The DDD score outperforms the RENAL score in predicting high-grade renal cell carcinoma

OBJECTIVES

To explore the relationship between Fuhrman grade of renal cell carcinoma (RCC) and the DDD score.

METHODS

We reviewed the records of 527 nonmetastatic RCC patients. Demographic, clinical, and pathologic characteristics were reviewed. Binary logistic regression was used to explore the independent risk factors for high-grade RCC (HGRCC).

RESULTS

Sex, BMI (Body Mass Index), RNS, and DDD score were significantly correlated with HGRCC. Based on these independent risk factors, we constructed two predictive models integrating the RNS and DDD scores with sex and BMI to predict tumor grade. The calibration curves of the predictive model showed good agreement between the observations and predictions. The concordance indexes (C-indexes) of the predictive models were 0.768 (95% CI, 0.713-0.824), and 0.809 (95% CI, 0.759-0.859). Receiver operating characteristic (ROC) curves were performed to compare the predictive power of the nomograms, and the prediction model including the DDD score had better prognostic ability (p = 0.01).

CONCLUSIONS

This study found that RNS, DDD score, BMI, and sex were independent predictors of HGRCC. We developed effective nomograms integrating the above risk factors to predict HGRCC. Of note, the nomogram including the DDD score achieves better prediction ability for HGRCC.

Toripalimab plus axitinib versus sunitinib as first-line treatment for advanced renal cell carcinoma: RENOTORCH, a randomized, open-label, phase III study

BACKGROUND

Immune checkpoint inhibitors in combination with tyrosine kinase inhibitors are standard treatments for advanced clear cell renal cell carcinoma (RCC). This phase III RENOTORCH study compared the efficacy and safety of toripalimab plus axitinib versus sunitinib for the first-line treatment of patients with intermediate-/poor-risk advanced RCC.

PATIENTS AND METHODS

Patients with intermediate-/poor-risk unresectable or metastatic RCC were randomized in a ratio of 1 : 1 to receive toripalimab (240 mg intravenously once every 3 weeks) plus axitinib (5 mg orally twice daily) or sunitinib [50 mg orally once daily for 4 weeks (6-week cycle) or 2 weeks (3-week cycle)]. The primary endpoint was progression-free survival (PFS) assessed by an independent review committee (IRC). The secondary endpoints were investigator-assessed PFS, overall response rate (ORR), overall survival (OS), and safety.

RESULTS

A total of 421 patients were randomized to receive toripalimab plus axitinib (n = 210) or sunitinib (n = 211). With a median follow-up of 14.6 months, toripalimab plus axitinib significantly reduced the risk of disease progression or death by 35% compared with sunitinib as assessed by an IRC [hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.49-0.86; P = 0.0028]. The median PFS was 18.0 months in the toripalimab-axitinib group, whereas it was 9.8 months in the sunitinib group. The IRC-assessed ORR was significantly higher in the toripalimab-axitinib group compared with the sunitinib group (56.7% versus 30.8%; P < 0.0001). An OS trend favoring toripalimab plus axitinib was also observed (HR 0.61, 95% CI 0.40-0.92). Treatment-related grade ≥3 adverse events occurred in 61.5% of patients in the toripalimab-axitinib group and 58.6% of patients in the sunitinib group.

CONCLUSION

In patients with previously untreated intermediate-/poor-risk advanced RCC, toripalimab plus axitinib provided significantly longer PFS and higher ORR than sunitinib and had a manageable safety profile TRIAL REGISTRATION: ClinicalTrials.gov NCT04394975.

Stereotactic Ablative Radiotherapy Boost to Bladder Tumor for Bladder Preservation in Patients with Muscle-Invasive Bladder Cancer

PURPOSE/OBJECTIVE(S)

Previous studies showed that selective bladder-sparing approach using TMT is an established therapy of MIBC with outcomes that are comparable to those of radical cystectomy. However, it has been shown that the 5-year local recurrence in the bladder is greater than 40% after TMT. One of the possible reasons was that the RT dose to the bladder tumor or tumor bed was insufficient. Thus, we assessed the effectiveness and safety of Stereotactic Ablative Radiotherapy (SABR) boost to bladder tumor or tumor bed for patients with muscle invasive bladder cancer (MIBC).

MATERIALS/METHODS

A total of 59 consecutive patients with cT2-4 bladder cancer underwent transurethral resection of bladder tumor (TURBT). TURBT was visibly complete in 25 cases. Patients received SABR to the tumor or tumor bed in the bladder followed by conventionally fractionated RT (CFRT) to pelvis and total bladder with concomitant weekly radio-sensitizing chemotherapy. During SABR intravesical installation of isovolumetric saline through urinary catheter ensured adequate bladder filling. Response rate was assessed by cystoscopic evaluation and pelvic MRI or CT. Toxicities were reported per the RTOG acute and late Radiation Morbidity Scoring Schema.

RESULTS

The median age of all patients was 76 years (35-90 years). All patients completed SBRT boost and 61% patients received concurrent Gemcitabine chemotherapy. After a median follow-up time of 28 months, the rate of local control (LC) at 3 years was 90.0%. The overall survival (OS) and cancer-specific survival (CSS) rates at 3 years were 61.6% and 77.5%, respectively. Of the surviving patients, 84.4% have a disease-free and functioning bladder. Acute grade 3 gastrointestinal (GI) or genitourinary (GU) toxicities occurred in only 1.7% of the patients. Late grade 3 GU toxicity occurred in 5.1% of the patients. No patients experienced grade 4 GI or GU toxicities.

CONCLUSION

SABR boost followed by chemoradiation to the pelvis was found to be a well-tolerated and effective treatment for MIBC patients who are either not candidates for cystectomy or who desire bladder preservation. Randomized study is required to further evaluate this novel tri-modality treatment paradigm.

Outcomes of Targeted Therapy Plus Immunotherapy and High-Dose Stereotactic Ablative Body Radiotherapy (SABR) for Metastatic Renal Cell Cancer Patients

PURPOSE/OBJECTIVE(S)

Stereotactic ablative body radiotherapy (SABR) is one of the treatment options for metastatic renal cell carcinoma (mRCC) but is limited by a lack of data to evaluate targeted therapy plus immunotherapy concurrently with high-dose SABR to multiple sites. We evaluated the safety and disease control for mRCC patients who concurrently received the above tri-modality treatment.

MATERIALS/METHODS

Patients were treated with SABR (40-70 Gy/5-10 fractions) for small lesions or partial-SABR (tumor center boosted with 6-8 Gy/3-5 fractions with 50-60 Gy/20-25 fractions to the whole tumor volume) for bulky tumors or tumors adjacent to critical organs. When SABR/partial-SABR was not feasible, a moderate fractionated radiotherapy plan, usually 60Gy/20 fractions were applied. of Targeted therapy plus immunotherapy (PD-1 inhibitor) was not interrupted during or after radiotherapy (RT). Adverse events (AEs) were evaluated. Disease control rate (DCR), objective response rate (ORR), progression-free survival (PFS) and overall survival (OS) were calculated. The PFS1 was defined as the first progression since the start of RT. The PFS2 was defined as the second progression after the second RT course, if new metastases occurred after first RT were all re-irradiated, and the systemic therapy was not changed. The Kaplan-Meier method was used for time-to-event endpoints.

RESULTS

A total of 51 patients, with a median age of 57 yr, were enrolled. The median follow-up was 12 months. There were 75% of patients with intermediate-risk and 18% with favorable-risk disease. 61% of the patients were oligometastatic. 71% had clear cell renal cancer. There were 241 metastases while 161 (67%) were irradiated. 80% of the lesions received SABRP/partial SABR. 1 patient with 14 lesions irradiated received proton therapy. All the surviving patients are continuing using targeted therapy while 81% patients complete at least 1-year PD-1 therapy. 10 patients (20%) had grade 3 drug-related AEs: pneumonitis (n = 2), elevated alanine transaminase (n = 4), myositis (n = 1), hand-foot syndrome myositis (n = 1), enteritis (n = 1), fatigue (n = 1). There were 1 grade 4 AEs of upper gastrointestinal bleeding. No grade 3-5 RT-related AEs was found. ORR and DCR for irradiated lesion were 51% and 98%. Median OS and PFS2 was not reached. Median PFS1 was 14(6-22) months. Estimated 1- and 2-yr OS, PFS1 and PFS2 were 90% and 90%, 56% and 38%, 74% and 51% respectively. Univariate analysis showed that an PFS1 benefit was found in patients who received radiation before systemic therapy failure (p = 0.038).

CONCLUSION

We investigated the high-dose RT in combination of concurrent targeted and immunotherapy in patients with metastatic RCC. We found that this treatment regimen was well tolerated, with good cancer control. Early use of high-dose RT to multi-lesions may improve PFS. Partial-SABR for bulky lesions close to critical organs could be safely and effectively applied under certain circumstances. These encouraging findings warrant further investigation.

