Renal cell carcinoma

Application of DKI and IVIM imaging in evaluating histologic grades and clinical stages of clear cell renal cell carcinoma

Purpose

To evaluate the value of quantitative parameters derived from diffusion kurtosis imaging (DKI) and intravoxel incoherent motion (IVIM) in differentiating histologic grades and clinical stages of clear cell renal cell carcinoma (ccRCC).

Materials and methods

A total of 65 patients who were surgically and pathologically diagnosed as ccRCC were recruited in this study. In addition to routine renal magnetic resonance imaging examination, all patients underwent preoperative IVIM and DKI. The corresponding diffusion coefficient (D), pseudo-diffusion coefficient (D*), perfusion fraction (f), mean diffusivity (MD), kurtosis anisotropy (KA), and mean kurtosis (MK) values were obtained. Independent-samples t-test or Mann-Whitney U test was used for comparing the differences in IVIM and DKI parameters among different histologic grades and clinical stages. The diagnostic efficacy of IVIM and DKI parameters was evaluated using the receiver operating characteristic (ROC) curve. Spearman's correlation analysis was used to separately analyze the correlation of each parameter with histologic grades and stages of ccRCC.

Results

The D and MD values were significantly higher in low-grade ccRCC than high-grade ccRCC (all p < 0.001) and in low-stage than high-stage ccRCC (all p < 0.05), and the f value of high-stage ccRCC was lower than that of low-stage ccRCC (p = 0.007). The KA and MK values were significantly higher in low-grade than high-grade ccRCC (p = 0.000 and 0.000, respectively) and in low-stage than high-stage ccRCC (p = 0.000 and 0.000, respectively). The area under the curve (AUC) values of D, D*, f, MD, KA, MK, DKI, and IVIM+DKI values were 0.825, 0.598, 0.626, 0.792, 0.750, 0.754, 0.803, and 0.857, respectively, in grading ccRCC and 0.837, 0.719, 0.710, 0.787, 0.796, 0.784, 0.864, 0.823, and 0.916, respectively, in staging ccRCC. The AUC of IVIM was 0.913 in staging ccRCC. The D, D*, and MD values were negatively correlated with the histologic grades and clinical stages (all p < 0.05), and the KA and MK values showed a positive correlation with histologic grades and clinical stages (all p < 0.05). The f value was also negatively correlated with the ccRCC clinical stage (p = 0.008).

Conclusion

Both the IVIM and DKI values can be used preoperatively to predict the degree of histologic grades and stages in ccRCC, and the D and MD values have better diagnostic performance in the grading and staging. Also, further slightly enhanced diagnostic efficacy was observed in the model with combined IVIM and DKI parameters.

Diffusion kurtosis imaging features of renal cell carcinoma: a preliminary study

OBJECTIVE

To explore the feasibility of diffusion kurtosis imaging (DKI) in differentiating different types of renal cell carcinoma (RCC).

METHODS

36 patients with clear cell RCC (CCRCC, low-grade,n = 20 and high-grade, n = 16), 19 with papillary RCC, 11 with chromophobe RCC, and 9 with collecting duct carcinoma (CDC) were examined with DKI technique. b values of 0, 500 and 1000 s/mm² were adopted. The DKI parameters, i.e., mean diffusivity (MD), mean kurtosis (MK), kurtosis anisotropy (KA), radial kurtosis (RK) and signa-to-noise ration (SNR) of DKI images at different b values were used.

RESULTS

The mean SNRs of DKI images at b = 0, 500 and 1000 s/mm² were 32.8, 14.2 and 9.18, respectively. For MD parameter, a significant higher value was shown in CCRCC than those of papillary RCC, chromophobe RCC and CDC (p < 0.05). In addition, both chromophobe RCC and CDC have larger MD values than papillary RCC (p < 0.05), however, there was no significant differences between chromophobe RCC and CDC (p > 0.05). For MK, KA and RK parameters, a significant higher value was shown in papillary RCC than those of CCRCC, chromophobe RCC and CDC (p < 0.05). Moreover, both chromophobe RCC and CDC have significantly larger values of MK, KA and RK than CCRCC (p < 0.05).

