Reduced mRNA expression level of corticotropin-releasing hormone-binding protein is associated with aggressive human kidney cancer.

BACKGROUND: Significance of Urocortin (Ucn or UcnI), Ucn2, Ucn3 and their receptors, Corticotropin Releasing Factor Receptor 1 and 2 (CRFR1 and CRFR2), and the binding protein, Corticotropin-Releasing Hormone-Binding Protein (CRHBP) in oncology is growing rapidly. The objective of our study was to assess the expression of the CRHBP mRNA and protein in renal cancer. METHODS: Tumoral tissues of 78 patients with clear cell renal cell cancer and their corresponding normal tissues were analyzed using quantitative mRNA expression analysis for detection of mRNA expression level. Protein expression and tissue localization of CRHBP protein in renal specimens was evaluated using western blotting, immunohistochemistry and double immunofluorescence, respectively. RESULTS: We found an approx. 33 fold decrease of average CRHBP mRNA level in tumoral tissues compared to paired normal tissues (p<0.001). Diminished CRHBP mRNA expression was positively correlated with advanced, metastasized and higher stage of disease (p<0.001, p=0.026, p=0.028 respectively). CRHBP protein was detected in glomeruli and proximal tubules of normal kidney while none or weak immunopositivity was found in cc-RCC (p<0.001). CONCLUSIONS: The expression analysis of CRHBP shows that cc-RCC is characterized by a significant loss of CRHBP mRNA expression that furthermore is associated with a more aggressive state of tumors. Depletion of CRHBP proteins also indicate that the protein as part of the UCN system may be involved in renal carcinogenesis.

GATA5 CpG island methylation in renal cell cancer: a potential biomarker for metastasis and disease progression.

UNLABELLED: GATA5 CpG island (CGI) methylation and transcriptional inactivation is involved in colorectal and gastric cancer. Whether DNA methylation of GATA5 affects clinical pathology is still unclear. In the present study, we analysed, for the first time, CGI methylation in RCC and its association with clinicopathological parameters and progression-free survival of patients. We show for the first time GATA5 CGI hypermethylation in RCC. Moreover, we found out that increased methylation is statistically associated with status of metastasis, progressive disease and shortened progression-free survival. The present study underline the necessity for further functional investigations as well as prospective survival analyses to clarify whether GATA5 promoter methylation can provide independent information for future clinical management of patients with RCC. OBJECTIVE: To investigate whether GATA5 CpG island (CGI) methylation occurs in renal cell carcinoma (RCC) and is associated with clinical, histopathological characteristics or progression-free survival of patients. PATIENTS AND METHODS: Methylation was quantified in 117 RCC samples and 89 paired adjacent normal tissues using quantitative combined bisulphite restriction analysis (COBRA). COBRA was evaluated in advance by pyrosequencing analyses of control RCC cell lines (coefficient of correlation, R = 0.95). Statistical analyses were carried out using the paired t-test for matched tumour tissue (TU) and adjacent normal tissue (adN) samples, logistic regression for comparisons of independent sample groups and Cox regression for analysis of progression-free survival. RESULTS: In the present study, we found a significant higher mean relative methylation in TU (20.4%) than in adN (7.9%, P < 0.001) in paired samples of all RCCs. Increased GATA5 methylation in tumours was associated with metastasis (P = 0.005) and decreased progression-free survival (P = 0.005, HR = 4.59) in the clear-cell RCC (ccRCC) group. CGI methylation in advanced ccRCCs (pT ≥3 and/or N1, M1 or G2-3/G3) exceeds those detected in localized tumours (pT ≤2, N0, M0, G1/G1-2) (27.8% vs 11.0%, P < 0.001). CONCLUSIONS: The association of GATA5 hypermethylation with metastasis and progression-free survival of patients indicates that epigenetic alterations of GATA5 participate in renal cell carcinogenesis. Moreover, GATA5 CGI methylation could serve as a biomarker for tumour progression, although prospective and functional investigations are necessary to clarify whether independent information for future clinical management of patients with RCC can be obtained.

Does male sex influence the prognosis of patients with renal cancer?

