Prognostic Value of the C-PLAN Index in Metastatic Renal Cell Carcinoma Treated with Nivolumab

Background/Objectives: Nivolumab has been shown to be an effective treatment for metastatic renal cell carcinoma (mRCC); however, patient responses vary considerably. The objective of this study is to evaluate the prognostic value of the C-PLAN index in predicting survival outcomes for patients with mRCC treated with nivolumab. Methods: This retrospective cohort study included 81 mRCC patients previously treated with tyrosine kinase inhibitors who subsequently received nivolumab. The C-PLAN index, which includes C-reactive protein, performance status, lactate dehydrogenase, albumin, and derived neutrophil-to-lymphocyte ratio, was used to classify patients into "good" and "poor" prognostic groups. Results: The median overall survival (OS) was 22 months, and the median progression-free survival (PFS) was 6.7 months. Patients in the "poor" C-PLAN group exhibited significantly shorter OS and PFS than those in the "good" group (median OS: 13 vs. 31 months, p = 0.003; median PFS: 3 vs. 10 months, p = 0.007). The C-PLAN index was identified as an independent predictor of both OS (HR = 1.19, 95% CI: 1.11-3.43, p = 0.020) and PFS (HR = 1.71, 95% CI: 1.04-2.78, p = 0.032) in multivariate analysis. Conclusions: These findings suggest that the C-PLAN index may serve as a valuable prognostic tool, offering insights into survival outcomes for patients undergoing nivolumab therapy. Further prospective and multicenter studies are warranted to validate its clinical utility.

C-Reactive Protein-Albumin Ratio Predicts Objective Response to Enfortumab Vedotin in Metastatic Urothelial Carcinoma

BACKGROUND

Enfortumab vedotin (EV), an antibody-drug conjugate that targets Nectin-4, is used for patients with metastatic urothelial carcinoma who have experienced progression on platinum-based chemotherapy and checkpoint inhibitors. Despite the widespread use of the drug, evidence remains scarce regarding clinical indicators that can predict the response to EV treatment.

OBJECTIVE

We aimed to explore the predictive value of clinical indicators derived from peripheral blood tests for treatment responses to EV.

METHODS

We utilized records of 109 patients with metastatic urothelial carcinoma treated by EV from our multi-institutional dataset. Receiver operating characteristic curve analyses for predicting objective responses including several indicators from blood examinations, such as C-reactive protein-albumin ratio (CAR), hemoglobin, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and lactate dehydrogenase, were performed. The optimal cutoff points were determined by the Youden index. Logistic regression analyses for achieving objective responses to EV treatment were performed among these indicators.

RESULTS

The median age of the cohort was 74 years, and the median follow-up duration was 10 months for the entire group. Median overall survival and progression-free survival from the initiation of EV were 12 and 6 months, respectively. The objective response rate and disease control rate were 48% and 70%, respectively. The receiver operating characteristic curve analysis aimed at predicting the achievement of an objective response to EV showed that the concordant index for the CAR was 0.774, significantly surpassing other indicators such as hemoglobin level, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and serum lactate dehydrogenase. The Youden index identified an optimal cutoff value of 1 for CAR (mg/L for C-reactive protein and g/dL for serum albumin level) in predicting the objective response to EV treatment. Using the cutoff value for the CAR, the cohort was divided into 32 patients (29%) with lower CAR and 77 patients (71%) with higher CAR. The objective response rate was observed to be 84% in the lower CAR group and 32% in the higher CAR group (p < 0.0001). A logistic regression analysis revealed that an Eastern Cooperative Oncology Group Performance Status ≥1 (p = 0.04) and a CAR ≥1 (p < 0.001) were identified as independent predictors for the objective response to EV.

CONCLUSIONS

The evaluation of the CAR from a concise blood examination at the initiation of EV could effectively predict the treatment response to EV in patients with metastatic urothelial carcinoma after the progression of platinum-based chemotherapy and checkpoint inhibitors.

Risk models for recurrence and survival after kidney cancer: a systematic review

OBJECTIVE

To systematically identify and compare the performance of prognostic models providing estimates of survival or recurrence of localized renal cell cancer (RCC) in patients treated with surgery with curative intent.

MATERIALS AND METHODS

We performed a systematic review (PROSPERO CRD42019162349). We searched Medline, EMBASE and the Cochrane Library from 1 January 2000 to 12 December 2019 to identify studies reporting the performance of one or more prognostic model(s) that predict recurrence-free survival (RFS), cancer-specific survival (CSS) or overall survival (OS) in patients who have undergone surgical resection for localized RCC. For each outcome we summarized the discrimination of each model using the C-statistic and performed multivariate random-effects meta-analysis of the logit transformed C-statistic to rank the models.

