Advanced Stage Renal Cell Carcinoma Research Articles

LINC00365 as a potential biomarker for total nephrectomy in advanced-stage renal cell carcinoma patients

BackgroundRenal cell carcinoma (RCC) is one of the most frequent urological cancers globally that has a good prognosis in the early tumor stages. However, there is a poor prognosis in metastatic RCC patients. Therefore, it is needed to evaluate the molecular biology of RCC progression to introduce the efficient diagnostic and therapeutic markers in these patients. Long non-coding RNAs (lncRNAs) have key roles in regulation of molecular mechanisms during RCC progression. In the present study, we assessed the levels of LINC00365 expressions in RCC patients to suggest that as a tumor marker in these patients. MethodsFifty fresh RCC tumor tissues and their normal margins were collected to assess the levels of LINC00365 expressions and probable correlations with clinicopathological features of RCC patients. ResultsThere was significant LINC00365 up regulation in females compared with males (p=0.050). Among the RCC patients with total nephrectomy, there was a significant LINC00365 up regulation in advanced stage compared with primary stage tumors (p=0.035). RCC patients older than 60 years old who were undergone the total nephrectomy had also significant LINC00365 up regulation compared with RCC patients younger than 60 years old (p=0.039). Conclusionsgiven the significant increase in LINC00365 expression in advanced stage RCC tumors and patients over 60 years old who had total nephrectomy; it could serve as a useful diagnostic marker in screening programs for old high-risk individuals. It was also noticed that female RCC patients had elevated levels of LINC00365 expressions in their tumor samples, suggesting its potential use as a gender-specific diagnostic marker for high-risk females. Nevertheless, evaluating the levels of LINC00365 in serum samples of RCC patients is necessary to suggest that as a reliable diagnostic marker in clinical settings.

49 Inhibition of AXL along with c-Met potentially halts resistance development in renal cell carcinoma

Abstract Background c-Met, a receptor tyrosine kinase (RTK), is overexpressed in renal cell carcinoma (RCC) and correlates with a decreased survival rate. Upon binding to its specific ligand, Hepatocyte Growth Factor (HGF), c-Met activates pro-tumorigenic signaling pathways. Cabozantinib (Cabo) inhibits c-Met and a few other RTKs, including AXL, and is approved for the treatment of patients with advanced-stage RCC. AXL and its ligand, GAS6, are overexpressed in RCC and are also markers of poor prognosis. The pro-tumorigenic role of AXL and its potential crosstalk with c-Met in renal cancer need to be thoroughly investigated. Methods We generated a Cabo-resistant (CaboR) cell line from wild-type Cabo-sensitive (CaboS) Caki-1 clear-cell RCC cells, and CRISPR/Cas9-mediated AXL knock-out cells (AXL-KO) from 786-O clear-cell RCC cells. Chromatin immunoprecipitation and sequencing (ChIP-seq) was performed to profile H3K27ac, a histone post-translational modification associated with active promoters and enhancers, in CaboR and CaboS cell lines. We also performed RNA sequencing (RNA-seq) on CaboR and CaboS and evaluated differentially expressed genes and enriched pathways using gene set enrichment analysis (GSEA). Transcriptional profiles of control clones and AXL-KO cells were also compared to identify the effect of AXL-KO on pro-tumorigenic signaling. We utilized an AXL-specific small molecule inhibitor, TP-0903, in combination with Cabo to validate our data. Finally, we studied how AXL silencing or inhibition may affect resistance to Cabo. Results Our findings revealed that AXL forms a complex with c-Met and may have a significant crosstalk which can be involved in therapeutic resistance. We found that prolonged treatment with c-Met inhibitors Cabo, Crizotinib, and PF-4217903, induced c-Met and AXL overexpression in RCC cells. Interestingly, c-Met inhibitor(s)-induced overexpressed c-Met can also be increasingly phosphorylated (at low concentrations) in the presence of HGF, which may cause enhanced downstream tumor-promoting signaling. We found that silencing AXL can prevent this c-Met-inhibitors-mediated c-Met overexpression. Moreover, we found marked activation of the promoters and enhancers of several transcription factors, including ETV1, HOXA9, and FOXK1, in CaboR cells compared to CaboS cells. In the CaboR cells, genes involved in oxidative phosphorylation, progression through the division cycle, DNA replication, the NRF2 pathway, and DNA repair were upregulated, whereas genes associated with glycolysis, angiogenesis, hypoxia, and the Met pathway were downregulated (Figure 1). Finally, silencing AXL (using siRNA) or inhibiting AXL (using TP0903) in CaboR cells, induced significant apoptosis. Conclusions Together, our data suggest that CaboR cells have a distinct epigenomic and transcriptomic profile, and that targeting AXL along with c-Met inhibition can be beneficial in preventing acquired therapeutic resistance in RCC.