Anti-SARS-CoV-2 spike immunoglobulin G and immunoglobulin M titers decline as interval from the second inactivated vaccine dose to the onset of illness is prolonged in breakthrough infection patients

BACKGROUND

Understanding of the early immune response in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) breakthrough infections is limited.

METHODS

Ninety-eight patients with coronavirus disease 2019 (COVID-19) breakthrough infections were divided into two groups, with intervals from receiving the second dose of inactivated vaccine to the onset of illness <60 or ≥60 days.

RESULTS

The median lymphocyte count and the median anti-SARS-CoV-2 spike immunoglobulin G (IgG) and immunoglobulin M (IgM) titers were higher in the <60-day interval group compared with the corresponding medians in the ≥60-day interval group (p = 0.005, p = 0.001, and p = 0.001, respectively). The median interleukin-6 (IL-6) level in the <60-day interval group was significantly lower than the median IL-6 level in the ≥60-day interval group (p < 0.001).

CONCLUSIONS

Our results highlight the different anti-SARS-CoV-2 spike IgG and IgM antibody titers among patients with different intervals from receiving the second dose of inactivated vaccine to the onset of illness.

Treatment-related neuroendocrine prostate cancer managed with partial stereotactic ablative radiotherapy (P-SABR) for long-term survival: a case series

Background

The amount of treatment-related neuroendocrine prostate cancer (t-NEPC) increases after hormonal therapy, especially novel androgen receptor pathway inhibitors (ARPIs). T-NEPC is considered a hormone refractory [androgen receptor (AR)-negative] subtype of prostate cancer. Although tumors are initially responsive to platinum-based chemotherapy, the drugs are only effective for a short time. Therefore, whether or not local treatment can prolong survival is of great concern.

Case Description

In this case series, we discuss 4 t-NEPC cases who were treated with partial stereotactic ablative radiotherapy (P-SABR) for bulky tumors. P-SABR is a radiotherapy regimen that is used in a SABR boost [such as 6 Gy × 4 fractions (f), 8 Gy × 3 f] prior to conventional radiotherapy to enhance the tumor biological effective dose (BED) without increasing the dose to organs at risk. All patients achieved good local control after P-SABR. For patient 1, P-SABR was used for the prostate tumor. After radiotherapy, pathological complete remission (pCR) was achieved, and the prostate lesion remained stable thus far. As of this writing, the patient has been in remission for 3 years after initial t-NEPC diagnosis.

Conclusions

We describe 4 cases and indicate that P-SABR is safe and effective in the treatment of a large prostate mass and may prolong the survival of these patients.

Single-cell transcriptomics reveals a low CD8+ T cell infiltrating state mediated by fibroblasts in recurrent renal cell carcinoma

Purpose

Recurrent renal cell carcinoma(reRCC) is associated with poor prognosis and the underlying mechanism is not yet clear. A comprehensive understanding of tumor microenvironment (TME) of reRCC may aid in designing effective anticancer therapies, including immunotherapies. Single-cell transcriptomics holds great promise for investigating the TME, however, this technique has not been used in reRCC. Here, we aimed to explore the difference in the TME and gene expression pattern between primary RCC (pRCC) and reRCC at single-cell level.

Experimental design

We performed single-cell RNA sequencing analyses of 32,073 cells from 2 pRCC, 2 reRCC, and 3 adjacent normal kidney samples. 41 pairs of pRCC and reRCC samples were collected as a validation cohort to assess differences observed in single-cell sequencing. The prognostic significance of related cells and markers were studied in 47 RCC patients underwent immunotherapy. The function of related cells and markers were validated via in vitro and in vivo experiments.

Results

reRCC had reduced CD8⁺ T cells but increased cancer-associated fibroblasts (CAFs) infiltration compared with pRCC. Reduced CD8⁺ T cells and increased CAFs infiltration were significantly associated with a worse response from immunotherapy. Remarkably, CAFs showed substantial expression of LGALS1 (Gal1). In vitro, CAFs could induce CD8⁺ T cells apoptosis via Gal1. In vivo, knockdown of Gal1 in CAFs suppressed tumor growth, increased CD8⁺ T cells infiltration, reduced the proportion of apoptotic CD8⁺ T cells and enhanced the efficacy of immunotherapy.

Conclusions

We delineated the heterogeneity of reRCC and highlighted an innovative mechanism that CAFs acted as a suppressor of CD8⁺ T cells via Gal1. Targeting Gal1 combined with anti-PD1 showed promising efficacy in treating RCC.

Small bowel obstruction caused by secondary jejunal tumor from renal cell carcinoma: A case report

BACKGROUND

Secondary jejunal tumor from renal cell carcinoma (RCC) is extremely rare in clinical practice and is easily missed and misdiagnosed because of the low incidence and atypical symptoms.

CASE SUMMARY

A 38-year-old male patient was diagnosed pathologically with left RCC after radical nephrectomy in 2012. The patient then suffered multiple lung metastases 2 years later and was treated with oral sorafenib without progression for 6 years. In 2020, an emergency intestinal segmental resection due to intestinal obstruction was required, and postoperative pathology confirmed a jejunal secondary tumor from RCC. The patient had a smooth recovery following surgery. Three months after surgery, the patient was diagnosed with left adrenal metastasis, and subsequent sintilimab therapy has stabilized his condition.

CONCLUSION

This report is written to remind urologists and pathologists of the potential for small intestinal secondary tumors when a patient with a history of RCC seeks treatment for digestive symptoms. Enteroscopy and abdominal contrast-enhanced computed tomography are essential means of examination, but severe cases require immediate surgical intervention despite the lack of a preoperative examination to distinguish tumor attributes.

Effect of voluntary breathing exercises on stable coronary artery disease in heart rate variability and rate-pressure product: a study protocol for a single-blind, prospective, randomized controlled trial

Background

At present, China has more than 11 million patients with stable coronary heart disease and this is becoming a major public health problem. The pathological changes of coronary heart disease can lead to dysfunction of the cardiac autonomic nervous system, which increases the risk of complications such as malignant arrhythmia (ventricular flutter, ventricular fibrillation, etc.), heart rate, systolic blood pressure, and rate-pressure product (RPP), which is highly correlated with myocardial oxygen consumption and indirectly reflects myocardial blood supply and oxygen consumption. Although the guidelines recommend that such patients take drugs to reduce heart rate and myocardial oxygen consumption, the clinical control of heart rate is still not ideal. Thus, in this trial, we will use voluntary breathing exercises as the strategy of exercise rehabilitation for patients with stable coronary artery disease (SCAD), in order to increase the vagus nerve activity and/or reduce the sympathetic nervous activity, help maintain or rebuild the balance of plant nerve system, improve the time-domain index of heart rate variability, reduce the burden on the heart, and relieve patients’ anxiety and other negative emotions.

Methods

This is a 6-month single-blind, randomized controlled clinical trial that will be conducted in the First Affiliated Hospital of Soochow University. A total of 140 patients who fill out the Informed Consent Form are registered and randomized 1:1 into the Voluntary Breathing Exercises (VBE)-based clinical trial monitoring group (n = 70) or the Routine follow-up group (n = 70). The VBE-based clinical trial monitoring group is given VBE training on the basis of conventional treatment and health education, while the control group received conventional health education and follow-up. The primary outcomes will be measured heart rate variability and RPP. Secondary outcomes will include changes in Self-rating Anxiety Scale, total cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, weight, and body mass index.

Discussion

This trial will carry out scientific respiratory exercise for patients with SCAD, which belongs to the category of active secondary prevention for patients, and changes from remedial to pre-protective. VBE is easy to operate and is not limited by time and place. It is important and meaningful to carry out VBE for patients with SCAD. This study will provide considerable evidence for further large-scale trials and alternative strategies for the rehabilitation nursing of patients with SCAD.

Trial registration

Chinese Clinical Trials Registry, 1900024043. Registered on 23 June 2019.

[Evaluating inferior vena cava wall invasion in renal cell carcinoma tumor thrombus with MRI]

OBJECTIVE

To evaluate the diagnostic performance of MRI for the assessment of inferior vena cava (IVC) wall invasion by IVC thrombus in patients with renal cell carcinoma (RCC).

METHODS

We retrospectively collected patients who underwent radical nephrectomy and thrombectomy for RCC between 2010 and 2018 at Peking University First Hospital. All the patients underwent imaging on a 1.5 Tesla or 3.0 Tesla MRI scanner. Fifty-six patients met the inclusion criteria. Preoperative imaging was reviewed by two radiologists blinded to details of the patient's surgical procedure and histopathology. Two radiologists measured the maximum anterior-posterior diameter and coronal diameters of the IVC and renal vein, and the craniocaudal extent of tumor thrombus, and evaluated the MRI features of IVC thrombus, including occlusion of the IVC lumen, the margin of the tumor thrombus (smooth vs. irregular), contact of the IVC thrombus and IVC wall, and altered signal of the IVC wall. Univariable and multivariable associations of clinical and radiographic features with IVC wall invasion were evaluated by Logistic regression.

