Prognostic factors in patients with renal cell carcinoma: retrospective analysis of 675 cases

The DDD score outperforms the RENAL score in predicting high-grade renal cell carcinoma

OBJECTIVES

To explore the relationship between Fuhrman grade of renal cell carcinoma (RCC) and the DDD score.

METHODS

We reviewed the records of 527 nonmetastatic RCC patients. Demographic, clinical, and pathologic characteristics were reviewed. Binary logistic regression was used to explore the independent risk factors for high-grade RCC (HGRCC).

RESULTS

Sex, BMI (Body Mass Index), RNS, and DDD score were significantly correlated with HGRCC. Based on these independent risk factors, we constructed two predictive models integrating the RNS and DDD scores with sex and BMI to predict tumor grade. The calibration curves of the predictive model showed good agreement between the observations and predictions. The concordance indexes (C-indexes) of the predictive models were 0.768 (95% CI, 0.713-0.824), and 0.809 (95% CI, 0.759-0.859). Receiver operating characteristic (ROC) curves were performed to compare the predictive power of the nomograms, and the prediction model including the DDD score had better prognostic ability (p = 0.01).

CONCLUSIONS

This study found that RNS, DDD score, BMI, and sex were independent predictors of HGRCC. We developed effective nomograms integrating the above risk factors to predict HGRCC. Of note, the nomogram including the DDD score achieves better prediction ability for HGRCC.

Artificial Intelligence in Renal Cell Carcinoma Histopathology: Current Applications and Future Perspectives

Renal cell carcinoma (RCC) is characterized by its diverse histopathological features, which pose possible challenges to accurate diagnosis and prognosis. A comprehensive literature review was conducted to explore recent advancements in the field of artificial intelligence (AI) in RCC pathology. The aim of this paper is to assess whether these advancements hold promise in improving the precision, efficiency, and objectivity of histopathological analysis for RCC, while also reducing costs and interobserver variability and potentially alleviating the labor and time burden experienced by pathologists. The reviewed AI-powered approaches demonstrate effective identification and classification abilities regarding several histopathological features associated with RCC, facilitating accurate diagnosis, grading, and prognosis prediction and enabling precise and reliable assessments. Nevertheless, implementing AI in renal cell carcinoma generates challenges concerning standardization, generalizability, benchmarking performance, and integration of data into clinical workflows. Developing methodologies that enable pathologists to interpret AI decisions accurately is imperative. Moreover, establishing more robust and standardized validation workflows is crucial to instill confidence in AI-powered systems' outcomes. These efforts are vital for advancing current state-of-the-art practices and enhancing patient care in the future.

A Novel Nomogram for Prediction and Evaluation of Lymphatic Metastasis in Patients With Renal Cell Carcinoma

Background

Lymphatic metastasis is an important mechanism of renal cell carcinoma (RCC) dissemination and is an indicator of poor prognosis. Therefore, we aimed to identify predictors of lymphatic metastases (LMs) in RCC patients and to develop a new nomogram to assess the risk of LMs.

Methods

This study included patients with RCC from 2010 to 2018 in the Surveillance, Epidemiology, and Final Results (SEER) database into the training cohort and included the RCC patients diagnosed during the same period in the Second Affiliated Hospital of Dalian Medical University into the validation cohort. Univariate and multivariate logistic regression analysis were performed to identify risk factors for LM, constructing a nomogram. The receiver operating characteristic (ROC) curves were generated to assess the nomogram’s performance, and the concordance index (C-index), area under curve value (AUC), and calibration plots were used to evaluate the discrimination and calibration of the nomogram. The nomogram’s clinical performance was evaluated by decision curve analysis (DCA), probability density function (PDF) and clinical utility curve (CUC). Furthermore, Kaplan-Meier curves were performed in the training and the validation cohort to evaluate the survival risk of the patients with lymphatic metastasis or not. Additionally, on the basis of the constructed nomogram, we obtained a convenient and intuitive network calculator.

Results

A total of 41837 patients were included for analysis, including 41,018 in the training group and 819 in the validation group. Eleven risk factors were considered as predictor variables in the nomogram. The nomogram displayed excellent discrimination power, with AUC both reached 0.916 in the training group (95% confidence interval (CI) 0.913 to 0.918) and the validation group (95% CI 0.895 to 0.934). The calibration curves presented that the nomogram-based prediction had good consistency with practical application. Moreover, Kaplan-Meier curves analysis showed that RCC patients with LMs had worse survival outcomes compared with patients without LMs.

Conclusions

The nomogram and web calculator (https://liwenle0910.shinyapps.io/DynNomapp/) may be a useful tool to quantify the risk of LMs in patients with RCC, which may provide guidance for clinicians, such as identifying high-risk patients, performing surgery, and establishing personalized treatment as soon as possible.

Assessment of predictors of renal cell carcinoma progression after nephrectomy at short and intermediate term follow-up and implication on surveillance protocols

BACKGROUND

Prediction of risk of RCC progression after surgery is important for follow-up planning. We identified predictors of progression-free survival (PFS) and cancer-specific survival (CSS) in a large single institutional cohort and investigated patterns and sites of progression according to stage and grade.

METHODS

Node-negative non-metastatic clear-cell RCC (ccRCC) patients treated with radical or partial nephrectomy from 2000 to 2020 were included. Sites of progression were defined as thoracic, abdominal and others (bone/brain). Kaplan Meier curves and multivariable Cox regression (MCR) models tested for PFS and CSS.

RESULTS

Of 384 clear cell RCC N0M0 patients, 301 (78.4%) vs. 83 (21.6%) were pT1-2 vs. pT3-4, respectively; 253 (65.9%) vs. 130 (33.9%) were G1-G2 vs. G3-G4. Thoracic progressions occurred in 2.7% pT1-T2 vs. 21.7% pT3-T4 and 2.8% G1-G2 vs. 14.6% G3-G4 tumors. Abdominal progressions occurred in 4.0% pT1-T2 vs. 13.3% pT3-T4 and 4.3% G1-G2 vs. 9.2% G3-G4. Other progressions occurred in 0.3% pT1-T2 vs. 9.6% pT3-T4 and 0.8% G1-G2 vs. 5.4% G3-G4 (5.4%). Five-year PFS and CSS were 81.7 and 90.6%, respectively. At MCR models, pT3-4 (HR 9.1, p<0.001), G3-G4 (HR 2.7, p=0.003) and PSMs (HR 6.1, p<0.001) independently predicted PFS. Similarly, pT3-4 (HR 10.1, p<0.001), G3-G4 (HR 4.1, p=0.02), and PSMs (HR 5.2, p=0.04) independently predicted CSS.

