Comprehensive analysis of m6 A methylome and transcriptome by Nanopore sequencing in clear cell renal carcinoma.

N6 -methyladenosine (m6 A) is the most prevalent epigenetic modification on eukaryotic messenger RNAs. Recent studies have focused on elucidating the key role of m6 A modification patterns in tumor progression. However, the relationship between m6 A and transcriptional regulation remains elusive. Nanopore technology enables the quantification of m6 A levels at each genomic site. In this study, a pair of tumor tissues and adjacent normal tissues from clear cell renal cell carcinoma (ccRCC) surgical samples were collected for Nanopore direct RNA sequencing. We identified 9644 genes displaying anomalous m6 A modifications, with 5343 genes upregulated and 4301 genes downregulated. Among these, 5224 genes were regarded as dysregulated genes, encompassing abnormal regulation of both m6 A modification and RNA expression. Gene Set Enrichment Analysis revealed an enrichment of these genes in pathways related to renal system progress and fatty acid metabolic progress. Furthermore, the χ2 test demonstrated a significant association between the levels of m6 A in dysregulated genes and their transcriptional expression levels. Additionally, we identified four obesity-associated genes (FTO, LEPR, ADIPOR2, and NPY5R) among the dysregulated genes. Further analyses using public databases revealed that these four genes were all related to the prognosis and diagnosis of ccRCC. This study introduced the novel approach of employing conjoint analysis of m6 A modification and RNA expression based on Nanopore sequencing to explore potential disease-related genes. Our work demonstrates the feasibility of the application of Nanopore sequencing technology in RNA epigenetic regulation research and identifies new potential therapeutic targets for ccRCC.

Efficacy and safety of surgery in renal carcinoma patients 75 years and older: a retrospective analysis.

OBJECTIVE: To investigate the efficacy and complications of surgical treatment in patients with renal cell carcinoma aged ≥ 75 years. METHODS: From January 2009 to May 2019, we assessed 166 patients aged 75 years and older, who either had radical nephrectomy (RN) or partial nephrectomy (PN) as treatments for diagnosed renal cell carcinoma. Patients were divided into one group of patients aged 75-79 years and the second group of patients ≥ 80 years. The complications and survival were compared between the two groups. RESULTS: All 166 patients were successfully operated on. Differences between the two groups were statistically significant in intraoperative and postoperative complications and Clavien-Dindo score of ≥ 1 (P = 0.02, P < 0.001, P = 0.001). Univariate analysis revealed no significant correlation between a Clavien-Dindo score ≥ 1 versus gender, body mass index (BMI), lack of symptoms, KPS, baseline GFR, postoperative GFR, tumor size, tumor location, surgical method, and transfusion or no transfusion (ALL P > 0.05). Multifactor analysis showed that age ≥ 80 years, partial nephrectomy, and operation time were independent predictors of a Clavien-Dindo score ≥ 1. No significant difference was found in OS between the two groups, (P < 0.0001), and no significant difference in CSS (P = 0.056). There was no significant difference in OS and CSS between the RN and PN groups (P = 0.143, P = 0.281, respectively). CONCLUSIONS: According to our findings, the overall safety of surgical therapy for elderly patients with renal cell carcinoma is adequate. PN should be carefully examined, especially over the age of 80. To select suitable patients based on an assessment of the tumor's complexity and patients' physical condition, such as age, underlying diseases and other conditions, technical feasibility, balance of benefits and a case-by-case.

Novel cut-off values of time from diagnosis to systematic therapy predict the overall survival and the efficacy of targeted therapy in renal cell carcinoma: A long-term, follow-up, retrospective study.

OBJECTIVES: Metastatic renal cell carcinoma can occur synchronously or metachronously. We characterized the time from diagnosis to systematic therapy as a categorical variable to analyze its effect on the overall survival and first-line treatment efficacy of metastatic renal cell carcinoma patients. METHODS: We initially enrolled 949 consecutive metastatic renal cell carcinoma patients treated with targeted therapies retrospectively from December 2005 to December 2019. X-tile analysis was used to determine cut-off values of time from diagnosis to systematic therapy referring to overall survival. Patients were divided into different groups based on the time from diagnosis to systematic therapy and then analyzed for survival. RESULTS: Of 358 eligible patients with metastatic renal cell carcinoma, 125 (34.9%) had synchronous metastases followed by cytoreductive nephrectomy, and 233 (65.1%) had metachronous metastases. A total of 28 patients received complete metastasectomy. Three optimal cut-off values for the time from diagnosis to systematic therapy (months) - 1.1, 7.0 and 35.9 - were applied to divide the population into four groups: the synchro group (time from diagnosis to systematic therapy ≤1.0), early group (1.0 < time from diagnosis to systematic therapy ≤ 7.0), intermediate group (7.0 < time from diagnosis to systematic therapy < 36.0) and late group (time from diagnosis to systematic therapy ≥36.0). The targeted therapy-related overall survival (P < 0.001) and progression-free survival (P < 0.001) values were significantly different among the four groups. Patients with longer time from diagnosis to systematic therapy had better prognoses and promising efficacy of targeted therapy. With the prolongation of time from diagnosis to systematic therapy, complete metastasectomy was more likely to achieve and bring a better prognosis. CONCLUSIONS: The time from diagnosis to systematic therapy impacts the survival of metastatic renal cell carcinoma patients treated with targeted therapy. The cutoff points of 1, 7 and 36 months were statistically significant. The statistical boundaries might be valuable in future model establishment.

