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Fang AM, Leahy S, Saidian A, Oster RA, Nix JW, Sudarshan S, Rais-Bahrami S, Peyton CC. Are markers of survival associated with perioperative outcomes for tumor thrombectomy patients? Urol Oncol 2023; 41:358.e17-358.e24. [PMID: 37301680 DOI: 10.1016/j.urolonc.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/29/2023] [Accepted: 05/18/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Despite modern advances in surgical and perioperative technologies, management of renal cell carcinoma (RCC) with tumor thrombus (TT) is a morbid procedure that necessitates careful patient selection. It is not known whether established prognostic models for metastatic RCC are suitable prognostic tools for more immediate perioperative outcomes in patients with RCC with TT. We evaluated if established risk models for cytoreductive nephrectomy, as a potential extension of their purpose-built use, are associated with immediate perioperative outcomes in patients undergoing nephrectomy and tumor thrombectomy. METHODS Perioperative outcomes of patients who underwent radical nephrectomy and tumor thrombectomy for RCC were compared to presences of established predictors of long-term outcomes from prior risk models individually and as stratified by risk grouping (International Metastatic Renal-Cell Carcinoma Database Consortium [IMDC], Memorial Sloan Kettering Cancer Center [MSKCC], M.D. Anderson Cancer Center [MDACC], and Moffitt Cancer Center [MCC]). Wilcoxon rank-sum test or the Kruskal-Wallis test compared continuous variables and the chi-square test or Fisher's exact test compared categorical variables. RESULTS Fifty-five patients were analyzed with 17 (30.9%) being cytoreductive. Eighteen (32.7%) patients had a level III or higher TT. Individually, preoperative variables were inconsistently associated with perioperative outcomes. Poorer risk patients per the IMDC model had more major postoperative complications (Clavien-Dindo grade≥3, P = 0.008). For the MSKCC model, poorer risk patients had increased intraoperative estimated blood loss (EBL), longer length of stay (LOS), more major postoperative complications, and more likely to discharge to a rehabilitation facility (P < 0.05). Less favorable risk patients per MDACC model had increased LOS (P = 0.038). Poorer risk patients per the MCC model had increased EBL, LOS, major postoperative complications, and 30-day hospital readmissions (P < 0.05). CONCLUSION Overall, cytoreductive risks models were heterogeneously associated with perioperative outcomes in patients undergoing nephrectomy and tumor thrombectomy. Of available models, the MCC model is associated with more perioperative outcomes including EBL, LOS, major postoperative complications, and readmissions within 30 days when compared to the IMDC, MSKCC, and MDACC models.
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Affiliation(s)
- Andrew M Fang
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen Leahy
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Ava Saidian
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert A Oster
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey W Nix
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sunil Sudarshan
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Soroush Rais-Bahrami
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles C Peyton
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.
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Nakayama T, Saito K, Kumagai J, Nakajima Y, Kijima T, Yoshida S, Kihara K, Fujii Y. Higher Serum C-reactive Protein Level Represents the Immunosuppressive Tumor Microenvironment in Patients With Clear Cell Renal Cell Carcinoma. Clin Genitourin Cancer 2018; 16:e1151-e1158. [PMID: 30213543 DOI: 10.1016/j.clgc.2018.07.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/19/2018] [Accepted: 07/27/2018] [Indexed: 01/25/2023]
Abstract
INTRODUCTION C-reactive protein (CRP), a representative inflammatory marker, could serve as a biomarker in renal cell carcinoma because CRP is an important prognostic factor. However, its detailed mechanism remains unknown. This study showed that higher CRP levels correlated with the tumor immune microenvironment, which leads to a worse prognosis. These findings can help to clarify the underlying mechanisms between the presence of systemic inflammatory reaction and prognosis. The aim of this study is to investigate the association between tumor immune microenvironment and CRP in patients with renal cell carcinoma (RCC) to explore the underlying mechanisms between CRP level and prognosis. PATIENTS AND METHODS Immunohistochemical measurement of CD4, CD8, CD163 (M2 macrophages), and Foxp3 (Regulatory T [Treg] cells) was performed in patients with clear-cell RCC (n = 111) treated with radical or partial nephrectomy at our institution. The association between immunohistochemical status and preoperative serum CRP level and cancer-specific survival (CSS) was analyzed. RESULTS Thirty-three patients (30%) had a high CRP level (≥ 5.0 mg/L), and the CSS rate was significantly worse among these patients than among the remaining patients (P < .001). In patients with strong infiltration of CD8+, Foxp3+, or CD163+ cells, CRP levels were significantly higher (P = .041, P = .001, and P = .035, respectively), and CSS was significantly worse compared with patients with weak infiltration (P = .040, P = .026, and P < .001, respectively). In multivariate analysis, strong CD163+ cells infiltration (P = .001) as well as pathologic T3 (P = .036), lymph-node involvement (P = .007), distant metastasis (P < .001), and Fuhrman nuclear grade 4 (P = .003) were independent prognostic factors for CSS. CONCLUSIONS Infiltration of the immunosuppressive cells known as Tregs and M2 macrophages in the tumor microenvironment is associated with higher CRP and poor prognosis in patients with clear-cell RCC. CRP could reflect an immunosuppressive microenvironment.
