DNA content, nuclear grading and early tumor progression in renal cell cancer: a prospective study on frozen specimens

INTRACAPSULAR CLEAR CELL RENAL CARCINOMA: PLOIDY STATUS IMPROVES THE PROGNOSTIC VALUE OF THE 2002 TNM CLASSIFICATION

PURPOSES

The TNM classification has been revised for the 2002 edition of the UICC publication to better stratify patients with intracapsular renal cell carcinoma (RCC) but few studies have been published to date to validate this new classification. Moreover, additional prognostic factors seem to be necessary to improve the prediction of intracapsular tumor aggressiveness and the definition of patient subgroups at high risk for metastases. We report the long-term results of the new TNM scheme. We evaluated the impact of DNA content, S-phase and MIB-1 (Dako, Glostrup, Denmark) score.

MATERIALS AND METHODS

A total of 136 patients with intracapsular clear cell RCC and a mean followup of 74 months were reclassified. Tumor specific survival (TSS) was compared with nuclear grade (NG), DNA content and proliferative status (S-phase fraction and MIB-1 score).

RESULTS

TSS was 92%, 81.1% and 40.1% for pT1a, pT1b and pT2, respectively (p <0.05). TSS according to DNA ploidy status (diploid vs aneuploid) was pT1a-95.2% vs 68.6% (p <0.05), pT1b-90% vs 46.7% (p <0.05) and pT2-49.2% vs 25% (p not significant). DNA ploidy was also significantly associated with survival when adjusted for NG. There was no significant association between TSS and MIB-1 score or tumor S-phase fraction.

CONCLUSIONS

The 2002 TNM classification is a useful prognostic factor for evaluating organ confined RCC of the clear cell subtype. Evaluation of the DNA content in clear cell RCC appears to significantly improve the predictive value of the TNM staging system, especially in the pT1a and pT1b categories. Fuhrman NG alone or combined should be routinely used in such patients.

The superior prognostic value of humoral factors compared with molecular proliferation markers in renal cell carcinoma

BACKGROUND

The American Joint Committee on Cancer and the Union Internationale Contre le Cancer have acknowledged routine laboratory parameters, such as serum calcium, alkaline phosphatase, hemoglobin, and the erythrocyte sedimentation rate (ESR), as predictors of survival in patients with renal cell carcinoma. The predictive value of these parameters compared with proliferation markers, such as Ki-67, proliferating cell nuclear antigen (PCNA), topoisomerase II-alpha, and p100, has not been determined.

METHODS

Forty-eight consecutive patients who underwent nephrectomy for nonmetastatic renal cell carcinoma between 1990 and 1994 were observed up to 120 months postoperatively. Ten of 48 patients developed tumor progression 6-69 months after surgery. Routine preoperative laboratory parameters as well as tumor-specific data were assessed. Findings were compared with tumor proliferation indices, which were obtained by immunohistochemical staining for nuclear antigens Ki-67, PCNA, topoisomerase II-alpha, and p100 in paraffin embedded tumor tissue.

RESULTS

Univariate and multivariate statistical analyses demonstrated superiority of routine laboratory values compared with tumor proliferation indices in predicting progression-free survival and disease-specific death. The best predictor after tumor size and symptomatic presentation was ESR (P < 0.0001), with ESR values > 70 mm at 2 hours indicating a significantly poorer prognosis. Only the proliferation marker Ki-67 reached univariate significance at a threshold of 7%.

CONCLUSIONS

Routine laboratory parameters, such as alkaline phosphatase, lactate dehydrogenase, thrombocyte count, and especially ESR, provided superior long-term prognostic information for patients with nonmetastatic renal cell carcinoma compared with the molecular tumor proliferation markers Ki-67, PCNA, topoisomerase II-alpha, and p100.

Growth fractions of human renal cell carcinoma defined by monoclonal antibody Ki-67. Predictive values for prognosis

BACKGROUND

We used immunohistochemical techniques to elucidate the role of growth fractions of renal cell carcinoma in the clinicopathology of the condition and patient survival.