BACKGROUND: The aim of this study was to investigate the influence of sex on stage, grade, subtype, and prognosis of patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: This study included 1,810 patients treated by surgery for RCC at the University Hospitals of Hannover and Marburg between 1990 and 2005. The median follow-up was 54 months. RESULTS: Of all the patients, 1,167 (64.5%) were men and 643 (35.5%) were women. Men were significantly younger (mean, 61.4 vs. 63.5 years; p < 0.001), and suffered more frequently from advanced tumor stages (45.2 vs. 37.6%; p = 0.002) and higher tumor grades (14.1 vs. 11.1%; p = 0.003). Kaplan Meier curves revealed a significant difference in cancer-specific survival between men and women (5-year survival 64.7 vs. 74.0%; p = 0.002). However, unlike tumor stage, grade, and N/M status, sex could not be retained as a significant independent prognostic marker in multivariate analysis. CONCLUSIONS: RCC in men is characterized by higher tumor stages and more frequent metastasis at diagnosis along with inferior tumor-specific survival. However, as sex failed to qualify as an independent prognostic marker for cancer-specific survival, delayed diagnosis due to insufficient or neglected (routine) medical check-up and/or more aggressive tumor biology could be concurrently causative for the higher incidence of RCC in men.

Partial nephrectomy using porcine small intestinal submucosa.

BACKGROUND: Whenever technically feasible and oncologically justified, nephron-sparing surgery is the current standard of care for localized renal cell carcinomas (RCC). The main complications of partial nephrectomy, especially for large and centrally located tumors, are urinary leakage and parenchymal bleeding. We prospectively evaluated the pros and cons of using porcine small intestinal submucosa (SIS, Surgisis®) to close the renal defect after nephron-sparing surgery. METHODS: We used Surgisis® (Cook medical, Bloomington, IN, USA) to secure and compress the capsular defect after tumor resection in 123 patients submitted to 129 partial nephrectomies between August 2003 and February 2011. RESULTS: The median tumor size was 3.7 cm (range 1.1-13.0 cm). Procedures were performed with cold ischemia in 24 cases (18.2%), with warm ischemia in 46 (35.6%), and without ischemia in 59 cases (44.8%). In the total group of patients, 4 (3.1%) developed urinary fistula, and only 2 (1.6%) required postoperative transfusions due to hemorrhage after the application of the small intestinal submucosa membrane. CONCLUSION: Small intestinal submucosa is an easy-to-use biomaterial for preventing complications such as postoperative bleeding and urinary fistula in nephron-sparing surgery, especially in cases where tumor excision causes significant renal capsular and/or renal pelvic defects.

Decreased galectin-8 is a strong marker for recurrence in urothelial carcinoma of the bladder.

OBJECTIVE: To investigate galectin-8 expression patterns in normal urothelium and bladder cancer specimens and to elucidate its prognostic value. MATERIALS AND METHODS: 162 samples of non-muscle-invasive transitional cell carcinoma, 25 samples of muscle-invasive transitional cell carcinoma and 10 samples of normal urothelium were investigated by immunohistochemistry using tissue microarrays. Complete patient and tumor characteristics were compared with galectin-8 staining patterns. The likelihood of tumor recurrence and progression was analyzed based on a 3-year follow-up. RESULTS: Loss of galectin-8 was associated with the likelihood of tumor recurrence in univariate (p < 0.05) and multivariate analyses (p < 0.01). No significance was observed for tumor progression. Patients whose specimens showed weak galectin-8 expression had a shorter recurrence-free interval (42 vs. 12 months; p < 0.01, log-rank test). All of the 10 normal urothelium samples showed high galectin-8 expression. Decreased staining was found to be associated with higher tumor stages and grades (p < 0.0001, one-way ANOVA). A significant difference was found comparing normal urothelium with any tumor stage (p < 0.01), pTa vs. pT1 tumors (p < 0.05) and non-muscle-invasive vs. muscle-invasive tumors (p < 0.0001). CONCLUSIONS: Loss of galectin-8 might be an early step in the development of malignant lesions of the bladder and is a significant independent predictor of recurrence.

Obesity is associated with improved survival in patients with organ-confined clear-cell kidney cancer.

