown to promote changes in c-reactive protein levels. Pre-treatment serum levels can predict disease characteristics, extent of disease, and prognosticate survival after intervention in renal cell carcinoma, prostate cancer, bladder cancer, upper tract urothelial carcinoma, and penile cancer. Changes in post-treatment serum levels have also shown promise in determining survival. As a result, c-reactive protein has been incorporated into various survival nomograms to improve predictive accuracy. While the association between c-reactive protein and survival in testicular cancer has not been studied, elevated serum levels may correlate with treatment side effects, such as cardiovascular disease and chronic cancer-related fatigue. Understanding the relationship between c-reactive protein and urologic cancers can help physicians determine the appropriate course of treatment and improve patient care.

Role of C-reactive protein as a biomarker for renal cell carcinoma

The presence of a systemic inflammatory response has been thought to indicate poor prognosis in renal cell carcinoma, based on the assumption that the processes underlying such a response play important roles in the progression of renal cell carcinoma. C-reactive protein (CRP) is a representative acute-phase reactant whose concentration can be objectively measured using a variety of reliable standardized assays. To show that CRP could be an indicator of normal or pathologic processes, recent studies have revealed that CRP is a significant prognostic factor for metastasis and mortality in patients with renal cell carcinoma. Incorporating CRP levels into prognostic algorithms could make those algorithms simpler without reducing their predictive accuracy. Furthermore, CRP kinetics, the analysis of dynamic changes in CRP concentrations, has been shown to generate valuable information relevant to prognosis, specifically information on the likelihood of tumor aggressiveness. Therefore, dynamic changes of CRP concentration could indicate clinical pharmacologic response to therapeutic intervention. Taken together, we could conclude that CRP is a significant biomarker for renal cell carcinoma.

[Clinical studies on renal cell carcinoma]

PURPOSE

We reviewed 193 patients of renal cell carcinoma treated at Osaka Police Hospital between 1990 and 2006.

METHODS

The patients consisted of 140 males and 53 females. The median age was 62 years, ranging from 26 to 88 years. Median follow-up period was 53 months. TNM system and pathologic findings were classified in accordance with the Japanese General Rules for Clinical and Pathological Studies on Renal Cell Carcinoma. Survival rates were calculated using the Kaplan-Meier method, and differences in survival curves were estimated with the log-rank test. Independent prognostic factors were analyzed using the Cox proportional hazards model.

RESULTS & CONCLUSIONS

The overall 3, 5, 10 and 15-year cause-specific survival rates were 92.6, 91.1, 86.1, 72.2%, respectively. Univariate analysis indicated age, chief complaint, performance status, tumor size, anemia, CRP, tumor extent, grade, infiltrating pattern, venous involvement, lymph node metastasis, distant metastasis, stage to be significant prognostic factors. Moreover, multivariate analysis with Cox's proportional hazard model revealed high age (60 < or =), positive CRP, and T4 to be independent poor prognosticators for cause specific survival. Using these three risk factors, patients with 0, 1, 2, and 3 poor risk factors were classified as 0, 1, 2, and 3 risk groups, respectively. The overall 5 and 10-year cause specific survival rates in 0, 1, 2, and 3 risk groups were 100 and 100%, 90.8 and 83.8%, 71.6 and 34.1%, 0 and 0%, respectively. The overall 5 and 10-year cause specific survival rates (69.2 and 33.0%) especially in 2 and 3 risk groups were significantly poor prognosis, comparing with those (94.8 and 91.9%) in 0 and 1 risk group (p< 0.0001). Thus, the intensity of the follow up period and the necessity of postoperative adjuvant therapy for a patient are recommended for 2 and 3 risk groups.