RESULTS

Of a total of 13 549 articles, 57 included data on the performance of 22 models in external populations. C-statistics ranged from 0.59 to 0.90. Several risk models were assessed in two or more external populations and had similarly high discriminative performance. For RFS, these were the Sorbellini, Karakiewicz, Leibovich and Kattan models, with the UCLA Integrated Staging System model also having similar performance in European/US populations. All had C-statistics ≥0.75 in at least half of the validations. For CSS, they the models with the highest discriminative performance in two or more external validation studies were the Zisman, Stage, Size, Grade and Necrosis (SSIGN), Karakiewicz, Leibovich and Sorbellini models (C-statistic ≥0.80 in at least half of the validations), and for OS they were the Leibovich, Karakiewicz, Sorbellini and SSIGN models. For all outcomes, the models based on clinical features at presentation alone (Cindolo and Yaycioglu) had consistently lower discrimination. Estimates of model calibration were only infrequently included but most underestimated survival.

CONCLUSION

Several models had good discriminative ability, with there being no single 'best' model. The choice from these models for each setting should be informed by both the comparative performance and availability of factors included in the models. All would need recalibration if used to provide absolute survival estimates.

Elevated Plasma Interleukin-35 as a Prognostic Indicator in Localized Clear Cell Renal Cell Carcinoma

Purpose

The aim of the study is to investigate the prognostic value of plasma interleukin-35 in the surgical treatment of patients with clear cell renal cell carcinoma (ccRCC). Material and Methods. Plasma IL-35 levels were measured in patients with ccRCC. The cut-off value of IL-35 was determined by the receiver operating characteristic (ROC) analysis and the area under the curve (AUC). The effects of the IL-35 and other clinicopathological characteristics on overall survival (OS) and progression-free survival (PFS) were evaluated using the univariate and multivariate logistic regression analysis.

Result

Sixty-four ccRCC patients admitted to the urology department at the First Affiliated Hospital of Soochow University were selected, of whom 50 were diagnosed with localized ccRCC. Plasma interleukin-35 levels were significantly higher in patients with ccRCC than that in healthy controls. The cut-off value of IL-35 was 99.7 pg/mL. Multivariate analysis selected by univariate analyses demonstrated that the preoperative IL-35 was an independent prognostic factor for 5-year OS (OR: 1.02, 95% CI: 1.01 to 1.04, p < 0.0001) and 5-year PFS (OR: 1.02, 95% CI: 1.00 to 1.03, p=0.011) in all patients with localized ccRCC.

Conclusion

Current results indicate that preoperative IL-35 is an independent prognostic marker for OS and RFS in patients with localized ccRCC after surgery.

Inflamasyon ilişkili indeksler, palyatif bakım hastalarında kötü prognozu tanımlayabilir mi?

Aim: Palliative medicine provides holistic care to increase the quality of life of patients. Predicting prognosis is critical for a personalized treatment plan. Therefore, we aimed to investigate the survival prediction properties of routine biochemistry tests, complete blood count (CBC) and neutrophil/lymphocyte ratios, in addition to biomarker-based indices (the mGPS, PI, and PNI). Materials and methods: The laboratory parameter values, prognostic factor scores, diagnoses and survival time of 139 palliative care patients in the last 5 weeks of their life were evaluated retrospectively. Results: Ninety-one (65.5%) patients were male and the average age was 65.9 years (28–91 years). Results of all three prognostic indices (the mGPS, PI, and PNI) investigated in this study were found to have a statistically significant relationship with the survival time of our patients. In addition, NLR, neutrophil percent, hemoglobin, serum albumin and CRP values were seen to have a statistically significant relationship with the scores of all three prognostic indices. Moreover, hand it is detected that WBC, NLR, albumin, and CRP values were associated with overall survival. Conclusion: The results of our study, which showed that these indices have prognostic markers in palliative care patients, will guide the management of the clinical process. We would like to emphasize the importance of palliative care clinicians in developing personalized treatment plans for patients using prognostic tools for survival prediction.

Association between the Lymphocyte-to-C-Reactive Protein Ratio and Survival Outcomes in Cancer Patients with GLIM-Defined Malnutrition: A Multicenter Study

BACKGROUND AND AIMS

This study assessed the prognostic value of LCR in patients with cancer-associated malnutrition (CAM). Systemic inflammatory markers, particularly the lymphocyte-to-C-reactive protein ratio (LCR), are related to the survival of patients with CAM. The present retrospective analysis based on a prospective multicenter cohort study, which involved 1,437 hospitalized patients with CAM.

METHODS

The area under the receiver operating characteristic curve (AUC) of ten inflammatory indicators-LCR, advanced lung cancer inflammation index, neutrophil-to-lymphocyte ratio, prognostic nutritional index, modified Glasgow prognostic score, systemic immune-inflammation index, albumin-to-globulin ratio, LCR score, glucose-to-lymphocyte ratio, and platelet-to-lymphocyte ratio-were constructed. Nutritional status, blood markers, and quality of life (QoL) were evaluated within 48 h of admission. The overall survival (OS) was evaluated from September 1 to December 29, 2021.

RESULTS

A total of 1,431 cancer patients diagnosed with malnutrition based on the Global Leadership Initiative on Malnutrition (GLIM) criteria. Male patients were 62.8% of all, and the mean age was 60.66 years old. The AUC of LCR was higher than that of other inflammatory markers. The restricted cubic spline (RCS) of the Hazard ratios (HRs) showed an inverse L-shaped relationship with LCR. In addition, patients with low LCR had significantly poorer OS than those with high LCR. The addition of LCR to the model increased the predictive ability of 1-year mortality (AUC increase of 0.036), 3-year mortality (AUC increase of 0.038), and 5-year mortality (AUC increase of 0.031).

