A Review of Translocation T(6;11) Renal Cell Carcinoma Tumors in the Adult Patient

TFEB promotes BCL-2 expression by upregulating its promoter activity in the t(6;11) translocation renal cell carcinomas

t(6;11) translocation renal cell carcinoma (RCC) is classified as a subset of the MiT family translocation RCCs and characterized by harboring the Alpha-TFEB fusion gene. However, the development mechanism of this tumor and its effective treatment have not been fully identified yet. The purpose of this study was to explore the relationship between TFEB and BCL-2 in Alpha-TFEB stably transfected cell lines and in t(6;11) RCC tumor tissue. An Alpha-TFEB eukaryotic expression vector was constructed and stably transfected into CaKi-2 and HK-2 cells. RT-PCR and real-time RT-PCR were used to measure the mRNA expressions of TFEB and BCL-2, and immunohistochemistry, Western blot and dual immunofluorescence assays were used to evaluate the TFEB and BCL-2 protein expressions. MTT proliferation assays and flow cytometry were also performed. Furthermore, luciferase reporter assays were used to evaluate the BCL-2 promoter activity. An Alpha-TFEB eukaryotic expression vector was successfully constructed and stably transfected into CaKi-2 and HK-2 cells (named CaKi-2-TFEB and HK-2-TFEB cells). Compared with the CaKi-2 and HK-2 groups, the TFEB and BCL-2 mRNA expression levels were significantly upregulated in the CaKi-2-TFEB and HK-2-TFEB groups respectively. The TFEB and BCL-2 protein expressions showed a similar result. The overexpression of TFEB and BCL-2 promoted cell proliferation and inhibited cell apoptosis. Moreover, the overexpression of TFEB upregulated the promoter activity of BCL-2. Our data suggest that the overexpression of TFEB promotes BCL-2 expression by upregulating its promoter activity and ultimately results in the development of t(6;11) translocation RCC. BCL-2 inhibitors may serve as potential therapeutic targets for t(6;11) translocation RCC.

An Intratumoral Aneurysm and an Extrarenal Synchronous Cystic Tumour in a Case of a Renal Cell Carcinoma

Background

Renal cell carcinoma is a heterogeneous group of malignant tumors originating from the kidney. We report a case of a renal cell carcinoma with two very rare associates, i.e., a large intratumoral aneurysm and a synchronous extrarenal cystic tumor outside the main tumor. Case Presentation. A 31-year-old woman, who presented with painless hematuria and loin pain, was diagnosed to have a large renal mass measuring 15 × 9 × 8.5 cm with an intralesional arterial aneurysm measuring 4.5 × 3.5 cm on radiological examination. During surgery, a separate cystic tumor measuring 5 × 4.5 × 4 cm with distinct vascular supply was noted anteromedial to the kidney, in addition to the renal mass. The histology of the main tumor was compatible with t(6:11) type microphthalmia-associated transcription factor (MiT) family translocation RCC. The aneurysm was of venous origin histologically, and a radiologically demonstrable arteriovenous fistula was recognized retrospectively. The extrarenal cyst has also showed similar histology to that of main tumor and had no evidence of a degenerated lymph node. Discussion. Although few cases were reported with various vascular anomalies associated with a renal tumor, this is the first ever case to find an arteriovenous fistula with a secondary venous aneurysm located inside a malignant renal mass. Similarly, no solid RCC is reported to present with an extrarenal malignant cystic nodule. The prognostic and oncological significance of the extrarenal malignant cyst is unclear. Both of these extraordinary features of this case were not properly identified on preoperative imaging. Reviewing the preoperative imaging when pathology reports are available helps to overcome difficulties in making the final diagnosis of complex cases.

Conclusion

RCCs can house vascular anomalies like arteriovenous fistula and venous aneurysms and can exist with concomitant extrarenal malignant cystic nodules.

