Volumetric imaging of the tumor microvasculature reflects outcomes and genomic states of clear cell renal cell carcinoma.

Tumor structure is heterogeneous and complex, and it is difficult to obtain complete characteristics by two-dimensional analysis. The aim of this study was to visualize and characterize volumetric vascular information of clear cell renal cell carcinoma (ccRCC) tumors using whole tissue phenotyping and three-dimensional light-sheet microscopy. Here, we used the diagnosing immunolabeled paraffin-embedded cleared organs pipeline for tissue clearing, immunolabeling, and three-dimensional imaging. The spatial distributions of CD34, which targets blood vessels, and LYVE-1, which targets lymphatic vessels, were examined by calculating three-dimensional density, vessel length, vessel radius, and density curves, such as skewness, kurtosis, and variance of the expression. We then examined those associations with ccRCC outcomes and genetic alteration state. Formalin-fixed paraffin-embedded tumor samples from 46 ccRCC patients were included in the study. Receiver operating characteristic curve analyses revealed the associations between blood vessel and lymphatic vessel distributions and pathological factors such as a high nuclear grade, large tumor size, and the presence of venous invasion. Furthermore, three-dimensional imaging parameters stratified ccRCC patients regarding survival outcomes. An analysis of genomic alterations based on volumetric vascular information parameters revealed that PI3K-mTOR pathway mutations related to the blood vessel radius were significantly different. Collectively, we have shown that the spatial elucidation of volumetric vasculature information could be prognostic and may serve as a new biomarker for genomic alterations. High-end tissue clearing techniques and volumetric immunohistochemistry enable three-dimensional analysis of tumors, leading to a better understanding of the microvascular structure in the tumor space.

Downregulation of UBB potentiates SP1/VEGFA-dependent angiogenesis in clear cell renal cell carcinoma.

Clear cell renal cell carcinoma (ccRCC) presents a unique profile characterized by high levels of angiogenesis and robust vascularization. Understanding the underlying mechanisms driving this heterogeneity is essential for developing effective therapeutic strategies. This study revealed that ubiquitin B (UBB) is downregulated in ccRCC, which adversely affects the survival of ccRCC patients. UBB exerts regulatory control over vascular endothelial growth factor A (VEGFA) by directly interacting with specificity protein 1 (SP1), consequently exerting significant influence on angiogenic processes. Subsequently, we validated that DNA methyltransferase 3 alpha (DNMT3A) is located in the promoter of UBB to epigenetically inhibit UBB transcription. Additionally, we found that an unharmonious UBB/VEGFA ratio mediates pazopanib resistance in ccRCC. These findings underscore the critical involvement of UBB in antiangiogenic therapy and unveil a novel therapeutic strategy for ccRCC.

Depiction rate of feeding arteries of renal cell carcinoma on four-dimensional computed tomography angiography.

PURPOSE: To retrospectively evaluate the depiction rate of feeding arteries in biopsy-proven clear cell renal cell carcinoma (CCRCC) on four-dimensional computed tomography angiography (4D-CTA) images. MATERIALS AND METHODS: This study included 22 patients with 22 CCRCC and 30 feeding arteries treated with transcatheter renal artery embolization. The depiction rate of the feeding arteries on preprocedural 4D-CTA was evaluated. Images were acquired by 320-row multi-detector computed tomography (CT) 15‒36 s after starting to inject a contrast agent (600 mg/kg iodine) intravenously into patients at 2.1 s intervals (11 phases). Two board-certified radiologists retrospectively assessed the feeder depiction rate in all 11 phases with reference to the procedural images as the gold standard. Discrepancies were resolved by consultation with a third radiologist. RESULTS: Among the feeders, 11 (36.7%) were segmental or lobar, and 19 (63.3%) were interlobar or arcuate arteries. The feeder depiction rate was the highest (25 [83.3%] of 30) in the 5th phase (delay, 23.4 s) where the gap in contrast enhancement between the renal artery and cortex was the largest. This was followed by the 6th (23 [76.7%] of 30), 4th (22 [73.3%] of 30]), and 7th (21 [70.0%] of 30) phases. The overall rate of depicting feeding arteries in the 11 phases of 4D-CTA was 28 (93.3%) of 30. CONCLUSIONS: The depiction rate of CCRCC feeding arteries including lobar or smaller artery branches by 4D-CTA was favorable. The feeding arteries were optimally visualized during the phase with the largest contrast gap between the renal artery and cortex.