CONCLUSIONS

Assessing the LCR can help the medical staff identify cancer patients with nutritional deficiency at high risk of oncological outcomes and develop individualized therapeutic strategies.

Comparison and development of preoperative systemic inflammation markers-based models for the prediction of unfavorable pathology in newly diagnosed clinical T1 renal cell carcinoma

BACKGROUND

We sought to investigate the preoperative risk factors associated with the unfavorable pathology (UP) of clinical T1 (cT1) renal lesions. The aims of this study were to develop and compare several novel models capable of accurately identifying those patients at high risk of harboring occult adverse histopathological characteristics.

METHODS

The clinical parameters and preoperative laboratory test results from 1281 cT1 renal cell carcinomas (RCCs) patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) were collected. The data was randomly split into training (70%) and testing (30%) datasets. We performed univariable and multivariable logistic regression analyses for significant predictors and, subsequently, constructed predictive models based on those significant risk factors. Receiver operating characteristic (ROC) analysis was used to determine the model with the highest discrimination power with corresponding area under the curve (AUC). Calibration curves were plotted and decision curve analyses (DCAs) were applied to explore clinical net benefit.

RESULTS

UP was identified in 21.1% (n = 270), 21.0% (n = 188) and 21.3% (n = 82) patients in the total population, training cohort and validation cohort, respectively. R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to the polar lines) nephrometry score, tumor size, neutrophil-to-lymphocyte ratio (NLR) and albumin-to-globulin ratio (AGR) were independent predictors of UP. Among those predictive models, the model that consisted of tumor size, hemoglobin, NLR and AGR performs best according to the highest AUC of 0.70 and the highest net benefit. When tumor histology was added to the biomarker-based model, including tumor size, hemoglobin, NLR and AGR, the AUC improved from 0.60 to 0.63 in the validation cohort.

CONCLUSIONS

In this analytical model study, our findings verified that systemic inflammation response markers showed high potential for identifying UP. Our biomarker-based models well predicted occult aggressive histopathological characteristics among patients with cT1 renal lesions, and the use of models may be greatly beneficial to urologists in tailoring precise management and therapy for patients. Robust validation is warranted prior to adoption into clinical practice.

Added Value of Systemic Inflammation Markers in Predicting Clinical Stage T1 Renal Cell Carcinoma Pathologically Upstaged to T3a

Objectives

We aimed to determine preoperative risk factors associated with pathologic T3a (pT3a) upstaging of clinical T1 (cT1) renal cell carcinomas (RCCs) and develop a novel model capable of accurately identifying those patients at high risk of harboring occult pT3a characteristics.

Methods

A retrospective analysis of 1324 cT1 RCC patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) was performed. The study cohort was divided into training and testing datasets in a 70:30 ratio for further analysis. Univariable and multivariable logistic regression analyses were performed to identify predictors associated with cT1 to pT3a upstaging and subsequently, those significant risk factors were used to construct models. We used the area under the curve (AUC) to determine the model with the highest discrimination power. Decision curve analyses (DCAs) were applied to evaluate clinical net benefit associated with using the predictive models.

Results

The rates of upstaging were 6.1% (n = 81), 5.8% (n = 54) and 6.8% (n = 27) in the total population, training cohort and validation cohort, respectively. Tumor size, clinical T stage, R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior) nephrometry score, lymphocyte to monocyte ratio (LMR), prognostic nutrition index (PNI) and albumin to globulin ratio (AGR) were significantly associated with pT3a upstaging. The model that consisted of R.E.N.A.L. score, LMR, AGR and PNI achieved the highest AUC of 0.70 in the validation cohort and yielded the highest net benefit. In the subpopulation with complete serum lipid profile, the inclusion of low-density lipoprotein cholesterol (LDL-C) and Castelli risk index-I (CRI-I) significantly improved the discrimination of model (AUC = 0.86).

Conclusions

Our finding highlights the importance of systemic inflammation response markers and serum lipid parameters in predicting pT3a upstaging. Our model had relatively good discrimination in predicting occult pT3a disease among patients with cT1 renal lesions, and the use of the model may be greatly beneficial to urologists in risk stratification and management decisions.

Modified Glasgow Prognostic Score is predictive of prognosis for non-small cell lung cancer patients treated with stereotactic body radiation therapy: a retrospective study

We aimed to assess the predictive value of the modified Glasgow prognostic score (mGPS) in patients with non-small cell lung cancer (NSCLC) who underwent stereotactic body radiation therapy (SBRT). We retrospectively reviewed the records of 207 patients, with a median age of 79 years. The pretreatment mGPS was calculated and categorized as high (mGPS = 1-2) or low (mGPS = 0). The median follow-up duration was 40.7 months. The five-year overall survival (OS), progression-free survival (PFS) and time to progression (TTP) rates were 44.3%, 36% and 54.4%, respectively. Multivariate analysis revealed that mGPS was independently predictive of OS (hazard ratio [HR] 1.67; 95% confidence interval 1.14-2.44: P = 0.009), PFS (HR 1.58; 1.10-2.28: P = 0.014) and TTP (HR 1.66; 1.03-2.68: P = 0.039). Patients who had high mGPS showed significantly worse OS (33.3 vs 64.5 months, P = 0.003) and worse PFS (23.8 vs 39 months, P = 0.008) than those who had low mGPS. The data showed a trend that patients with high mGPS suffered earlier progression compared to those with low mGPS (54.3 vs 88.1 months, P = 0.149). We confirmed that mGPS is independently predictive of prognosis in NSCLC patients treated with SBRT.

