Paraneoplastic elevation of serum alkaline phosphatase in renal cell carcinoma: incidence and implication on prognosis

The association between serum albumin and alkaline phosphatase in cancer patients

The role of serum albumin (ALB) has been extensively studied in patients with cancer; however, research on its effect on bone metastasis in these patients remains limited. This study aimed to investigate the relationship between serum ALB and alkaline phosphatase (ALP) levels in patients with tumors. Using data from the National Health and Nutrition Examination Survey 2011 to 2018, we assessed the correlation between serum ALB and ALP levels using a weighted multivariate linear regression model, whereas a weighted generalized additive model and smooth curve fitting were used to address potential nonlinearities. A total of 1876 patients with cancer were included in our study. In the subgroup analysis stratified by sex, race/ethnicity, and liver disease, the negative correlation of ALB with ALP remained for most groups, except in blacks (β = -1.755, 95%CI: [-3.848, 0.338], P = .103) and patients with gout (β = -0.676, 95%CI: [-2.061, 0.709], P = .340). In black people and patients with gout, the relationship between ALB and ALP showed an inverted U-shaped curve, with an inflection point at approximately 42 g/dL. Our study showed an inverse correlation between ALB and ALP levels in most patients with tumors, but not in black patients and those with gout. The measurement of ALB levels can serve as a screening tool for bone metastases while guiding therapeutic intervention strategies.

Highly Sensitive Homogeneous Electrochemiluminescence Biosensor for Alkaline Phosphatase Detection Based on Click Chemistry-Triggered Branched Hybridization Chain Reaction

Alkaline phosphatase (ALP) has been used as a diagnostic index of clinical diseases since its expression level is closely related to many pathological processes. In this work, a highly sensitive electrochemiluminescence (ECL) method for the determination of ALP based on a click chemistry-induced branched hybridization chain reaction (BHCR) for signal amplification and ultrafiltration technology for the separation of homogeneous amplification products is introduced. ALP can release copper ions from a Cu²⁺/PPi complex by hydrolyzing pyrophosphoric acid, which initiates click chemistry in the system. A BHCR amplification is triggered afterward by the long single-stranded DNA (ssDNA) generated by click chemistry, resulting in a three-dimensional double-stranded DNA (dsDNA) with a large molecular weight. Based on the characteristic that Ru(phen)₃²⁺ can stably insert into the groove of dsDNA, a large amount of Ru(phen)₃²⁺ is retained together with the amplified product after ultrafiltration, and therefore a significantly enhanced ECL signal can be obtained. The test results show that this method can be used for the quantitative determination of ALP ranging from 0.002 to 50 U/L, with a detection limit of 0.7 mU/L. This method has also been confirmed to have good selectivity and anti-interference, and the results of the analysis of the ALP content in the diluted serum samples are satisfactory, showing great application potential in clinical diagnosis.

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.

Albumin-to-alkaline phosphatase ratio as a promising indicator of prognosis in human cancers: is it possible?

Background

The impact of albumin-to-alkaline phosphatase ratio (AAPR) on prognosis in cancer patients remains uncertain, despite having multiple relevant studies in publication.

Methods

We systemically compiled literatures from 3 databases (Cochrane Library, PubMed, and Web of Science) updated to May 24th, 2020. Hazard ratios (HRs) and 95% confidence intervals (CIs) were computed and synthesized using STATA 14, values were then pooled and utilized in order to assess the overall impact of AAPR on patient’s prognosis.

Results

In total, 18 studies involving 25 cohorts with 7019 cases were incorporated. Pooled results originated from both univariate and multivariate analyses (HR = 2.14, 95%CI:1.83–2.51, random-effects model; HR = 1.93, 95%CI:1.75–2.12, fixed-effects model; respectively) suggested that decreased AAPR had adverse effect on overall survival (OS). Similarly, pooled results from both univariate and multivariate analysis of fixed-effects model, evinced that decreased AAPR also had adverse effect on disease-free survival (DFS) (HR = 1.81, 95%CI:1.60–2.04, I² = 29.5%, P = 0.174; HR = 1.69, 95%CI:1.45–1.97, I² = 13.0%, P = 0.330; respectively), progression-free survival (PFS) (HR = 1.71, 95%CI:1.31–2.22, I² = 0.0%, P = 0.754; HR = 1.90, 95%CI:1.16–3.12, I² = 0.0%, P = 0.339; respectively), and cancer-specific survival (CSS) (HR = 2.22, 95%CI:1.67–2.95, I² = 5.6%, P = 0.347; HR = 1.88, 95%CI:1.38–2.57, I² = 26.4%, P = 0.244; respectively). Admittedly, heterogeneity and publication bias existed, but stratification of univariate meta-analytic results, as well as adjusted meta-analytic results via trim and fill method, all showed that AAPR still significantly correlated with poor OS despite of confounding factors.

