Epidemiology of Renal Cell Carcinoma

Adrenal Crisis and Adrenal Insufficiency Admissions in Patients 30-59 Years: Contribution of Psychosocial Factors

BACKGROUND AND OBJECTIVE

Adrenal crises (AC) occur in middle aged adults with adrenal insufficiency (AI). Psychosocial difficulties may impede effective self-management in some cases. This study aimed to investigate associations between psychosocial problems and hospital admissions for AI/AC in middle aged adults.

DESIGN AND PATIENTS

Data on all hospitalisations among patients aged 30-59 years with a diagnosis of AI were extracted from a regional database for the years 2005-2020.

MEASUREMENTS

Trends in hospitalisations and associations between admissions and comorbid psychosocial problems were assessed.

RESULTS

Of the 3948 admissions for AI between 2005 and 2020, 63.4% were in women. Admissions increased by 91.4%, from 61.89 to 118.44/million (p < 0.0001), while AC admission rates increased by 176.5% (from 7.71 to 21.33/million, p=NS). Secondary AI (SAI) admissions rose by 133.0%, from 27.98/million to 65.20/million (p < 0.001). Admissions increased in women in each decade but only in males aged 50-59 years. Comorbid infection was identified in 28.1% of admissions and at least one comorbid contributory psychological problem was found in 25.6%. Males, patients with SAI and those not living in a domestic partnership had a higher combined psychosocial problem burden. Females admitted with at least one sign of an AC had significantly higher psychosocial problem scores than those with less severe presentations.

CONCLUSIONS

These results suggest that psychosocial factors may play a role in some admissions for AI/AC in adults aged between 30 and 59 years, possibly contributing to the otherwise unexplained rise in hospitalisations for AI.

Urologic Imaging of the Kidneys: Cancers and Mimics

Renal cell carcinoma (RCC) is a growing problem in global oncology, with a steadily increasing incidence, especially in developed regions. Its different histologic subtypes present different challenges in diagnosis and management. Advanced imaging techniques have a crucial role in distinguishing between these subtypes by highlighting unique radiographic features such as exophytic growth patterns, cystic components, and enhancement patterns. Practical suggestions discussed in this review include using chemical shift MRI to differentiate fat-poor angiomyolipomas from RCC, recognizing specific imaging markers such as pseudo-capsule in papillary RCC, and understanding the implications of negative pixel count in computed tomography scans.

Renal cell carcinoma presents as portal vein thrombosis, a very rare combination

Key Clinical Message

Portal vein thrombosis (PVT) can indicate underlying conditions, such as malignancy. A case of PVT was later diagnosed as renal cell carcinoma (RCC), highlighting the need to consider cancer in PVT cases and ensure a comprehensive evaluation.

Abstract

Portal vein thrombosis (PVT) is a rare complication that can arise from various underlying conditions. We present a case report of a patient initially presenting with PVT, which was later diagnosed as renal cell carcinoma (RCC). This case highlights the importance of considering malignancy as a potential cause of PVT and the need for a comprehensive evaluation.

New players in the landscape of renal cell carcinoma bone metastasis and therapeutic opportunities

Approximately one-third of advanced renal cell carcinoma (RCC) patients develop osteolytic bone metastases, leading to skeletal complications. In this review, we first provide a comprehensive perspective of seminal studies on bone metastasis of RCC describing the main molecular modulators and growth factor signaling pathways most important for the RCC-stimulated osteoclast-mediated bone destruction. We next focus on newer developments revealing with in-depth details, the bidirectional interplay between renal cancer cells and the immune and stromal microenvironment that can through epigenetic reprogramming, profoundly affect the behaviors of transformed cells. Understanding their mechanistic interactions is of paramount importance for advancing both fundamental and translational research. These new investigations into the landscape of RCC-bone metastasis offer novel insights and identify potential avenues for future therapeutic interventions.

Unanchored simulated treatment comparison on survival outcomes using parametric and Royston-Parmar models with application to lenvatinib plus pembrolizumab in renal cell carcinoma

BACKGROUND

Population-adjusted indirect comparison using parametric Simulated Treatment Comparison (STC) has had limited application to survival outcomes in unanchored settings. Matching-Adjusted Indirect Comparison (MAIC) is commonly used but does not account for violation of proportional hazards or enable extrapolations of survival. We developed and applied a novel methodology for STC in unanchored settings. We compared overall survival (OS) and progression-free survival (PFS) of lenvatinib plus pembrolizumab (LEN + PEM) against nivolumab plus ipilimumab (NIVO + IPI), pembrolizumab plus axitinib (PEM + AXI), avelumab plus axitinib (AVE + AXI), and nivolumab plus cabozontanib (NIVO + CABO) in patients with advanced renal cell carcinoma (RCC). Unanchored comparison was necessitated as the control groups differed in their use of PD-1/PD-L1 rescue therapy.

METHODS

We fit covariate-adjusted survival models to individual patient data from phase 3 trial of LEN + PEM, including standard parametric distributions and Royston-Parmar spline models with up to 3 knots. We used these models to predict OS and PFS in the population of comparator treatments. The base case model was selected by minimum Akaike Information Criterion (AIC). Treatment effects were measured using difference in restricted mean survival time (RMST), over shortest follow-up of input trials, and hazard ratios at 6, 12, 18, and 24 months.

RESULTS

The survival model with the lowest AIC was 1-knot spline odds for OS and log-logistic for PFS. Difference in RMST OS was 6.90 months (95% CI: 1.95, 11.36), 5.31 (3.58, 7.28), 5.99 (1.82, 9.42), and 11.59 (8.41, 15.38) versus NIVO + IPI (over 64.8 months follow-up), AVE + AXI (46.7 months), PEM + AXI (64.8 months), NIVO + CABO (53.0 months), respectively. Difference in RMST PFS was 4.50 months (95% CI: 0.92, 8.26), 8.23 (5.60, 10.57), 5.38 (2.06, 9.09), and 4.58 (0.09, 9.44) versus NIVO + IPI (over 57.8 months), AVE + AXI (44.9 months), PEM + AXI (57.8 months), NIVO + CABO (23.8 months), respectively. Hazard ratios indicated strong evidence of greater OS and PFS on LEN + PEM at most timepoints.

CONCLUSIONS

We developed and applied a novel methodology for comparing survival outcomes in unanchored settings using STC. Pending investigation with a simulation study or further examples, this methodology could be used for clinical decision-making and, if long-term data are available, inform economic models designed to extrapolate outcomes for the evaluation of lifetime cost-effectiveness.

TRIAL REGISTRATION

NCT02811861 (registered: 23/06/2016).

Fully automated segmentation and classification of renal tumors on CT scans via machine learning

BACKGROUND

To develop and test the performance of a fully automated system for classifying renal tumor subtypes via deep machine learning for automated segmentation and classification.

MATERIALS AND METHODS

The model was developed using computed tomography (CT) images of pathologically proven renal tumors collected from a prospective cohort at a medical center between March 2016 and December 2020. A total of 561 renal tumors were included: 233 clear cell renal cell carcinomas (RCCs), 82 papillary RCCs, 74 chromophobe RCCs, and 172 angiomyolipomas. Renal tumor masks manually drawn on contrast-enhanced CT images were used to develop a 3D U-Net-based deep learning model for fully automated tumor segmentation. After segmentation, the entire classification pipeline, including feature extraction and subtype classification, was conducted without any manual intervention. Both conventional radiological features (Hounsfield units, HUs) and radiomic features extracted from areas predicted by the deep learning models were used to develop an algorithm for classifying renal tumor subtypes via a random forest classifier. The performance of the segmentation model was evaluated using the Dice similarity coefficient, while the classification model was assessed based on accuracy, sensitivity, and specificity.

RESULTS

For tumors larger than 4 cm, the Dice similarity coefficient (DSC) for automated segmentation was 0.83, while for tumors smaller than 4 cm, the DSC was 0.65. The classification accuracy (ACC) for distinguishing RCC subtypes was 0.77 for tumors larger than 4 cm and 0.68 for tumors smaller than 4 cm. Additionally, the accuracy for benign versus malignant classification was 0.85.

CONCLUSIONS

Our automatic segmentation and classifier model showed promising results for renal tumor segmentation and classification.

Chemoprotective Effect of Myrrhone against Diethylnitrosamine and Ferric Nitrile Induced Renal Cancer via Alteration of HO-1/Nrf2 and TRL4/NF-κB Signaling Pathway

. Renal cell carcinoma (RCC) is the most prevalent form of kidney cancer and is the primary malignancy affecting the genitourinary system. It represents the majority of kidney cancer cases and is distinguished by its aggressive nature and high mortality rate. The current study investigates the chemoprotective effect of myrrhone against Diethylnitrosamine (DEN) and ferric nitrile (Fe-NTA) induced RCC in rats and elucidates the underlying mechanism.

METHODS

. Following a single dose of intraperitoneal DEN (200 mg/kg) and a twice-weekly administration of Fe-NTA, rats were administered either an oral dose of myrrhone (5, 10, or 15 mg/kg). The body weights and food intake of the rats were monitored at regular intervals, and the levels of renal cancer markers, antioxidants, inflammatory markers, and other parameters were assessed. Additionally, histopathological studies were conducted on the renal tissues, and the mRNA expression of Bax, Bcl-2, HO-1, SOD2, mtDNA, ATP8, PGC-1α, TRL4, and NF-κB was analyzed.

RESULTS

. The dosage-dependent administration of myrrhone demonstrated a remarkable suppression of tumor incidence and an improvement in body weight and food intake. Myrrhone markedly decreased the level of ODC, Thymidine [3H] incorporation, and renal parameters such as creatinine, uric acid, BUN, Kim-1, Cysc-C, and LDH. Additionally, myrrhone significantly altered the levels of MDA, GSH, GPx, CAT, and SOD, as well as inflammatory cytokines such as TNF-α, INF-γ, IL-1β, IL-6, and IL-10, and inflammatory parameters such as COX-2, PGE2, TGF-β1, NF-κB, and iNOS. Furthermore, myrrhone significantly decreased the histopathological score and improved the condition of histopathology. Finally, myrrhone significantly altered the mRNA expression of Bax, Bcl-2, HO-1, SOD2, mtDNA, ATP8, PGC-1α, TRL4, and NF-κB.

