A systematic review and meta-analysis of clinicopathologic factors linked to oncologic outcomes for renal cell carcinoma with tumor thrombus treated by radical nephrectomy with thrombectomy

Survival outcomes and risk factors for liver and pancreatic metastases in renal cell carcinoma after curative nephrectomy

BACKGROUND

Renal cell carcinoma (RCC) has a high recurrence risk, with 20-40% of patients developing metastatic disease post-nephrectomy. This study aimed to identify risk factors associated with liver and pancreatic metastases in patients who have previously undergone curative nephrectomy for RCC.

METHODS

This retrospective cohort study with a nested case-control design included adults who underwent nephrectomy for non-metastatic RCC (non-mRCC) between 2009 and 2021. Patients who developed liver or pancreatic metastases, confirmed by secondary surgery, formed the case group. A randomly selected control group of non-mRCC patients were included to assess risk factors. Clinical, radiological, and pathological data were analyzed.

RESULTS

Among 967 nephrectomy patients, 754 (78%) had RCC, and 6% developed liver or pancreatic metastases. Advanced tumor stage (T3) was a significant predictor of RCC metastasis in these patients. Patients with a prolonged disease-free interval demonstrated better surgical eligibility and survival outcomes. Median time from nephrectomy to metastasis was 57 months in surgical cases compared to 22 months in non-surgical cases. Notably, 92% of patients eligible for metastasis surgery had clear cell RCC (ccRCC). Surgical resection was associated with improved survival, with 1-, 3-, and 5-year survival rates of 92%, 83%, and 75%, respectively, compared to 77%, 65%, and 56% for non-surgical patients.

CONCLUSIONS

Advanced tumor stage and local invasiveness were key predictors of liver and pancreatic metastases in RCC. Prolonged time to metastasis improved surgical eligibility and survival. The majority of patients eligible for metastasis surgery had ccRCC. Further studies are needed to evaluate whether early, individualized follow-up for high-risk RCC subtypes improved surgical eligibility for liver and pancreatic metastasis.

Biology of renal cancer tumor thrombus - towards the personalized approach

Renal cell carcinoma - related thrombus arising within venous system (venous tumor thrombus, VTT) represents a distinct compartment within cancer, situated at the frontline with the continual interaction with host blood cells. Various host immune blood cells may possibly interact with VTT influencing its biology. While many authors have reviewed the current state-of-the-art of the management of VTT, its biology and microenvironment has not been comprehensively reviewed to date. In this narrative review, we described the current concepts on formation of thrombus, its histopathology, immune microenvironment, genetic and molecular features with potential impact on prognostication and tailored therapy. Although it is the sophisticated and challenging surgery that remains the primary modality in the management of RCC with VTT, recent advances in the research on cancer biology and microenvironment shed some light on the numerous future perspectives. The formation of tumor thrombus is a complex process, understanding of which may trigger onset of novel therapies leading to the improvement of not only oncological results but also patients' safety in these life-threatening conditions.

New mouse models for exploring renal tumor extension into the inferior vena cava

Renal tumors with inferior vena cava tumor thrombus (IVCTT) remain a challenge in urology. However, in vivo models remain unavailable, which hampers the elucidation of its pathogenesis, identification of therapeutic targets, and screening for effective drugs. In this study, we initially develop two IVCTT models in BALB/c and BALB/c-nu/nu mice using the mouse Renca cell line. The pathological features and immune microenvironment of IVCTT in immunocompetent mice closely resembles those observed in humans. Single-cell transcriptome sequencing, immunohistochemistry and multiplex immunohistochemistry reveal a predominance of monocytes, macrophages, and neutrophils within IVCTT, mirroring the cellular composition of the human IVCTT; however, fewer lymphocytes are observed. The IVCTT in immunodeficient mice progresses much faster than in immunocompetent mice. More importantly, we successfully use the human tumor cell line on the BALB/c nu/nu mice to create an IVCTT model. The proposed in vivo models mimic the progression of renal tumors with IVCTT, clarify that the immune system can inhibit tumor thrombus progression, and provide tools for subsequent mechanistic research and translational preclinical studies.

The value of a postoperative nomogram based on the primary tumor score for overall survival of patients with renal cell carcinoma and inferior vena cava tumor thrombus

BACKGROUND

Radical surgery can achieve remarkable improvements in the survival of patients with renal cell carcinoma (RCC) and inferior vena cava tumor thrombus (IVCTT); however, not all patients can obtain the desired results. Therefore, identifying patients with poor survival after surgery is crucial for guiding follow-up adjuvant therapies and patient counseling.

OBJECTIVE

To evaluate the impact of primary tumor score based on tumor necrosis and tumor thrombus morphology on overall survival (OS), and create a postoperative prognostic model for patients with RCC and IVCTT.

METHODS

This retrospective study included 182 patients with RCC and IVCTT who underwent radical nephrectomy and thrombectomy (RNTE). Preoperative contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), ultrasound imaging, and clinical records were collected. Kaplan-Meier analysis was used to evaluate the overall survival (OS). Prognostic factors for OS were identified by univariate and multivariate analyses using the Cox proportional hazards regression model. A nomogram was developed and internally calibrated using the bootstrap resampling method.

RESULTS

The mean follow-up time was 24.1 months (1-84.5 months), and 34.1% (62 of 182) of the patients died of all causes. The primary tumor score possesses a superior prognostic value for the primary tumor compared with the level of IVCTT and tumor size. Multivariate Cox regression analysis showed that primary tumor score, distant metastasis, nonclear cell subtype, sarcomatoid degeneration, preoperative anemia grade, and ASA level were independent prognostic factors. Based on these factors, a nomogram was built; the concordance index was 0.77, and the AUC for predicting 1-3 years OS were 0.80, 0.81, and 0.78, respectively.

CONCLUSIONS

Primary tumor score is a independent prognostic factors for patients with RCC and IVCTT. Combined with 5 easily acquired prognostic factors, a postoperative nomogram was developed and internally validated, and can be used to select patients who may benefit from adjuvant therapy or aggressive surveillance regimens.