Conclusions

In summary, decreased AAPR had adverse effect on prognosis in cancer patients. As an inexpensive and convenient ratio derived from liver function test, AAPR might become a promising indicator of prognosis in human cancers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07921-6.

Prognostic Value of Peripheral Inflammatory Markers in Preoperative Mucosal Melanoma: A Multicenter Retrospective Study

Background: Peripheral neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) have been widely reported prognostic predictors for many cancers. However, data predicting prognosis on mucosal melanoma is currently limited. This study aimed to identify the value of these inflammatory markers in predicting prognosis in preoperative mucosal melanoma.

Methods: In this multicenter retrospective study, we assessed patients with preoperative mucosal melanoma for 7 years. Connection between baseline inflammatory markers (NLR, PLR, and LMR) and overall survival (OS) and progression-free survival (PFS) was analyzed by Kaplan–Meier curve with a log-rank test. Then, NLR, PLR, and LMR, along with characteristics of patients, were included in the univariate and multivariate Cox hazards regression model to examine the correlation with OS and PFS. The optimal cutoff value of these inflammatory markers was stratified by receiver operating characteristic (ROC) curve.

Results: Patients with baseline NLR > 3.07, PLR > 118.70, or LMR ≤ 7.38 had significantly poorer OS and PFS according to Kaplan–Meier curve with a log-rank test. Univariate analysis indicated that surgery, alkaline phosphatase (ALP), NLR, PLR, and LMR were statistically connected to both OS and PFS. In multivariate analysis, LMR (hazard ratio [HR] = 0.113; 95% CI: 0.017–0.772; P = 0.026) and surgery (HR = 0.166; 95% CI: 0.033–0.846; P = 0.031) maintained significant relevance with OS.

Conclusions: This research revealed that a higher NLR and PLR and a lower LMR than the cutoff point was associated with a worse prognosis of preoperative mucosal melanoma. Thus, we assumed that NLR, PLR, and especially LMR were potential prognostic predictors of preoperative mucosal melanoma.

Identification of prognostic signatures associated with long-term overall survival of thyroid cancer patients based on a competing endogenous RNA network

Competing endogenous RNAs (ceRNAs) are considered as transcripts that can regulate each other at post-transcription level by competing for shared miRNAs. Considering the key roles of lncRNAs acting as ceRNAs in progression of solid tumors, to develop prognostic signatures in thyroid cancer (THCA), patients with corresponding clinical data were selected and two ceRNA networks were constructed using online databases. Two prognostic signatures (Lnc5m4 and Lnc2mi1m2) were found to be more efficient in predicting long-term survival of THCA patients. However, the high-risk score of Lnc2mi1m2 was not an independent factor.The risk score of Lnc5m4 was able to effectively stratify patients in stage III-IV into low- and high-risk groups, and also could predict poor prognosis of patients in stage III-IV. In conclusion, these findings indicate that Lnc5m4 is a novel prognostic signature for predicting long-term overall survival of THCA patients, which could provide a new approach to lncRNA research in THCA progression.

Serum Alkaline Phosphatase Predicts Poor Disease-Free Survival in Patients Receiving Radical Gastrectomy

Background

Serum alkaline phosphatase (ALP) has been proved to be a negative prognostic factor for several malignancies, but its clinical significance in gastric cancer (GC) patients has not been sufficiently studied. In the present retrospective study, we investigated the effect of serum ALP on disease-free survival (DFS) after radical gastrectomy.

Material/Methods

We included 491 GC patients receiving radical gastrectomy at the Chinese People’s Liberation Army 309^th Hospital. Univariate and multivariate analyses were performed to determine factors influencing serum ALP and DFS. The changes in serum ALP and its clinical relevance were also analyzed using the log-rank test and Cox proportional hazards model.

Results

There were 491 patients who met our inclusion and exclusion criteria. Pre-treatment serum ALP was elevated in 87 of these patients and was normal in the other 404 patients. Elevation of pre-treatment serum ALP was correlated with the tumor diameter (OR=2.642, P=0.017), TNM stage (OR=4.592, P=0.005), and T classification (OR=1.746, P=0.043). DFS was significantly different between patients with normal or elevated pre-treatment serum ALP (median 42.1 vs. 32.8 months, P=0.001) and multivariate analysis suggested pre-treatment serum ALP is an independent risk factor for poor DFS after radical gastrectomy (HR=2.035, P=0.021). In addition, removal of the primary tumor lesion led to an obvious decline in serum ALP activity (median 262 U/L vs. 152 U/L, P<0.001), and monitoring changes in serum ALP can help evaluate the risk of tumor relapse in GC patients (χ²=17.814, P<0.001).