CONCLUSION

: The result clearly showed the chemoprotective effect of myrrhone against diethylnitrosamine and ferric nitrile induced Renal Cancer via alteration of HO-1/Nrf2 and TRL4/NF-κB Signaling pathway.

Management of renal cell carcinoma with ablation in comparison to nephrectomy: A 5-year analysis of inpatient procedural data to evaluate utilization disparities in the United States

PURPOSE

To perform a nationwide analysis of ablation compared to partial and total nephrectomy for the management of renal cell carcinoma (RCC) to evaluate utilization trends and disparities in the USA.

MATERIALS AND METHODS

The 2016-2020 National Inpatient Sample was analyzed. Using ICD-10, we identified the diagnosis of RCC then analyzed the utilization trends of ablation and nephrectomies (both partial and complete). To determine if any disparities exist, a multivariate logistic regression was performed to assess the influence of age, sex, race, income, payer, illness severity, geographical location, and hospital factors.

RESULTS

From the 183,885 inpatient encounters with RCC, 3045 (1.65 %) underwent ablation, 70,080 (38.1 %) underwent partial nephrectomy, and 110,760 (60.2 %) underwent total nephrectomy. There was no significant difference in the sex between all groups. There was a statistically significant difference in the mean age of those undergoing ablation (67.30, SD = 12.05) versus those undergoing partial nephrectomy (59.27, SD = 13.26) and total nephrectomy (62.22, SD = 14.42) (OR: 1.04, 95%CI: 1.03-1.05, P < 0.001). Compared to White patients, Hispanic and African Americans were more likely to undergo ablation versus nephrectomy (OR: 1.52, 95%CI: 1.16-1.98, P = 0.002 and OR: 1.65, 95%CI: 1.28-2.13, P < 0.001, respectively). Compared to patients on private insurance, those on Medicaid and Medicare were more likely to have ablation than nephrectomy (OR: 1.85, 95%CI: 1.31-2.61, P < 0.001, and OR: 1.62, 95%CI: 1.26-2.08, P < 0.001, respectively). Furthermore, patients were less likely to undergo ablation than nephrectomies in 2020 compared to 2016 (OR: 0.69, 95%CI: 0.53-0.90, P = 0.006).

CONCLUSION

Since 2016, there has been a decreasing trend in the use of ablation for treating RCC in hospitalized patients. Those undergoing ablation tend to be older, African American, Hispanic, and insured by Medicare or Medicaid. Further research is needed to ensure equitable access for optimal treatment of RCC.

First-line pembrolizumab-axitinib versus sunitinib in metastatic RCC: subgroup analysis of patients enrolled in the phase 3 KEYNOTE-426 in Eastern Asia

BACKGROUND

The phase 3 open-label KEYNOTE-426 study demonstrated that first-line pembrolizumab plus axitinib improved overall survival (OS) and progression-free survival (PFS) versus sunitinib for metastatic renal cell carcinoma (mRCC) in a global population. This subgroup analysis investigated the efficacy and safety of pembrolizumab-axitinib versus sunitinib in patients enrolled in KEYNOTE-426 in East Asia (Japan, South Korea, and Taiwan).

METHODS

Adults with clear cell mRCC were randomly assigned 1:1 to receive intravenous pembrolizumab 200 mg every 3 weeks with oral axitinib 5 mg twice daily or oral sunitinib 50 mg once daily (4 weeks on/2 weeks off). Dual primary endpoints were OS and PFS, assessed by blinded independent central review. Secondary endpoints were objective response rate (ORR) and safety.

RESULTS

The East Asian subgroup comprised 130 patients (pembrolizumab-axitinib, n = 62; sunitinib, n = 68; 15.1% of the global intention-to-treat population). Compared with sunitinib, pembrolizumab-axitinib OS hazard ratio (HR) was 0.85 [95% confidence interval (CI) 0.50-1.44; 36-month rates, 62.9% and 58.8%, respectively] and PFS HR was 0.59 (95% CI 0.38-0.92) in favor of pembrolizumab-axitinib. ORR favored pembrolizumab-axitinib (64.5% vs 44.1% for sunitinib). The results were generally consistent with the intention-to-treat population. Grade ≥3 treatment-related adverse events (TRAEs) occurred in 69.4% of patients on pembrolizumab-axitinib and 74.6% on sunitinib; 16 (25.8%) patients on pembrolizumab-axitinib and 17 (25.4%) patients on sunitinib discontinued due to adverse events. No deaths from TRAEs occurred.

CONCLUSION

Pembrolizumab-axitinib improved efficacy for East Asian patients with untreated clear cell mRCC, consistent with results from the global population. Safety was manageable. ClinicalTrials.gov identifier: NCT02853331.

Validation of urine p-cresol glucuronide as renal cell carcinoma non-invasive biomarker

Renal cell carcinoma (RCC) stands among the most lethal urological malignancies. Most RCCs are incidentally diagnosed as initial symptoms are unspecific. Novel, minimally-invasive diagnostic and prognostic methods for RCC are needed, ideally in urine. Using UPLC-Q-ToF MS untargeted metabolomic analysis in urine, we previously revealed p-cresol glucuronide as potential RCC diagnostic marker. Additionally, urine samples one-year post-nephrectomy revealed isobutyryl-l-carnitine and L-proline betaine as potential RCC prognostic markers. Our present aim was to validate these differences in an independent cohort of RCC patients and healthy controls to strengthen their value as non-invasive biomarkers. In an independent cohort of 69 RCC patients and 52 controls we validated an increase in p-cresol glucuronide in urine from patients at diagnosis compared to controls (P = 0.0043). It remained increased one-year post-nephrectomy (P = 0.0288). The value of p-cresol glucuronide for RCC diagnosis was assessed with ROC curves analysis (AUC = 0.66, 95 % Confidence Interval 0.56-0.76). The role of isobutyryl-l-carnitine and L-proline betaine as prognostic markers could not be validated and will require a larger cohort. Our findings confirm the value of p-cresol glucuronide in urine as diagnostic marker for RCC in an independent cohort. This non-invasive method holds promise for enhancing patient care by reducing the need for potentially risky diagnostic procedures. Further metaproteomics-oriented approaches towards the tyrosine oxidation pathway and microbiota metagenomics studies may promote a holistic management of RCC. SIGNIFICANCE: Current imaging techniques available to diagnose and monitor renal cell carcinoma (RCC) are harmful for the patient given the high-radiation dose, and unspecific in low-grade tumors. Thus, novel non-invasive biomarkers with diagnostic and prognostic capabilities are of utmost importance. Herein, we have validated urine p-cresol glucuronide as diagnostic marker for RCC. This novel non-invasive biomarker could improve accurate assessments of tumor behavior, while enhancing patient outcomes by reducing discomfort and detrimental side effects.

Zinc nanoparticles from oral supplements accumulate in renal tumours and stimulate antitumour immune responses

A successful therapeutic outcome in the treatment of solid tumours requires efficient intratumoural drug accumulation and retention. Here we demonstrate that zinc gluconate in oral supplements assembles with plasma proteins to form ZnO nanoparticles that selectively accumulate into papillary Caki-2 renal tumours and promote the recruitment of dendritic cells and cytotoxic CD8+ T cells to tumour tissues. Renal tumour targeting is mediated by the preferential binding of zinc ions to metallothionein-1X proteins, which are constitutively overexpressed in Caki-2 renal tumour cells. This binding event further upregulates intracellular metallothionein-1X expression to induce additional nanoparticle binding and retention. In both tumour animal models and human renal tumour samples, we show that ZnO nanoparticles actively cross the vascular wall to achieve high intratumoural accumulation. We further explore this feature of ZnO nanoparticles for the delivery of chemotherapeutics to mouse and rabbit cancer models. Our findings demonstrate that ZnO nanoparticles derived from supplements can serve as a multifunctional drug delivery and cancer immunotherapy platform.

Leveraging explainable AI and large-scale datasets for comprehensive classification of renal histologic types

Recently, as the number of cancer patients has increased, much research is being conducted for efficient treatment, including the use of artificial intelligence in genitourinary pathology. Recent research has focused largely on the classification of renal cell carcinoma subtypes. Nonetheless, the broader categorization of renal tissue into non-neoplastic normal tissue, benign tumor and malignant tumor remains understudied. This gap in research can primarily be attributed to the limited availability of extensive datasets including benign tumor and normal tissue in addition to specific type of renal cell carcinoma, which hampers the ability to conduct comprehensive studies in these broader categories. This research introduces a model aimed at classifying renal tissue into three primary categories: normal (non-neoplastic), benign tumor, and malignant tumor. Utilizing digital pathology while slide images (WSIs) from nephrectomy specimens of 2,535 patients from multiple institutions, the model provides a foundational approach for distinguishing these key tissue types. The study utilized a dataset of 12,223 WSIs comprising 1,300 WSIs of normal tissue, 700 WSIs of benign tumors, and 10,223 WSIs of malignant tumors. Employing the ResNet-18 architecture and a Multiple Instance Learning approach, the model demonstrated high accuracy, with F1-scores of 0.934 (CI: 0.933-0.934) for normal tissue, 0.684 (CI: 0.682-0.687) for benign tumors, and 0.878 (CI: 0.877-0.879) for malignant tumors. The overall performance was also notable, achieving a weighted average F1-score of 0.879 (CI: 0.879-0.880) and a weighted average area under the receiver operating characteristic curve of 0.969 (CI: 0.969-0.969). This model significantly aids in the swift and accurate diagnosis of renal tissue, encompassing non-neoplastic normal tissue, benign tumor, and malignant tumor.