CONCLUSION

Our preliminary study demonstrated significant differences in the DKI parameters between the subtypes of RCCs, given an adequate SNR of DKI images.

ADVANCES IN KNOWLEDGE

1.The MD value is the best parameter to distinguish CCRCC from other RCCs.2.The MK, KA and RK values are the best parameters to distinguish papillary RCC from other RCCs.3.DKI is able to provide images with sufficient SNRs in kidney disease.

Scale-Up Evaluation of a Composite Tumor Marker Assay for the Early Detection of Renal Cell Carcinoma

The early detection of renal cell carcinoma (RCC) using tumor markers remains an attractive prospect for the potential to downstage the disease. To validate the scale-up clinical performance of potential tumor markers for RCC (as a single marker and as a composite tumor marker composed of nicotinamide N-methyltransferase (NNMT), L-Plastin (LCP1), and non-metastatic cells 1 protein (NM23A)), the scale-up assay was performed. Patients with RCC from multiple domestic institutes were included in the clinical evaluation for reassessment and improvement of the established triple markers of our product. For the diagnostic performance of the composite markers, the best-split cutoff points of each marker (147 pg/mL for NNMT, 1780 pg/mL for LCP1, and 520 pg/mL for NM23A) were installed. Serum levels of NNMT, LCP1, and NM23A were greatly increased in subjects with RCC (p < 0.0001). In 1042 blind sample tests with control individuals (n = 500) and patients with RCC (n = 542), the diagnostic sensitivity and specificity of the composite three-marker assay were 0.871 and 0.894, respectively, and the resulting AUC (Area under Curve) of ROC (Receiver Operating Characteristic) was 0.917. As a single marker, the diagnostic accuracies of NNMT, LCP1, and NM23A, as estimated by ROC, were 0.833, 0.844, and 0.601, respectively. The composite three-marker assay with NNMT, LCP1, and NM23A is a more improved novel serum marker assay for the early detection of RCC in cases of renal mass or unknown condition. The NNMT, LCP1, and NM23A triple marker assay could be a powerful diagnostic tumor marker assay to screen the early stage of RCC.

Sinonasal Metastatic Renal Cell Carcinoma: A Report of Two Cases with Varied Presentation and a Review of Literature

Renal cell carcinoma is usually slow growing with delayed vague symptoms and may not be detected until an advanced stage. In only 9% of the cases the classical triad of "haematuria, costovertebral pain and abdominal mass" is seen. Less commonly, sinonasal metastasis may also be the presenting feature of RCC. So, in any case of sinonasal mass, possibility of metastasis from renal malignancy should be considered. Sinonasal metastasis from renal malignancy can occur even several years after the primary is treated with nephrectomy. In sinonasal region maxillary sinus is the most commonly affected. Isolated metastasis to the nose is extremely rare. Malignancies from various other sites of the body can also metastasize to sinonasal region. Epistaxis is the most common symptom. This is because of vascular stroma of the metastatic deposit. A 45 year old male with history of right nephrectomy 1 year back presented with intractable epistaxis. A 66 year old male presented with profuse epistaxis without any history of previous malignancies. Both the cases were evaluated resulting to the diagnosis of sinonasal metastasis from Renal Cell carcinoma. In the first case, metastasis occurred 1 year post surgery whereas in second case sinonasal metastasis was the presenting feature of Renal Cell carcinoma. Epistaxis is the most common symptom. This is because of vascular stroma of this metastatic deposit. In renal cancer, symptoms of metastasis often precede the symptoms of primary tumor.

Analysis of dual energy spectral CT and pathological grading of clear cell renal cell carcinoma (ccRCC)

OBJECTIVE

To discuss the dual energy spectral computer tomography (CT) imaging features of the pathological grading of clear cell renal cell carcinoma (ccRCC) and the correlation between spectral CT imaging features and pathology.

