Multiple Renal Cell Carcinoma Research Articles

Impact of tumor multiplicity on the prognosis of patients with primary renal cell carcinoma: a SEER database analysis

To compare clinical characteristics and survival outcomes of patients with multiple renal cell carcinoma versus single renal cell carcinoma. Develop a prognostic model for predicting prognosis in patients with multiple tumors and analyze prognostic factors. Patients with primary multiple renal cell carcinoma were selected from the Surveillance, Epidemiology, and End Results database (2004–2015). They were divided into single-tumor and multiple-tumor groups. Survival analysis was conducted using the Kaplan–Meier method and log-rank test. A Cox regression model was used to identify potential prognostic factors. A total of 19,489 renal cell carcinoma cases were included, with 947 in the multiple-tumor group and 18,542 in the single-tumor group. The multiple-tumor group had lower cancer-specific survival (P = 0.03, HR = 1.431). Cox regression identified risk factors for the multiple-tumor group including number of tumors, gender, combined summary stage, T stage, N stage, tumor size, and type of surgery. The predicted probabilities showed acceptable agreement with the actual observations at 3-, 5-, and 8-years area under the curve values in both the training and validation cohorts (0.831 vs. 0.605; 0.775 vs. 0.672; and 0.797 vs. 0.699, respectively). Compared with single renal cell carcinoma, multiple renal cell carcinoma is associated with decreased cancer-specific survival. Additionally, we identified several prognostic factors including the number of tumors, T stage, tumor size, and type of surgery. These findings offer valuable insights for selecting appropriate treatment strategies for patients diagnosed with multiple renal cell carcinomas.

25 Enrichment of tertiary lymphoid structures provides novel insight into mediators of anti-tumor immune activity in sarcomatoid renal cell carcinoma

Abstract Background Renal cell carcinoma (RCC) comprises various histological subtypes, with clear cell RCC (ccRCC) being the most prevalent histotype. RCC with sarcomatoid features (sRCC) is a unique kidney cancer subtype associated with aggressive biological features and poor clinical outcomes that can arise from multiple RCC histologies, most commonly ccRCC. While clinically aggressive, sRCC paradoxically has also demonstrated preferential responsiveness to immune checkpoint blockade (ICB) therapies in subgroup analyses of multiple phase III trials. However, the mediators of this immune sensitivity are largely unknown. We therefore applied transcriptomic techniques to identify orchestrators of immune activity within the sRCC tumor microenvironment (TME). Methods Nephrectomy specimens from patients with sRCC and ccRCC were procured for single cell RNA sequencing (scRNAseq). Clustering and dimensionality reduction were performed, and cell populations were annotated based on expression of canonical lineage markers. Immune populations (CD8+ T cells, CD4+ T cells, B/plasma cells, myeloid cells) were computationally extracted and differential gene expression between sRCC- and ccRCC-derived cells within each subpopulation was performed. Gene expression programs enriched in sRCC samples by scRNAseq were validated on publicly available bulk gene expression data comparing sRCC to ccRCC. Spatial transcriptomics were performed on sRCC tumor sections using the 10X Visium platform. Results Across 18 RCC specimens (10 sRCC; 8 ccRCC), 73,123 cells were analyzed by scRNAseq. Within the CD8+ T cell compartment, CXCL13 was the most significantly enriched nuclear-encoded gene in sRCC samples (log 2-fold change=1.29; q<0.001). CXCL13 was also significantly enriched in CD4+ T cells from sRCC (q<0.001), suggesting enhanced presence of follicular T cells within the sRCC TME. As follicular T cells function in support of B cells, we next interrogated the B lymphocyte population. sRCC samples were enriched for mature B cell and plasma cells, with a five-fold increase in the relative abundance of plasma cells compared to ccRCC samples. Immune deconvolution of patient-derived RNA sequencing from the IMmotion 151 trial revealed a significant increase in the predicted proportion of B lymphocytes (including plasma cells) within the sRCC TME relative to ccRCC (p=0.034). Further, over 20 B lymphocyte activation and maturation pathways were consistently enriched (q<0.25) in sRCC across clinical datasets (Javelin101, CheckMate, and TCGA KIPAN), including Signaling by the B Cell Receptor, Positive Regulation of B Cell Activation, and Immunoglobulin Production Involved in Immunoglobulin Mediated Immune Response, amongst others. B lymphocytes mediate anti-tumor immunity through antibody dependent cellular cytotoxicity (ADCC), and thus the phagocytic effectors of ADCC were interrogated. Myeloid populations differentially expressed FCγR3A in sRCC vs ccRCC (q<0.001), which was recapitulated in bulk gene expression populations (q=0.002, 0.12, and 1.08x10-4 in Javelin101, CheckMate, and TCGA cohorts, respectively). Given the enrichment of follicular T cell and differentiated B lymphocyte programs, we explored the presence of tertiary lymphoid structures (TLS) in sRCC. Two distinct TLS signatures – the 12 Chemokine Score and the TLS Imprint Signature – were significantly enriched in sRCC vs ccRCC across RCC patient datasets (Figure 1). Furthermore, spatial transcriptomics were applied to H&E slides of sRCC to successfully identify the presence of TLS by expression of TLS-associated genes adjacent to sarcomatoid regions. Conclusions TLS, which have previously been associated with response to ICB in RCC (Meylan et al. Immunity. 2022), are transcriptomically enriched for in sRCC, paralleling an observed increase in CXCL13-expressing T cells and differentiated B lymphocytes. Together, TLS and their constituents offer a previously unexplored mediator of immunosurveillance in the sRCC TME that may underlie the paradoxical responsiveness to ICB seen within this population clinically.