Clinicopathologic and Molecular Analysis of the TFEB Fusion Variant Reveals New Members of TFEB Translocation Renal Cell Carcinomas (RCCs): Expanding the Genomic Spectrum

Xp11 renal cell carcinoma (RCC) with different gene fusions may have different clinicopathologic features. We sought to identify variant fusions in TFEB translocation RCC. A total of 31 cases of TFEB RCCs were selected for the current study; MALAT1-TFEB fusion was identified in 25 cases (81%, 25/31) using fusion probes. The remaining 6 cases (19%, 6/31) were further analyzed by RNA sequencing and 5 of them were detected with TFEB-associated gene fusions, including 2 ACTB-TFEB, 1 EWSR1-TFEB, 1 CLTC-TFEB, and 1 potential PPP1R10-TFEB (a paracentric inversion of the TFEB gene, consistent with "negative" TFEB split FISH result, and advising a potential diagnostic pitfall in detecting TFEB gene rearrangement). Four of the 5 fusion transcripts were successfully validated by reverse transcription-polymerase chain reaction and Sanger sequencing. Morphologically, approximately one third (29%, 9/31) of TFEB RCCs showed typical biphasic morphology. The remaining two thirds of the cases (71%, 22/31) exhibited nonspecific morphology, with nested, sheet-like, or papillary architecture, resembling other types of renal neoplasms, such as clear cell RCC, Xp11 RCC, perivascular epithelioid cell tumor (PEComa), or papillary RCC. Although cases bearing a MALAT1-TFEB fusion demonstrated variable morphologies, all 9 cases featuring typical biphasic morphology were associated with MALAT1-TFEB genotype. Accordingly, typical biphasic morphology suggests MALAT1-TFEB fusion, whereas atypical morphology did not suggest the specific type of fusion. Isolated or clustered eosinophilic cells were a common feature in TFEB RCCs, which may be a useful morphology diagnostic clue for TFEB RCCs. Clinicopathologic variables assessment showed that necrosis was the only morphologic feature that correlated with the aggressive behavior of TFEB RCC (P=0.004). In summary, our study expands the genomic spectrum and the clinicopathologic features of TFEB RCCs, and highlights the challenges of diagnosis and the importance of subtyping of this tumor by combining morphology and multiple molecular techniques.

Comprehensive Immunoprofiles of Renal Cell Carcinoma Subtypes

In recent years, renal epithelial tumors have been among the fastest reclassifying tumors, requiring updates to the tumor classification system. Nonetheless, immunohistochemistry (IHC) remains the most widely used tool for renal epithelial tumors. In this proposal, we aimed to create the most efficient IHC panel for categorizing the diverse subtypes of renal tumors, and to find out more specific immunohistochemical results in each subtype or each antibody. A total of 214 renal tumors were analyzed using 10 possible IHC markers to differentiate subtypes, including three major renal cell carcinoma (RCC) subtypes, clear-cell type (50 cases), papillary type (50 cases), and chromophobe type (20 cases), and minor subtypes (MiT RCC, 13 cases; collecting duct carcinoma, 5 cases; and oncocytoma, 10 cases). A triple immunomarker (cytokeratin 7 (CK7)-carbonic anhydrase IX (CAIX)- alpha-methylacyl-CoA racemase (AMACR)) panel is useful in particular high-grade clear-cell tumors. If IHC remains ambiguous, the use of an adjunctive panel can be suggested, including CD10, epithelial membrane antigen, cathepsin K, c-kit, hepatocyte nuclear factor 1-β, and E-cadherin. For an efficient immunohistochemical strategy for subtyping of RCC, we conclude that the CK7-CAIX-AMACR panel is the best primary choice for screening subtyping.

[MiT family translocation renal cell carcinomas: Natural history, molecular features and multidisciplinary management]

MiT family translocation renal cell carcinomas (tRCC) represent a rare subtype of renal cell carcinomas. These tumors have been introduced for the first time in the World Health Classification (WHO) classification of kidney cancers in 2004. tRCC are characterized by reccurent translocations involving members of the MiT family transcription factors, mainly TFE3 and TFEB. The estimated incidence of these tumors is ∼1-5 % among all renal cell carcinomas, with female prodominance. tRCC were initially described in children, and the spectrum has been expanded over time to encompass adolescents and adults. TFE3- and TFEB-rearranged RCC harbor characteristic clinicopathological and immunohistochemical features and fluorescent hybridization in situ is considered the gold standard for their diagnosis, although it has some limitations especially when the partners are located in the vicinity of TFE3. Nephron-sparing surgery is an efficient treatment of localized cases when achievable. In metastatic setting, targeted agents and immunotherapy showed modest efficacy, with response rates and median overall survival inferior to those observed in clear-cell renal cell carcinomas. Management of tRCC necessite a multidisciplinary team and accrual in clinical trials have to be encouraged when possible. Novel biological insights are urgently awaited to better understand the mechanisms associated with kidney oncogenesis in this setting, and ultimately help to identify therapeutic targets.