Distinct effect of body mass index by sex as a prognostic factor in localized renal cell carcinoma treated with nephrectomy ~ data from a multi-institutional study in Japan ~

Background

We assessed the prognostic value of body mass index (BMI) in Asian patients with localized RCC who underwent nephrectomy.

Methods

A total of 665 patients who underwent nephrectomy for localized RCC were enrolled in the present study and divided into the two BMI groups: i.e., BMI < 25 in 463 (69.6%) and BMI > 25 in 202 (30.4%) patients.

Results

In total, there were 482 (72.5%) males and 183 (27.5%) females. Five-year cancer-specific survival (CSS) rates were significantly higher in increased BMI than the lower BMI group (97.1 and 92.5%: P = 0.007). When stratified by sex, significantly longer CSS in higher BMI was confirmed in males (5-year CSS of 92.7% in BMI < 25 and 98.1% in BMI > 25, p = 0.005), while there was no difference in CSS between BMI groups for female patients. Multivariable analysis exhibited that higher BMI was an independent predictor for favorable CSS in male (cox model: p = 0.041, Fine & Gray regression model: p = 0.014), but not in the female. Subgroup analysis for CSS revealed that favorable CSS with higher BMI was observed in patient subgroups of age < 65 (p = 0.019), clear cell histology (p = 0.018), and tumor size > 4 cm, p = 0.020) as well as male (p = 0.020).

Conclusion

Our findings collected from the multi-institutional Japanese dataset demonstrated longer survival in patients with higher BMI than lower BMI for non-metastatic RCC treated with nephrectomy. Intriguingly, this finding was restricted to males, but not to females.

Prognostic Value of Preoperative Albumin-to-Alkaline Phosphatase Ratio in Patients with Muscle-Invasive Bladder Cancer After Radical Cystectomy

Objective

This study investigated the prognostic value of the preoperative albumin alkaline phosphatase ratio (AAPR) in patients with muscle-invasive bladder cancer after radical cystectomy.

Materials and Methods

We performed a retrospective, single-center cohort study among patients with muscle-invasive bladder cancer who underwent radical cystectomy and urinary diversion at the Department of Urology Surgery of the Affiliated Hospital of Qingdao University from 2007 to 2015. Cox proportional hazards regression was used to evaluate the relationship between preoperative AAPR and outcomes which include OS and CSS and RFS. Survival analysis was conducted using the Kaplan–Meier method and the log rank test.

Results

In total, 174 patients were followed up for 1–125 months, with a median follow-up of 30 months, 93 survived and 81 patients died. The median serum AAPR level in all patients was 0.62 (range: 0.12–1.67). In multivariate analysis, the preoperative AAPR showed to be associated with overall survival (OS: HR 0.22,95% CI 0.06 to 0.82, P=0.024), cancer-specific survival (CSS: HR 0.12,95% CI 0.02 to 0.63, P=0.013) and recurrence-free survival (RFS: HR 0.15,95% CI 0.03 to 0.82, P=0.029) after adjustment for potential confounders. Kaplan–Meier analysis showed that patients with low AAPR tertiles had shorter OS, CSS and RFS than patients with high AAPR tertiles (OS: P<0.001, CSS: P<0.001, RFS: P<0.001). The relationship between AARP and OS, CSS and RFS was linear.

Conclusion

Preoperative AAPR may be a potentially valuable prognostic marker in patients who underwent radical cystectomy for muscle-invasive bladder cancer.

Modified Glasgow Prognostic Score as a Predictor of Prognosis in Metastatic Renal Cell Carcinoma Treated With Nivolumab

BACKGROUND

The modified Glasgow prognostic score (mGPS), which incorporates serum albumin and C-reactive protein levels, reflects systemic inflammation and nutritional status. In this study, we evaluate the role of mGPS as a predictor of prognosis in metastatic renal cell carcinoma treated with nivolumab.

PATIENTS AND METHODS

Forty-five consecutive patients with metastatic renal cell carcinoma receiving nivolumab therapy after tyrosine kinase inhibitor therapy between September 2013 and August 2019 at our institution were retrospectively analyzed. The prognostic factors associated with overall survival were statistically analyzed.

RESULTS

The median follow-up period was 26.4 months. The median progression-free survival and 1- and 3-year progression-free survival rates were 11.6 months, 48.9%, and 17.1%, respectively. The median overall survival and 1- and 3-year overall survival rates were not reached, 88.7%, and 62.3%, respectively. In multivariate analysis, mGPS at the time of nivolumab administration (P < .0001; hazard ratio [HR], 95.7; P = .0004 [Score 1 vs. 0]; HR, 98.9; P = .0002 [Score 2 vs. 0]; and HR, 1.03; P = .971 [Score 2 vs. 1]) was extracted as the strongest predictor for overall survival followed by duration from diagnosis to treatment (P = .0001), lactate dehydrogenase (P = .0005), and lymphocyte count (P = .021). Overall survival curves were distinctly separated between mGPS Score 0 and mGPS Score 1 + 2, with median overall survival periods being not reached and 32.4 months, respectively (P = .0004).