CONCLUSIONS

In ccRCC N0M0 patients, G3-G4, pT3-4, PSMs were independent predictors of progression after surgery. Lower stage and grade ccRCCs progress predominantly in the abdominal sites and may be followed with less frequent extra-abdominal imaging compared to more advanced/aggressive tumors.

Effect of radiomics from different virtual monochromatic images in dual-energy spectral CT on the WHO/ISUP classification of clear cell renal cell carcinoma

AIM

To investigate the effect of radiomics obtained from different virtual monochromatic images (VMIs) in dual-energy spectral computed tomography (CT) on the World Health Organization/International Association for Urological Pathology (WHO/ISUP) classification of clear cell renal cell carcinoma (ccRCC).

MATERIALS AND METHODS

A retrospective study of 99 ccRCC patients who underwent contrast-enhanced dual-energy CT was undertaken. ccRCC was confirmed at surgery or biopsy and graded according to the WHO/ISUP pathological grading criteria as low grade (n=68, grade I and II) or high grade (n=31, grade III and IV). Radiomics risk scores (RRSs) for differentiating high and low grades of ccRCC were constructed from 11 sets of VMI in (40-140 keV, 10 keV interval) the cortical phase. Receiver operating characteristic (ROC) curves were drawn and the area under the curves (AUCs) was calculated to evaluate the discriminatory power of RRS for each VMI. The Hosmer-Lemeshow test was used to evaluate the goodness-of-fit of each model and the decision curve was used to analyse its net benefit to patients.

RESULTS

The AUC values for distinguishing low-from high-grade ccRCC with RRS of 40-140 keV VMIs were all >0.920. The Hosmer-Lemeshow test showed that the p-values of RRS of VMIs were >0.05, suggesting good fits. In the decision curve analysis, RRS from the 40-140 keV VMIs had similar decision curves and provided better net benefits than considering all patients either as high-grade or low-grade.

CONCLUSIONS

The RRS obtained from multiple VMIs in dual-energy spectral CT have high diagnostic efficiencies for distinguishing between low- and high-grade ccRCC with no significant differences between different VMIs.

Renal cell carcinoma in children and adolescents: Single-center experience and literature review

Renal cell carcinoma (RCC) is infrequent in the pediatric population. In addition, till date, only a few reports have summarized the characteristics of pediatric RCC and differences between pediatric and adult RCC. Therefore, the current study aimed to investigate the clinical characteristics of RCC in children and adolescents, and identify the differences between children and adolescent patients and adult patients through literature retrieval.The data of 13 pediatric patients diagnosed with RCC at the Children's Hospital of Zhejiang University School of Medicine between 2005 and 2019 were retrospectively analyzed.Three patients were aged <5 years, 2 were aged 6 to 10 years, and 8 were aged 11 to 18 years. Among the 13 patients, common clinical manifestations included abdominal pain in 5 patients, gross hematuria in 4, and an abdominal mass in 1, while the other 3 patients were incidentally detected after an abdominal contusion. The pathological types were microphthalmia family translocation RCC in 9 patients, clear-cell RCC in 2, papillary RCC in 1, and unclassified in 1. All the children underwent radical nephrectomy, including 2 patients with advanced disease who underwent preoperative transcatheter arterial chemoembolization. The mean follow-up time was 58.6 months. Two patients died after 4 and 17 months of follow-up, respectively.In conclusion, microphthalmia family translocation renal cell carcinoma is the predominant type of pediatric RCC associated with advanced tumor stage. The early diagnosis and treatment of pediatric patients is important for improving prognosis. Nevertheless, future studies are urgently needed to determine the treatment for pediatric advanced RCC to increase the survival rate.

Lymph node yield in pediatric, adolescent and young adult Renal Cell Carcinoma - How many are enough?

PURPOSE

Pediatric, adolescent and young adult (PAYA) patients with renal cell carcinoma (RCC) have a high rate of LN involvement, yet data to guide surgical lymph node (LN) management in this group is limited. The objective is to describe a LN yield threshold to quantify the chance of missing occult LN involvement at ≤10% in PAYAs with RCC.

MATERIALS & METHODS

The National Cancer Database was queried for patients aged ≤30 y with unilateral, non-metastaticRCC from 2004 to 2013. The probability of a false negative LN sampling was determined on the cohort of patients who had at least one positive LNand ≥ 2 LNs examined. For a given LN yield, the probability that a positive LN exists but none were found was estimated using a beta-binomial model.

RESULTS

We identified 112 patients meeting study criteria. Median age was 24 y and median tumor size was 9.5 cm (IQR 5.8-14). The median number of LNs sampled was 7 (IQR 4-12) and the median number of LNs positive was 4 (IQR 2-7). To achieve ≤10% probability of a false-negativeLN sampling, the beta-binomial model estimated that 5 LNs (95% CI4-7) must be sampled.

CONCLUSIONS

The desired LN yield to reduce the risk of a false-negativeLN sampling in PAYAs with RCC to ≤10% is 5. This is in keeping with prior studies identifying a LN yield of 6-10 to achieve the same. These data may be used to standardize surgical guidelines when treating PAYAs with renal tumors.

LEVEL OF EVIDENCE

II.

Prediction models for clear cell renal cell carcinoma ISUP/WHO grade: comparison between CT radiomics and conventional contrast-enhanced CT

OBJECTIVE

Comparing the prediction models for the ISUP/WHO grade of clear cell renal cell carcinoma (ccRCC) based on CT radiomics and conventional contrast-enhanced CT (CECT).

METHODS

The corticomedullary phase images of 119 cases of low-grade (I and II) and high-grade (III and IV) ccRCC based on 2016 ISUP/WHO pathological grading criteria were analyzed retrospectively. The patients were randomly divided into training and validation set by stratified sampling according to 7:3 ratio. Prediction models of ccRCC differentiation were constructed using CT radiomics and conventional CECT findings in the training setandwere validated using validation set. The discrimination, calibration, net reclassification index (NRI) and integrated discrimination improvement index (IDI) of the two prediction models were further compared. The decision curve was used to analyze the net benefit of patients under different probability thresholds of the two models.

RESULTS

In the training set, the C-statistics of radiomics prediction model was statistically higher than that of CECT (p < 0.05), with NRI of 9.52% and IDI of 21.6%, both with statistical significance (p < 0.01).In the validation set, the C-statistics of radiomics prediction model was also higher but did not show statistical significance (p = 0.07). The NRI and IDI was 14.29 and 33.7%, respectively, both statistically significant (p < 0.01). Validation set decision curve analysis showed the net benefit improvement of CT radiomics prediction model in the range of 3-81% over CECT.

CONCLUSION

The prediction model using CT radiomics in corticomedullary phase is more effective for ccRCC ISUP/WHO grade than conventional CECT.