Identifying ADME-related gene signature for immune landscape and prognosis in KIRC by single-cell and spatial transcriptome analysis

Kidney renal clear cell carcinoma (KIRC) is the most prevalent subtype of kidney cancer. Although multiple therapeutic agents have been proven effective in KIRC, their clinical application has been hindered by a lack of reliable biomarkers. This study focused on the prognostic value and function of drug absorption, distribution, metabolism, and excretion- (ADME-) related genes (ARGs) in KIRC to enhance personalized therapy. The critical role of ARGs in KIRC microenvironment was confirmed by single cell RNA-seq analysis and spatial transcriptome sequencing analysis for the first time. Then, an ADME-related prognostic signature (ARPS) was developed by the bulk RNA-seq analysis. The ARPS, created through Cox regression, LASSO, and stepAIC analyses, identified eight ARGs that stratified patients into high-risk and low-risk groups. High-risk patients had significantly poorer overall survival. Multivariate analysis confirmed the independent predictive ability of ARPS, and an ARPS-based nomogram was constructed for clinical application. Gene ontology and KEGG pathway analyses revealed immune-related functions and pathways enriched in these groups, with low-risk patients showing better responses to immunotherapy. Finally, the expression of ARGs was validated by qRT-PCR and Western blotting experiments. These findings underscore the prognostic significance of ARPS in KIRC and its potential application in guiding personalized treatment strategies.

Safety of CT-guided percutaneous cryoablation in patients treated for clinical T1 renal cell carcinoma with the need for pre-procedural ureteral stenting: an international cohort study

AIM

To assess the safety of computed tomography-guided percutaneous cryoablation (PCA) in patients who had pre-procedural ureteral stenting, while they were treated for clinical T1 renal cell carcinoma (RCC) with complex location.

MATERIALS AND METHODS

This retrospective international multicenter cohort study included patients treated between January 2016 and February 2021 at two University Hospitals, X1 and X2. Patients aged more than 18 years with suspected RCC were included. All patients underwent pre-procedural ureteral stenting. The complications were recorded within 30 days and graded according to the Clavien-Dindo classification and the Society of Interventional Radiology classification of adverse events. Major complications were defined as complications ≥ grade 3 on the Clavien-Dindo classification.

RESULTS

The cohort included 61 patients with a median age of 66 years (IQR 55-75 years). The median tumour size was 33 mm (IQR 24-38 mm), with a median R.E.N.A.L score of 8 (IQR 7-10). A complication rate of 36% (n=22) was recorded, and major complications occurred following 10% (n=6) of the procedures. A statistically significant association was found between using more than three cryoprobes and postoperative complications (OR, 4.19; 95% CI: 1.38-12.75; p=0.010). In addition, no associations were found between postoperative complications and prophylactic antibiotics, patient age, tumour complexity, tumour size, histological type, or whether the ice ball was touching the ureter.

CONCLUSION

This multicenter cohort study found a relatively high rate of postoperative complications in patients having a ureteral stent before PCA. However, no complications resulted in a chronic outflow obstruction. The number of high-complexity tumours could explain the high rate of complications.

Prognostic significance of body mass index in patients with metastatic renal cell carcinoma receiving first-line therapies

OBJECTIVES

Higher body mass index (BMI) is reportedly associated with improved prognosis of patients with various cancers. However, it is unclear whether this phenomenon, also known as the obesity paradox, applies to metastatic renal cell carcinoma (mRCC). We aimed to determine the prognostic significance of BMI in patients with mRCC receiving first-line therapies.

MATERIALS AND METHODS

We retrospectively reviewed patients with mRCC receiving first-line immune checkpoint inhibitor (ICI)-based combination therapy or tyrosine kinase inhibitor monotherapy. Overall survival (OS) was defined as the time from systemic therapy initiation to death from any cause or last follow-up. Baseline patient characteristics were compared by Mann-Whitney U test or Fisher's exact test. OS curves were constructed by Kaplan-Meier estimates and were compared by log-rank test. Multivariable analysis was performed via Cox proportional-hazards regression.

RESULTS

Of the 183 patients included, 130 (71 %) were overweight (≥22 and 18 kg/m2 in men and women, respectively), and 63 (34 %) received ICI-based combination therapy. There was a significantly higher proportion of men in the overweight subgroup (87 % versus 64 %; P = 0.002). During the study period, 97 patients died, and median (95 % confidence interval) OS was 39.0 months (31.5-66.3 months) and 28.1 months (17.6-39.7 months) in overweight and normoweight patients, respectively (P = 0.015). On multivariable analysis, overweight was independently associated with longer OS (HR 0.57; P = 0.014). Subgroup analyses of patients receiving ICI-based combination therapy yielded similar results.

CONCLUSION

Overweight is associated with favorable outcomes in patients with mRCC receiving first-line therapies.

Non-coding RNAs secreted by renal cancer include piR_004153 that promotes migration of mesenchymal stromal cells

BACKGROUND

Renal cell cancer (RCC) is the most common and highly malignant subtype of kidney cancer. Mesenchymal stromal cells (MSCs) are components of tumor microenvironment (TME) that influence RCC progression. The impact of RCC-secreted small non-coding RNAs (sncRNAs) on TME is largely underexplored. Here, we comprehensively analysed the composition of exosomal sncRNAs secreted by RCC cells to identify those that influence MSCs.

METHODS

Exosomal sncRNAs secreted by RCC cells and normal kidney cells were analyzed using RNAseq, followed by qPCR validation. MSCs were treated by conditioned media (CM) derived from RCC cells and transfected with piRNA, followed by the analysis of proliferation, viability, migration and immunocytochemical detection of piRNA. Expression of MSCs genes was evaluated using microarray and qPCR. TCGA data were analyzed to explore the expression of sncRNAs in RCC tumors.

RESULTS

RNAseq revealed 40 miRNAs, 71 tRNAs and four piRNAs that were consistently secreted by RCC cells. qPCR validation using five independent RCC cell lines confirmed that expressions of miR-10b-3p and miR-125a-5p were suppressed, while miR-365b-3p was upregulated in exosomes from RCC cells when compared with normal kidney proximal tubules. The expression of miR-10b-3p and miR-125a-5p was decreased, whereas the expression of miR-365b-3p was increased in RCC tumors and correlated with poor survival of patients. Expressions of tRNA-Glu, tRNA-Gly, and tRNA-Val were the most increased, while tRNA-Gln, tRNA-Leu, and tRNA-Lys were top decreased in RCC exosomes when compared with normal kidney cells. Moreover, hsa_piR_004153, hsa_piR_016735, hsa_piR_019521, and hsa_piR_020365 were consistently upregulated in RCC exosomes. piR_004153 (DQ575660.1; aliases: hsa_piRNA_18299, piR-43772, piR-hsa-5938) was the most highly expressed in exosomes from RCC cells when compared with normal kidney cells. Treatment of MSCs with RCC CM resulted in upregulation of piR_004153 expression. Transfection of MSCs with piR_004153 stimulated their migration and viability, and altered expression of 35 genes, including downregulation of FGF2, SLC7A5, and WISP1. Immunocytochemistry confirmed the nuclear localization of piR_004153 transfected in MSCs.

CONCLUSION

RCC cells secrete multiple sncRNAs, including piR_004153 which targets MSCs, alters expression of FGF2, SLC7A5, and WISP1, and stimulates their motility and viability. To our knowledge, this is the first study showing that cancer-derived piRNA can enhance MSC migration.

Long non-coding RNA OSTM1-AS1 promotes renal cell carcinoma progression by sponging miR-491-5p and upregulating MMP-9

Long noncoding RNAs (lncRNAs) have been recognized as essential regulators in various human malignancies. Hundreds of lncRNAs were known to be abnormally expressed in renal cell carcinoma (RCC) through a lncRNA expression microarray, among which lncRNA OSTM1 antisense RNA 1(OSTM1-AS1) was revealed as one of the most abundant lncRNAs. However, the function of OSTM1-AS1 in RCC remains unknown. Here, we examined OSTM1-AS1 functional roles and mechanism in RCC development. OSTM1-AS1 expression was significantly highly expressed among RCC tissue specimens and cell lines. Functionally, OSTM1-AS1 knockdown significantly suppressed cell proliferation, migration along with metastasis of RCC cells. Mechanistically, miR-491-5p was targeted via OSTM1-AS1, and down-regulation of miR-491-5p reversed OSTM1-AS1 knockdown impact on RCC migration and invasion. MMP-9 was targeted via miR-491-5p, and MMP-9 overexpression reversed miR-491-5p or OSTM1-AS1 knockdown impact on cell migration and invasion. MMP-9 abundance was decreased by OSTM1-AS1 silence, that was reduced by miR-491-5p deficiency. Importantly, our investigation revealed that OSTM1-AS1 has the ability to interact with miR-491-5p, thereby increasing the MMP-9 expression. The in vivo trial demonstrated that OSTM1-AS1 suppression resulted in tumor growth inhibition among nude mice. In summary, our findings indicate, for the first time, at least to the best of our knowledge, that OSTM1-AS1 serves as an oncogene among RCC by promoting proliferation, invasion, and metastasis through its targeting of the miR-491-5p/MMP9 axis. Therefore, this axis could represent a promising alternative therapeutic target for RCC treatment.

Pembrolizumab and axitinib induced pathological complete response in metastatic clear cell renal cell carcinoma with inferior vena cava thrombus: A case report

Clear cell renal cell carcinoma is the predominant subtype of kidney cancer. With distant metastasis, the overall survival rate for patients with renal cell carcinoma decreases significantly compared to localized disease. However, pembrolizumab plus axitinib combination is safe and improves long-term survival. Herein, we report a case of a pathological complete response from systemic pembrolizumab plus axitinib therapy in a 57-year-old male with locally advanced renal cell carcinoma with extensive kidney, inferior vena cava, and hepatic invasion, as well as metastatic disease to the retroperitoneal lymph nodes and lung. After 2-years of systemic treatment, there was absent radiographic evidence of renal cell carcinoma in the lung. The patient underwent right radical nephrectomy, adrenalectomy, partial hepatectomy, and inferior vena cava ligation. Pathology indicated no evidence of tumor consistent with a pathological complete response. This case highlights the possibility of a pathological complete response with pembrolizumab plus axitinib in metastatic renal cell carcinoma and potential disparate findings between radiological response and pathological response.

Aggressiveness classification of clear cell renal cell carcinoma using registration-independent radiology-pathology correlation learning

BACKGROUND

Renal cell carcinoma (RCC) is a common cancer that varies in clinical behavior. Clear cell RCC (ccRCC) is the most common RCC subtype, with both aggressive and indolent manifestations. Indolent ccRCC is often low-grade without necrosis and can be monitored without treatment. Aggressive ccRCC is often high-grade and can cause metastasis and death if not promptly detected and treated. While most RCCs are detected on computed tomography (CT) scans, aggressiveness classification is based on pathology images acquired from invasive biopsy or surgery.