A novel nomogram can predict pathological T3a upstaged from clinical T1a in localized renal cell carcinoma.

HYPOTHESIS: Nomogram can be built to predict the pathological T3a upstaging from clinical T1a in patients with localized renal cell carcinoma before surgery. PURPOSE: Renal cell carcinoma (RCC) patients with clinical T1a (cT1a) disease who are upstaged to pathological T3a (pT3a) have reduced survivals after partial nephrectomy. We aimed to develop a nomogram-based model predicting pT3a upstaging in RCC patients with preoperative cT1a based on multiple preoperative blood indexes and oncological characteristics. MATERIALS AND METHODS: Between 2010 and 2019, 510 patients with cT1a RCC were individually matched according to pT3a upstaging and pathological T1a (pT1a) at a 1:4 ratio using clinicopathologic features. Least absolute shrinkage and selection operator regression analysis was used to identify the most important risk factor from 40 peripheral blood indicators, and a predictive model was established. Multivariate logistic regression analysis was performed with the screened blood parameters and clinical data to identify significant variables. Harrell's concordance index (C-index) was applied to evaluate the accuracy of the model for predicting pT3a upstaging in patients with cT1a RCC. RESULTS: Out of 40 blood indexes, the top ranked predictor was fibrinogen (FIB). Age, the ratio of the tumor maximum and minimum diameter (ROD), FIB, and tumor size were all independent risk factors for pT3a upstaging in multivariate analysis. A predictive ARFS model (Age, ROD, FIB, tumor Size) was established, and the C-index was 0.756 (95% CI, 0.681-0.831) and 0.712 (95% CI, 0.638-0.785) in the training and validation cohorts, respectively. CONCLUSIONS: Older age, higher ROD, increased FIB level, and larger tumor size were independent risk factors for upstaging. The ARFS model has a high prediction efficiency for pT3a upstaging in patients with cT1a RCC.

Characteristics, dynamic changes, and prognostic significance of TCR repertoire profiling in patients with renal cell carcinoma.

The co-evolving tumour cells and the systemic immune environment are mutually dysregulated. Tumours affect the immune response in a complex manner. For example, although lymphocytes are mobilized in response to tumours, their function is impaired by tumour progression. This study aimed to explore how the baseline and dynamic renal cell carcinoma (RCC) tumour burdens affect the T-cell repertoire, and whether the baseline T-cell receptor ß-chain (TCRB) diversity predicts prognosis. To characterise the TCRB repertoire, the baseline and follow-up peripheral TCRB repertoires of 45 patients with RCC and 2 patients with benign renal disease patients were examined using high-throughput TCRB sequencing. To explain the significance of TCRB diversity, 56 peripheral leukocyte samples from 28 patients before and after surgery were subjected to transcriptome sequencing. To validate the results, an advanced RCC patient's sample was subjected to single-cell RNA sequencing (scRNA, 10x Genomics). Higher TCRB diversity was found to be correlated with a higher lymphocyte-to-neutrophil ratio, especially indicating more naïve T cells. High-baseline TCRB diversity predicted a better prognosis for stage IV patients, and different tumour burdens exerted distinct effects on the immune status. The pre-operative TCRB diversity was significantly higher in benign and stage I (low tumour burden) RCC patients than in stage IV (high tumour burden) patients. After the tumour burden of advanced patients was mostly relieved, we observed that the TCRB diversity was restored, T-cell exhaustion was reduced, and naïve T-cells were mobilized. It was demonstrated that the circulating TCRB repertoire could reflect the immune status and predict prognosis, and to some extent that cytoreductive nephrectomy (CN) reduces the burden of the immune system in advanced patients, which might provide a good opportunity for immunotherapy. © 2020 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.

Establishment of a nomogram to predict the overall survival of patients with collecting duct renal cell carcinoma.