OBJECTIVES: Obesity increases the risk of developing renal cell carcinoma (RCC); however, it remains unclear whether obesity is associated with RCC aggressiveness and survival. We assessed whether different body mass index (BMI) levels at the time of surgery had an effect on long-term prognosis of RCC patients. METHODS: We evaluated 1,338 clear-cell RCC patients with complete information about their BMI, who had undergone surgery for renal cell cancer at the University Hospitals in Hannover and Marburg between 1991 and 2005. The mean follow-up was 5.1 years. RESULTS: Underweight, normal weight, pre-obesity, and obesity were diagnosed in 14 (1.0%), 444 (33.2%), 593 (44.3%), and 287 (21.4%) RCC patients, respectively. A lower BMI was significantly associated with higher age, tumor grade, and the rate of metastasis at diagnosis. Overweight patients had a significantly lower risk of cancer-related death; their median 5-year tumor-specific survival rate was 70.9% (pre-obese), 74.0% (obese grad I), and 85.6% (obese grad ≥II) as opposed to 63.8% for patients with a BMI below 25 (p < 0.001). Interestingly, subgroup analysis revealed that the positive association between overweight and survival was found in organ-confined RCC only. CONCLUSION: We identified overweight as an independent prognostic marker of improved cancer specific survival in patients with organ-confined but not advanced RCC. Basic research is required to resolve the dilemma of why, if a higher BMI predisposes to RCC, it concurrently prolongs survival after patients have undergone (partial) nephrectomy.

Fibronectin 1 mRNA expression correlates with advanced disease in renal cancer.

BACKGROUND: Fibronectin 1 (FN1) is a glycoprotein involved in cellular adhesion and migration processes. The aim of this study was to elucidate the role of FN1 in development of renal cell cancer (RCC) and to determine a prognostic relevance for optimal clinical management. METHODS: 212 renal tissue samples (109 RCC, 86 corresponding tissues from adjacent normal renal tissue and 17 oncocytomas) were collected from patients undergoing surgery for renal tumors and subjected to total RNA extraction. Detection of FN1 mRNA expression was performed using quantitative real time PCR, three endogenous controls, renal proximal tubular epithelial cells (RPTEC) as biological control and the ΔΔCt method for calculation of relative quantities. RESULTS: Mean tissue specific FN1 mRNA expression was found to be increased approximately seven fold comparing RCC and corresponding kidney control tissues (p < 0.001; ANOVA). Furthermore, tissue specific mean FN1 expression was increased approx. 11 fold in clear cell compared to papillary RCC (p = 9×10-5; Wilcoxon rank sum test). Patients with advanced disease had higher FN1 expression when compared to organ-confined disease (p < 0.001; Wilcoxon rank sum test). Applying subgroup analysis we found a significantly higher FN1 mRNA expression between organ-confined and advanced disease in the papillary and not in the clear cell RCC group (p = 0.02 vs. p = 0.2; Wilcoxon rank sum test). There was an increased expression in RCC compared to oncocytoma (p = 0.016; ANOVA). CONCLUSIONS: To our knowledge, this is the first study to show that FN1 mRNA expression is higher in RCC compared to normal renal tissue. FN1 mRNA expression might serve as a marker for RCC aggressiveness, indicating early systemic progression particularly for patients with papillary RCC.

External validation of the preoperative anatomical classification for prediction of complications related to nephron-sparing surgery.

PURPOSE: Ficarra et al. (Eur Urol 56:786-793, 2009) published a preoperative anatomical classification (PADUA) to assess the impact of anatomical parameters of renal tumors on complication rate of nephron-sparing surgery (NSS). The objective of this study is to provide a bi-center external validation of this classification using the technique of hilar arterial clamping during open and laparoscopic NSS and to correlate the PADUA score to the ischemia time. METHODS: 240 consecutive tumors treated with open and laparoscopic NSS were reclassified according to the PADUA classification. Complications were graded according to the modified Clavien system (Dindo et al. in Ann Surg 240:205-213, 2004). Chi-square tests and multivariate logistic regression models addressed the predictive value of PADUA classification on overall complication rate and grade. RESULTS: Mean patient age was 62.2 +/- 13.3 years. Eastern Cooperative Oncology Group performance was 0 in 76%, 1 in 22% and 2 in 2%. 61 (25%) were treated laparoscopically. The median PADUA score was 7.5 (range 6-13). Mean surgery and ischemia time was 189 +/- 95 and 24 +/- 22 min, respectively. Overall complication rate was 23% (n = 54). On univariate analysis, the PADUA score correlated with complication rate (p < 0.001) of open and laparoscopic NSS. On multivariate, only the PADUA score correlated with complication rate (p = 0.0056). Ischemic time correlated with the PADUA score and was significantly higher in PADUA score > or = 10 (p = 0.034). CONCLUSIONS: The PADUA score is a reliable tool to preoperatively predict the risk of complications. In addition, it might be beneficial for a more objective patient selection for laparoscopic surgery and teaching NSS.

