Sunitinib therapy in renal cell carcinoma

TGMIL: A hybrid multi-instance learning model based on the Transformer and the Graph Attention Network for whole-slide images classification of renal cell carcinoma

BACKGROUND AND OBJECTIVES

The pathological diagnosis of renal cell carcinoma is crucial for treatment. Currently, the multi-instance learning method is commonly used for whole-slide image classification of renal cell carcinoma, which is mainly based on the assumption of independent identical distribution. But this is inconsistent with the need to consider the correlation between different instances in the diagnosis process. Furthermore, the problem of high resource consumption of pathology images is still urgent to be solved. Therefore, we propose a new multi-instance learning method to solve this problem.

METHODS

In this study, we proposed a hybrid multi-instance learning model based on the Transformer and the Graph Attention Network, called TGMIL, to achieve whole-slide image of renal cell carcinoma classification without pixel-level annotation or region of interest extraction. Our approach is divided into three steps. First, we designed a feature pyramid with the multiple low magnifications of whole-slide image named MMFP. It makes the model incorporates richer information, and reduces memory consumption as well as training time compared to the highest magnification. Second, TGMIL amalgamates the Transformer and the Graph Attention's capabilities, adeptly addressing the loss of instance contextual and spatial. Within the Graph Attention network stream, an easy and efficient approach employing max pooling and mean pooling yields the graph adjacency matrix, devoid of extra memory consumption. Finally, the outputs of two streams of TGMIL are aggregated to achieve the classification of renal cell carcinoma.

RESULTS

On the TCGA-RCC validation set, a public dataset for renal cell carcinoma, the area under a receiver operating characteristic (ROC) curve (AUC) and accuracy of TGMIL were 0.98±0.0015,0.9191±0.0062, respectively. It showcased remarkable proficiency on the private validation set of renal cell carcinoma pathology images, attaining AUC of 0.9386±0.0162 and ACC of 0.9197±0.0124. Furthermore, on the public breast cancer whole-slide image test dataset, CAMELYON 16, our model showed good classification performance with an accuracy of 0.8792.

CONCLUSIONS

TGMIL models the diagnostic process of pathologists and shows good classification performance on multiple datasets. Concurrently, the MMFP module efficiently diminishes resource requirements, offering a novel angle for exploring computational pathology images.

Dataset for the reporting of renal biopsy for tumour: recommendations from the International Collaboration on Cancer Reporting (ICCR)

The International Collaboration on Cancer Reporting (ICCR) has developed a suite of detailed datasets for international implementation. These datasets are based on the reporting protocols developed by the Royal College of Pathologists (UK), The Royal College of Pathologists of Australasia and the College of American Pathologists, with modifications undertaken by international expert groups appointed according to ICCR protocols. The dataset for the reporting of renal biopsy for tumour is designed to provide a structured reporting template containing minimum data recording key elements suitable for international use. In formulating the dataset, the ICCR panel incorporated recommendations from the 2012 Vancouver Consensus Conference of the International Society of Urological Pathology (ISUP) and the 2016 edition of the WHO Bluebook on tumours of the urinary and male genital systems. Reporting elements were divided into Required (Core) and Recommended (Non-core) components of the report. Required elements are as follows: specimen laterality, histological tumour type, WHO/ISUP histological tumour grade, sarcomatoid morphology, rhabdoid morphology, necrosis, lymphovascular invasion and coexisting pathology in non-neoplastic kidney. Recommended reporting elements are as follows: operative procedure, tumour site(s), histological tumour subtype and details of ancillary studies. In particular, it is noted that fluorescence in situ hybridisation studies may assist in diagnosing translocation renal cell carcinoma (RCC) and in distinguishing oncocytoma and eosinophilic chromophobe RCC. It is anticipated that the implementation of this dataset into routine clinical practice will facilitate uniformity of pathology reporting worldwide. This, in turn, should have a positive impact on patient treatment and the quality of demographic information held by cancer registries.

Data set for the reporting of carcinoma of renal tubular origin: recommendations from the International Collaboration on Cancer Reporting (ICCR)

AIMS

The International Collaboration on Cancer Reporting (ICCR) has provided detailed data sets based upon the published reporting protocols of the Royal College of Pathologists, the Royal College of Pathologists of Australasia and the College of American Pathologists.

