Postoperative better than preoperative C-reactive protein at predicting outcome after potentially curative nephrectomy for renal cell carcinoma

Association of Elevated C-Reactive Protein with Worsened Outcomes in Different Histologies of Renal Cortical Tumors: Analysis of the INMARC Registry

BACKGROUND

To evaluate relationship between histological subtypes of renal cell carcinoma (RCC) and preoperative c-reactive protein (CRP).

PATIENTS AND METHODS

We queried the International Marker Consortium for Renal Cancer database for patients affected by RCC. Patients were classified according to their histology: benign tumors, clear cell (cc) RCC, chromophobe (ch) RCC, papillary (p) RCC, and variant histology (vh) RCC; and according to CRP (mg/L): low CRP ≤5 and high CRP >5. Primary outcome was all-cause mortality (ACM). Secondary outcomes were cancer-specific mortality (CSM), recurrence and association between CRP and histology. Multivariable analysis (MVA) via Cox regression and multivariable logistic regression were fitted to elucidate predictors of outcomes.

RESULTS

Total 3902 patients (high CRP n = 1266) were analyzed; median follow up 51 (IQR 20-91) months. On MVA elevated CRP was an independent risk factor associated with increased risk of ACM in benign tumors (HR 5.98, P < .001), ccRCC (HR 2.69, P < .001), chRCC (HR 3.99, P < .001), pRCC (HR 1.76, P = .009) and vhRCC (HR 2.97, P =.007). MVA for CSM showed CRP as risk factor in ccRCC (HR 2.77, P < .001), chRCC (HR 6.16, P = .003) and pRCC (HR 2.29, P = .011), while in vhRCC was not (P = .27). MVA for recurrence reported CRP as risk factor for ccRCC (HR 1.30, P = .013), while in chRCC (P = .33), pRCC (P = .34) and vhRCC (P = .52) was not. On multivariable logistic regression CRP was a predictor of pRCC (OR 1.003, P = .002), while decreasing CRP was associated with benign tumors (OR 0.994, P = .048).

CONCLUSION

Elevated CRP was a robust predictor of worsened ACM in all renal cortical neoplasms. While most frequently observed in pRCC patients, elevated CRP was independently associated with worsened CSM in non-vhRCC. Conversely, elevated CRP was least likely to be noted in benign tumors, and elevation in this subgroup of patients should prompt further consideration for surveillance given increased risk of ACM. Further investigation is requisite.

Prognostic Value of Post-Operative C-Reactive Protein-Based Inflammatory Biomarkers in Colorectal Cancer Patients: Systematic Review and Meta-Analysis

Post-operative inflammation in cancer patients can be modulated by drugs and diets, but evidence on its prognostic role, which would be crucial for personalized treatment and surveillance schemes, remains rather limited. We aimed to systematically review and meta-analyse studies on the prognostic value of post-operative C-reactive protein (CRP)-based inflammatory biomarkers among patients with colorectal cancer (CRC) (PROSPERO#: CRD42022293832). PubMed, Web of Science and Cochrane databases were searched until February 2023. Studies reporting associations between post-operative CRP, Glasgow Prognostic Score (GPS) or modified Glasgow Prognostic Score (mGPS) with overall survival (OS), CRC-specific survival (CSS) and recurrence-free survival (RFS) were included. Hazard ratios (HRs) with 95% confidence intervals (CIs) for the predictor-outcome associations were pooled using R-software, version 4.2. Sixteen studies (n = 6079) were included in the meta-analyses. Elevated post-operative CRP was a predictor of poor OS, CSS and RFS compared with low CRP levels [HR (95% CI): 1.72 (1.32-2.25); 1.63 (1.30-2.05); 2.23 (1.44-3.47), respectively]. A unit increase in post-operative GPS predicted poor OS [HR (95% Cl): 1.31 (1.14-1.51)]. Moreover, a unit increase in post-operative mGPS was associated with poor OS and CSS [HR (95% Cl): 1.93 (1.37-2.72); 3.16 (1.48-6.76), respectively]. Post-operative CRP-based inflammatory biomarkers have a significant prognostic role for patients with CRC. Prognostic value of these easy-to-obtain routine measurements thereby seems to outperform most of the much more complex blood- or tissue-based predictors in the current focus of multi-omics-based research. Future studies should validate our findings, establish optimal time for biomarker assessment and determine clinically useful cut-off values of these biomarkers for post-operative risk-stratification and treatment-response monitoring.

The predictive value of perioperative circulating markers on surgical complications in patients undergoing robotic-assisted radical prostatectomy

BACKGROUND

The occurrence of postoperative complications was associated with poor outcomes for patients undergoing robotic-assisted radical prostatectomy. A prediction model with easily accessible indices could provide valuable information for surgeons. This study aims to identify novel predictive circulating biomarkers significantly associated with surgical complications.

