The superior prognostic value of humoral factors compared with molecular proliferation markers in renal cell carcinoma

Proliferative potential and response to nivolumab in clear cell renal cell carcinoma patients

Background

Biomarkers predicting immunotherapy response in metastatic renal cell cancer (mRCC) are lacking. PD-L1 immunohistochemistry is a complementary diagnostic for immune checkpoint inhibitors (ICIs) in mRCC, but has shown minimal clinical utility and is not used in routine clinical practice.

Methods

Tumor specimens from 56 patients with mRCC who received nivolumab were evaluated for PD-L1, cell proliferation (targeted RNA-seq), and outcome.

Results

For 56 patients treated with nivolumab as a standard of care, there were 2 complete responses and 8 partial responses for a response rate of 17.9%. Dividing cell proliferation into tertiles, derived from the mean expression of 10 proliferation-associated genes in a reference set of tumors, poorly proliferative tumors (62.5%) were more common than moderately (30.4%) or highly proliferative (8.9%) counterparts. Moderately proliferative tumors were enriched for PD-L1 positive (41.2%), compared to poorly proliferative counterparts (11.4%). Objective response for moderately proliferative (29.4%) tumors was higher than that of poorly (11.4%) proliferative counterparts, but not statistically significant (p = .11). When cell proliferation and negative PD-L1 tumor proportion scores were combined statistically significant results were achieved (p = .048), showing that patients with poorly proliferative and PD-L1 negative tumors have a very low response rate (6.5%) compared to moderately proliferative PD-L1 negative tumors (30%).

Conclusions

Cell proliferation has value in predicting response to nivolumab in clear cell mRCC patients, especially when combined with PD-L1 expression. Further studies which include the addition of progression-free survival (PFS) along with sufficiently powered subgroups are required to further support these findings.

Prognostic and clinicopathological value of Ki-67/MIB-1 expression in renal cell carcinoma: a meta-analysis based on 4579 individuals

Background

Previous studies have investigated the prognostic significance of Ki-67/MIB-1 expression in renal cell carcinoma (RCC), however, the reports are controversial and inconsistent. This study aimed to investigate Ki-67/MIB-1 expression in RCC and its correlation with prognosis and clinicopathological features.

Methods

We searched relevant studies that reported associations between Ki-67/MIB-1 expression and prognosis in RCC from PubMed, Embase, Web of Science, and Cochrane Library studies published until April 14, 2017. Hazard ratios (HRs) and 95% confidence intervals (CIs) were extracted from eligible studies. Fixed and random effects models were used to calculate pooled HRs and 95% CIs according to heterogeneity.

Results

A total of 4579 participants from 23 eligible studies were included in this analysis. The results showed that Ki-67/MIB-1 expression was associated with poor overall survival (HR=2.06, 95% CI: 1.64-2.57) and cancer specific survival (HR=2.01, 95% CI: 1.66-2.44). In addition, Ki-67/MIB-1 expression was also correlated with TNM stage (III/IV vs I/II: OR=1.92, 95% CI: 1.61-2.28), pathological T stage (pT3/pT4 vs pT1/pT2: OR=1.56, 95% CI: 1.21-2.02), distant metastasis (M1 vs M0: OR=1.81, 95% CI: 1.34-2.43), and Fuhrman grade (III/IV vs I/II: OR=1.94, 95% CI: 1.21-3.10).

Conclusion

Our study demonstrates that the presence of high Ki-67/MIB-1 expression and advanced clinicopathological features were correlated with poor prognosis in RCC patients.

Prognostic and clinicopathological role of high Ki-67 expression in patients with renal cell carcinoma: a systematic review and meta-analysis