A Novel Three-dimensional Planning Tool for Selective Clamping During Partial Nephrectomy: Validation of a Perfusion Zone Algorithm.

BACKGROUND: Selective clamping during robot-assisted partial nephrectomy (RAPN) requires extensive knowledge on patient-specific renal vasculature, obtained through imaging. OBJECTIVE: To validate an in-house developed perfusion zone algorithm that provides patient-specific three-dimensional (3D) renal perfusion information. DESIGN, SETTING, AND PARTICIPANTS: Between October 2020 and June 2022, 25 patients undergoing RAPN at Ghent University Hospital were included. Three-dimensional models, based on preoperative computed tomography (CT) scans, showed the clamped artery's ischemic zone, as calculated by the algorithm. SURGICAL PROCEDURE: All patients underwent selective clamping during RAPN. Indocyanine green (ICG) was administered to visualize the true ischemic zone perioperatively. Surgery was recorded for a postoperative analysis. MEASUREMENTS: The true ischemic zone of the clamped artery was compared with the ischemic zone predicted by the algorithm through two metrics: (1) total ischemic zone overlap and (2) tumor ischemic zone overlap. Six urologists assessed metric 1; metric 2 was assessed objectively by the authors. RESULTS AND LIMITATIONS: In 92% of the cases, the algorithm was sufficiently accurate to plan a selective clamping strategy. Metric 1 showed an average score of 4.28 out of 5. Metric 2 showed an average score of 4.14 out of 5. A first limitation is that ICG can be evaluated only at the kidney surface. A second limitation is that mainly patients with impaired renal function are expected to benefit from this technology, but contrast-enhanced CT is required at present. CONCLUSIONS: The proposed new tool demonstrated high accuracy when planning selective clamping for RAPN. A follow-up prospective study is needed to determine the tool's clinical added value. PATIENT SUMMARY: In partial nephrectomy, the surgeon has no information on which specific arterial branches perfuse the kidney tumor. We developed a surgeon support system that visualizes the perfusion zones of all arteries on a three-dimensional model and indicates the correct arteries to clamp. In this study, we validate this tool.

Percutaneous image-guided cryoablation with temporary balloon occlusion of the renal artery for the treatment of central renal tumors.

PURPOSE: The purpose of this study was to report the technical feasibility and outcomes of percutaneous image-guided cryoablation with temporary balloon occlusion of the renal artery for the treatment of central renal tumors. MATERIALS AND METHODS: All consecutive patients with central renal tumors treated with cryoablation and temporary renal artery occlusion from January 2017 to October 2021 were retrospectively included. Patient demographics, tumor's characteristics, procedural data, technical success, primary and secondary clinical efficacy, complications (according to Cardiovascular and Interventional Radiology Society of Europe [CIRSE] classification) and follow-up were investigated. RESULTS: A total of 14 patients (8 men, 6 women; mean age 72.4 years ± 21.4 [SD] years; age range: 42-93 years) with 14 central renal tumors (median size, 32 mm; IQR: 23.5, 39.5 mm; range: 13-50 mm) were treated with percutaneous image-guided cryoablation and temporary balloon occlusion of the renal artery. Technical success was 13/14 (93%), with 1/14 (7%) failure of vascular access. A median of 4 cryoprobes (IQR: 3, 4.75) were inserted and protective hydrodissection was performed in 11/14 (79%) patients. Median time to perform cryoprobes insertion, hydrodissection and vascular access was 26.5 min (IQR: 18, 35 min), 10 min (IQR: 10, 17 min) and 30 min (IQR: 20, 45 min) respectively. Median duration of the whole intervention was 150 min (IQR: 129, 180 min; range: 100-270 min). Median hospital stay was 2.5 days (IQR: 2, 4 days; range: 2-14 days). Major complications occurred in 3/14 (21%) patients. Primary efficacy rate was 93% (13/14 patients). Median oncological follow-up was 25 months (IQR: 11, 33 months; range: 6-39 months). One patient experienced renal tumor recurrence at 14-months of follow-up, which was successfully treated with repeat cryoablation. CONCLUSION: Percutaneous image-guided cryoablation of renal tumors with temporary balloon occlusion of the renal artery is technically feasible, with a high technical success rate and paths the way for percutaneous treatment of central renal tumors.

N6-methyladenosine-modified TRAF1 promotes sunitinib resistance by regulating apoptosis and angiogenesis in a METTL14-dependent manner in renal cell carcinoma.

