Immune context characterization and heterogeneity in primary tumors and pulmonary metastases from renal cell carcinoma

Analyses of tumor microenvironment in patients with advanced renal cell carcinoma receiving immunotherapy (Meet-URO 18 study)

Introduction: The Meet-URO 18 study is a multicentric study of patients with metastatic renal cell carcinoma receiving nivolumab in the second-line and beyond, categorized as responders (progression-free survival ≥ 12 months) and non-responders (progression-free survival < 3 months).Areas covered: The current study includes extensive immunohistochemical analysis of T-lineage markers (CD3, CD4, CD8, CD8/CD4 ratio), macrophages (CD68), ph-mTOR, CD15 and CD56 expression on tumor cells, and PD-L1 expression, on an increased sample size including 161 tumor samples (113 patients) compared with preliminary presented data. Responders' tumor tissue (n = 90; 55.9%) was associated with lower CD4 expression (p = 0.014), higher CD56 expression (p = 0.046) and higher CD8/CD4 ratio (p = 0.030).Expert opinion/commentary: The present work suggests the regulatory role of a subpopulation of T cells on antitumor response and identifies CD56 as a putative biomarker of immunotherapy efficacy.

Retrospective immunophenotypical evaluation of MET, PD-1/PD-L1, and mTOR pathways in primary tumors and pulmonary metastases of renal cell carcinoma: the RIVELATOR study addresses the issue of biomarkers heterogeneity

Aim

In renal cell carcinoma (RCC), tumor heterogeneity generated challenges to biomarker development and therapeutic management, often becoming responsible for primary and acquired drug resistance. This study aimed to assess the inter-tumoral, intra-tumoral, and intra-lesional heterogeneity of known druggable targets in metastatic RCC (mRCC).

Methods

The RIVELATOR study was a monocenter retrospective analysis of biological samples from 25 cases of primary RCC and their paired pulmonary metastases. The biomarkers analyzed included MET, mTOR, PD-1/PD-L1 pathways and the immune context.

Results

High multi-level heterogeneity was demonstrated. MET was the most reliable biomarker, with the lowest intratumor heterogeneity: the positive mutual correlation between MET expression in primary tumors and their metastases had a significantly proportional intensity (P = 0.038). The intratumor heterogeneity grade was significantly higher for the mTOR pathway proteins. Combined immunophenotypical expression patterns and their correlations with the immune context were uncovered [i.e., mTOR expression in the metastases positively correlated with PD-L1 expression in tumor-infiltrating lymphocytes (TILs), P = 0.019; MET expression was related to PD-1 expression on TILs (P = 0.041, ρ = 0.41) and peritumoral lymphocytes (RILs; P = 0.013, ρ = 0.49)], suggesting the possibility of predicting drug response or resistance to tyrosine kinase, mTOR, or immune checkpoint inhibitors.

Conclusions

In mRCC, multiple and multi-level assays of potentially predictive biomarkers are needed for their reliable translation into clinical practice. The easy-to-use immunohistochemical method of the present study allowed the identification of different combined expression patterns, providing cues for planning the management of systemic treatment combinations and sequences in an mRCC patient population. The quantitative heterogeneity of the investigated biomarkers suggests that multiple intralesional assays are needed to consider the assessment reliable for clinical considerations.

Cellular milieu in clear cell renal cell carcinoma

Clear cell renal cell carcinoma (ccRCC) is globally the most prevalent renal cancer. The cells of origin in ccRCC have been identified as proximal tubular epithelial cells (PTEC); however, the transcriptomic pathways resulting in the transition from normal to malignant PTEC state have remained unclear. Immunotherapy targeting checkpoints have revolutionized the management of ccRCC, but a sustained clinical response is achieved in only a minority of ccRCC patients. This indicates that our understanding of the mechanisms involved in the malignant transition and resistance to immune checkpoint therapy in ccRCC is unclear. This review examines recent single-cell transcriptomics studies of ccRCC to clarify the transition of PTEC in ccRCC development, and the immune cell types, states, and interactions that may limit the response to targeted immune therapy, and finally suggests stromal cells as key drivers in recurrent and locally invasive ccRCC. These and future single-cell transcriptomics studies will continue to clarify the cellular milieu in the ccRCC microenvironment, thus defining actional clinical, therapeutic, and prognostic characteristics of ccRCC.