ADVANCES IN KNOWLEDGE

As a non-invasive analysis method, radiomics can predict the ISUP/WHO grade of ccRCC more effectively than traditional enhanced CT.

Characteristics and Outcome of Children with Renal Cell Carcinoma: A Narrative Review

Pediatric renal cell carcinoma (RCC) is a rare type of kidney cancer, most commonly occurring in teenagers and young adolescents. Few relatively large series of pediatric RCC have been reported. Knowledge of clinical characteristics, outcome and treatment strategies are often based on the more frequently occurring adult types of RCC. However, published pediatric data suggest that clinical, molecular and histological characteristics of pediatric RCC differ from adult RCC. This paper summarizes reported series consisting of ≥10 RCC pediatric patients in order to create an up-to-date overview of the clinical and histopathological characteristics, treatment and outcome of pediatric RCC patients.

Association Between Systemic Therapy and/or Cytoreductive Nephrectomy and Survival in Contemporary Metastatic Non-clear Cell Renal Cell Carcinoma Patients

BACKGROUND

Optimal management of metastatic non-clear cell renal cell carcinoma (non-ccmRCC) remains largely unknown.

OBJECTIVE

To test the effect of systemic therapy (ST) and/or cytoreductive nephrectomy (CNT) on overall mortality (OM) in patients with non-ccmRCC.

DESIGN, SETTING, AND PARTICIPANTS

Within the Surveillance, Epidemiology and End Results (SEER) registry (2006-2015), we identified patients with papillary, chromophobe, sarcomatoid, and collecting duct metastatic renal cell carcinoma (mRCC).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Temporal trends (estimated annual percentage change [EAPC]), Kaplan-Meier plots, and multivariable Cox regression models were used.

RESULTS AND LIMITATIONS

Of 1573 patients with non-ccmRCC, 22%, 25%, 25%, and 28% underwent no treatment, ST, CNT, and CNT with ST, respectively. Between 2006 and 2015, rates of CNT and the combination of CNT and ST decreased (EAPC: -6.3% and -3.2%, respectively). Conversely, rates of no treatment and ST increased over time (EAPC: 4.6% and 7.5%, respectively). In multivariable Cox regression models, relative to no treatment, ST (hazard ratio [HR]: 0.5; p < 0.001), CNT (HR: 0.4; p < 0.001), and CNT with ST (HR: 0.3; p < 0.001) were associated with lower OM. Histological subtypes were associated with OM, relative to papillary renal cell carcinoma (RCC): chromophobe (HR: 0.7; p < 0.01), sarcomatoid (HR: 2.1; p < 0.001), and collecting duct RCC (HR: 1.9; p < 0.001). Limitations include the impossibility to stratify patients according to mRCC risk groups.

CONCLUSIONS

Most non-ccmRCC patients are treated with a combination of CNT and ST or CNT alone or ST alone. The rates of ST alone are increasing. Conversely, the rates of combined CNT and ST and CNT alone are decreasing. These observed temporal patterns of treatment rates are counterintuitive with respect to associated OM benefits, where combination of CNT and ST, as well as CNT alone, resulted in the lowest absolute OM, relative to ST alone, or, even worse, no treatment.

PATIENT SUMMARY

We investigated the effect of treatment modalities on survival of patients with metastatic non-clear cell renal cell carcinoma. The combination of cytoreductive nephrectomy and systemic therapy confers greater benefit with respect to single treatments alone.

Pediatric renal cell carcinoma

PURPOSE OF REVIEW

To review the presentation, natural history and treatment of renal cell carcinoma in children and young adults with renal cell carcinoma (RCC).

RECENT FINDINGS

Complete resection of lymph nodes at the time of tumor resection can improve clinical outcomes and limit the need for adjuvant chemotherapy. Genetic alterations that lead to translocation tumors are a therapeutic target of receptor tyrosine kinase inhibitors.

SUMMARY

The incidence of RCC increases with age. Unlike adult patients, young patients with RCC present symptomatically and at higher stage and grade. Translocation tumors predominate RCC in children with biologic activity characterized by early spread to lymph nodes with small primary tumors. Preoperative imaging is poorly sensitive for positive lymph nodes; as such, surgeons should have a low threshold for lymph node sampling during tumor resection. Despite the advanced stage at presentation, the prognosis in children is more favorable than their adult counterparts. Complete resection of lymph nodes at the time of surgical resection improves patient prognosis. Chemotherapy targeting the PI3/AKT pathway has demonstrated clinical benefit.

The prognostic significance of nodal disease burden in patients with lymph node metastases from renal cell carcinoma

OBJECTIVES

To assess the relationship between nodal disease burden and overall survival (OS) among patients with lymph node (LN) metastases from renal cell carcinoma (RCC) METHODS: The National Cancer Data Base was used to identify 2,975 patients with RCC who were treated with radical nephrectomy and were found to have regional LN metastases. Associations between the number of positive and negative LN removed and OS were assessed using Cox proportional hazards regression. The median follow-up time among survivors was 3.6years.

RESULTS

The median number of positive LN was 1 (interquartile range 1-3). A higher number of positive LN was associated with higher all-cause mortality on multivariable analysis (HR 1.06 per 1 positive LN, 95% CI 1.04, 1.07, P < 0.001). Conversely, higher negative LN counts were associated with better OS (HR 0.97 per 1 negative LN, 95% CI 0.96, 0.99, P < 0.001). The adjusted probability of a patient with 1 LN removed that was positive surviving at least 2 years was 56%, a figure that increased to 64% when 1 out of 10 LN removed was positive and decreased to 38% when 10 out of 10 LN removed were positive.

CONCLUSIONS

Ours is the first study to show that differences in nodal disease burden translate into clinically significant differences in survival among patients with LN metastases from RCC.

Does tumour effraction during robotic partial nephrectomy have any impact on recurrence?

OBJECTIVE

To evaluate the impact of accidental surgical incision into the tumour (ASIT) on oncological outcomes in patients undergoing RPN for a malignant tumour.

MATERIALS AND METHODS

A retrospective review of our prospectively maintained database was performed to identify all patients who underwent RPN for a localized RCC between June 2010 and July 2016. We stratified our cohort into two groups according to the presence of an ASIT. Perioperative data were compared between the two groups. Logistic regression analyses were used to assess the variables associated with ASIT. Recurrence-free survival was estimated using the Kaplan-Meier method and compared between groups with the log-rank test.