Abstract 4555: c-Met/AXL crosstalk in mediating therapeutic resistance in renal cell carcinoma

Abstract Receptor Tyrosine Kinase (RTK), c-Met, is overexpressed in renal cancer and correlates with a decreased survival rate. Upon binding with its specific ligand, Hepatocyte Growth Factor (HGF), c-Met activates pro-tumorigenic signaling. c-Met/RTK inhibitors are used for the treatment of advanced renal cell carcinoma (RCC). However, acquired therapeutic resistance is a major clinical problem and the underlying mechanisms are largely unknown. Hence, novel therapeutic targets are needed to overcome the clinical hurdles; and the RTK, AXL, can be a potential target. AXL is overexpressed and a poor prognostic marker in RCC. AXL overexpression drives wide-ranging processes, including epithelial-to-mesenchymal transition (EMT), tumor angiogenesis, and resistance to chemotherapeutics. Cabozantinib (XL184/Cabo), is approved for advanced-stage RCC and can inhibit c-Met and VEGFR2 activation (including AXL and a few other RTKs); however, it is not a specific/potent inhibitor of AXL. Hence, inhibiting c-Met alone may not be sufficient when AXL remains active. Therefore, the pro-tumorigenic role of AXL and its cross-talk with c-Met in renal cancer need to be thoroughly investigated. We compared the expression of c-Met and AXL in TCGA and found significantly high expression of both c-Met and AXL in primary renal tumor tissues compared to normal tissues. Our data showed that AXL forms a complex with c-Met and may have a significant cross-talk which can be involved in therapeutic resistance. We have also found that prolonged treatment of c-Met inhibitor Cabo, (including Crizotinib and PF-4217903) induced c-Met and AXL overexpression in RCC cells. Interestingly, c-Met inhibitor(s)-induced overexpressed c-Met can also be increasingly phosphorylated (at low concentrations) in the presence of HGF, which may cause enhanced downstream tumor-promoting signaling. To understand the role of AXL in tumor-promoting pathways and therapeutic resistance, we have generated CRISPR/Cas9-mediated AXL knock-out cells (AXL-KO) and found that silencing AXL can prevent c-Met-inhibitor(s)-mediated c-Met overexpression. Furthermore, to identify the effect of AXL-KO on pro-tumorigenic signaling, transcriptional profiles of control clones and AXL-KO cells were compared. The gene set enrichment analysis (GSEA) showed that genes involved in ‘EMT’, ‘Hypoxia’, and ‘K-Ras’ signaling pathways were significantly downregulated. We have also utilized an AXL-specific small molecule inhibitor, TP-0903, in combination with Cabo and validated our data. We have also generated a Cabo-resistant cell line (Caki-1) and found high expression of c-Met and AXL in these cells. Furthermore, either silencing of AXL (using siRNA) or inhibiting AXL (using TP0903) induced significant apoptosis in these Cabo-resistant cells. Together, our data suggest that inhibition of AXL along with c-Met can be beneficial in preventing acquired therapeutic resistance in RCC. Citation Format: Akash Sabarwal, Laxminarayan Rawat, Johannes Wedel, Murugabaskar Balan, Gwo-Shu Mary Lee, Toni K. Choueiri, Soumitro Pal. c-Met/AXL crosstalk in mediating therapeutic resistance in renal cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4555.

Identification of PANoptosis-related signature reveals immune infiltration characteristics and immunotherapy responses for renal cell carcinoma

PANoptosis is a specific type of inflammatory programmed cell death (PCD) modality that can be involved in three key modes of cellular programmed cell death-pyroptosis, apoptosis and necroptosis. We analyzed PANoptosis activity in three common renal cell carcinoma subtypes (Clear cell renal cell carcinoma, Papillary renal cell carcinoma, and Chromophobe renal cell carcinoma) separately and constructed a new PANoptosis immunity index (PANII). In three renal cell carcinomas, we found that PANII was an effective predictor of immunotherapy efficacy in KIRC, KIRP and KICH, and the high PANII group was characterized by high immune infiltration and sensitivity to immunotherapy, while the low PANII group was prone to immune escape and immunotherapy resistance. We performed molecular docking prediction of each core protein comprising PANII and identified natural small molecule compounds with the highest affinity to target proteins. In addition, we found that down-regulation of PYCARD inhibited the proliferation and migration of renal clear cell carcinoma cells by in vitro functional assays, suggesting that PYCARD could be a novel target for renal clear cell carcinoma therapy. Our findings that the PANoptosis characterization-based index (PANII) helps to elucidate the tumor microenvironmental features of three common renal cell carcinoma subtypes and identify patient populations that will benefit from immunotherapy, providing a new tool for the clinical diagnosis and treatment of patients with intermediate- and advanced-stage renal cell carcinoma.

Lifestyle and Clinical Factors in a Nationwide Stage III and IV Renal Cell Carcinoma Study.