BACKGROUND: Sunitinib resistance can be classified into primary and secondary resistance. While accumulating research has indicated several underlying factors contributing to sunitinib resistance, the precise mechanisms in renal cell carcinoma are still unclear. METHODS: RNA sequencing and m6A sequencing were used to screen for functional genes involved in sunitinib resistance. In vitro and in vivo experiments were carried out and patient samples and clinical information were obtained for clinical analysis. RESULTS: We identified a tumor necrosis factor receptor-associated factor, TRAF1, that was significantly increased in sunitinib-resistant cells, resistant cell-derived xenograft (CDX-R) models and clinical patients with sunitinib resistance. Silencing TRAF1 increased sunitinib-induced apoptotic and antiangiogenic effects. Mechanistically, the upregulated level of TRAF1 in sunitinib-resistant cells was derived from increased TRAF1 RNA stability, which was caused by an increased level of N6-methyladenosine (m6A) in a METTL14-dependent manner. Moreover, in vivo adeno-associated virus 9 (AAV9) -mediated transduction of TRAF1 suppressed the sunitinib-induced apoptotic and antiangiogenic effects in the CDX models, whereas knockdown of TRAF1 effectively resensitized the sunitinib-resistant CDXs to sunitinib treatment. CONCLUSIONS: Overexpression of TRAF1 promotes sunitinib resistance by modulating apoptotic and angiogenic pathways in a METTL14-dependent manner. Targeting TRAF1 and its pathways may be a novel pharmaceutical intervention for sunitinib-treated patients.

Anti-chloride Intracellular Channel Protein 1 (CLIC1) Antibodies Induce Tumour Necrosis and Angiogenesis Inhibition on In Vivo Experimental Models of Human Renal Cancer.

BACKGROUND/AIM: Chloride intracellular channel protein 1 (CLIC1) is known as a promoter of cancer progression, metastasis, and angiogenesis. Thus, CLIC1 could be a future therapeutic target. This study aimed to evaluate the effect of anti-CLIC1 antibodies on tumour cells and vessels of human renal cell carcinoma (RCC) in rabbit cornea and chick embryo chorioallantoic membrane (CAM) models. MATERIALS AND METHODS: Human cc-RCC xenografts on rabbit cornea and CAM surface were performed. Anti-CLIC1 antibodies were applied for 5 consecutive days on both tumor models. We comparatively evaluated treated and untreated tumors by combining ultrasonography with microscopic techniques. RESULTS: RCC implants rapidly recruited blood vessels and had an exponential growth rate on both tumor models. Anti-CLIC1 antibodies suppressed tumor growth by inducing tumor cell necrosis. Tumor vessels regressed rapidly but not completely during anti-CLIC1 antibodies based therapy. CONCLUSION: Anti-CLIC1 antibodies induced tumor necrosis and tumor vasculature regression in human cc-RCC xenografts in both in vivo experimental models.

Step-by-step and orderly lowering of the height of inferior vena cava tumor thrombus is the key to robot-assisted thrombectomy for Mayo III/IV tumor thrombus.

BACKGROUND: The surgical management of Mayo III/IV tumor thrombi is difficult and risky, and robotic surgery is even more difficult. The purpose of this study was to introduce the step-by-step and orderly lowering of the height of inferior vena cava tumor thrombus, which was the core technique of robot operation for Mayo III/IV tumor thrombus. METHOD: A total of 18 patients were included in this study. The average tumor thrombus height was 2.4 cm above the level of the second porta hepatis (SPH), and 9 patients were prepared for cardiopulmonary bypass (CPB) before surgery. During the operation, the height of the tumor thrombus was lowered orderly for 2-3 times, and the blood flow blocking method was changed sequentially. The CPB was required when tumor thrombus in the atrium; After the height of the thrombus was lowered to the atrium entrance, CPB was stopped and the blood flow was blocked in the upper- and retro-hepatic inferior vena cava (IVC); After the tumor thrombus continued to descend to the lower part of the SPH, liver blood flow could be restored, and then, the blood flow was simply blocked in the retro-hepatic IVC to complete the removal of the thrombus and the repair or resection of the IVC. Finally, the diseased kidney and renal vein were removed. RESULTS: All operations were successfully completed, and 2 cases were transferred to laparotomy. Seven cases received CPB, while the other 11 did not. 15 patients underwent two times of the lowering of the tumor thrombus, 2 patients underwent one time and 1 patient underwent three times. The mean liver/IVC dissociation and vascular suspension time was 22.0 min. All patients had less than Clavien-Dindo grade III complications, no serious complications occurred during operation, and no patient died within 90 days. CONCLUSIONS: The step-by-step and orderly decline of tumor thrombus height is the key to the success of robot Mayo III / IV tumor thrombus surgery. This method can shorten FPH and CPB time and improve the success rate of surgery.