CONCLUSIONS

mGPS was the strongest significant prognostic biomarker in patients with metastatic renal cell carcinoma treated with nivolumab. This simple classification could be useful in clinical practice.

A Meta-Analysis of Glasgow Prognostic Score and Modified Glasgow Prognostic Score as Biomarkers for Predicting Survival Outcome in Renal Cell Carcinoma

Purpose: Accumulative studies suggest the Glasgow prognostic score (GPS) and modified Glasgow prognostic score (mGPS) to be potential biomarkers; however, their prognostic value remains debatable. Our meta-analysis focused on assessing the accurate prognostic value of GPS and mGPS in patients with renal cell carcinoma (RCC) in addition to their effectiveness.

Methods: To investigate the relationship between mGPS/GPS and prognostic value in patients with RCC, we performed a comprehensive retrieval of relevant articles from databases such as PubMed, Embase, Web of Science, and Medline up to February 1, 2020. STATA 15.0 software was used to obtain pooled hazard ratios (HRs) and their 95% confidence intervals for survival outcome, including overall survival (OS), recurrence-free survival (RFS), progression-free survival (PFS), and cancer-specific survival (CSS). A formal meta-analysis of these outcomes was performed.

Results: In total, 2,691 patients with RCC were enrolled from 15 cohort studies. Higher GPS/mGPS (GPS/mGPS of 2) indicated poorer OS, CSS, PFS, and RFS in patients with RCC. Similarly, medium GPS/mGPS (GPS/mGPS of 1) also had a significant association with poorer OS, CSS, PFS, and RFS but superior than higher GPS/mGPS in these patients.

Conclusion: GPS and mGPS are effective biomarkers for predicting prognosis in patients with RCC, and higher GPS and mGPS are closely related to inferior survival outcomes. More randomized controlled trials are needed to investigate the promising value of GPS/mGPS in the future.

Oncological outcomes of a multicenter cohort treated with axitinib for metastatic renal cell carcinoma

The present study aimed to evaluate the efficacy of the real-world use of axitinib and to develop a prognostic model for stratifying patients who could derive long-term benefit from axitinib. This was a retrospective, descriptive study evaluating the efficacy of axitinib in patients with metastatic renal cell carcinoma that had been treated with 1 or 2 systemic antiangiogenic therapy regimens at 1 of 36 hospitals belonging to the Japan Urologic Oncology Group between January 2012 and February 2019. The primary outcome was overall survival (OS). Using a split-sample method, candidate variables that exhibited significant relationships with OS were chosen to create a model. The new model was validated using the rest of the cohort. In total, 485 patients were enrolled. The median OS was 34 months in the entire study population, whereas it was not reached, 27 months, and 14 months in the favorable, intermediate, and poor risk groups, respectively, according to the new risk classification model. The following 4 variables were included in the final risk model: the disease stage at diagnosis, number of metastatic sites at the start of axitinib therapy, serum albumin level, and neutrophil : lymphocyte ratio. The adjusted area under the curve values of the new model at 12, 36, and 60 months were 0.77, 0.82, and 0.82, respectively. The efficacy of axitinib in routine practice is comparable or even superior to that reported previously. The patients in the new model's favorable risk group might derive a long-term survival benefit from axitinib treatment.

The prevalence of cancer associated systemic inflammation: Implications of prognostic studies using the Glasgow Prognostic Score

The prognostic importance of SIR in patients with cancer is widely recognised. More recently it has become clear that the systemic inflammatory response is an important etiologic factor in the development of cancer cachexia. Two recent meta-analysis carried out in 2017 and 2018 were interrogated and the number of patients with specific cancer types were identified. The percentage of patients with operable cancer (n>28,000) who were systemically inflamed varied from 21% to 38%. The percentage of patients with inoperable cancer (n>12,000) who were systemically inflamed varied from 29% to 79%. Overall, the percentage of patients (n>40,000) who were systemically inflamed varied from 28% to 63% according to tumour type. The most commonly studied cancer was colorectal cancer (n∼10,000 patients) and 40% were systemically inflamed.