RESULTS

A total of 234 patients were identified. 32 (14%) ASIT were observed. Patients' characteristics were similar in the two groups. Most of intraoperative outcomes were comparable between the two groups, but patients in the ASIT group had greater EBL (475 vs. 300 mL; p = 0.01). In multivariate analysis, tumour size (p = 0.02), RENAL score (p = 0.02), EBL (p = 0.05) and low surgeon experience (p = 0.03) were all predictive factors of ASIT. 15 (6%) of recurrences were observed over a median follow-up of 36 months. There was no difference in recurrence-free survival between the two groups (p = 0.57).

CONCLUSIONS

In our experience, accidental surgical incision into the tumour during RPN was a common event that did not appear to compromise oncological outcome.

The effect of AST/ALT (De Ritis) ratio on survival and its relation to tumor histopathological variables in patients with localized renal cell carcinoma

Purpose

To assess the relationship between De Ritis (aspartate aminotransaminase [AST]/Alanine aminotransaminase [ALT]) ratio and pathological variables and whether it is an independent prognostic factor.

Materials and Methods

We analyzed 298 consecutive patients who underwent radical or partial nephrectomy for non-metastatic renal cell carcinoma (RCC) between 2006 and 2015. The association between De Ritis ratio and pathological variables including tumor size, presence of renal vein invasion, vena cava invasion, renal capsule infiltration, Gerota fascia invasion, renal sinus involvement, renal pelvic invasion, angiolymphatic invasion, adrenal gland involvement, lymph node involvement, tumor necrosis, and Fuhrman's grade was tested. Multivariable Cox analysis was performed to evaluate the impact of this ratio on overall survival and cancer-specific survival.

Results

An increased preoperative De Ritis ratio was significantly associated with renal vein invasion, renal capsule infiltration and renal pelvis involvement (p<0.05) in non-metastatic RCC. On multivariate analysis we found that tumor size, Fuhrman grade and lymph node involvement were independent prognostic factors for cancer-specific survival. AST/ALT ratio had no influence on the risk of overall and cancer-specific survival.

Conclusion

An increased preoperative AST/ALT ratio had a significant association with renal vein invasion, renal capsule infiltration and renal pelvis involvement in patients with non-metastatic RCC. However, it does not appear to be an independent prognostic marker in non-metastatic RCC.

Systematic review of renal carcinoma prognostic factors

CONTEXT AND OBJECTIVES

The natural history of renal cell carcinoma is heterogeneous. Some scenarios can be found in terms of clinical presentation, clinical evolution or type of recurrence (local/metastatic). The aim of this publication is to analyze the most important prognostic factors published in the literature.

EVIDENCE ACQUISITION

A literature review ob published papers was performed using the Pubmed, from first Motzer's classification published in 1999 to 2015, according to PRISMA declaration. Search was done using the following keywords: kidney neoplasm, kidney cancer, renal cell carcinoma, prognostic factors, mortality, survival and disease progression. Papers were classified according to level of evidence, the number of patients included and the type of study performed.

EVIDENCE SYNTHESIS

The evolution in the knowledge of molecular pathways related to renal oncogenesis and the new targeted therapies has left to remain obsolete the old prognostic models. It's necessary to perform a continuous review to actualize nomograms and to adapt them to the new scenarios.

CONCLUSIONS

Is necessary to perform a proper external validation of existing prognostic factors using prospective and multicentric studies to add them into the daily urologist clinical practice.

Impact of preoperative thrombocytosis on prognosis after surgical treatment in pathological T1 and T2 renal cell carcinoma: results of a multi-institutional comprehensive study

Background

The prognostic significance of preoperative thrombocytosis (TC) in renal cell carcinoma (RCC) is not without some debate. The aim of the present multi-institutional study was to determine the association of preoperative TC with the clinicopathological features and prognosis of localized RCC patients who underwent surgery in a large cohort.

Methods

A study involving 8 institutions, and 4,376 patients with pT1 and pT2 RCC from the Korean renal cell carcinoma (KORCC) database, was conducted. TC was defined as a platelet count ≥400,000/μL. Patients were divided into 2 groups based on the presence of preoperative TC. Clinicopathological variables and survival rates were compared between the 2 groups.

Results

Out of the 4,376 patients in the study, 106 (2.4%) had preoperative TC. Compared to patients without TC, these patients had a lower body mass index. Additionally, these patients had more advanced stage tumors with a higher Fuhrman grade, and higher incidence of symptoms at the time of diagnosis. Kaplan-Meier curves revealed that patients with TC had a significantly lower rate of recurrence-free survival (RFS). Furthermore, a lower rate of overall survival (OS) was exhibited amongst patients with TC. Multivariate analysis revealed that TC was an independent prognostic factor in terms of the RFS and OS.

Conclusions

TC appeared to be an important prognostic determinant in localized RCC. Furthermore, preoperative platelet count may be clinically useful for risk stratification of patients with surgically treated localized RCC.

Survival after partial and radical nephrectomy for high-risk disease: A propensity-matched comparison

INTRODUCTION

Increasingly, partial nephrectomy has been applied to high-risk disease without evidence that its survival benefits can be extrapolated to this entity. We aimed to compare overall survival after partial vs. radical nephrectomy in patients with high-risk renal cell carcinoma.

METHODS

Using the National Cancer Data Base, we identified patients who underwent partial or radical nephrectomy for high-risk disease between 2003 and 2006. High-risk disease was defined as the presence of adverse pathological features within the primary tumour, namely high-grade or unfavourable histology, T3 stage, or both. After matching the partial and radical nephrectomy groups based on propensity scores, 1680, 276, and 76 patients with high-grade or unfavourable histology, T3 stage, or both adverse pathologic features, respectively, were available for analysis. Five-year overall survival was compared after partial vs. radical nephrectomy for each high-risk cohort using the Kaplan-Meier and log rank tests.

RESULTS

Partial nephrectomy was associated with a statistically significant improvement in five-year overall survival compared to radical nephrectomy for small tumours (median size 3.0 cm; interquartile range 2.1-4.5 cm) with high-grade or unfavourable histology (87% vs. 81%; p<0.01) or with pT3a stage (82% vs. 71%; p<0.01). For patients concomitantly harbouring both adverse pathologic features, no difference in survival was detected (p=0.21).

CONCLUSIONS

Partial nephrectomy is associated with survival benefits in patients with adverse pathologic features, suggesting that renal preservation is not only safe, but also potentially beneficial for high-risk disease. Due to inherent selection bias associated with partial nephrectomy use, prospective validation of these findings is needed.

Clinical significance of preoperative thrombocytosis in patients who underwent radical nephrectomy for nonmetastatic renal cell carcinoma

Purpose

The aim of this study was to examine the association of preoperative thrombocytosis with the prognosis of patients with nonmetastatic renal cell carcinoma (RCC).