METHODS AND RESULTS

The data set for carcinomas of renal tubular origin treated by nephrectomy was developed to provide a minimum structured reporting template suitable for international use, and incorporated recommendations from the 2012 Vancouver Consensus Conference of the International Society of Urological Pathology (ISUP) and the fourth edition of the World Health Organisation Bluebook on tumours of the urinary and male genital systems published in 2016. Reporting elements were divided into those, which are required and recommended components of the report. Required elements are: specimen laterality, operative procedure, attached structures, tumour focality, tumour dimension, tumour type, WHO/ISUP grade, sarcomatoid/rhabdoid morphology, tumour necrosis, extent of invasion, lymph node status, surgical margin status, AJCC TNM staging and co-existing pathology. Recommended reporting elements are: pre-operative treatment, details of tissue removed for experimental purposes prior to submission, site of tumour(s) block identification key, extent of sarcomatoid and/or rhabdoid component, extent of necrosis, presence of tumour in renal vein wall, lymphovascular invasion and lymph node status (size of largest focus and extranodal extension).

CONCLUSIONS

It is anticipated that the implementation of this data set in routine clinical practice will inform patient treatment as well as provide standardised information relating to outcome prediction. The harmonisation of data reporting should also facilitate international research collaborations.

WHO/ISUP classification, grading and pathological staging of renal cell carcinoma: standards and controversies

PURPOSE

Pathological parameters assessed on biopsies and resection specimens have a pivotal role in the diagnosis, prognosis and management of patients with renal cell carcinoma (RCC).

METHODS

A non-systematic literature search was performed, updated to January 2018, to identify key standards and controversies in the pathological classification, grading and staging of RCC.

RESULTS

Although most RCCs exhibit characteristic morphology that enables easy categorisation, RCCs show considerable morphological heterogeneity and it is not uncommon for there to be difficulty in assigning a tumour type, especially with rarer tumour subtypes. The differentiation between benign and malignant oncocytic tumours remains a particular challenge. The development of additional immunohistochemical and molecular tests is needed to facilitate tumour typing, because of the prognostic and therapeutic implications, and to enable more reliable identification of poorly differentiated metastatic tumours as being of renal origin. Any new tests need to be applicable to small biopsy samples, to overcome the heterogeneity of renal tumours. There is also a need to facilitate identification of tumour types that have genetic implications, to allow referral and management at specialist centres. Digital pathology has a potential role in such referral practice.

CONCLUSION

Much has been done to standardise pathological assessment of renal cell carcinomas in recent years, but there still remain areas of difficulty in classification and grading of these heterogeneous tumours.

Predictive value of baseline serum vascular endothelial growth factor and neutrophil gelatinase-associated lipocalin in advanced kidney cancer patients receiving sunitinib

To identify factors that might predict response to sunitinib in patients with renal cell carcinoma, we measured serum vascular endothelial growth factor (VEGF) and neutrophil gelatinase-associated lipocalin (NGAL) levels. A total of 85 patients were selected and, using the Motzer classification, 46 were assigned to the good- and 38 to the intermediate-risk groups. With univariate Cox analysis, both baseline serum VEGF and NGAL titers, determined by enzyme-linked immunosorbent assay, significantly predicted progression-free survival. For each biomarker, a threshold value was identified, which proved useful to classify patients into groups having titers above or below the thresholds. We then stratified patients according to the two dichotomous variables into good-, intermediate-, and poor-risk groups, and found significantly different progression-free survival rates ranging from 3.5 to 11.6 months. Both VEGF and NGAL maintained their predictive significance at bivariate analysis. Our study shows that serum levels of VEGF and NGAL are significant predictors of progression-free survival in patients with renal cell carcinoma treated with sunitinib.

Sunitinib and sorafenib in metastatic renal cell carcinoma patients with renal insufficiency

BACKGROUND

Although clinical trials with sunitinib and sorafenib in metastatic renal cell carcinoma (mRCC) have included patients with moderate renal insufficiency (RI), the incidence of renal toxicity induced by their administration as well as the safety of these agents in patients with more severe renal insufficiency has not been extensively reported.

PATIENTS AND METHODS

Patients with mRCC treated with vascular endothelial growth factor-targeted therapy with either RI at time of treatment initiation or who developed RI during therapy were identified. RI was defined as serum creatinine (Cr) > or = 1.9 mg/dl or a creatinine clearance (CrCl) < 60 ml/min/1.73 m(2) for >3 months before treatment. Objective outcomes and toxic effects of treatment were also measured.