The aim was to investigate whether patient-related or clinical risk factors present at the diagnosis of advanced stage renal cell carcinoma (RCC) had an impact on the overall mortality, cancer-specific mortality, and recurrence risk in a national cohort. Patients registered with stage III and IV RCC in the Danish Renal Cancer Database (DaRenCa) in 2014-2016 were included in the study and followed up until recurrence or death. We conducted a Cox Proportional Hazard Model to examine the association between several variables and the development of RCC. These variables included BMI, hypertension, smoking status, symptoms at diagnosis, performance status, multidisciplinary team (MDT) discussion, surgical margin, and primary metastasis. Separate analyses were performed for cc-RCC and non-ccRCC patients. In our cohort of 929 patients, 424 individuals died from RCC during the follow-up period, with a median follow-up time of 4.1 (95% CI: 0.8-5.0) years for ccRCC and 2.0 (95% CI: 0.1-5.0) years for non-ccRCC. A multivariate analysis demonstrated that a positive surgical margin (HR 1.53 and 1.43), synchronous metastasis (HR 2.06 and 3.23), and poor performance status (HR 4.73 and 5.27) were significantly associated with a decreased 5-year overall and cancer-specific survival, respectively. Furthermore, a positive surgical margin was associated with a higher risk of recurrence in ccRCC. MDT discussion was found to reduce mortality risk in non-ccRCC. Clinical- and disease-related variables have a greater impact on RCC mortality and recurrence than the selected lifestyle-related factors. The inclusion of MDT discussion in the diagnosis and management of advanced RCC should be further evaluated for its potential to improve patient outcomes.

Onconephrology: Renal cancer

Renal cancer (RC) ranks eighth among the most prevalent oncopathologies, making it one of the most widespread types of cancer. Over the last decade, there has been an average annual increase in morbidity of 2 percent. RC is a collective term that encompasses parenchymal tumors and pelvis tumors with distinct histologic characteristics.
 Renal cancer can appear in intact kidneys and cause additional damage except for the actual tumor process, or in patients with previously affected kidneys.
 The main treatment option for renal cell carcinoma (RCC) is surgery, which can be performed through various approaches, including open-access surgery, laparoscopic surgery, and robotic-assisted surgery. These surgical techniques enable the performance of radical nephrectomy, partial nephrectomy, and cytoreductive nephrectomy. The selection of the surgical method and the extent of the intervention fall within the expertise of oncourologists.
 Anti-angiogenic drugs, including tyrosine kinase inhibitors, humanized monoclonal antibodies, and immune checkpoint inhibitors, as well as mTOR inhibitors, are commonly utilized in the treatment of advanced-stage RCC (II-IV) or its relapse. However, it is important to note that these drugs possess considerable nephrotoxicity. Therefore, kidney status plays a crucial role in determining the appropriate treatment options, the dosage of antitumor drugs, and the potential nephrotoxicity associated with them, thereby becoming the main limiting factor affecting the quality and duration of life for RCC patients.
 The present review focuses on the analysis of recent data concerning the issues mentioned above, primarily in relation to RCC, and provides recommendations for the investigation and treatment of this specific category of patients.

The involvement of PDIA2 gene in the progression of renal cell carcinoma is potentially through regulation of JNK signaling pathway.

Renal cell carcinoma (RCC) with poor prognosis and high incidence rate is a common malignant disease. Current therapies could bring little benefit for the patients with advanced-stage RCC. PDIA2 is an isomerase responsible for protein folding and its role in cancer including RCC is under investigation. In this study, we found that PDIA2 was expressed much higher in RCC tissues than the control but the methylation level of PDIA2 promoter was lower based on the TCGA data. Patients with higher PDIA2 expression exerted worse survival. In clinical specimen, PDIA2 expression was correlated to patients' clinical factors such as TNM stage (I/II vs III/IV, p = 0.025) and tumor size (≤ 7cm vs > 7cm, p = 0.004). Moreover, K-M analysis showed that PDIA2 was associated with patients' survival in RCC. PDIA2 was expressed much higher in cancer cells A498 than 786-O than that in 293T cells. After PDIA2 was knocked down, cell proliferation, migration and invasion was potently inhibited. But cell apoptotic rate increased reversely. Furthermore, the efficacy of Sunitinib on RCC cells was strengthened after PDIA2 knockdown. In addition, knockdown of PDIA2 gene leaded to downregulation of levels of JNK1/2, phosphorylated JNK1/2, c-JUN, and Stat3. But this inhibition was partially released when JNK1/2 was overexpressed. In consistent, cell proliferation was also partially recovered. In summary, PDIA2 plays important role in progression of RCC and JNK signaling pathway might be regulated by PDIA2. This study suggests PDIA2 as a candidate target for therapy of RCC.

Preoperative neutrophil-lymphocyte ratio/platelet-lymphocyte ratio: A potential and economical marker for renal cell carcinoma.