Renal Cell Carcinoma With Tumor Thrombus Extending Into the Inferior Vena Cava and the Right Atrium Demonstrated by 68 Ga-DOTATATE PET/CT

ABSTRACT

Approximately 10% of all renal cell carcinoma (RCC) patients develop a venous tumor thrombus, a major negative prognostic factor. Surgical excision is commonly required for RCC patients with tumor thrombus. Accurate preoperative diagnosis and assessment of tumor thrombus level is vital because the level of thrombus may influence treatment decisions. MRI, contrast-enhanced CT, 18 F-FDG PET/CT, and 68 Ga-PSMA PET/CT have been used to diagnose and evaluate the extent of tumor thrombus in RCC. However, no case of RCC with inferior vena cava tumor thrombus showing 68 Ga-DOTATATE uptake has been reported yet. Herein, we report a case of metastatic RCC with tumor thrombus in the inferior vena cava on 68 Ga-DOTATATE PET/CT.

Renal Cell Carcinoma with Venous Tumor Thrombus: 15 Years of Experience in an Oncology Center

Background: The purpose of this study is to report the experience of a single Portuguese oncology center in the management of patients with renal cell carcinoma (RCC) and venous tumor thrombus (VTT). Methods: This is a retrospective analysis of all patients with RCC and VTT surgically treated in our center between 2008 and 2023. Only patients with VTT up to level III (Mayo Clinic classification) were included. Patient, tumor characteristics and peri-operative outcome data were registered. Administration of systemic therapy was performed upon progression. Survival analysis was conducted with the collected data. Results: A total of 64 patients (n = 16 women) were included in this study. The mean age at diagnosis was 66.3 ± 10.7 years old. The VTT level was 0, I, II and III in 40 (62.5%), 12 (18.7%), 6 (9.4%) and 6 (9.4%) patients, respectively. Nine patients (14.1%) had distant metastasis at diagnosis. No peri-operative deaths occurred, and the major complication rate was 3.1%. Histology revealed 98.4% of clear cell RCC, with sarcomatoid differentiation present in 12.5% of the cases. A negative margin status was achieved in 54 (84.4%) patients. Systemic therapy was administered in 24 (37.5%) patients during follow-up. The median progression-free (PFS), cancer-specific (CSS) and overall (OS) survival were 23, 60 and 48 months, respectively. In multivariable analysis, significant predictors of CSS were tumor size, sarcomatoid differentiation and collecting system invasion. Conclusions: Radical nephrectomy with VTT excision up to level III is a feasible and safe procedure. Patients with large tumor size, sarcomatoid differentiation and collecting system invasion are at the highest risk and should be closely monitored.

Influence of tumor thrombus morphology on the surgical complexity in renal cell carcinoma with inferior vena cava tumor thrombus: a single-center, large-sample study from China

BACKGROUND

The morphology of tumor thrombus varies from person to person and it may affect surgical methods and tumor prognosis. However, studies on the morphology of tumor thrombus are limited. The purpose of our study was to evaluate the impact of tumor thrombus morphology on surgical complexity.

METHODS

We retrospectively reviewed the clinical data of 229 patients with renal cell carcinoma combined with inferior vena cava (IVC) tumor thrombus who underwent surgical treatment at Peking University Third Hospital between January 2014 and December 2021. The patients were divided into floating morphology (107 patients) and filled morphology (122 patients) tumor thrombi groups. Chi-square and Mann-Whitney U tests were used for categorical and continuous variables, respectively. Postoperative complications were evaluated using the Clavien-Dindo surgical complication classification method.

RESULTS

Patients with filled morphology tumor thrombus required more surgical techniques than those with floating morphology tumor thrombus, which was reflected in more open surgeries (P < 0.001), more IVC interruptions (P <0.001), lesser use of the delayed occlusion of the proximal inferior vena cava (DOPI) technique (P < 0.001), and a greater need for cut-off of the short hepatic vein (P < 0.001) and liver dissociation (P = 0.001). Filled morphology significantly increased the difficulty of surgery in patients with renal cell carcinoma with tumor thrombus, reflected in longer operation time (P < 0.001), more surgical blood loss (P <0.001), more intra-operative blood transfusion (P < 0.001), and longer postoperative hospital stay (P < 0.001). Filled morphology tumor thrombus also led to more postoperative complications (53% vs. 20%; P < 0.001).

CONCLUSION

Compared with floating morphology thrombus, filled morphology thrombus significantly increased the difficulty of surgery in patients with renal cell carcinoma with IVC tumor thrombus.

Survival benefits after radical nephrectomy and IVC thrombectomy of renal cell carcinoma patients with inferior vena cava thrombus

Objective

The role of tumor thrombus as a predictor of survival in patients with renal cell carcinoma (RCC) is controversial. This study aims to evaluate surgical and oncological outcomes after surgery in RCC with inferior vena cava (IVC) tumor thrombus patients.

Materials and methods

A total of 58 patients (2002-2019) underwent radical nephrectomy and IVC thrombectomy at our institute, were retrospectively reviewed. Kaplan-Meier analysis was utilized to compare survival benefits between cohorts and Cox-regression to evaluate potential predictors of patient survival.

Results

There were 5(8.6%), 21(36.2%), 23(39.7%) and 9 (15.5%) patients with tumor thrombus level I, II, III and IV respectively. The major complications (Clavien 3-5) were observed in 15 patients (25.8%) and 12 patients (80%) were patients with high thrombus level (III-IV). There was 9%mortality (5patients): 2 intraoperatively and 3 postoperatively. Median follow-up was 15 months (IQR:5-41). Two-year overall survival (OS) was 80% and 75% in all patients and pN0M0 cohort, respectively. There was significant difference in OS among each IVC thrombus level cohort (p < 0.02). Two-year OS of metastatic RCC patients was 67% and not significantly different when compared to non-metastatic cohort (p = 0.12). On multivariate analysis, only sarcomatoid dedifferentiation was associated with OS(p = 0.04). Disease-free survival was not significantly different among thrombus-level cohorts (p = 0.65).