The Interplay between Inflammation, Anti-Angiogenic Agents, and Immune Checkpoint Inhibitors: Perspectives for Renal Cell Cancer Treatment

Treatment options for metastatic renal cell carcinoma (RCC) have been expanding in the last years, from the consolidation of several anti-angiogenic agents to the approval of immune checkpoint inhibitors (ICIs). The rationale for the use of immunomodulating agents derived from the observation that RCC usually shows a diffuse immune-cell infiltrate. ICIs target Cytotoxic T Lymphocytes Antigen 4 (CTLA-4), programmed death 1 (PD-1), or its ligand (PD-L1), showing promising therapeutic efficacy in RCC. PD-L1 expression is associated with poor prognosis; however, its predictive role remains debated. In fact, ICIs may be a valid option even for PD-L1 negative patients. The establishment of valid predictors of treatment response to available therapeutic options is advocated to identify those patients who could benefit from these agents. Both local and systemic inflammation contribute to tumorigenesis and development of cancer. The interplay of tumor-immune status and of cancer-related systemic inflammation is pivotal for ICI-treatment outcome, but there is an unmet need for a more precise characterization. To date, little is known on the role of inflammation markers on PD-1 blockade in RCC. In this paper, we review the current knowledge on the interplay between inflammation markers, PD-1 axis, and anti-angiogenic agents in RCC, focusing on biological rationale, implications for treatment, and possible future perspectives.

Pre-treatment Glasgow prognostic score and modified Glasgow prognostic score may be potential prognostic biomarkers in urological cancers: a systematic review and meta-analysis

Background

The prognostic role of Glasgow prognostic score (GPS) or modified GPS (mGPS) in various cancers has been investigated. However, no unified conclusion could be drawn in urological cancers. So, we aimed to explore the potential role of GPS/mGPS in urological cancers.

Methods

Related studies were searched from PubMed, Web of Science and Embase up to May 30th, 2019 comprehensively. Their associations were assessed by the pooled hazard ratios (HRs) with its 95% confidence intervals (CIs).

Results

A total of 20 related studies were enrolled in this meta-analysis. The outcomes revealed that a relatively lower level of pre-treatment GPS/mGPS was associated with better overall survival (OS), cancer specific survival (CSS)/disease-specific survival (DSS) and disease-free survival (DFS)/progress-free survival (PFS)/recurrence-free survival (RFS) (pooled HR =2.70; 95% CI, 1.81-4.01; pooled HR =2.90; 95% CI, 2.00-4.22; pooled HR =2.43; 95% CI, 1.62-3.66, respectively). Subgroup analysis by cancer type for OS indicated that GPS/mGPS could also be a predictor no matter in renal cell cancer (RCC) or bladder cancer (BC) (pooled HR =3.60; 95% CI, 2.07-6.28 and pooled HR =2.71; 95% CI, 1.08-6.82). Similar results could be found in CSS/DSS (RCC: HR =4.12; 95% CI, 2.69-6.30) and in DFS/ PFS/RFS (RCC: HR =2.66; 95% CI, 1.82-3.90 and BC: HR =1.52; 95% CI, 1.23-1.88). As for the treatment subgroup, pre-treatment GPS/mGPS played an independent role in OS for patients no matter in which treatment type (Surgery: pooled HR =2.16; 95% CI, 1.43-3.26; Chemotherapy: pooled HR =4.41; 95% CI, 2.27-8.58); the same in CSS/DSS (Surgery: pooled HR =3.28; 95% CI, 1.73-6.20; Immunotherapy: pooled HR =2.72; 95% CI, 1.87-3.96) and DFS/RFS/PFS (Surgery: pooled HR =2.54; 95% CI, 1.65-3.92). Lastly, both GPS and mGPS played prognostic role in OS, CSS/DSS or DFE/RFS/PFS (OS: GPS: pooled HR =2.12; 95% CI, 1.04-4.32; mGPS: pooled HR =3.12; 95% CI, 1.87-5.20; CSS/DSS: GPS: pooled HR =2.87; 95% CI, 2.11-3.91; mGPS: pooled HR =3.00; 95% CI, 1.60-5.63; DFS/RFS/PFS: GPS: pooled HR =3.61; 95% CI, 1.43-9.07; mGPS: pooled HR =1.99; 95% CI, 1.32-2.99).

Conclusions

This study shed light on that GPS/mGPS might be an independent prognostic factor in urological cancers, indicating that a lower level of pre-treatment GPS/mGPS was closely related to better survival outcomes.

The prognostic value of preoperative controlling nutritional status score in non-metastatic renal cell carcinoma treated with surgery: a retrospective single-institution study

Purpose

This study aimed to investigate the significance of the controlling nutritional status (CONUT) score as a predictor for survival outcomes for non-metastatic renal cell carcinoma (RCC) patients.

Methods

We retrospectively reviewed 325 patients who received surgical treatment for renal cell carcinoma between 2010 and 2012 at Peking University First Hospital. Patients were divided into two groups according to the optimal cut-off value of CONUT score. Kaplan–Meier method and log-rank test were used for survival analysis according to different CONUT groups. Cox proportional hazards regression models were performed to assess the prognostic value of clinicopathological parameters for overall survival (OS), cancer-specific survival (CSS) and disease-free survival (DFS) respectively.

Results

The optimal cut-off value of CONUT score was 3. High CONUT score significantly correlated to higher tumor grade (P<0.001), later pathological T stage (P<0.001) and tumor necrosis (P<0.001). Patients with higher CONUT score had worse OS (HR 5.34, 95% CI 2.29–12.46, P<0.001), CSS (HR 5.51, 95% CI 2.12–14.33, P<0.001) and DFS (HR 4.23, 95% CI 2.16–8.29, P<0.001). In multivariable analysis, high CONUT score was an independent risk factor for OS, CSS and DFS (OS: HR=3.36, 95% CI 1.73–6.56, P<0.001; CSS: HR=3.34, 95% CI 1.59–6.98, P=0.001; DFS: HR=1.85, ]95% CI 1.07–3.21, P=0.029)

Conclusion

Preoperative CONUT score was an independent prognostic factor for OS, CSS and DFS in non-metastatic RCC patients treated with surgery.