Emerging evidences have elucidated the crucial role of inflammation in carcinogenesis and tumor progression. In the recent years, many inflammatory biomarkers showed promising prognostic factors in renal cell carcinoma (RCC). We intended to evaluate the significance of one such inflammatory factor which is potential, noninvasive, simple, as well as economical. The preoperative neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in RCC patients have shown favorable results. The objective was to assess the prognostic role of NLR/PLR in the advanced stage and high-grade RCC. This is a retrospective study. Ethical clearance was obtained from the institute ethics committee. One hundred and fifty histopathologically proven RCC cases during the period of January 2010-September 2018 were chosen from the pathology department and corresponding blood reports were obtained from the medical records department. We divided the cases based on their staging and grading. NLR/PLR values were calculated using formulas. Statistical analysis was done using R software. Data were expressed as mean ± standard deviation, median, and percentage. Independent t-test, Mann-Whitney test, and Chi-square test were used. P < 0.05 was considered statistically significant. The receiver operating characteristic curve (ROC) was plotted to assess the sensitivity of NLR/PLR. The elevated NLR/PLR values showed a significant relation with high-grade and advanced stage RCC. The ROC curve proved the accuracy of NLR/PLR in the advanced stage and high-grade RCC. A multicentric, prospective study can be planned in the future. Follow-up studies are needed to assess their prognostic role. NLR/PLR values can become part of routine investigations for all RCC patients. The values may help to estimate pathological outcomes, chance of recovery, recurrence, and survival rates.

Renal Cell Carcinoma Health Disparities in Stage and Mortality among American Indians/Alaska Natives and Hispanic Americans: Comparison of National Cancer Database and Arizona Cancer Registry Data.

Simple SummaryThis study assessed renal cell carcinoma disparities in American Indians/Alaska Natives and Hispanic Americans using the National Cancer Database and the Arizona Cancer Registry, focusing on advanced-stage and mortality. Renal cell carcinoma disparities in American Indians/Alaska Natives have been partially explained by neighborhood socioeconomic factors and residence (rural or urban) pattern, but not in Hispanic Americans. Greater health disparities in renal cell carcinoma stage and mortality for Hispanic Americans and renal cell carcinoma mortality for American Indians/Alaska Natives were observed at the Arizona state level compared to national levels.Renal cell carcinoma (RCC) is one of the top 10 cancers in the United States. This study assessed RCC health disparities in American Indians/Alaska Natives (AIs/ANs) and Hispanic Americans (HAs) focusing on advanced-stage and mortality. RCC patients’ data were obtained from the National Cancer Database (NCDB) and Arizona Cancer Registry (ACR). Logistic and Cox regression analyses were performed to ascertain the effect of race/ethnicity on stage and mortality, adjusting for neighborhood socioeconomic factors, rural/urban residence pattern, and other factors. In both data sets, AIs/ANs had significantly increased odds of advanced-stage RCC in the unadjusted model, but not in adjusted models. Mexican Americans had higher odds of advanced-stage compared to non-Hispanic Whites in NCDB (OR 1.22, 95% CI: 1.11–1.35) and ACR (OR 2.02, 95% CI: 1.58–2.58), even after adjusting for neighborhood characteristics. AIs/ANs did not show increased mortality risk in NCDB after adjusting for neighborhood characteristics, while the association remained significant in ACR (HR 1.33, 95% CI: 1.03–1.72). The great risk of all-cause and RCC-specific mortality was observed in U.S.-born Mexican Americans in Arizona (HR 3.21, 95% CI: 2.61–3.98 and sub-distribution HR 2.79, 95% CI: 2.05–3.81). RCC disparities in AIs/ANs is partially explained by neighborhood factors, but not in HAs.

Beyond conventional immune-checkpoint inhibition - novel immunotherapies for renal cell carcinoma.

The management of advanced-stage renal cell carcinoma (RCC) has been transformed by the development of immune-checkpoint inhibitors (ICIs). Nonetheless, most patients do not derive durable clinical benefit from these agents. Importantly, unlike other immunotherapy-responsive solid tumours, most RCCs have only a moderate mutational burden, and paradoxically, high levels of tumour CD8+ T cell infiltration are associated with a worse prognosis in patients with this disease. Building on the successes of antibodies targeting the PD-1 and CTLA4 immune checkpoints, multiple innovative immunotherapies are now in clinical development for the treatment of patients with RCC, including ICIs with novel targets, co-stimulatory pathway agonists, modified cytokines, metabolic pathway modulators, cell therapies and therapeutic vaccines. However, the successful development of such novel immune-based treatments and of immunotherapy-based combinations will require a disease-specific framework that incorporates a deep understanding of RCC immunobiology. In this Review, using the structure provided by the well-described cancer-immunity cycle, we outline the key steps required for a successful antitumour immune response in the context of RCC, and describe the development of promising new immunotherapies within the context of this framework. With this approach, we summarize and analyse the most encouraging targets of novel immune-based therapies within the RCC microenvironment, and review the landscape of emerging antigen-directed therapies for this disease.

Splice variants of lysosome‑associated membrane proteins 2A and 2B are involved in sunitinib resistance in human renal cell carcinoma cells.