Previous studies have elevated the prognostic value of Ki-67 in renal cell carcinoma (RCC), but the reports are controversial and inconsistent. We conducted a systematic review and meta-analysis to clarify the significance of Ki-67 in RCC prognosis. We systematically searched PubMed, Web of Science, and Embase to identify relevant studies until April 2016. Based on the inclusion and exclusion criteria, 20 studies, including 5,398 patients, were eligible for further analysis. Results showed that high Ki-67 expression in RCC was associated with poor OS (HR = 1.95, 95% CI: 1.44–2.64), CSS (HR = 1.67, 95% CI: 1.47–1.89), and DFS (HR = 2.56, 95% CI: 1.79–3.67). In addition, high Ki-67 expression was significantly associated with TNM stage (III/IV vs. I/II: RR = 2.03, 95% CI: 1.68–2.44), pathological T stage (T3/T4 vs. T1/T2: RR = 1.67, 95% CI: 1.35–2.06), metastasis (yes vs. no: RR = 2.15, 95% CI: 1.77–2.62), and Fuhrman grade (III/IV vs. I/II: RR = 1.77, 95% CI: 1.20–2.60). Our study suggested that Ki-67 was a prognostic marker in RCC. High Ki-67 expression was correlated with poor prognosis and advanced clinicopathological features, and it could serve as a biomarker for disease management.

Prognostic Value of Serum Lactate Dehydrogenase in Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Recently, many studies have shown that the serum lactate dehydrogenase (LDH) level is related to the prognosis of renal cell carcinoma (RCC). We launched this meta-analysis to assess the prognostic value of serum LDH in patients with RCC.

METHODS

We searched PubMed, Embase and Web of Science for information on serum LDH and the outcome of RCC through June 14, 2016. The hazard ratio (HR) and its 95% confidence interval (CI) for overall survival (OS) and progression-free survival (PFS) were extracted and integrated from the matching studies.

RESULTS

A total of 29 studies including 6629 patients with RCC were incorporated in this meta-analysis. Patients whose serum LDH levels were elevated had a lower OS (HR = 2.13, 95% CI = 1.69-2.69, P < 0.001). Meanwhile, the pooled data showed that a higher serum LDH level was a negative prognostic factor for PFS (HR = 1.74, 95% CI = 1.48-2.04, P < 0.001). Furthermore, subgroup analyses indicated elevated serum LDH was associated with poor survival in different tumor types. Elevated serum LDH was significantly associated with worse prognosis for patients with all stages of RCC (OS, HR = 2.41, 95% CI = 1.09-5.33), metastatic RCC (OS, HR = 2.62, 95% CI 1.57-2.59; CSS, HR = 1.79, 95% CI 1.49-2.15), and non-metastatic RCC (OS, HR = 3.67, CI = 1.33-10.13). Besides, elevated serum LDH also indicated a worse prognosis in subgroups of cut-off values, analysis types and ethnicity.

CONCLUSIONS

Our results show that serum LDH levels are associated with the outcomes of RCC and can be used as a valuable biomarker for monitoring prognoses.

Prognostic serum markers in patients with high-grade upper tract urothelial carcinoma

INTRODUCTION

The role of preoperative serum-based markers in predicting survival outcomes of patients has been reported for several cancer types; however, their association with upper tract urothelial carcinoma (UTUC) prognosis is unclear. We evaluated the role of systemic serum-based markers in predicting adverse pathological features and survival outcomes in patients surgically treated for high-grade (HG) UTUC.

METHODS

We retrospectively reviewed all patients undergoing surgery for HG UTUC between June 2006 and July 2013 at our institution. Comprehensive clinicopathologic data and preoperative serum-based markers including hemoglobin, white blood cell count, platelet count, serum albumin, calcium, and liver function tests were recorded. Associations of serum markers with pathologic features and recurrence-free survival (RFS) were determined by logistic and Cox regression analyses, respectively. The concordance index for the oncologic outcomes model was determined.

RESULTS

In total, 101 patients were identified with a median follow-up of 18.5 months (range: 1-74mo). In all, 60% of patients had pT2 or less and 11% had nodal metastases. Preoperative elevated alkaline phosphatase (ALP) (≥116IU/l) was associated with multiple adverse pathologic features including advanced T stage, lymphovascular invasion, and histologic necrosis. On univariate analysis, serum markers independently associated with RFS included hemoglobin≤12.9 (hazards ratio [HR] = 2.51; 95% CI: 1.17-5.36, P = 0.018), albumin≤4g/dl (HR = 4.4; 95% CI: 2.04-9.30; P<0.0001), ALP≥116U/l (HR = 13.3; 95% CI: 5.3-33.52, P<0.0001), alanine transaminase≥27 (HR = 2.63, 95% CI: 1.11-6.21, P = 0.028), serum aspartate transaminase≥20 (HR = 2.21, 95% CI: 1.04-4.69, P = 0.038), and corrected calcium≥9.3 (HR = 2.45, 95% CI: 1.01-5.93, P = 0.047). The 2 strongest predictors, albumin and ALP, were combined to form an AA score (range: 0-2), which improved the baseline preoperative clinical model concordance index for prediction of RFS from 0.626 to 0.799.