Conclusions

Serum ALP is a good predictor of GC patient DFS after radical gastrectomy, and patients with elevated serum ALP have shorter relapse times.

Methods for the evaluation of biomarkers in patients with kidney and liver diseases: multicentre research programme including ELUCIDATE RCT

Background

Protein biomarkers with associations with the activity and outcomes of diseases are being identified by modern proteomic technologies. They may be simple, accessible, cheap and safe tests that can inform diagnosis, prognosis, treatment selection, monitoring of disease activity and therapy and may substitute for complex, invasive and expensive tests. However, their potential is not yet being realised.

Design and methods

The study consisted of three workstreams to create a framework for research: workstream 1, methodology – to define current practice and explore methodology innovations for biomarkers for monitoring disease; workstream 2, clinical translation – to create a framework of research practice, high-quality samples and related clinical data to evaluate the validity and clinical utility of protein biomarkers; and workstream 3, the ELF to Uncover Cirrhosis as an Indication for Diagnosis and Action for Treatable Event (ELUCIDATE) randomised controlled trial (RCT) – an exemplar RCT of an established test, the ADVIA Centaur® Enhanced Liver Fibrosis (ELF) test (Siemens Healthcare Diagnostics Ltd, Camberley, UK) [consisting of a panel of three markers – (1) serum hyaluronic acid, (2) amino-terminal propeptide of type III procollagen and (3) tissue inhibitor of metalloproteinase 1], for liver cirrhosis to determine its impact on diagnostic timing and the management of cirrhosis and the process of care and improving outcomes.

Results

The methodology workstream evaluated the quality of recommendations for using prostate-specific antigen to monitor patients, systematically reviewed RCTs of monitoring strategies and reviewed the monitoring biomarker literature and how monitoring can have an impact on outcomes. Simulation studies were conducted to evaluate monitoring and improve the merits of health care. The monitoring biomarker literature is modest and robust conclusions are infrequent. We recommend improvements in research practice. Patients strongly endorsed the need for robust and conclusive research in this area. The clinical translation workstream focused on analytical and clinical validity. Cohorts were established for renal cell carcinoma (RCC) and renal transplantation (RT), with samples and patient data from multiple centres, as a rapid-access resource to evaluate the validity of biomarkers. Candidate biomarkers for RCC and RT were identified from the literature and their quality was evaluated and selected biomarkers were prioritised. The duration of follow-up was a limitation but biomarkers were identified that may be taken forward for clinical utility. In the third workstream, the ELUCIDATE trial registered 1303 patients and randomised 878 patients out of a target of 1000. The trial started late and recruited slowly initially but ultimately recruited with good statistical power to answer the key questions. ELF monitoring altered the patient process of care and may show benefits from the early introduction of interventions with further follow-up. The ELUCIDATE trial was an ‘exemplar’ trial that has demonstrated the challenges of evaluating biomarker strategies in ‘end-to-end’ RCTs and will inform future study designs.

Conclusions

The limitations in the programme were principally that, during the collection and curation of the cohorts of patients with RCC and RT, the pace of discovery of new biomarkers in commercial and non-commercial research was slower than anticipated and so conclusive evaluations using the cohorts are few; however, access to the cohorts will be sustained for future new biomarkers. The ELUCIDATE trial was slow to start and recruit to, with a late surge of recruitment, and so final conclusions about the impact of the ELF test on long-term outcomes await further follow-up. The findings from the three workstreams were used to synthesise a strategy and framework for future biomarker evaluations incorporating innovations in study design, health economics and health informatics.

Trial registration

Current Controlled Trials ISRCTN74815110, UKCRN ID 9954 and UKCRN ID 11930.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 3. See the NIHR Journals Library website for further project information.

Stauffer's syndrome: A comprehensive review and proposed updated diagnostic criteria

BACKGROUND

Stauffer's syndrome corresponds to a set of clinical and analytical changes of paraneoplastic nature firstly recognized more than 50 years ago, in association to renal cell carcinoma. A definitive review including universal diagnostic criteria and updated knowledge since the original description is lacking.