BACKGROUND: Collecting duct carcinoma (CDC) is a rare histological type of renal cell carcinoma that lacks a prognostic prediction model. In this study, we developed a nomogram to predict the prognosis of CDC patients. METHODS: Data for patients (n = 247) diagnosed with CDC from 2004 to 2015 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database, and the patients were randomized into training (n = 165) and validation (n = 82) cohorts. Survival outcomes were evaluated by the Kaplan-Meier method. Significant variables determined by univariate and multivariate Cox regression analyses were used to construct the nomogram. C-indexes and calibration plots were applied to evaluate the performance of the nomogram. RESULTS: CDC patients had a median overall survival (OS) of 18.0 months (95% confidence interval: 13.7-22.3); 1-year, 3-year, and 5-year OS rates were 58.7%, 34.2%, and 29.4%, respectively. Independent prognostic factors, including age at diagnosis, tumor size, tumor grade, T stage, N stage, M stage, and surgery information, were identified by multivariate analysis. The nomogram was constructed based on significant factors in the training cohort. The C-indexes were 0.769 (training cohort) and 0.767 (validation cohort). The calibration curves for survival rates showed that the predicted and observed values were consistent. CONCLUSIONS: This study constructed a nomogram to predict prognosis in patients with CDC. The nomogram performed well in predicting the 1-year, 3-year, and 5-year OS, which can help doctors actively monitor and follow up patients.

Machine learning algorithms being an auxiliary tool to predict the overall survival of patients with renal cell carcinoma using the SEER database.

Background: The clinical prognosis assessment of renal cell carcinoma (RCC) still relies on nuclear grading and nuclear score by naked eye with microscope, which has defects long time, low efficiency, and uneven evaluation level criteria. There are few machine learning (ML) studies investigating the prognosis in the RCC literature which could also quantify the risk of postoperative recurrence of RCC patients and guide cancer patients to conduct individualized postoperative clinical management. This study evaluated the suitability of ML algorithms for survival prediction in patients with RCC. Methods: A total of 192,912 RCC patients from the Surveillance, Epidemiology, and End Results (SEER) were obtained from 2004 to 2015. Six ML algorithms including support vector machine (SVM), Bayesian method, decision tree, random forest, neural network, and Extreme Gradient Boosting (XGBoost) were applied to predict overall survival (OS) of RCC. Results: Patients from the SEER with a median age of 62 years and the pathological types were clear cell RCC (47.6%), papillary RCC (9.5%), chromophobe RCC (4.0%) and others (4.1%) were collected. In the deleting patients with missing data, the highest accurate model was XGBoost [area under the curve (AUC) 67.0%]. In the deleting patients with missing data and survival time <5 years, the accuracy of random forest, neural network and XGBoost were high, with AUC of 80.8%, 81.5% and 81.8%, respectively. In the only deleting the missing tumor diameter and filling the missing dataset with missForest, the highest accurate model was random forest (AUC: 71.9%). In this study, the overall accuracy of the SVM model was not high, apart from in the population of patients with deleting the missing tumor diameter and survival time <5 years, and filling the missing data with missForest. Random forest, neural network and XGBoost had high accuracy, with AUC of 84.1%, 84.7% and 84.8%, respectively. Conclusions: ML algorithms could be used to predict the prognosis of RCC. It could quantify the recurrence possibility of patients and help more individualized postoperative clinical management. Given the limitations and complexity of datasets, ML may be used as an auxiliary tool to analyze and process larger datasets and complex data.

Optimizing targeted drug selection in combination therapy for patients with advanced or metastatic renal cell carcinoma: A systematic review and network meta-analysis of safety.