METHODS

Fifty-two fresh-frozen nephrectomy specimens were immunostained with Ki-67 monoclonal antibody. Ki-67 indexes were determined to examine the relationship between tumor size, grade, stage and survival curve. This study included 43 men and nine women with the mean age 58.4 +/- 11.7 years, who had been followed up for 39 +/- 25 months.

RESULTS

The Ki-67 index ranged from 0.6 to 14.1%, averaging 4.6 +/- 5.8%. It was 2.8 +/- 2.4% in tumors <5 cm, 4.7 +/- 3.6% in tumors > or =5 cm and 7.1 +/- 9.0% in tumors > or =10 cm. The Ki-67 index of grades 1, 2 and 3 tumors was 2.3 +/- 1.1%, 3.3 +/- 2.7% and 12.0 +/- 10.4%, respectively. Grade 3 tumors had a significantly higher Ki-67 index than grade 1 or grade 2 tumors. There was no correlation between the Ki-67 index and tumor stage. Patients with a Ki-67 index < 5.6% had a better prognosis than those with an index > 5.6% (P=0.029). However, multivariate analysis demonstrated that tumor size (P=0.034) and grade (P=0.038) were higher in hazard ratio than the Ki-67 index.

CONCLUSIONS

Most renal cell carcinomas had low growth fractions. Although a high Ki-67 index should indicate a poor prognosis, Ki-67 did not correlate to metastasis. We believe it is necessary to investigate the factors, other than growth potential, that affect metastasis.

Prognostic significance of tumor grade for renal cell carcinoma

BACKGROUND

The natural history and prognosis of renal cell carcinoma cannot be predicted. Based on the Japanese classification system, the value of nuclear grade were assessed as a possible prognostic factor for renal cell carcinomas.

METHODS

In this retrospective study of 116 patients with renal cell carcinoma, radical nephrectomy was performed. Survival rates were calculated using the Kaplan-Meier method and multivariate analysis was performed using Cox's proportional hazard model.

RESULTS

Distribution by stage and grade in the population of renal cell carcinomas was as follows: pT1 in 13 cases (11.3%), pT2 in 65 cases (56.5%), pT3 in 36 cases (31.3%) and pT4 in one case (0.9%) and grade 1, 28 (24.1%), grade 2, 69 (59.5%) and grade 3, 16 (13.8%). Three cases could not be determined because of pre-operative embolization of the renal cell carcinomas. Nuclear grade was correlated with stage (P=0.0002), the presence of perirenal fat involvement (P=0.003) and metastases (P=0.007). A significant difference in survival was found between grades 1 and 3 (P=0.0001) and grades 2 and 3 (P=0.0001), respectively. Survival was significantly correlated with sex (P=0.0125), tumor size (P=0.0001), the presence of lymph node metastasis (P=0.0001), renal vein involvement (P=0.0001), perirenal fat involvement (P=0.002) or distant metastasis (P=0.0001). The multivariate analysis showed that the occurrence of tumor grade (P=0.0006) or distant metastasis were independent prognostic values.

CONCLUSION

The observations lead us to conclude that the nuclear grade according to the Japanese classification system appears to be of reliable prognostic value for renal cell carcinomas.

Renal cell carcinoma: Pathological prognostic criteria

– Pathological criteria so far employed in the prognosis of renal cell carcinoma provide no clinically useful information. This paper emphasises the possibilities offered by histopathology today for tackling this clinical problem more effectively. Nuclear analysis, with objective and quantitative evaluation of the degree of distortion, may provide extremely useful information. The authors correctly classified 90% of the 50 cases of renal cell carcinoma considered and whose follow-up at 5 years was known.