MATERIALS AND METHODS

We performed analyses of 62 patients with confirmed diagnosis of ccRCC. All patients underwent non-enhanced CT and dual-phase (cortex phase, CP and parenchyma phase, PP) contrast-enhanced CT with dual energy spectral mode. The subjects were pathologically divided into two groups: low-grade group (Fuhrman 1/2) and high-grade group (Fuhrman 3/4). The CT value of each lesion was measured on the monochromatic image at 70 keV. The normalized iodine concentrations (NIC) and the slope of the spectrum curve were calculated. The qualitative morphological parameters, including tumor shape, calcification, pseudocapsule, necrosis, and enhancement mode, were compared between the two groups. The quantitative data were compared using Student's t-test, and the enumeration data were analyzed using the chi-square test between low-grade and high-grade ccRCC.Receiver operating characteristic curve was used to determine the sensitivity and specificity of the quantitative parameters in two groups.

RESULTS

The CT value, NIC, and mean slope of the low-grade group were increased compared with the high-grade group during CP (P = 0.001, P = 0.043, and P<0.001, respectively). The CT did not differ significantly during PP (P = 0.134); however, the NIC and mean slope varied considerably in the low grade compared with the high-grade group (P = 0.048, P = 0.017, respectively). The CT threshold value, NIC, and slope had high sensitivity and specificity in differentiating low-grade ccRCC from high-grade ccRCC. The tumor shape, pseudocapsule, and necrosis differed significantly between the two groups (P<0.05).

CONCLUSIONS

Dual energy spectral CT with the quantitative analysis of iodine concentration and qualitative analysis of morphological characteristics increases the accuracy of diagnosing the pathological grade of ccRCC.

Renal cell carcinoma metastases to the maxillary sinus

Metastasis of renal cell carcinoma (RCC) to the head and neck region is rare. We report the case of a 65-year-old man with history of RCC, presented 7 years after nephrectomy, adrenalectomy and lung metastasectomy for his primary tumour, with symptoms of nasal obstruction, postnasal drip, productive cough and pressure sensation in the left maxillary sinus. CT revealed a unilateral, irregular opacification in the left maxillary sinus with bony erosion of the infraorbital canal wall. A yellow cystic lesion was completely removed from the maxillary sinus during functional endoscopic sinus surgery and histopathological analysis confirmed the diagnosis of a metastatic RCC. Patient continued to be managed with his pre-existing treatment for advanced RCC.

The vitamin D receptor gene ApaI polymorphism is associated with increased risk of renal cell carcinoma in Chinese population

Molecular epidemiologic studies previously reported that 1,25-dihydroxy vitamin D₃ (1,25(OH)₂ D₃) appears to influence cancer risk. It exerts its activity through the intracellular vitamin D receptor (VDR), which regulates the transcription of genes. This study aimed to investigate the genetic association of VDR polymorphisms with renal cell carcinoma (RCC) risk in the Chinese population. The genotypes of five VDR polymorphisms (TaqI, BsmI, Cdx-2, ApaI, and FokI) were studied using polymerase chain reaction in 302 RCC patients and 302 healthy controls. ApaI variant AA and AC genotypes were found to be associated with a significantly increased risk of RCC compared with the CC genotype (OR = 2.60, 95% CI = 1.39–4.85 for AA vs. CC, and OR = 1.52, 95% CI = 1.08–2.13 for AC vs. CC). The AA genotype was also associated with a higher Fuhrman grade (OR = 2.87, 95% CI = 1.15–7.16 for AA vs. CC). No significant difference was found between the other four VDR polymorphisms and RCC risk. Our study suggests that VDR ApaI genotypes may be involved in the increased risk and progression of RCC in the Chinese Han population.

A retained plastic protective cover mimicking malignancy: Case report

INTRODUCTION

Cases of retained foreign bodies during surgery are more frequently seen in developing countries. Following surgical procedures, unintentionally retained foreign bodies can cause serious complications, in addition to medico-legal issues.