CONCLUSION

In HG UTUC, elevated preoperative ALP was associated with adverse pathologic features. Additionally, elevated ALP and low albumin were independently associated with worse RFS and overall survival. These serum-based markers are often measured in the preoperative workup of UTUC, and thus they can be included in future prognostic models to risk stratify patients.

The association of platelet count with clinicopathological significance and prognosis in renal cell carcinoma: a systematic review and meta-analysis

OBJECTIVE

Elevated platelet count (PC), a measure of systemic inflammatory response, is inconsistently reported to be associated with poor prognosis in patients with renal cell carcinoma (RCC). We conducted a systematic review and meta-analysis to clarify the significance of PC in RCC prognosis.

METHODS

PubMed, Embase, and Web of Science databases were searched to identify eligible studies to evaluate the associations of PC with patient survival and clinicopathological features of RCC.

RESULTS

We analyzed 25 studies including 11,458 patients in the meta-analysis and categorized the included articles into three groups based on RCC stage. An elevated PC level was associated with poor overall survival (OS, hazard ratio [HR] 2.24, 95% confidence interval [CI] 1.87-2.67, P<0.001) and cancer-specific survival (CSS, HR 2.59, 95% CI 1.92-3.48, P<0.001) when all stages were examined together; with poor CSS (HR 5.09, 95% CI 2.41-10.73, P<0.001) and recurrence-free survival (HR 6.68, 95% CI 3.35-13.34, P<0.001) for localized RCC; with poor OS (HR 2.00, 95% CI 1.75-2.28, P<0.001) for metastatic RCC; and with poor OS (HR 2.05, 95% CI 1.04-4.03, P = 0.038), CSS (HR 3.38, 95% CI 1.86-6.15, P<0.001), and PFS (HR 2.97, 95% CI 1.47-6.00, P = 0.002) for clear cell RCC. Furthermore, an elevated PC level was significantly associated with TNM stage (OR 3.11, 95% CI 1.59-6.06, P = 0.001), pathological T stage (OR 3.13, 95% CI 2.60-3.77, P<0.001), lymph node metastasis (OR 4.01, 95% CI 2.99-5.37, P<0.001), distant metastasis (OR 3.85, 95% CI 2.46-6.04, P<0.001), Fuhrman grade (OR 3.70, 95% CI 3.00-4.56, P<0.001), tumor size (OR 4.69, 95% CI 2.78-7.91, P<0.001) and Eastern Cooperative Oncology Group score (OR 5.50, 95% CI 3.26-9.28, P<0.001).

CONCLUSION

An elevated PC level implied poor prognosis in patients with RCC and could serve as a readily available biomarker for managing this disease.

Psychological states, serum markers and survival: associations and predictors of survival in patients with renal cell carcinoma

This study sought to determine if there was an association between prognostic-based serum biomarkers, survival, and psychosocial factors in patients with metastatic renal cell carcinoma. Associations were found between psychosocial factors and biomarker levels (hemoglobin with depressive symptoms (r = -0.29), positive affect (r = 0.30), social support (r = 0.19), and perceived stress (r = -0.27); albumin with depressive symptoms (r = -0.19), positive affect (r = 0.22), and social support (r = 0.20); alkaline phosphatase with depressive symptoms (r = 0.21), all p values <0.05. After adjustment for disease-related risk factors, only the associations between positive affect and perceived stress with hemoglobin remained significant (p's < 0.05). Positive affect (HR = 0.90; 95% CI = 0.83, 0.97; p = 0.009) and depressive symptom total scores (HR = 1.03; 95% CI = 1.01, 1.06; p = 0.013), and alkaline phosphatase (HR 2.72; 95% CI = 1.41, 5.24; p = 0.003) were associated with survival. This study suggests that measures of positive and negative psychological outlook may contribute differently to health, well-being, and survival.