BASIC PROCEDURES

The authors conducted a comprehensive bibliographical review and propose updated diagnostic criteria to standardize diagnosis for clinical practice purposes and avoid misclassification.

MAIN FINDINGS

Although having been described in association with renal cell carcinoma, the syndrome has been reported in correlation with other malignancies-either solid or hematological tumors. Additionally, a variant syndrome presenting with jaundice has also been characterized, but appears to have a similar clinical course to that of the classical Stauffer's syndrome. Although often described as rare, it may be more frequent than previously recognized. Stauffer's syndrome etiopathogenesis is still poorly understood, but immune mechanisms seem to play a role underscored by the malignancies to which the syndrome is associated, several of which having immunotherapy drugs approved for their treatment.

PRINCIPAL CONCLUSIONS

A set of diagnostic criteria should be used to simplify, broaden and standardized diagnosis, under the entity characterized by reversible paraneoplastic intrahepatic cholestasis. Clinicians should be aware of the syndrome, namely consider further investigation if a plausible cause for unexplained intrahepatic cholestasis in an otherwise healthy patient is not found. Even though no universal approach is available, investigation should be considered regarding metastatic disease after resection of a primary tumor which has revealed persistence or recurrence of symptoms.

A case of paraneoplastic liver dysfunction with elevated serum interleukin-6 in clinically localized renal cell carcinoma

We report a case of paraneoplastic liver dysfunction associated with a renal cell carcinoma, which disappeared after surgery. A 62-year-old male presented with fatigue and weight loss. The most prominent laboratory abnormality was elevated alkaline phosphatase, C-reactive protein, and interleukin-6 while normal aminotransferases. Computed tomography scan revealed a solid mass in the left kidney. A left radical nephrectomy was performed. After the surgery, biochemical abnormalities returned to normal.

The regulatory roles of phosphatases in cancer

The relevance of potentially reversible post-translational modifications required for controlling cellular processes in cancer is one of the most thriving arenas of cellular and molecular biology. Any alteration in the balanced equilibrium between kinases and phosphatases may result in development and progression of various diseases, including different types of cancer, though phosphatases are relatively under-studied. Loss of phosphatases such as PTEN (phosphatase and tensin homologue deleted on chromosome 10), a known tumour suppressor, across tumour types lends credence to the development of phosphatidylinositol 3-kinase inhibitors alongside the use of phosphatase expression as a biomarker, though phase 3 trial data are lacking. In this review, we give an updated report on phosphatase dysregulation linked to organ-specific malignancies.

Stauffer's syndrome as a prominent manifestation of renal cancer: a case report

Background

Renal cell carcinoma is associated with a wide spectrum of para-neoplastic syndromes, which may be precursors of primary or recurrent disease. Non-metastatic hepatic dysfunction in patients suffering from renal cell carcinoma is known as Stauffer's syndrome. It is associated with the production of cytokines by the tumour, and several biochemical abnormalities, including elevated serum alkaline phosphatase.

Case presentation

We describe a 36-year-old woman presenting with various non-specific, systemic disease manifestations, and elevated liver enzymes due to cholestasis as the main laboratory abnormality. Imaging studies showed a solid mass in the left kidney, which, after surgical excision, was identified as renal cell carcinoma. No metastasis was found.

Conclusion

Stauffer syndrome may precede other manifestations of renal cell carcinoma. In case of unexplained abnormal liver function, particularly in presence of systemic symptoms, underlying renal cell carcinoma should be excluded by focused investigations.

Association of abnormal preoperative laboratory values with survival after radical nephrectomy for clinically confined clear cell renal cell carcinoma

OBJECTIVES

To determine whether preoperative laboratory values are independently associated with death from clinically confined clear cell renal cell carcinoma (RCC) after radical nephrectomy.

METHODS

We identified 1707 patients with clinically confined (pNx/pN0, pM0), unilateral, sporadic clear cell RCC treated with radical nephrectomy between 1970 and 2002. Associations of abnormal preoperative laboratory values including hypercalcemia, anemia, elevated erythrocyte sedimentation rate (ESR), and elevated alkaline phosphatase with death from RCC were evaluated using Cox proportional hazards regression models, both univariately and multivariately by adjusting for known prognostic features of the 2002 primary tumor classification, tumor size, nuclear grade, and coagulative tumor necrosis.