Advances and controversies in grading and staging of renal cell carcinoma

Despite the considerable progress made in our understanding of the pathogenesis, genetics, and pathology of renal cell carcinoma (RCC), difficulties remain relating to the prediction of clinical outcome for individual cases. Although there is evidence to show that high-grade tumors have a poorer prognosis when compared to those of low grade, debate remains regarding the predictive value of grading, especially for those tumors classified into the intermediate grades. Numerous composite morphologic and nuclear grading systems have been proposed for RCC and although that of the Fuhrman classification have achieved widespread usage, the validity of the grading criteria of this classification has been questioned. In addition, there are few studies that have attempted to validate the Fuhrman system for RCCs beyond that of the clear cell subtype. Recent studies have indicated that grading of papillary RCC should be based on nucleolar prominence alone and that the components of the Fuhrman grading classification do not provide prognostic information for chromophobe RCC. Independent of tumor grade, the prognostic importance of tumor stage for RCC is well recognized. The Union Internationale Contre le Cancer/American Joint Committee for Cancer Staging and End Results Reporting TNM staging system is now in its sixth edition (2002) and recent refinements have focused on defining size cut points that will identify apparently localized tumors that will develop recurrence and/or metastases despite attempted curative surgery. In parallel with these studies it has been shown that infiltration of the renal sinus is an important prognostic factor, being observed in almost all tumors >7 cm in diameter. Questions remain as to the appropriate stratification of regional extension of RCC, as defined in the T3 tumor-staging category. Recent modifications to this category have been suggested combining the level of infiltration of the venous outflow tract with the presence or absence of infiltration of the adrenal gland and/or perirenal fat. Similarly, the utility of classifying lymph node involvement by tumor is debated, although it is well recognized that lymph node infiltration is associated with a poor prognosis. Although the current TNM classification does provide useful prognostic information it would appear that further modifications are justified to enhance the predictive value of staging for RCC.

Vitamin D receptor gene polymorphisms are associated with increased risk and progression of renal cell carcinoma in a Japanese population

AIM

Biological and epidemiologic data suggest that 1 alpha, 25 dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) levels may influence development of renal cell carcinoma. The vitamin D receptor (VDR) is a crucial mediator for the cellular effects of 1,25(OH)(2)D(3) and additionally interacts with other cell signaling pathways that influence cancer progression. VDR gene polymorphisms may play an important role in risk of incidence for various malignant tumors. This study investigated whether VDR gene polymorphisms were associated with increased risk and prognosis of renal cell carcinoma (RCC) in a Japanese population.

METHODS

To analyze risk of RCC depending on VDR polymorphism, a case-control association study was performed. The VDR gene polymorphisms at three locations, BsmI, ApaI and TaqI, were genotyped in 135 RCC patients and 150 controls in a Japanese population. Logistic regression models were used to assess the genetic effects on prognosis.

RESULTS

Significant differences in the ApaI genotype were observed between RCC patients and controls (chi(2) = 6.90, P = 0.032). No statistical significant difference was found in the BsmI and TaqI polymorphisms. The frequency of the AA genotype in the ApaI polymorphism was significantly higher in the RCC patients than in the controls (odds ratio, 2.59; 95% confidence intervals, 1.21-5.55; P = 0.012). Multivariate regression analysis showed that the AA genotype was an independent prognostic factor for cause-specific survival (relative risk 3.3; P = 0.038).

CONCLUSION

The AA genotype at the ApaI site of the VDR gene may be a risk of incidence and poor prognosis factor for RCC in the Japanese population. Additional studies with a large sample size and investigation of the functional significance of the ApaI polymorphism in RCC cells are warranted.

Matrix metalloproteinase-9 polymorphisms and renal cell carcinoma in a Japanese population

Matrix metalloproteinase-9 (MMP-9) plays a pivotal role in cancer invasion and metastasis. Recently, experimental study has shown that MMP-9 is also implicated in early carcinogenesis. We hypothesized that MMP-9 polymorphisms influence the predisposition to develop renal cell carcinoma (RCC). To test the hypothesis, we determined MMP-9 C-1562T and R279Q genotypes in Japanese RCC cases (n=179) and controls (n=211). Furthermore, we investigated the relationship between MMP-9 polymorphisms and clinicopathological features. The distribution of C-1562T and R279Q genotypes was not significantly associated with the risk of RCC (odds ratio [OR]=1.14, 95% confidence interval [CI]=0.73-1.77 for -1562 CT/TT genotypes versus CC genotype; OR=1.29, 95% CI=0.86-1.93 for 279 RQ/QQ genotypes versus RR genotype). However, the distribution of R279Q genotypes was significantly associated with the histological grade (P<0.01). The present results suggest that MMP9 R279Q polymorphism has influence on the malignant potential of RCC.