METHODS

We consecutively assessed all multiport robotic-assisted radical prostatectomies performed between 2021 and 2022. The clinicopathological factors and perioperative levels of multiple circulating markers were retrospectively obtained from the included patients. The associations of these indices with Clavien-Dindo grade II or greater complications, and surgical site infection were assessed using univariable and multivariable logistic regression models. Further, the models were validated for the overall performance, discrimination, and calibration.

RESULTS

In total, 229 patients with prostate cancer were enrolled in this study. Prolonged operative time could independently predict surgical site infection (OR, 3.39; 95% CI, 1.09-10.54). Higher RBC (day 1-pre) implied lower risks of grade II or greater complications (OR, 0.24; 95% CI, 0.07-0.76) and surgical site infection (OR, 0.23; 95% CI, 0.07-0.78). Additionally, RBC (day 1-pre) independently predicted grade II or greater complications of obese patients (P value = 0.005) as well as those in higher NCCN risk groups (P value = 0.012). Regarding the inflammatory markers, NLR (day 1-pre) (OR, 3.56; 95% CI, 1.37-9.21) and CRP (day 1-pre) (OR, 4.16; 95% CI, 1.69-10.23) were significantly associated with the risk of grade II or greater complications, and both the indices were independent predictors in those with higher Gleason score, or in higher NCCN risk groups (P value < 0.05). The NLR (day 0-pre) could also predict the occurrence of surgical site infection (OR, 5.04; 95% CI, 1.07-23.74).

CONCLUSIONS

The study successfully identified novel circulating markers to assess the risk of surgical complications. Postoperative increase of NLR and CRP were independent predictors for grade II or greater complications, especially in those with higher Gleason score, or in higher NCCN risk groups. Additionally, a marked decrease of RBC after the surgery also indicated a higher possibility of surgical complications, especially for the relatively difficult procedures.

Systemic Immunological Determinants of Oncological Outcomes After Surgery for Localized Renal Cell Carcinoma

INTRODUCTION & OBJECTIVES

In systemic therapy trials, a decreasing neutrophil-to-lymphocyte ratio (NLR) after treatment for metastatic renal cell carcinoma (RCC) has been associated with improved oncologic outcomes. Paradoxically, for patients with localized RCC treated with upfront surgery the opposite effect has been reported. We thus aimed to evaluate NLR dynamics on localized RCC recurrence.

MATERIALS AND METHODS

Treatment naïve patients with localized RCC managed surgically between 2005 and 2020 were included. Preoperative NLR was calculated within 6-weeks prior to surgery and postoperative NLR was calculated between 4 and twelve-weeks after surgery. Patients were followed for disease recurrence, noting metastatic sites and postoperative infections. Cox regression were used to determine whether the relative change in postoperative NLR was associated with metastasis-free survival (MFS) and cancer-specific survival (CSS), adjusted for preoperative NLR.

RESULTS

In the cohort of 3310 patients, 996 (30%) had postoperative NLR available. These patients generally had more advanced disease, with 100 developing metastases and 38 dying from kidney cancer. Median MFS follow-up was 4.4 years. Decreasing 2-month postoperative NLR was associated with non-statistically significant worse MFS and CSS (HR 0.79, 95% 0.50, 1.24, P = .3; HR 0.83, 95% C.I. 0.40, 1.73; P = .6). On sensitivity analysis, across all NLR measurements, with NLR as a time-dependent covariate, results were similar, with a declining NLR associated with adverse MFS (HR 0.85, 95% CI 0.69, 1.30, P-value = .10), though not meeting conventional levels of significance.

CONCLUSION

In higher-risk localized RCC patients, postoperative NLR is not suitable as a biomarker for predicting recurrences.

Inflammatory Markers in Cancer Immunotherapy

Simple Summary

Inflammation has been recognized to be linked to tumor development. Several markers of inflammation can be detected via blood such as variety of blood cells, which can be readily and easily obtained. These markers have been studied as ways to predict and prognosticate tumor response to chemotherapy. With the development of immunotherapy, namely immune checkpoint inhibitors (ICIs) such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed death ligand 1 (PDL-1) PDL-1 inhibitors, several markers have also been studied in assessing tumor response. In this review, we will discuss the various inflammatory markers that have been studied in several tumors treated with ICIs.

Abstract

Chronic inflammation is considered a major risk factor for cancer formation. Inflammation within the tumor environment plays a role in its response to therapy, growth, and prognosis. Cancer associated inflammation is known to occur in the tumor microenvironment and in the systemic circulation, and is correlated with disease progression and prognosis in many cancers. Blood cells such as neutrophils, lymphocytes, platelets, and circulating proteins such as C-reactive protein, and interleukins, such as IL-6, have been associated with inflammatory responses, which contribute to tumorigenesis. Cancer has found ways to evade the immune response; a pathway that can attenuate the innate immune response is via blocking immune checkpoints. Development of monoclonal antibodies against inhibitory immune checkpoints such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1) have given rise to immunotherapy, which has shown remarkable responses in anti-tumor activity resulting in several U.S. Federal and Drug Administration (FDA)-approved checkpoint inhibitors. Various inflammatory markers and their prognostic and predictive implications in malignancies treated with immunotherapy will be discussed in this review.