CD103+ Tissue Resident T-Lymphocytes Accumulate in Lung Metastases and Are Correlated with Poor Prognosis in ccRCC

Clear cell renal cell carcinoma (ccRCC) is a highly immunogenic tumor with variable responses to immune checkpoint therapy. The significance of the immune cell infiltrate in distant metastases, their association with the immune infiltrate in the primary tumors and their impact on prognosis are poorly described. We hypothesized that specific subtypes of immune cells may be involved in the control of metastases and may have an impact on the prognosis of ccRCC. We analyzed the immune microenvironment in ccRCC primary tumors with distant metastases, paired distant metastases and non-metastasized ccRCC (n = 25 each group) by immunohistochemistry. Confirmatory analyses for CD8+ and CD103+ cells were performed in a large ccRCC cohort (n = 241) using a TCGA-KIRC data set (ITGAE/CD103). High immune cell infiltration in primary ccRCC tumors was significantly correlated with the development of distant tumor metastasis (p < 0.05). A high density of CD103+ cells in ccRCC was more frequent in poorly differentiated tumors (p < 0.001). ccRCCs showed high levels of ITGAE/CD103 compared with adjacent non-neoplastic tissue. A higher density of CD103+ cells and a higher ITGAE/CD103 expression were significantly correlated with poor overall survival in ccRCC (log rank p < 0.05). Our results show a major prognostic value of the immune pattern, in particular CD103+ cell infiltration in ccRCC, and highlight the importance of the tumor immune microenvironment.

Renal cell carcinoma and viral infections: A dangerous relationship?

Virus-related cancers in humans are widely recognized, but in the case of renal cancer, the link with the world of viruses is not clearly established in humans, despite being known in animal biology. In the present review, we aimed to explore the literature on renal cell carcinoma (RCC) for a possible role of viruses in human RCC tumorigenesis and immune homeostasis, hypothesizing the contribution of viruses to the immunogenicity of this tumor. A scientific literature search was conducted using the PubMed, Web of Science, and Google Scholar databases with the keywords “virus” or “viruses” or “viral infection” matched with (“AND”) “renal cell carcinoma” or “kidney cancer” or “renal cancer” or “renal carcinoma” or “renal tumor” or “RCC”. The retrieved findings evidenced two main aspects testifying to the relationship between RCC and viruses: The presence of viruses within the tumor, especially in non-clear cell RCC cases, and RCC occurrence in cases with pre-existing chronic viral infections. Some retrieved translational and clinical data suggest the possible contribution of viruses, particularly Epstein-Barr virus, to the marked immunogenicity of sarcomatoid RCC. In addition, it was revealed the possible role of endogenous retrovirus reactivation in RCC oncogenesis, introducing new fascinating hypotheses about this tumor’s immunogenicity and likeliness of response to immune checkpoint inhibitors.

Metastatic Clear Cell Renal Cell Carcinoma: The Great Pretender and the Great Dilemma

Metastatic renal cell carcinoma (mRCC) may present with a wide range of clinical pictures. Reportedly, paraneoplastic syndromes are the first sign in 20% of cases and only 15% of cases show the classic triad (flank pain, gross hematuria, and palpable abdominal mass) at presentation. The remaining cases present with signs and symptoms related to the site of distant metastases. These data may explain the reason why about 20-30% of patients are metastatic at presentation. We report the case of a 63-year-old woman who came to our attention for lower back pain. After imaging studies, we detected a left kidney mass of 86 × 61 × 79 mm, multiple right pulmonary nodules and six bone lesions. She underwent left radical nephrectomy. After 1 month, she developed signs of spinal cord compression with neurological deficits and she underwent emergency spinal decompression. In order to allow complete motor recovery, the subsequent stereotactic body radiation therapy was not performed, and she is currently taking combination immunotherapy regimens. Management of mRCC is in a continuous evolution due to availability of new target therapies and the possibility of a multimodal approach with surgical, focal and radiotherapy treatments. However, the ideal treatment algorithm is yet to come. This is why mRCC diagnosis and management are still challenging for the clinicians.