PRESENTATION OF CASE

A 60-year-old man presented with abdominal cramps. He had previously undergone a laparoscopic radical right nephrectomy due to renal cell carcinoma. Abdominal tomography revealed a mass surrounding the main vascular structures with malignant features in the location of previously performed nephrectomy. Further evaluation of the mass was undertaken by PET/CT. Increased FDG uptake on the PET/CT scan suggested disease recurrence. Retroperitoneal lymph node dissection was performed. The dissection specimen was opened to determine the nature of the mass. Retained plastic foreign bodies were found. There were no malignant cells in the histopathological examination of the surgical specimen.

DISCUSSION

A granulomatous reaction which is mainly responsible for morbidity occurs around the foreign bodies due to the inflammatory response. These granulomas may cause confusion during patient follow-up, especially in those who have undergone major abdominal surgery due to cancer.

CONCLUSION

Following surgical resection for malignancy, unintentionally retained foreign bodies can produce a moderate increase in FDG uptake mimicking disease recurrence.

The G-protein-coupled receptor CLR is upregulated in an autocrine loop with adrenomedullin in clear cell renal cell carcinoma and associated with poor prognosis

PURPOSE

The G-protein-coupled receptor (GPCR) calcitonin receptor-like receptor (CLR) and its ligand peptide adrenomedullin (encoded by ADM gene) are implicated in tumor angiogenesis in mouse models but poorly defined in human cancers. We therefore investigated the diagnostic/prognostic use for CLR in human tumor types that may rely on adrenomedullin signaling and in clear cell renal cell carcinoma (RCC), a highly vascular tumor, in particular.

EXPERIMENTAL DESIGN

In silico gene expression mRNA profiling microarray study (n = 168 tumors) and cancer profiling cDNA array hybridization (n = 241 pairs of patient-matched tumor/normal tissue samples) were carried out to analyze ADM mRNA expression in 13 tumor types. Immunohistochemistry on tissue microarrays containing patient-matched renal tumor/normal tissues (n = 87 pairs) was conducted to study CLR expression and its association with clinicopathologic parameters and disease outcome.

RESULTS

ADM expression was significantly upregulated only in RCC and endometrial adenocarcinoma compared with normal tissue counterparts (P < 0.01). CLR was localized in tumor cells and vessels in RCC and upregulated as compared with patient-matched normal control kidney (P < 0.001). Higher CLR expression was found in advanced stages (P < 0.05), correlated with high tumor grade (P < 0.01) and conferred shorter overall survival (P < 0.01).

CONCLUSIONS

In human tissues ADM expression is upregulated in cancer type-specific manner, implicating potential role for adrenomedullin signaling in particular in RCC, where CLR localization suggests autocrine/paracrine mode for adrenomedullin action within the tumor microenvironment. Our findings reveal previously unrecognized CLR upregulation in an autocrine loop with adrenomedullin in RCC with potential application for this GPCR as a target for future functional studies and drug development.

Prolonged survival after sequential multimodal treatment in metastatic renal cell carcinoma: two case reports and a review of the literature

INTRODUCTION

In this case series and short review of the literature, we underline the impact of nephrectomy combined with sequential therapy based on cytokines, antiangiogenic factors, and mammalian target of rapamycin inhibitors along with metastasectomy on overall survival and quality of life in patients with metastatic clear cell renal carcinoma.