Predictive Value of C-Reactive Protein for Early Postoperative Complications in Children After Hypospadias Surgery

Background: This study explored the predictive value of postoperative C-reactive protein in children with hypospadias for postoperative complications and the risk factors. Methods: The clinical and follow-up data of 106 children with hypospadias who were treated with operations at Kunming Children's Hospital in 2020 were, respectively, analyzed. According to the occurrence of postoperative complications, the patients were divided into two groups: 25 patients with postoperative complications were the complications group, and 81 without postoperative complications were the control group. The baseline data, clinical characteristics, laboratory test indexes, and outcome of the two groups were collected. Receiver operating characteristic (ROC) was used to calculate the optimal cutoff value of C-reaction protein (CRP). Logistic regression was used to analyze the risk factors of hypospadias after surgery. A probability value (P) < 0.05 was considered statistically significant. Results: According to the result of the ROC curve, the optimal cutoff value of CRP was 11.7 mg/L. Logistic regression showed that the length of urethral defect, the urethral material, the operative produce, and the postoperative CRP level were related to the occurrence of postoperative complications of patients with DCC. The length of the urethral defect and the CRP level were the independent risk factors of the prognosis of hypospadias patients. The CRP level was related to the occurrence of postoperative complications and fistula. Conclusions: Postoperative CRP level can be used as a reliable marker for predicting the prognosis of hypospadias patients.

The Biological Context of C-Reactive Protein as a Prognostic Marker in Renal Cell Carcinoma: Studies on the Acute Phase Cytokine Profile

High serum levels of the acute phase protein C-reactive protein (CRP) are associated with an adverse prognosis in renal cancer. The acute phase reaction is cytokine-driven and includes a wide range of inflammatory mediators. This overall profile of the response depends on the inducing event and can also differ between patients. We investigated an extended acute phase cytokine profile for 97 renal cancer patients. Initial studies showed that the serum CRP levels had an expected prognostic association together with tumor size, stage, nuclear grading, and Leibovich score. Interleukin (IL)6 family cytokines, IL1 subfamily mediators, and tumor necrosis factor (TNF)α can all be drivers of the acute phase response. Initial studies suggested that serum IL33Rα (the soluble IL33 receptor α chain) levels were also associated with prognosis, although the impact of IL33Rα is dependent on the overall cytokine profile, including seven IL6 family members (IL6, IL6Rα, gp130, IL27, IL31, CNTF, and OSM), two IL1 subfamily members (IL1RA and IL33Rα), and TNFα. We identified a patient subset characterized by particularly high levels of IL6, IL33Rα, and TNFα alongside an adverse prognosis. Thus, the acute phase cytokine reaction differs between renal cancer patients, and differences in the acute phase cytokine profile are associated with prognosis.

Serum levels of the IL-6 family of cytokines predict prognosis in renal cell carcinoma (RCC)

Purpose

An improved understanding of RCC immunology should shed further light on RCC tumor biology. Our objective was to study to what extent serum levels of the IL-6 family of cytokines at diagnosis were relevant to survival.

Methods

A total of 118 consecutively patients with RCC, in which the tumor was surgically removed at Haukeland University Hospital during the period from 2007 to 2010, were included. The patients were followed-up for 10 years. The morning before surgery blood was sampled and serum frozen, with levels of IL-6, IL-27, IL-31, OSM, CNTF, IL-6Rα and gp130 determined.

Results

Among patients with the highest quartile of IL-6 (> 8 pg/ml) (n = 29), six of nine who had metastasis at diagnosis had such high IL-6 values. Among presumed radically treated patients, a high IL-6 and IL-27 strongly predicted recurrence. In particular, the predictions among patients with large (diameter > 7 cm) tumors were excellent regarding both IL-6 and IL-27 values. High gp130 serum levels predicted an overall survival (OS) among RCC patients with large tumors. Patients with a high IL-6 exhibited a strong expression of IL-6 in endothelial- and vascular smooth muscle cells. Moreover, the level of intra-tumoral CD3-positive cells predicted survival.

Conclusions

IL-6 and IL-27 seem to play a role in RCC biology. IL-6 enables the pinpointing of metastatic condition at diagnosis, as well as together with IL-27, the predicting of survival and recurrence. Endothelial cells and vascular smooth muscle cells are both suggested as important sources of IL-6.

Electronic supplementary material

The online version of this article (10.1007/s00262-020-02655-z) contains supplementary material, which is available to authorized users.