Multiple Onychopapillomas and BAP1 Tumor Predisposition Syndrome

BRCA1-associated protein (BAP1) tumor predisposition syndrome (TPDS) is a cancer genodermatosis associated with high risk of uveal and cutaneous melanoma, basal cell carcinoma, and multiple internal malignant neoplasms, including mesothelioma and renal cell carcinoma. Early detection of the syndrome is important for cancer surveillance and genetic counseling of family members who are at risk. To determine the prevalence of nail abnormalities in individuals with pathogenic germline variants in BAP1. In this prospective cohort study, individuals who were known carriers of pathogenic BAP1 germline variants were consecutively enrolled between October 10, 2023, and March 15, 2024. Dermatologic evaluation for nail abnormalities was performed, including a history of nail abnormalities and associated symptoms, physical examination, medical photography, and nail biopsy for histopathology. This was a single-center study conducted at the National Institutes of Health Clinical Center. Primary outcomes were the prevalence and spectrum of nail changes and histopathologic characterization. Among 47 participants (30 female [63.8%]; mean [SD] age, 46.4 [15.1] years) ranging in age from 13 to 72 years from 35 families, nail abnormalities were detected in 41 patients (87.2%) and included leukonychia, splinter hemorrhage, onychoschizia, and distal nail hyperkeratosis. Clinical findings consistent with onychopapilloma were detected in 39 patients (83.0%), including 35 of 40 individuals aged 30 years or older (87.5%). Nail bed biopsy was performed in 5 patients and was consistent with onychopapilloma. Polydactylous involvement with onychopapillomas was detected in nearly all patients who had nail involvement (38 of 39 patients [97.4%]). This study found that BAP1 TPDS was associated with a high rate of nail abnormalities consistent with onychopapillomas in adult carriers of the disease. Findings suggest that this novel cutaneous sign may facilitate detection of the syndrome in family members who are at risk and patients with cancers associated with BAP1 given that multiple onychopapillomas are uncommon in the general population and may be a distinct clue to the presence of a pathogenic germline variant in the BAP1 gene.

Surgical resection of double advanced pancreatic neuroendocrine tumors with multiple renal cell carcinoma associated with von Hippel-Lindau disease.

Von Hippel-Lindau (VHL) disease, an autosomal dominant genetic disorder caused by a germline mutation, is associated with non-functional and slow-growing pancreatic neuroendocrine tumor (PNET) and kidney cancer. We describe the case of a 46year-old man with a 35mm mass in the pancreatic head causing stricture of the bile duct and main pancreatic duct, a 55mm mass in the pancreatic tail causing obstruction of the splenic vein (SV), and multiple masses of > 36mm on both kidneys. We performed a two-stage resection. First, a total pancreatectomy with superior mesenteric vein (SMV) resection and reconstruction and retroperitoneoscopic right partial nephrectomy (NP) for five lesions was performed, followed by retroperitoneoscopic left partial NP of the five lesions 6months later. Postoperative histopathological examination revealed NET G2 in the pancreatic head with SMV invasion and somatostatin receptor type 2A (SSTR2A) positivity, NET G2 in the pancreatic tail showed SV invasion and negative SSTR2A, and multiple clear cell renal cell carcinomas (RCC) were also noted. Multiple liver recurrences occurred 22months after primary surgery. The patient remains alive 41months after primary surgery. Kidney cancer generally determines VHL prognosis; however, we experienced dual-advanced PNETs with a more defined prognosis than multiple RCC associated with VHL.