Conclusions

Our study suggested that surgical treatment for RCC with IVC thrombus provided substantial OS outcomes. Although survival was significantly reduced with higher IVC thrombus level cohort, the level of thrombus itself was not an independent factor. Only sarcomatoid dedifferentiation was a predictor for reduced OS after radical nephrectomy and tumor thrombectomy. Meticulous patient selection and prompt counselling are substantial step for the operation.

Assessment of Ki-67 proliferation index in prognosis prediction in patients with nonmetastatic clear cell renal cell carcinoma and tumor thrombus

PURPOSE

To determine the optimal cut-off value of Ki-67 for predicting the survival of patients with clear cell renal cell carcinoma (ccRCC) and tumor thrombus and to explore the correlation between Ki-67 expression and pathological features.

PATIENTS AND METHODS

We retrospectively analyzed Ki-67 immunohistochemical staining of ccRCC and tumor thrombus resected from February 2006 to February 2022. The survival rate was evaluated using the Kaplan-Meier method. The optimal cut-off value of the Ki-67 expression for predicting survival was determined by the minimum P-value method. Clinicopathological data were compared based on Ki-67 status (low versus high expression). Univariate and multivariate Cox regression analysis was used to explore independent predictors.

RESULTS

A total of 202 patients (median age, 58 years [IQR, 52-65 years], 147 men) with ccRCC and tumor thrombus were included in the study. The optimal cut-off value of Ki-67 for predicting survival was 30%. 159 (78.7%) and 43 (21.3%) patients were included in the low-expression and high-expression groups. Patients with Ki-67 high expression had significantly worse recurrence-free survival (P < 0.001) and cancer-specific survival (P < 0.001). Ki-67 high expression was associated with adverse pathological features, including tumor necrosis, ISUP nuclear grade, sarcomatoid differentiation, perirenal fat invasion, renal pelvis invasion, and inferior vena cava wall invasion (all P < 0.050). Ki-67 expression ≥ 30% (P = 0.016), tumor side (P = 0.003), diabetes (P = 0.040), blood loss (P = 0.016), inferior vena cava wall invasion (P = 0.016), and sarcomatoid differentiation (P = 0.014) were independent predictors of cancer-specific survival.

CONCLUSION

The optimal cut-off level of Ki-67 in predicting the prognosis of ccRCC and tumor thrombus was 30%. The high expression of Ki-67 was associated with the aggressive pathological phenotype and poor prognosis.

Based on disulfidptosis, revealing the prognostic and immunological characteristics of renal cell carcinoma with tumor thrombus of vena cava and identifying potential therapeutic target AJAP1

BACKGROUND

Patients with clear cell renal cell carcinoma (ccRCC) with venous tumor thrombus have a poor prognosis, high surgical risk, and lack of targeted therapeutic agents.

METHODS

Genes with consistent differential expression trends in tumor tissues and VTT groups were first screened, and then differential genes associated with disulfidptosis were found by correlation analysis. Subsequently, identifying ccRCC subtypes and constructing risk models to compare the differences in prognosis and the tumor microenvironment in different subgroups. Finally, constructing a nomogram to predict the prognosis of ccRCC and validate key gene expression levels in cells and tissues.

RESULTS

We screened 35 differential genes related to disulfidptosis and identified 4 ccRCC subtypes. Risk models were constructed based on the 13 genes, and the high-risk group had a higher abundance of immune cell infiltration, tumor mutational load, and microsatellite instability scores, predicting high sensitivity to immunotherapy. The 1-year AUC = 0.869 for predicting OS by nomogram has a high application value. The expression level of the key gene AJAP1 was low in both tumor cell lines and cancer tissues.

CONCLUSIONS

Our study not only constructed an accurate prognostic nomogram for ccRCC patients but also identified an AJAP1 biomarker as a potential biomarker for the disease.

The multispeciality approach to the management of localised kidney cancer

Historically, kidney cancer was approached in a siloed single-speciality way, with urological surgeons managing the localised stages of the disease and medical oncologists caring for patients if metastases developed. However, improvements in the management of localised kidney cancer have occurred rapidly over the past two decades with greater understanding of the disease biology, diagnostic options, and innovations in curative treatments. These developments are favourable for patients but provide a substantially more complex landscape for patients and clinicians to navigate, with associated challenging decisions about who to treat, how, and when. As such, the skill sets needed to manage the various aspects of the disease and guide patients appropriately outstrips the capabilities of one particular specialist, and the evolution of a multispeciality approach to the management of kidney cancer is now essential. In this Review, we summarise the current best multispeciality practice for the management of localised kidney cancer and the areas in need of further research and development.

Nomograms for Predicting Overall Survival and Cancer-Specific Survival of Patients With Renal Cell Carcinoma and Venous Tumor Thrombus: A Population-Based Study

Background

To provide better prognostic information for patients with renal cell carcinoma (RCC) combined with venous tumor thrombus (VTT). In turn, guide patients’ families and doctors to formulate plans for follow-up treatment and follow-up. We developed nomograms to predict cancer-specific survival (CSS) and overall survival (OS).

Methods

A total of 2961 cases were included in this study. Through univariate and multivariate Cox proportional hazard regression analysis, independent risk factors affecting CSS and OS were screened out, and then a nomogram was drawn based on the screened variables.

Results

Independent risk factors affecting CSS include: tumor size (HR = 1.05), histology (HR = 1.75), grade (HR = 1.94), N staging (HR = 2.06), and M staging (HR = 2.87). The median survival time for CSS was 106 months. Independent risk factors for OS include age (HR = 1.60), tumor size (HR = 1.04), histology (HR = 1.60), grade (HR = 1.68), N staging (HR-1.99), M staging (HR = 2.45). The median survival time for OS is 67 months.