Sunitinib, a tyrosine kinase inhibitor, is among the first-line treatments for metastatic or advanced stage renal cell carcinoma (RCC). However, patients with RCC develop resistance to sunitinib. We have previously demonstrated that lysosome-associated membrane protein 2 (LAMP-2), which has three splice variants with different functions (LAMP-2A, LAMP-2B, and LAMP-2C), is involved in RCC. In the present study, we examined which splice variants of LAMP-2 contributed to sunitinib resistance in RCC cells. In vitro analysis using ACHN, human RCC cell line, revealed that the IC50 of sunitinib was significantly increased by overexpression of LAMP-2A and LAMP-2B, but not LAMP-2C (P<0.01). Kaplan-Meier survival analysis using clinical samples revealed an association between shorter survival and high expression of LAMP-2A and LAMP-2B, but not LAMP-2C, in patients with RCC treated with sunitinib (P=0.01). Furthermore, high expression of LAMP-2A and LAMP-2B in RCC revealed a weak to moderate inverse correlation with the tumor shrinkage rate and progression-free survival, respectively. Thus, high expression of LAMP-2A and LAMP-2B contributed to the acquisition of sunitinib resistance, indicating that the expression of these two variants can predict the efficacy of sunitinib treatment in patients with RCC.

Avelumab and axitinib combination therapy for the treatment of advanced renal cell carcinoma.

Owing to an improved understanding of the immunobiological profile of renal cell carcinoma (RCC), the past few years have ushered in significant changes in systemic therapies for advanced stage RCC. First-line treatment with single-agent tyrosine kinase inhibitors (TKI) has been virtually replaced for most patients by immunotherapy combinations. The first ofsuch treatments was the dual immune checkpoint inhibitor combination of ipilimumab and nivolumab. More recently, the combination of an immune checkpoint inhibitor and a TKI has also moved into the first-line setting. This review summarizes the pharmacologic properties, evidence for use and safety of avelumab, a PD-L1inhibitor and axitinib a small-molecule TKI, each as monotherapy, and in combination for the management of metastatic RCC.

Abstract C059: Clinical and molecular profile of renal cell carcinoma in Hispanic Americans, Native Americans, and European Americans

Abstract Background: Racial/ethnic minority groups, including Hispanic Americans (HAs) and Native Americans (NAs), have a heavier burden of kidney cancer with a higher incidence and mortality than European Americans (EAs). However, HAs and NAs are under-represented in clinical and molecular genomic studies of renal cell carcinoma (RCC), the most common type of kidney cancer, and clinical and molecular characteristics of RCC among them are also unknown. We investigated variations in clinical and molecular characteristics of RCC patients. Methods: A total of 284 patients, including 90 HAs (31.6%) and 22 NAs (7.7%), who were diagnosed with RCC and without prior diagnosis of cancer were included to understand the patients' clinical characteristics. A subset of 51 samples were selected to screen for somatic mutations on the VHL gene, and 33 samples were selected for whole-transcriptome sequencing analysis. Results: Compared to EAs, HA and NA patients were diagnosed with RCC at younger ages (P&amp;lt;0.001). HA had about 5 years younger average age at diagnosis than EAs (55.2 vs. 60.6) and an over 2-fold increased odds of diagnosis before age 60 years (OR 2.50, 95% C.I.: 1.36-4.60). Mean age of diagnosis among NAs was 48.9, and NAs had more than 4-fold higher odds of diagnosis at a younger age (OR 4.12, 95% C.I.: 1.31-12.95). NA patients had higher body mass index than EA patients with 77.3% of NA obese patients. Diabetes was more common in HA (45.6%) and NA (50.0%) patients compared to EA (19.6%) patients. An RCC histologic subtype, clear cell RCC (ccRCC), was more common in HAs and NAs than EAs. Over 90% of HA patients had ccRCC, while only 77.6% of EA patients had ccRCC. HAs had increased odds of diagnosis with ccRCC compared to EAs (OR 2.39, 95% C.I.: 1.01-5.67). Among HAs, older patients were more likely to have advanced-stage RCC diagnosis (OR 7.06, 95% C.I.: 1.46-34.11). HAs who used Spanish as their primary language were more likely to have radical nephrectomy rather than partial nephrectomy (OR 5.13, 95% C.I.: 1.23-21.33). We detected pathogenic somatic mutations on the VHL gene, which is known to cause von Hippel-Lindau syndrome, in 4 patients, and these patients were younger than the patients without these mutations (45.5 vs. 57.1). We were able to assign 32 out of 33 patients into molecular subtypes (ccA and ccB). Molecular subtype could not be assigned to one HA patient with high-grade and advanced-stage ccRCC. Molecular subtype, ccA, was more common in HAs than EAs (64.3% vs. 41.2%), but this difference was not statistically significant. One gene, HABP2, showed evidence of differential expression between HA and EA tumors (PADJ&amp;lt;0.05) and was downregulated in HA tumors with log2 fold change &amp;lt;-2.0. Conclusion: HA and NA RCC patients had different clinical and molecular characteristics from EA patients. Impact: As we move toward a precision medicine approach for RCC care, it is necessary to better understand the clinical and molecular characteristics of these underserved HA and NA populations with high kidney cancer burden. Citation Format: Ken Batai, Alfredo Harb de la Rosa, Francine Gachupin, Elliot Imlaer, Erika R. Bracamonte, Bruce Seligmann, Benjamin R. Lee. Clinical and molecular profile of renal cell carcinoma in Hispanic Americans, Native Americans, and European Americans [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C059.