RESULTS

At last follow-up, 1009 patients had died, including 425 who died from RCC at a median of 3.0 years after surgery (range, 0 to 26 years). Even after adjusting for known prognostic features, 9% of patients with preoperative hypercalcemia exhibited significantly increased likelihood of dying from RCC compared with patients with normal or lower levels of serum calcium (relative ration [RR] 1.64; P = 0.002). Similarly, preoperative anemia (35% of patients; RR 1.27; P = 0.026) and elevated ESR (44% of patients; RR 1.66; P = 0.003) portended an increased risk of death from RCC even after multivariate adjustment.

CONCLUSIONS

Abnormal preoperative laboratory values including hypercalcemia, anemia, and elevated ESR are independently associated with increased risk of cancer-specific death from clinically confined clear cell RCC. Consideration of these variables in future models may improve prognostic accuracy. We believe these factors should be routinely assessed and included in prospective studies of outcome in RCC patients.

The involvement of the liver in systemic diseases

The liver has a double blood supply and plays a central role in the metabolism of proteins, carbohydrates, and many medications. In addition, it has a role in the induction of immune tolerance and may also be a target for immune-mediated damage. For these reasons, the liver may be involved in many systemic diseases. In this review, we discuss the involvement of the liver in granulomatous, rheumatologic, malignant, and circulatory diseases. An understanding of the wide spectrum of liver involvement in systemic diseases will aid in both diagnosis and treatment of patients with a wide range of medical conditions.

Unusual causes of intrahepatic cholestatic liver disease

We report five cases with unusual causes of intrahepatic cholestasis, including consumption of Teucrium polium (family Lamiaceae) in the form of tea, Stauffer’s syndrome, treatment with tamoxifen citrate for breast cancer, infection with Coxiella Burnetii (acute Q fever), and infection with Brucella melitensis (acute brucellosis).

[Superior vena cava syndrome with bilateral jugular and subclavian vein thrombosis. Paraneoplastic manifestion of renal cell carcinoma]

At present thrombosis of the superior vena cava is an uncommon event that is now more frequently associated with diagnostic or therapeutic catheterization. If an apparent spontaneous thrombosis occurs, malignancy should be considered in the differential diagnosis. One case of clinically symptomatic thrombosis of the internal jugular, subclavian, and superior vena cava is presented. We detected an asymptomatic left renal cell carcinoma in a 54-year-old patient and nephrectomy was performed. Increased blood coagulability as part of a paraneoplastic syndrome was considered to be the possible etiology. In patients with otherwise unexplained superior vena cava thrombosis, examination not only of the head and neck but also of the abdomen, retroperitoneum, and pelvis should be pursued. A review of the literature pertinent to this rare case is provided.

Utilidad de marcadores séricos del carcinoma renal

OBJECTIVES

To select a group of useful serum markers in renal cell carcinoma (RCC) with investigational purpose in future.

MATERIAL AND METHODS

Periodic determination in serum of 21 RCC patients of the following markers: EGR, RPC, hemogram and leucocyte differential count (LDC), standard biochemist parameters, beta-2 microglobuline, CEA, CA 12.5, CA 50, CA 15.3, ferritin, interleukin-6, serum interleukin-2 receptor, TNF-alpha and TPSA.

RESULTS

Different elements within the LDC had relations with the presence of symptoms/signs, tumour size, pathological stage and disease progression. There was a significant increase of beta-2 microglobuline and sIL-2 receptor when disease progressed, as well as a similar statistical trend with RPC and alkaline phosphatases. Beta-2 microglobuline and sIL-2 receptor also decreased after treatment of the disease progression.

CONCLUSIONS

We will keep analysing hemogram, LDC and standard byochemics, RPC, ferritin, beta-2 microglobuline and sIL-2 receptor only with investigational purposes, obviating the determination of the rest of the tested markers.

Renal cell carcinoma

In addition to the known risk factors for renal cell carcinoma, hypertension, obesity, and tobacco use, a diet high in consumption of fried or sautéed meat and the frequent consumption of poultry may increase the risk for renal cell carcinoma. A diet high in consumption of fruits and vegetables appears to have a protective effect. Molecular markers, in particular markers of cell proliferation, may have prognostic value and be of assistance in identifying patients who would benefit from more aggressive therapy. Surgery continues to the mainstay of treatment of localized disease, and may be the optimal treatment for patients with isolated solitary metastatic disease. Response rates to systemic therapy with cytokines vary from 5% to 20% with significant adverse effects.

Surgery in advanced and metastatic renal cell carcinoma

Curative surgery in more advanced renal cell carcinoma is limited to solitary metastases or regional disease. Response to systemic immunotherapy continues to be reported; however, most responses are limited and not durable. Only randomized, prospective clinical trials will prove the efficacy of systemic therapy.