Conclusions

The nomogram based on independent risk factors affecting CSS and OS can well predict the prognosis of renal cell carcinoma with venous tumor thrombus.

Nomogram for predicting survival of renal cell carcinoma with tumor thrombus based on perioperative clinicopathological factors from a Chinese high-volume center

OBJECTIVES

To investigate perioperative clinicopathological predictors and establish a predictive nomogram for survival in patients with renal cell carcinoma and venous tumor thrombus undergoing nephrectomy and thrombectomy.

METHODS

Patients with renal cell carcinoma and venous tumor thrombus undergoing nephrectomy and thrombectomy were included in the study between January 2014 and June 2020. Cox regression analysis was used for univariate and multivariate survival analyses. A predictive nomogram for survival was established and internally validated using bootstrap resampling method.

RESULTS

A total of 228 patients were enrolled in this study. The median age was 60 years (interquartile range 53-66 years), consisting of 174 (76.3%) males and 54 (23.7%) females. The median follow-up time was 17.5 months (range 1-74 months), 26.8% (61 of 228) patients died of all causes. In multivariable analysis, hemoglobin less than the lower limit of normal (hazard ratio 1.73; 95% confidence interval 1.01-2.96; P = 0.045), sarcomatoid feature (hazard ratio 3.67; 95% confidence interval 1.97-6.82; P < 0.001), perirenal fat invasion (hazard ratio 1.80; 95% confidence interval 1.05-3.09; P = 0.033), histological subtype (hazard ratio 2.74; 95% confidence interval 1.39-5.41; P = 0.004), and metastasis at surgery (hazard ratio 1.71; 95% confidence interval 1.01-2.90; P = 0.047) were independently associated with overall survival. The result of internal validation presented that the predictive performance of the nomogram for survival measured by C-index was 0.77.

CONCLUSIONS

We developed a predictive nomogram with well-internal validation for survival in patients with renal cell carcinoma and venous tumor thrombus, which can greatly promote risk stratification and treatment planning.

Influence of Deep Invasive Tumor Thrombus on the Surgical Complexity and Prognosis of Patients With Non-Metastatic Renal Cell Carcinoma Combined With Venous Tumor Thrombus

BACKGROUND

To evaluate the impact of deep invasive tumor thrombus (DITT) on the surgical complexity and prognosis of patients with renal cell carcinoma with venous tumor thrombus.

METHODS

We retrospectively reviewed clinical data of 138 patients with non-metastatic renal cell carcinoma combined with venous tumor thrombus, who underwent surgical treatment in Peking University Third Hospital from January 2015 to June 2020. Patients were divided into the DITT group (84 patients) and non-invasive tumor thrombus (NITT) group (54 patients). Chi-square, t-test and Mann-Whitney U test were used for categorical and continuous variables, respectively. Kaplan-Meier plots were performed to evaluate the influence of DITT. Univariable and multivariable Cox regressions were conducted to determine independent prognostic factors and then assembled to make a nomogram to predict the survival. The performance of the nomogram was evaluated by Harrell's consistency index (C-index) and calibration plot.

RESULTS

Deep invasive tumor thrombus significantly increased the difficulty of surgery for patients with renal cell carcinoma with venous tumor thrombus, which is mainly reflected in longer operation time (p < 0.001), more surgical bleeding (p  < 0.001), a higher proportion of perioperative blood transfusion (p  = 0.006), a higher proportion of open surgery (p = 0.001), a longer postoperative hospital stay (p = 0.003), and a higher proportion of postoperative complications (p = 0.001). DITT (hazard ratio [HR] = 2.781, p = 0.040) was one of the independent risk factors for worse prognosis. Multivariate analysis showed that sarcoma-like differentiation (p = 0.040), tumor thrombus invasion (p = 0.040), low hemoglobin (p = 0.003), and pathological type (p < 0.001) were independent prognostic factors. The nomogram, combining all these predictors, showed powerful prognostic ability with a C-index of 78.8% (CI: 71.2%-86.4%). The predicted risk closely matches the observed recurrence probability.

CONCLUSION

Deep invasive tumor thrombus significantly increased the difficulty of surgeries for patients of renal cell carcinoma with venous tumor thrombus, and may lead to poor prognosis.

Predictors of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus

INTRODUCTION

Surgical resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is a complex procedure with significant morbidity. Patient selection is critical to determining whether the benefits of the procedure outweigh the risks. In this study, we identified and stratified the risk factors that were associated with overall survival (OS) and recurrence-free survival (RFS) in patients undergoing surgical resection of RCC with IVC thrombus.

METHODS

We identified all patients with RCC with IVC tumor thrombus (stages cT3b and cT3c) who had undergone radical nephrectomy with tumor thrombectomy between December 1, 1993 and June 30, 2009. Kaplan-Meier method was used to estimate OS and RFS. Cox proportional hazards models were used to determine the association between risk factors and OS. Patients were stratified into 3 groups based on the number of risk factors present at diagnosis.

RESULTS

Two hundred twenty-four patients were included in the study. A total of 45.3% of patients had metastasis at presentation, 84.5% had cT3b, and 90.2% had clear cell RCC. cT3c, cN1, and cM1 were significantly associated with the risk of death. Group 1 patients (0 risk factors) had a median OS duration of 77.6 months (95% CI 50.5-90.4), group 2 (1 risk factor) 26.0 months (95% CI 19.5-35.2), and group 3 (≥2 risk factors) 8.9 months (95% CI 5.2-12.9; P < .001).

CONCLUSIONS

Stratification of patients with RCC and IVC thrombus by risk factors allowed us to predict survival duration. In patients with ≥2 risk factors, new treatment strategies with preoperative systemic therapy may improve survival.

PUTH Grading System for Urinary Tumor With Supradiaphragmatic Tumor Thrombus: Different Surgical Techniques for Different Tumor Characteristics

Purpose

To explore the different treatment strategies for urinary tumors with Mayo IV thrombus.