RESULTS

Of the 56 patients [male: 43, female: 13, mean age: (55.64±0.43) years], 17 (30.36%) were detected with IVC wall invasion, and most were clear cell carcinoma. Tumor thrombus with IVC wall invasion showed an increase in length of IVC thrombus [(7.91±3.59) cm vs. (5.94±3.57) cm, P=0.049], and more features of complete occlusion of the IVC lumen (P=0.002), irregular margin of the IVC thrombs (P=0.005), contact of the IVC thrombus and IVC wall (P=0.001), and altered signal of the low-intensity vessel wall (P<0.001), with a sensitivity of 94.12% and a specificity of 79.49%.

CONCLUSION

The present study indicates that MRI could be a means of evaluating RCC with IVC wall invasion, and the combination of tumor thrombus length and subjective impression of IVC wall invasion achieved a high sensitivity and specificity for diagnosis.

[Clinicopathologic features and prognostic analyses of locally recurrent renal cell carcinoma patients after initial surgery]

OBJECTIVE

To evaluate the clinicopathologic features and potential prognostic predictors of locally recurrent renal cell carcinoma patients after initial surgery.

METHODS

Authors retrospectively analyzed data extracted from 81 patients who were treated for postoperative locally recurrence of renal cell carcinoma from January 2006 to June 2016 in the Department of Urology, Peking University First Hospital. Postoperative locally recurrence of renal cell carcinoma was defined as disease recurring in the remnant kidney, renal fossa, adjacent abdomen, ipsilateral adrenal and retroperitoneal lymph nodes.

RESULTS

In the study, 81 patients were finally included, of whom 43 were initially treated in our hospital and 38 were initially treat in other centers. Partial nephrectomy (PN) was performed for 38 cases (26 in our hospital and 12 in other hospitals) as initial treatment and radical nephrectomy (RN) was conducted for the remnant 43 cases (17 in our hospital and 26 in other hospitals). Overall median recurrence time was 26 months (range: 3-164 months), in which 26 months (range: 3-55 months) for PN cases and 30 months (range: 4-164 months) for RN cases (P=0.009). Sixty-nine patients had single site recurrence, including remnant kidney (n=29), renal fossa (n=20), abdomen (n=4), ipsilateral lymph nodes (n=5), ipsilateral adrenal (n=11), while 12 patients had multiple sites recurrence. Seventy-eight patients were managed by complete surgical resection, while three patients were managed by radiofrequency ablation. Postoperative pathological diagnoses included clear cell carcinoma (n=72), papillary renal cell carcinoma (n=8, 7 cases with type 1, 1 case with type 2) and Xp11 translocation/TFE3 gene fusion renal cell carcinoma (n=1). Complete pathologic information of the initial surgery could be extracted from 43 patients who were initially treated in our hospital. Seventeen patients with initial radical nephrectomy were staged as T1a (n=4), T1b (n=2), T2a (n=1), T3a (n=8), and T3b (n=2). Twenty-six patients with initial partial nephrectomy were staged as T1a (n=18), T1b (n=7), and T3a (n=1). For PN cohort, the patients with T1a stage disease had longer median recurrence time than those with beyond T1a stage disease, and the difference was significant (29 months vs. 18 months, P=0.041). At the end of the follow-up, 58 patients were alive, 4 died and 19 lost the follow-up. Overall, 3-year and 5-year disease free survival rates were 81.9%, and 53.6%, respectively.

CONCLUSION

The present research reported a large-scale single central experience of locally recurrent renal cell carcinoma. The recurrence time of the PN group is shorter than that of the RN group. For patients after PN surgery, median recurrence time is longer for patients with T1a stage tumor when compared with those with stage beyond T1a. Patients can obtain relative long-term survival after complete secondary surgery resection.

Short-term benefit of neoadjuvant hormone therapy in patients with localized high-risk or limited progressive prostate cancer

Purpose: Radical surgery is the preferred method for local high-risk and limited progressive prostate cancer in the routine clinical setting. However, current guidelines do not recommend neoadjuvant hormone therapy (NHT). Opinions regarding NHT vary among individual clinicians. According to the experience gained at our center, we explored the benefits of NHT for patients with prostate cancer during the perioperative period in this study.

Methods: In this retrospective study, we explored the perioperative benefits of NHT among 189 patients with local high-risk or limited progressive prostate cancer who underwent radical prostatectomy and divided them into two groups: the NHT group and the non-NHT group. The NHT regimens were a gonadotropin-releasing hormone (GnRH) agonist alone (3.75/11.25 mg of leuprolide or 3.6/10.8 mg of goserelin acetate), an androgen receptor antagonist (ARA) alone, or a combination of the two. The duration of treatment was <3 months, 3 to 6 months, or >6 months.

Results: We found that NHT could reduce the surgery time and intraoperative hemorrhage, thus reducing the difficulty of surgery; NHT could also improve the postoperative recovery of patients. However, it did not reduce the stage of prostate cancer or positive surgical margin rate.

Conclusions: Neoadjuvant therapy is optional for some patients. We believe that NHT will improve the overall prognosis of patients as progress continues in the medical field in the future.

[The clinical focus and prospect of medical treatments in genitourinary tract tumors]

In recent years, the field of medical treatment of genitourinary tract tumors has made rapid progress. Precision medicine has provided important role in selecting the potential patients. Immunotherapy is a new choice for metastatic disease. The combination therapy has also brought the light for better tumor control. This article briefly introduces these progresses and provides new conception and research directions for treatment of genitourinary tract tumors.

Segmental ureterectomy can be performed safely in patients with urothelial carcinoma of distal ureter

INTRODUCTION

We aimed to compare oncological outcomes by surgery type (segmental ureterectomy [SU] vs. radical nephroureterectomy [RNU]) in a large cohort of patients with upper tract urothelial carcinoma (UTUC) of the distal ureter.

METHODS

We performed a retrospective analysis of 219 patients with UTUC of the distal ureter among 931 patients with UTUC who underwent SU and RNU. Clinicopathological outcomes were evaluated. Cancer-specific survival (CSS), overall survival (OS), local recurrence-free survival (RFS), intravesical recurrence-free survival (IVRFS), contralateral recurrence-free survival, and distal metastasis-free survival were assessed by the Kaplan-Meier method and Cox regression, estimating hazard ratios (HR) and 95% confidence intervals (CIs).

RESULTS

A total of 179 (81.7%) patients underwent RNU and 40 (18.3%) underwent SU: 85 males (47.5%) with RNU and 17 (42.5%) with SU (p=0.568). The median age with RNU and SU was 71 years (range 31-86) and 70 years (range 46-90), respectively (p=0.499). The T stage of the two groups did not differ (p=0.122), nor did mean tumour length (3.35±2.62 vs. 3.25±2.14; p=0.953), grade (p=0.075), tumour necrosis (p=0.634), or followup time (months) (58.1±8.1 vs. 63.7±3.4; p=0.462). The two groups did not differ in CSS (p=0.358) or OS (p=0.206), and surgery type did not predict CSS (HR 0.862; 95% CI 0.469-1.585; p=0.633) or OS (HR 0.764; 95% CI 0.419-1.392; p=0.379). Local RFS was higher with RNU than SU (96.2% vs. 86.0%; p=0.02), but the groups did not differ in IVRFS (p=0.661), contralateral RFS (p=0.183), or distant metastasis-free survival (p=0.078). On multivariate analysis, SU was associated with local RFS (HR 5.069; 95% CI 1.029-24.968; p=0.046) and distant metastasis-free survival (HR 6.497; 95% CI 1.196-35.283; p=0.03). Local RFS was lower with SU than RNU for patients with pT3-4 stage (p=0.006).

CONCLUSIONS

Long-term oncological outcomes were equivalent with SU and RNU in patients with UTUC of the distal ureter. SU affected local recurrence survival, especially with advanced tumour stage, and distant metastasis survival.

The Institute of Urology, Peking University prostatectomy score: a simple preoperative classification of prostate cancer for predicting surgical difficulty and risk

Traditional laparoscopic radical prostatectomy is a treatment choice in many developing countries and regions for most patients with localized prostate cancer; however, no system for predicting surgical difficulty and risk has been established. This study aimed to propose a simple and standard preoperative classification system of prostate cancer using preoperative data to predict surgical difficulty and risk and to evaluate the relationship between the data and postoperative complications. We collected data from 236 patients and divided them into three groups to evaluate and validate the relationships among preoperative, operative, and postoperative data. This new scoring system is based on the body mass index, ultrasonic prostate volume, preoperative prostate-specific antigen level, middle lobe protrusion, and clinical stage. In the scoring group, we classified 89 patients into two groups: the low-risk group (score of <4) and high-risk group (score of ≥4), and then compared the postoperative data between the two groups. The positive surgical margin rate was higher in the high-risk group than low-risk group. The results in validation Groups A and B were similar to those in the scoring group. The focus of our scoring system is to allow for preliminary assessment of surgical difficulty by collecting the patients' basic information. Urologists can easily use the scoring system to evaluate the surgical difficulty and predict the risks of a positive surgical margin and urinary incontinence in patients undergoing laparoscopic radical prostatectomy.