Materials and Methods

We conducted a retrospective analysis of 187 patients who underwent a radical nephrectomy for nonmetastatic RCC between July 1997 and June 2009. Thrombocytosis was defined as a platelet count≥400,000 µL, and patients were divided into 2 groups according to presence of preoperative thrombocytosis, and the cancer-specific survival rates and overall survival rates of the 2 groups after radical nephrectomy were compared.

Results

The mean age of the patients was 56.0±11.7 years and the mean follow-up period was 59.3±42.1 months; there were 20 patients with preoperative thrombocytosis. Thirty patients developed metastases and 9 patients died during the follow-up period. In Kaplan-Meier analysis using a univariate log-rank test, both cancer-specific survival rate (p=0.013) and overall survival rate (p=0.012) showed significant association with preoperative thrombocytosis. Controlling for pathological TNM stage, Fuhrman grade and tumor diameter, the Cox proportional hazards model for cancer-specific survival rates showed that preoperative thrombocytosis was an independent prognostic factor (p=0.025).

Conclusions

Preoperative thrombocytosis was associated with poorer prognosis in patients with nonmetastatic RCC. Thus, preoperative platelet count may be clinically useful for risk stratification of patients undergoing surgery for nonmetastatic RCC.

Factors impacting survival in children with renal cell carcinoma

PURPOSE

Renal cell carcinoma (RCC) is an uncommon tumor in the pediatric population. We examined a large national cancer database to determine outcomes for children with RCC and to identify variables affecting long-term survival.

METHODS

The National Cancer Data Base (NCDB) was queried for patients age 0 to 17 years diagnosed with RCC from 1998-2011. Patient demographics, tumor stage and characteristics, management, and outcomes were evaluated.

RESULTS

A total of 304 children met inclusion criteria. Overall, 39% of children had stage I disease, 16% stage II, 33% stage III, and 12% stage IV. One-year and five-year survival for all children was 87% and 70%, respectively. Eighty-six percent of patients underwent surgical resection. In comparison to children who underwent complete nephrectomy, patients undergoing partial nephrectomy had smaller tumors and were of lower clinical stages. Survival following partial resection was 100% at one and five years. Age and gender had no significant impact on survival. Survival was negatively impacted by increasing tumor size (P<0.001), positive nodal status (P=0.001), and higher pathologic stage (P<0.001).

CONCLUSION

Children with renal cell carcinoma who undergo surgical resection have excellent one-year and five-year survival. Overall survival is significantly affected by pathologic stage, tumor size, and nodal status.

Restaging clear cell renal carcinoma with 18F-FDG PET/CT

AIM

The aim of our retrospective study was to assess the usefulness of F-FDG PET/CT in the restaging of clear cell renal cell carcinoma (RCC) patients.

PATIENTS AND METHODS

Sixty-nine patients (median age = 62 years; range = 36-86 years) affected by clear cell RCC (TNM at staging: T1, 42 patients; T2, 13 patients; T3, 11 patients; T4, 3 patients; Fuhrman grade: G2, 47 patients; G3, 20 patients; G4, 2 patients) underwent whole-body F-FDG PET/CT to restage the disease after nephrectomy for clinical or radiological suspicion of metastases. Areas of abnormal uptake at PET/CT were classified, taking the liver uptake as reference, as follows: 1 = faint uptake, lower than liver; 2 = moderate uptake, equal to liver; and 3 = high uptake, higher than liver. Validation of F-FDG PET/CT results was established by (1) biopsy (23 patients) and (2) other imaging modalities (addressed BS; c.e.CT; MRI; F-fluoride PET/CT; subsequent F-FDG PET/CT), and/or clinical and radiological follow-up of 12 months (46 patients).

RESULTS

F-FDG PET/CT was positive in 42 patients and negative in 27 patients. Sixteen patients presented single lesions and 26 patients presented multiple localizations of the disease. On a patient basis, 40 patients resulted true positive, 2 patient false positive, 23 patients true negative, and 4 patients false negative. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 90%, 92%, 91%, 95%, and 85%, respectively. On a lesion basis, PET/CT detected 114 areas of abnormal uptake in 42 positive patients of which 112 resulted to be true positive. FDG uptake of the true positive lesions resulted to be high in 83 cases, moderate in 17 lesions, and finally faint in 12 lesions.

CONCLUSIONS

F-FDG PET/CT demonstrated a good sensitivity in the restaging of clear cell RCC. Most of the lesions showed intense activity. According to our results, it seems that the use of F-FDG PET/CT in the restaging of RCC is feasible because the number of false-negative cases is limited.

Automated grading of renal cell carcinoma using whole slide imaging

INTRODUCTION

Recent technology developments have demonstrated the benefit of using whole slide imaging (WSI) in computer-aided diagnosis. In this paper, we explore the feasibility of using automatic WSI analysis to assist grading of clear cell renal cell carcinoma (RCC), which is a manual task traditionally performed by pathologists.

MATERIALS AND METHODS

Automatic WSI analysis was applied to 39 hematoxylin and eosin-stained digitized slides of clear cell RCC with varying grades. Kernel regression was used to estimate the spatial distribution of nuclear size across the entire slides. The analysis results were correlated with Fuhrman nuclear grades determined by pathologists.

RESULTS

The spatial distribution of nuclear size provided a panoramic view of the tissue sections. The distribution images facilitated locating regions of interest, such as high-grade regions and areas with necrosis. The statistical analysis showed that the maximum nuclear size was significantly different (P < 0.001) between low-grade (Grades I and II) and high-grade tumors (Grades III and IV). The receiver operating characteristics analysis showed that the maximum nuclear size distinguished high-grade and low-grade tumors with a false positive rate of 0.2 and a true positive rate of 1.0. The area under the curve is 0.97.

CONCLUSION

The automatic WSI analysis allows pathologists to see the spatial distribution of nuclei size inside the tumors. The maximum nuclear size can also be used to differentiate low-grade and high-grade clear cell RCC with good sensitivity and specificity. These data suggest that automatic WSI analysis may facilitate pathologic grading of renal tumors and reduce variability encountered with manual grading.

Clinico-pathological analysis of renal cell carcinoma demonstrates decreasing tumour grade over a 17-year period

INTRODUCTION

Renal cell carcinoma (RCC) represents about 3% of adult malignancies in Ireland. Worldwide there is a reported increasing incidence and recent studies report a stage migration towards smaller tumours. We assess the clinico-pathological features and survival of patients with RCC in a surgically treated cohort.

METHODS

A retrospective analysis of all nephrectomies carried out between 1995 and 2012 was carried out in an Irish tertiary referral university hospital. Data recorded included patient demographics, size of tumour, tumour-node-metastasis (TNM) classification, operative details and final pathology. The data were divided into 3 equal consecutive time periods for comparison purposes: Group 1 (1995-2000), Group 2 (2001-2006) and Group 3 (2007-2012). Survival data were verified with the National Cancer Registry of Ireland.

