Application of Genomic Sequencing to Refine Patient Stratification for Adjuvant Therapy in Renal Cell Carcinoma

PURPOSE

Patients with resected localized clear-cell renal cell carcinoma (ccRCC) remain at variable risk of recurrence. Incorporation of biomarkers may refine risk prediction and inform adjuvant treatment decisions. We explored the role of tumor genomics in this setting, leveraging the largest cohort to date of localized ccRCC tissues subjected to targeted gene sequencing.

EXPERIMENTAL DESIGN

The somatic mutation status of 12 genes was determined in 943 ccRCC cases from a multinational cohort of patients, and associations to outcomes were examined in a Discovery (n = 469) and Validation (n = 474) framework.

RESULTS

Tumors containing a von-Hippel Lindau (VHL) mutation alone were associated with significantly improved outcomes in comparison with tumors containing a VHL plus additional mutations. Within the Discovery cohort, those with VHL+0, VHL+1, VHL+2, and VHL+≥3 tumors had disease-free survival (DFS) rates of 90.8%, 80.1%, 68.2%, and 50.7% respectively, at 5 years. This trend was replicated in the Validation cohort. Notably, these genomically defined groups were independent of tumor mutational burden. Amongst patients eligible for adjuvant therapy, those with a VHL+0 tumor (29%) had a 5-year DFS rate of 79.3% and could, therefore, potentially be spared further treatment. Conversely, patients with VHL+2 and VHL+≥3 tumors (32%) had equivalent DFS rates of 45.6% and 35.3%, respectively, and should be prioritized for adjuvant therapy.

CONCLUSIONS

Genomic characterization of ccRCC identified biologically distinct groups of patients with divergent relapse rates. These groups account for the ∼80% of cases with VHL mutations and could be used to personalize adjuvant treatment discussions with patients as well as inform future adjuvant trial design.

Abstract LB113: Genomic classification to refine prognosis in clear cell renal cell carcinoma

Renal cell carcinomas (RCC) are characterized by their heterogenous clinical outcomes, and due to their indeterminate behavior and the absence of routine biomarkers, it is difficult to identify patients who are at high-risk for relapse after curative nephrectomy. To identify genomic biomarkers for clear cell RCC (ccRCC) risk-stratification we interrogated somatic mutation status of 12 RCC-relevant genes using next-generation sequencing (NGS) in tumor-normal pairs from 943 patients with matched follow up data from the Cancer Genomics of the Kidney (CAGEKID) study. We examined associations between genomically-defined patient groups, explained below, and disease-free as well as RCC-specific survival independently in two cohorts of patients (N=469 for cohort 1; 474 for cohort 2). We used the Kaplan-Meier method with log-rank tests to compare survival functions, and Cox proportional hazards models to stratify for patient stage and age to estimate association of each group with survival. RCC-specific survival was assessed with a competing-risks method to include deaths from other causes. Within these cohorts, 76.4% of patients harbored somatic mutations in VHL, the most common driver gene in ccRCC. The most commonly mutated genes within VHL-mutated tumors were PBRM1 (39.7%), SETD2 (19%), BAP1 (14.3%), and KDM5C (8.3%). Less frequently mutated genes included ATM, COL11A1, DMD, TP53, and TRRAP (~3-5%).Among VHL-driven tumors, we identified a new genomic classifier on the basis of the number of mutations in additional RCC driver genes in the panel examined. Patients were classified based on the presence of mutations only in VHL (VHL+0), those with mutations in VHL and one other driver gene (VHL+1), two other driver genes (VHL+2), and 3 or more other driver genes (VHL≥3). We observed within both cohorts that both the risk of disease recurrence as well as RCC-specific death were associated with an increased number of mutations within this classification. When stratified for patient stage and age, the hazard-ratio for 5-year disease-free survival for VHL≥3 patients was 6.69 (p=0.000212), 4.31 for VHL+2 (p=0.000862), and 2.43 for VHL+1 (p=0.035662), compared to patients with only mutations in VHL. These observations were replicated in the second patient cohort, with hazards ratios of 4.55, 2.49, and 1.40, for VHL≥3, VHL+2, and VHL+1 classified patients respectively, indicating that risk of disease recurrence increases with the number of driver mutations. Notably, tumor mutational burden (TMB) was not significantly different between the aforementioned groups, demonstrating that our classifier is independent of TMB. We created a model based on a set of 12 RCC-relevant genes, which can predict risk of relapse for the ~80% of patients with ccRCC that are VHL-driven. This classification can be defined based on a small panel of genes, making it easily applicable to the clinic, in the context of tumor or liquid biopsy analysis.