Correlation between bone metastasis and thrombocytosis in pulmonary adenocarcinoma patients

Thrombocytosis is commonly observed in patients exhibiting a variety of malignancies, including pulmonary, gastrointestinal and hepatic cancer. In the present study, the correlation between distant metastasis and thrombocytosis was retrospectively reviewed in 308 cases of histopathologically confirmed pulmonary adenocarcinoma. The patients were classified as having thrombocytosis or not, based on their platelet counts upon diagnosis; thrombocytosis was documented in 82/308 patients (26.6%). A log-rank test indicated a statistically significant difference in survival between patients exhibiting thrombocytosis compared with patients not exhibiting thrombocytosis (P<0.001). In addition, the occurrence of distant metastasis and the survival period were correlated with the presence of thrombocytosis upon diagnosis. In descending order of frequency, metastases were documented at the following sites: Lymph nodes (218/308 patients; 70.8%), bone (138/308 patients; 44.8%), lung (93/308 patients; 30.2%), brain (67/308 patients; 21.8%), liver (46/308 patients; 4.9%), adrenal glands (11/308 patients; 3.6%) and kidneys (5/308 patients; 1.6%). Bone metastasis occurred significantly more frequently in patients exhibiting thrombocytosis (50/82 patients: 61.0%; P<0.05) compared with patients not exhibiting thrombocytosis (88/226 patients; 38.9%). Furthermore, according to univariate analysis, thrombocytosis, weight loss, an Eastern Cooperative Oncology Group performance status score of ≥2 points, anemia, increased erythrocyte sedimentation rate, and increased alkaline phosphatase (AKP) and carcinoembryonic protein (CEA) levels were risk factors for bone metastasis. According to multivariate analysis, thrombocytosis, weight loss, and increased AKP and CEA levels were correlated with bone metastasis. Therefore, patients exhibiting pulmonary adenocarcinoma and thrombocytosis have a higher risk of bone metastasis compared with patients not exhibiting thrombocytosis.

Serum calcium level used as a prognostic predictor in patients with resectable pancreatic ductal adenocarcinoma

BACKGROUND AND OBJECTIVE

There is a relative scarcity of reports to evaluate the associations between serum calcium level and the prognosis in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to determine whether serum calcium level is a significant predictor for survival in PDAC patients.

METHODS

This is a retrospective cohort study. The clinicopathological characteristics, preoperative serum calcium levels and the survival data of 114 patients who underwent surgery for PDAC between January 1, 2009 and January 31, 2012 were collected. The associations between serum calcium level and overall survival were evaluated using the multivariate Cox proportional hazards model.

RESULTS

The median age of the patients was 60 years, and 64 (56.1%) of them were male. Eighty-one cases (71.1%) were dead at the last follow up. Forty-four patients (38.6%) died within the first year after surgery. The receiver operating characteristics (ROC) curve indicated a significant result for serum calcium level in predicting one-year death after surgery [area under the curve (AUC), 0.629; 95% CI 0.527-0.730, P=0.021]. In multivariate analysis, higher serum calcium levels [hazard ratio (HR), 1.922; P=0.036], diabetes (HR, 1.820; P=0.017), histologically poorly-differentiated tumor (HR, 3.342; P=0.001) and vessel invasion (HR, 1.729; P=0.023) were independent predictors of poor prognosis. Similarly, the albumin-adjusted albumin level was also an independent prognostic factor.

CONCLUSIONS

The higher serum calcium level is associated with poor prognosis in patients with resectable PDAC and the level of serum calcium can predict death within one year after surgery.

Liver transplantation for hepatocellular carcinoma: Role of inflammatory and immunological state on recurrence and prognosis