RESULTS

In total, 507 patients underwent nephrectomies in the study period. The median tumour size was 5.8 cm (range: 1.2-20 cm) and there was no statistical reduction in size observed over time (p = 0.477). A total of 142 (28%) RCCs were classified as pT1a, 111 (21.9%) were pT1b, 67 (13.2%) were pT2, 103 (20.3%) were pT3a, 75 (14.8%) were pT3b and 9 (1.8%) were pT4. There was no statistical T-stage migration observed (p = 0.213). There was a significant grade reduction over time (p = 0.017). There was significant differences noted in overall survival between the T-stages (p < 0.001), nuclear grades (p < 0.001) and histological subtypes (p = 0.022).

CONCLUSION

There was a rising incidence in the number of nephrectomies over the study period. Despite previous reports, a stage migration was not evident; however, a grade reduction was apparent in this Irish surgical series. We can demonstrate that tumour stage, nuclear grade and histological subtype are significant prognosticators of relative survival in RCC.

Current status of targeted therapy for advanced renal cell carcinoma

The treatment of metastatic renal cell carcinoma (mRCC) has recently evolved from being predominantly cytokine-based treatment to the use of targeted agents, which include sorafenib, sunitinib, bevacizumab (plus interferon alpha [IFN-α]), temsirolimus, everolimus, pazopanib, and most recently, axitinib. Improved understanding of the molecular pathways implicated in the pathogenesis of RCC has led to the development of specific targeted therapies for treating the disease. In Korea, it has been 5 years since targeted therapy became available for mRCC. Thus, we now have broader and better therapeutic options at hand, leading to a significantly improved prognosis for patients with mRCC. However, the treatment of mRCC remains a challenge and a major health problem. Many questions remain on the efficacy of combination treatments and on the best methods for achieving complete remission. Additional studies are needed to optimize the use of these agents by identifying those patients who would most benefit and by elucidating the best means of delivering these agents, either in combination or as sequential single agents. Furthermore, numerous ongoing research activities aim at improving the benefits of the new compounds in the metastatic situation or their application in the early phase of the disease. This review introduces what is currently known regarding the fundamental biology that underlies clear cell RCC, summarizes the clinical evidence supporting the benefits of targeted agents in mRCC treatment, discusses survival endpoints used in pivotal clinical trials, and outlines future research directions.

Evaluation of response to multikinase inhibitor in metastatic renal cell carcinoma by FDG PET/contrast-enhanced CT

PURPOSE

Multikinase inhibitor (MKI) is a promising drug for treatment of metastatic renal cell carcinoma (mRCC). We explained the usefulness of [¹⁸F]-2-fluoro-2-deoxyglucose positron emission tomography/contrast-enhanced computed tomography (FDG PET/CECT) for mRCC in evaluating the early response to MKI and in predicting progression-free survival (PFS).

METHODS

Patients who planned MKI treatment for mRCC were included in this prospective study. FDG PET/CECT was performed before MKI treatment and after one cycle of MKI treatment. Evaluation of the response to MKI was assessed by PET according to the European Organization for Research and Treatment of Cancer, by CT according to the Response Evaluation Criteria in Solid Tumors and appearance of central hypoattenuation (CHA).

RESULTS

Twelve patients were enrolled in the study. Equality of response evaluation between PET and CT was in 8 patients (partial response [PR]: 1, stable disease [SD]: 6, progressive disease [PD]: 1). Among the other 4 patients, PET showed 2 patients with PR and 2 patients with PD, in contrast to the CT finding of SD in all 4 patients. PFS according to PET response showed a statistically significant difference between PR and SD (P < 0.05) and between PR and PD (P < 0.05), but not between PR and SD (P = 0.083). Positive CHA in metastatic lesions after MKI treatment was confirmed in 8 patients. PFS with positive CHA was 233.8 days, while that without CHA was 75.0 days (P < 0.05).

CONCLUSION

FDG PET/CECT shows potential for evaluating early treatment response to MKI in mRCC and for predicting PFS.

Renal cell carcinoma: stage, grade and histology migration over the last 15 years in a large Australian surgical series

OBJECTIVE

• To verify whether migration towards earlier-stage renal cell carcinoma (RCC), which has been observed in the USA over the last decade, also applies to Australia.

PATIENTS AND METHODS

• Between January 1993 and December 2007, 547 nephrectomies performed in public and private hospitals in western Sydney were analysed from a retrospectively collected database. • Data were divided into three consecutive time groups. • Tumour-node-metastasis (TNM) stage as well as patient demographics, size, grade and histology of tumours and proportion of benign tumours were also assessed.

RESULTS

• In all, 499 nephrectomies were performed for RCC. The median age was 62 years, with a male:female ratio of 1.9 : 1. Similarly sized tumours were identified in each time group [group 1 (1993-1997), 54.8 mm; group 2 (1998-2002), 52.0 mm; group 3 (2003-2007), 52.2 mm, P= 0.6]. • Pathological stage II disease decreased from 18.1 to 11.1%, but stage III disease showed an increase from 13.9 to 21.5% over that time period (P= 0.02). • The proportion of stage I and stage IV disease has remained relatively the same. There has been a statistically significant upward histological migration for the papillary subtype from 1.3 to 10.2% (P= 0.01). • There has also been an increasing representation of Fuhrman grade III tumours over time, from 17.6 to 30.8%, and a decreasing proportion of Fuhrman grade I tumours from 16.2 to 7.1% (P= 0.03). • There was a decrease in the incidence of benign tumours originally thought to be malignant on preoperative investigations, from 10% in group 1 to 4% in group 3 (P= 0.03).

CONCLUSION

• The recent US phenomenon of migration towards earlier-stage, smaller RCCs as well as increased representation of benign tumours was not observed in the present study. The results of the present study, however, show an upward histological migration for papillary RCCs and an increasing representation of more aggressive Fuhrman grade III tumours.

[Significance of anemia as an independent prognostic factor in patients with renal cell carcinoma]

BACKGROUND AND OBJECTIVE

The aim of this study was to analyze the significance of anemia as well as other prognostic factors influencing survival in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

A retrospective review of data of 316 patients who underwent surgery between 1970 and 2003 was performed. Most important known prognostic factors of RCC were investigated.