Materials and Methods

We retrospectively analyzed the patients with Mayo IV thrombus in Peking University Third Hospital from January 2014 to April 2021. We used the Peking University Third Hospital (PUTH) grading system to classify urinary tumors with supradiaphragmatic thrombus. PUTH-A referred to the filled thrombus whose tip just reached above the diaphragm, or the thrombus entering the right atrium (< 2cm). PUTH-B referred to the filled thrombus entering the right atrium (> 2cm), or the thrombus invading the wall of the inferior pericardial vena cava. Detailed techniques were described for various scenarios. Clinicopathological data and perioperative outcomes were reported. Group difference statistical analysis was performed.

Results

A total of 26 cases of urinary tumors with supradiaphragmatic IVC thrombus (Mayo grade IV) underwent treatment were enrolled in this study. 19 patients in the PUTH-A group received the open approach without sternotomy and cardiopulmonary bypass. Seven patients in the PUTH-B group received open thoracotomy assisted by cardiopulmonary bypass. No intraoperative death occurred. After 56 months of follow-up, 46.2% (12 of 26) patients died of all causes. Estimated 1-year, 2-year, and 3-year overall survival were 72.0% (95% CI, 54.4%-89.6%), 58.2% (95% CI, 38.0%-78.4%), and 52.4% (95% CI, 31.2%-73.6%), respectively.

Conclusions

We introduced the PUTH grading system for the characteristics of urinary tumors with supradiaphragmatic tumor thrombus, and selected different surgical techniques according to different classifications. This grading system was relatively feasible and effective.

Renal cell carcinoma with tumor thrombus growing against the direction of venous return: an indicator of complicated surgery and poor prognosis

PURPOSE

To explore the effect of tumor thrombus growing against the direction of venous return (GADVR) tumor thrombus on the choice of surgical approach, the impact on the complexity of the surgery and the prognosis.

METHODS

We retrospectively analyzed the clinicopathological data of 213 patients, who underwent surgery in a single center of Peking University Third Hospital between January 2016 and June 2020. For right renal cell carcinoma (RCC) and venous tumor thrombus (VTT), imaging revealed a filling defect in the left renal vein, which was significantly enhanced in enhanced imaging, suggesting that the tumor thrombus grew against the direction of venous return into the left renal vein. For left RCC and VTT, at least one of the left renal vein branches has tumor thrombus. The branches include the left adrenal vein, the left gonadal vein (testicular vein or ovarian vein), and the left ascending lumbar vein. The patients were divided into two groups according to whether they were GADVR tumor thrombus, and we compare the clinicopathological characteristics of GADVR tumor thrombus and non-GADVR tumor thrombus. Univariate and multivariate Cox regression analyses were performed to explore the risk factors that affect the prognosis of patients with RCC and VTT. Kaplan-Meier plots were conducted to evaluate the effect of GADVR on progression-free survival (PFS).

RESULTS

Compared with non-GADVR tumor thrombus, patients with GADVR tumor thrombus had a higher proportion of open surgery (76.2% vs. 52.1%, P = 0.035), a higher proportion of tumor thrombus adhering to the inferior vena cava (IVC) vessel wall (81% vs. 45.8%, P = 0.002), a higher proportion of segmental resection of the IVC vessel wall (61.9% vs. 15.6%, P < 0.001); higher preoperative serum creatinine value (110.0 μmol/L vs. 91.0 μmol/L, P = 0.015), a higher proportion of tumor thrombus combined with bland thrombus (non-tumor thrombus) (57.1% vs. 19.8%, P < 0.001). In terms of surgical complexity, patients with GADVR tumor thrombus had a longer median operation time (379 min vs. 308 min, P = 0.038), more median surgical blood loss (1400 mL vs. 600 mL, P = 0.018), and more postoperative complications (52.4% vs. 30.7%, P = 0.045). Multivariate Cox regression analysis showed that GADVR tumor thrombus, symptoms, postoperative serum creatinine, distant metastasis, sarcomatoid feature, pathological type, lymph node dissection were independent risk factors for PFS. Patients with GADVR tumor thrombus's median survival time was 14.0 months, while patients with non-GADVR tumor thrombus were 32.0 months (P = 0.016). GADVR tumor thrombus is an independent risk factor for PFS in patients with RCC and VTT.

CONCLUSION

GADVR tumor thrombus is a characteristic feature of tumor thrombus, with an incidence of 9.9%. It has a higher proportion of open surgery and higher surgical complexity, which is an independent risk factor for PFS.

Discovery and construction of prognostic model for clear cell renal cell carcinoma based on single-cell and bulk transcriptome analysis

Background

Clear cell renal cell carcinoma (ccRCC) is the most common malignant kidney tumor in adults. Single-cell transcriptome sequencing can provide accurate gene expression data of individual cells. Integrated single-cell and bulk transcriptome data from ccRCC samples provide comprehensive information, which allows the discovery of new understandings of ccRCC and the construction of a novel prognostic model for ccRCC patients.

Methods

Single-cell transcriptome sequencing data was preprocessed by using the Seurat package in R software. Principal component analysis (PCA) and the t-distributed stochastic neighbor embedding (t-SNE) algorithm were used to perform cluster classification. Two subtypes of cancer cells were identified, pseudotime trajectory analysis and gene ontology (GO) analysis were conducted with the monocle and clusterProfiler packages. Two novel cancer cell biomarkers were identified according to the single-cell sequencing and were confirmed by The Cancer Genome Atlas (TCGA) data. T cell-related marker genes according to single-cell sequencing were screened by a combination of Kaplan-Meier (KM) analysis, univariate Cox analysis, least absolute shrinkage and selection operator (Lasso) regression and multivariate Cox analysis of TCGA data. Four survival predicting genes were screened out to develop a risk score model. A nomogram consisting of the risk score and clinical information was constructed to predict the prognosis for ccRCC patients.