Citation Format: Kate I. Glennon, Naveen S. Vasudev, Ghislaine Scelo, Michelle Wilson, Louis Letourneau, Robert Eveleigh, Nazanin Nourbehesht, Madeleine Arseneault, Antoine Paccard, Lars Egevad, Juris Viksna, Edgars Celms, Sharon M. Jackson, Behnoush Abedi-Ardekani, Anne Y. Warren, Peter J. Selby, Sebastian Trainor, Michael Kimuli, Naeem Soomro, Adebanji Adeyoju, Poulam Patel, Magdalena B. Wozniak, Ivana Holcatova, Antonin Brisuda, Vladimir Janout, Estelle Chanudet, David Zaridze, Anush Moukeria, Oxana Shangina, Lenka Foretova, Marie Navratilova, Dana Mates, Viorel Jinga, Ljiljana Bogdanovic, Bozidar Kovacevic, Anne Cambon-Thomsen, Guillaume Bourque, Alvis Brazma, Jörg Tost, Paul Brennan, Mark Lathrop, Yasser Riazalhosseini, Rosamonde E. Banks. Genomic classification to refine prognosis in clear cell renal cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB113.

Knowledge and attitudes on medical waste management among Belgrade medical and dental students

Introduction/Objective. Knowledge and practical skills in medical waste (MW) management are of equal importance for medical and dental doctors. The first comparative study on the knowledge and skills in the field of MW management among Belgrade students was conducted with the goal of examining whether students of medicine and dentistry are equally familiar with this extremely important field. Methods. A cross-sectional study included 558 students of the sixth year of studies (430 medical and 128 dental students) who completed an anonymous semi-structured questionnaire to determine attitudes and knowledge on MW management. Results. The majority of medical and dental students had no training in MW management (79.5% and 74.6%, respectively). Dental students use protective equipment more frequently than medical students (94.5% vs. 42%, p < 0.001). However, full vaccinal protection against hepatitis B is better among medical students compared to dental students (57.7% vs. 39.1%, p < 0.001). Complete knowledge on postexposal prophylaxis is better among medical students compared to dental students (44.5% vs. 13.3%, p < 0.001). However, dental students are more disciplined in reporting injuries (63.1% vs. 52.4%, p = 0.038). The students? knowledge on primary separation of infectious waste (93% vs. 77.8%, p < 0.001) and used needles (80.3% vs. 70.4%, p = 0.007) is better among dental students compared to medical students? correct answers. Conclusion. Dental students show better knowledge on MW management and are more disciplined in using personal infection protection compared to medical students. The students support continued training on MW management and investigations on this topic.

Immunohistochemical study of cyclin A and p16 expression in patients with renal cell carcinoma

PURPOSE

Renal cell carcinoma (RCC) is the most common malignant kidney tumor in adults. Dysregulation of the cell cycle can lead to cancer development. In this study, the mitosis-associated cyclin A and p16, a negative controller, were investigated as potential key points in the RCC development.

METHODS

This retrospective study included 74 patients with RCC. The expression of cyclin A and p16 and their correlation to histopathological parameters (TNM stage, histological subtype, nuclear grade, tumor size), gender, age, and clinical outcome were studied and analyzed.

RESULTS

The highest median value for cyclin A (40%; range 0-70)) and for p16 (57.5%); range 35-80) were found in the papillary histological subtype. Survival analysis showed that in the group of patients that had died before September 2015, the median value for cyclin A was 20% (range 0-60), which was significantly higher than 5% (range 0-70), found in the group of patients that survived (p=0.019).

CONCLUSIONS

In relation to the histological subtype, the papillary type of RCC was associated with a significantly higher expression of cyclin A and p16 compared to other subtypes of RCC. High expression of cyclin A indicated worse prognosis, therefore cyclin A could be considered to be a significant prognostic marker.