LncRNA-SERB promotes vasculogenic mimicry (VM) formation and tumor metastasis in renal cell carcinoma

A growing body of evidence shows that vasculogenic mimicry (VM) is closely related to the invasion and metastasis of many tumor cells. Although the estrogen receptor (ER) can promote initiation and progression of renal cell carcinoma (RCC), how the downstream biomolecules are involved, and the detailed mechanisms of how ER expression is elevated in RCC remain to be further elucidated. Here, we discovered that long noncoding RNA (LncRNA)-SERB is highly expressed in tumor cells of RCC patients. We used multiple RCC cells and an invivo mouse model for our study, and results indicated that LncRNA-SERB could boost RCC VM formation and cell invasion invitro and invivo. Although a previous report showed that ERβ can affect the VM formation in RCC, it is unclear which factor could upregulate ERβ. This is the first study to show LncRNA-SERB can be the upstream regulator of ERβ to control RCC progression. Mechanistically, LncRNA-SERB may increase ERβ via binding to the promoter area, and ERβ functions through transcriptional regulation of zinc finger E-box binding homeobox 1 (ZEB1) to regulate VM formation. These results suggest that LncRNA-SERB promotes RCC cell VM formation and invasion by upregulating the ERβ/ZEB1 axis and that therapeutic targeting of this newly identified pathway may better inhibit RCC progression.

Molecular underpinnings of dedifferentiation and aggressiveness in chromophobe renal cell carcinoma.

Sarcomatoid dedifferentiation is common to multiple renal cell carcinoma (RCC) subtypes, including chromophobe RCC (ChRCC), and is associated with increased aggressiveness, resistance to targeted therapies, and heightened sensitivity to immunotherapy. To study ChRCC dedifferentiation, we performed multiregion integrated paired pathological and genomic analyses. Interestingly, ChRCC dedifferentiates not only into sarcomatoid but also into anaplastic and glandular subtypes, which are similarly associated with increased aggressiveness and metastases. Dedifferentiated ChRCC shows loss of epithelial markers, convergent gene expression, and whole genome duplication from a hypodiploid state characteristic of classic ChRCC. We identified an intermediate state with atypia and increased mitosis but preserved epithelial markers. Our data suggest that dedifferentiation is initiated by hemizygous mutation of TP53, which can be observed in differentiated areas, as well as mutation of PTEN. Notably, these mutations become homozygous with duplication of preexisting monosomes (i.e., chromosomes 17 and 10), which characterizes the transition to dedifferentiated ChRCC. Serving as potential biomarkers, dedifferentiated areas become accentuated by mTORC1 activation (phospho-S6) and p53 stabilization. Notably, dedifferentiated ChRCC share gene enrichment and pathway activation features with other sarcomatoid RCC, suggesting convergent evolutionary trajectories. This study expands our understanding of aggressive ChRCC, provides insight into molecular mechanisms of tumor progression, and informs pathologic classification and diagnostics.

Abstract CT163: FIT-001: A phase 1 clinical trial of the farnesyl transferase inhibitor KO-2806 alone or as part of combination therapy for advanced solid tumors

Abstract Background: Farnesyl transferase inhibitors (FTIs) block post-translational modification of RAS and other farnesylated proteins. HRAS-driven tumors are highly sensitive to FTI treatment. Recent clinical trials (NCT03719690, NCT02383927) of the FTI, tipifarnib, in patients with HRAS-mutant (HRAS-m) head and neck squamous cell carcinoma harboring high variant allele frequency mutations (VAF ≥20%), showed objective response rates of up to 50% and favorable long-term outcomes. KO-2806 is a next-generation FTI that has increased potency and improved pharmacokinetic properties. In preclinical studies, KO-2806 has been shown to: (1) enhance tumor growth inhibition of tyrosine kinase inhibitors, including cabozantinib, in multiple clear cell renal cell carcinoma (ccRCC) cell line- and patient-derived xenograft models; and (2) enhance activity of KRAS inhibitors, including adagrasib, in KRAS mutant non-small cell lung cancer (NSCLC), colorectal cancer (CRC), and pancreatic ductal adenocarcinoma (PDAC) mouse models. These preclinical data support clinical investigation of KO-2806 alone and in combination therapy. Study Design: FIT-001 is a first-in-human, multicenter, open-label clinical trial that will evaluate the safety, tolerability, pharmacokinetics, pharmacodynamics (Pd), and preliminary antitumor activity of KO-2806 as monotherapy or in combination therapy in advanced solid tumors (KO-2806-001; NCT06026410). Up to 270 patients will be enrolled in phase 1a and phase 1b combined across 50 sites. Phase 1a will have separate monotherapy and combination dose-escalation arms. As monotherapy, the study will enroll patients with N/K/HRAS alterations in specific solid tumor types, such as NSCLC, CRC, and PDAC, who are refractory to standard-of-care therapies. KO-2806 and cabozantinib will be combined in patients with advanced or metastatic ccRCC who progressed on ≥1 prior line of immunotherapy-based systemic therapy; KO-2806 and adagrasib will be combined in patients with KRAS-G12C mutant locally advanced or metastatic NSCLC who received ≥1 prior systemic therapy. On the basis of emerging data from phase 1a, two Pd cohorts (n≤12) with mandatory pre- and on-treatment tumor biopsies may be enrolled. In each Phase 1b dose expansion, patients will receive the recommended phase 2 dose [RP2D] of KO-2806 with cabozantinib (in ccRCC) or adagrasib (in NSCLC), or will be randomized by dose if 2 potential KO-2806 RP2Ds are identified for a combination. Other combination arms may also be considered. The study began accrual in October 2023. Citation Format: Glenn J. Hanna, Douglas R. Adkins, Jacob S. Thomas, Justine Y. Bruce, Manish R. Patel, Guru Sonpavde, Jason Henry, Nawal Bendris, Zijing Zhang, Amitava Mitra, Amaya Gascó, Andrew Saunders, Stephen Dale. FIT-001: A phase 1 clinical trial of the farnesyl transferase inhibitor KO-2806 alone or as part of combination therapy for advanced solid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT163.