Prognostic indicators for response to therapy and survival in patients with metastatic renal cell cancer treated with interferon alpha-2 beta and vinblastine

OBJECTIVES

Only one third of all patients with metastatic renal cell carcinoma respond to immunochemotherapy. Improved patient selection could render such treatment unnecessary in many cases. The goal of the study was to test various factors for their prognostic value as predictors of success of immunochemotherapy and patient survival in metastatic renal cell carcinoma.

METHODS

Fifty patients with metastatic renal cell carcinoma were subjected to immunochemotherapy with interferon alpha-2 beta and vinblastine. Different variables such as age, sex, location of metastasis, primary or late metastasis, performance status, histologic status, overexpression of the p53 protein and cell proliferation as assessed by immunohistochemistry, and deoxyribonucleic acid-ploidy were considered as potential prognostic factors for response to immunochemotherapy and survival.

RESULTS

Thirty percent (15) of the cases responded to therapy: 2 complete and 13 partial remissions. In univariate analysis, the proliferative activity (Ki-S5 labeling index) emerged as the statistically most significant prognostic factor (P = 0.0013) for prediction of successful immunochemotherapy in metastatic renal cell carcinoma. The second most significant factor was the location of metastases (P = 0.015), whereas all other parameters did not achieve statistical significance. As to overall survival, responsiveness to therapy was the most significant predictor (P = 0.0003), followed by Ki-S5 scores (P = 0.025). All other factors, including the sites of metastasic spread (P = 0.21), were not statistically relevant.

CONCLUSIONS

Proliferation status in terms of Ki-S5 immunoreactive scores appears to be a valuable predictor of the responsiveness to immunochemotherapy. Overall survival appears to depend essentially on disease progression and tumor cell proliferation. Other alleged prognostic factors, such as performance status, sarcomatoid histology, and metastasis location, were not significant in this study.

Significance of conventional and new prognostic factors for locally confined renal cell carcinoma

BACKGROUND

The prognosis of patients with locally confined renal cell carcinoma is variable. To improve the prognostic knowledge and select patients at high risk, additional prognostic parameters are needed.

METHODS

The significance with respect to survival and tumor recurrence of "classic" and "new" prognostic parameters has been examined by following 41 patients with locally confined renal cell carcinoma after nephrectomy (mean follow-up, 5.2 years). The significance of histologic grade, tumor stage, Ki-67 index, proliferating cell nuclear antigen index, 3H-thymidine labeling index, tumor ploidy status, and tumor growth after xenotransplantation into nude mice (GAX range) was tested using the Kaplan-Meier plots by the log rank test or Tarone's test and also by the Cox multiple hazard regression analysis.

RESULTS

Tumor stage (P < 0.0025), histologic grade (P < 0.005), Ki-67 index (P < 0.006), and GAX range (P < 0.00004) were found to be significant prognostic parameters for survival and tumor recurrence using single-factor analysis. Applying the multivariate analysis, the combination of the "new" factors, GAX range and Ki-67 index, resulted in even a higher prognostic relevance than the combination of the "classic" prognostic factors, tumor stage and histologic grade. The calculated prognostic index based on the results of the Cox analysis, which, except for stage and grade, included the Ki-67 index, was shown to be highly correlated with survival (P = 0.00002) and tumor recurrence (P = 0.0004). Its prognostic validity was studied with the receiver operating characteristics procedure and was found to be considerably superior to that of the two conventional prognosticators.

CONCLUSIONS

The additional determination of the Ki-67 labeling index increases the prognostic assessment of patients with locally confined renal cell carcinoma.

Renal cancer and tumoral markers: Biological features and prognostic implications

In this work we have examined the studies carried out on tumoral markers of renal carcinoma, in order to point out useful characteristics for understanding the evolution of the tumour. We have examined the cytogenetic studies, the molecular oncology, the studies of cellular proliferation and the DNA analysis, reporting our own experience on the last method. However clashing opinions stili exist on the predictive ability of these investigations. DNA analysis by cytometry seems to be the most applicable one at a clinical level.