Dynamic contrast-enhanced CT-derived blood flow measurements enable early prediction of long term outcome in metastatic renal cell cancer patients on antiangiogenic treatment.

PURPOSE: To evaluate the role of dynamic contrast-enhanced CT (DCE-CT) as an independent non-invasive biomarker in predicting long term outcome in patients with metastatic renal cell carcinoma (mRCC) on antiangiogenic treatment. MATERIAL AND METHODS: Eighty two mRCC patients were prospectively enrolled from 09/2011 to 04/2015, out of which 71 were included in the final data analysis; the population was observed until 12/2020 to obtain complete overall survival data. DCE-CT imaging was performed at baseline and 10 to 12 weeks after start of treatment with targeted therapy. DCE-CT included a dynamic acquisition after injection of 50 ml of nonionic contrast agent at 6 ml/s using a 4D spiral mode (10 cm z-axis coverage, acquisition time 43 sec, 100 kVp (abdomen), 80 kVp (chest), 80-100 mAs) on a dual source scanner (Definition FLASH, Siemens). Blood flow (BF) was calculated for target tumor volumes using a deconvolution model. Progression free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier statistics (SPSS version 24). RESULTS: Patients were treated with either sunitinib, pazopanib, sorafenib, tivozanib, axitinib, or cabozantinib. A cut-off value of 50% blood flow reduction at follow-up allowed for identification of patients with favorable long-term outcome: Median OS in n = 42 patients with an average blood flow reduction of >50% (mean, 79%) was 34 (range, 14-54) months, while n = 21 patients with an average reduction of less than 50% (mean, 28%) showed a median OS of 12 (range, 6-18) months, and n = 8 patients with an increase in blood flow survived for a median of 7 (range, 3-11) months. CONCLUSION: Blood flow in metastases measured with DCE-CT at first follow-up is a strong predictor of overall survival in mRCC patients on antiangiogenic treatment.

Clinical Outcomes of Robotic Assisted Partial Nephrectomy for Pathologic T3a Renal Masses With Venous Tumor Thrombus.

OBJECTIVE: To evaluate the safety, efficacy, and early oncologic outcomes of pathologic T3a (pT3a) renal cell carcinoma with venous involvement treated with robotic partial nephrectomy (RPN), given that experience and outcomes in this group is limited. METHODS: A retrospective chart review of patients undergoing RPN from September 2009 to July 2020 was performed. Outcomes were captured from patients with pT3a disease with vein involvement. Clinical characteristics were analyzed using SPSS (IBM, Armonk, NY). Local recurrence-free survival and metastasis-free survival at 2 years were calculated from Kaplan-Meier survival curves. RESULTS: For 45 included patients, mean operative and warm ischemia times were 199.6 ± 47.3 minutes and 30.5 ± 10.5 minutes, with mean estimated blood loss of 324.9 ± 209.5 cc. Rates of transfusion, embolization, re-admission, and re-operation at 30 days were 8.9% (4/45), 2.2% (1/45), 11.1% (5/45), and 6.7% (3/45; cystoscopic stent placement), respectively. All tumors were malignant on pathology, with clear cell renal cell carcinoma being the most common (91.0%, n = 41). The positive margin rate was 6.7% (n = 3). Local recurrence occurred in 4.4% (n = 2) at a mean time of 5.2 ± 2.3 months. Four patients (8.9%) progressed to metastatic disease at a mean of 22.2 ± 23.0 months. At 2 years, local recurrence-free survival was 95.4% and metastasis-free survival was 95.3%. CONCLUSION: We present the largest known series of patients RPN for pT3a renal masses with venous tumor involvement. We found it both feasible and safe in the appropriate hands. Short term oncologic outcomes for these patients appear more favorable than historic literature suggested.

Novel Volumetric and Morphological Parameters Derived from Three-dimensional Virtual Modeling to Improve Comprehension of Tumor's Anatomy in Patients with Renal Cancer.