Development and initial clinical testing of a multiplexed circulating tumor cell assay in patients with clear cell renal cell carcinoma

Although therapeutic options for patients with advanced renal cell carcinoma (RCC) have increased in the past decade, no biomarkers are yet available for patient stratification or evaluation of therapy resistance. Given the dynamic and heterogeneous nature of clear cell RCC (ccRCC), tumor biopsies provide limited clinical utility, but liquid biopsies could overcome these limitations. Prior liquid biopsy approaches have lacked clinically relevant detection rates for patients with ccRCC. This study employed ccRCC-specific markers, CAIX and CAXII, to identify circulating tumor cells (CTC) from patients with metastatic ccRCC. Distinct subtypes of ccRCC CTCs were evaluated for PD-L1 and HLA-I expression and correlated with patient response to therapy. CTC enumeration and expression of PD-L1 and HLA-I correlated with disease progression and treatment response, respectively. Longitudinal evaluation of a subset of patients demonstrated potential for CTC enumeration to serve as a pharmacodynamic biomarker. Further evaluation of phenotypic heterogeneity among CTCs is needed to better understand the clinical utility of this new biomarker.

Tumour Seeding After a Thoracic Biopsy for Renal Cell Carcinoma: A Case Report and a Review of the Literature

The role of percutaneous tumour biopsies had gain importance in the management of renal cell carcinoma to provide diagnostic specimen for the patients with metastatic disease that could benefit a systemic treatment. Among the possible complications of this procedure, however, there is the risk of tumoral cells seeding along the biopsy’s tract; this complication, albeit being reported as anecdotal, could have devastating effects. Here we report a case of a young male who developed subcutaneous chest metastasis of renal cell carcinoma after a biopsy of a lung nodule. We subsequently reviewed other cases reported in literature

PSA-IgM and iXip in the diagnosis and management of prostate cancer: clinical relevance and future potential. A review

The Prostate Specific Antigen (PSA) is the first filter in the diagnosis of prostate cancer. Unfortunately, it is organ-specific but not cancer-specific. In addition, some prostate cancers are not clinically-significant and their diagnosis and treatment may lead to overdiagnosis and overtreatment. For these reasons, other markers have been proposed in the last years, such as PCA3 and PHI, but none of these are currently used in the clinical practice on large scale. In the last decade, PSA-IgM and the algorithm iXip have emerged for the diagnosis of prostate cancer and showed to perform well in decreasing the detection of clinically-insignificant prostate cancer and in reducing the number of unnecessary prostate biopsies. This review focuses on data reported in the literature on PSA-IgM and iXip as well as on the future perspectives of their usage in the clinical practice on large scale.

PD1/PD-L1 Axis in Uro-oncology

The immune system is important to control tumor development and progression in humans. However, tumor cells and cells of the tumor microenvironment can induce immune escape mechanisms including activation of immune checkpoints such as PD-1/PD-L1. Based on this knowledge, new immune therapies, including PD-1 and PD-L1 inhibition, have been developed and are already recommended as a standard treatment in metastatic bladder and kidney cancer patients. In addition to its role as a therapeutic target, PD-L1 seems to be a prognostic parameter although data are controversial. Only little is known about signaling pathways inducing PD-L1 expression in tumor cells on one hand and about its functional role for tumor cells itself. However, the understanding of the complex biological function of PD-L1 will improve therapeutic options in urological malignancies. This review is giving an overview of the current knowledge concerning the PD-1/PD-L1 axis in urological tumors including bladder, kidney, prostate, testicular and penile cancer.

Abscopal effect after hypofractionated radiotherapy in metastatic renal cell carcinoma pretreated with pazopanib

Background: The abscopal effect consists of distant metastases response after local treatment based on systemic immune stimulation. It is a rare event observed in many tumors, especially with radiotherapy and immunotherapy. Clinical case: We report the long-term abscopal effect in a metastatic renal cell carcinoma patient with lung metastasectomy, after hypofractionated radiotherapy on lymph node metastasis. The patient was pretreated with pazopanib, which was discontinued early owing to toxicity before radiotherapy. Methodology: Immunohistological analyses of the primary tumor and metastases were performed. Discussion: We supposed that radiotherapy, and maybe tyrosine kinase inhibitors, could act as immune-primers for abscopal effect modifying the immune tumor microenvironment. Conclusion: Future studies are needed to optimize the combination of radiotherapy with systemic therapy for better long-term tumor control in selected patients.