OBJECTIVE: For patients with advanced or metastatic renal cell carcinoma (RCC), the dose of targeted agents was recommended in combination with immune checkpoint inhibitors. We performed a network meta-analysis to describe a categorized safety ranking profile and assess the adaptability of the combination options of targeted agents. METHODS: The targeted agents refer to vascular endothelial growth factor tyrosine kinase inhibitors (VEGF-TKIs) and mammalian target of rapamycin (mTOR) inhibitors. Randomized controlled trials comparing these drugs were enrolled in a Bayesian model network meta-analysis. RESULTS: Nineteen clinical trials with 11 treatments and 10,615 patients were included. For grade ≥ 3 adverse events (AEs), compared with placebo, lenvatinib plus everolimus showed worse safety than all other treatments except for lenvatinib (placebo vs. OR 0.23, 95% CI 0.07-0.78). Everolimus was generally the safest agent (OR 1.23, 95% CI 0.50-3.14). Sorafenib arose the least renal AEs (placebo vs. OR 0.85, 95% CI 0.06-11.64), whereas lenvatinib plus everolimus had the highest risk of renal toxicity (placebo vs. 0.17 95% CI 0.01-1.02). For gastrointestinal symptoms, everolimus was related to much lower toxicity than other agents. In the respiratory safety analysis, tivozanib (placebo vs. OR 0.15, 95% CI 0.07-0.31) and axitinib (OR 5.43, 95% CI 3.26-9.22) were the riskiest agents. In terms of hepatobiliary (placebo vs. OR 0.44, 95% CI 0.09-2.10) and hemotoxicity (placebo vs. OR 1.03, 95% CI 0.14-7.68) related AEs, lenvatinib was found to be the safest treatment compared to placebo. CONCLUSIONS: Everolimus, with the best safety of grade ≥ 3, gastrointestinal, and respiratory AEs, was more likely to be considered for combination therapies. Lenvatinib appears to be the safest for blood/lymphatic and hepatobiliary AEs. For patients with renal disorders, sorafenib arises the least renal toxicity AEs. This study will guide treatment options and optimize the trial design for advanced or metastatic RCC.

Persistent Depressive Symptoms and the Changes in Serum Cystatin C Levels in the Elderly: A Longitudinal Cohort Study.

Background: The burden of depression in the elderly is increasing worldwide with global aging. However, there is still a lack of research on the relationship between depressive symptoms and the progression of renal function. Our aim is to evaluate the longitudinal association between baseline depressive symptoms and the changes in serum cystatin C levels over 10 years' follow-up period. Methods: We used longitudinal data from the Health and Retirement Study (HRS), an existing community based nationally representative aging cohort study which enrolled individuals over age 50 in the USA. Depressive symptoms were determined using an eight-item version of the Center for Epidemiologic Studies Depression Scale (CESD) at wave 7 (2004) and wave 8 (2006). Persistent depressive symptoms were defined as both CESD scores measured at waves 7 and 8 were ≥3; episodic depressive symptoms were defined as CESD scores ≥3 at wave 7 or wave 8. A linear mixed model was used to evaluate the correlation between baseline depressive symptoms and future changes in cystatin C levels. Results: The mean age of the 7,642 participants was 63.8 ± 10.8 years, and 60.9% were women. Among the participants, 1,240 (16.2%) had episodic depressive symptoms and 778 (10.2%) had persistent depressive symptoms. Compared with participants with no depressive symptoms at both waves, a significant increase in serum cystatin C levels was found among those with persistent depressive symptoms. Conclusions: Our results showed that baseline persistent depressive symptoms were significantly associated with an increased rate of serum cystatin C levels. The level of serum cystatin C should be monitored in the elderly with persistent depressive symptoms.

Case report: Capillary hemangioma in the renal hilum mimicking paraganglioma.

Background: Capillary hemangioma is a common benign tumor in children. Its presence in the kidney is rare, and there have been only case reports in the English literature. Herein, we report a special case of capillary hemangioma located in the renal hilum, which was suspected to be a paraganglioma. Case presentation: A 44-year-old woman had an irregular mass in the right hilar region. She had a history of hypertension for 3 years, and her 24-hour urinary norepinephrine was slightly high (41.53 µg, normal range: 16.69-40.65 µg). Abdominal MRI revealed a mass in the renal hilum measuring approximately 4.8×4.0×3.2 cm, slightly low signal intensity on T1WI, and very high signal intensity on both T2WI and DWI. The multiphase enhanced scan showed that the tumor had obvious enhancement with a central hypointense area. Therefore, paraganglioma was initially diagnosed. Phenoxybenzamine was administered over the next 2 weeks. She performed laparoscopic right hilar area tumor resection, and the kidney was preserved. Unexpectedly, the final pathology report was capillary hemangioma. Conclusions: Capillary hemangioma in the renal hilum is extremely rare. Surgery is the first choice to reduce the risk of compression symptoms and to rule out malignancy with respect to an undefined growing retroperitoneal mass. In addition, renal-sparing surgery should be preferred.

Phenotypical screening on metastatic PRCC-TFE3 fusion translocation renal cell carcinoma organoids reveals potential therapeutic agents.