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Affiliation(s)
- Takayuki Nakayama
- Department of Urology, Tokyo Medical and Dental Graduate University, Tokyo, Japan
| | - Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental Graduate University, Tokyo, Japan.
| | - Jiro Kumagai
- Department of Pathology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Yutaka Nakajima
- Department of Surgical Pathology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshiki Kijima
- Department of Urology, Tokyo Medical and Dental Graduate University, Tokyo, Japan
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental Graduate University, Tokyo, Japan
| | - Kazunori Kihara
- Department of Urology, Tokyo Medical and Dental Graduate University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental Graduate University, Tokyo, Japan
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Gu L, Li H, Wang Z, Wang B, Huang Q, Lyu X, Shen D, Gao Y, Fan Y, Li X, Xie Y, Du S, Liu K, Tang L, Peng C, Ma X, Zhang X. A systematic review and meta-analysis of clinicopathologic factors linked to oncologic outcomes for renal cell carcinoma with tumor thrombus treated by radical nephrectomy with thrombectomy. Cancer Treat Rev 2018; 69:112-120. [PMID: 29960124 DOI: 10.1016/j.ctrv.2018.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND There remain discrepancies over the factors that influence oncologic outcomes after radical nephrectomy with thrombectomy (RNTE). To assess significant predictors of oncologic outcomes after RNTE from a systematic review and meta-analysis. METHODS A comprehensive search of PubMed, Embase, Cochrane Library and Web of Science was performed to identify eligible studies. The endpoints included cancer-specific survival (CSS), overall survival (OS), and recurrence-free survival (RFS). A formal meta-analysis was performed for studies containing non-metastatic and metastatic tumors. Additionally, a sensitivity analysis including the subgroup of studies containing non-metastatic tumors only was conducted. Cumulative analyses of hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) were conducted. RESULTS Overall, 35 retrospective studies of low to moderate risk of bias including 11,929 patients were included. The results indicated that large tumor size, high Fuhrman grade, tumor necrosis, positive lymph node, and metastasis at surgery were adverse significant predictors for both CSS and OS. Also, IVC tumor thrombus, sarcomatoid differentiation, perinephretic fat invasion, and adrenal gland invasion were associated with poor CSS. In the subset of non-metastatic patients, the significant predictors were clinical symptom, thrombus level, Fuhrman grade and adrenal gland invasion for CSS; thrombus consistency, Fuhrman grade and tumor necrosis for OS; tumor size, Fuhrman grade and perinephretic fat invasion for RFS. CONCLUSIONS A meta-analysis of available data identified significant prognostic factors of CSS, OS and RFS that should be systematically evaluated to propose a risk-adapted approach to postoperative patient counseling, risk stratification, and therapy selection.
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Affiliation(s)
- Liangyou Gu
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Hongzhao Li
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Zihuan Wang
- Institute of Occupational Health, Beijing Center for Disease Control and Prevention, Beijing, China
| | - Baojun Wang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Qingbo Huang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Xiangjun Lyu
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Dan Shen
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Yu Gao
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Yang Fan
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Xintao Li
- Department of Urology, Chinese Air Force General Hospital, Beijing, China
| | - Yongpeng Xie
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Songliang Du
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Kan Liu
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Lu Tang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Cheng Peng
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Xin Ma
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China.
| | - Xu Zhang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China.