Abstract 6154: Targeted CRISPRi screen identifies functional variants and novel target genes at multiple renal cell carcinoma (RCC) susceptibility loci

Abstract Genome-wide association studies (GWAS) have identified 13 renal cell carcinoma (RCC) risk regions, as well as 7 regions with nominal significance, but detailed investigation of how these regions function is required to reveal the underlying biological bases of disease susceptibility. While detailed study of four loci have implicated critical pathways in RCC, causal genes and pathways for most loci remain unidentified. To identify such causative variants and target genes, we evaluated a set of variants based on Massively Parallel Reporter Assays (MPRA), eQTL analysis, capture Hi-C, and an arrayed CRISPR inhibition (CRISPRi) screen. The MPRA identified 196 variants across 19 regions with significant allele-specific effects, indicating cis-regulatory activity. Of these, 39 variants across 10 RCC loci displayed chromatin loops allowing physical interaction with the promoter of 24 nearby putative gene targets, as well as a significant cis-eQTL with the same gene. To confirm the presence of a cis-regulatory relationship between these 39 candidate variants and 24 putative target genes, we performed an arrayed CRISPRi screen in ACHN (RCC) and HEK293T (embryonic renal) cells covering each of the 10 nominated regions. Cells were stably transduced with inactive Cas9 fused to the ZIM3 transcriptional repressor domain and cis-regulatory relationships were assessed by TaqMan qPCR for the target genes. The screen identified multiple novel relevant target genes of RCC predisposition variants, including UCK2 at 1q24, ABL2 and TDRD5 at 1q25, GTDC1 at 2q22, GPR37 at 7q31, AGBL3 and CALD1 at 7q33, and MAP2K1 at 15q22. At some regions, evidence indicates cis-regulatory relationships occur between a target gene and all variants predicted to be ‘causative’ at the region (e.g., UCK2 at 1q24 and ABL2 at 1q25). For other regions, cis-regulatory relationships occur between a gene and only one variant tested (e.g., GPR37 at 7q31 and TDRD5 at 1q25).Previously, target genes of only four RCC susceptibility regions had been identified and published. This study identifies eight novel target genes across six additional RCC susceptibility regions, representing a significant advance in understanding of the underlying biology of RCC susceptibility variants. Furthermore, ongoing screening using the orthologous method, CRISPR activation (CRISPRa), and integration of both normoxic and hypoxic conditions continues to provide further insight into the underlying biology at these regions. Citation Format: Timothy Winter, Timothy Myers, Leandro Colli, Lea Jessop, Jiyeon Choi, Mitchell J. Machiela, Mark P. Purdue, Kevin Brown, Stephen Chanock. Targeted CRISPRi screen identifies functional variants and novel target genes at multiple renal cell carcinoma (RCC) susceptibility loci [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 6154.