PURPOSE: Translocation renal cell carcinoma (tRCC) is a subtype that occurs predominantly in children and young individuals. Metastatic tRCC occurring in young patients is more aggressive than that occurring in older patients, and there are still no effective therapies. Organoids can mimic original tissues and be assessed by high-throughput screening (HTS). We aimed to utilize patient-derived organoids and HTS to screen drugs that can be repurposed for metastatic tRCC with PRCC-TFE3 fusion. METHODS: Tumor tissues were obtained from treatment-naïve metastatic tRCC patients who underwent surgery. Histopathology and fluorescence in situ hybridization (FISH) confirmed the tRCC. Organoids derived from the dissected tissues were cultured and verified by FISH and RNA-seq. HTS was performed to seek promising drugs, and potential mechanisms were explored by RNA-seq and cell-based studies. RESULTS: We successfully established a metastatic tRCC organoid with PRCC-TFE3 fusion, a common fusion subtype, and its characteristics were verified by histopathology, FISH, and RNA-seq. An HTS assay was developed, and the robustness was confirmed. A compound library of 1816 drugs was screened. Eventually, axitinib, crizotinib, and JQ-1 were selected for further validation and were found to induce cell cycle arrest and apoptosis. RNA-seq analyses of posttreatment organoids indicated that crizotinib induced significant changes in autophagy-related genes, consistent with the potential pathogenesis of tRCC. CONCLUSIONS: We established and validated organoids derived from tissues dissected from a patient with metastatic tRCC with PRCC-TFE3 fusion and achieved the HTS process for the first time. Crizotinib might be a targeted therapy worthy of exploration in the clinic for metastatic tRCC with PRCC-TFE3 fusion. Such organoid and HTS assays may represent a promising model system in translational research assisting in the development of clinical strategies.

Impact of Primary Tumor Size on Prognosis in Patients With Metastatic Renal Cell Carcinoma Receiving Cytoreductive Nephrectomy: A Population Study of a Chinese Center and the US SEER Database.

BACKGROUND: The relationship between the size of the primary tumor and the prognosis of patients with metastatic renal cell carcinoma (mRCC) is unclear. In this study, we aimed to investigate the significance of the size of the primary tumor in mRCC. METHODS: We retrospectively reviewed the data of patients with mRCC who underwent cytoreductive nephrectomy (CN) from 2006 to 2013 in a Chinese center (n = 96) and those in the Surveillance, Epidemiology, and End Results (SEER) database (from 2004 to 2015, n = 4403). Tumors less than 4 cm in size were defined as small. Prognostic factors were analyzed using univariate and multivariate Cox proportional hazards regression analyses. RESULTS: Patients with small tumors had a longer overall survival than other patients, both in the Chinese cohort (median, 30.0 vs 24.0 months, P = 0.026) and the SEER cohort (median, 43.0 vs 23.0 months, P < 0.001). After adjusting for other significant prognostic factors, small tumor size was still an independent protective factor in the Chinese cohort (adjusted hazard ratio [HR], 0.793; 95% confidence interval [CI]: 0.587-0.998, P = 0.043). In the SEER cohort, multivariate analysis showed that small tumor size was also an independent protective factor (HR, 0.880; 95% CI: 0.654-0.987, P = 0.008). In addition, as a continuous variable, a 1 cm elevation in tumor size translated into a 3.8% higher risk of death (HR, 1.038; 95% CI, 1.029-1.046; P < 0.001). CONCLUSION: Patients with small tumors may have a favorable prognosis after CN for mRCC. Although CN is not a standard protocol in mRCC, small tumor size may be a candidate when we are deciding to perform CN because of the potential benefit for OS.

Ratio of maximum to minimum tumor diameter can predict the pathology type of renal cell carcinoma before surgery.

INTRODUCTION: Previous reports have described several methods and markers used to distinguish pathologic subtypes of renal cell carcinoma (RCC). This study aimed to evaluate the utility of the ratio of maximum to minimum tumor diameter (ROD) in predicting pathologic subtypes of RCC. METHODS: Data from patients with RCC who underwent surgery between January 2015 and December 2019 were reviewed retrospectively. The cutoff value for ROD was calculated using receiver operating characteristic (ROC) curve analysis. RESULTS: In the clear cell RCC (ccRCC) and non-ccRCC groups, the optimal ROD cutoff value to predict ccRCC was determined to be 1.201 (sensitivity, 90.7%; specificity, 76.1%; area under the ROC curve [AUC], 0.827; p < 0.001). In the non-ccRCC group, the cutoff value for ROD in predicting papillary RCC was 1.092 (sensitivity, 87.9%; specificity, 40.5%; AUC, 0.637; p = 0.003). Compared with patients with ROD <1.201, more patients in the ccRCC group exhibited tumors with an ROD ⩾1.201 (14.2% versus 85.8%, respectively; p < 0.001). Multivariate analysis of preoperative features revealed that ROD ⩾1.201 was an independent predictive factor for ccRCC. In addition, patients with ROD ⩾1.201 had higher percentages of Fuhrman grade III/IV (91.2% versus 8.8%; p = 0.014), tumor necrosis (86.7% versus 13.3%; p = 0.012) and sarcomatoid differentiation (90.6% versus 9.4%; p < 0.001). CONCLUSIONS: ROD was a novel indicator for preoperatively predicting histologic type in patients with RCC. ROD cutoff values of 1.201 and 1.092 were the most discriminative for ccRCC and papillary RCC, respectively. Moreover, ROD ⩾1.201 was associated with high Fuhrman grade, sarcomatoid features, and tumor necrosis.