110P - Presence of circulating tumour DNA in surgically resected renal cell carcinoma is associated with advanced disease and poor patient prognosis

BackgroundCirculating tumor DNA (ctDNA) is a promising, non-invasive biomarker for preclinical detection and monitoring of various cancers. The utility of ctDNA assessment in renal cell carcinoma (RCC) in not well established. Here, we evaluate the potential of a bespoke, multiplex PCR, whole exome sequencing (WES)-based approach for ctDNA detection. MethodsThe cohort consisted of 42 patients with stage Ib-IV RCC who underwent complete surgical resection. ctDNA was measured in plasma samples drawn pre-surgery (n=34; baseline) and at post-operative time points (n=41) using the bespoke assay targeting patient-specific tumor variants. ResultsA median of 11.7ng (1.4-175ng) of cfDNA was extracted from a median plasma volume of 3.2mL (1.2-3.8mL). ctDNA was detected with a mean mutant molecules/mL of 5.3 (0.22-62). Baseline ctDNA was detected in 41% (14/34) of patients. Presence of ctDNA was significantly associated with increased tumor size (mean 9.7 vs 7.1cm, p<0.05), advanced tumor stage (stage III-IV vs I-II, p<0.05) and poorly differentiated tumors (grade III-IV vs II, p<0.0001). In the postoperative setting, 8/8 ctDNA-positive patients relapsed (positive predictive value (PPV=100%), while 16/33 ctDNA-negative patients relapsed (NPV=52%). Positive ctDNA status was associated with reduced relapse-free survival at post-surgical timepoints (HR: 2.8; 95% CI:1.2-6.6). None of the post-surgical samples from a control cohort of 17 non-relapsing patients were ctDNA-positive (specificity of 100%; median follow up of 64 months). ConclusionsPresence of presurgical ctDNA strongly correlates with advanced stage RCC. Despite low plasma volumes, the bespoke assay detected ctDNA in 41% of baseline samples. Postoperative ctDNA presence is correlated with clinical relapse. However, absence of ctDNA does not preclude recurrence as RCC is known to shed limited amounts of ctDNA. Higher sample volumes and multiregion tumor biopsies could enhance detection rates. This personalized approach has the potential to be used for ctDNA-based detection of relapse in patients with advanced stage RCC. Legal entity responsible for the studyNatera, Inc.; Fox Chase Cancer Center. FundingNatera, Inc.; Fox Chase Cancer Center. DisclosureM. Balcioglu: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. H. Wu: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. S. Dashner: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. S. Shchegrova: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. E. Kalashnikova: Full / Part-time employment: Natera, Inc. H. Pawar: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. R.G. Uzzo: Advisory / Consultancy: Janssen; Advisory / Consultancy: Pfizer; Advisory / Consultancy: Novartis; Advisory / Consultancy: Argos. A. Aleshin: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. H. Sethi: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. R. Salari: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. M. Louie: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. B. Zimmermann: Shareholder / Stockholder / Stock options, Full / Part-time employment, I am an employee of Natera and own stock/options to stock.: Natera, Inc. P. Abbosh: Advisory / Consultancy, Advisory: Janssen; Advisory / Consultancy, Advisory: AstraZeneca. All other authors have declared no conflicts of interest.

Elevated neutrophil to lymphocyte and platelet to lymphocyte ratios predict high grade and advanced stage renal cell carcinoma.

Renal cell carcinoma is the most common malignancy of the kidney, which accounts 85% of all renal tumors. In recent years, the incidence of renal cell carcinoma was increased due to the widespread use of imaging techniques. The aim of this study is to investigate the clinical significance of pretreatment neutrophil to lymphocyte and platelet to lymphocyte ratios in patients with renal cell carcinomas. The patients who underwent nephrectomy for renal tumor between 2010 and 2018 in two centers were reviewed retrospectively. The age, sex, complete blood test, and pathological results were recorded. The patients who were diagnosed with other carcinomas, benign renal tumors, and missing data of age, complete blood test, and pathological results, were excluded. The patients were divided into two groups according to the T stage and Fuhrman grade, T1-2 and T3-4, G1-2 and G3-4. There were 271 patients in the current study. The male to female ratio was 1.97 and the mean age of the patients was 59.37±11.62 years. Clear cell renal cell carcinoma was the most common subtype in 72.7% of the patients. Both the neutrophil to lymphocyte ratio and the platelet to lymphocyte ratio were significantly higher in patients with high-grade and advanced-stage disease than in the others. The receiver operating characteristic curve showed no significant difference between platelet to lymphocyte ratio and neutrophil to lymphocyte ratio to diagnose the high grade and stage of renal cell carcinoma. The neutrophil to lymphocyte and platelet to lymphocyte ratios are easily accessible biomarkers which are used for the prognosis of malignancy. The current study found that these biomarkers may predict the pathological results during the preoperative period.

Racial and Ethnic Disparities in Renal Cell Carcinoma: An Analysis of Clinical Characteristics.