Early postoperative inflammatory response by procedure types: stapler-based segmentectomy versus lobectomy

OBJECTIVE

Perioperative C-reactive protein (CRP) levels have become a contentious topic on the surgical outcome of lung cancer, but the influence of the procedure types has not been precisely investigated. From this viewpoint, we compared two types of thoracoscopic anatomical lung resection: segmentectomy and lobectomy.

METHODS

This was a retrospective study involving patients who underwent standardized anatomical lung resection at a single institute from 2014 to 2017; CRP levels were routinely measured on postoperative days 1, 3, and 5. Changes in the CRP levels from the preoperative period were calculated (ΔCRP), and factors associated with a higher ΔCRP value were analyzed.

RESULTS

Among 186 patients included, 91 (48.9%) patients underwent stapler-based segmentectomy and 95 (51.1%) patients underwent lobectomy. The segmentectomy group showed significantly higher ΔCRP values on every measurement day than the lobectomy group, in spite of shorter operation time, smaller blood loss, shorter drainage periods, shorter dissection time, and limited lymph node dissection. The number of stapler cartridges for the lung parenchyma was significantly larger in the segmentectomy group. Regression analyses indicated that procedure type and smoking history were associated with a higher ΔCRP value, whereas no significant difference was indicated in the smoking history between the groups.

CONCLUSION

In our cohort, stapler-based thoracoscopic segmentectomy was associated with an increase in acute inflammatory response despite favorable perioperative outcome compared to lobectomy. Local surgical stress and damage in the remaining segments might play a key role and warrants further investigation.

Prognostic value of the combination of pre- and postoperative C-reactive protein in colorectal cancer patients

PURPOSE

Inflammation is closely related to cancer development and progression. This retrospective study investigated the prognostic value of the combination of pre- and postoperative C-reactive protein (CRP) levels in patients with colorectal cancer (CRC).

METHODS

The subjects of this study were 406 patients who underwent surgery for CRC.

RESULTS

Based on receiver-operating characteristic analysis, patients were divided into the following groups: those with a preoperative CRP of ≥ 0.5 mg/dL (pre-CRP^High), those with a preoperative CRP of < 0.5 mg/dL (pre-CRP^Low), those with a postoperative CRP of ≥ 17.0 mg/dL (post-CRP^High), and those with a postoperative CRP of < 17.0 mg/dL (post-CRP^Low). They were then allocated to one of the following three groups: Group A, comprised of those in the pre-CRP^High and post-CRP^High groups; Group B, comprised of those in either the pre-CRP^High and post-CRP^Low or pre-CRP^Low and post-CRP^High groups; and Group C, comprised of those in the pre-CRP^Low and post-CRP^Low groups. The disease-specific 5-year survival rates were 53.8%, 72.8%, and 87.2% in Groups A, B, and C, respectively, and these differences were significant. Finally, multivariate analysis revealed that the combination of pre- and postoperative CRP levels was an independent prognostic indicator.

CONCLUSIONS

The combination of pre- and postoperative CRP was predictive of the prognosis of CRC patients.

Role of Postoperative C-Reactive Protein Levels in Predicting Prognosis After Surgical Treatment of Esophageal Cancer

BACKGROUND

Elevated preoperative serum C-reactive protein (CRP) levels are reportedly associated with a poor prognosis for patients with various types of malignant tumors. However, the impact of postoperative CRP levels on the prognosis of patients with esophageal cancer remains unknown. The present study aims to clarify the prognostic significance of postoperative CRP levels on the survival of patients with esophageal cancer.

METHODS

We reviewed the records of consecutive 202 patients with thoracic esophageal squamous cell carcinoma who underwent transthoracic esophagectomy. We measured serum CRP levels on postoperative days (PODs) 1, 2, 3, 5 and 7 and evaluated the relationships between postoperative CRP levels and survival.

RESULTS

The findings of Cox regression analyses suggested that elevated CRP levels on POD 3, 5 and 7 were associated with poor recurrence-free survival (RFS). We divided CRP levels on POD 7 into three tertiles and found that RFS could be clearly stratified, being the poorest (p < 0.001) in the highest tertile (high CRP). The trend was similar even in patients with or without infectious complications and with or without advanced pathological stage. Multivariate analysis showed that pathologically advanced stage (Hazard ratio [HR], 5.14; 95% confidence interval [CI] 2.67-9.87; p < 0.001) and high CRP (HR, 2.27; 95% CI 1.3-3.96; p = 0.004) were independent predictors of RFS.

CONCLUSION

Postoperative CRP levels could predict the prognosis of patients with esophageal cancer. We propose that the clinical course of postoperative CRP level should be carefully monitored as a predictor of survival.