Abstract 3457: Distinct signatures of tumor-associated macrophage subpopulations predict survival in renal cell carcinoma

Abstract Background: Comprising 90% of renal cancer cases in adults, renal cell carcinoma (RCC) is marked by significant heterogeneity in its tumor microenvironment. This study aims to test the hypothesis that tumor-associated macrophages (TAMs) play a role in modulating RCC progression and patient response to treatment. We explored the prognostic implications of TAM signatures on RCC survival, leveraging immunomics to decipher TAM-related alterations in the tumor microenvironment. Methods: Utilizing independent single-cell RNA-seq data from human RCC samples, we crafted 8 distinct RCC TAM signatures reflective of TAM presence. A LASSO Cox regression model was developed to prognosticate survival, tested against the TCGA dataset and independently validated across multiple RCC cohorts. Model performance was corroborated through Kaplan-Meier survival plots, receiver operating characteristic (ROC) curves, principal component analysis, and t-SNE analyses. Results: We identified two TAM signatures that correlate positively with patient survival, indicative of the abundance of specific subsets of TAMs in RCC. These signatures showed a strong association of specific TAM markers and macrophage infiltration. Survival analysis demonstrated that specific TAM signature gene expressions are significant prognostic markers. Forest plots underscored their prognostic relevance. A 32-gene risk score model was established, successfully stratifying patients into distinct risk categories, with low-risk patients exhibiting markedly improved overall survival. Conclusions: The study underscores the positive association between abundance of specific TAM subsets of and RCC patient survival. The precision of our LASSO Cox regression model, informed by novel abundance markers of specific TAM subsets, advances our understanding of TAM roles in TIME and RCC progression. These TAM signatures could potentially provide additional insights and targets to enhance the efficacy of RCC treatments. Keywords: Tumor associated macrophage, renal cell carcinoma, prognosis, tumor microenvironment, immunomics. Citation Format: Youngsoo Han, Aidan Shen, Zhaohui Wang, Aliesha Garrett, Chongming Jiang. Distinct signatures of tumor-associated macrophage subpopulations predict survival 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 3457.

DNA Methylation Modification Patterns Identify Distinct Prognosis and Responses to Immunotherapy and Targeted Therapy in Renal Cell Carcinoma.

Considering the remarkable heterogeneity of biological features of renal cell carcinoma (RCC), the current clinical classification that only relies on classic clinicopathological features is in urgent need of improvement. Herein, we aimed to conduct DNA methylation modification patterns in RCC. We retrospectively curated multiple RCC cohorts, comprising TCGA-KIRC, TCGA-KICH, TCGA-KIRP, and E-MTAB-1980. DNA methylation modification patterns were proposed with an unsupervised clustering algorithm based on 20 DNA methylation regulators. Immunological features were characterized using tumor-infiltrating immune cells and immunomodulators. Sensitivity to immuno- or targeted therapy was estimated with submap and Genomics of Drug Sensitivity in Cancer (GDSC). DNA methylation score (DMS) was developed with principal component analysis. Three DNA methylation modification patterns were conducted across RCC patients, namely C1, C2 and C3. Among them, C3 displayed the most remarkable survival advantage. The three patterns presented in agreement with immune phenotypes: immune-desert, immune-excluded, and immune-inflamed, respectively. These patterns displayed distinct responses to anti-PD-1 and targeted drugs. DMS enabled the quantification of DNA methylation status individually as an alternative tool for prognostic estimation. The DNA methylation molecular patterns we proposed are an innovative complement to the traditional classification of RCC, which might contribute to precision medicine.

PERK Inhibition by HC-5404 Sensitizes Renal Cell Carcinoma Tumor Models to Antiangiogenic Tyrosine Kinase Inhibitors.

Tumors activate protein kinase R (PKR)-like endoplasmic reticulum kinase (PERK, also called EIF2AK3) in response to hypoxia and nutrient deprivation as a stress-mitigation strategy. Here, we tested the hypothesis that inhibiting PERK with HC-5404 enhances the antitumor efficacy of standard-of-care VEGF receptor tyrosine kinase inhibitors (VEGFR-TKI). HC-5404 was characterized as a potent and selective PERK inhibitor, with favorable in vivo properties. Multiple renal cell carcinoma (RCC) tumor models were then cotreated with both HC-5404 and VEGFR-TKI in vivo, measuring tumor volume across time and evaluating tumor response by protein analysis and IHC. VEGFR-TKI including axitinib, cabozantinib, lenvatinib, and sunitinib induce PERK activation in 786-O RCC xenografts. Cotreatment with HC-5404 inhibited PERK in tumors and significantly increased antitumor effects of VEGFR-TKI across multiple RCC models, resulting in tumor stasis or regression. Analysis of tumor sections revealed that HC-5404 enhanced the antiangiogenic effects of axitinib and lenvatinib by inhibiting both new vasculature and mature tumor blood vessels. Xenografts that progress on axitinib monotherapy remain sensitive to the combination treatment, resulting in ∼20% tumor regression in the combination group. When tested across a panel of 18 RCC patient-derived xenograft (PDX) models, the combination induced greater antitumor effects relative to monotherapies. In this single animal study, nine out of 18 models responded with ≥50% tumor regression from baseline in the combination group. By disrupting an adaptive stress response evoked by VEGFR-TKI, HC-5404 presents a clinical opportunity to improve the antitumor effects of well-established standard-of-care therapies in RCC.