Promising Immunotherapy in Metastatic Testicular Sex Cord Stromal Tumours After First-Line Chemotherapy.

Background: Testicular sex cord stromal tumours (TSCSTs) are rare, with few studies focusing on the metastatic TSCST prognosis. The value of treatments, including radical orchiectomy (RO) and retroperitoneal lymph node dissection (RPLND), in preventing metastasis is controversial. Additionally, metastatic TSCSTs are resistant to chemotherapy. We aimed to assess the effectiveness and safety of immunotherapy in metastatic TSCSTs after first-line chemotherapy. Methods: We retrospectively screened patients with testicular tumours undergoing testis surgery between January 2005 and January 2019. Patients with TSCSTs who had undergone testis-sparing surgery (TSS) or RO were identified. The malignant type was defined as metastasis confirmed by pathology. Treatment responses, progression-free survival (PFS), overall survival (OS) and safety were analysed. Results: Among the 494 testicular tumour patients who received TSS or RO, 11 (2.2%) patients with histologically proven TSCSTs were identified. At the last follow-up, 7 patients survived without tumours, and 4 patients developed metastasis and received first-line cisplatin-based chemotherapy, with 1 of them achieving an objective response. Their PFS times were 1.5, 2.2, 9.0, and 17.0 months, respectively. Two patients received immune checkpoint inhibitors (ICIs) after developing chemotherapy resistance and achieved a partial response up to the last follow-up; one of them experienced Grade 1 adverse events, and the other experienced Grade 2 adverse events during immunotherapy. The median OS time of the 4 patients with metastatic TSCSTs was 32 months. Conclusions: TSCSTs are rare, and most are benign with a good prognosis. ICIs represent a promising option for improving clinical outcomes in metastatic TSCSTs.

Prognostic Significance of NLR About NETosis and Lymphocytes Perturbations in Localized Renal Cell Carcinoma With Tumor Thrombus.

BACKGROUND: Non-metastatic renal cell carcinoma (RCC) with tumor thrombus showed a greater tendency for developing metastases after surgery. Early identification of patients with high risk of poor prognosis is especially important to explore adjuvant treatment of improving outcomes. Neutrophil-to-lymphocyte ratio (NLR) was a systemic inflammation marker and outcome predictor in RCC, reflecting the chaos in systemic immune status in cancer as myeloid cell expansion and lymphatic cell suppression. Neutrophil extracellular traps (NET) formation (NETosis) is the process of neutrophils generating an extracellular DNA net-like structure. NETosis in tumor was demonstrated to conduce to the subsequent metastases of tumor. However, the role of NLR for systemic immune status and tumor local immune infiltration, especially for neutrophil-associated NETs, in non-metastatic RCC with thrombus remains unclear. PATIENTS AND METHODS: In our clinical cohort, we enrolled the clinical, pathologic, and preoperative laboratory parameters of 214 RCC patients with tumor thrombus who were treated surgically. The clinical endpoint was defined as cancer-specific survival (CSS). In our basic research cohort, RNA-seq, TCR-seq, and scRNA-seq data were analyzed. Patients who reached the endpoint as recurrence-free survival (RFS) were defined as the "High-risk" group. Otherwise, they were separated into the "Low-risk" group. RESULTS: In the clinical cohort, NLR≥4 was an independent risk factor for 203 localized RCC with tumor thrombus. In the basic research cohort, tumor thrombi were separated into NETosis-thrombi belonging to the "High-risk" group and non-NETosis-thrombi to the "Low-risk" group. NETs induced by tumor-derived G-CSF in tumor thrombus has a mechanistic role in unfavorable prognosis. Besides, NETs-score from single sample GSEA (ssGSEA) algorithm was an independent prognostic factor validated in the TCGA data. Apart from the neutrophils-associated NETosis, systemic immune perturbations of lymphocytes occurred in the "High-risk" group, represented with decreased TCR diversity and increasingly high proportion of CD4-positive effector memory T (Tem) cells, which indirectly represented the state of lymphopenia. CONCLUSIONS: Our findings firstly demonstrated that neutrophils-associated NETosis and systemic lymphocytes perturbations were considered as tumor progression in patients of localized RCC with tumor thrombus, which reflected NLR≥4 as an independent risk factor for patients.