Prognostic significance of the combination of preoperative hemoglobin and albumin levels and lymphocyte and platelet counts (HALP) in patients with renal cell carcinoma after nephrectomy

Background

To evaluate the prognostic significance of the novel index combining preoperative hemoglobin and albumin levels and lymphocyte and platelet counts (HALP) in renal cell carcinoma (RCC) patients.

Methods

We enrolled 1360 patients who underwent nephrectomy in our institution from 2001 to 2010. The cutoff values for HALP, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were defined by using X-tile software. Survival was analyzed by the Kaplan–Meier method, with differences analyzed by the log-rank test. Multivariate Cox proportional-hazards model was used to evaluate the prognostic significance of HALP for RCC.

Results

Low HALP was significantly associated with worse clinicopathologic features. Kaplan-Meier and log-rank tests revealed that HALP was strongly correlated with cancer specific survival (P < 0.001) and Cox multivariate analysis demonstrated that preoperative HALP was independent prognostic factor for cancer specific survival (HR = 1.838, 95%CI:1.260–2.681, P = 0.002). On predicting prognosis by nomogram, the risk model including TNM stage, Fuhrman grade and HALP score was more accurate than only use of TNM staging.

Conclusions

HALP was closely associated with clinicopathologic features and was an independent prognostic factor of cancer-specific survival for RCC patients undergoing nephrectomy. A nomogram based on HALP could accurately predict prognosis of RCC.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0333-8) contains supplementary material, which is available to authorized users.

[Clinical features analysis of metanephric adenoma: a series of 16 cases]

Objective: To study the clinical characteristics, image findings, therapeutic method and prognosis of metanephric adenoma. Method: The clinical characteristic, image findings, operation methods and prognosis of 16 metanephric adenoma patients treated at Department of Urology, Peking University First Hospital from January 2004 to March 2016 were analyzed retrospectively. Results: There were 6 male and 10 female patients in the study. The mean age of patients was 33.7 years (ranging from 14 to 83 years). Two patients came to the hospital because of fever, while other 14 patients had no symptoms and found renal tumor by medical examination. One case was found polythemia vera and another 1 case showed mild anemia. Serum creatine of all the cases were in normal range. The tumor of 11 cases were at left side and 5 cases were at right. All patients took urinary tract ultrasound. Fifteen patients took CT examination. Among them, 14 cases were solid mass and 1 case was cystosolid.CT value was (41±4) HU. CT scan showed that the tumor was slight enhanced and CT value increased to (77±9) HU. Six patients took MRI examination. The MRI showed high or low signal of T1WI or T2WI scans.Tumor size was (4.7±3.9)cm (ranging from 1.7 to 17.5 cm). All 16 patients took operation and 11 of them took laparoscopic surgery while the other 5 cases took open surgery. Eleven cases took partial nephrectomy, 4 cases took nephrectomy and 1 case took nephroureterectomy. The surgical procedures were all successful and no complications occured during perioperative period. All cases were all confirmed metanephric adenoma by postoperative pathology and surgery cut edge were all negative. Immunohistochemical study showed that the positive rate of Vimentin, CD57, AE1/AE3, WT1, CK7 and AMACR respectively were 16/16, 15/16, 12/16, 10/16, 3/16 and 2/16. The median follow-up time of 16 cases was 44 months (ranging from 8 to 125 months) and none had recurrence or metastasis.One case died 125 months after surgery because of advanced age(83 years old). Conclusions: Metanephric adenoma is difficult to be diagnosed relying on clinical characteristics and image features. Pathology can help confirm the diagnosis. Partial nephrectomy is the first choice for operation and can achieve good prognosis. But it still needs a regular follow-up.

Partial nephrectomy for T3aN0M0 renal cell carcinoma: shall we step forward?

Objectives:

To evaluate the prognosis of non-metastatic T3a renal cell carcinoma (RCC) with partial nephrectomy (PN).

Patients and Methods:

We retrospectively evaluated 125 patients with non-metastatic T3a RCC. Patients undergoing PN and radical nephrectomy (RN) were strictly matched by clinic-pathologic characteristics. Log-rank test and Cox regression model were used for univariate and multivariate analysis.

Results:

18 pair patients were matched and the median follow-up was 35.5 (10-86) months. PN patients had a higher postoperative eGFR than RN patients (P=0.034). Cancer-specific survival (CSS) and recurrence-free survival (RFS) did not differ between two groups (P=0.305 and P=0.524). On multivariate analysis, CSS decreased with positive surgical margin and anemia (both P <0.01) and RFS decreased with Furhman grade, positive surgical margin, and anemia (all P<0.01).

Conclusions:

For patients with non-metastatic pT3a RCC, PN may be a possible option for similar oncology outcomes and better renal function.

[The impact to operation safety of preoperative renal artery embolization for management of diameter≥10 cm renal cell carcinoma]

Objective: To study the impact to operation safety of preoperative renal artery embolization for management of ≥10 cm renal cell carcinoma. Methods: The clinical data of 239 cases with ≥10 cm renal cell carcinoma which all had underwent operation in Department of Urology, Peking University First Hospital from January 2002 to December 2014 were retrospectively analyzed. Fifty-three patients underwent preoperative renal artery embolization (therapeutic group) and 186 patients did not (control group). The effect of embolization on operative time, transfusion requirements, hospitalization, ICU stay and perioperative complications were analyzed by comparing the two groups using rank sum test and χ(2) test or Fisher exact test. Results: Comparing the therapeutic group and control group, there was significant difference in tumor location (on the left or right). The mean age, sex, mean primary tumor size, and TNM stage were similar in both groups. Comparing the therapeutic group and control group, there were more open surgeries in therapeutic group (96.2% vs. 82.3%, χ(2)=6.438, P=0.013). There were no significant differences in mean operative time (238 (525) minutes vs. 208 (583) minutes, Z=-2.182, P=0.062). The mean blood transfusion (700 (1 900) ml vs. 925 (8 800) ml, Z=-1.064, P=0.006) had significant difference. The therapeutic group had a longer mean hospitalization (21 (50) days vs. 15 (79) days, Z=-4.322, P=0.000) and higher rate of intensive care unit stay (54.7% vs. 34.4%, χ(2)=6.103, P=0.027). There was no significant difference in perioperative complications between two groups (0 vs.3.2%, P=0.408). Conclusion: Preoperative renal artery embolization in ≥10 cm renal cell carcinoma patients undergoing operation provides benefit in increasing operation safety and reducing perioperative death.

[Percutaneous biopsy of the renal masses under ultrasound: a single-center 14 years experience]

OBJECTIVE

To assess the diagnostic rate, safety and clinical application of percutaneous renal masses biopsy for advanced renal cell carcinoma patients.

METHODS

In this retrospective study, we collected the data of renal masses from the patients who underwent renal masses biopsy under ultrasound from April 2001 to December 2014 in Peking University First Hospital. A total of 75 patients who were undiagnosed or diagnosed with advanced renal cell carcinoma by the imageological method were enrolled in this study. The patient and lesion characteristics such as tumor size, pathology of tumor, histologic subtype, pathological grade, biopsied location and biopsied cores were recorded and analyzed.

RESULTS

Among all the 75 patients, biopsy was diagnostic in 64 cases (85.3%) and non-diagnostic in 11 cases (14.7%). Of the 64 diagnostic biopsies, 60 were malignant, including 37 (61.7%) renal cell carcinoma (RCC), 13 (21.7%) urothelial carcinoma and 10 (16.7%) other malignant masses. Of all the RCC subjects, 24 suffered from clear cell RCC, 5 papillary RCC, 3 collecting duct carcinomas, 1 unclassified RCC and 4 unknown subtypes. The 11 non-diagnostic biopsied samplings included inflammatory, blood and extrarenal tissue and normal renal tissue. The proportion of collecting duct carcinoma in RCC was 10.8% and the proportion of squamous carcinoma in urothelial carcinoma was 23.1%, which were both higher than the previous research findings. For the male and female groups, non-diagnostic yields were 6.5% and 30.4%, respectively (P=0.022). Of all the 75 patients, 13 renal cell carcinoma patients underwent the surgical treatment and got the results of postoperative pathology. Comparing preoperative biopsy pathological diagnosis with postoperative pathological diagnosis, we found the diagnostic correct rates for benign and malignant lesions, pathological subtype and pathological grade were 100%, 81.8% and 60%, respectively. Mild macroscopic hematuria occurred in 1 case after RMB and there were no serious complications in all the cases.

CONCLUSION

Percutaneous renal masses biopsy under ultrasound with a high diagnostic rate which can define the histologic subtype of renal cell carcinoma. With targeted therapy, more and more patients whose evaluation suggests local advanced disease or metastatic tumors adopt renal tumor biopsy to define the histologic subtype, which could avoid unnecessary surgical treatment.

Preoperative Prognostic Nutritional Index is a Significant Predictor of Survival with Bladder Cancer after Radical Cystectomy: a retrospective study

BACKGROUND

To explore the prognostic significance of preoperative prognostic nutritional index (PNI) in bladder cancer after radical cystectomy and compare the prognostic ability of inflammation-based indices.