Expression and clinical significance of p73 in Wilms tumor in children

Expression and clinical significance of p73 in children with Wilms tumor (WT) were investigated. A retrospective analysis was carried out on 50 children diagnosed with WT in the People's Hospital of Rizhao, from July 2013 to January 2015 (study group), and 20 healthy children with similar age and sex who received health examinations in the same hospital during the same period (control group). The relative expression of p73 mRNA in the peripheral blood of each group was detected by reverse transcription-quantitative PCR (RT-qPCR) in order to study the association between p73 and the clinicopathological parameters of WT, as well as the impact of p73 on the patient prognosis. The two groups were not statistically different in respect to the clinical data of patients (P>0.05); the expression level of p73 in the blood samples of the study group was significantly higher than that of the control group (t=11.44, P<0.01); the expression of p73 in the study group was associated with factors, including tumor size, pathological type and lymphatic metastasis. Considering the mean value of the expression of p73 (3.32) as the boundary, the patients with expression value of p73 <3.32 were studied as the low-expression group, and patients with expression value of p73 >3.32 comprised the high-expression group. At the end of the follow-up, the median survival time and the survival rate of the patients in the high-expression group were significantly lower than those of the low-expression group (P<0.05). The high expression of p73 in the peripheral blood of children with WT was positively correlated with the clinical stage of the tumor, and was closely related with the low survival rate of patients.

Microphthalmia family of transcription factors associated renal cell carcinoma

The microphthalmia (MiT) subfamily of transcription factors includes TFE3, TFEB, TFEC, and MITF. In the 2016 World Health Organization classification, MiT family translocation renal cell carcinoma (tRCC) including Xp11 tRCC and t(6;11) RCC, was newly defined as an RCC subtype. Xp11 and t(6;11) RCC are characterized by the rearrangement of the MiT transcription factors TFE3 and TFEB, respectively. Recent studies identified the fusion partner-dependent clinicopathological and immunohistochemical features in TFE3-rearranged RCC. Furthermore, RCC with TFEB amplification, melanotic MiT family translocation neoplasms, was identified may as a unique subtype of MiT family associated renal neoplasms, along with MITF associated RCC. In this review, we will collect available literature of these newly-described RCCs, analyze their clinicopathological and immunohistochemical features, and summarize their molecular and genetic evidences. We expect this review would be beneficial for the understanding of these rare subtypes of RCCs, and eventually promote clinical management strategies.

WHO/ISUP classification, grading and pathological staging of renal cell carcinoma: standards and controversies

PURPOSE

Pathological parameters assessed on biopsies and resection specimens have a pivotal role in the diagnosis, prognosis and management of patients with renal cell carcinoma (RCC).

METHODS

A non-systematic literature search was performed, updated to January 2018, to identify key standards and controversies in the pathological classification, grading and staging of RCC.

RESULTS

Although most RCCs exhibit characteristic morphology that enables easy categorisation, RCCs show considerable morphological heterogeneity and it is not uncommon for there to be difficulty in assigning a tumour type, especially with rarer tumour subtypes. The differentiation between benign and malignant oncocytic tumours remains a particular challenge. The development of additional immunohistochemical and molecular tests is needed to facilitate tumour typing, because of the prognostic and therapeutic implications, and to enable more reliable identification of poorly differentiated metastatic tumours as being of renal origin. Any new tests need to be applicable to small biopsy samples, to overcome the heterogeneity of renal tumours. There is also a need to facilitate identification of tumour types that have genetic implications, to allow referral and management at specialist centres. Digital pathology has a potential role in such referral practice.

CONCLUSION

Much has been done to standardise pathological assessment of renal cell carcinomas in recent years, but there still remain areas of difficulty in classification and grading of these heterogeneous tumours.