PD-L1 and VEGFR-2 expression in synchronous metastatic renal cell carcinoma treated with targeted therapy following cytoreductive nephrectomy.

OBJECTIVES: Few studies have independently investigated the population of patients with synchronous metastatic renal cell carcinoma (smRCC). In this study, we evaluated programmed death protein-ligand 1 (PD-L1) and vascular endothelial growth factor receptor 2 (VEGFR-2) expression in primary tumor tissue of smRCC. METHODS: A total of 96 patients with smRCC who were treated with cytoreductive nephrectomy followed by targeted therapy from January 2006 to January 2013 were identified. PD-L1 and VEGFR-2 expression were evaluated by immunohistochemistry. Kaplan-Meier and Cox methods were used for analysis. RESULTS: PD-L1 and VEGFR-2 protein immunopositivity were observed in 39.6% (38 of 96) and 58.3% (56 of 96) of patients, respectively. A significant correlation was detected between VEGFR-2 and PD-L1 expression (P = 0.030). Based on PD-L1 and VEGFR-2 expression, patients with intermediate-risk disease (n = 63) were divided into 4 subgroups including patients who were PD-L1 (+) VEGFR-2 (+) (n = 21), PD-L1 (+) VEGFR-2 (-) (n = 11), PD-L1 (-) VEGFR-2 (+) (n = 15) and PD-L1 (-) VEGFR-2 (-) (n = 16). Compared to the PD-L1 (-) VEGFR-2 (+), PD-L1 (+) VEGFR-2 (+) and PD-L1 (-) VEGFR-2 (-) groups, patients in the PD-L1 (+) VEGFR-2 (-) group had shorter progression-free survival (median, 9.0 vs. 20.0, 16.0 and 15.5 months, P < 0.05) and overall survival (median, 14.0 vs. 33.0, 24.0 and 26.5 months, P < 0.05). CONCLUSIONS: Intermediate-risk smRCC patients with PD-L1-positive and VEGFR-2-negative expression who were treated with targeted therapy following cytoreductive nephrectomy had poor prognoses. We suggest that other treatments beyond sunitinib or sorafenib may be explored in this subgroup.

Neoadjuvant Chemotherapy-Guided Bladder-Sparing Treatment for Muscle-Invasive Bladder Cancer: Results of a Pilot Phase II Study.

PURPOSE: Reduced quality of life after cystectomy has made bladder preservation a popular research topic for muscle-invasive bladder cancer (MIBC). Previous research has indicated significant tumor downstaging after neoadjuvant chemotherapy (NAC). However, maximal transurethral resection of bladder tumor (TURBT) was performed before NAC to define the pathology, impacting the real evaluation of NAC. This research aimed to assess real NAC efficacy without interference from TURBT and apply combined modality therapies guided by NAC efficacy. MATERIALS AND METHODS: Patients with cT2-4aN0M0 MIBC were confirmed by cystoscopic biopsy and imaging. NAC efficacy was assessed by imaging, urine cytology, and cystoscopy with multidisciplinary team discussion. Definite responders (≤ T1) underwent TURBT plus concurrent chemoradiotherapy. Incomplete responders underwent radical cystectomy or partial cystectomy if feasible. The primary endpoint was the bladder preservation rate. RESULTS: Fifty-nine patients were enrolled, and the median age was 63 years. Patients with cT3-4 accounted for 75%. The median number of NAC cycles was three. Definite responders were 52.5%. The complete response (CR) was 10.2%, and 59.3% of patients received bladder-sparing treatments. With a median follow-up of 44.6 months, the 3-year overall survival (OS) was 72.8%. Three-year OS and relapse-free survival were 88.4% and 60.0% in the bladder-sparing group but only 74.3% and 37.5% in the cystectomy group. The evaluations of preserved bladder function were satisfactory. CONCLUSION: After stratifying MIBC patients by NAC efficacy, definite responders achieved a satisfactory bladder-sparing rate, prognosis, and bladder function. The CR rate reflected the real NAC efficacy for MIBC. This therapy is worth verifying through multicenter research.

Responses to Targeted Therapy among Organs Affected by Metastasis in Patients with Renal Cell Carcinoma are Organ-Specific.