PURPOSE

CT imaging-based aggressiveness classification would be an important clinical advance, as it would facilitate non-invasive risk stratification and treatment planning. Here, we present a novel machine learning method, Correlated Feature Aggregation By Region (CorrFABR), for CT-based aggressiveness classification of ccRCC.

METHODS

CorrFABR is a multimodal fusion algorithm that learns from radiology and pathology images, and clinical variables in a clinically-relevant manner. CorrFABR leverages registration-independent radiology (CT) and pathology image correlations using features from vision transformer-based foundation models to facilitate aggressiveness assessment on CT images. CorrFABR consists of three main steps: (a) Feature aggregation where region-level features are extracted from radiology and pathology images at widely varying image resolutions, (b) Fusion where radiology features correlated with pathology features (pathology-informed CT biomarkers) are learned, and (c) Classification where the learned pathology-informed CT biomarkers, together with clinical variables of tumor diameter, gender, and age, are used to distinguish aggressive from indolent ccRCC using multi-layer perceptron-based classifiers. Pathology images are only required in the first two steps of CorrFABR, and are not required in the prediction module. Therefore, CorrFABR integrates information from CT images, pathology images, and clinical variables during training, but for inference, it relies solely on CT images and clinical variables, ensuring its clinical applicability. CorrFABR was trained with heterogenous, publicly-available data from 298 ccRCC tumors (136 indolent tumors, 162 aggressive tumors) in a five-fold cross-validation setup and evaluated on an independent test set of 74 tumors with a balanced distribution of aggressive and indolent tumors. Ablation studies were performed to test the utility of each component of CorrFABR.

RESULTS

CorrFABR outperformed the other classification methods, achieving an ROC-AUC (area under the curve) of 0.855 ± 0.0005 (95% confidence interval: 0.775, 0.947), F1-score of 0.793 ± 0.029, sensitivity of 0.741 ± 0.058, and specificity of 0.876 ± 0.032 in classifying ccRCC as aggressive or indolent subtypes. It was found that pathology-informed CT biomarkers learned through registration-independent correlation learning improves classification performance over using CT features alone, irrespective of the kind of features or the classification model used. Tumor diameter, gender, and age provide complementary clinical information, and integrating pathology-informed CT biomarkers with these clinical variables further improves performance.

CONCLUSION

CorrFABR provides a novel method for CT-based aggressiveness classification of ccRCC by enabling the identification of pathology-informed CT biomarkers, and integrating them with clinical variables. CorrFABR enables learning of these pathology-informed CT biomarkers through a novel registration-independent correlation learning module that considers unaligned radiology and pathology images at widely varying image resolutions.

Impact of platelet-lymphocyte ratio after robot-assisted partial nephrectomy with renorrhaphy

Renorrhaphy is often performed after tumor resection during robotic-assisted laparoscopic partial nephrectomy (RAPN). This study aimed to investigate the association between renorrhaphy performance and inflammatory markers. A retrospective cohort study was conducted including patients with renal cell carcinoma who underwent RAPN at eight institutions in Japan between April 2016 and November 2023. The primary endpoint was the association between the renorrhaphy performance in RAPN and the postoperative inflammatory markers. The secondary endpoints were perioperative outcomes in patients with and without renorrhaphy. The patients were divided into two groups at the time of RAPN: those who underwent renorrhaphy (renorrhaphy group) and those who did not (omitted group). In total, 934 patients were enrolled in this study. After propensity score matching, the rate of change in C-reactive protein and neutrophil-lymphocyte ratio on postoperative day 28 were not significant difference between the two groups. In contrast, the rate of change in platelet-lymphocyte ratio (PLR) on postoperative day 28 was significantly higher in renorrhaphy group than omitted group. Regarding surgical outcomes, the renorrhaphy group had a significantly longer hospital stay, operative time, and warm ischemia time (P = 0.038, P = 0.022, and P = 0.009, respectively) than the omitted group did. Furthermore, the omitted group had a significantly higher rate of Trifecta achievement than the renorrhaphy group did. This study demonstrated that renorrhaphy performance in RAPN was significantly associated with the higher value of postoperative PLR.

Racial differences in real-world outcomes of first-line therapies for advanced renal cell carcinoma

BACKGROUND

Given the historical underrepresentation of racial minorities in clinical trials, little is known about racial differences in outcomes of first-line therapies for advanced renal cell carcinoma (aRCC). This study described patient characteristics and clinical outcomes of first-line therapies for aRCC, including nivolumab + ipilimumab, pembrolizumab + axitinib, and tyrosine kinase inhibitors, by race in the real-world setting.

METHODS

We conducted a retrospective medical chart review of patients with intermediate/poor-risk clear-cell aRCC. Treating physicians abstracted patient data from electronic medical charts.

RESULTS

Among 346 patients with intermediate/poor-risk aRCC, a higher proportion of African-American/Black (n = 78) versus White (n = 268) patients had poorer baseline functional performance (ECOG-PS ≥ 2: 37.2% versus 21.3%). African-American/Black patients trended toward numerically lower overall response rates and shorter overall survival for nivolumab + ipilimumab or pembrolizumab + axitinib than White patients.

CONCLUSIONS

These findings provide important insights into racial differences in first-line aRCC treatment outcomes within real-world settings. Additional research with larger sample sizes is warranted.

Dysregulation of ubiquitination modification in renal cell carcinoma

Renal cell carcinoma (RCC) is a malignant tumor of the renal tubular epithelial cells with a relatively high incidence rate worldwide. A large number of studies have indicated that dysregulation of the ubiquitination, including ubiquitination and dysregulation, is associated with the occurrence and development of RCC. This review focuses on several abnormal signaling pathways caused by E3 ligases and deubiquitinases. Additionally, we discuss research progress in RCC treatment by targeting key enzymes related to ubiquitination modifications.

Correlation Between BMI and Kidney Tumor Lateralization: Insights into Survival and Risk Factors

Background: Kidney cancer accounts for approximately 2% of all diagnosed cancers and fatalities worldwide, and a notable increase in its incidence has been observed in recent years. Previous studies have identified various risk factors for renal cell carcinoma (RCC), including age, gender, smoking, hypertension, overweight, and obesity. However, limited information is available regarding the correlation between RCC risk factors and tumor lateralization. Objectives: To investigate the relationship between body mass index (BMI) and the lateralization of kidney tumors in patients undergoing surgery for renal cell carcinoma. Moreover, we aim to evaluate the impact of lateralization of malignant kidney tumors on overall survival (OS) and cancer-specific survival (CSS). Materials and Methods: This single-center study included 287 patients who underwent surgical treatment for kidney tumors between January 2016 and December 2019. The patients were allocated into the following groups based on their BMI: normal (18.5-24.99 kg/m2), overweight (25-29.99 kg/m2), or obese (≥30 kg/m2). The study collected demographic and histopathological data, as well as patient history, including risk factors such as smoking and hypertension. Results: Right-sided kidney tumors occurred more frequently (55.05%, n = 158) than left-sided ones (44.95%, n = 129). A statistically significant relationship (p = 0.04731) was observed between BMI and the frequency of right-sided kidney tumors in the overweight group (70 vs. 43 cases). There was no correlation between BMI and the occurrence of kidney tumors in the normal BMI and obesity groups. Furthermore, the analysis revealed no association between the lateralization of kidney tumors, smoking, and hypertension. The 5-year survival rate was 62%, with a mean follow-up duration of 104 months (approximately 8.5 years). No statistically significant difference was observed between the right- and left-sided cancer groups, with survival rates of 58% and 66%, respectively (p = 0.652). Conclusions: This study highlighted that right-sided kidney tumors occurred significantly more frequently in overweight individuals in our cohort of patients. No association was observed between lateralization of kidney cancer and overall survival (OS) or cancer-specific survival (CSS).

Is Frequent Imaging Necessary? Impact of Computed Tomography During Follow-up After Surgical Treatment for Nonmetastatic Renal Cell Carcinoma: A Systematic Review

BACKGROUND AND OBJECTIVE

Current guidelines on radiological follow-up (FU) for patients after treatment for nonmetastatic renal cell carcinoma (RCC) are not based on robust evidence. This review aims to evaluate whether the 2022 European Association of Urology (EAU) guidelines are noninferior, in terms of recurrence and (overall) survival, to a higher imaging frequency of computed tomography (CT) of the chest and abdomen.

METHODS

A literature search of relevant search machines (PubMed/Medline and EMBASE) was performed up to May 29, 2024. Studies describing patients with nonmetastatic RCC who underwent curative treatment by means of partial or radical nephrectomy were included. Studies with a higher number of CT scans than recommended by the EAU were compared with those that followed guidelines by examining recurrences and survival data. Outcomes were classified into risk groups according to the 2022 EAU guidelines.

KEY FINDINGS AND LIMITATIONS

Twenty studies met our inclusion criteria. Sixteen (80%) studies employed a higher imaging frequency during FU compared with 2022 EAU guideline recommendations, two studies (10%) followed the guidelines, and two studies (10%) performed less imaging. Recurrences were rare in low-risk studies (0-7.6%) and varied among high-risk studies, ranging between 33% and 40% in randomized controlled trials and 11% and 28% in retrospective studies. A meta-analysis was not suited due to clinical diversity, and the risk of bias was high among cohort studies.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Most studies employ a higher imaging frequency during FU after treatment for nonmetastatic RCC than recommended by the 2022 EAU guidelines. Survival and recurrence rates suggest that more frequent imaging than recommended by the EAU may not be advantageous, although high-quality evidence is needed to further improve guidelines.

PATIENT SUMMARY

In this review, we assessed radiological follow-up schedules for patients after surgery for kidney cancer and compared these with the follow-up schedules recommended by the European Association of Urology guidelines. We found that most studies apply more frequent imaging during follow-up than recommended by guidelines, although survival and recurrence rates are similar among studies with different imaging frequencies. We conclude that more frequent imaging than recommended by guidelines may not be necessary and that prospective studies are needed to determine whether imaging can be reduced further during follow-up.