METHODS

We retrospectively analyzed data for 516 patients with bladder cancer who underwent radical cystectomy in our institution between 2006 to 2012. Clinicopathologic characteristics and inflammation-based indices (PNI, neutrophil/lymphocyte ratio [NLR], platelet/lymphocyte ratio [PLR], lymphocyte/monocyte ratio [LMR]) were evaluated by pre-treatment measurements. Overall survival (OS) and progression-free survival (PFS) were estimated by the Kaplan-Meier method and compared by log-rank test. Multivariate analysis with a Cox proportional hazards model was used to confirm predictors identified on univariate analysis. The association between clinicopathological characteristics and PNI or NLR was tested.

RESULTS

Among the 516 patients, the median follow-up was 37 months (interquartile range 20 to 56). On multivariate analysis, PNI and NLR independently predicted OS (PNI: hazard ratio [HR] = 1.668, 95% CI: 1.147-2.425, P = 0.007; NLR: HR = 1.416, 95% CI:1.094-2.016, P = 0.0149) and PFS (PNI: HR = 1.680, 95% CI:1.092-2.005, P = 0.015; NLR: HR = 1.550, 95% CI:1.140-2.388, P = 0.008). Low PNI predicted worse OS for all pathological stages and PFS for T1 and T2 stages. Low PNI was associated with older age (>65 years), muscle-invasive bladder cancer, high American Society of Anesthesiologists grade and anemia.

CONCLUSION

PNI and NLR were independent predictors of OS and PFS for patients with bladder cancer after radical cystectomy and PNI might be a novel reliable biomarker for bladder cancer.

A Novel Predictor of Survival with Renal Cell Carcinoma After Nephrectomy

PURPOSE

To validate plasma fibrinogen and serum cholesterol levels as prognostic factors for patients with renal cell carcinoma (RCC) and to explore the prognostic value of their combination.

PATIENTS AND METHODS

Medical data for 1360 RCC patients after nephrectomy were collected. X-tile software was used to determine the cutoff values. The association between clinicopathological factors and fibrinogen and cholesterol levels was determined, and factors predicting survival were examined by multivariate analysis.

RESULTS

The median follow-up was 67 months (interquartile range 36-74 months). On univariate and multivariate analysis, both preoperative plasma fibrinogen and serum cholesterol were independent prognostic factors of cancer-specific survival (CSS) and progression-free survival (PFS). By combining the two factors, we developed a novel index, fibrinogen-cholesterol (FC) score and found it to have better prognostic accuracy than the two factors alone. FC was an independent prognostic factor for both CSS (FC score = 1: hazard ratio [HR] = 3.207, 95% confidence interval [CI] = 1.775-5.793; FC score = 2: HR = 5.516, 95% CI = 2.891-10.527) and PFS (FC score = 1: HR = 2.178, 95% CI = 1.545-3.071; FC score = 2: HR = 3.709, 95% CI = 2.355-5.840).

CONCLUSION

Both preoperative plasma fibrinogen and serum cholesterol levels are independent prognostic factors for CSS and PFS in RCC patients after nephrectomy. A novel indicator, FC score, could be considered a novel preoperative prognostic index in RCC.

[Clinical and pathological characteristics of prostate cancer patients younger than 55 years old]

Objective: Prostate cancer is commonly diagnosed among old men while younger men are rarely diagnosed with prostate cancer. In this study we identify clinical and pathological features of 154 patients with prostate cancer younger than 55 years old and to assist intreatment decisions. Methods: The medical records of 154 prostate cancer patients younger than 55 years old in Peking University First Hospital from Feb 1953 to Jun 2016 were reviewed, retrospectively. Data was collected including symptoms, digital rectal examination (DRE), prostate-specific antigen (PSA), Gleason score, tumor stage, treatment strategies. Results: The mean age was 50.9±4.5, and 25.3% patients were between 40-50 years. Fifty-six (36.4%) patients initially presented with lower urinary tract symptoms. A solid mass could be found by digital rectal examination in 48(31.2%) patients. All patients were diagnosed by pathology of biopsy or surgery. The median Gleason score was 8. Gleason 2-6, 3+ 4, 4+ 3, 8, 9-10 were 15 cases(9.7%), 28 cases(18.2%), 21 cases(13.6%), 15 cases(9.7%), 51 cases(33.1%), respectively. Based on 2009 AJCC TNM Classification criteria the distribution of tumor stage was T1, T2, T3, and T4 in 2(1.3%), 54 (35.1%), 60 (39.0%), and 37 (24.0%) patients. Forty patients (25.9%) were found with bone metastasis and four (2.5%) suffered from visceral metastasis. Fifty-three(34.4%)underwent hormonal therapy and 79(51.3%) underwent radical prostatectomy. Conclusion: Younger prostate caner patients usually presented with LUTS symptoms and were featured for higher tumor stage and aggressiveness. More optimal and personalized risk-based therapy options are required.

Sorafenib versus sunitinib as first-line treatment agents in Chinese patients with metastatic renal cell carcinoma: the largest multicenter retrospective analysis of survival and prognostic factors

BACKGROUND

To compare the efficacy of sorafenib and sunitinib with regard to overall survival (OS) and progression free survival (PFS) in Chinese patients with metastatic renal cell carcinoma (mRCC).

METHODS

A multicenter, retrospective study was performed to elucidate the relationship between clinical variables and prognosis comparing sorafenib and sunitinib as first-line treatment agents in Chinese patients with mRCC. Between September 2006 and December 2014, 845 patients received either sorafenib (400 mg bid; n = 483) or sunitinib (50 mg q.d; n = 362). The primary end point was OS and PFS.

RESULTS

The percentage of patients with low and moderate risk according to Memorial Sloan-Kettering Cancer Centre (MSKCC) score was significantly higher in sunitinib group, and that with high risk was significantly higher in sorafenib group (15.1 vs. 5.2%; p < 0.001). Median OS was similar in sorafenib and sunitinib group (24 vs. 24 months; p = 0.298). Sorafenib group exhibited higher mPFS compared to sunitinib group (11.1 vs. 10.0 months; p = 0.028). Treatment (sorafenib vs sunitinib), pathology, Eastern Cooperative Oncology Group (ECOG) performance status, MSKCC scores, Heng's criteria of risk, and number of metastases were identified as significant predictors for OS and along with liver metastasis for PFS. Clinical outcomes in terms of mOS was significantly better with sorafenib in patients ≥65 years of age (p = .041), ECOG 0 (p = 0.0001), and median MSKCC risk score (p = 0.008).

CONCLUSIONS

Sorafenib and sunitinib are both effective in treating mRCC. However, sorafenib might be more effective in elderly patients (≥65 years) and in patients with an ECOG status of 0, classified under MSKCC moderate risk.

[Preoperative prognostic factors and preoperative risk stratification of upper tract urothelial carcinoma]

OBJECTIVE

To identify the preoperative prognostic factors of upper tract urothelial carcinoma (UTUC) and construct preoperative risk stratification system.

METHODS

A retrospective study including 686 patients who were diagnosed with UTUC and received radical nephroureterectomy or partial ureterectomy in Peking University First Hospital during 2003 and 2013.

RESULTS

Of the 686 UTUC patients, 303 (44.2%) were male and 383 (55.8%) female. The postoperative pathological examination showed that 203 (29.6%) had high tumor stages (T3, T4), 300 (43.7%) had high tumor grades (G3) and 54 (7.9%) had lymph nodes metastasis (N1). After multivariate analysis, renal pelvic tumor, large tumor, estimated glomerular filtration rate (eGFR)≥30 mL/min, and male were associated with high tumor stage. Ureteral tumor, large tumor, and non-smoking history were associated with high tumor grade. Renal pelvis tumor, large tumor, and preoperative anemia were associated with positive N status. During the follow-up, 208 (30.3%) died for cancer and 210 (30.6%) developed intravesical recurrence. Multivariate analysis showed: large tumor (P=0.001), concomitant ipsilateral hydronephrosis (P=0.041), and preoperative anemia (P=0.001) were independently associated cancer-specific mortality after surgery, while ureteral tumor (P=0.04), multiple tumor (P=0.005), and high preoperative creatinine (P=0.036) were independent risk factors for intravesical recurrence.

CONCLUSION

Of the preoperative clinical parameters of UTUC patients, the large tumor, concomitant ipsilateral hydronephrosis, and preoperative anemia were independently associated with cancer-specific mortality after surgery. Ureteral tumor, multiple tumor, and high preoperative creatinine were independently associated with intravesical recurrence after surgery.

[Prognostic factors of patients with T3N0M0 renal cell carcinoma: a single-center retrospective study of 182 patients]

OBJECTIVE

To evaluate the impacts of clinical, pathological, and laboratory factors on oncological outcomes of patients with T3N0M0 renal cell carcinoma.