PURPOSE: Previous reports showed that targeted therapy efficacy varied due to different metastatic organs in patients with metastatic renal cell carcinoma (mRCC). This study aimed to further evaluate the response and progression-free time (PFT) of individual metastatic organs. MATERIALS AND METHODS: Data from mRCC patients, who were treated with sunitinib between January 2008 to December 2018, were retrospectively reviewed. Individual metastatic organs were assessed separately by The Response Evaluation Criteria in Solid Tumors criteria. RESULTS: We evaluated response heterogeneity and PFT as characteristics of 281 individual organs affected by mRCC in 213 patients. The objective response rates in these organs were 72.7% in pancreas, 63.7% in spleen, 14.3% in adrenal glands, 13.5% in bone and soft tissue, 11.6% in lymph nodes, 11.6% in lungs, and 9.1% in liver. The median PFT was 15.2 months (95% confidence interval [CI] 2.7-27.7 months) for adrenal glands, 13.2 months (95% CI 3.5-22.9 months) for bone and soft tissue, 9.0 months (95% CI 7.6-10.4 months) for lymph nodes, 8.6 months (95% CI 6.3-10.9 months) for lungs, and 5.2 months (95% CI 2.9-7.5 months) for liver. Median PFT was not reached in pancreas and spleen, but was > 22.8 months and > 20.6 months, respectively. CONCLUSION: Our results indicated that organs affected by metastasis may have individual responses to sunitinib treatment. The pancreas and spleen may have the best responses, and liver may have the worst response. Further research is needed to verify these findings.

Pre-operative risk factors predicting missed diagnosis of renal vein tumor thrombus in renal cell carcinoma: a retrospective cohort study.

PURPOSE: Previous reports showed that some patients with renal cell carcinoma (RCC) and renal vein tumor thrombus (RVTT) were misdiagnosed pre-operatively. To improve the accuracy of this diagnosis, the clinical characteristics of RCC with missed RVTT diagnosis were analyzed. METHODS: We retrospectively reviewed RCC patients with RVTT between January 2000 and December 2015. The survival analysis was estimated using the Kaplan-Meier method. The Cox proportional hazard models were applied to identify risk factors. RESULTS: The missed diagnosis rate of RVTT in RCC was 30.5%. In multivariate analysis, maximal tumor diameter, tumor located in the middle part, renal vein contrast agents filling insufficiently and tumor with collateral vessels (odds ratio = 1.22, 1.35, 1.25, 1.22; and p = .034, .003, .015 and .037, respectively) were independent predictors of missed RVTT diagnosis. A missed-diagnosis score was presented as area under curve of 0.852 (p < .001). Moreover, the missed diagnosis group had favorable prognosis, and tumor with collateral vessels was an independent prognostic indicator of poor overall survival time (hazard ratio = 1.15, p = .025). CONCLUSIONS: This was the first study exploring clinical features as predictors of missed RVTT diagnosis. The possibility of complicating tumor thrombus should be considered when there is pre-operative presence of tumor with large diameter, renal tumor in the middle part, renal tumor with collateral vessels and renal vein contrast agents filling insufficiently. Patients with three points in missed-diagnosis scoring suggested a high possibility of missed RVTT diagnosis, and tumor with collateral vessels indicated poor prognosis.

Combination of Hematology Indicators and Oncological Characteristics as a New Promising Prognostic Factor in Localized Clear Cell Renal Cell Carcinoma.

PURPOSE: This study aimed to construct a predictive model for recurrence and metastasis in patients with localized clear cell renal cell carcinoma (ccRCC) based on multiple preoperative blood indexes and oncological characteristics. PATIENTS AND METHODS: Overall, 442 patients with localized ccRCC between 2013 and 2015 were included. Using least absolute shrinkage and selection operator (LASSO) Cox regression analysis, the top three risk factors from the peripheral blood indicators were screened to construct a risk score, and a prognostic model was established. Harrell's concordance index (C-index) was applied to evaluate the predictive accuracy of the model for predicting disease-free survival (DFS) in ccRCC. RESULTS: Out of 38 blood indexes, the top three predictors were fibrinogen (FIB), C-reactive protein (CRP) and neutrophil-lymphocyte ratio (NLR). The FIB-CRP-NLR (FCN) score (hazard ratio [HR]: 1.86, 95% confidence interval [CI]: 1.21-2.9, P = 0.005) was an independent prognostic factor in multivariate analysis. Furthermore, the FIB-CRP-NLR-T-Grade (FCNTG) risk model combining FCN score, T stage and Furhman grade achieved a higher prognostic accuracy (mean C-index, 0.728) than both the FCN score alone (mean C-index, 0.675) and the stage, size, grade, and necrosis (SSIGN) score (mean C-index, 0.686) in the validation cohort. CONCLUSION: The FCN score combining peripheral blood indicators of inflammation and coagulation is an independent prognostic marker of ccRCC. The FCNTG model, which systemically incorporates preoperative blood indexes to oncological characteristics, shows its advantages of convenience and high prediction efficiency.