Results

A total of 5,933 cells were included in the study after quality control. Fifteen cell clusters were classified by PCA and t-SNE algorithm. Two clusters of cancer cells with distinct differentiation status were identified. Besides, GO analysis revealed that biological processes were different between the two subgroups. Egl-9 family hypoxia-inducible factor 3 (EGLN3) and nucleolar protein 3 (NOL3) were specifically expressed in cancer cell clusters, bulk RNA sequencing data from TCGA confirmed their high expression in ccRCC tissues. GTSE1, CENPF, SMC2 and H2AFV were screened out and applied to the construction of risk score model. A nomogram was generated to predict prognosis of ccRCC by combing the risk score and clinical parameters.

Conclusions

We integrated single-cell and bulk transcriptome data from ccRCC in this study. Two subtypes of ccRCC cells with different biological characteristics and two potential biomarkers of ccRCC were discovered. A novel prognostic model was constructed for clinical application.

Prognostic significance of extent of venous tumor thrombus in patients with non-metastatic renal cell carcinoma: Results from a Canadian multi-institutional collaborative

PURPOSE

The prognostic significance of level of venous tumor thrombus (VTT) extension in patients with non-metastatic renal cell carcinoma (RCC) has been controversial. The aim of this study was to examine the prognostic significance of VTT extent in patients who underwent surgery for non-metastatic RCC.

MATERIALS AND METHODS

The Canadian Kidney Cancer information system database was used to identify patients who underwent surgery for non-metastatic RCC and VTT from January 2011 to December 2019. Association between VTT level and recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) was examined. Univariable and multivariable analyses were performed to estimate predictors of survival.

RESULTS

Out of 6,340 patients during the study period, 228 patients (3.6%) had VTT. VTT was level 0 in 84 (37%), level I to II in 112 (49%), and level III to IV in 33 (14%) patients as per the Mayo Clinic classification. Median age was 65.4 years (interquartile range [IQR] 57.6-72.2) and 169 (74.1%) were male. After a median follow-up of 21.2 months, VTT level did not significantly impact the RFS, CSS, or OS. For VTT level 0, I to II, and III to IV, there was no significant difference in estimated 5-year RFS (31%, 23%, and 30.5%; P > 0.05), CSS (70%, 69%, and 55%; P > 0.05) and OS (64%, 66%, and 50%; P > 0.05). Adjusting for known prognostic factors, thrombus level was not associated with risk of recurrence or death.

CONCLUSION

In a large, multi-institutional cohort of patients undergoing surgery for non-metastatic RCC with tumor thrombus, thrombus extent was not independently associated with recurrence or death.

Analysis of Clinicopathological Factors Influencing Survival in Patients with Renal Cell Carcinoma and Venous Tumor Thrombus

This study aimed to define patients with renal cell cancer and coexisting tumor thrombus in order to address concerns regarding survival and prognostic factors after radical surgery. Several prognostic factors for overall survival (OS) were assessed in patients treated surgically at five institutions from 2012 to 2018. Univariate and multivariate analyses were used to determine the independent risk factors of OS. A total of 142 patients were eligible for further analysis (mean age of 64.75 years, 56% males). Most patients presented with clear cell carcinoma (95%). The Mayo stage was predominantly 0–1 (88%). Distant visceral metastases at the time of diagnosis were present in 36 patients (25%), whereas nodal metastases were present in 24 patients (16.9%). During the follow-up period (mean of 32.5 months), the 3-year OS rate reached 68.2%. The majority of patients received no adjuvant treatment (n = 107). In a multivariable model predicting OS, regional lymph node status (p < 0.001), distant metastases (p = 0.009), tumor grade (p = 0.002), duration of hospitalization (p = 0.016), and Clavien–Dindo grade (p = 0.047) were identified as independent prognostic factors. A subgroup of patients with specific clinicopathological factors may benefit most from the radical surgery, including patients without regional lymph node or distant metastases and with low tumor grades, whereas short hospitalization and low Clavien–Dindo grades represent additional independent prognostic factors.

[Influence of deep invasive tumor thrombus on the surgical treatment and prognosis of patients with non-metastatic renal cell carcinoma complicated with venous tumor thrombus]

OBJECTIVE

To evaluate the impact of deep invasive tumor thrombus on the surgical complexity and prognosis of patients with renal cell carcinoma complicated with inferior vena cava tumor thrombus.

METHODS

We retrospectively reviewed the clinical data of 94 patients with non-metastatic renal cell carcinoma complicated with inferior vena cava tumor thrombus, who underwent surgical treatment in Peking University Third Hospital from January 2017 to June 2020. The patient's general condition, clinicopathological characteristics, surgery and survival information were collected. The patients were divided into two groups based on the intra-operative findings of tumor thrombus adhesion to the venous wall, of which 64 cases were in the deep invasive tumor thrombus (DITT) group and 30 cases were in the non-invasive tumor thrombus (NITT) group. Chi-square, t test and Mann-Whitney U test were used for categorical and continuous variables respectively. Kaplan-Meier plots and multivariable Cox regressions were performed to evaluate the influence of DITT on the prognosis of the patients with renal cell carcinoma with inferior vena cava tumor thrombus.

RESULTS

DITT significantly increase the difficulty of surgery for the patients with renal cell carcinoma with venous tumor thrombus, which was mainly reflected in the longer operation time (362.5 vs. 307.5 min, P=0.010), more surgical bleeding (1 200 vs. 450 mL, P=0.006), more surgical blood transfusion (800 vs. 0 mL, P=0.021), more plasma transfusion (200 vs. 0 mL, P=0.001), a higher proportion of open surgery (70.3% vs. 36.7%, P=0.002), a longer post-operative hospital stay (9.5 vs. 8 days, P=0.036), and a higher proportion of post-operative complications (46.9% vs. 13.8%, P=0.002). DITT was associated with worse overall survival of the patients with renal cell carcinoma with inferior vena cava tumor thrombus (P=0.022). Even in the multivariate analysis, DITT was still a poor prognostic factor for the overall survival of these patients [HR: 4.635 (1.017-21.116), P=0.047].

CONCLUSION

For patients with non-metastatic renal cell carcinoma with inferior vena cava tumor thrombus, DITT will significantly increase the difficulty of surgery, and may lead to poor prognosis.