METHODS

The clinical data, laboratory exam results, and follow-up outcomes of 182 patients with T3N0M0 renal cell carcinoma who underwent nephrectomy from 2007 to 2012 in Peking University First Hospital were retrospectively collected. The 5-year cancer-specific survival and 5-year recurrence-free survival of all the patients were calculated using Kaplan-Meier method, and the statistical significance between the survival curves were compared using the Log-rank test. Variables with significant differences in the univariate analysis were subjected to the multivariate analysis by Cox regression model. All the comparisons were conducted using two-tailed test and P<0.05 was considered statistically significant.

RESULTS

A total of 182 patients were included in this study. Of all the 182 patients, 126 were male (69.23%) and 56 were female (30.77%). The mean age was (56.75±12.45) years. The median follow-up time was 48 months (3-99 months). At the end of the follow-up, 50 patients (27.47%) died due to the disease after a median of 29.74 months and 59 patients (32.42%) had tumor recurrence after a median of 22.12 months. The 5-year cancer-specific survival of all patients was 68.30% (95% CI: 60.16%-75.84%); the 5-year recurrence-free survival was 60.70% (95% CI: 53.16%-68.84%). In the univariate analysis, diabetes mellitus, tumor invasion status, Fuhrman grade, serum album, serum cholestenone, anemia, and neutrophils percentage were associated with the cancer-specific survival and Fuhrman grade, serum album and anemia were associated with the recurrence-free survival. Variables with significant differences on univariate analysis were included in Cox multivariate regression analysis. Multivariate Logistic regression analysis showed that diabetes mellitus (HR=2.434, 95% CI: 1.243-4.769, P=0.010), hypoalbuminemia (HR=2.188, 95% CI: 1.074-1.074, P=0.031), and anemia (HR=3.320, 95% CI: 1.839-5.991, P<0.001) were independent risk factors significantly associated with cancer-specific survival; and higher Fuhrman grade (HR=2.552, 95% CI: 1.433-4.545, P=0.001), anemia (HR=2.535, 95% CI: 1.497-4.293, P=0.001) were independent factors significantly associated with recurrence-free survival.

CONCLUSION

Diabetes mellitus, hypoalbuminemia, and anemia were independent risk factors significantly associated with cancer-specific survival of T3N0M0 renal cell carcinoma patients; higher Fuhrman grade and anemia were independent risk factors significantly associated with tumor recurrence of T3N0M0 renal cell carcinoma patients.

[Impact of different surgical methods of radical cystectomy on the perioperative complications in patients over 75 years]

OBJECTIVE

To analyze the impact of different surgical methods on perioperative complication rate after radical cystectomy in patients over 75 years of age.

METHODS

A retrospective study reviewed 1 432 patients who received radical cystectomy from January 2003 to January 2015. A total of 239 patients were ≥75 years (median age: 78 years), of whom, 74 patients (31.0%) suffered one or more perioperative complications. According to the different operation methods, patients could be divided into ileal conduit group and cutaneous ureterostomy group. The ileal conduit group included laparoscopic and open radical cystectomy with ileal conduit. The cutaneous ureterostomy group included transperitoneal laparoscopic, transperitoneal and extraperitoneal open radical cystectomy with cutaneous ureterostomy.

RESULTS

Perioperative complications were significantly associated with the patient's age (P=0.012), American Society of Anesthesiologists (ASA) score (P=0.001), node staging (P=0.043), and different surgical methods. Perioperative complications caused a prolonged hospital stay and delayed recovery (34 d vs. 21 d, P=0.002). For different surgical methods, the perioperative complication rate of ileal conduit was higher than cutaneous ureterostomy (P=0.013). However, there were no significant differences between transperitoneal laparoscopic and open radical cystectomy with ileal conduit in perioperative complication rate (P=0.836). The perioperative complication rate was statistically significant among transperitoneal laparoscopic, transperitoneal and extraperitoneal open radical cystectomy with cutaneous ureterostomy (P=0.022). On multivariate analysis, age (hazard ratio=4.856, 95% CI: 1.465-16.103, P=0.010), ASA score (P=0.008), and different surgical methods (P=0.016) were significantly associated with the perioperative complication rate.

CONCLUSION

The perioperative complication rate after radical cystectomy in elderly patients was associated with the patients' age, ASA score, and different surgical methods. Patients who received extraperitoneal open radical cystectomy with cutaneous ureterostomy suffered fewer perioperative complications, which was an appropriate choice for elderly patients.

Preoperative Plasma Fibrinogen Level Represents an Independent Prognostic Factor in a Chinese Cohort of Patients with Upper Tract Urothelial Carcinoma

Background

Increased plasma fibrinogen is thought to contribute to tumor progression and metastasis. The association of plasma fibrinogen with clinicopathological characteristics, and the optimal cutoff with an ideal predictive value has not been fully determined in patients with upper tract urothelial carcinoma (UTUC). We aimed to investigate the clinical significance of this parameter in a Chinese cohort of patients with UTUC.

Methods

A retrospective study was conducted to analyze the clinical data of 184 operable UTUC patients in a Chinese cohort with a high incidence of chronic kidney disease (CKD). An optimal cutoff was set for further analysis according to validated web-based software. The associations of plasma fibrinogen with clinicopathological characteristics and survival were assessed. Multivariate analyses were performed to determine the independent prognostic factors.

Results

Elevated plasma fibrinogen was significantly associated with tumor necrosis, lymph node involvement, and a higher preoperative CKD stage, pathological tumor stage and grade (all P < 0.05). Kaplan-Meier analysis showed that plasma fibrinogen ≥ 3.54 g/L predicted a poorer overall and cancer-specific survival than < 3.54 g/L (P < 0.001 for both). Multivariate analyses revealed that elevated preoperative plasma fibrinogen was an independent negative prognostic factor for overall survival (HR = 2.026; 95% CI: 1.226–3.349; P = 0.006) and cancer-specific survival (HR = 1.886; 95% CI: 1.019–3.490; P = 0.043).

Conclusions

Increased plasma fibrinogen was an independent prognostic risk factor for poor outcomes in UTUC. This parameter may serve as an effective biomarker with easy accessibility for evaluating prognosis for patients with UTUC.

[Impact of different surgical methods of radical cystectomy on the perioperative complications in patients over 75 years]

OBJECTIVE

To analyze the impact of different surgical methods on perioperative complication rate after radical cystectomy in patients over 75 years of age.

METHODS

A retrospective study reviewed 1 432 patients who received radical cystectomy from January 2003 to January 2015. A total of 239 patients were ≥75 years (median age: 78 years), of whom, 74 patients (31.0%) suffered one or more perioperative complications. According to the different operation methods, patients could be divided into ileal conduit group and cutaneous ureterostomy group. The ileal conduit group included laparoscopic and open radical cystectomy with ileal conduit. The cutaneous ureterostomy group included transperitoneal laparoscopic, transperitoneal and extraperitoneal open radical cystectomy with cutaneous ureterostomy.

RESULTS

Perioperative complications were significantly associated with the patient's age (P=0.012), American Society of Anesthesiologists (ASA) score (P=0.001), node staging (P=0.043), and different surgical methods. Perioperative complications caused a prolonged hospital stay and delayed recovery (34 d vs. 21 d, P=0.002). For different surgical methods, the perioperative complication rate of ileal conduit was higher than cutaneous ureterostomy (P=0.013). However, there were no significant differences between transperitoneal laparoscopic and open radical cystectomy with ileal conduit in perioperative complication rate (P=0.836). The perioperative complication rate was statistically significant among transperitoneal laparoscopic, transperitoneal and extraperitoneal open radical cystectomy with cutaneous ureterostomy (P=0.022). On multivariate analysis, age (hazard ratio=4.856, 95% CI: 1.465-16.103, P=0.010), ASA score (P=0.008), and different surgical methods (P=0.016) were significantly associated with the perioperative complication rate.

CONCLUSION

The perioperative complication rate after radical cystectomy in elderly patients was associated with the patients' age, ASA score, and different surgical methods. Patients who received extraperitoneal open radical cystectomy with cutaneous ureterostomy suffered fewer perioperative complications, which was an appropriate choice for elderly patients.

Simultaneous surgery in patients with both cardiac and noncardiac diseases

BACKGROUND

To investigate the possibility and feasibility of simultaneous cardiac and noncardiac surgery.

METHODS

From August 2000 to March 2015, 64 patients suffering from cardiac and noncardiac diseases have been treated by simultaneous surgeries.

RESULTS

Two patients died after operations in hospital; thus, the hospital mortality rate was 3.1%. One patient with coronary heart disease, acute myocardial infarction, and a recurrence of bladder cancer accepted emergency simultaneous coronary artery bypass grafting (CABG), bladder cystectomy, and ureterostomy. He died of acute cerebral infarction complicated with multiple organ failure on the 153rd day after operation. The other patient with chronic constrictive pericarditis and right lung cancer underwent pericardial stripping and right lung lower lobectomy, which resulted in multiple organ failure, and the patient died on the tenth day postoperatively. The remaining 62 patients recovered and were discharged. The total operative morbidity was 17.2%: postoperative hemorrhage (n, % [1, 1.6%]), pulmonary infection and hypoxemia (2, 3.1%), hemorrhage of upper digestive tract (1, 1.6%), incisional infection (3, 4.7%), subphrenic abscess (1, 1.6%), and postoperative acute renal failure and hemofiltration (3, 4.7%). Of the 62 patients discharged, 61 patients were followed up. Eleven patients died with 10 months to 10 years during the follow-up. The mean survival time is 116.2±12.4 months. The cumulative survival rate is 50.8%.