RESULTS

A total of 39 patients were identified: 21 patients who initiated therapy with preexisting RI and 18 patients who developed RI during treatment. In patients with RI at the start of therapy, Cr increased in 57%, and 48% of patients required dose reduction. The median time to maximum RI was 6.6 months (range 0.4-19.6 months). In patients who developed RI while receiving therapy, median serum Cr and CrCl at the start of therapy were 1.5 mg/dl (range 1.1-1.8) and 61 ml/min (range 43-105), respectively. Patients experienced a median increase in serum Cr of 0.8 mg/dl (range 0.3-2.8) and a median decrease in CrCl of 25 ml/min (range 8.54-64.76). Overall, 5 patients (24%) achieved a partial response (PR), 13 (62%) had stable disease (SD) and 3 (14%) had progressive disease (PD). Estimated progression-free survival (PFS) was 8.4 months. The most common toxic effects (all grades) were fatigue (81%), hand-foot syndrome (HFS) (52%) and diarrhea (48%). Six patients experienced grade III toxicity (29%), primarily HFS.

CONCLUSIONS

Sunitinib and sorafenib can be safely given to patients with renal insufficiency, provided adequate monitoring of renal function. For those patients developing an increase in Cr, dose modifications may be required to allow continuation of therapy. The clinical outcome of patients with baseline renal dysfunction and patients who develop renal dysfunction does not appear to be compromised.

Sunitinib (SUTENT) for the treatment of metastatic renal cell carcinoma

Kidney cancer accounts for approximately 2% of new cancers and conventional treatment with nephrectomy followed by IL-2 or IFN-alpha treatment does not provide long-term survival benefit in many patients. Increased understanding of the pathophysiology of renal cell carcinoma has prompted the development of targeted therapies for patients with this disease, including sunitinib. This paper reviews the most recent efficacy and safety data for sunitinib, as well as currently ongoing and planned studies for this receptor tyrosine kinase inhibitor. Results from a large-scale, long-term, Phase III trial have established sunitinib as the standard of care for first-line treatment of patients with advanced renal cell carcinoma, and it is now the reference standard against which other therapies for this cancer should be evaluated.

Targeting the hypoxia-inducible factor (HIF) pathway in cancer

The central component of hypoxia sensing in the cell is the hypoxia-inducible factor (HIF) transcriptional complex. HIF activity is deregulated in many human cancers, especially those that are highly hypoxic. Hypoxic tumour cells are usually resistant to radiotherapy and most conventional chemotherapeutic agents, rendering them highly aggressive and metastatic. Overexpression of HIF-alpha, the regulatory subunit of HIF, is associated with increased vascular density, severity of tumour grade, treatment failure and a poor prognostic outcome with conventional therapies. Therefore HIF is an attractive, although challenging, therapeutic target, and several different strategies have been developed to target HIF directly or indirectly in recent years. This review outlines the preclinical and clinical advances in this arena and discusses which cancers may benefit from HIF-targeted therapy.

Advanced-stage renal cell carcinoma treated by radical nephrectomy and adjacent organ or structure resection

OBJECTIVE

To examine the effect of radical nephrectomy (RN) with adjacent organ and structure resection on survival, as invasion of adjacent organs in patients with renal cell carcinoma (RCC) is rare.

PATIENTS AND METHODS

After institutional review board approval, we reviewed our database and statistically analysed of patients with pathological stage T3 or T4 RCC who had RN and resection of a contiguous organ or structure.

RESULTS

We identified 38 patients of 2464 (1.5%) who had RN with adjacent organ or structure resection. The median (interquartile range) size of the mass was 11 (8-14) cm, and the follow-up 13 (5-33) months. Most patients (68%) were pT4 stage and had conventional clear cell carcinoma (95%). Fourteen patients (37%) had positive surgical margins. The liver (10) was the most commonly resected adjacent organ or structure. Only one patient remains alive with no evidence of disease at 5 years, while three are currently alive with disease. Overall, 34 of 38 patients (90%) ultimately died from disease at a median (range) of 11.7 (5.4-29.2) months after surgical resection. The surgical margin status was the only statistically significant factor for recurrence and death (P = 0.006).

CONCLUSIONS

The prognosis for patients with advanced RCC and adjacent organ or structure involvement is extremely poor and similar to that of patients with metastatic disease. These patients should be thoroughly counselled about the impact of surgical management and considered for entry into neoadjuvant or adjuvant clinical trials with new targeted systemic agents.

Novel therapies in genitourinary cancer: an update

In recent years, new treatment for renal cell carcinoma (RCC) has been a spotlight in the field of cancer therapeutics. With several emerging agents branded as 'targeted therapy' now available, both medical oncologists and urologists are progressively more hopeful for better outcomes. The new remedies may provide patients with improved survival and at the same time less toxicity when compared to traditional cytotoxic agents. This article will center on current and emerging treatment strategies for advanced RCC and other GU malignancies with updates from 2008 annual ASCO meeting.