Oncological Outcomes of Patients With Different Pathological Features of pT3a Renal Tumor: A Systematic Review and Quantitative Synthesis

Purpose

To identify the differences in oncological outcomes for patients with different pT3a renal tumor invasion patterns and pathological features.

Methods

The protocol of this study was registered on PROSPERO (CRD42021234475). Relevant studies were identified by searching the PubMed, Cochrane library, Embase, and Web of Science databases. Cancer-specific survival (CSS) was selected as the endpoint. Pooled hazard ratio (HR) and 95% confidence interval (CI) extracted from multivariate Cox models were evaluated to identify the hazard association.

Results

A total of 22 studies, which enrolled 12384 patients were included for quantitative synthesis. Sinus fat invasion (SFI) + perinephric fat invasion (PFI) was associated with inferior CSS compared to SFI only (p = 0.02). Comparable CSS was observed between SFI and PFI (p = 0.57). SFI ± PFI showed inferior CSS compared to PFI only (p = 0.0002). The presence of pelvicalyceal system invasion significantly increased the risk of cancer-specific mortality (p = 0.0005). Renal vein invasion (RVI) indicated poor oncological outcomes in terms of CSS (p = 0.002). The concomitant RVI and fat invasion (FI) significantly increased the risk of deterioration of CSS compared to RVI or FI (p < 0.0001). Multiple invasion patterns translated into a significantly decreased CSS (p < 0.0001). Aggressive tumor behavior, including lymph node involvement (p = 0.006), distant metastases (p < 0.00001), sarcomatoid differentiation (p < 0.0001), necrosis (p < 0.0001), Fuhrman grade III or IV (p < 0.0001), positive margin (p < 0.0001), and tumor size >7cm (p < 0.0001) were the predictors of inferior CSS. The lymphovascular invasion (p = 0.67) was indolent in terms of CSS.

Conclusion

This study confirmed the heterogenicity of pT3a renal tumors. Multiple invasion patterns could translate into a significantly decreased CSS, and SFI should not be merged in the SFI + PFI group. The presence of PSI or RVI could significantly increase the risk of cancer-specific mortality. Lymph node involvement, distant metastases, sarcomatoid differentiation, necrosis, high Fuhrman grade, positive margin, and size >7cm were the predictors of inferior CSS. A precise-risk grade of CSS for different invasion patterns including comprehensive combinations may be useful for the further refinements of the TNM system.

Systematic Review Registration

The current study was registered on PROSPERO, and the registration numbers is CRD42021234475.

Predictive factors for disease recurrence in patients with locally advanced renal cell carcinoma treated with curative surgery

BACKGROUND

Few prognostic factors have been proposed for patients with locally advanced renal cell carcinoma (RCC). This study aimed to investigate the possible predictive factors for disease-free survival (DFS) after curative surgery for RCC stage T3 or higher.

METHODS

Patients with locally advanced RCC who underwent cure-intended partial or radical nephrectomy, with or without tumor thrombectomy, at our institution from April 1, 2005 to October 31, 2013 were retrospectively reviewed. Those undergoing cytoreductive nephrectomy were excluded. Preoperative data, including surgical and pathologic characteristics, were assessed for correlation with DFS. Chi-square tests, univariate and multivariate Cox regression analysis, and Kaplan-Meier survival curve analyses were performed to determine potential predictive factors. A p value less than 0.05 was considered statistically significant.

RESULTS

A total of 159 patients were included for analysis. The mean duration of follow-up was 37.9 months, and 119 (74.8%) patients remained disease-free during follow-up. Disease recurrence was found in 40 (25.2%) patients, and pathologic T stage, capsule penetration, Fuhrman grade, thrombocytosis, renal vein thrombosis, and elevated serum alkaline phosphatase, platelet/lymphocyte ratio, and γ-glutamyl transpeptidase levels were significantly associated with disease recurrence on univariate analysis. On multivariate analysis, Fuhrman grade 3 or 4 (HR = 5.70, p = 0.0003, 95% CI = 2.23-14.56) showed significant associations with DFS.

CONCLUSION

In patients with locally advanced RCC, Fuhrman grade was associated with worse DFS after curative surgery. Urologists should closely monitor patients with high Fuhrman grades.

Overexpression of MAX dimerization protein 3 (MXD3) predicts poor prognosis in clear cell renal cell carcinoma

Background

Clear cell renal cell carcinoma (ccRCC) is the most common histological subtype of malignant kidney tumor. The molecular mechanism of ccRCC is complicated, and few effective prognostic predictors have been applied to clinical practice. MAX dimerization protein 3 (MXD3) is generally considered a transcription factor of the MYC/MAX/MAD transcriptional network. This study aimed to investigate the impact of MXD3 in ccRCC.

Methods

Gene expression profiles and clinical data of ccRCC were downloaded from The Cancer Genome Atlas (TCGA) database. MXD3 expression levels between tumors and adjacent normal tissues were compared. The influence of MXD3 on overall survival (OS) was evaluated using the Kaplan-Meier method. Associations between MXD3 expression and clinical features were assessed with the Kruskal test and Wilcoxon test. Univariate and multivariate Cox analyses were performed to observe the impact of MXD3 expression and clinical features on prognosis. The correlation between MXD3 and ccRCC immune infiltration was estimated with TIMER. The DNA methylation levels of the MXD3 promoter were obtained from UALCAN. Gene set enrichment analysis (GSEA) was conducted to explore the biological signaling pathways.

Results

MXD3 was overexpressed in ccRCC tumor tissues compared with adjacent normal kidney tissues. High expression of MXD3 was significantly correlated with poor prognosis. MXD3 expression levels were associated with tumor grade, tumor stage, tumor (T) classification and metastasis (M) classification. Univariate and multivariate Cox analyses showed that high expression of MXD3 was an independent risk factor for OS in ccRCC. MXD3 expression was positively correlated with the infiltrating levels of B cells and myeloid dendritic cells, and negatively correlated with macrophages. The MXD3 promoter region tended to be hypomethylated in ccRCC compared with normal tissues. GSEA identified homologous recombination, base excision repair, and glycerophospholipid metabolism as differentially enriched in ccRCC with high MXD3 expression.