BACKGROUND: Three-dimensional (3D) models improve the comprehension of renal anatomy. OBJECTIVE: To evaluate the impact of novel 3D-derived parameters, to predict surgical outcomes after robot-assisted partial nephrectomy (RAPN). DESIGN, SETTING, AND PARTICIPANTS: Sixty-nine patients with cT1-T2 renal mass scheduled for RAPN were included. Three-dimensional virtual modeling was achieved from computed tomography. The following volumetric and morphological 3D parameters were calculated: VT (volume of the tumor); VT/VK (ratio between tumor volume and kidney volume); CSA3D (ie, contact surface area); UCS3D (contact to the urinary collecting system); Tumor-Artery3D: tumor's blood supply by tertiary segmental arteries (score = 1), secondary segmental artery (score = 2), or primary segmental/main renal artery (scoren = 3); ST (tumor's sphericity); ConvT (tumor's convexity); and Endophyticity3D (ratio between the CSA3D and the global tumor surface). INTERVENTION: RAPN with a 3D model. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Three-dimensional parameters were compared between patients with and without complications. Univariate logistic regression was used to predict overall complications and type of clamping; linear regression was used to predict operative time, warm ischemia time, and estimated blood loss. RESULTS AND LIMITATIONS: Overall, 11 (15%) individuals experienced overall complications (7.2% had Clavien ≥3 complications). Patients with urinary collecting system (UCS) involvement at 3D model (UCS3D = 2), tumor with blood supply by primary or secondary segmentary arteries (Tumor-Artery3D = 1 and 2), and high Endophyticity3D values had significantly higher rates of overall complications (all p ≤ 0.03). At univariate analysis, UCS3D, Tumor-Artery3D, and Endophyticity3D are significantly associated with overall complications; CSA3D and Endophyticity3D were associated with warm ischemia time; and CSA3D was associated with selective clamping (all p ≤ 0.03). Sample size and the lack of interobserver variability are the main limits. CONCLUSIONS: Three-dimensional modeling provides novel volumetric and morphological parameters to predict surgical outcomes after RAPN. PATIENT SUMMARY: Novel morphological and volumetric parameters can be derived from a three-dimensional model to describe surgical complexity of renal mass and to predict surgical outcomes after robot-assisted partial nephrectomy.

FGD5 regulates endothelial cell PI3 kinase-ß to promote neo-angiogenesis.

Angiogenesis is required in embryonic development and tissue repair in the adult. Vascular endothelial growth factor (VEGF) initiates angiogenesis, and VEGF or its receptor is targeted therapeutically to block pathological angiogenesis. Additional pro-angiogenic cues, such as CXCL12 acting via the CXCR4 receptor, co-operate with VEGF/VEGFR2 to cue vascular patterning. We studied the role of FGD5, an endothelial Rho GTP/GDP exchange factor (RhoGEF), to regulate CXCR4-dependent signals in the endothelial cell (EC). Patient-derived renal cell carcinomas produce a complex milieu of growth factors that stimulated sprouting angiogenesis and endothelial tip cell differentiation ex vivo that was blocked by EC FGD5 loss. In a simplified model, CXCL12 augmented sprouting and tip gene expression under conditions where VEGF was limiting. CXCL12-stimulated tip cell differentiation was dependent on PI3 kinase (PI3K)-ß activity. Knockdown of EC FGD5 abolished CXCR4 signaling to PI3K-ß and Akt. Further, inhibition of Rac1, a Rho GTPase required for PI3K-ß activity, recapitulated the signaling defects of FGD5 deficiency, suggesting that FGD5 may regulate PI3K-ß activity through Rac1. Overexpression of a RhoGEF deficient, Dbl domain-deleted FGD5 mutant reduced CXCL12-stimulated Akt phosphorylation and failed to rescue PI3K signaling in native FGD5-deficient EC, indicating that FGD5 RhoGEF activity is required for FDG5 function. Endothelial expression of mutant PI3K-ß with an inactivated Rho binding domain confirmed that CXCL12-stimulated PI3K activity in EC requires Rac1-GTP co-regulation. Together, this data identify the role of FGD5 to generate Rac1-GTP to regulate pro-angiogenic CXCR4-dependent PI3K-ß signaling in EC. Inhibition of FGD5 activity may complement current angiogenesis inhibitor drugs.

The WIRE study a phase II, multi-arm, multi-centre, non-randomised window-of-opportunity clinical trial platform using a Bayesian adaptive design for proof-of-mechanism of novel treatment strategies in operable renal cell cancer - a study protocol.