Acute Renal Failure in Different Malignant Tumors

Acute renal failure (ARF) represents a severe complication of malignancies, that causes significant morbidity and mortality. ARF is a common part of multiple organ dysfunction in critically ill patients with cancer with reported mortality rates from 72% to 85% in patients who need renal replacement therapy. The pathways leading to ARF in cancer patients are common to the development of ARF in other conditions. However, certain factors leading to the development of ARF may be associated to the tumor or to the tumor therapy. The purpose of this review is to give specific aspects of renal disease in critically ill cancer patients (CICPs), to overview the causes of ARF in CICPs and to describe recent progress in the management of these complications, including treatment toxicity and bone marrow transplantation (BMT). The prevention of ARF is obligatory and therefore the possible treatments of ARF in CICPs are also discussed.

Polymorphisms of survivin -31 G/C gene are associated with risk of urothelial carcinoma in Serbian population

PURPOSE

Survivin is thought to play an important role in carcinogenesis and is found to be associated with poor clinical outcome in various malignancies. Gene -31 G/C polymorphism has been identified as a risk factor for the development of several types of tumors. The purpose of this study was to investigate the association between survivin gene promoter -31C/G polymorphism and urothelial carcinoma (UC) risk in Serbian population and to compare the different expressions of survivin in UC of different disease stages, histological grades and tumor location in the upper or lower urinary tract.

METHODS

DNA from 94 patients with primary UC and from 82 healthy subjects was subjected to PCR restriction fragment length polymorphism analysis (PCR-RFLP) to identify individual genotypes. UC samples were subjected to immunohistochemical analysis to assess survivin expression in these lesions.

RESULTS

It was observed that the frequency of G/G genotype was greater in patients with UC (58.7%) than in controls (32%). Compared with study subjects carrying the C/G or C/C genotypes, significantly increased UC risk was found for individuals carrying the G/G genotype. Those carrying the G/G genotype had a significantly increased UC risk compared with those with C/G or C/C genotypes. Patients with UC carrying the G/G genotype had a greater prevalence of muscle-invading (stage T2-T4), high-grade (G2) tumor and immunohistochemicaly overexpressed survivin compared with those carrying the C/G or C/C genotypes.

CONCLUSIONS

G/G genotype of the -31C/G polymorphism might be a risk factor for UC development.

Cytomegalovirus induces Interleukin-6 mediated inflammatory response in salivary gland cancer

PURPOSE

The purpose of this study was to examine whether cytomegalovirus (CMV) is present in different histological types of salivary gland cancer (SGC) by detecting CMV immediate-early (IE) and early gene products, and to determine the presence of its association with the overexpression of interleukin (IL)-6.

METHODS

Immunohistochemical analysis of 92 cases of different histological types of SGC was performed to determine the presence of IL-6 and CMV antigen and its intensity in tumor tissue. Twenty samples of normal salivary gland tissue obtained during autopsy served as healthy controls.

RESULTS

CMV antigens were not found in healthy acinar tissue of salivary glands, but were expressed in epithelium of salivary gland ducts. Negative expression of CMV antigens was also found in salivary gland tissue surrounding tumors. On the other hand, CMV was detected in 65/92 SGC cases (70.6%). Higher expression of IL-6 was found in SGC (70.7%) than in normal tissue (20%). There was a high association of CMV antigen presence with the presence of IL-6, and with the IL-6 expression intensity.

CONCLUSIONS

Positive expression of CMV antigens in a high percentage of SGC cells suggests that it might play an important role in carcinogenesis by increasing IL-6 production and leading to inhibition of apoptosis and tumor development.

Unexpectedly high occurrence of Escherichia coli and Staphylococcus aureus isolates from raw milk in Ilam, Western Iran

Raw milk contains diverse nutritional components that provide a suitable medium for spoilage and the growth of potentially pathogenic microorganisms. Unpasteurized milk consumption by a large number of people can threaten health and increase public concerns. In this study, sixty-two raw cow’s milk samples were collected from the dairy farms of Ilam, Western Iran. All samples were collected in sterilized containers and were transferred via ice boxes to the laboratory. Isolates were then identified by standard methods. Totally, 88.7% (n=55) of samples were contaminated. Our study also showed that Escherichia coli had a high prevalence among isolates (43: 69.4%), while Klebsiella pneumoniae and Klebsiella planticola showed the lowest prevalence (1: 1.6%). Staphylococcus aureus was also detected in 17.7% (n=11) of samples. The raw milk microbial contamination is complex. Some of the microorganisms threaten public health via different traits, therefore it is recommended that raw milk consumption should be avoided.