CONCLUSION

Simultaneous surgeries in patients suffering from both cardiac and noncardiac benign or malignant diseases are safe and possible with satisfactory short-term and long-term survival.

Prognostic Significance of Preoperative Albumin-Globulin Ratio in Patients with Upper Tract Urothelial Carcinoma

Background

Preoperative albumin-globulin ratio (AGR) reflects both malnutrition and systemic inflammation in cancer patients. In particular, systemic inflammation has been reported to contribute to tumor progression and poor oncological outcome in various malignancies. However, the prognostic value of preoperative AGR in upper tract urothelial carcinoma (UTUC) has not been examined.

Methods

We retrospectively reviewed medical data of 187 operable UTUC patients in a Chinese cohort with a high incidence of chronic kidney disease (CKD). AGR was calculated as [AGR = albumin/(serum total protein—albumin)]. The associations of preoperative AGR with clinicopathologic characteristics and prognosis were assessed. Multivariate analyses using Cox regression models were performed to determine the independent prognostic factors.

Results

The median (IQR) preoperative AGR was 1.50 (1.30–1.70), and the optimal cutoff value was determined to be 1.45 according to the receiver operating curve analysis. Low AGR was significantly associated with female gender, high CKD stage and tumor grade (P < 0.05). Eighty-three patients died before the follow-up endpoint. Kaplan-Meier analysis showed that an AGR < 1.45 predicted significantly poorer overall and cancer-specific survivals compared to an AGR ≥ 1.45 (P < 0.001 and P = 0.008, respectively). Multivariate analyses showed that an AGR < 1.45 was an independent risk factor for poorer overall and cancer-specific survivals (P = 0.002 and P = 0.015, respectively).

Conclusions

Preoperative AGR can act as an effective biomarker with easy accessibility for evaluating the prognosis of patients with UTUC. AGR should be applied in UTUC patients for risk stratification and determination of optimal therapeutic regimens.

[Urachal carcinoma: experience of a clinical center within 30 years]

OBJECTIVE

To summarize more than thirty years of experience with urachal carcinoma and to discuss the clinical features of urachal carcinoma.

METHODS

The clinical data of 22 patients with urachal carcinoma, 18 males and 4 females, their median age at diagnosis was 52 years (range: 31-77 years), were analyzed retrospectively.

RESULTS

Twenty-one cases were urachal adenocarcinoma, and 1 was small cell carcinoma. The first common symptom was gross hematuria in the urachal carcinoma patients (20/22, 90.9%), and CT showed calcification in 18.75% of them (3/16). The cystoscopic finding was a mass seen at the dome of the bladder or anterior wall in all. Twenty cases were followed up (90.9%), with the median follow-up 28 months (range: 3-184 months). The overall 5-year cancer-specific survival rate was 49.5%. It was significantly different in survival between T2 and T3 or more in the urachal carcinoma patients by survival analysis (P=0.026).

CONCLUSION

The results indicate that the most important predictor of prognosis is tumor stage, and it is critical for diagnosis of urachal carcinoma by CT scan and cystoscopy. Extended partial cystectomy is the main surgery of patients with urachal carcinoma. Active multimodal treatments may improve the survival of patients with recurrent and metastatic disease.

A sequence-based approach for predicting protein disordered regions

Protein disordered regions are associated with some critical cellular functions such as transcriptional regulation, translation and cellular signal transduction, and they are responsible for various diseases. Although experimental methods have been developed to determine these regions, they are time-consuming and expensive. Therefore, it is highly desired to develop computational methods that can provide us with this kind information in a rapid and inexpensive manner. Here we propose a sequence-based computational approach for predicting protein disordered regions by means of the Nearest Neighbor algorithm, in which conservation, amino acid factor and secondary structure status of each amino acid in a fixed-length sliding window are taken as the encoding features. Also, the feature selection based on mRMR (maximum Relevancy Minimum Redundancy) is applied to obtain an optimal 51-feature set that includes 39 conservation features and 12 secondary structure features. With the optimal 51 features, our predictor yielded quite promising MCC (Mathew's correlation coefficients): 0.371 on a rigorous benchmark dataset tested by 5-fold cross-validation and 0.219 on an independent test dataset. Our results suggest that conservation and secondary structure play important roles in intrinsically disordered proteins.

Predictive factors for worse pathological outcomes of upper tract urothelial carcinoma: experience from a nationwide high-volume centre in China

OBJECTIVES

To analyse the predictive factors for worse pathological outcome (muscle invasive pT2+, non-organ-confined pT3+ or N+ and histological Grade 3) of upper tract urothelial carcinoma (UTUC) in a Chinese population from a nationwide high-volume centre in China.

PATIENTS AND METHODS

Predictors were studied by retrospectively reviewing the clinicopathological data of 729 consecutive patients with UTUC treated in our centre from January 2002 to December 2010. Univariate and multivariate logistic regression analyses were used.

RESULTS

There were more female patients (56.4%) than males and more tumours were located in the ureter (52.7%) than in the pelvis. In multivariate analysis, male gender (hazard ratio [HR] 1.898, P = 0.001), sessile architecture (HR 3.249, P < 0.001), high grade (HR 5.007, P < 0.001), ipsilateral hydronephrosis (HR 4.768, P < 0.001), renal pelvis location (HR 2.620, P < 0.001) and tumour without multifocality (HR 1.639, P = 0.028) were predictive factors for muscle-invasive UTUC. Male gender (HR 2.132, P < 0.001), renal pelvis location (HR 3.466, P < 0.001), tumour without multifocality (HR 2.532, P = 0.001), sessile tumour architecture (HR 3.274, P < 0.001), and high grade (HR 3.019, P < 0.001) were predictive factors for non-organ-confined disease. Chronological old age (HR 1.047, P < 0.001), sessile tumour architecture (HR 25.192, P < 0.001), ipsilateral hydronephrosis (HR 1.689, P = 0.024), and positive urinary cytology (HR 1.997, P = 0.006) were predictive factors for histological Grade 3 UTUC.

CONCLUSIONS

There was a predominance of female patients and ureteric tumours in UTUCs of this Chinese population. Male gender, sessile architecture, tumour location, tumour without multifocality, high histological grade and preoperative ipsilateral hydronephrosis were independent predictive factors for worse pathological outcome of UTUCs.

Involvement of TL1A and DR3 in induction of ischaemia and inflammation in urinary bladder dysfunction in the elderly

Benign prostatic hyperplasia often causes intravesical obstruction in elderly men; however, the processes of aging and bladder outlet obstruction independently evoke alterations in the structure and function of the bladder. These changes lead to lower urinary tract symptoms; however, it is difficult to separate the effects of prostatic obstruction on the bladder from those of aging. Nevertheless, few studies have focused on elucidating the pathophysiological mechanisms in the aged bladder. Bladder dysfunction due to detrusor instability (caused by old age) is considered to be associated with chronic ischaemia and inflammation. The aim of this study was to explore the role of tumour necrosis factor (TNF)-like ligand 1A (TL1A) and death-domain receptor (DR)3 in the ischaemic and inflammatory process of aged bladder dysfunction. Sixteen bladder tissue samples collected from patients with urothelial tumours of the bladder were divided into two groups according to age: group 1 (controls, n=8) and group 2 (aged group, n=8). Urodynamic examinations were preformed before radical cystectomy. The full-thickness bladder tissues were obtained at least 5 cm away from the margin of the tumours. The mRNA expression levels of TL1A, DR3, von Willebrand factor (vWF), interleukin (IL)-6 and nerve growth factor (NGF) in the two groups were determined using real-time reverse transcription-PCR and the protein expression levels of TL1A, DR3 and p65 were determined by western blot analysis. The TL1A and DR3 mRNA and protein expression levels of the aged bladders were upregulated compared to the control group (p<0.05). Compared to the control, the mRNA expression levels of vWF in the aged bladder tissues were markedly lower (p<0.01); however, the mRNA expression levels of IL-6 were significantly higher in the aged bladder tissues (p<0.01) compared to the control. No significant difference in NGF mRNA expression between the two groups was detected (p>0.05). In conclusion, the aged bladder was associated with ischaemic and inflammatory alterations in comparison to the control group. TL1A and DR3 may play an important role in the pathophysiological process of the aged bladder.

Growth pattern of renal cell carcinoma (RCC) in patients with delayed surgical intervention

PURPOSE

Few studies have evaluated the growth pattern of renal cell carcinoma (RCC) in patients with delayed treatment. This report investigated the growth rate and stage progression of incidentally discovered RCC following a long period of active surveillance.