BACKGROUND: Window-of-opportunity trials, evaluating the engagement of drugs with their biological target in the time period between diagnosis and standard-of-care treatment, can help prioritise promising new systemic treatments for later-phase clinical trials. Renal cell carcinoma (RCC), the 7th commonest solid cancer in the UK, exhibits targets for multiple new systemic anti-cancer agents including DNA damage response inhibitors, agents targeting vascular pathways and immune checkpoint inhibitors. Here we present the trial protocol for the WIndow-of-opportunity clinical trial platform for evaluation of novel treatment strategies in REnal cell cancer (WIRE). METHODS: WIRE is a Phase II, multi-arm, multi-centre, non-randomised, proof-of-mechanism (single and combination investigational medicinal product [IMP]), platform trial using a Bayesian adaptive design. The Bayesian adaptive design leverages outcome information from initial participants during pre-specified interim analyses to determine and minimise the number of participants required to demonstrate efficacy or futility. Patients with biopsy-proven, surgically resectable, cT1b+, cN0-1, cM0-1 clear cell RCC and no contraindications to the IMPs are eligible to participate. Participants undergo diagnostic staging CT and renal mass biopsy followed by treatment in one of the treatment arms for at least 14 days. Initially, the trial includes five treatment arms with cediranib, cediranib + olaparib, olaparib, durvalumab and durvalumab + olaparib. Participants undergo a multiparametric MRI before and after treatment. Vascularised and de-vascularised tissue is collected at surgery. A ≥ 30% increase in CD8+ T-cells on immunohistochemistry between the screening and nephrectomy is the primary endpoint for durvalumab-containing arms. Meanwhile, a reduction in tumour vascular permeability measured by Ktrans on dynamic contrast-enhanced MRI by ≥30% is the primary endpoint for other arms. Secondary outcomes include adverse events and tumour size change. Exploratory outcomes include biomarkers of drug mechanism and treatment effects in blood, urine, tissue and imaging. DISCUSSION: WIRE is the first trial using a window-of-opportunity design to demonstrate pharmacological activity of novel single and combination treatments in RCC in the pre-surgical space. It will provide rationale for prioritising promising treatments for later phase trials and support the development of new biomarkers of treatment effect with its extensive translational agenda. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03741426 / EudraCT: 2018-003056-21 .

Vascular architectural patterns in clear cell renal cell carcinoma and clear cell papillary renal cell carcinoma.

Renal cell carcinomas (RCC) are well-vascularized tumors. Although clear cell RCC (CCRCC) show a characteristic vascular network, some cases show overlapping features with other RCC. We aimed to evaluate vascular architectural patterns, microvessel density (MVD), and endothelial cell density (ECD) in CCRCC compared to clear cell papillary RCC (ccpRCC). Thirty-four RCC (17 CCRCC and 17 ccpRCC) were included in the study. CD34 was used to evaluate vascular architectural patterns by microscopic estimation in all cases. CD34, ERG, and Bioquant Osteo 2019 Imaging Analysis Software were used to evaluate MVD and ECD in 17 CCRCC and 15 ccpRCC. Mean MVD was 526.63 in CCRCC vs. 426.18 in ccpRCC (p = 0.16); mean ECD was 937.50 in CCRCC vs. 1060.21 in ccpRCC (p = 0.25). CD34 highlighted four distinct vascular architectural patterns: pseudoacinar, Golgi-like, lacunae, and scattered. Lacunae and pseudoacinar was the most frequent combination in CCRCC; lacunae and Golgi-like was the predominant combination among ccpRCC. Pseudoacinar was most extensive in CCRCC and least in ccpRCC; Golgi-like was predominant in ccpRCC and uncommon in CCRCC. The extent of pseudoacinar and Golgi-like vascular architectural patterns was significantly different between CCRCC and ccpRCC (p < 0.05). Pathologists acquainted with these different vascular architectural patterns may utilize them as an additional tool in the distinction of CCRCC from ccpRCC.

[Criteria for an improved prognostic stratification in category pT renal carcinoma]. / La Categoría Tumor en el carcinoma renal. Criterios morfológicos para una mejor estratificación pronóstica.