Urinary collecting system invasion is no independent prognostic factor in renal cell carcinoma.

OBJECTIVES: To assess the specific impact of urinary collecting system (UCS) invasion on the long-term prognosis of patients with renal cell carcinoma (RCC). METHODS: We evaluated 1,678 patients with complete information about UCS invasion of their primary RCC who had undergone renal surgery between 1990 and 2005 in two high volume centers (MH Hannover and Marburg, Germany); the mean follow-up was 5.4 years. RESULTS: Hundred and forty-nine (8.9%) patients demonstrated collecting system invasion. These patients incurred a significant increase in the likelihood of cancer-related death (HR 1.7, 95% CI: 1.4-2.0; P < 0.001), their median 5-year tumor-specific survival rate was 45% as opposed to 73% for patients without UCS invasion (P < 0.001). UCS invasion was significantly associated with tumor stage, grade, lymph node, and visceral metastasis at diagnosis but not with age, gender, histologic subtype, or body mass index. However, using multivariate analysis, UCS invasion disqualified as individual prognostic factor for RCC, neither for localized nor for advanced disease. CONCLUSION: Facing the results of this large trial, we do not support the inclusion of UCS invasion into upcoming TNM staging systems. In contrast, future research should focus on novel molecular markers expressed by the tumor and/or specific immunological characteristics of patients with RCC which could improve prediction of RCC-associated prognosis.

SFRP1 CpG island methylation locus is associated with renal cell cancer susceptibility and disease recurrence.

Loss of the secreted Fzd-related protein 1 (SFRP1) and concurrent alteration of the SFRP1/WNT pathway are frequently observed in human cancers such as in renal cell cancer (RCC). Whether methylation of a SFRP1 CpG island locus in normal human solid tissues is associated with increased tissue specific cancer risk has not been determined to date. Here we measure the cancer risk attributable to SFRP1 DNA methylation in renal tissue. Pyrosequencing of bisulfite treated DNA was used for a case-control study including 120 normal-appearing renal tissues of autopsy specimens and 72 normal-appearing tissues obtained from tumor adjacent areas, and a cross sectional study of 96 RCCs. Association of methylation with demographic risk factor age, clinicopathological parameters and course of patients was investigated. We show significant hypermethylation of a SFRP1 CpG island locus in normal-appearing renal tissues from RCC patients compared with normal-appearing autopsy kidney tissues. Inter quartile analysis revealed a 6-, 13- and 11-fold increased cancer risk for the second, third and fourth quartiles of methylation in the age matched subgroup of tissues (p = 0.001, p = 1.3E-6, p = 6.9E-6). Methylation in autopsy tissues increased with age and methylation in tumors was an independent predictor of recurrence free survival. SFRP1 DNA methylation, accumulates with age in normal-appearing kidney tissues and is associated with increased renal cancer risk, suggesting this CGI sub region as an epigenetic susceptibility locus for RCC. Our data underline the need to further analyze the tissue specific risks conferred by methylated loci for the development of human cancers.

Is there a need to further subclassify pT2 renal cell cancers as implemented by the revised 7th TNM version?