Racial/ethnic minority groups, including Hispanic Americans (HAs) and Native Americans (NAs), have a heavier burden of kidney cancer than European Americans (EAs). We investigated variations in clinical characteristics of HA and NA patients with renal cell carcinoma (RCC) who were previously underrepresented. Clinical records of 294 patients with RCC (151 EAs, 95 HAs, 22 NAs, and 26 others) without prior diagnosis of cancer were reviewed. Logistic regression analysis was performed to understand patients' clinical characteristics. HAs had about 5 years younger average age at diagnosis than EAs (55.8 vs. 60.5 years) and an almost 3-fold increased odds of diagnosis before age 50 years (odds ratio [OR], 2.77; 95% confidence interval [CI], 1.39-5.54). The mean age of diagnosis among NAs was 49.7 years, and NAs had an over 6-fold higher odds of diagnosis at a younger age (OR, 6.23; 95% CI, 2.00-19.46). Clear-cell RCC (ccRCC) was more common in HAs and NAs than EAs. Over 90% of HA patients had ccRCC, whereas only 78.8% of EA patients had ccRCC. HAs had increased odds of diagnosis with ccRCC compared with EAs (OR, 2.79; 95% CI, 1.15-6.80). Among HAs, older patients and patients who spoke Spanish as their primary language were more likely to have advanced stage RCC at diagnosis (OR, 10.48; 95% CI, 1.69-64.89 and OR, 4.61; 95% CI, 1.38-15.40). HA and NA patients with RCC had different clinical characteristics than EA patients. It is necessary to better understand the clinical characteristics of these underserved HA and NA populations with high kidney cancer burden.

Acarbose Delays Renal Cancer Progression in Mice: Implications for Obesity‐Induced Immunotherapeutic Failure

Obesity is a regarded as a major risk factor for developing renal cell carcinoma (RCC). Advanced‐stage RCC exhibits chemotherapeutic resistance, but is responsive to high‐dose IL‐2 and anti‐PD‐1 immunotherapies. Despite successes in these treatments, response rates remain low (20–30%). Currently, pre‐clinical evaluations of immunotherapeutic strategies typically use lean, young mice and do not account for the presence of patient comorbidities. This may partially explain the underwhelming success in clinical translation. Our laboratory previously demonstrated that a T cell‐based immunotherapy clears orthotopic renal tumors in lean mice, but fails in diet‐induced obese mice. This illustrates the importance of identifying methods to rescue obesity‐induced immunotherapeutic failure in this model. Calorie restriction (CR) delays the onset of chronic diseases, such as obesity and cancer. This attribute has prompted interest in investigating CR and its substitutes as potential cancer therapeutics. Recent murine research shows that diets containing calorie restriction mimetics (CRMs) improve anti‐tumor immunity and chemotherapeutic efficacy. Here we examined acarbose, an α‐glucosidase inhibitor with CRM properties, in a preclinical model of kidney cancer. BALB/c mice were fed an acarbose‐supplemented or control diet following orthotopic tumor challenge with syngeneic Renca renal carcinoma cells. Acarbose reduced endpoint tumor weights (p=0.02) and lung metastases (p=0.03). Flow cytometric analysis at endpoint revealed similar frequencies of splenic and intra‐tumoral CD8 T cells in mice treated with acarbose. These findings suggest that acarbose may exhibit anti‐tumor properties, and indicates a potential treatment opportunity for mice with diet induced obesity. Future experiments will focus on evaluating acarbose in combination with immunotherapy, in lean and obese mice.Support or Funding InformationT32HL105349This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Analyzing Abnormal Liver Enzymes in a Patient With Renal Cell Carcinoma