Postoperative renormalization of C-reactive protein with adjuvant lienal polypeptide and its association with tumour recurrence in T1 clear cell renal cell carcinoma

OBJECTIVES

To evaluate the effect of pre- and postoperative C-reactive protein (CRP) levels on tumour recurrence following curative nephrectomy in patients with stage T1 clear cell renal cell carcinoma (CCRCC).

METHODS

Patients with stage T1 CCRCC were recruited. CRP was quantified 3 days before and 4 weeks after surgery. Patients were followed-up for clinical outcome every 3 months. A subset of patients received lienal polypeptide as adjuvant treatment.

RESULTS

Patients with elevated preoperative CRP levels (≥8.2 mg/l; n = 61) had higher grade tumours, were more likely to require radical nephrectomy and were more likely to experience recurrence than those with normal CRP levels. Non-normalization of elevated preoperative CRP was associated with tumour recurrence, but elevated CRP was not an independent risk factor of tumour recurrence.

CONCLUSION

Postoperative renormalization of elevated CRP is associated with decreased risk of recurrence in CCRCC.

C-Reactive Protein Is an Important Biomarker for Prognosis Tumor Recurrence and Treatment Response in Adult Solid Tumors: A Systematic Review

PURPOSE

A systematic literature review was done to determine the relationship between elevated CRP and prognosis in people with solid tumors. C-reactive protein (CRP) is a serum acute phase reactant and a well-established inflammatory marker. We also examined the role of CRP to predict treatment response and tumor recurrence.

METHODS

MeSH (Medical Subject Heading) terms were used to search multiple electronic databases (PubMed, EMBASE, Web of Science, SCOPUS, EBM-Cochrane). Two independent reviewers selected research papers. We also included a quality Assessment (QA) score. Reports with QA scores <50% were excluded. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology was utilized for this review (S1 PRISMA Checklist).

RESULTS

271 articles were identified for final review. There were 45% prospective studies and 52% retrospective. 264 had intermediate QA score (≥50% but <80%); Seven were adequate (80% -100%); A high CRP was predictive of prognosis in 90% (245/271) of studies-80% of the 245 studies by multivariate analysis, 20% by univariate analysis. Many (52%) of the articles were about gastrointestinal malignancies (GI) or kidney malignancies. A high CRP was prognostic in 90% (127 of 141) of the reports in those groups of tumors. CRP was also prognostic in most reports in other solid tumors primary sites.

CONCLUSIONS

A high CRP was associated with higher mortality in 90% of reports in people with solid tumors primary sites. This was particularly notable in GI malignancies and kidney malignancies. In other solid tumors (lung, pancreas, hepatocellular cancer, and bladder) an elevated CRP also predicted prognosis. In addition there is also evidence to support the use of CRP to help decide treatment response and identify tumor recurrence. Better designed large scale studies should be conducted to examine these issues more comprehensively.

C-reactive protein in urologic cancers

C-reactive protein is an acute-phase reactant that is elevated in the setting of systemic infections, trauma, and malignancies. Urologic cancers have been shown to promote changes in c-reactive protein levels. Pre-treatment serum levels can predict disease characteristics, extent of disease, and prognosticate survival after intervention in renal cell carcinoma, prostate cancer, bladder cancer, upper tract urothelial carcinoma, and penile cancer. Changes in post-treatment serum levels have also shown promise in determining survival. As a result, c-reactive protein has been incorporated into various survival nomograms to improve predictive accuracy. While the association between c-reactive protein and survival in testicular cancer has not been studied, elevated serum levels may correlate with treatment side effects, such as cardiovascular disease and chronic cancer-related fatigue. Understanding the relationship between c-reactive protein and urologic cancers can help physicians determine the appropriate course of treatment and improve patient care.

Systematic review of the evidence of a relationship between chronic psychosocial stress and C-reactive protein

INTRODUCTION

C-reactive protein (CRP) is an acute-phase reactant with an increasing number of clinical functions. Studies in recent years have identified several social, economic, demographic, and psychological factors that contribute to baseline inflammation. Psychosocial stress represents a significant contributor to baseline inflammation. Given the importance of understanding background drivers of CRP levels, we conducted this review to assess the impact of chronic psychosocial stress on CRP levels.

METHODS

Medline was searched through February 2013 for human studies examining CRP levels with respect to chronic psychosocial stress.

RESULTS

The initial search identified 587 articles from which 129 potentially appropriate articles were reviewed. Of these 129 articles, 41 articles were included in the review. These studies were published between 2003 and 2013. Of these studies, 6 analyzed employment stress, 2 analyzed unemployment stress, 6 analyzed burnout and vital exhaustion, 6 analyzed caregiver stress, 3 analyzed interpersonal stress, 17 analyzed socioeconomic position, and 2 analyzed discrimination.

CONCLUSION

We conclude that psychosocial stress significantly impacts CRP and should be considered when interpreting the meaning of CRP elevations.