Asymptomatic renal carcinomas are usually small and localized and thus, for the assessment of pT, precise criteria are required, able to identify the initial phases of a local extension and correlate them with current prognostic prospects. Various studies and consensus meetings have defined precisely how to measure tumoral nodules (solid, cystic and multiple). Furthermore, they have distinguished tumoral extension to the renal sinus, which has a worse prognosis, from that to the perirenal adipose tissue. They have also analyzed the clinical significance of invasion of the sinus vessels, the hilar veins and parenchymal vascular retroinvasion. Our aim is to revise and update the criteria of the different pT subcategories and consider those morphological aspects which could be clinically significant and that are not currently included in the TNM classification.

The efficacy evaluation of partial nephrectomy with selective renal artery branch occlusion by laparoscopy.

BACKGROUND: To investigate the clinical application and effect of laparoscopic partial nephrectomy with renal artery branch occlusion in the treatment of early renal tumors. METHODS: A retrospective analysis was conducted on the clinical data of 15 cases of renal tumor patients who underwent partial nephrectomy by laparoscopic selective renal artery branch occlusion in our department from January 2017 to January 2018. Nine male patients and 6 female patients were aged 46 to 65 years, with an average age of 54.3 ±â€Š7.2 years. The diameters of tumors were 2.2 to 4.0 cm, with an average of 3.3 ±â€Š0.7 cm. There are 10 tumors locating on the left side and 5 on the right side. Preoperative renal glomerular filtration rate (GFR) were 77.3 to 61.9 mL/min with an average of 47.6 ±â€Š7.5 mL/min. All patients' diseased kidneys underwent renal computer tomography angiography examination before surgery. And the diseased kidney underwent reexamination of renal GFR. The operation time, renal artery branch occlusion time, intraoperative blood loss, postoperative hospital stay, changes of renal function, and complications were evaluated. RESULTS: All surgery were completed successfully, the surgery time was 136.7 ±â€Š15.2 min, intraoperative renal artery branch occlusion time was 21.3 ±â€Š4.5 min, the intraoperative blood loss was 223.3 ±â€Š69.5 mL, the postoperative hospital stay was 6.5 ±â€Š1.7 days, and the postoperative 1-month GFR was 49.5 ±â€Š6.6 mL/min. There was no significant difference between the renal GFR before and after surgery (P > .05). There was no blood transfusion and transfer open surgery cases. The patients were followed up for 3 to 15 months without complications. CONCLUSIONS: Partial nephrectomy with selective renal artery branch occlusion by laparoscopy is a safe, feasible, and effective method for the treatment of early renal cancer. It makes good use of the technical advantages of clear operation field and fine operation of laparoscopic surgery, avoids the heat ischemia process of the whole kidney, and can better protect the renal function.

Surgically induced ischemia has no impact on protein expression levels of HIF-1α and related biomarkers in renal cell carcinoma.

The increasing demands for personalized targeted therapy directed against renal cell carcinoma have driven a search for predictive markers. Novel therapies targeting HIF-1α in renal cell carcinoma have been developed, and HIF-1α has been suggested as a novel predictive marker of response to therapy. The surgical resection of a kidney tumor induces tissue ischemia, and HIF-1α is an oxygen-sensitive transcription factor, which is known to be upregulated during hypoxia. This study investigated the impact of intra-surgical and post-surgical ischemia on protein expression levels of HIF-1α and three related biomarkers (VEGF, GLUT-1, and CAIX) in 20 patients with renal cell carcinoma with immunohistochemistry and Western blotting. Surgical ischemia did not have a significant impact on protein expression levels of any of the investigated markers. Long-post-surgical ischemia resulted in reduced expression levels of HIF-1α, probably due to autolysis. Our results suggest that HIF-1α is a stable protein, with expression levels not affected by intra-surgical ischemia, and hence, HIF-1α is suited for marker analysis.

Varying Outcomes among Patients with Large Angiomyolipomas according to the Treatment Method.