The prevalence rate of Porphyromonas gingivalis and its association with cancer: A systematic review and meta-analysis

It seems that Porphyromanas gingivalis is carcinogenic, because it activates a number of inflammatory immune responses in the host and causes disorders in bacterial clearance mechanisms. There is little information on the prevalence of this bacterium in cancer patients. The aim of this study was to evaluate and compare the prevalence of P. gingivalis in cancer patients by meta-analysis methods.Different databases including PubMed, EMBASE, the Cochrane Library, Scopus, and ISI web of Knowledge were investigated and eight relevant articles published in 2000-2013 were finally analyzed. Data were analyzed by meta-analysis method, fixed effect model. I² statistics were calculated to examine the heterogeneity of papers. The information was analyzed by R and STATA Ver 12.2.A total of 711 people infected with P. gingivalis were included in this study. In total, the prevalence of P. gingivalis was 40.7% (95% CI, 19.3-62.1). The prevalence of P. gingivalis was evaluated in four case-control studies. The results of this study showed that P. gingivalis increased the chance of cancer development and periodontal disease as much as 1.36 times (OR, 1.36; 95%CI, 0.47-3.97).Although there was no significant correlation between P. gingivalis and cancer, this bacterium increased the chance of cancer and periodontal disease and could be considered as a main potential risk factor.

Prognostic value of survivin expression in Wilms tumor

PURPOSE

To determine survivin expression patterns in Wilms tumor (WT) and compare it with the expression in normal renal tissue. Also, to analyse cytoplasmic and nuclear survivin expression in relation to histological type, prognostic group and tumor stage.

METHODS

Immunohistochemical expression of survivin was analysed in 59 cases of primary WT and in 10 normal kidney specimens, taken from the same patients, but distant from the tumor.

RESULTS

51 out of 59 cases of WT (86.44%) showed decreased cytoplasmic survivin expression and 4 out of 59 cases of WT (6.78%) showed nuclear overexpression of survivin. There was statistically significant difference in the frequency of decreased cytoplasmic expression of survivin in individual components of WT (p=0.005). Decreased cytoplasmic expression of survivin in epithelial, blastemal and stromal component was found significantly more often in low stage WT compared to high stage WT (Fisher exact test, p=0.0002, p=0.002, p=0.002, respectively). There was no statistically significant difference in the frequency of survivin nuclear overexpression between different stages of WT (Fisher exact test, p=0.564), histological types (Fisher exact test, p=0.915), or between different prognostic groups (Fisher exact test, p=1).

CONCLUSION

Decreased survivin cytoplasmic expression or nuclear overexpression may be related to favorable prognosis of WT.

Malignant diseases as suicidal motives

Introduction Suicide is a conscious and intentional destruction of one?s own life, which occurs as a result of mutual influence of a person?s disposition and motives (facts inspiring the commitment of suicide). It is well known that various diseases, including malignancies, could be important and in some cases the only motive for committing suicide. Objective The purpose of the study was to analyze in detail suicides of persons whose only motive was an established malignant disease. Method The analysis was performed using the autopsy material of the Institute of Forensic Medicine, School of Medicine, University of Belgrade, during the period from 1990 to 2004. The reports on performed medico-legal autopsies were used, as well as history data obtained from the family members of suicidal persons, investigation reports and the available medical documents. Results In 1931 cases there was established suicidal nature of a violent death. Neoplasms were the suicidal motive in 37 persons (1.9%). The basic characteristics of the analyzed sample were predominance of males (26:11, ratio 2.4:1), the age of over 70 years and the highest incidence of malignant lung and breast tumors. Almost all cases were the persons who underwent treatment for malignant neoplasms over a longer period of time. During 19 autopsies (51.3% out of 37), a progressive phase of malignancy was established, i.e. metastases. The data on prior oral announcement of suicide intention were obtained for 70.3% (26 cases), and on previous suicidal attempts only for 13.5% (5) cases. In the majority of cases (78.4%) the place of committed suicide was the person?s home. In 16 cases (43.2%) the suicide was committed with a firearm. Hanging as a manner of destroying one?s own life was chosen by 12 persons (32.4%), while other ways were less frequently used. Conclusion Although malignancies were not present with high incidence as a suicidal motive in our analyzed sample, such cases require particular care of health workers in order to enable the application of adequate measures in the prevention of suicides in persons with malignant diseases. The suicide analyses performed so far indicated that a malignant disease was the motive. Doctors have to show maximal interest for the patient. Prevention is crucial, so the patient should be provided with such surroundings in which the person will not feel alone and abandoned.