C-reactive protein/albumin ratio is a predictive factor for prognosis in patients with metastatic renal cell carcinoma

OBJECTIVES

To evaluate the effect of pretreatment C-reactive protein/albumin ratio and modified Glasgow prognostic score on the prognosis in patients with metastatic renal cell carcinoma.

METHODS

A retrospective study was carried out in 176 patients with metastatic renal cell carcinoma who received first-line tyrosine kinase inhibitors. The effect of adding inflammatory prognostic scores to the International Metastatic Renal Cell Carcinoma Database Consortium model (International Metastatic Renal Cell Carcinoma Database Consortium-C-reactive protein/albumin ratio and International Metastatic Renal Cell Carcinoma Database Consortium-Glasgow prognostic score models) on overall survival was evaluated using receiver operating characteristic curves. The prognostic value of inflammatory prognostic scores (C-reactive protein/albumin ratio-modified Glasgow prognostic score) was tested using the Kaplan-Meier method and Cox proportional regression models.

RESULTS

Patients were stratified into two groups using the cut-off value of 0.05: C-reactive protein/albumin ratio-low (<0.05) and C-reactive protein/albumin ratio-high (≥0.05). The area under the curve was significantly higher in the International Metastatic Renal Cell Carcinoma Database Consortium-C-reactive protein/albumin ratio model (0.720) than that of the International Metastatic Renal Cell Carcinoma Database Consortium model (0.689) and the International Metastatic Renal Cell Carcinoma Database Consortium-modified Glasgow prognostic score model (0.703). Significant differences were observed in overall survival stratified by the number of risk factors in the International Metastatic Renal Cell Carcinoma Database Consortium-C-reactive protein/albumin ratio risk model between one or two and three or four factors (P < 0.001), and three or four and five or more factors (P = 0.001). For the patients in the International Metastatic Renal Cell Carcinoma Database Consortium intermediate-risk group, overall survival was significantly different between the C-reactive protein/albumin ratio-low and -high groups (P = 0.001), whereas it was not significantly different between the patients with one and two International Metastatic Renal Cell Carcinoma Database Consortium risk factors (P = 0.106).

CONCLUSION

The C-reactive protein/albumin ratio is a simple and independent predictor of overall survival in patients with metastatic renal cell carcinoma. The predictive activity was significantly improved in the International Metastatic Renal Cell Carcinoma Database Consortium-C-reactive protein/albumin ratio model compared with the International Metastatic Renal Cell Carcinoma Database Consortium/International Metastatic Renal Cell Carcinoma Database Consortium-modified Glasgow prognostic score models.

Modified Glasgow prognostic score as a prognostic factor for renal cell carcinomas: a systematic review and meta-analysis

Objective

The modified Glasgow prognostic score (mGPS), a combination of C-reactive protein (CRP) and albumin levels, reflects systemic inflammation and nutritional status. This score has been shown to have prognosis value for various tumors. In the present study, we evaluated the prognostic value of mGPS for patients with renal cell carcinoma (RCC).

Methods

Literature search was conducted based on PubMed, Embase, and Cochrane Central Register of Controlled Trials up to December 2018. We pooled HRs and 95% CIs to evaluate the correlation between mGPS and survival in patients with RCC.

Results

Twelve studies comprising 2,391 patients were included in the present study for quantitative synthesis. Our studies demonstrated that higher mGPS was significantly correlated to poor overall survival (HR=4.31; 95%CI, 2.78–6.68; P<0.001), cancer-specific survival (HR=5.88; 95%CI, 3.93–8.78; P<0.001), recurrence-free survival (HR=3.15; 95%CI, 2.07–4.79; P<0.001), and progression-free survival (HR=1.91; 95%CI, 1.27–2.89; P=0.002). Subgroup analyses also confirmed the overall results.

Conclusion

mGPS could serve as a predictive tool for the survival of patients with RCC. In the different subgroups, the results are also consistent with previous results. In conclusion, pretreatment higher mGPS is associated with poorer survival in patients with RCC. Further external validations are necessary to strengthen this concept.

The CANLPH Score, an Integrative Model of Systemic Inflammation and Nutrition Status (SINS), Predicts Clinical Outcomes After Surgery in Renal Cell Carcinoma: Data From a Multicenter Cohort in Japan

BACKGROUND

A myriad of studies have demonstrated the clinical association of systemic inflammatory and nutrition status (SINS) including C-reactive protein/albumin ratio (CAR), the neutrophil/lymphocyte ratio (NLR), and the platelet/hemoglobin ratio (PHR). This study aimed to investigate the predictive value of the score integrating these variables (CANLPH) in patients with renal cell carcinoma (RCC).