Criteria for liver transplantation (LT) for hepatocellular carcinoma (HCC) and post-LT indicators of prognosis are historically based on the measurement of the tumor mass. Recently, high throughput technologies have increased the prediction of recurrence, but these tools are not yet routinely available. The interaction between HCC and the immune system has revealed an imbalance of lymphocyte phenotypes in the peritumoral tissue, and the increase of regulatory T cells with respect to cytotoxic lymphocytes has been linked to a higher rate of post-LT HCC recurrence. Moreover, some inflammatory markers have shown good reliability in predicting cancer reappearance after surgery, as a result of either a systemic inflammatory response or a decreased capacity of the organism to control the tumor growth. Among these markers, the neutrophil-to-lymphocyte ratio appears to be the most promising and easily available serum parameter able to predict HCC recurrence after LT and following other types of treatment, although the exact mechanisms determining its elevation have not been clarified. Post-LT immunosuppression may impact on cancer control, and the exposure to high levels of calcineurin inhibitors or other immunusuppressants has recently emerged as a negative prognostic factor for HCC recurrence and patient survival. Despite the absence of prospective randomized trials, inhibitors of the mammalian target of rapamycin have been shown to be associated with lower rates of tumor recurrence compared to other immunosuppressors, suggesting their use especially in patients with HCC exceeding the conventional indication criteria for LT.

Risk group stratification based on preoperative factors to predict survival after nephroureterectomy in patients with upper urinary tract urothelial carcinoma

BACKGROUND

After radical nephroureterectomy (RNU), substantial numbers of patients with upper urinary tract urothelial carcinoma (UUT-UC) are ineligible for adjuvant chemotherapy owing to diminished renal function. Accurate preoperative prediction of survival is considered important because neoadjuvant chemotherapy may be as effective for high-risk UUT-UC as for muscle-invasive bladder cancer. We performed risk group stratification to predict survival based on specific preoperative factors.

METHODS

We enrolled 536 UUT-UC patients treated with RNU in this retrospective cohort study and assessed preoperative clinical and laboratory variables influencing disease-specific survival.

RESULTS

The median follow-up was 40.9 months. Using univariate analysis, tumor location; number of tumors; hydronephrosis; clinical T stage; clinical N category; voided urine cytology; neoadjuvant chemotherapy; hemoglobin; white blood cell (WBC) counts; and C-reactive protein had a significant influence on disease-specific survival (P < 0.05). Multivariate analysis revealed that clinical T stage, voided urine cytology, and WBC were independent predictors (P = 0.041, P = 0.020, and P = 0.017, respectively). We divided patients into three risk groups based on the number of the three independent predictors: 0, low risk; 1, intermediate risk; 2 and 3, high risk. Significant differences in disease-specific survival were found among these risk groups (P ≤ 0.0047).

CONCLUSIONS

Our results suggest that risk group stratification based on preoperative clinical T stage, voided urine cytology, and WBC counts may be useful for selection of UUT-UC patients for neoadjuvant chemotherapy. Prospective studies with larger numbers of patients and a longer follow-up period are needed to confirm our results.

Preoperative Erythrocyte Sedimentation Rate Independently Predicts Overall Survival in Localized Renal Cell Carcinoma following Radical Nephrectomy

Objectives. To determine the relationship between preoperative erythrocyte sedimentation rate (ESR) and overall survival in localized renal cell carcinoma (RCC) following nephrectomy. Methods. 167 patients undergoing nephrectomy for localized RCC had ESR levels measured preoperatively. Receiver Operating Characteristics curves were used to determine Area Under the Curve and relative sensitivity and specificity of preoperative ESR in predicting overall survival. Cut-offs for low (0.0–20.0 mm/hr), intermediate (20.1–50.0 mm/hr), and high risk (>50.0 mm/hr) groups were created. Kaplan-Meier analysis was conducted to assess the univariate impact of these ESR-based groups on overall survival. Univariate and multivariate Cox regression analysis was conducted to assess the potential of these groups to predict overall survival, adjusting for other patient and tumor characteristics. Results. Overall, 55.2% were low risk, while 27.0% and 17.8% were intermediate and high risk, respectively. Median (95% CI) survival was 44.1 (42.6–45.5) months, 35.5 (32.3–38.8) months, and 32.1 (25.5–38.6) months, respectively. After controlling for other patient and tumor characteristics, intermediate and high risk groups experienced a 4.5-fold (HR: 4.509, 95% CI: 0.735–27.649) and 18.5-fold (HR: 18.531, 95% CI: 2.117–162.228) increased risk of overall mortality, respectively. Conclusion. Preoperative ESR values represent a robust predictor of overall survival following nephrectomy in localized RCC.