Abstract B026: Combined inhibition of mammalian target of rapamycin (mTOR) and survivin augments radiation therapy in renal cell carcinoma

Abstract Purpose: Although renal cell carcinoma (RCC) is relatively more resistant to radiation therapy (RT) compared to other cancer indications, recent advances in single-fraction and multi-fraction stereotactic ablative radiotherapy (SABR) made it possible to achieve better outcome and reduce treatment related toxicities. In addition, with studies demonstrating that certain therapeutic agents including chemotherapies can act as radiosensitizers, the idea of combining radiotherapy with those agents are being actively pursued. Among them, mammalian target of rapamycin (mTOR) inhibitor everolimus (E) and survivin inhibitor YM155 (Y) are of special interest since they target multiple RT-resistance mechanisms simultaneously. Additionally, YM155 has been shown to help in overcoming resistance to mTOR inhibitors in various cancer including RCC. Hence, the present study aims to evaluate the efficacy of a tumor-targeted liposomal formulation combining everolimus and YM155 (EY-L) in sensitizing RCC tumors towards radiation. Experimental Design: Previously we developed a tumor-targeted liposomal formulation and used it successfully to deliver multiple drugs for the treatment of RCC in both immune-deficient and immune-competent mouse models. Here we developed a similar formulation combining everolimus and YM155 (EY-L) and assessed its efficacy in RCC cell lines in vitro and in RCC tumors in vivo. We further evaluated the efficacy of EY-L in sensitizing RCC cell lines and tumors towards radiation in vitro using clonogenic assay and in vivo in RCC xenografts in immunodeficient mice and murine RCC models in immunocompetent mice. Results: EY-L (2 mg/kg E, 1.4 mg/kg Y, twice a week intravenous administration) was better than E-L or Y-L, the corresponding single drug loaded formulations in containing the primary tumor growth and improving survival in an immunocompetent syngeneic mouse model of RCC. Furthermore, EY-L leads to significantly higher sensitization of RCC cells towards radiation in vitro than E-L or Y-L. Finally, EY-L was able to sensitize RCC tumors towards radiation therapy in both RCC xenograft and murine RCC model. Conclusion: Taken together, our study demonstrated the efficacy of a strategic combination therapy in sensitizing RCC to radiation therapy using in vitro clonogenic assay and in vivo radiosensitization studies in multiple RCC tumor models. Citation Format: Krishnendu Pal, Vijay S. Madamsetty, Hari K. Rachamala, Shamit K. Dutta, Enfeng Wang, Debabrata Mukhopadhyay. Combined inhibition of mammalian target of rapamycin (mTOR) and survivin augments radiation therapy in renal cell carcinoma [abstract]. In: Proceedings of the AACR Special Conference: Advances in Kidney Cancer Research; 2023 Jun 24-27; Austin, Texas. Philadelphia (PA): AACR; Cancer Res 2023;83(16 Suppl):Abstract nr B026.

AKR1B10 Is a New Sensitive and Specific Marker for Fumarate Hydratase-Deficient Renal Cell Carcinoma

Fumarate hydratase (FH)–deficient renal cell carcinoma (RCC) is a rare and distinct subtype of renal cancer caused by FH gene mutations. FH negativity and s-2-succinocysteine (2SC) positivity on immunohistochemistry can be used to screen for FH-deficient RCC, but their sensitivity and specificity are not perfect. The expression of AKR1B10, an aldo-keto reductase that catalyzes cofactor-dependent oxidation-reduction reactions, in RCC is unclear. We compared AKR1B10, 2SC, and FH as diagnostic biomarkers for FH-deficient RCC. We included genetically confirmed FH-deficient RCCs (n = 58), genetically confirmed TFE3 translocation RCCs (TFE3-tRCC) (n = 83), clear cell RCCs (n = 188), chromophobe RCCs (n = 128), and papillary RCCs (pRCC) (n = 97). AKR1B10, 2SC, and FH were informative diagnostic markers. AKR1B10 had 100% sensitivity and 91.4% specificity for FH-deficient RCC. The nonspecificity of AKR1B10 was shown in 26.5% of TFE3-tRCCs and 21.6% of pRCCs. 2SC showed 100% sensitivity and 88.9% specificity. However, nonspecificity for 2SC was evident in multiple RCCs, including pRCC, TFE3-tRCC, clear cell RCCs, and chromophobe RCCs. FH was 100% specific but 84.5% sensitive. AKR1B10 served as a highly sensitive and specific diagnostic biomarker. Our findings suggest the value of combining AKR1B10 and 2SC to screen for FH-deficient RCC. AKR1B10+/2SC+/FH− cases can be diagnosed as FH-deficient RCC. Patients with AKR1B10+/2SC+/FH+ are highly suspicious of FH-deficient RCC and should be referred for FH genetic tests.