Clinical outcomes and prognostic factors in metastatic nonclear cell renal cell carcinoma treated with immuno-oncology combination therapy

BACKGROUND

Metastatic nonclear cell renal cell carcinoma (nccRCC) is a heterogeneous disease with poor prognosis. The clinical characteristics and prognostic factors of immuno-oncology (IO) combination therapy for nccRCC are not well known. This study analyzed patients with metastatic nccRCC treated with IO combination therapy.

METHODS

We retrospectively collected data from 447 patients with metastatic RCC treated with IO-based combination therapy as first-line treatment between September 2018 and July 2023 in a Japanese multicenter study. The primary endpoints were objective response rate, progression-free survival (PFS), and overall survival (OS), comparing groups treated with IO-IO and IO-tyrosine kinase inhibitor (TKI) therapies.

RESULTS

Seventy-five patients with metastatic nccRCC were eligible for analysis: 39 were classified into the IO-IO group and 36 into the IO-TKI group. Median PFS was 5.4 months (95% CI: 1.6-9.1) for the IO-IO group and 5.6 (95% CI: 3.4-12.0) for the IO + TKI group. Median OS was 24.2 months (95% CI: 7.5-NA) for the IO-IO group and 23.4 (95% CI: 18.8-NA) for the IO + TKI group, with no significant difference. In univariate analysis, International Metastatic Renal Cell Carcinoma Database Consortium scores, Karnofsky performance status, neutrophil-to-lymphocyte ratio, and the presence of liver metastases were significantly associated with OS, whereas in multivariate analysis, only the presence of liver metastases was significantly associated with OS (P = .035).

CONCLUSIONS

There was no significant difference in OS or PFS between IO-IO and IO-TKI combination therapy as first-line treatment for patients with nccRCC. Liver metastasis is a poor prognostic factor for such patients.

The Novel HDAC Inhibitor OBP-801 Promotes MHC Class I Presentation Through LMP2 Upregulation, Enhancing the PD-1-Targeting Therapy in Clear Cell Renal Cell Carcinoma

BACKGROUND

Histone deacetylase (HDAC) inhibitors have been reported to exhibit immunomodulatory activities, including the upregulation of major histocompatibility complex class I (MHC class I). Although the immunoproteasome plays a pivotal role in MHC class I antigen presentation, its effect on immunotherapy for clear cell renal cell carcinoma (ccRCC) remains unclear.

METHODS

This study assessed whether OBP-801, a novel HDAC inhibitor, affects the expression of immunoproteasome subunits and subsequently the MHC class-I-mediated anti-cancer immunity in ccRCC. We analyzed the data of 531 patients with ccRCC from the Cancer Genome Atlas Kidney Clear Cell Carcinoma database. We further evaluated the treatment efficacy of the combination of OBP-801 and anti-PD-1 in a ccRCC mouse model.

RESULTS

Low molecular mass polypeptide (LMP) 2 was correlated most positively with CD3E, CD8A, and CD8B expression and estimated CD8+ T cell number. In vitro studies showed that OBP-801 upregulated MHC class I presentation by inducing LMP2 expression in the ccRCC cell lines RENCA, 786-O, and Caki-1. In vivo studies in a syngeneic mouse model with subcutaneous implantation of RENCA cells showed that OBP-801 treatment increased the percentage of CD45+CD3e+ T cells in tumor-infiltrating lymphocytes. The combination of anti-PD-1 antibody and OBP-801 enhanced the anti-tumor effect, LMP2 protein expression, and MHC class I presentation in tumor cells. MHC class I presentation in the tumors of each mouse was positively correlated with the percentage of CD45+CD3e+ T cells.

CONCLUSIONS

Our results demonstrate that OBP-801 promotes MHC class I presentation through LMP2 upregulation in tumor cells and thereby potentiates PD-1-targeting therapy. These data suggest that the combination of OBP-801 and anti-PD-1 treatment is a promising therapeutic strategy for ccRCC.

Aristolochic acid-related renal cell carcinoma exhibits a distinct tumor-immune microenvironment favoring response to immune checkpoint blockade

Immune checkpoint blockade (ICB) is currently the standard of care for metastatic renal cell carcinoma (RCC), but treatment responses remain unpredictable. Aristolochic acid (AA), a prevalent supplement additive in Taiwan, has been associated with RCC and induces signature mutations, although its effect on the tumor-immune microenvironment (TIME) is unclear. We aimed to investigate the immune profile of AA-positive RCCs and explore its potential role as a susceptible candidate for ICB. Tissue samples from 22 patients with clear cell RCC (ccRCC) were collected for whole-exome sequencing to determine the genetic features and AA mutational signature (the discovery cohort). The corresponding RNA was sent for NanoString PanCancer IO 360 gene expression analysis to explore the immunological features. The formalin-fixed, parafilm-embedded slides of ccRCCs were sent for multiplex immunohistochemistry/immunofluorescence stain using Vectra system to evaluate the TIME. Tissues from two patients with metastatic RCC demonstrating complete response to ICB were sent for studies to validate the findings (the index patients). The results showed that AA mutational signatures with high tumor mutational burden (TMB) were present in 31.81% of the tumors in the discovery cohort. Three distinct clusters were observed through NanoString analysis. Clusters 1 and 3 were composed mainly of AA-positive RCCs. Cluster 3 RCCs exhibited higher tumor inflammation signature scores and higher immune cell type scores. Vectra analysis revealed a higher percentage of CD15+ and BATF3+ cells in cluster 1, whereas the percentage of CD8+ cells was potentially higher in cluster 3. Strong AA mutational signatures were found in the tumors of two index patients, and both were grouped to cluster 3. In conclusion, AA may induce higher TMB and alter the immune microenvironment in RCCs, which makes the tumors more susceptible to ICB. © 2024 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Chromene-based compounds as drug candidates for renal and bladder cancer therapy - A systematic review

Renal (RC) and bladder cancers (BC) are common urological malignancies prevalent in the male population. Incidence and mortality rates are expected to increase in the near future. Drug toxicity and development of drug resistance in both diseases are major obstacles to achieve successful treatments. Chromenes are heterocyclic compounds constituted by a benzene ring fused to a pyran nucleus. Natural and synthetic chromene-based compounds have proven to be promising anticancer agents. Additionally, re-sensitization of cancer cells to classical treatments has also been demonstrated. Thus, the aim of this systematic review is to assess the potential of chromene-based compounds in the treatment of RC and BC. Study collection was performed in six different databases, to compile existing information on preclinical (in vitro and in vivo) and clinical studies developed to date. Overall, multiple chromene-based compounds showed potent anticancer effects, affecting several biological features such as reduction in cell viability, proliferation, migration and invasion in vitro, and induction of cell cycle arrest and cell death. Tumor volume and weight were generally decreased in vivo upon chromene-based treatment. Modest results have been obtained in two clinical trials, with reports of a partial response and two objective responses in RC patients. Thus, the chromene family can be considered an attractive chemical scaffold, harboring promising drug candidates for RC and BC therapeutics.

Prognostic significance of CD3+ and CD8+ T-cells immunoscore in renal cell carcinoma: A comparison between two simple models for assessment

The immunoscore (ISc) has been extensively investigated as a prognostic indicator for numerous solid tumors. In renal cell carcinoma (RCC), its prognostic significance has been evaluated in a small number of studies. This study was designed to ascertain the prognostic value of ISc based on CD3+ and CD8+ T cells in patients with RCC. This study included 115 non-metastatic RCC patients who underwent nephrectomy. The ISc was obtained by estimating the densities of CD3+ and CD8+ cells at the invasive margin and center of the tumor using two methods: cell count per square millimeter (cell count/mm2) and percentage of cells per square millimeter (% of cells/mm2). The patients were categorized into low and high groups according to the ISc. The associations between the ISc and clinicopathological characters, including survival, were analyzed statistically. Adverse clinicopathologic factors were significantly associated with high ISc. Patients with high ISc had significantly worse overall survival (OS) and disease-free survival (DFS) rates over three years (p < 0.001). High ISc was considered a predictor of shortened DFS in univariate analysis (p < 0.001). However, in multivariate analysis, it was a dependent predictor. High ISc could help identify individuals more likely to develop recurrence and may impact treatment strategy for more effective personalized care. Moreover, establishing a modified objective, automated, digital quantification method of immune cells (% of cells/mm2 instead of cell count/mm2) is expected to be simple to implement in routine, highly affordable, time efficient, clinically meaningful, and will improve assay performance.

Late-Onset Metastasis of Renal Cell Carcinoma: A Rare Case of Sinonasal Malignancy Post-Nephrectomy

This case report highlights a rare case of renal cell carcinoma metastasis to nose and paranasal sinuses in a 55-year-old male 8 years post-nephrectomy. Contrast imaging revealed a vascular mass and histopathology confirmed metastatic RCC. Partial maxillectomy was done and patient remained disease free at 6 month follow up.

Multi-instance learning for identifying high-risk subregions associated with synchronous distant metastasis in clear cell renal cell carcinoma

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) is one of the most common histological subtypes of renal tumors.

PURPOSE

To identify high-risk subregions associated with synchronous distant metastasis.

METHODS

This study enrolled a total of 277 patients with ccRCC. Voxel intensity and local entropy values were compiled within the region of interest for all patients. Unsupervised k-means clustering yielded three subregions per tumor. Radiomic features were extracted, and random forest-based feature selection was conducted. The selected features were used in a multi-instance support vector machine (mi-SVM) model for training, and predictions were made on the validation cohort. Model performance was evaluated using five-fold cross-validation. The subregion with the highest score for patients with synchronous distant metastasis was identified across all cohorts.

RESULTS

The mi-SVM model yielded an average area under the curve (AUC) of 0.812 in the training cohort and 0.805 in the validation cohort. In the entire cohort of patients with synchronous distant metastasis, subregion 2, characterized by tumor periphery and intratumoral transitional components, accounted for the highest proportion (48.57%, 30.6/63) among all subregions. It represents a high-risk subregion for synchronous distant metastasis of clear cell renal cell carcinoma.

CONCLUSION

The peripheral and intratumoral transition zones of clear cell renal cell carcinoma are high-risk subregions associated with synchronous distant metastasis.