Impact of clinical variables on predicting disease-free survival of patients with surgically resected renal cell carcinoma

OBJECTIVE

To determine the value of particular clinical variables for the preoperative prognostic Cindolo formula (PPCF) to predict disease-free survival (DFS) of patients with surgically treated renal cell carcinoma (RCC).

PATIENTS AND METHODS

In all, 771 consecutive patients (T1-4NxM0) who had radical or partial nephrectomy were reviewed retrospectively. For each patient with RCC, PPCF was constructed according to clinical size and clinical presentation. On the basis of PPCF, patients were divided into Cindolo good prognosis (CGP) and Cindolo poor prognosis (CPP) groups. We also analysed further clinical variables (Eastern Cooperative Oncology Group score, American Society of Anesthesiologists score, body mass index, hepatic dysfunction, night sweat, fever, value of blood platelets, leukocytes, haemoglobin level, gender, age and location). DFS was estimated using the Kaplan-Meier method. Univariable and multivariable Cox proportional hazard regression models were fitted to determine associations between the PPCF, measured clinical features, and DFS.

RESULTS

Four of the variables emerged as statistically significant for DFS from the univariable analysis (P < 0.001), i.e. clinical presentation, clinical tumour size, haemoglobin level and blood platelet count. In the multivariable analysis, only clinical tumour size and blood platelet count remained significant for DFS. By contrast, clinical presentation, used in the PPCF, had no significant influence. According to the PPCF we developed the preoperative Amissah Prognosis Score (PAPS) calculated as (0.19 x clinical size) + (0.492 x platelet count (<or=400/nL = 0, >400/nL = 1) with a threshold between the two resulting prognosis groups at 1.76. The multivariable hazard ratio (95% confidence interval, CI) for the PAPS was 2.98 (2.15-4.12) (P < 0.001) compared to a hazard ratio for the PPCF of 1.36 (0.99-1.87) (P = 0.061). Furthermore, the predictive ability was greater when using the PAPS (area under the curve 0.721; 95% CI, 0.680-0.763; P <or= 0.001) than the PPCF (0.690; 0.647-0.734; P <or= 0.001).

CONCLUSIONS

Using preoperative prognostic models is reasonable to provide patients with pertinent information about their prognosis, and for tailoring the treatment to each patient's needs. Applying the PPCF allows a prediction of the outcome of patients with surgically treated RCC on the basis of preoperatively available variables. However, clinical presentation, included in this model, had no significant influence on DFS in the present patients. By contrast, using the PAPS resulted in an improvement in the predictive value and in a greater discrimination between patients subdivided into a good and a poor prognosis group and hence is suitable for preoperative risk assignment.

Prognostic factors in renal cell carcinoma: association of preoperative sodium concentration with survival

PURPOSE

Conventional renal cell carcinoma (RCC) has a variable natural history, and determining individual prognosis is important to guide management. We have examined the prognostic significance of a large number of hematologic and biochemical variables, as well as traditional tumor-related factors in patients with RCC.

EXPERIMENTAL DESIGN

Patients undergoing nephrectomy for newly diagnosed RCC between September 1998 and March 2005 were invited to participate. Clinical, pathologic, and laboratory data were recorded in each case, and immunophenotyping was carried out on a subset of patients. A planned subset analysis of patients presenting with N0M0 disease was done.

RESULTS

Two hundred twelve patients with RCC formed the study population. In addition to tumor-related factors, multivariate analyses revealed preoperative serum sodium concentration to be independently and significantly associated with overall survival and disease-free survival when considered as both a continuous variable and when dichotomized to above and below the median value [139 mmol/L; reference range 135-145 mmol/L, hazard ratio 0.44, 95% confidence interval (95% CI) 0.22-0.88, P = 0.014]. Five-year overall survival estimates for patients above and below the median serum sodium were 67.6% (95% CI 54.2-80.9) and 44.3% (95% CI 32.8-55.8), respectively. These findings persisted in the N0M0 subgroup analysis.

CONCLUSIONS

We have confirmed the prognostic value of traditional tumor-related factors but, to our knowledge, these are the first data to show that low preoperative sodium concentration may be an important factor associated with reduced survival in patients with RCC, suggesting that serum sodium should be considered with established prognostic variables in modeling survival in RCC.