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Gu L, Wang Z, Chen L, Ma X, Li H, Nie W, Peng C, Li X, Gao Y, Zhang X. A proposal of post-operative nomogram for overall survival in patients with renal cell carcinoma and venous tumor thrombus. J Surg Oncol 2017; 115:905-912. [PMID: 28230236 DOI: 10.1002/jso.24575] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/03/2017] [Accepted: 01/26/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Liangyou Gu
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
| | - Zihuan Wang
- Institute of Occupational Health; Beijing Center for Disease Control and Prevention; Beijing China
| | - Luyao Chen
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
| | - Xin Ma
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
| | - Hongzhao Li
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
| | - Wenyuan Nie
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
| | - Cheng Peng
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
| | - Xintao Li
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
| | - Yu Gao
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
| | - Xu Zhang
- Department of Urology, State Key Laboratory of Kidney Diseases; Chinese PLA General Hospital, PLA Medical School; Beijing China
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Preoperative Gamma-Glutamyltransferase Is Associated with Cancer-Specific Survival and Recurrence-Free Survival of Nonmetastatic Renal Cell Carcinoma with Venous Tumor Thrombus. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3142926. [PMID: 28168196 PMCID: PMC5266806 DOI: 10.1155/2017/3142926] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/23/2016] [Accepted: 12/20/2016] [Indexed: 12/23/2022]
Abstract
Introduction. To evaluate the prognostic significance of preoperative gamma-glutamyltransferase (GGT) on the subgroup of nonmetastatic renal cell carcinoma (RCC) with venous tumor thrombus. Materials and Methods. We retrospectively reviewed the institutional database and collected the medical data of 156 patients with nonmetastatic RCC with venous tumor thrombus between March 2004 and December 2014. Kaplan-Meier and Cox regression analyses were applied to determine the prognostic factors for cancer-specific survival (CSS) and recurrence-free survival (RFS). Results. The median value and optimal cutoff point of preoperative GGT were 23.0 and 37.5 IU/L, respectively. In the entire cohort, 67 (42.9%) patients experienced disease recurrence, and 46 (29.5%) patients died. Kaplan-Meier analysis revealed that the CSS and RFS rates were lower in patients with preoperative GGT ≥ 37.5 IU/L than in those with preoperative GGT < 37.5 IU/L. Multivariate Cox proportional hazard analysis demonstrated that high preoperative GGT was significantly associated with shorter CSS (hazard ratio [HR]: 2.115; 95% CI: 1.164–3.843; p = 0.014) and RFS (HR: 1.955; 95% CI: 1.166–3.276; p = 0.011), after adjusting other covariates. Conclusions. Preoperative GGT can serve as an independent prognostic biomarker of nonmetastatic RCC patients with venous tumor thrombus. Further prospective study is warranted to confirm our results.
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Haddad AQ, Leibovich BC, Abel EJ, Luo JH, Krabbe LM, Thompson RH, Heckman JE, Merrill MM, Gayed BA, Sagalowsky AI, Boorjian SA, Wood CG, Margulis V. Preoperative multivariable prognostic models for prediction of survival and major complications following surgical resection of renal cell carcinoma with suprahepatic caval tumor thrombus. Urol Oncol 2015; 33:388.e1-9. [PMID: 26004163 DOI: 10.1016/j.urolonc.2015.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 03/24/2015] [Accepted: 04/19/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Surgical resection for renal cell carcinoma (RCC) with suprahepatic inferior vena cava tumor thrombus is associated with significant morbidity, yet there are currently no tools for preoperative prognostic evaluation. Our goal was to develop a preoperative multivariable model for prediction of survival and risk of major complications in patients with suprahepatic thrombi. METHODS We identified patients who underwent surgery for RCC with suprahepatic tumor thrombus extension from 2000 to 2013 at 4 tertiary centers. A Cox proportional hazard model was used for analysis of overall survival (OS) and logistic regression was used for major complications within 90 days of surgery (Clavien ≥ 3A). Nomograms were internally calibrated by bootstrap resampling method. RESULTS A total of 49 patients with level III thrombus and 83 patients with level IV thrombus were identified. During median follow-up of 24.5 months, 80 patients (60.6%) died and 46 patients (34.8%) experienced major complication. Independent prognostic factors for OS included distant metastases at presentation (hazard ratio = 2.52, P = 0.002) and Eastern Cooperative Oncology Group (ECOG) performance status (hazard ratio = 1.84, P<0.0001). Variables associated with increased risk of major complications on univariate analysis included preoperative systemic symptoms, level IV thrombus, and elevated preoperative alkaline phosphatase and aspartate transaminase levels; however, only systemic symptoms (odds ratio = 8.45, P<0.0001) was an independent prognostic factor. Preoperative nomograms achieved a concordance index of 0.72 for OS and 0.83 for major complications. CONCLUSIONS We have developed and internally validated multivariable preoperative models for the prediction of survival and major complications in patients with RCC who have a suprahepatic inferior vena cava thrombus. If externally validated, these tools may aid in patient selection for surgical intervention.
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Affiliation(s)
- Ahmed Q Haddad
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Bradley C Leibovich
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX; Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN
| | - Edwin Jason Abel
- Department of Urology, University of Wisconsin School of Medicine, Madison WI
| | - Jun-Hang Luo
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Laura-Maria Krabbe
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX; University of Muenster Medical Center, Muenster, Germany
| | | | - Jennifer E Heckman
- Department of Urology, University of Wisconsin School of Medicine, Madison WI
| | - Megan M Merrill
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Bishoy A Gayed
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Arthur I Sagalowsky
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Stephen A Boorjian
- Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN
| | - Christopher G Wood
- Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Vitaly Margulis
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX.
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