METHODS

Using cohort data from a multi-institutional study, 757 of 1109 patients were retrospectively analyzed. The optimal cutoff value for outcome prediction of continuous variables in CAR, NLR, and PHR was determined and the CANLPH score was then calculated as the sum score of 0 or 1 by the cutoff value in each ratio.

RESULTS

The median follow-up time was 76 months for the patients who survived (n = 585) and 31 months for those who died (n = 172). The Youden Index offered an optimal cutoff of 1.5 for CAR and 2.8 for NLR, and a higher value from the cutoff was assigned as a score of 1. The cutoff value of the PHR was defined as 2.1 for males and 2.3 for females. The patients were assigned a CANLPH score of 0 (47.2%), 1 (31.3%), 2 (13.1%), or 3 (8.5%). In the multivariate analysis, the CANLPH score served as an independent predictor of cancer-specific mortality in both localized and metastatic RCC.

CONCLUSION

The score was well-correlated with clinical outcome for the RCC patients. Because this score can be concisely measured at the point of diagnosis, physicians may be encouraged to incorporate this model into the treatment for RCC.

C-reactive protein-albumin ratio as a prognostic factor in renal cell carcinoma - A data from multi-institutional study in Japan

INTRODUCTION

The C-reactive protein to albumin ratio (CAR) has been shown to provide prognostic information in several cancers. The objective in the study is to examine the prognostic value of CAR in patients with RCC who underwent nephrectomy.

MATERIAL AND METHODS

The record data from multi-institutional study of 1,028 patients was analyzed in the study. The cut-off value of the CAR was defined by receive operating characteristic (ROC) analysis. Overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were evaluated, and univariate and multivariate analyses were conducted to assess the predictive value of the variables including CAR.

RESULT

The optimal cut-off value of 0.073 in CAR was defined according to the ROC analysis. The AUC in CAR for CSS was greater than that of NLR and PLR, and that for RFS was also greater than GPS and mGPS. Multivariate analysis demonstrated that the CAR was an independent prognostic factor for OS (P < 0.001), CSS (P < 0.001) in total cohort and RFS (P = 0.029) in nonmetastatic cohort.

CONCLUSION

The findings of the present study suggested that the preoperative CAR is an independent prognostic indicator of OS, CSS and RFS for patients with RCC. Since CAR can be assessed prior to surgery, clinicians should this take into account for the treatment decision making.

Role of systemic inflammatory response markers in urological malignancy

The systemic inflammatory response is associated with survival in patients with a variety of cancers. This inflammatory response is measured in the peripheral blood, and can be monitored using two categories of indices: concentration of specific serum proteins (albumin, C-reactive protein) and differential blood cell count (neutrophils, lymphocytes and platelets). Furthermore, combinations of these indices, such as the Glasgow Prognostic Score, which consists of the serum C-reactive protein and albumin level; the neutrophil-to-lymphocyte ratio; the platelet-to-lymphocyte ratio; and the prognostic nutritional index, which is based on peripheral blood lymphocyte count and serum albumin level, have also been evaluated and compared in cancer research. To date, there are hundreds of studies that have shown the prognostic value of systemic inflammatory response markers in patients with urological cancer. Most studies have evaluated the prognostic and predictive role of the pretreatment value of the markers, although some have focused on the role of the post-treatment value at specific points during the clinical course. The advantages of systemic inflammatory response markers are that they are easily measurable and inexpensive in the clinical setting. However, it is important to consider how clinicians use these markers in clinical practice. The present review provides a concise overview regarding systemic inflammatory markers in urological cancers, specifically C-reactive protein, Glasgow Prognostic Score/modified Glasgow Prognostic Score, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and prognostic nutritional index.

The combination of preoperative platelet count and neutrophil lymphocyte ratio as a prognostic indicator in localized renal cell carcinoma

Introduction

The combination of platelet count and neutrophil to lymphocyte ratio (COP-NLR) has been shown to provide prognostic information in several cancers, whereas its prognostic value in renal cell carcinoma (RCC) has not been reported. The objective of the present study was to examine the preoperative prognostic value of the COP-NLR in patients with localized RCC undergoing nephrectomy.

Material and Methods

The record of 268 patients, who underwent nephrectomy due to a diagnosis of RCC at our institute was analyzed in the study. The cut-off value of platelet count and NLR were defined by receive operating characteristic (ROC) analysis and the areas under the curve (AUC). Patients with both an increased platelet count (> 310×10⁹/l) and an elevated NLR (> 3.85) were assigned to the score 2, and patients with one or neither of these indicators were assigned to the score 1 or 0, respectively. The impact of the COP-NLR and other clinicopathological characteristics on overall survival (OS) and recurrence-free survival (RFS) were evaluated using the univariate and multivariate Cox regression analysis.

Result

The median follow-up duration after surgical resection was 60 months. Multivariate analysis using the 10 clinicopathological findings selected by univariate analyses demonstrated that the preoperative COP-NLR was an independent prognostic factor for OS (HR: 2.32, 95%CI: 1.22 to 4.26, p=0.011) and RFS (HR: 1.91, 95%CI: 1.02 to 3.53, p=0.044).

Conclusion

The findings of the current study suggested that the preoperative COP-NLR is an independent prognostic indicator of OS and RFS for patients with localized RCC.