Comparing Frailty Indices for Risk Stratification in Urologic Oncology: Which Index to Choose?

OBJECTIVE

To compare the predictive ability of the modified Frailty Index (mFI) and the revised Risk Analysis Index (RAI-Rev) for perioperative outcomes in patients undergoing major urologic oncologic surgery, aiming to identify the optimal frailty screening tool for surgical risk stratification.

METHODS

NSQIP was queried to identify patients undergoing radical prostatectomy, partial or radical nephrectomy, or radical cystectomy between 2013 and 2017. We investigated the association of mFI and RAI-Rev with the following 30-day perioperative outcomes using multivariable logistic regression: major complications, Clavien grade ≥4 complications, non-home discharge, 30-day readmission, and all-cause mortality. Receiver-operating characteristic curve analysis compared the predictive performances of the 2 frailty instruments, with differences between the C-statistics assessed using DeLong's test.

RESULTS

Among 101,739 patients, 30-day major complication rates varied from 2.40% in prostatectomy to 26.86% in cystectomy, non-home discharge rates ranged from 1.92% to 13.54%, and mortality rates were between 0.16% and 1.43%. RAI-Rev showed higher discriminatory ability for mortality (C-statistic: 0.688-0.798) and non-home discharge (C-statistic: 0.638-0.734) compared to mFI (C-statistic: 0.594-0.677 and 0.593-0.639, respectively). Both frailty indices had similar discriminatory ability for major perioperative complications (C-statistic: 0.531-0.607). DeLong's test confirmed statistically significant differences in C-statistics between RAI-Rev and mFI for mortality (P <.001) and non-home discharge (P <.001) across all surgical cohorts.

CONCLUSION

RAI-Rev may have greater utility as a frailty prognostic tool than mFI among patients undergoing major urologic surgery. Prospective studies and clinical trials exploring frailty should consider these results during trial design.

The Current State of the Diagnoses and Treatments for Clear Cell Renal Cell Carcinoma

Clear cell renal cell carcinoma is the most common form of kidney cancer, accounting for 75% of malignant kidney tumors, and is generally associated with poor patient outcomes. With risk factors including smoking, obesity, and hypertension, all of which have a high prevalence in the United States and Europe, as well as genetic factors including tuberous sclerosis complex and Von Hippel-Lindau syndrome, there is an increasing need to expand our present understanding. The current clear cell renal cell carcinoma knowledge is outdated, with obsolete diagnostic criteria and moderately invasive surgical treatments still prevailing, partially ascribed to its resistance to chemotherapy and radiation therapy. The standard of treatment relies on surgical intervention, including radical nephrectomy and partial nephrectomy, while more recent treatments target neoplastic growth pathways and immune regulation checkpoints.

First-line Systemic Therapy Following Adjuvant Immunotherapy in Renal Cell Carcinoma: An International Multicenter Study

BACKGROUND AND OBJECTIVE

Adjuvant pembrolizumab significantly improved overall survival (OS) in renal cell carcinoma (RCC), but real-world data on sequential treatment are scarce. We sought to evaluate the clinical outcomes of first-line (1L) systemic therapy following adjuvant immune oncology (IO)-based regimens.

METHODS

A retrospective study including patients with recurrent RCC following adjuvant IO across 29 international institutions was conducted. The primary endpoint was progression-free survival (PFS) on 1L systemic therapy estimated using the Kaplan-Meier method. Preplanned subanalyses of clinical outcomes by type of 1L systemic therapy, recurrence timing, and International Metastatic RCC Database Consortium (IMDC) risk groups were performed. Treatment-related adverse events leading to treatment discontinuation, dose reduction, or corticosteroid use were assessed.

KEY FINDINGS AND LIMITATIONS

A total of 94 patients were included. Most received adjuvant pembrolizumab (n = 37, 39%), atezolizumab (n = 28, 30%), or nivolumab + ipilimumab (n = 15, 16%). The cohort included 49 (52%) patients who had recurrence within 3 mo of the last adjuvant IO dose, whereas 45 (48%) recurred beyond 3 mo. Bone metastases were significantly higher in tumors recurring at <3 mo (10/49, 20%) than those recurring at >3 mo (1/45, 2.2%; p = 0.008). Most patients received 1L vascular endothelial growth factor-targeted therapy (VEGF-TT; n = 37, 39%), IO + VEGF-TT (n = 26, 28%), or IO + IO (n = 12, 13%). The remaining underwent local therapy. The median follow-up for the 1L systemic therapy cohort was 15 mo. The 18-mo PFS and OS rates were 45% (95% confidence interval [CI]: 34-60) and 85% (95% CI: 75-95), respectively. Treatment-related adverse events occurred in 32 (42%) patients and included skin toxicity (n = 7, 9.2%), fatigue (n = 6, 7.9%), and diarrhea/colitis (n = 4, 5.3%). Limitations included selecting patients from large academic centers and the short follow-up period.

CONCLUSIONS AND CLINICAL IMPLICATIONS

A subset of patients with recurrent RCC following adjuvant IO respond to systemic therapies, including VEGF-TT and IO-based regimens. Notably, patients with favorable-risk disease may derive more benefit from VEGF-TT than from IO therapies in this setting. Future approaches utilizing radiographic tools and biomarker-based liquid biopsies are warranted to detect occult metastatic disease and identify candidate patients for adjuvant IO therapy.

PATIENT SUMMARY

Adjuvant pembrolizumab significantly improved overall survival in renal cell carcinoma (RCC). There are limited data on clinical outcomes after the recurrence of RCC tumors following adjuvant immunotherapy. In this study, we find that patients respond to subsequent systemic therapies across different treatment options.

Delayed partial nephrectomy following complete response to immunotherapy: feasibility and results (UroCCR n°157)

BACKGROUND

Complete responses to immunotherapy in metastatic kidney cancer have led to a renewed interest in primary-site surgery. The prolonged survival of these patients has prompted consideration for nephron-sparing surgery when technically feasible. Given the surgical difficulties reported in the literature, it is essential to assess the feasibility as well as functional and oncological results of partial nephrectomy (PN) after immunotherapy.

METHODS

Multicentric retrospective study based on UroCCR database, including all metastatic patients who underwent PN after a complete response to immunotherapy at metastatic sites. Morbidity, renal function, positive margin rate, and oncological outcomes were assessed.

RESULTS

Thirteen patients underwent PN after immune checkpoint inhibitor (ICI), between January 2019 and September 2023. Median age at surgery was 64 [50-68]; 84.6% received ICI as first-line treatment with a median duration of 11.7 [7.7-14.9] months. None of the patients had positive surgical margins, five patients (38.5%) were ypT0. Two patients (15.4%) presented intraoperative complications and 1 a severe postoperative complication. Median GFR at 3 months was 84.7 [66.6-95.2] mL/min/1.73 m2 with no significant difference from preoperative GFR. After surgery, immunotherapy was not reintroduced in ten patients (77%). Median follow- up was 25.6 [19.6-30.2] months, median treatment-free survival was 22.4 [15.8-34.7] months. RFS at 12 months and at last follow-up were 84.6% and 53.8%. OS rate at last follow-up was 92.3%.

CONCLUSION

This series demonstrates the feasibility of partial nephrectomy following immune checkpoint inhibitor treatment, with acceptable morbidity rates and no major difficulties specifically attributable to the prior treatment. While the data suggest promising functional and oncological outcomes, further investigation is needed. The study underscores the importance of early re-evaluation of metastatic cases in multidisciplinary tumor boards.

Late Survival and Long-Term Follow-Up After Radical Resection of Advanced Renal Cell Carcinoma With Associated Venous Tumor Thrombus

BACKGROUND AND OBJECTIVES

This study evaluates the prognostic value of venous tumor thrombus (VTT) in patients with advanced renal cell carcinoma (RCC) undergoing radical resection and inferior vena cava (IVC) thrombectomy.

METHODS

Retrospective review of patients with radical nephrectomy for RCC and associated VTT (2000-2024). Patients were dichotomized into Neves 0-II (infrahepatic) and Neves III-IV groups (suprahepatic) IVC involvement for univariate analysis.

RESULTS

A total of 64 patients (34 Neves 0-II and 30 Neves III-IV) were analyzed. No significant differences in patient or cancer characteristics. Neves III-IV was associated with greater blood loss (> 2 L) (62.1% vs. 37.9%, p = 0.02), greater intensive care unit length of stay (LOS) (4.4 vs. 1.4 days, p = 0.02), and postoperative LOS (11.0 vs. 6.5 days, p = 0.005). Overall, 30-day mortality was only 1.6% with a mean follow-up of 56.1 months. Local recurrence was 7.8% and IVC patency 96.9%. One-year survival was 82.0%, 5-year survival was 58.4%, and 15-year survival was 42.5% without significant difference between Neves levels.

CONCLUSIONS

Radical nephrectomy with VTT thrombectomy and primary IVC repair is safe with high early survival and low local recurrence. Extent of IVC tumor thrombus extension is not a poor prognostic factor for early or late survival.

Recurrences and Subsequent Treatments After Curative-Intent Surgery for Localised and Locally Advanced Renal Cell Carcinoma

BACKGROUND

There is a lack of evidence concerning recurrent patterns and treatment of repeat recurrences for surgically treated renal cell carcinoma (RCC). Thus, the objective was to describe patterns of recurrences and subsequent treatments in patients with recurrent RCC.

PATIENTS AND METHODS

We identified 525 patients who received surgical treatment for RCC at our institution in 2010-2015. The treatment of recurrences was classified as no active treatment, treatment with the aim to achieve no evidence of disease (NED) or systemic oncological treatment (OT). Relationships were analysed using multivariable Cox regression and log-rank analysis.

RESULTS

The median follow-up was 7.8 [interquartile range (IQR 6.5-9.4)] years. Ninety-one patients experienced a first recurrence, of which 49 received NED-aimed treatment-47 of these patients had their recurrence more than 2 years after surgery. Thirty patients experienced a second recurrence with 17 patients undergoing NED-aimed treatment. Eight patients had a third recurrence with four undergoing NED-aimed treatment. The most common locations of recurrence were pulmonary, local or multiple sites-30% and 38% of patients experienced a second or third recurrence in the same location, respectively. The 3-year overall survival estimates for patients receiving NED-aimed treatment for their first recurrence were 83.1% [95% confidence interval (CI) 72.3-93.8%] and 79.3% (95% CI 58.4-100%) for patients receiving NED following a second recurrence.