Impact of haemoglobin levels on the outcome of cancers treated with chemotherapy

Anaemia is the most frequently observed haematological abnormality faced by cancer patients. Yet, its impact on tumour biology is not well understood. Several recent retrospective clinical studies showed that anaemia is not only a negative prognostic factor but also, in some situations, a negative predictive parameter in chemotherapy-treated patients with solid tumours or haematological malignancies. These include lymphomas, leukaemias, non-small-cell lung cancer, ovarian cancer, cervical cancer, urothelial and renal cancers, and head and neck carcinoma. The basis for the impact of anaemia on prognosis or outcome of chemotherapy is complex. In vitro and animal models have shown that cellular hypoxia, the consequence of anaemia, may provide a selection pressure for tumour cells with higher rates of mutation, which may ultimately result in increased metastatic potential, increased cellular growth, therapy resistance, and decreased apoptotic potential. There is also evidence to indicate that the anaemia itself may induce a feedback mechanism that results in angiogenesis. Finally, the effect of anaemia on the pharmacokinetics of cytostatics may be an underestimated parameter for therapeutic outcome. The treatment of anaemia in patients with cancer undergoing chemotherapy may improve outcome in terms of both response rate to treatment and survival.

Clinical significance of cell proliferation, microvessel density, and CD44 adhesion molecule expression in renal cell carcinoma

Renal cell carcinoma (RCC) is known to have a wide variation in clinical outcome despite the use of conventional prognostic factors, such as staging or grading. A better knowledge of the biologic aggressiveness of RCC could facilitate the selection of patients at high risk of tumor progression. The aim of this study was to determine if use of measurements of vascular density, cell proliferation, and cell adhesion could better predict the biologic behavior of RCC. We immunohistochemically analyzed CD34, Ki-67, and CD44H expression on formalin-fixed, paraffin-embedded tissues from 73 RCCs for quantifying microvessel density (MVD), Ki-67 labeling index (LI), and CD44H LI, respectively. Univariate cancer-specific survival analysis showed that tumor stage (P < .01), tumor size (P < .001), nuclear grade (P < .01), metastasis (P < .001), MVD (P < .03), Ki-67 LI (P < .001), and CD44H LI (P < .0001) were predictors of tumor-related death. There was a statistical correlation between CD44H LI and both Ki-67 LI (r' = .3) and MVD (r' = -44). Ki-67 LI (P < .04) and CD44H LI (P < .02), as well as metastasis (P < .008), emerged as independent predictors of cancer-specific survival in multivariate analysis in patients with metastases (P < .04 and P < .02, respectively) and in patients without metastases (P < .006 and P < .00001, respectively). Our study suggests that vascular density, cell proliferation, and cell adhesion represent a complex tumor-host interaction that may favor progression of RCC. Cell proliferation and CD44H expression appear to be powerful markers to identify patients with an adverse prognosis.

Predictive value of serum immunosuppressive acidic protein for lung metastasis after amputation of murine osteosarcoma of the lower limb

A spontaneously occurring murine osteosarcoma cell line (POS-1) was inoculated into the footpads of 88 mice. In 59 mice, the tumor-bearing leg was amputated at 1, 3, 5, or 7 weeks after inoculation and the mice sacrificed at 9 weeks. Lung metastasis was observed in 82.6-100% of the mice undergoing leg amputation at 5 or 7 weeks after inoculation. There were no lung metastasis in the mice amputated at 1 or 3 weeks. The serum immunosuppressive acidic protein (IAP) concentration showed a significant increase at 5 or 7 weeks after inoculation (P<0.005 and P<0.0005, respectively). When amputation was done 5 weeks after inoculation, the serum IAP concentration increased further to 5.9 times the pre-amputation level 1 week after the amputation. The IAP concentration increased only 1.3-fold in the control group without inoculation. Thus, a high serum IAP concentration before amputation and a further increase after amputation were indicators of lung metastasis in this mouse model of osteosarcoma.

Value of immunohistochemical Ki-67 and p53 determinations as predictive factors of outcome in renal cell carcinoma

OBJECTIVES

Nuclear grade and tumor stage are important prognostic factors in renal cell carcinoma, but tumors of similar stage and grade can exhibit a wide variation in biologic behavior and clinical outcome. In this retrospective study, we evaluated the immunologic markers, Ki-67 (MIB1) and p53, in 73 cases of conventional (clear cell) renal cell carcinoma and compared these markers with the accepted prognostic features of grade, stage, and tumor size in predicting outcome.