CASE PRESENTATION

In the first of two cases reported here, a 53-year-old Caucasian man underwent a radical left nephrectomy for renal cell cancer and relapsed with a bone metastasis in his right humerus. He was treated with closed nailing and cytokine-based chemotherapy. For 5 years, the disease was stable and he had great improvement in quality of life. Subsequently, the disease relapsed in his lymph nodes, lung, and thorax soft tissue. He was then treated with antiangiogenic factors and mammalian target of rapamycin inhibitors. The disease progressed until September 2009, when he died of allergic shock during a blood transfusion, 9 years after the initial diagnosis of renal cell cancer.In the second case, a 54-year-old Caucasian man underwent a radical left nephrectomy for renal cell cancer. A year later, the disease progressed to his neck lymph nodes, and cytokine-based chemotherapy was initiated. While he was on cytokines, a solitary pulmonary nodule appeared and he underwent a metastasectomy. Nine months later, magnetic resonance imaging of his brain revealed a focal right occipitoparietal lesion, which was resected. After two years of active surveillance, the disease relapsed as a pulmonary metastasis and he was treated with an antiangiogenic factor. Further progressions presenting as enlarged axillary lymph nodes, chest soft tissue lesions, and thoracic spine bone metastases were sequentially observed. He then received a first-generation mammalian target of rapamycin inhibitor, an antiangiogenic factor, and later a second-generation mammalian target of rapamycin inhibitor and palliative radiotherapy. Ten years after the initial diagnosis of renal cell cancer, his disease is stable and he is on a third antiangiogenic factor and leads an active life.

CONCLUSIONS

One multidisciplinary approach to patients with metastatic renal cell cancer combines nephrectomy, metastasectomy, and radiotherapy (when feasible) with medical therapy based on cytokines and targeted treatment employing agents inhibiting angiogenesis, other receptor tyrosine kinases, and mammalian target of rapamycin. This approach could prolong survival and improve quality of life.

Metastatic renal cell carcinoma to the orbit and the ethmoid sinus

The orbit is an unusual site for metastatic renal cell carcinoma (RCC), and concurrent metastases of RCC to the ethmoid sinus and the orbit occur very rarely. The treatment goal of orbital and paranasal metastatic RCC is total exenteration. We report a rare case of metastatic RCC to the orbit and the ethmoid sinus. The patient underwent total exenteration, craniotomy, and total maxillectomy. Six years after surgery, the patient showed no sign of metastasis and had successful cosmetic result by using orbital prosthesis.

Polymorphisms in the IL-13 and IL-4R genes are associated with the development of renal cell carcinoma

BACKGROUND

Cytokines are the important modulators that bind to their relevant receptors in response to some stimuli to mediate the homeostasis. It has been suggested that the imbalance of immune system of the host might affect the generation of diseases, including cancers.

PATIENTS AND METHODS

We investigated the association between six functional polymorphisms of IL-4, IL-13, and IL-4R genes and susceptibility to renal cell cancer in a hospital-based study, including 620 renal cell carcinoma (RCC) patients and 623 controls. Logistic regression model was used to assess the genetic effects on the development of RCC.

RESULTS

Overall, individuals with IL-4R Ile50Val CT/TT genotypes had a 0.34-fold significantly decreased RCC risk (CT/TT versus CC), and the T variant allele was associated with a decreased risk of RCC in a dose-response manner (Ptrend=0.009). In addition, we also observed that IL-13 C-1055T and Arg130Gln polymorphisms could decrease the risk of RCC [TT versus

CC/CT

odds ratio=0.36, 95% confidence interval (CI)=0.16-0.78; AA versus GG/GA: 0.66, 0.44-0.97, respectively]. Furthermore, a multiplicative interaction association between the combined IL-4R Ile50Val and IL-13 C-1055T genotypes was observed to decrease the risk of RCC (P=0.036).

CONCLUSION

IL-13 and IL-4R may play an important role in the etiology of RCC.

Vitamin D receptor gene polymorphisms are associated with increased risk and progression of renal cell carcinoma in a Japanese population

AIM

Biological and epidemiologic data suggest that 1 alpha, 25 dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) levels may influence development of renal cell carcinoma. The vitamin D receptor (VDR) is a crucial mediator for the cellular effects of 1,25(OH)(2)D(3) and additionally interacts with other cell signaling pathways that influence cancer progression. VDR gene polymorphisms may play an important role in risk of incidence for various malignant tumors. This study investigated whether VDR gene polymorphisms were associated with increased risk and prognosis of renal cell carcinoma (RCC) in a Japanese population.