Lymphopenia is an independent predictor of inferior outcome in clear cell renal carcinoma

PURPOSE

A low absolute lymphocyte count is a likely index of poor systemic immunity that may be associated with aggressive features and inferior survival in patients with clear cell renal cell carcinoma.

MATERIALS AND METHODS

To determine the absolute lymphocyte count we retrospectively analyzed the preoperative blood count of 430 patients with a mean age of 60 years treated with primary surgical resection at our cancer center. Absolute lymphocyte count values as a continuous variable and at a level below 1,300 cells per μl, which was our lowest reference value, were correlated with nuclear grade, pathological stage and TNM stage. We used the Kaplan-Meier method to estimate overall survival, stratified by absolute lymphocyte count status.

RESULTS

As a continuous variable, low absolute lymphocyte count was associated with higher grade (p = 0.009), and higher pT stage (p = 0.034) and TNM stage (p <0.0001). Lymphopenia below 1,300 cells per μl was associated with high grade (p = 0.0043), pT stage (p = 0.051) and TNM stage (p <0.0001). At a median followup of 33.5 months lymphopenia was associated with inferior overall survival in a univariate model (p <0.0001), and on multivariate analysis independent of pT, N and M stages, patient age, grade, smoking history and comorbidities (p = 0.0102). Lymphopenia was also associated with inferior overall survival in a subset of young patients (age 60 years or less) with no distant metastasis (p = 0.014).

CONCLUSIONS

In 430 patients with clear cell renal cell carcinoma lymphopenia was associated with lower overall survival independent of pT and TNM stages, nuclear grade, age, tobacco smoking and comorbidity index.

Role of C-reactive protein in urological cancers: a useful biomarker for predicting outcomes

Based on increasing evidence of the association between cancer-related inflammation and the progression of cancer, the external symptoms of systemic inflammatory response has been shown to be an indicator for the prognosis of many malignancies, including urological cancers. C-reactive protein, a representative acute-phase reactant, is a significant and sensitive inflammatory marker that can be objectively measured using reliable assays in clinical practice worldwide. C-reactive protein has been shown to be significant in the prediction of outcomes of urological cancers. The elevation of C-reactive protein levels, which indicate the presence of cancer-associated systemic inflammatory response, is linked to poorer survival in patients with urological cancers, including renal cell carcinoma, upper urinary tract and bladder cancers, and prostate cancer. With this strong prognostic ability, C-reactive protein can be incorporated into prognostic models and will make them simpler and improve their predictive accuracy. Furthermore, the longitudinal change of C-reactive protein level, C-reactive protein kinetics, provides additional information on patient survival outcomes. As such, C-reactive protein can be used to monitor treatment efficacy and disease course using serial measurements. In testicular cancer, C-reactive protein is associated with a risk of late complications, such as cardiovascular disease, and with the development of second non-germ-cell cancer. Taken together, these findings show that C-reactive protein can act as an important biomarker for urological cancers. This review discusses the importance of C-reactive protein as a prognostic biomarker in urological cancers on the basis of the currently available evidence.

Followup of neutrophil-to-lymphocyte ratio and recurrence of clear cell renal cell carcinoma

PURPOSE

An increase in the pretreatment neutrophil-to-lymphocyte ratio is associated with poor prognosis for various cancers, including renal cell carcinoma. However, the clinical implication of a posttreatment change in the neutrophil-to-lymphocyte ratio in patients with cancer remains unclear.

MATERIALS AND METHODS

We reviewed the records of 250 patients with nonmetastatic clear cell renal cell carcinoma and analyzed associations among clinicopathological variables, the preoperative and postoperative neutrophil-to-lymphocyte ratio, and recurrence-free survival.

RESULTS

The 10-year recurrence-free survival rate for patients with a preoperative neutrophil-to-lymphocyte ratio of 2.7 or greater was significantly lower than that for those with a ratio of less than 2.7 (64.4% vs 83.7%, p = 0.0004). When combined with the postoperative ratio, patients with a preoperative ratio of 2.7 or greater could be further divided into 2 groups with a significantly different prognosis. The 10-year recurrence-free survival rate for patients with a preoperative neutrophil-to-lymphocyte ratio of 2.7 or greater and postoperative ratio of less than 2.7 was significantly lower than that for those with a preoperative and postoperative ratio of 2.7 or greater (52.0% vs 83.5%, p = 0.0487). The latter was similar to the 83.7% for patients with a preoperative ratio of less than 2.7. In patients with recurrence the ratio at recurrence was significantly increased compared with the postoperative ratio (mean ± SD 2.82 ± 1.63 vs 2.00 ± 0.90, p = 0.0090). Multivariate analysis showed that tumor size, pathological tumor stage and the neutrophil-to-lymphocyte ratio change (a combination of the preoperative and postoperative ratios) were independent predictors of recurrence. Using these 3 significant variables patients were stratified into low, intermediate and high risk groups, among which the recurrence-free survival rate significantly differed.