BACKGROUND: The recently modified TNM classification of renal cell carcinoma (RCC) (7th edition) has implemented a subdivision of pT2 tumours into stage pT2a (>7 or ≤10 cm) versus pT2b disease (>10 cm). OBJECTIVE: Our aim was to evaluate whether this subdivision of pT2 RCC is justified due to a clinical prognosis divergence between the two groups (pT2a vs pT2b) DESIGN, SETTING, AND PARTICIPANTS: In total, 5122 patients were subjected to either radical nephrectomy or nephron-sparing surgery at three centres in Germany (University Hospitals of Hannover, Homburg/Saar, and Marburg). Patients were reclassified into stage pT2a and pT2b according to the maximum tumour diameter as suggested by the 7th revised version of the TNM classification system. MEASUREMENTS: The t test and Fisher exact test were applied to evaluate the comparability of the two groups (pT2a vs pT2b) regarding several additional patients' and tumour-specific characteristics of known prognostic relevance for RCC. Univariable (Kaplan-Meier analysis) and multivariable statistical analyses (Cox proportional hazards regression model) were applied to identify a possible difference between the two groups (pT2a vs pT2b) regarding cancer-specific survival (CSS). RESULTS AND LIMITATIONS: Applying the new TNM classification, 579 previously pT2-staged patients were divided into 445 (76.9%) with pT2a and 134 (23.1%) with pT2b tumours. Kaplan-Meier curves revealed no significant difference in CSS between pT2a and pT2b patients; 5-yr CSS was 79.0% and 74.1%, respectively (p=0.38). When applying multivariable analysis, unlike tumour grade and N/M status, pT2 subclassification failed to independently predict survival in RCC patients. CONCLUSIONS: The new subclassification of pT2 RCC into two different subgroups as suggested by the latest modification of the TNM system does not yield additional/prognostic information.

Caveolin 1 mRNA is overexpressed in malignant renal tissue and might serve as a novel diagnostic marker for renal cancer.

BACKGROUND & AIM: Caveolae play a significant role in disease phenotypes, such as cancer, diabetes, bladder dysfunction and muscular dystrophy. The aim of this study was to elucidate the expression of caveolin (CAV)1 in the development of renal cell cancer (RCC) and to determine a possible prognostic relevance for optimal clinical management. MATERIAL & METHODS: 109 RCC and 81 corresponding normal tissue specimens from the same kidney were collected from patients undergoing surgery for renal tumors and subjected to total RNA extraction. Quantification of CAV1 mRNA expression was performed using real-time reverse transcription PCR with three endogenous controls for renal proximal tubular epithelial cells and the ΔΔCt method for calculation of relative quantities. Expression levels were correlated to clinical variables. RESULTS: Tissue-specific mean CAV1 expression was significantly increased in RCC compared with normal renal tissue (p = 0.0003; paired Wilcoxon rank sum test). CAV1 expression was increased 1.9-fold in clear cell RCC compared with papillary RCC (p = 1.48 × 10(-7); unpaired Wilcoxon rank sum test). Patients with advanced disease had higher CAV1 expression when compared with organ-confined disease (p = 0.019; unpaired Wilcoxon rank sum test). Moreover, mean tissue-specific CAV1 expression was increased in patients with distant metastasis at the time of diagnosis compared with patients without metastasis (p = 0.0058; unpaired Wilcoxon rank sum test). CONCLUSION: To our knowledge, this is the first study to show that CAV1 mRNA expression, using quantitative real-time PCR, is significantly higher in RCC compared with normal renal tissue and increases with tumor stage. CAV1 mRNA expression might serve as a candidate biomarker for objective prognosis indicating RCC aggressiveness. Our data encourage further investigations to determine the role of CAV1 in RCC.

Altered expression of Akt signaling pathway parameters in prostate needle biopsies derived from benign, adjacent and cancerous tissue.

PTEN, p-Akt and p27kip1 are known to be altered in prostate cancer. The aim of the present study was to determine the addition of molecular markers to a classical histopathological approach to enhance the sensitivity in detection of malignant or premalignant lesions within prostatic biopsies. Forty-two fine needle biopsies from malignant, tumor adjacent and benign areas were obtained from 14 patients scheduled for a prostatic biopsy. Biomarker expression was determined by immunohistochemistry and correlated to different localizations. We observed a reduction of Akt signaling proteins in cancer tissue compared to benign controls with significantly lower expression of p27kip1 (P=0.0024), PTEN (P=0.0045) and p-Akt (P=0.028). A pathologist histopathologically classified the tumor adjacent tissue obtained from areas distinctly apart from the primary tumor as benign in all cases. In these regions we observed an intermediate expression of Akt signaling proteins without significant difference in relation to the findings in the malignant samples. The expression of Akt signaling proteins is reduced in prostate cancer compared to normal prostate tissue. The intermediate expression of these proteins in tumor adjacent tissue warrants further investigations into the role of Akt signaling in the carcinogenesis and early detection of prostate cancer. There seems to be a marked difference between the molecular and histopathological characterization of prostate tissue. Molecular markers might further augment the histopathological diagnosis suggesting the need for earlier repeated prostate biopsy in case of microscopic malignancy.