Inter- and intra-tumor heterogeneity of genetic and immune profiles in inherited renal cell carcinoma

Patients with von Hippel-Lindau disease (vHL) are at risk of developing spatially and temporally multiple clear cell renal cell carcinomas (ccRCCs), which offers a valuable opportunity to analyze inter- and intra-tumor heterogeneity of genetic and immune profiles within the same patient. Here, we perform whole-exome and RNA sequencing, digital gene expression, and immunohistochemical analyses for 81 samples from 51 ccRCCs of 10 patients with vHL. Inherited ccRCCs are clonally independent and have less genomic alterations than sporadic ccRCCs. Hierarchical clustering of transcriptome profiles shows two clusters with distinct immune signatures: immune hot and cold clusters. Interestingly, not only samples from the same tumors but also different tumors from the same patients tend to show a similar immune signature, whereas samples from different patients frequently exhibit different signatures. Our findings reveal the genetic and immune landscape of inherited ccRCCs, demonstrating the relevance of host factors in shaping anti-tumor immunity.

Minimal Fat Content in Papillary Renal Cell Carcinoma Diagnosed with Dual-Layer Dual-Energy CT.

A 56-year-old man with a previous right nephrectomy for multiple papillary renal cell carcinomas (pRCC) underwent a follow-up CT scan. Using a dual-layer dual-energy CT (dlDECT), we demonstrated the presence of a small amount of fat in a 2.5 cm pRCC that mimicked the diagnosis of angiomyolipoma (AML). Histological examination demonstrated the absence of macroscopic intratumoral adipose tissue, showing a fair amount of enlarged foam macrophages loaded with intracytoplasmic lipids. The presence of fat density in an RCC is an extremely rare occurrence in the literature. To our knowledge, this is the first description using dlDECT of a minimal amount of fat tissue in a small RCC due to the presence of tumor-associated foam macrophages. Radiologists should be aware of this possibility when characterizing a renal mass with DECT. The option of RCCs must be considered, especially in the case of masses with an aggressive character or a positive history of RCC.

Coexistence of multiple clear cell papillary renal cell carcinoma with renal oncocytoma: a case report.

The authors report a case of a female 65-year-old suffering from end-stage kidney failure for 10 years, who presented with a double left renal tumor, composed by an oncocytoma associated to multiple CCPRCC, a very rare entity. A radical left nephrectomy was realized by lumbotomy, with an uneventful postoperative course. Histological examination was challenging. Immunohistological examination showed diffuse positivity of cytokertain 7. No local recurrence nor metastatic progression were found during the 12 months of follow-up. CCPRCC, is a new entity, previously known as the unclassified rena cell carcinoma, is a malignant renal tumor, initially reported in patients at end-stage kidney failure. Oncocytoma is a well-known rare benign renal tumor. The association of both is rare, and should be kept in mind, especially when scanoguided diagnosis biopsy is realized. Histopathological confirmation may be challenging, given the recent identification of CCPRCC. The nuclei disposal toward the luminal surface is a characteristic pathological landmark of CCPRCC. Immunohistopathological examination is of great help, showing a distinctive profile: diffuse staining for cytokertain 7 and carbonic anhydrase IX. CCPRCC is a new malignant pathological entity in renal tumors. It can be associated with other benign renal lesions. This should be taken into consideration while histopathological examination, mainly of scanoguided biopsy cores.