PURPOSE: This study aimed to evaluate the outcomes of large angiomyolipoma (AML) treatment by selective arterial embolization (SAE) versus nephron-sparing surgery (NSS) using a robotic surgical system. MATERIALS AND METHODS: Between January 2011 and June 2018, we retrospectively reviewed 25 patients who underwent robot-assisted partial nephrectomy (RAPN) or SAE for large AMLs. Ten patients underwent RAPN, and 15 underwent SAE. Patient demographics, AML characteristics, and operative and postoperative clinical outcomes were recorded and analyzed. Outcomes were compared between patients who underwent RAPN and patients who underwent SAE. Specifically, changes in renal function and size were evaluated after the treatment. RESULTS: The mean age of the patients was 52.9 years, and 22 of 25 patients were female. The mean maximum AML diameter on computed tomography was 8.9 cm, and 8 patients had multiple masses. Twenty-two of 25 patients had moderate to high RENAL complexity. Patients who underwent SAE had more symptoms (p = 0.018) and higher RENAL complexity scores (p = 0.013) on average. On average, tumor size decreased by 99% among RAPN patients and by 58% among SAE patients (p = 0.001). Although the mean pretreatment estimated glomerular filtration rate (eGFR) was higher among RAPN patients (99.8 vs. 80.0 mL/min/1.73 m2, p = 0.043), there were no significant changes in eGFR in either group after the treatment. One patient in the RAPN group experienced complications, but the postoperative ileus resolved without intervention. CONCLUSIONS: Both RAPN and SAE were effective and feasible treatment options for large AMLs. The AML characteristics and the condition of the patient might be important in determining the appropriate treatment method.

Multi-omics analysis of tumor angiogenesis characteristics and potential epigenetic regulation mechanisms in renal clear cell carcinoma.

BACKGROUND: Tumor angiogenesis, an essential process for cancer proliferation and metastasis, has a critical role in prognostic of kidney renal clear cell carcinoma (KIRC), as well as a target in guiding treatment with antiangiogenic agents. However, tumor angiogenesis subtypes and potential epigenetic regulation mechanisms in KIRC patient remains poorly characterized. System evaluation of angiogenesis subtypes in KIRC patient might help to reveal the mechanisms of KIRC and develop more target treatments for patients. METHOD: Ten independent tumor angiogenesis signatures were obtained from molecular signatures database (MSigDB) and gene set variation analysis was performed to calculate the angiogenesis score in silico using the Cancer Genome Atlas (TCGA) KIRC dataset. Tumor angiogenesis subtypes in 539 TCGA-KIRC patients were identified using consensus clustering analysis. The potential regulation mechanisms was studied using gene mutation, copy number variation, and differential methylation analysis (DMA). The master transcription factors (MTF) that cause the difference in tumor angiogenesis signals were completed by transcription factor enrichment analysis. RESULTS: The angiogenesis score of a prognosis related angiogenesis signature including 189 genes was significantly correlated with immune score, stroma score, hypoxia score, and vascular endothelial growth factor (VEGF) signal score in 539 TCGA KIRC patients. MMRN2, CLEC14A, ACVRL1, EFNB2, and TEK in candidate gene set showed highest correlation coefficient with angiogenesis score in TCGA-KIRC patients. In addition, all of them were associated with overall survival in both TCGA-KIRC and E-MTAB-1980 KIRC data. Clustering analysis based on 183 genes in angiogenesis signature identified two prognosis related angiogenesis subtypes in TCGA KIRC patients. Two clusters also showed different angiogenesis score, immune score, stroma score, hypoxia score, VEGF signal score, and microenvironment score. DMA identified 59,654 differential methylation sites between two clusters and part of these sites were correlated with tumor angiogenesis genes including CDH13, COL4A3, and RHOB. In addition, RFX2, SOX13, and THRA were identified as top three MTF in regulating angiogenesis signature in KIRC patients. CONCLUSION: Our study indicate that evaluation the angiogenesis subtypes of KIRC based on angiogenesis signature with 183 genes and potential epigenetic mechanisms may help to develop more target treatments for KIRC patients. Video Abstract.

Renal intravascular large B-cell lymphoma predominantly localized in peritubular capillaries.

We report on a 70-year-old woman with intravascular large B-cell lymphoma, in whom the renal lesion was localized in the peritubular capillaries. The patient complained of fatigue, general malaise, and unsteadiness when walking. Laboratory tests showed anemia, increased C-reactive protein, and mild renal failure, with a serum creatinine level of 1.31 mg/dL and no remarkable proteinuria or hematuria. Renal biopsy showed intravascular large B-cell lymphoma. The large atypical cells were mainly accumulated within the peritubular capillaries and no large atypical cells were found in the glomeruli. Skin and bone marrow biopsies confirmed intravascular large B-cell lymphoma. Brain magnetic resonance imaging showed multiple small infarctions in the cerebral white matter. The patient was treated with dexamethasone, methotrexate, and cytarabine followed by CHOP (combined cyclophosphamide, doxorubicin, vincristine, and prednisone) and R-CHOP (CHOP with the recombinant anti-CD20 antibody rituximab), and her renal function improved soon after the start of chemotherapy.