RESULTS

Most of patients had T1b-T2, low nuclear grade and single tumours. In 8.2% and 9% of cases, lymph node and metastatic dissemination were detected at the time of diagnosis, respectively. At the beginning, most frequent symptoms were hematuria and pain, with anemia (Hb >10g/dl) in 69 patients. After a median follow-up of 50 months, 24.1% of patients had a recurrence. From these, more than 50% developed recurrence within one year after nephrectomy. Advanced tumours (T3-4) consisted of high nuclear grade (III-IV) tumours, larger size tumours, with necrosis and vascular infiltration in surgical specimen, as well as lymph node and metastatic dissemination. In multivariate analysis, anemia, time to recurrence, type of treatment for recurrence as well as lymph node dissemination were independent factors of cancer specific survival.

CONCLUSION

Anemia seems to be a marker of recurrence and progression in patients with renal cell carcinoma undergoing nephrectomy. From our point of view, anemia could be considered a significantly high mortality rate for renal cancer in these patients.

[Value of the postoperative Störkel score. Predict disease-free survival of patients with surgically resected renal cell carcinoma]

OBJECTIVE

To determine the value of clinical and pathological parameters defining the Störkel score in order to predict outcomes of patients with surgically treated renal cell carcinoma (RCC).

MATERIAL AND METHODS

A total of 834 consecutive patients having radical or partial nephrectomy were retrospectively reviewed. For each patient with RCC, the prognostic Störkel score was calculated according to the following variables: Robson stage, Thoenes nuclear grading, histological type, pattern of growth, and age. Based on the Störkel score, patients were divided into groups: those with good prognosis (GP), intermediate prognosis (IP), and poor prognosis (PP). Cancer-specific survival (CSS) and overall survival (OS) were estimated using the Kaplan-Meier method. The accuracy of prediction of CSS and OS with the Störkel score was analyzed using Kaplan-Meier analysis, proportional hazards regression, and graphic representation [(Kaplan-Meier curves, area under the curve (AUC)]. In 564 patients who were still alive, the median follow-up was 79 months (mean 84.8 months).

RESULTS

In the GP, IP, and PP groups, CSS after 8 years was 86.7%, 75.6%, and 13.7%, respectively (p<0.001). In the multiple analysis, only the Robson stage and Thoenes nuclear grading independently predicted CSS. Accordingly, the prognostic accuracy of the Störkel score (CSS prediction: AUC=0.744, 95% CI=0.70-0.79) was not better than with a reduced model that included the Robson stage and grading only (CSS prediction: AUC=0.765, 95%CI=0.72-0.81).

CONCLUSIONS

Of all parameters included in the Störkel score, only the Robson stage and nuclear grading are significant prognostic factors. Hence, we recommend an accordant modification of the score with additional variables.

Local lymph node involvement in pediatric renal cell carcinoma: a report from the Italian TREP project

BACKGROUND

One of the most important adverse prognostic factors for adult renal cell carcinoma (RCC) is the retroperitoneal lymph node involvement. The aim of this article is to study the prognostic significance of local lymph node involvement in pediatric RCC and the role of retroperitoneal lymph node dissection (RLND) at diagnosis.

PROCEDURE

The series included 16 patients with RCC and lymph nodes involvement registered in the Italian Rare Tumors Pediatric Age (TREP) project, accounting for 26.2% of 61 pediatric RCC observed at AIEOP centers.

RESULTS

A radical nephrectomy was performed in all cases: at diagnosis in 12 cases, after preoperative chemotherapy (CT) in 4 cases. As a part of the same procedure 9 patients underwent RLND, and 7 received a more limited lymph nodes resection. Five (31.2%) developed disease recurrence 2-34 months after diagnosis (median, 6 months) plus 1 developed progression; 6 patients died, 1 of them from secondary leukemia. Among the nine patients receiving RLND, eight are alive and disease free. This compares with only one patient surviving among the seven receiving a more limited lymph nodes resection. The estimated 25-year PFS and OS rates for all patients were 61.4% (95% CI 33.2-80.5) and 50.8% (95% CI 16.5-77.5), respectively.

CONCLUSIONS

Lymph node involvement is an unfavorable prognostic factor in children with RCC. RLND appears to be a critical factor to improve the outcome. However, when compared to similar adult patients, the outcome in children appears to be better, suggesting that pediatric RCC, or the host, may be critical differences.

Extension of survival by resection of asynchronous renal cell carcinoma metastases to mediastinal lymph nodes

OBJECTIVE

The aim of this study was to determine whether or not resection of isolated mediastinal lymph node renal cell carcinoma metastases confers a survival advantage, as compared with patients with stage IV disease.

PATIENTS AND METHODS

We retrospectively reviewed the charts of all patients with renal cell carcinoma whose histologic specimens were evaluated at our institution from January 1, 2000, through December 31, 2006. Using Kaplan-Meier estimates, we compared the survival of patients who underwent resection of asynchronous mediastinal lymph node metastases with that of patients with stage IV disease.

RESULTS

During the 7-year study period, of the 386 patients with renal cell carcinoma who were evaluated at our institution, 9 underwent resection of asynchronous mediastinal lymph node metastases. After primary tumor resection and before diagnosis of asynchronous mediastinal lymph node metastases, all patients completed chemotherapy, cytokine therapy, or tumor vaccination; 3 underwent radiotherapy. The median age at resection of mediastinal lymph nodes was 57.7 years (range, 39.7-81.2). The median time from primary tumor resection to mediastinal lymph node resection was 2.8 years (range, 0.5-23.3). In all, 4 patients underwent resection of metastases via thoracotomy and 5, via thoracoscopy. The median number of mediastinal lymph nodes pathologically evaluated was 7 (range, 2-28); the median number of positive mediastinal lymph nodes per patient was 1.5 (range, 1-3). We found no surgical complications. The median survival after resection of metastases (3.2 years) was significantly longer (P = .021) than for other patients with stage IV disease at our institution (1.1 years).

CONCLUSIONS

Resection of renal cell carcinoma mediastinal lymph node metastases is safe, appears to extend survival, and should be considered an important component of treating patients with renal cell carcinoma who have asynchronous mediastinal lymph node metastases.

Translocation renal cell carcinoma: lack of negative impact due to lymph node spread

BACKGROUND

Pediatric renal cell carcinoma (RCC) is clinically distinct from adult RCC. Characterization of the unique biological and clinical features of pediatric RCC are required.

METHODS

A retrospective review and biological analysis of all RCC cases presenting to Cincinnati Children's Hospital Medical Center (CCHMC) in the last 30 years was undertaken. Cases were classified according to the recent World Heath Organization morphologic classification and according to TFE3/TFEB status. A literature review of pediatric TFE+ cases was performed.