The pattern and prognostic relevance of immune activity scores and tumor-infiltrating immune cells in metastatic clear cell renal cell carcinoma: Evidence from multiple datasets

PURPOSE

To investigate the immune activity scores (IAS) and tumor-infiltrating immune cells (TIIC) in metastatic clear cell renal cell carcinoma (mccRCC) patients and to explore their patterns and potential prognostic values.

METHODS

The gene expression profiles and clinical information of ccRCC patients from multiple Gene Expression Omnibus (GEO) datasets and TCGA were used as study cohorts. Overall, 3 sets of 69 variables associated with tumor-immune interactions were collected from several tumor immunophenotype analysis websites. Least absolute shrinkage and selection operator (LASSO) and area under receiver operating characteristic (AUC) analyses were performed to establish and evaluate the predictive models.

RESULTS

Several TIIC and IAS variables are significantly different between patients and between different sites within the same patient. The AUC of the multivariable logistic models based on IAS and the two TIIC groups is 0.705 (95%CI 0.643-0.766), 0.719 (95%CI 0.650-0.788), and 0.685 (95%CI 0.623-0.747), respectively. The AUC of the LASSO model is 0.715 (95%CI 0.652-0.777). Certain subtypes identified by the consensus clustering method show a favorable OS (log-rank, p < 0.01) in both nonmetastatic and metastatic ccRCC patients.

CONCLUSION

IAS and TIIC could vary between patients and different sites within the same patient, and distinct patterns of these variables could correlate with clinical features. Heterogeneity might exist in the biological process of metastasis. LASSO logistic regression reveals that the infiltration of two TIICs would be a predictor of metastatic ccRCC. Last, certain subtypes may have a better prognosis in both ccRCC and mccRCC patients.

Management of oligometastatic and oligoprogressive renal cell carcinoma: state of the art and future directions

INTRODUCTION

The aim of this paper was to perform a narrative review of the literature on the available approaches in the treatment of two emerging subpopulations of metastatic renal cell carcinoma (mRCC) patients: the oligometastatic disease (less than 5 metastasis) and the oligoprogressive disease, defined as worsening in maximum 3-5 sites while all other tumor sites are controlled by systemic therapy.

AREAS COVERED

We explore all possible approaches in these settings of patients: the role of local therapies, considering both surgical metastasectomy and/or ablative techniques, the efficacy of systemic therapies and the rationale behind active surveillance. We also discuss ongoing clinical trials in these settings.

EXPERT OPINION

Two different strategies are emerging as the most promising for the approach to the oligometastatic/oligoprogressive mRCC patient: (1) the use of immunocheckpoint inhibitors following metastasectomy; (2) the use of stereotactic radiotherapy alone or combined with immunotherapy for oligometastatic disease. The lack of validated biomarkers of response in these mRCC patient subpopulations is opening the way to the employment of novel technologies. Among them, the use of artificial intelligence seems to be the candidate to contribute to precision oncology in patients with mRCC.

Optimizing PD-L1 evaluation on cytological samples from advanced non-small-cell lung cancer

Aim: Programmed cell death-ligand 1 (PD-L1) predicts response to immune checkpoint inhibitors in non-small-cell lung cancer (NSCLC) patients. Most NSCLCs are diagnosed at an advanced stage and using minimally invasive diagnostic procedures that yield small biopsies or cytological samples. Methods: Cytological smears and paired histological samples from 52 advanced NSCLC patients were tested for PD-L1 expression by immunocyto/histochemistry (ICC/IHC) and for PD-L1 gene status by FISH. Results:PD-L1 was overexpressed in 9/52 (17%) cytological samples and in seven (13.5%) matched biopsies. The concordance between immunocytochemistry and IHC was 92.3% (48/52; p < 0.001). The concordance between PD-L1 gene status on cytology and histology was 69.2% (18/26; p < 0.001). No correlation between IHC and fluorescence in situ hybridization results was found. Conclusion: Our data support the feasibility and reliability of PD-L1 protein and PD-L1 gene assessment on direct cytological smears from NSCLC patients whenever histological sample are inadequate.