METHODS

Thirty-two patients who did not receive immediate surgical treatment for renal solid masses that later proved to be RCC were reviewed retrospectively. Annual tumor growth rates were calculated according to changes in the maximal diameter on CT or MRI. Clinical and pathological characteristics associated with tumor growth rate and stage progression were analyzed.

RESULTS

The median tumor size grow from 2.14 (range, 0.30-6.70) cm to 4.33 (range, 1.40-8.80) cm after a median 46.0 months observation period. The average tumor growth rate was 0.80 (range, 0.16-3.80) cm/year. Clear cell carcinoma (0.86 cm/year) tended to grow faster than papillary cell carcinoma (0.28 cm/year) (P = 0.066). The mean growth rate of grade 2 tumors (0.88 cm/year) was faster than that of grade 1 tumors (0.36 cm/year) (P = 0.041). Thirteen tumors (40.6%) were upstaged at a median 48 months after initial presentation. Cox regression analysis revealed initial tumor size as the only risk factor for upstaging (P = 0.018). No local and systemic recurrences were noted in our cohort after the intervention at a median of 47 (range, 6-248) months of follow-up.

CONCLUSIONS

RCCs were found to be slow growing in a group of untreated renal cell carcinoma patients. However, some tumors progressed in stage under observation. The growth rate of RCC tended to correlate with histologic grade and histologic subtype.

Efficacy and safety of sunitinib in the treatment of metastatic renal cell carcinoma

BACKGROUND

The tyrosine kinase inhibitors (TKIs) sunitinib, the first targeted agent for the first line treatment of metastatic renal cell carcinoma (RCC), targets the vascular endothelial growth factor (VEGF) pathway. The objective of this study was to investigate the efficacy and safety of sunitinib in treating metastatic clear-cell RCC and to confirm if hypertension is an effective predictive factor.

METHODS

A total of 36 patients with metastatic RCC were enrolled between June 2008 and December 2010. Among them 29 cases were first line therapy and 7 cases were in progression on first-line cytokine or sorafinib therapy. The pathology of all patients was confirmed predominant in clear cell type. Sunitinib mono-therapy was administered in repeated 6-week cycles of daily oral therapy for 4 weeks, followed by 2 weeks off in 34 patients; and 3 patients were administered with 37.5 mg/d continuously until disease progression or unacceptable toxicities occurred. Overall response rate and safety were evaluated. We divided patients into Group A and Group B according to the blood pressure level.

RESULTS

The median follow-up was 15 months (10 cycles, range 1.5 - 30.0 months (1 - 20 cycles)). Ten patients (29.4%) achieved partial responses (PR); 23 patients (67.6%) demonstrated stable disease (SD) lasting ≥ 2 cycles. Seventeen patients (50%) developed progressive disease (PD) during follow-up. The median progression-free survival (PFS) was 15 months (range 3.0 - 28.5) months. A total of 9 patients died; the overall survival has not been reached; the median survival time of the deceased patients was 13 months (range 7 - 24) months. The most common adverse events were hand-foot syndrome (77.8%), thrombocytopenia (75.0%), hypertension (61.1%) and diarrhea (46.0%). Most adverse events were reversible by treatment interruption. Twenty-two patients (61.1%) developed hypertension; and hypertension was associated with a long time to disease progression and long overall survival (P = 0.004, 0.000, respectively).

CONCLUSIONS

The results of this study demonstrate the efficacy and manageable adverse event profile of sunitinib as a single agent in first- or second-line therapy for patients with metastatic clear cell RCC. Further, sunitinib-associated hypertension may be a strong predictive marker for treatment efficacy in metastatic RCC.

The nucleosome binding protein NSBP1 is highly expressed in human bladder cancer and promotes the proliferation and invasion of bladder cancer cells

NSBP1 is a recently identified member of the HMGN protein family which binds to nucleosomes and regulates gene transcription through chromatin remodeling. In this study, we aimed to investigate the potential role of NSBP1 in human bladder cancer. We examined NSBP1 expression in 114 surgically removed bladder cancer specimens as well as 11 human bladder cell lines by immunohistochemistry and Western blot analysis, and found that NSBP1 level was correlated with the increased tumor grade and pathologic stage, and lymph node metastasis. RNAi-mediated knockdown of NSBP1 in EJ cells, a bladder cancer cell line that overexpressed NSBP1, resulted in moderate decrease of cell viability, moderate blockage of cell cycle at G2/M phase, and decreased cyclin B1 expression, but had no effects on apoptosis. Moreover, NSBP1 knockdown led to reduced activity of MMP-9 but not MMP-2. Taken together, these results suggest that NSBP1 promotes the viability of bladder cancer cells through increased cell proliferation but not decreased apoptosis, and increases the invasion ability of metastatic bladder cancer cells through the upregulation of MMP-9 activity. Our findings not only provide a molecular understanding of the role of NSBP1 in bladder cancer, but also suggest NSBP1 RNAi as a novel therapeutic approach for bladder cancer.

Modulation of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 in RAW264.7 cells by irradiation

Radiation-induced pulmonary injury is a severe complication affecting the quality of life of patients. Although the pathophysiology of the process is not fully understood, we hypothesized that it is potentially related to macrophages and their secretion of matrix metalloproteinase-9 (MMP-9). Macrophages are a type of inflammatory cell that synthesize hundreds of bioactive substances and enzymes. MMP-9 is closely involved in the maintenance of the basilar membrane, and leads to increased extracellular matrix deposition within the lung, which is a characteristic feature of radiation-induced lung fibrosis. We examined the role of ionizing radiation in modulating the production of MMP-9 in a macrophage cell line. RAW264.7 cells were irradiated with various doses of γ-rays, and then MMP-9 and tissue inhibitor of metalloproteinase-1 (TIMP-1) levels were determined at several time points. RT-PCR revealed a marked increase in the levels of MMP-9 mRNA, which peaked at 24 h post-irradiation and had begun to decline by 48 h. By contrast, TIMP-1 mRNA experienced only a slight increase at 24 h post-irradiation, reaching significance at 48 h post-irradiation. Western blot analysis demonstrated an increased expression of MMP-9 protein in the irradiated cells, while TIMP-1 protein levels were not notably changed. Dexamethasone inhibited the increased expression of MMP-9 protein induced by ionizing radiation. These results indicate that MMP-9 expression by RAW264.7 cells, and an imbalance between MMP-9 and TIMP-1, may be involved in radiation-induced lung injury.

[Differential transcription of Bcl-2 and Bax through the cell cycle in prostate cancer cell line]

OBJECTIVE

To investigate the differential expression of apoptosis associated gene Bcl-2 and Bax through cell cycle and its possible clinical meaning.

METHODS

The prostate cancer cell line PC-3 was synchronized in M, G1, S and G2 phase using modified thymine deoxyriboside blockage and high pressure N2O technique. The efficiency of synchronization was detected by flow-cytometry. RT-PCR and Western blot methods were used to examine the expression of Bcl-2 and Bax in mRNA and protein level.

RESULTS

The synchronized rate of M, G1, S and G2 phase were 92.1%, 87.0%, 80.2% and 75.9% respectively. Bcl-2 was constitutively expressed through the cell cycle, but both the mRNA and protein expression level of Bcl-2 were very high in the G1 phase, dramatically decreased in M, S and G2 phase. The expression level of Bax had no change through the cell cycle.

CONCLUSIONS

Cell cycle could influence the expression level of Bcl-2 significantly but not Bax, these might have some clinical relevance.

[Diagnosis and treatment of retroperitoneal fibrosis: report of 26 cases]

OBJECTIVE

To evaluate and improve the diagnosis and surgical treatment of the retroperitoneal fibrosis (RPF).

METHODS

The medical records of 26 patients with the RPF (21 men and 5 women with mean age 54 years) were analyzed retrospectively. They were been treated from January 1996 to May 2007. Fourteen cases received double-J inter-ureter drainage or pricking pyelostomy and 9 of 15 cases who received open surgery were performed bilateral ureterolysis with their ureters translocated intraperitoneally.

RESULTS

For masses in retroperitoneal space, the diagnostic rate of B mode ultrasonography, CT and MRI was 12% (3/26), 86% (18/21) and 57% (8/14) respectively. The patients were followed up from 1 to 106 months. After drained by double-J inter-ureter stent or pricking pyelostomy, the mean serum creatinine level decreased from 373.9 micromol/L to 157.1 micromol/L of 14 patients. Those patients who underwent ureterolysis with ureteral intraperitoneal translocation had good results and their mean serum creatinine level decreased from 171.0 micromol/L before operation to 139.6 micromol/L after operation. Four patients had normal B-ultrasound and intravenous urogram findings with at least 24 months of follow-up.

CONCLUSIONS

CT scan has better accuracy for diagnosis of the RPF than B mode ultrasonography and MRI. Prompt and appropriate relief of urinary obstruction with surgical intervention can effectively protect the renal function in patients with the RPF, and the ureterolysis with ureteral intraperitoneal translocation is an effective surgical procedure to treat this disease.