Maspin protein expression correlates with tumor progression in non-muscle invasive bladder cancer.

Maspin is a 42-kDa protein that belongs to the family of serine protease inhibitors. It is involved in various physiological processes. In cancer tissue, Maspin was found to influence angiogenesis, tumor growth, metastasis and the prognosis of tumor patients. This study was performed to analyze the involvement of Maspin in transitional cell carcinoma of the bladder as well as its prognostic impact in a large patient cohort. Specimens from 162 non-muscle invasive bladder cancer patients (pTa, 91; pT1, 71) treated by transurethral resection with a minimum 3-year follow-up (median 58.5 months) were included in the present investigation. Tissue microarrays were constructed, and the specimens were immunohistochemically stained for Maspin protein expression. Each tissue specimen was assessed on a staining scale ranging from 0 (no staining) to 300 (strong staining) and correlated with various clinicopathological parameters. Maspin protein expression predicted progression with a sensitivity of 95% and a specificity of 70% (p<0.001). In predicting recurrence, Maspin staining showed 52% sensitivity and 67% specificity (p<0.05). Kaplan-Meier analyses were performed, and a low Maspin protein expression was correlated with a higher incidence of tumor progression (p<0.0001). However, expression levels of Maspin protein did not distinguish between pTa and pT1 specimens. Multivariate analyses indicated Maspin expression as an independent factor for predicting progression (p<0.0001) and recurrence (p<0.05). The present results suggest that the Maspin protein expression is an independent prognostic indicator for predicting recurrence and progression to muscle invasive disease. This study further emphasizes a possible clinical role of this novel tumor suppressor gene in transitional cell carcinoma of the bladder.

Present state of target therapy for disseminated renal cell carcinoma.

Both experimental and clinical researches focusing on advanced kidney cancer have increased continuously since the successful introduction of targeted therapy in the treatment of advanced metastatic renal cell carcinoma. Being refractory to conventional hormone therapy, chemotherapy or radiotherapy, renal cell carcinoma has become a model tumor for the development and evaluation of diverse novel targeted drugs. This review highlights currently available agents and summarizes evidence-based data regarding their effectiveness in metastatic renal cell carcinoma. Furthermore, the role of debulking tumor nephrectomy followed by systemic therapy as part of an optimum treatment algorithm is being elucidated.

Sorafenib reveals efficacy in sequential treatment of metastatic renal cell cancer.

Metastatic renal cell carcinoma (mRCC) is a highly vascularized tumor with a generally poor prognosis. It is largely resistant to conventional cancer treatment, including most schemes of hormonal and cytokine therapy as well as to modern chemotherapy. Although IFN-alpha has been the first choice in mRCC treatment strategies for more than a decade, recent recommendations of the European Association of Urology focus on so-called molecular-targeted therapies, with multikinase inhibitors, such as sorafenib and sunitinib, blocking the progression of cell proliferation and tumor angiogenesis, as preferential therapy. Sorafenib targets the VEGF receptor, the PDGF receptor beta and, finally, Raf kinase, and is approved for patients who have either received cytokines or are unsuitable for such a therapy. Although targeted therapies reveal superior efficacy compared with previous cytokine-based approaches, they do not cure patients with metastatic disease. Therefore, following tumor progression, most patients require a second-line or sequential therapy during the further progress of the disease. Owing to the fact that optimal sequencing of these new agents has not been fully elucidated, some recent mainly retrospective studies compared the sequence of sorafenib and sunitinib in order to assess the best clinical benefit in mRCC patients. Apparently, no cross-resistance could be observed in any trial, and most results demonstrated a superior efficacy of a sequence strategy when sorafenib was applied as first-line treatment. Regarding current investigations, the aim of the present article is to address and critically discuss the clinical data concerning the efficacy of sorafenib as part of a sequential treatment of mRCC.