Conclusions

This study suggests that high expression of MXD3 is an independent risk factor for poor prognosis in ccRCC. MXD3 expression potentially contributes to regulation of immune infiltration and cell proliferation in ccRCC, and the aberrant expression of MXD3 in tumor tissues could be caused by hypomethylation of gene promoter. MXD3 could be an effective prognostic biomarker and potential therapeutic target for ccRCC.

[Criteria for an improved prognostic stratification in category pT renal carcinoma]

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.

[Radical nephrectomy and partial nephrectomy]

Renal cell carcinoma is the 2nd most frequent urological malignancy in women and the third most frequent in men, with an age peak in the seventh decade of life. If detected early in a local non-metastatic stage, options for complete recovery are excellent. While two decades ago, even locally limited cancers of the kidney were cured by radical nephrectomy, treatment today mostly consists of local treatment for locally confined cancers. Guidelines today recommend local surgical excision (open or minimally-invasive) or - in selected cases - topical energy application (radio-frequency ablation, cryoablation). The surgeon's expertise is most important in the selection of the appropriate kind of surgery and different guidelines have slightly different recommendations.Treatment decisions should be made on an individual basis in due consideration of an individual's age and co-morbidities. This may lead to the recommendation that, due to low perioperative morbidity, even localised carcinomas should be treated by (minimally-invasive) radical nephrectomy instead of nephron-sparing surgery and, in other cases, a non-interventional, active surveillance strategy may be pursued without compromising the patient's life expectancy. For higher-grade renal cell carcinomas, there is usually an indication for radical nephrectomy, as long as no metastases are detected. This also applies to carcinomas with venous thrombi extending into the atrium of the heart. Complications in the treatment of renal carcinomas are usually rare and easily treatable in most cases.

Prevalence and prognostic value of FBXO11 expression in patients with clear cell renal cell carcinoma

BACKGROUND

FBXO11, a member of the F-box protein family, regulates the cell-cycle by promoting the degradation of Bcl-6 and p53. This protein has been implicated in the progression of several cancers, including renal cell carcinoma (RCC). The aim of this study was to determine the prognostic role of FBXO11 in the clinical outcome of RCC patients.

METHODS

FBXO11 mRNA expression was analysed in normal and RCC tissue microarrays of the Oncomine database. In addition, the in situ expression levels of stromal FBXO11 protein were assessed in primary RCC tissues from 227 patients (training and validation cohorts) using immunohistochemistry (IHC). Kaplan Meier and Cox regression analyses were used to determine the association between FBXO11 expression and cliniopathological factors. A nomogram was established using the significant prognostic factors to predict overall survival (OS) of RCC patients after one, three and 5 years.

RESULTS

In the Oncomine database, FBXO11 mRNA levels were lower in normal tissues than in cancer tissues, including clear cell renal cell carcinoma (ccRCC), papillary renal cell carcinoma (pRCC), hereditary ccRCC, non-hereditary ccRCC, VHL mutant ccRCC and VHL wild-type ccRCC. In addition, FBXO11 expression was also significantly higher in metastatic kidney cancer than in primary cancer. Immunohistochemical analysis reported that 57.3% (86 of 150) of the training cohort and 57.1% (44 of 77) of the validation cohort were scored as having high FBXO11 staining density. FBXO11 expression was significantly associated with Fuhrman grade (p = 0.003), UISS score (p = 0.021) and age (p = 0.048) in the training cohort. Furthermore, Kaplan-Meier survival analysis showed that higher FBXO11 levels, T stage, UISS scores and SSIGN score were associated with poor OS in ccRCC patients. Multivariate Cox analysis demonstrated that higher FBXO11 levels and higher UISS score were independent prognostic indicators for OS. Nomogram, calibration plots, AUC values and the C-index showed that the predictive accuracy of conventional prognostic models, including UISS score and SSIGN score, was improved when FBXO11 expression was added.

CONCLUSIONS

FBXO11 expression was closely related to RCC malignancy and poor prognosis, indicating its potential as a prognostic marker as well as a therapeutic target for RCC.

CT texture analysis in the differentiation of major renal cell carcinoma subtypes and correlation with Fuhrman grade

OBJECTIVE

CT texture analysis (CTTA) using filtration-histogram-based parameters has been associated with tumor biologic correlates such as glucose metabolism, hypoxia, and tumor angiogenesis. We investigated the utility of these parameters for differentiation of clear cell from papillary renal cancers and prediction of Fuhrman grade.

METHODS

A retrospective study was performed by applying CTTA to pretreatment contrast-enhanced CT scans in 290 patients with 298 histopathologically confirmed renal cell cancers of clear cell and papillary types. The largest cross section of the tumor on portal venous phase axial CT was chosen to draw a region of interest. CTTA comprised of an initial filtration step to extract features of different sizes (fine, medium, coarse spatial scales) followed by texture quantification using histogram analysis.

RESULTS

A significant increase in entropy with fine and medium spatial filters was demonstrated in clear cell RCC (p = 0.047 and 0.033, respectively). Area under the ROC curve of entropy at fine and medium spatial filters was 0.804 and 0.841, respectively. An increased entropy value at coarse filter correlated with high Fuhrman grade tumors (p = 0.01). The other texture parameters were not found to be useful.

CONCLUSION

Entropy, which is a quantitative measure of heterogeneity, is increased in clear cell renal cancers. High entropy is also associated with high-grade renal cancers. This parameter may be considered as a supplementary marker when determining aggressiveness of therapy.

KEY POINTS

• CT texture analysis is easy to perform on contrast-enhanced CT. • CT texture analysis may help to separate different types of renal cancers. • CT texture analysis may enhance individualized treatment of renal cancers.