Metastasis is promoted by a bioenergetic switch: new targets for progressive renal cell cancer

Targeted therapies have demonstrated clinical benefit with limited impact on long-term disease specific survival in the treatment of renal cell cancer (RCC). New opportunities for the treatment of tumors that are resistant or have relapsed, are needed. Increased anaerobic glucose fermentation to lactate (aerobic glycolysis), leading to oxygen- and mitochondria-independent ATP generation is a hallmark of aggressive cancer growth. This metabolic shift results in increased lactate production via cycling through the pentose phosphate pathway (PPP), and plays an important role in tumor immune escape, progression and resistance to immune-, radiation- and chemo-therapy. This study explored the activity and impact of the oxidative and nonoxidative branches of the PPP on RCC to evaluate new therapeutic options. Activity was determined in the oxidative branch by glucose-6-phosphate-dehydrogenase (G6PD) activity, and in the nonoxidative branch by the total transketolase activity and the specific expression of the transketolase-like-1 (TKTL1) protein. Transketolase and G6PD activity were intensely elevated in tumor tissues. Transketolase, but not G6PD activity, was more elevated in metastasizing tumors and TKTL1 protein was significantly overexpressed in progressing tumors (p = 0.03). Lethal tumors, where surrogate parameters such as grading and staging had failed to predict progression, showed intensive TKTL1 protein expression. RCC was found to have activated oxidative and nonoxidative glucose metabolism through the PPP, displaying a bioenergetic shift toward nonoxidative glucose fermentation in progressing tumors. The coexistence of cancer cells with differentially regulated energy supplies provides new insights in carcinogenesis and novel anticancer targets.

Ki-67 and coagulative tumor necrosis are independent predictors of poor outcome for patients with clear cell renal cell carcinoma and not surrogates for each other

BACKGROUND

Ki-67 is a cell proliferation protein associated with aggressive clear cell renal cell carcinoma (ccRCC). A recent report suggests that Ki-67 may represent a surrogate marker for coagulative tumor necrosis. Thus, the goal was to directly test whether Ki-67 and necrosis convey similar or distinct information for the prognostic assessment of ccRCC.

METHODS

Tumor specimens from 741 consecutively treated patients who underwent surgery for ccRCC between 1990 and 1999 were evaluated. Tumor specimens were assessed for various clinicopathologic features, including levels of tumor cell Ki-67 expression. Associations of these features with death from RCC were evaluated using Cox proportional hazards regression models.

RESULTS

At last follow-up, 396 patients had died, including 238 who died from ccRCC at a median of 2.1 years after surgery. Although tumor cell Ki-67 expression and coagulative tumor necrosis were highly correlated, the prognostic information conveyed by these 2 markers failed to overlap. For the subset of patients with necrotic tumors, high levels of Ki-67 more than doubled the risk of death from RCC (risk ratio, 2.18; 95% confidence interval [CI], 1.52-3.11; P < .001). For patients with tumors lacking necrosis, high levels of Ki-67 expression were similarly correlated with an increased risk of death from RCC (risk ratio, 2.50; 95% CI, 1.66-3.77; P < .001).

CONCLUSIONS

Prognostic information conveyed by Ki-67 and coagulative tumor necrosis are not interchangeable. Thus, Ki-67 and coagulative tumor necrosis should not be treated as surrogates for one another and both of these features should be evaluated when generating outcome predictions for patients with ccRCC.

Prognostic significance of common preoperative laboratory variables in clear cell renal cell carcinoma

OBJECTIVE

To investigate the prognostic significance of common preoperative laboratory variables evaluated before surgery for clear cell renal cell carcinoma (RCC).

PATIENTS AND METHODS

We retrospectively analysed the records of 355 patients who had surgery for clear cell RCC, assessing: clinical factors, including preoperative laboratory measurements, i.e. haemoglobin level, leukocyte count, platelet count, erythrocyte sedimentation rate (ESR), serum calcium, alkaline phosphatase (ALP), albumin, bilirubin, alanine aminotransferase, aspartate aminotransferase, and red blood cells in urine; and pathological factors, with the survival rates after surgery.