METHODS

To analyze risk of RCC depending on VDR polymorphism, a case-control association study was performed. The VDR gene polymorphisms at three locations, BsmI, ApaI and TaqI, were genotyped in 135 RCC patients and 150 controls in a Japanese population. Logistic regression models were used to assess the genetic effects on prognosis.

RESULTS

Significant differences in the ApaI genotype were observed between RCC patients and controls (chi(2) = 6.90, P = 0.032). No statistical significant difference was found in the BsmI and TaqI polymorphisms. The frequency of the AA genotype in the ApaI polymorphism was significantly higher in the RCC patients than in the controls (odds ratio, 2.59; 95% confidence intervals, 1.21-5.55; P = 0.012). Multivariate regression analysis showed that the AA genotype was an independent prognostic factor for cause-specific survival (relative risk 3.3; P = 0.038).

CONCLUSION

The AA genotype at the ApaI site of the VDR gene may be a risk of incidence and poor prognosis factor for RCC in the Japanese population. Additional studies with a large sample size and investigation of the functional significance of the ApaI polymorphism in RCC cells are warranted.

Metastatic renal cell carcinoma to the nose and ethmoid sinus

We report a rare case of metastatic renal cell carcinoma involving the nose and ethmoid sinus, 17 years after initial nephrectomy and diagnosis of Stage T1N0 clear cell renal cell carcinoma. The patient complained of nasal obstruction and epistaxis. Intensity-modulated radiotherapy (IMRT) was delivered using a higher-than-conventional daily fraction size concurrently with interferon and thalidomide. The patient achieved a complete response both clinically and by magnetic resonance imaging, without any side effects. Late and rare sites of recurrences and treatment options are discussed.

[Renal pseudotumor secondary to acute pancreatitis. Report of one case]

We present the case of a renal pseudotumor corresponding to a esteatonecrotic granuloma, secondary to an enolic acute pancreatitis a few months ago. The main caractheristics, diagnosis and terapeuthics of the renal pseudotumors are discussed with the case report of a 60 year old man who presents a renal mass founded incidentally at a control computed tomography.

Cytokine gene polymorphisms as potential risk and protective factors in renal cell carcinoma

The major aim of this study was to investigate the association of the cytokine gene polymorphisms with the development of renal cell carcinoma (RCC). The study included 29 patients with RCC and 50 healthy controls. All genotyping (TNF-alpha, TGF-beta, IL-10, IL-6, IFN-gamma) experiments were performed using sequence-specific primers PCR (PCR-SSP). It was found that TNF-alpha -308 G/G and TGF-beta codon 10-25 T/T-G/C genotypes were significantly higher in frequency in the patients with RCC group compared with the healthy control group. Additionally, the frequency of TNF-alpha -308 G allele was significantly higher in the patients when compared to controls. On the other hand, the frequencies of TNF-alpha -308 G/A, IL-6 C/C and TGF-beta1 codon 10-25 C/C-G/G genotypes were significantly lower in the cancer group compared with the healthy control group. However, after correction for multiple comparisons (Bonferroni), these results did not remain significant. Nevertheless, these findings suggest that the TNF-alpha -308 G/G and TGF-beta codon 10-25 T/T-G/C genotypes may be potential risk factors for RCC, whereas TNF-alpha -308 G/A, IL-6 C/C and TGF-beta1 codon 10-25 C/C-G/G genotypes may be possible protective factors. The number of the cases has to be increased to investigate the independency of these polymorphisms involved in the oncogenesis of RCC.

Renal Tumours, Epidemiology and Diagnostic Profile

Our understanding of the natural history of renal cell carcinoma and the possibilities of new technologies are evolving and being integrated with advances in classification and staging. In this article we reviewed the literature in order to provide an analysis of the changing epidemiology of renal cell carcinoma.

Radiological evaluation of renal masses has rapidly progressed from conventional angiography and intravenous urography to ultrasounds, CT and MRI. As more patients are imaged for many opportunities, the incidental detection has increased. This article reviews the imaging and not techniques in order to characterize these lesions accurately.