CONCLUSIONS

Treatments aimed at achieving NED seem to provide good oncological control and in repeat recurrences, 50% or more were managed with repeat NED-aimed treatments.

Androgen Receptor and Non-Coding RNAs' Interaction in Renal Cell Carcinoma

Renal cell carcinoma (RCC), the most prevalent among the urogenital cancers, accounts for around 3% of new cancer cases worldwide. Significantly, the incidence of RCC has doubled in developed world countries, ranking it as the sixth most common cancer in males, who represent two-thirds of RCC cases. Males with RCC exhibit a higher mortality rate and tend to develop a more aggressive form of the disease than females. Sex-related risk factors, including lifestyle and biological variations, explain this difference. The androgen receptor (AR) oncogenic signaling pathway has been extensively studied among the biological factors that affect RCC. Recent advancements in high-throughput RNA sequencing techniques have underscored the significant roles played by noncoding-RNAs (ncRNAs), previously dismissed as "junk". The oncogenic potential of AR is manifested through its dysregulation of the ncRNAs' availability and function, promoting RCC tumorigenesis. This review offers a summary of the most recent findings on the role and molecular mechanisms of the AR in dysregulating the ncRNAs that play a role in the progression of RCC and the possibility of utilizing ncRNAs to target AR as a potential therapeutic strategy.

IKBKE regulates renal cell carcinoma progression and sunitinib resistance through the RRM2-AKT pathway

Tyrosine kinase inhibitors (TKIs), such as sunitinib, have emerged as promising agents in renal cell carcinoma (RCC) treatment, particularly in patients at advanced/metastatic clinical stages. However, acquired resistance to sunitinib is common following prolonged clinical treatment in RCC. Increasing evidence has demonstrated a strong correlation between inhibitor of nuclear factor kappa B kinase subunit epsilon (IKBKE) and cancer progression as well as drug resistance. Here, we found that IKBKE is upregulated in RCC tissues and sunitinib-resistant RCC cells. High IKBKE expression is positively correlated with advanced clinical staging and a poor prognosis in RCC. Silencing IKBKE downregulates ribonucleotide reductase M2 (RRM2) and induces cell cycle arrest at G2/M phase, suppressing RCC progression and enhancing sunitinib sensitivity to RCC cells. Mechanistically, IKBKE interacts with and phosphorylates RRM2 to activate the AKT signaling pathway to promotes RCC progression and sunitinib resistance. Notably, the IKBKE inhibitor CYT387 restores sunitinib sensitivity in RCC cells by downregulating RRM2 expression. Collectively, these results indicate that inhibition of IKBKE restrains RCC progression and enhances sunitinib sensitivity by downregulating RRM2 through the RRM2-AKT pathway, suggesting that IKBKE may be a potential therapeutic target for RCC.

Preparing the ground for bespoke nursing training in advanced renal cell carcinoma care (RCC4Nurses): An international prospective study

OBJECTIVES

Nurses require specialist knowledge and skills to effectively support an increasing population of people affected by advanced renal cell cancer (aRCC). RCC4Nurses was a three-phase project that aimed to develop bespoke training in aRCC for nurses in Europe. Phase 1 examined pre-existing educational programs in kidney cancer, then developed a curriculum of core education topics in aRCC care to suit generalist and specialist nurses' education needs.

METHODS

Phase 1 employed a prospective design that involved two parts. Part 1 was a scoping review of educational programs developed for multidisciplinary health professionals in kidney cancer/RCC. Findings of Part 1 formed the basis for Part 2, which was a three-round Delphi study that involved experts by personal experience or profession in aRCC, who rated the importance of a range of education topics and education methods for inclusion in the developing RCC4Nurses.

RESULTS

The scoping review identified eight education programs via two published reports and six online resources. Existing programs had limitations in accessibility, recency and target professional groups; none of them was developed specifically for nurses. Program content was primarily focused on diagnostic, treatment and management procedures in kidney cancer. Fourteen educational topics were derived from the review and evaluated during Round 1 of the Delphi by 47 experts. By Round 3, 17 topics had iteratively reached consensus for inclusion within RCC4Nurses. Experts showed preference to problem-solving and clinical-scenario learning methods, but not reflective practice learning.

CONCLUSIONS

Given the dearth of up-to-date, evidence-based training for nurses in aRCC, we have prepared the ground to develop a bespoke training course in this area of practice.

IMPLICATIONS FOR NURSING PRACTICE

The RCC4Nurses project will offer accessible, state-of-the-art education to registered nurses in Europe to help enhance nursing competency in aRCC and enhance the standard of care provided to people affected by aRCC.

The clinical application value of mixed reality in robotic laparoscopic partial nephrectomy

Purpose

Robot-assisted laparoscopic partial nephrectomy (RAPN) has become a key technology in the treatment of renal tumors. Effective preoperative planning and precise intraoperative navigation are critical to a successful surgical outcome. This study aimed to evaluate the clinical application value of mixed reality (MR) in robotic nephron-sparing partial nephrectomy for patients with renal tumors of different complexity based on the R.E.N.A.L. score.

Patients and methods

A retrospective analysis was conducted on 68 eligible patients with renal cancer who underwent RAPN at The Second Affiliated Hospital of Nanchang University from January 2021 to December 2023, with postoperative pathology confirmation. Patients were divided into two groups: the MR group, with 28 cases, and the traditional imaging (control) group, with 40 cases. All patients underwent mid-abdominal CT plain scans and enhancements. The MR group utilized three-dimensional reconstruction of CT data and employed 3D tablets and HoloLens glasses for preoperative discussions, surgical planning, and intraoperative guidance. Collect clinical data and metrics to assess surgical outcomes, as well as evaluate performance in areas such as preoperative discussions, doctor-patient communication, surgical planning, and intraoperative navigation.

Results

Compared to robot-assisted partial nephrectomy in the control group, the MR group experienced a reduction in operation time by approximately 30 min [(135.89 ± 23.494) min vs. (165.00 ± 34.320) min, P< 0.001)] and a decrease in ischemia time by around 2.5 min [(20.36 ± 3.956) min vs. (23.80± 6.889) min, P = 0.02)]. Within the subgroup with a R.E.N.A.L. score of less than 7 points, the MR group only showed a significant reduction in operation time [(134.55 ± 150.190) min vs. (150.19 ± 28.638) min, P = 0.045], with no notable differences in other parameters. For the subgroup with a R.E.N.A.L. score of 7 points or higher, the MR group exhibited shorter operation time [(140.83 ± 25.183) min vs. (195.77 ± 23.080) min, P< 0.001] and reduced warm ischemia time [(21.17 ± 2.714) min vs. (28.85 ± 7.570) min, P = 0.029]. Additionally, there was less estimated blood loss [(53.33 ± 5.164) min vs. (114.62 ± 80.376) min, P = 0.018]. All patients had negative resection margins, indicating equivalent therapeutic outcomes between the two groups.

Conclusion

In comparison to traditional RAPN, MR technology demonstrates the ability to decrease operation time and warm ischemia time all the while maintaining equivalent curative outcomes. Additionally, it enhances preoperative discussions, doctor-patient interactions, preoperative strategizing, and intraoperative navigation, particularly excelling in complex renal tumor cases of RAPN, where its benefits are most pronounced.

Histopathologic classification and immunohistochemical features of papillary renal neoplasm with potential therapeutic targets

BACKGROUND

Papillary renal cell carcinoma (pRCC) is the second most common histological subtype of renal cell carcinoma and is considered a morphologically and molecularly heterogeneous tumor. Accurate classification and assessment of the immunohistochemical features of possible therapeutic targets are needed for precise patient care. We aimed to evaluate immunohistochemical features and possible therapeutic targets of papillary renal neoplasms.

METHODS

We collected 140 papillary renal neoplasms from three different hospitals and conducted immunohistochemical studies on tissue microarray slides. We performed succinate dehydrogenase B, fumarate hydratase, and transcription factor E3 immunohistochemical studies for differential diagnosis and re-classified five cases (3.6%) of papillary renal neoplasms. In addition, we conducted c-MET, p16, c-Myc, Ki-67, p53, and stimulator of interferon genes (STING) immunohistochemical studies to evaluate their pathogenesis and value for therapeutic targets.

RESULTS

We found that c-MET expression was more common in pRCC (classic) (p = .021) among papillary renal neoplasms and Ki-67 proliferation index was higher in pRCC (not otherwise specified, NOS) compared to that of pRCC (classic) and papillary neoplasm with reverse polarity (marginal significance, p = .080). Small subsets of cases with p16 block positivity (4.5%) (pRCC [NOS] only) and c-Myc expression (7.1%) (pRCC [classic] only) were found. Also, there were some cases showing STING expression and those cases were associated with increased Ki-67 proliferation index (marginal significance, p = .063).

CONCLUSIONS

Our findings suggested that there are subsets of pRCC with c-MET, p16, c-MYC, and STING expression and those cases could be potential candidates for targeted therapy.

Successful Targeting of Somatic VHL Alterations With Belzutifan in Two Cases

Clear cell renal cell carcinoma (RCC) is commonly associated with alterations in the VHL tumor suppressor gene, resulting in upregulation of hypoxia-inducible factor pathways. Immune checkpoint inhibitors and vascular endothelial growth factor inhibitors are the mainstays of systemic treatment for metastatic RCC; however, most patients encounter disease progression after the initial response. The phase 3 clinical trial LITESPARK-005-belzutifan (HIF-2α inhibitor) demonstrated improvement in progression-free survival compared with everolimus in heavily pretreated patients unselected for somatic/germline VHL alterations (an objective response rate of 23% and a median time on therapy of 7.6 months in the belzutifan cohort), resulting in U.S. FDA approval for patients with advanced RCC. Herein, we present two cases of refractory metastatic RCC (including one with brain metastases) with somatic VHL mutations who received belzutifan after discussion in the institutional Molecular Tumor Board. Both patients had an excellent clinical response (partial remissions ongoing at >12 and >20 months). Future studies should assess the merits of biomarker selection for belzutifan treatment.