RESULTS

Eleven cases of RCC with clinical data were identified in our institutional review as follows: 6 clear cell, 2 papillary, 2 translocation, and 1 sarcomatoid. Upon reanalysis, 1 papillary and 1 sarcomatoid were confirmed, 1 case was "unclassified", and 8 of 11 (72.7%) had features consistent with translocation morphology. Of these 8, all demonstrated immunoreactivity for TFE3 (7 patients) or TFEB (1 patient) protein. In 3 cases, cytogenetics was available, each demonstrating confirmatory MiTF/TFE translocations. Seven of 8 TFE+ RCC patients presented with TNM Stage III/IV disease. Literature analysis confirmed a significant increase in advanced stage presentation in pediatric TFE+ RCC compared with TFE- RCC. Fourteen of fifteen (93.3%) patients with TFE+ stage III/IV RCC due to lymph node spread (N+ M(0)) remain disease free with a median and mean follow-up of 4.4 and 6.3 years, respectively (range, 0.3-15.5).

CONCLUSIONS

Translocation morphology RCC is the predominant form of pediatric RCC, associated with an advanced stage at presentation. Patients with TFE+ N+ M(0) RCC maintain a favorable short-term prognosis after surgery alone. Young RCC patients should be screened for translocation morphology, and the screening information should be considered when debating adjuvant therapy.

Pathologic concordance of sporadic synchronous bilateral renal masses

OBJECTIVES

To review the collective experience evaluating pathologic concordance rates of sporadic bilateral synchronous renal tumors reported in the Surveillance, Epidemiology, and End Results (SEER) database and the published English literature and treated at Fox Chase Cancer Center; specifically, to analyze concordance rates of malignant versus benign disease, histologic type, tumor stage, and nuclear grade.

METHODS

We reviewed the SEER database, the published English language literature, and our own institutional tumor registry to identify all cases of sporadic, synchronous localized (cT1-3N0M0) bilateral renal masses. Malignant and benign concordance rates were defined as agreement of any benign or malignant tumor type bilaterally. Histologic concordance was defined as bilateral histologic agreement. Tumors with mixed histologies were discordant unless all patterns were identical bilaterally. Nuclear grades were concordant if bilateral tumors were either "high" grade or "low" grade.

RESULTS

The malignant concordance rate in the SEER data was 99% (273 of 274), and benign concordance was 0 (0 of 1). In the published literature and Fox Chase Cancer Center series, malignant concordance rates ranged from 84% to 95%, whereas benign concordance ranged from 39% to 67%. The SEER data revealed a histologic concordance rate of 93% (256 of 274), and nuclear grade concordance was 85% (88 of 103).

CONCLUSIONS

These data demonstrate that in cases of bilateral sporadic localized synchronous renal masses, a diagnosis of ipsilateral renal cell carcinoma is associated with contralateral renal cell carcinoma in the vast majority of patients, whereas ipsilateral benign pathology is associated with contralateral benign disease at a substantially lower rate. Histologic concordance is similarly high, meaning most cases of clear cell or papillary tumors ipsilaterally are concordant in the contralateral kidney. Concordance rates of nuclear grade were slightly lower. These data are important when counseling and managing patients with bilateral synchronous sporadic renal tumors.

Cystinyl aminopeptidase activity is decreased in renal cell carcinomas

The involvement of peptidases in carcinogenetic processes of several tumor types has been researched in recent years. Although kidney is one of the major tissues known to express cystinyl-aminopeptidase (CAP), little is known about its role in renal neoplasia. This study analyzes fluorimetrically membrane-bound and soluble CAP activity in the three main renal cancers: clear cell (CCRCC), papillary (PRCC), and chromophobe (ChRCC) renal cell carcinomas. Overall, a marked decrease of membrane-bound CAP activity in all the three renal cell carcinomas was detected when compared with their respective surrounding non-tumor tissues. So, the tumor vs. non-tumor CAP ratios (units of peptidase per mg of protein) was as follows: 926+/-111 vs. 3778+/-276 for CCRCCs, 737+/-181 vs. 4351+/-950 for PRCCs, and 592+/-118 vs. 4905+/-935 for ChRCCs. In contrast, the soluble fraction of this enzyme displayed minor and non-significant changes when comparing tumor and non-tumor CAP activities in the whole series. After stratification by stage and grade, CCRCCs displayed significant differences: pT3 category had significantly higher levels of membrane-bound activity than pT1, and high grade cases (G3-4) had higher soluble CAP activity than low grade ones (G1-2). These data may open additional possibilities in the study of renal cell carcinoma with regard to the prognosis of patients.

Part II: Treatment of primary malignant non-Wilms' renal tumours in children

Renal-cell carcinoma, clear-cell sarcoma, (congenital) mesoblastic nephroma, rhabdoid tumour, and renal medullary carcinoma form a heterogeneous group of childhood renal malignancies known as non-Wilms' tumours. Progress has been slow in improving the management of these tumours to decrease morbidity and increase survival. However, greater cooperation between national and international centres should engender specialisation, and an increased knowledge of the molecular biology of these tumours will inevitably lead to substantial progress over the next decade. This review is the second of two parts: the first part provided an updated review of the clinical presentation, imaging, and pathology of non-Wilms' tumours and this second part provides an updated review of the treatment of these tumours.

Key clinical issues in renal cancer: a challenge for proteomics

Renal cancer has many clinical challenges which proteomics is ideally placed to address. The issues cover all aspects of the disease including diagnosis, prognosis, treatment selection and monitoring to detect metastatic disease. In all cases novel biomarkers would considerably help in clinical management and with the relative resistance to conventional chemotherapy and radiotherapy, a better understanding of the underlying pathogenesis may contribute to the much needed development of novel therapeutic targets and the better use of promising new anti-angiogenic treatments. This review briefly highlights some of the clinical issues and describes proteomics-based approaches generally, before focussing on reviewing the proteomic studies to date in this area.

Significance of lymphatic invasion and proliferation on regional lymph node metastasis in renal cell carcinoma

We studied the associations of lymphatic invasion and lymphatic vessel density around tumors with lymph node (LN) status in renal cell carcinoma (RCC) by immunohistochemical analysis using D2-40 antibody as a lymphatic marker. Surgically removed specimens from 76 cases with RCC, including 16 cases with LN metastasis, were used. Lymphatic vessel density around the tumor increased compared with normal kidneys but was not significant by LN status. Tumor size, tumor cell types, patterns of tumor growth, nuclear grade of tumor cells, venous invasion, lymphatic invasion, and primary tumor stage were predictive factors for LN metastasis. Based on multivariate regression analysis, only lymphatic invasion was an independent risk factor for LN metastasis. The immunohistochemical detection of lymphatics was useful for identifying the lymphatic invasion of RCC, and the presence of lymphatic invasion around RCC was an independent predictive factor for LN metastasis.