CONCLUSIONS

The posttreatment neutrophil-to-lymphocyte ratio change was a significant prognostic factor for recurrence as well as tumor size and pathological tumor stage in patients with clear cell renal cell carcinoma.

Clinical utility of the Glasgow Prognostic Score in patients undergoing curative nephrectomy for renal clear cell cancer: basis of new prognostic scoring systems

Background:

Measurement of the systemic inflammatory response in malignancy has been recently refined using a selective combination of C-reactive protein and albumin (modified Glasgow Prognostic Score, mGPS). This has prognostic value in patients with metastatic kidney cancer. This study examines the prognostic value of the mGPS in patients undergoing curative nephrectomy for clear cell cancer.

Methods:

Patients with localised renal cell carcinoma undergoing potentially curative resection between March 1997 and July 2007 in a single institution were prospectively studied. The mGPS, University of California Los Angeles Integrated Staging System (UISS), ‘Stage Size Grade Necrosis’ (SSIGN), Kattan and Leibovich scores were constructed.

Results:

A total of 169 patients were studied. The minimum follow-up was 49 months; the median follow-up of the survivors was 98 months. During this period, 35 patients died of their cancer; a further 24 patients died of intercurrent disease. On univariate survival analysis of the scoring systems, Kattan (P<0.05), UISS (P<0.001), SSIGN (P<0.001) and Leibovich (P<0.001) were significantly associated with cancer-specific survival. Using cancer-specific mortality at 4 years as an endpoint, the area under the receiver operator curve was 0.726 (95% CI 0.629–0.822; P=0.001) for Kattan, 0.776 (95% CI 0.671–0.880; P<0.001) for UISS, 0.812 (95% CI 0.733–0.892; P<0.001) for SSIGN, 0.778 (95% CI 0.666–0.889; P<0.001) for Leibovich and 0.800 (95% CI 0.687–0.912; P<0.001) for the mGPS scoring system. On multivariate analysis of significant independent scoring systems and mGPS, UISS (HR 3.08, 95% CI 1.54–6.19, P=0.002) and mGPS (HR 5.13, 95% CI 2.89–9.11, P<0.001) were significant independent predictors of cancer-specific survival.

Conclusions:

The present prospective study shows that the mGPS, an inflammation-based prognostic score, is at least equivalent to and independent of other current validated prognostic scoring systems for patients undergoing curative nephrectomy for renal clear cell cancer. The mGPS is simple, measured preoperatively, based on well-standardised, widely available protein assays, and therefore provides an objective and rational basis before treatment for future staging systems in patients with operable renal cancer.

Characteristics of aggressive variants in T1a renal cell carcinoma

PURPOSE

To explore factors associated with metastasis and prognosis in T1a renal cell carcinoma (RCC).

METHODS

We retrospectively reviewed 451 cases of sporadic T1aRCC among 1,060 patients admitted to the Department of Urology at Hamamatsu University Hospital and affiliated hospitals between 1978 and 2007. Clinicopathological factors were analyzed for metastatic and prognostic risks.

RESULTS

We identified 32 RCC patients with metastatic disease, 22 with synchronous and 10 with metachronous metastatic RCC. Patients with metastatic disease had a significantly higher incidence of symptomatic cancer, as well as greater tumor size, C-reactive protein (CRP) level, sarcomatoid component ratio, histological grade 3 and microvascular invasion than those without metastasis. Among the 32 patients with metastasis, there is no significant difference in clinicopathological factors. The most common site of metastasis was bone. Among patients with metastatic T1aRCC, findings at diagnosis of a symptomatic cancer, CRP level of 0.4 mg/dL or more, tumor size of 3.0 cm or greater, histological grade 3, a sarcomatoid component and microvascular invasion appeared to be significant and independent risk factors. Significant independent risk factors with metachronous metastatic RCC were a symptomatic cancer and a sarcomatoid component at diagnosis. A CRP level of 0.4 mg/dL or more was also an independent prognostic factor for overall survival.

CONCLUSION

RCC patients with findings at diagnosis of a symptomatic cancer, a sarcomatoid component and CRP level of 0.4 mg/dL or more require intensive follow-up.

Impact of postoperative C-reactive protein level on recurrence and prognosis in patients with N0M0 clear cell renal cell carcinoma

PURPOSE

Preoperative C-reactive protein is a strong predictor of recurrence and prognosis in patients with renal cell carcinoma while postoperative C-reactive protein reportedly predicts survival in patients with metastatic renal cell carcinoma. We evaluated the impact of postoperative C-reactive protein on recurrence and prognosis in patients with N0M0 clear cell renal cell carcinoma.