The prognostic role of perirenal fat tissue in non-metastatic renal cell carcinoma

PURPOSE

The aim of this study was to evaluate the impact of perirenal fat volume and perirenal fat density on prognosis in surgically treated non-metastatic renal cell carcinomas (RCC).

METHODS AND MATERIALS

All consecutive patients who underwent partial or total nephrectomy surgery between March 2019 and December 2021 were assessed. Measurements of perirenal fat volume and perirenal fat density were performed on computed tomography (CT) images. The relationship between progression and perirenal fat parameters was evaluated using ROC analysis, Cox regression analysis, and Kaplan-Meier analysis.

RESULTS

In the study population comprising 118 patients diagnosed with RCC (74.6% male, mean age of 59.1 ± 11.8 years), the median follow-up duration was 43 months (interquartile range: 33-51 months). Perirenal fat volume (AUC: 0.669, 95% CI 0.538-0.799, p = 0.011) and perirenal fat density (AUC: 0.680, 95% CI 0.558-0.803, p = 0.007) demonstrated acceptable discrimination performance in predicting progression. There was a significant association between high perirenal fat volume and high perirenal fat density with poor progression-free survival (HR: 1.007, 95% CI 1.003-1.011, p = 0.001 vs. HR: 1.084, 95% CI 1.033-1.137, p = 0.001; respectively).

CONCLUSION

High perirenal fat volume and high perirenal fat density are independent predictors for poor progression-free survival. Perirenal fat parameters, easily obtainable from preoperative CT images, may serve as potential tools in predicting the prognosis of non-metastatic RCC.

Exploring the Role of Intracorporeal Ultrasound in Partial Nephrectomies: A Systematic Review

Renal cell carcinoma accounts for the sixth most common cancer in the United Kingdom. With the increasing application of cross-sectional imaging, the frequency of incidental renal masses has increased over time. Laparoscopic and robot-assisted partial nephrectomy has become the standard of care in the management of size and stage-appropriate renal masses. The objective of this systematic review was to analyse the surgical outcomes when intracorporeal ultrasound was utilised as an adjunct in partial nephrectomy. A comprehensive search in PubMed and Google Scholar was performed in July 2024 for publications in the English language. The primary endpoint was to evaluate the role of intracorporeal ultrasound as an adjunct in robotic partial nephrectomies and its impact on tumour clearance. After identifying 609 records, 52 records were screened and 44 records were sought for retrieval. Eight publications were included in this systematic review comprising 765 patients. Seven of the eight studies reported outcomes from single centres. The mean percentage of negative surgical margins was 97.6% (range = 92.1-100%). The use of intracorporeal ultrasound as an adjunct in partial nephrectomy for T1 renal cell cancer has proven to improve the rates of negative surgical margins thereby reducing the incidence of local recurrence and distant metastasis.

Recent advancements in management for noncolorectal, nonneuroendocrine hepatic metastases

BACKGROUND

Owing to the heterogeneity of underlying primary tumors, noncolorectal, nonneuroendocrine metastases to the liver (NCNNMLs), although relatively rare, pose major challenges to treatment and long-term management. Despite being considered the gold standard for colorectal cancer liver metastases, the role of surgical resection for NCNNML remains controversial. Furthermore, advancements in locoregional treatment modalities, such as ablation and various chemotherapeutic modalities, have contributed to the treatment of patients with NCNNML.

METHODS

This was a comprehensive review of literature that used Medline/PubMed, Google Scholar, the Cochrane Library, and the Web of Science, which were accessed between 2014 and 2024.

RESULTS

NCNNMLs are rare tumor entities with varied presentation and outcomes. A multidisciplinary approach, which includes chemotherapy, surgery, and interventional radiologic techniques, can be implemented with good results.

CONCLUSION

Given the complex nature of NCNNML, its management should be highly individualized and multidisciplinary. Locoregional treatments, such as surgical resection and/or ablation, may be more appropriate for select patients and should be offered as a viable therapeutic option for a subset of individuals.

Paraneoplastic Resolution Holds Prognostic Utility in Patients with Metastatic Renal Cell Carcinoma

Background/Objectives: The presence of paraneoplastic syndromes (PNS) in patients with renal cell carcinoma (RCC) is associated with worse survival; however, little is known about whether resolution of PNS after intervention has any prognostic value. We sought to determine if resolution of PNS by one year after cytoreductive nephrectomy was significantly associated with improved overall survival (OS) and cancer-specific survival (CSS). Methods: We retrospectively reviewed a prospectively maintained nephrectomy database for patients with any histology metastatic RCC (mRCC) who underwent nephrectomy between 2000 and 2022. Patients with the necessary laboratory studies available within 90 days before and by one year after surgery were included for study. PNS resolution was defined as an abnormal value compared to established laboratory cutoffs by one year after surgery. Multiple PNS in one patient was allowed, and resolution of each PNS was measured separately. OS and CSS were assessed using Kaplan-Meier curves and Cox proportional hazards models. Results: A total of 253 patients met inclusion criteria. A total of 177 patients (70.0%) met criteria for at least one PNS resolution by one year. Five-year OS and CSS rates were 15.7% and 36.2% for no PNS resolved, 24.5% and 31.6% for 1 PNS resolved, and 43.0% and 58.2% for ≥2 PNS resolved, respectively (p < 0.001). On multivariable analysis, no PNS resolution was associated with worse OS (HR 2.75, p < 0.001) and CSS (HR 2.62, p < 0.001) compared to ≥2 PNS resolved. Conclusions: Resolution of preoperative PNS abnormalities by one year following surgery is associated with improved OS and CSS in patients with mRCC.

Implementation of surgical rehearsal utilizing patient specific hydrogel kidney phantoms prior to complex renal cancer surgery: a pilot study

INTRODUCTION

With the advancement of surgical technology, the opportunity to integrate novel surgical preparation is imperative to improve patient outcomes and enhance safety.

METHODS

Patient specific perfused kidney phantoms including the tumor, parenchyma, artery, vein, and calyx were fabricated using 3D-printing and hydrogel injection molding from scans of 25 patients scheduled for robotic partial-nephrectomy (RAPN). Models are validated for anatomical accuracy, mechanical, functional properties and surrounded by the other models of relevant anatomy in a body cast for a simulated surgical rehearsal. We investigated the impact of these preoperative rehearsals preceding complex RAPN by analyzing changes in surgeons' decisions following review of both axial-imaging and following rehearsal simulation. Predictive ability of these rehearsal platforms was compared to live surgery outcomes and trifecta of cases as an outcome was calculated.

RESULTS

25 patients with complex renal tumors, average 9.8 nephrometry score and 4.9 cm mean tumor diameter were consented. Mean blood loss and WIT were 193.2 ml and 19.8 min. Two Clavien 2 complications were reported at 30-day postoperative. Trifecta was achieved in 17 (68%) of surgical cases. Surgeons' confidence in their ability to complete a partial nephrectomy and ability to predict WIT significantly increased from initial viewing the axial imaging to after the rehearsal. The correlation coefficient between the procedural clinical data collected during the rehearsals and live surgery were calculated.

CONCLUSION

The application of this versatile method for creating authentic perfused kidney phantoms can result in increased confidence in surgical plan and thus improved surgical performance and outcomes.

Treatment Modalities and Risks of Complication for Patients With Localized Renal Cell Carcinoma Aged 75 and Older

BACKGROUND AND OBJECTIVES

Partial (PN)/radical (RN) nephrectomy is the standard treatment for localized renal-cell carcinoma (RCC). The potential risks of these procedures are concerns for the elderly. We evaluated perioperative outcomes/survival for patients aged ≥ 75 years with localized RCC who underwent PN, RN, or thermal ablation (TA).

METHODS

Localized RCC patients undergoing PN/RN/TA (2000-2023) were retrospectively reviewed. Logistic-regression assessed factors associated with major complications. Kaplan-Meier estimated survival.

RESULTS

A total of 278 patients (≥ 75 years) with RCC who received intervention (107RN, 101PN, and 70TA) were identified. Median age was 78 years. PN patients were younger than other cohorts (77 vs. 79, p = 0.006). Patients with cancer comorbidities underwent TA than PN/RN (93% vs. 88%/76%, respectively). Median tumor size was 4.0, 3.0, and 2.6 cm in RN, PN, and TA cohorts, respectively. RN patients had more complex masses compared to other cohorts (9 vs. 7, p < 0.001). Postoperative complications were significantly greater among PN patients (p = 0.03), but there was no significant difference in Clavien ≥ 3 complications. Peripheral vascular disease (PVD) was associated with Clavien ≥ 3 complications on multivariable analysis (p = 0.03). RN was performed at a stable rate while PN decreased in favor of TA. There was no significant difference in RCC-/non-RCC-specific survival among treatment modalities.

CONCLUSIONS

It is important to make informed decisions about treating RCC in the elderly to reduce morbidity/mortality. PVD could be a determining factor favoring TA for amenable tumors.

Diagnostic Value of Contrast-Enhanced Ultrasound in Differentiating Malignant from Benign Small Renal Masses After CT/MRI

Background: The aim of this study was to assess the diagnostic performance of contrast-enhanced ultrasound (CEUS) in characterizing small renal masses (SRMs) measuring less than 3 cm and in distinguishing between malignant and benign SRMs. Methods: A retrospective study was conducted between January 2022 and January 2023 at the Radiology Department of (Anonymized data), with a total of 43 patients assessed via CT and MRI scans, which were subsequently studied by experienced radiologists who were blinded to the pathology results. The CEUS findings were then compared with histopathological examination outcomes or follow-up imaging results. Results: The study results revealed a notably high level of diagnostic accuracy, with sensitivity at 0.875, specificity at 0.94, positive predictive value at 0.95, and negative predictive value at 0.86 for characterizing SRMs. Spearman rank correlation analysis substantiated a robust positive linear correlation between the CEUS findings and biopsy results (r = 0.972). Conclusions: These findings underscore the potential utility of CEUS as a valuable tool for discriminating between malignant and benign SRMs, carrying significant implications for clinical decision-making and leading to improved patient outcomes. However, larger validation studies are imperative to establish its role in routine clinical practice and to address potential limitations.