RESULTS

The presence of metastasis, tumour stage and tumour size, with the ESR and ALP before surgery, were identified as significant prognostic factors for progression-free survival in a multivariate analysis. The same factors were significant independent factors for disease-specific survival, except for ESR and ALP, which were nearly statistically significant. When limited to non-metastatic tumours only, the multivariate analysis showed that ESR and ALP, with tumour stage, grade, size and necrosis, were independent prognostic factors for disease-specific survival.

CONCLUSIONS

Along with traditionally accepted prognostic factors, these results suggest that common laboratory variables assessed before surgery, e.g. ESR and ALP, might also be useful in assessing the prognosis for patients with non-metastatic clear cell RCC. Including various laboratory variables in prognostic algorithms for RCC should be considered after further validation in RCCs of various histological subtypes and stages.

Transitional cell carcinoma of the ureter: prognostic factors influencing progression and survival

OBJECTIVES

We retrospectively evaluated prognostic factors for progression-free and disease-specific survival in a large cohort of patients with transitional cell carcinoma (TCC) of the ureter.

METHODS

A single-centre series of 145 consecutive patients treated with partial resection of the ureter or nephroureterectomy between 1975 and 2004 was evaluated. Median follow-up was 96 mo. Routine preoperative laboratory parameters as well as clinical and tumour-specific data were assessed. Univariate and multivariate statistical analyses were performed.

RESULTS

Five-year disease-specific survival ranged from 96.1% for stages pTa to 28.6% for pT4. Grade1 tumours were associated with 5-yr disease-specific survival rates of 100% compared with 84% for G2, and 51.9% for G3 tumours, respectively. Univariate analyses identified pT stage and grade, tumour diameter, cM and pN categories, weight loss, the presence of synchronous tumour in the renal pelvis as well as elevated levels for humoral factors such as serum alkaline phosphatase (AP), white blood cell (WBC) count, platelet count, gamma-glutamyl transferase, creatinin, and blood urea nitrogen as prognostic factors. In multivariate analyses, tumour grade and WBC counts were predictive for low progression-free survival rates, whilst simultaneous tumour in the renal pelvis, high AP levels, and WBC counts were correlated with worse disease-specific survival.

CONCLUSIONS

Our retrospective analysis provides clinical factors to identify patients with TCC of the ureter at high risk for progression and death of disease. Interestingly, humoral factors such as elevated serum AP levels and high WBC counts were demonstrated to be of paramount prognostic significance besides tumour stage, grade and multifocality.

The preoperative erythrocyte sedimentation rate is an independent prognostic factor in renal cell carcinoma

BACKGROUND

Prognostic nomograms are used increasingly in clinical trials and to guide surveillance for patients with renal cell carcinoma (RCC). An elevated erythrocyte sedimentation rate (ESR) reportedly has been associated with a poor prognosis among patients with RCC, but the ESR is not incorporated into existing nomograms. Hence, the current study was conducted to expand on prior observations pertaining to the ESR as a prognostic indicator in patients with RCC.

METHODS

The authors identified 3008 patients who underwent nephrectomy for RCC between 1970 and 2002. Disease-specific survival was estimated using the Kaplan-Meier method, and its association with the ESR and other clinical and pathologic features was evaluated using Cox proportional hazards regression analysis.

RESULTS

A preoperative ESR was available for 1075 patients (35.7%), 501 of whom (46.6%) exhibited an elevated ESR, including 437 of 881 patients (49.2%) with clear cell RCC, 41 of 134 patients (30.6%) with papillary RCC, and 20 of 48 patients (41.7%) with chromophobe RCC. An elevated ESR was associated with adverse clinical, laboratory, and pathologic profiles for all three histologic subtypes. The risk ratios (RRs) and 95% confidence intervals (95% CIs) for death because of clear cell RCC, papillary RCC, and chromophobe RCC for patients with an elevated ESR were 3.6 (95% CI, 1.1-1.9), 3.8 (95% CI, 1.4-10.6), and 10.3 (95% CI, 1.2-89.5), respectively. The association between an elevated ESR and death from clear cell RCC persisted even after multivariate analysis (RR of 1.5; 95% CI, 1.2-2.0).

CONCLUSIONS

An elevated ESR in patients with RCC suggested the presence of aggressive disease and poorer outcomes after surgical treatment. For patients with clear cell RCC, the ESR provided useful information above and beyond traditional prognostic algorithms, and it may be valuable for preoperative prognostication.