METHODS

Specimens of 73 renal cell carcinomas of different nuclear grade (20 Furhman I/II, 32 Fuhrman III, and 21 Fuhrman IV) and different stage (10 pT1, 23 pT2, 36 pT3, and 4 pT4) were immunostained with monoclonal antibodies against Ki-67 and p53.

RESULTS

Univariate statistical analysis showed that tumor size (P <0. 001), nuclear grade (P <0.01), tumor stage (P <0.01), Ki-67 index (P <0.001), and p53 immunostaining (P <0.03) correlated significantly with a poor prognosis. A Ki-67 index of 20% was a powerful predictor of survival in all patients (P <0.00001), with strong predictive values. On multivariate analysis, the Ki-67 index and metastases were significant independent prognostic factors (P <0.02 and <0.01, respectively).

CONCLUSIONS

Ki-67 immunostaining appeared to be an additional prognostic indicator of biologic aggressiveness in renal cell carcinoma. Immunohistochemical assessment of tumor antigens could be used to identify patients at high risk of tumor progression in addition to conventional prognostic factors.

Prognostic significance of tumor grade for renal cell carcinoma

BACKGROUND

The natural history and prognosis of renal cell carcinoma cannot be predicted. Based on the Japanese classification system, the value of nuclear grade were assessed as a possible prognostic factor for renal cell carcinomas.

METHODS

In this retrospective study of 116 patients with renal cell carcinoma, radical nephrectomy was performed. Survival rates were calculated using the Kaplan-Meier method and multivariate analysis was performed using Cox's proportional hazard model.

RESULTS

Distribution by stage and grade in the population of renal cell carcinomas was as follows: pT1 in 13 cases (11.3%), pT2 in 65 cases (56.5%), pT3 in 36 cases (31.3%) and pT4 in one case (0.9%) and grade 1, 28 (24.1%), grade 2, 69 (59.5%) and grade 3, 16 (13.8%). Three cases could not be determined because of pre-operative embolization of the renal cell carcinomas. Nuclear grade was correlated with stage (P=0.0002), the presence of perirenal fat involvement (P=0.003) and metastases (P=0.007). A significant difference in survival was found between grades 1 and 3 (P=0.0001) and grades 2 and 3 (P=0.0001), respectively. Survival was significantly correlated with sex (P=0.0125), tumor size (P=0.0001), the presence of lymph node metastasis (P=0.0001), renal vein involvement (P=0.0001), perirenal fat involvement (P=0.002) or distant metastasis (P=0.0001). The multivariate analysis showed that the occurrence of tumor grade (P=0.0006) or distant metastasis were independent prognostic values.

CONCLUSION

The observations lead us to conclude that the nuclear grade according to the Japanese classification system appears to be of reliable prognostic value for renal cell carcinomas.

CD44v6 expression is related to progression in renal epithelial tumours

AIMS

Expression of CD44 variant isoform including exon 6 has been associated to tumour progression in several carcinomas. However, no studies have been performed to assess the prognostic value of the expression of this marker in renal cell tumours.

METHODS AND RESULTS

We studied 58 renal cell tumours. All patients were followed up for at least 3 years after nephrectomy. Tumours were analysed for expression of CD44v6 assessed by two isoform-specific monoclonal antibodies. RT-PCR was performed to detect CD44 variant transcripts in 10 cases in which immunohistochemistry was negative. Twenty-two tumours showed reactivity in at least 1% cells for both antibodies with a strong membrane pattern. RT-PCR did not show CD44v6 transcripts in any of 10 studied tumours. Immunohistochemical staining was more frequent in perivascular areas or in areas of vascular invasion. In fact, CD44v6 expression correlated well with nuclear grade (P = 0.009), stage at diagnosis (P = 0.04) and appearance of metastasis after nephrectomy (P = 0.007). Although univariate survival analysis showed stage (P < 0.001), grade (P = 0.009) and CD44v6 expression (P = 0.04) to be significant predictive factors, only stage remained significant (P = 0.0013) in the multivariate analysis.

CONCLUSIONS

CD44v6 expression, assessed immunohistochemically, is related to tumour progression. However, its prognostic value in renal cell tumours is dependent on tumour stage at diagnosis.