Reliability of serum iron, ferritin, nitrite, and association with risk of renal cancer in women

Reliability of serum levels of iron, ferritin and nitrite (NO(2)(-)) over a 2-year period were evaluated in 40 healthy women (20 pre-menopausal and 20 post-menopausal), ages 39-65 years, from the New York University Women's Health Study (NYUWHS). Three blood samples per woman collected at yearly intervals were analyzed. Reliability coefficients (RCs) of serum iron, ferritin, and nitrite were 0.03 (95% confidence interval (CI), 0-0.33), 0.90 (95% CI, 0.79-0.95), and 0.72 (95% CI, 0.50-0.86), respectively, for pre-menopausal women, and 0.26 (95% CI, 0-0.56), 0.77 (95% CI, 0.59-0.89), and 0.55 (95% CI, 0.30-0.77), respectively, for post-menopausal women. In a case-control study nested within NYUWHS cohort, serum levels of nitrite, ferritin, and iron were measured in women apparently healthy at the time of blood donation but diagnosed with renal cancer 1.8-12.2 years later (n=24) and in individually matched controls (two per case). The results suggest that high serum levels of ferritin and nitrite may be associated with a decreased risk of renal cancer (odds ratio (OR), 0.55, 95% CI, 0.15-2.01 for ferritin, and OR, 0.52, 95% CI, 0.17-1.60 for nitrite in women with above median level as compared to women with below median level). The possible role of ferritin and nitrite in renal cancer is discussed.

A Rare Case of Renal Cell Carcinoma Metastatic to the Sinonasal Area

We report a rare case of a hypernephroma that had metastasized to the sinonasal area as a solitary mass. Despite much difficulty, a confirmatory biopsy of the nasal mass was obtained. After radiotherapy had failed to arrest the tumor's growth, the mass was removed via a craniofacial resection. This case illustrates the importance of(1)a high index of suspicion in differentiating this rare tumor from other benign or malignant diseases, (2) awareness of the risk of hemorrhage and the role of preoperative embolization, (3) the need for paraffin histology rather than fine-needle aspiration or frozen section diagnosis, (4) individualizing therapy after due consideration of the characteristics of both the patient and the tumor, and (5) keeping abreast of the most current therapeutic modalities so that patient management can be individualized and optimized. Surgical excision offers the best hope for long-term survival, and it reduces the degree of pain, epistaxis, and disfigurement from the expanding tumor. When such tumors are not resectable, management with radiotherapy, hormonal therapy, immunotherapy, or chemotherapy can be considered.

Cytokine secretion associated with the clearance of apoptotic bodies in renal cell carcinoma patients

The factors determining the outcome of immunotherapy in metastatic renal cell carcinoma (RCC) patients remain elusive. Macrophages from normal donors that phagocytose apoptotic cells secrete the immunosuppressive cytokine IL-10 in vitro. Conversely, IL-10 genetic deletion enhances the immunogenicity of apoptotic tumor cells in vivo. Elevated pre-treatment levels of IL-10 are associated with an unfavorable outcome of RCC. We examined whether the ability to release IL-10 by macrophages from RCC patients that phagocytosed apoptotic cells correlated with the outcome of immunotherapy. To this aim, we derived macrophages from 30 patients with metastatic RCC and from 21 healthy subjects (11 sex- and age-matched healthy controls and 10 younger donors). Patients either had a clinical response after immunotherapy, with a median survival after treatment of more than 18 months (n = 16), or were beginning immunotherapy after diagnosis of metastatic disease (n = 14). Macrophages from responding patients challenged with apoptotic cells released significantly less IL-10 than controls (p = 0.0075) and recently diagnosed patients (p = 0.0198), as ascertained by a 2-sided Student's t-test. This was not because macrophages from responding patients lost the ability to secrete IL-10, because antibody opsonization of apoptotic cells rescued IL-10 secretion. In contrast, macrophages from all groups of donors released similar amounts of TNF-alpha. The failure in IL-10 secretion by engulfing macrophages of responding subjects may exalt the immunogenicity of dying tumor cells, contributing to the success of immunotherapy.