MATERIALS AND METHODS

We defined increased preoperative C-reactive protein as 1 mg/dl or greater and postoperative C-reactive protein normalization as at least 1 postoperative measurement of less than 0.3 mg/dl. We reviewed the records of 263 patients with N0M0 clear cell renal cell carcinoma who underwent nephrectomy, and in whom preoperative and postoperative C-reactive protein values were available. We used multivariate analysis to identify independent factors predicting recurrence and prognosis. We also evaluated C-reactive protein at recurrence and its impact on survival.

RESULTS

Increased preoperative C-reactive protein and nonnormalization of postoperative C-reactive protein were associated with worse clinicopathological factors. Postoperative C-reactive protein nonnormalization, increased preoperative C-reactive protein, microvascular invasion and histological tumor necrosis were independent predictors for recurrence. Risk stratification using these factors effectively predicted the possibility of recurrence. Anemia, thrombocytosis and postoperative C-reactive protein nonnormalization were independent predictors of overall survival. Postoperative followup revealed recurrence in 50 patients. The 3-year survival rate in patients with C-reactive protein 0.3 mg/dl or greater at recurrence was significantly lower than that in patients with less than 0.3 mg/dl at recurrence (47.3% vs 81.6%).

CONCLUSIONS

Nonnormalization of postoperative C-reactive protein is a strong predictor of recurrence and prognosis. Patients with C-reactive protein 0.3 mg/dl or greater at recurrence might not survive as long as those with C-reactive protein less than 0.3 mg/dl at recurrence.

Role of C-reactive protein as a biomarker for renal cell carcinoma

The presence of a systemic inflammatory response has been thought to indicate poor prognosis in renal cell carcinoma, based on the assumption that the processes underlying such a response play important roles in the progression of renal cell carcinoma. C-reactive protein (CRP) is a representative acute-phase reactant whose concentration can be objectively measured using a variety of reliable standardized assays. To show that CRP could be an indicator of normal or pathologic processes, recent studies have revealed that CRP is a significant prognostic factor for metastasis and mortality in patients with renal cell carcinoma. Incorporating CRP levels into prognostic algorithms could make those algorithms simpler without reducing their predictive accuracy. Furthermore, CRP kinetics, the analysis of dynamic changes in CRP concentrations, has been shown to generate valuable information relevant to prognosis, specifically information on the likelihood of tumor aggressiveness. Therefore, dynamic changes of CRP concentration could indicate clinical pharmacologic response to therapeutic intervention. Taken together, we could conclude that CRP is a significant biomarker for renal cell carcinoma.

Non-malignant drivers of elevated C-reactive protein levels differ in patients with and without a history of cancer

PURPOSE

Elevations in C-reactive protein (CRP) levels predict metastasis and mortality in a number of malignancies. However, the impact of non-malignant factors on CRP levels in patients with cancer remains unknown. To address this issue, we conducted an investigation of the National Social Life, Health, and Aging Project (NSHAP) cohort.

METHODS

NSHAP participants with a history of malignancy were included. The 222-participant cohort was subdivided by CRP levels into low-risk (CRP <3 mg/L) and high-risk (CRP ≥3 mg/L) groups. Univariate and multivariate binary logistic regression analyses examined the impact of variables spanning social factors, demographic characteristics, and past medical history on high-risk CRP levels.

RESULTS

Of the cohort, 42.3% exhibited high-risk CRP levels. These participants were more likely to be unmarried (p = 0.013), to be a racial/ethnic minority (p = 0.012), to not use HMG-CoA reductase inhibitor (statin) medications (p = 0.032), and to be obese (p = 0.002). On multivariate logistic regression analysis, these variables were also significant predictors of high-risk CRP levels. For example, compared with participants who had a normal body mass index (BMI), obese participants were nearly 5 times more likely (odds ratio 5.725; 95% CI 1.848, 12.079; p = 0.001) to exhibit high-risk CRP levels.

CONCLUSIONS

CRP remains an important prognostic biomarker in the management of known malignancies. However, patients with a known history of cancer can also exhibit elevated CRP levels due to non-malignant factors such as race and ethnicity, statin use, marital status, and BMI. Consequently, further studies are needed to assess the predictive potential of CRP levels for cancer prognostication in the face of these social and biologic variables before use of this biomarker is widely adopted in clinical practice.

Prognostic variables and nomograms for renal cell carcinoma

The term renal cell carcinoma (RCC) is used to describe a heterogeneous group of tumors that vary histologically, genetically and molecularly. Extensive research has been conducted to identify characteristics that predict outcomes among patients with RCC. In addition to histological subtype these include tumor size, patient age, mode of presentation and various hematological indices, among others. Several groups have incorporated these clinical and pathological features into nomograms which help the clinician better define individual patient prognosis and direct the optimum therapeutic approach. In the present article we review these prognostic variables and nomograms for RCC.