Introduction: Targeted agents have greatly improved the prognosis of patients with advanced-stage renal cell carcinoma (RCC). However, tyrosine kinase inhibitors (TKI) may induce liver injury, which may present a challenge in diagnostic evaluation. Case Description: A 75-year-old male patient with metastatic RCC presented with new-onset nausea, decreased appetite, and jaundice, in association with abnormal liver profile testing. Metastatic sites included the ribs, thoracic vertebrae, and pancreas. He started treatment with pazopanib six weeks prior, during which liver enzymes and synthetic function tests were normal. Acetaminophen use was not significant; the patient denied the use of herbal supplements. On physical examination, he was jaundiced, and the abdomen was soft, non-tender, non-distended, without ascites or hepatosplenomegaly. He exhibited no stigmata of advanced liver disease. Labs showed ALT 484 U/L, AST 277 U/L, alkaline phosphatase 562 U/L, total bilirubin 7.9 mg/dL, direct bilirubin 6.2 mg/dL, albumin 3.3 g/dL, and INR 1.02. Abdominal ultrasound did not reveal hepatobiliary abnormalities. Abdominal MRI/MRCP did not show intrahepatic or extrahepatic biliary ductal dilatation. Laboratory testing for ANA, anti-smooth muscle antibody, anti-LKM-1 antibody, anti-mitochondrial antibody, serum ceruloplasmin, ferritin/iron profile, and viral hepatitides (A, B, and C) were unrevealing. Serum IL-6 levels were elevated. After nine days, the ALT and AST improved to 183 U/L and 186 U/L, respectively, although the total bilirubin continued to gradually increase from 7.9 g/dL to 16.1 g/dL. The patient did not develop signs or symptoms of acute liver failure. Liver biopsy showed moderate inflammatory infiltrate in portal tracts, with predominance of lymphocytes, admixed with eosinophils and neutrophils, as well as cholestasis without cirrhosis. The patient was diagnosed with pazopanib-induced hepatotoxicity, and supportive care was offered. Discussion: Pazopanib is a VEGF-receptor TKI approved for use in patients with advanced RCC. In clinical trials, incidence of hepatotoxicity was as high as 53%. Patients with a diagnosis of RCC may encounter scenarios that would require clinician interpretation of abnormal liver tests, whether as a result of therapy such as pazopanib, or a paraneoplastic syndrome of cholestasis, namely Stauffer's syndrome. Careful analysis of history and exclusion of other causes of hepatitis may allow for a more confident diagnosis.Figure: Liver biopsy: Cholestatic hepatitis with portal and lobular mixed lymphocytic and neutrophilic inflammation (H&E stain, 100X).Figure: Liver biopsy: Expansion of portal tract with inflammatory infiltrate (H&E stain, 200X).Figure: Liver biopsy: Cholestasis, mild steatosis, and inflammatory infiltrate involving the lobule (H&E stain, 200X).Table: Table. Liver enzymes and hepatic function laboratory results relative to day of pazopanib administration

Palliative Surgery for Advanced Cancer: Identifying Evidence-Based Criteria for Patient Selection: Case Report and Review of Literature

Criteria for selecting patients with advanced cancer for palliative surgery (PS) remains poorly defined. Decision making for PS requires realistic treatment goals with well-defined criteria. Here we discuss a 71-year-old Jehovah's Witness with advanced stage renal cell carcinoma (RCC) who presented with profound anemia due to intractable bleeding from gastric metastasis. After repeated attempts with endoscopic and angiographic management, she underwent surgical palliation. Through this case, we developed 10-item evidence-based criteria for selecting patients for PS. The study objective was to provide a review of pertinent literature for PS and identify evidence-based criteria for patient selection. These criteria were relevant for selecting this patient with metastatic RCC and may prove beneficial for selecting advanced cancer patients for PS. A MEDLINE search revealed 175 publications relevant to PS. Among these, 17 articles defining patient selection criteria (PSC) were reviewed. A frequency-based analysis of each criterion was performed. Another search returned 30 cases of RCC gastric metastases from 25 published reports. Outcome analysis was determined by the Kaplan-Meier actuarial method. Ten criteria were identified: symptom control, prognosis, preoperative performance status, quality of life (QoL), tumor burden amenable to palliation, procedure-related morbidity and mortality, feasibility of nonsurgical therapies, anticipated hospitalization, requirement for additional palliation, and cost. This patient met all inclusion criteria and underwent a successful gastrectomy. Median survival for patients with RCC gastric metastasis was 20 months. This report illustrates an example of implementation of evidence-based criteria for selecting advanced cancer patients for PS. Validation of these criteria is warranted.

The impact of immunohistochemical staining with ezrin-carbonic anhydrase IX and neuropilin-2 on prognosis in patients with metastatic renal cell cancer receiving tyrosine kinase inhibitors.

The identification of prognostic factors in patients with renal cell carcinoma (RCC) represents an area of increasing interest. In this retrospective study, we evaluated the prognostic role of carbonic anhydrase-IX, ezrin, and neuropilin in metastatic RCC patients. The expression of several biomarkers were measured by immunohistochemistry (IHC) in 45 patients with advanced stage RCC treated with second-line tyrosine kinase inhibitors (TKIs) targeting vascular endothelial growth factor (VEGF) after failure of interferon-alpha between January 2007 and June 2012. Kaplan-Meier curves and log-rank tests were used for analysis of progression-free survival (PFS) and overall survival (OS), and a multivariate Cox proportional hazard model was employed to identify factors with an independent effect on the survival. Age, ezrin and neuropilin-2 overexpression were found to be statistically significant factors (P < 0.05) for PFS in the univariate analysis. Ezrin and neuropilin-2 overexpression, hemoglobin and albumin level were statistically significant factors (P < 0.05) for OS in the univariate analysis. Multivariate analysis revealed that low expression of ezrin and neuropilin-2 was an independent prognostic factor for PFS and OS. The median PFS was 4 months for patients overexpressing neuropilin-2 versus 11 months for those with lower expression of neuropilin-2 (p = 0.033). The median OS was longer in patients with low levels of neuropilin-2 expression (26 months) compared to patients overexpressing neuropilin-2 (13 months) (p = 0.023). Increased expression of ezrin was associated with poor prognosis in patients treated with TKIs targeting VEGF (PFS, 3 vs 7 months; p = 0.012). High ezrin expression was associated with shorter OS (p = 0.009). This is the first study in the literature showing that neuropilin-2 and ezrin are related with prognosis in patients with advanced RCC.