Incidence of Metastatic Renal Cell Carcinoma in Sulaimaniyah Government, Iraq

Renal cell carcinoma (RCC) has a well-known tendency to metastasize. Kidney Cancer (KC) has some histopathological subtypes; the most common one is clear cell renal cell carcinoma (ccRCC), which can spread to distant organs in the body like the lungs, brain, bone, and lymphatic system. Multiple RCC metastasis can be treated by complete surgical resection of all metastases if the patient is amenable for surgery, in spite that there is another option in the management of (metRCC) like chemotherapy, radiotherapy and immunotherapy. Full metastasectomy was related to a significant extension of median cancer-specific survival. Also, it is important during multiple metastasectomies; the surgical beds have free of tumours. Primary systemic therapy is targeted therapy (TT) that affect the vascular endothelial growth factor pathway, which improves progression-free survival and overall survival. The results of this study demonstrate that the incidence of metastasized RCC was 0.28 in 2017, which increased until in 2018, it became 0.92, which was the first pick. The second pick was in 2019, which was 1.26. After that, the incidence steadily decreased till 2020 and became 0.57 per 100,000 populations. Regarding types of operation and laterality, partial nephrectomy was done for (45%), radical nephrectomy for 52.5% and 2.5% were non operated, and (64.8%) of the primary tumour was right-sided, and 35.2% was left-sided. Regarding male gender 75 (61.5%) and female 47 (38.5%), non-symptomatic patients were 57.4% while 28.7% had flank pain history, 7.4% had gross hematuria, and 4.1% had back pain symptoms. Route of diagnosis only by ultrasound (US) in 86% and least diagnostic tool is magnetic resonance image (MRI) (0.8%). The most frequent (72.7%) histologic subtype was ccRCC. The most frequent site of distant metastasis was a respiratory system which was 9.8%, then 4.9% metastasized to the skeletal system. In contrast, connective tissue, the endocrine system, and the digestive system had the least common site (0.8%), 10.7% had metachronous, and 13.9% had synchronous metastasis, respectively. Regarding risk factors, 83.4% had a smoking history, the mean body mass index (BMI) was 27.3 kg/m2 , and 46.7% had ahypertension history. This study demonstrated the incidence of MetRCC in the Sulaimaniyah government. Finally, we concluded that the incidence of metastatic RCC increases annually, also synchronous metastasis has higher than metachronous metastasis. In contrast, metastatic RCC is more common in males than females, and most cases of RCC are diagnosed incidentally by a noninvasive imaging method, which was US.

Technique and short-term outcomes of surgical treatment in patients with renal cell carcinoma and tumor venous thrombosis: experience of the Urology Clinic, N.N. Blokhin National Medical Research Center of Oncology

Objective: to describe the technique of nephrectomy and thrombectomy used in patients with renal cell carcinoma (RCC) and tumor venous thrombosis of various levels, and to identify risk factors of in-hospital death among operated patients.Materials and methods. This study included 768 patients with RCC and tumor venous thrombosis who have undergone surgical treatment. Median age was 58 years (range: 16-82 years); the male to female ratio was 2.3:1. The symptoms of venous tumor thrombosis were identified in 199 patients (25.9 %). In the majority of patients (n = 509; 66.3 %), the tumor thrombus originated from the right renal vein. The cranial border of the tumor thrombus was located in the perirenal inferior vena cava (IVC) in 219 patients (28.5 %), subhepatic IVC in 201 patients (26.2 %), intrahepatic IVC in 171 patients (22.3 %), and above the diaphragm in 177 patients (23.0 %). We used an individual approach to choose an optimal method of vascular control and to identify indications for circulatory support. Two-thirds of patients (n = 512; 66.7 %) underwent temporary block of the second renal vein; 268 patients (34.9 %) - temporary block of the hepatoduodenal ligament and right heart; 11 patients (3.2 %) were operated on with cardiopulmonary bypass.Results. The median surgery time was 190 ± 63.6 min; median blood loss was 3,000 ± 71.6 mL (≥50 % of circulating blood in 35.1 % of patients). Intraoperative complications were registered in 23 patients (3.0 %); eight patients (1.0 %) died during surgery with 4 of them died due to pulmonary embolism (0.5 %), 3 died due to hemorrhagic shock (0.4 %), and 1 died due to myocardial infarction (0.1 %). One hundred and ninety individuals (25.0 %) developed postoperative complications with Clavien-Dindo grade III-V complications observed in 115 cases (15.1 %). Forty-one patients (5.3 %) died in the early postoperative period. The causes of death included multiple organ dysfunction (n = 21; 2.8 %), pulmonary embolism (n = 7; 0.9 %), sepsis (n = 6; 0.8 %), stroke (n = 4; 0.5 %), myocardial infarction (n = 2; 0.2 %), and RCC progression (n = 1; 0.1 %). We have identified several independent risk factors for in-hospital mortality, including ascites (hazard ratio (HR) 8.3; 95 % confidence interval (CI) 3.2-21.4; p < 0.0001), preoperative pulmonary embolism (HR 3.5; 95 % CI 1.3-9.4; p = 0.013), supradiaphragmatic thrombi (HR 1.5; 95 % CI 1.1-2.0; p = 0.003). The in-hospital mortality rate was 3.5 % (20/575) among patients with no risk factors, 9.8 % (16/163) among those with 1 risk factor, 40.0 % (10/25) among those with 2 risk factors, and 60.0 % (3/5) among those with 3 risk factors (area under the curve (AUC) 0.705; p <0.0001 for all).Conclusion. The incidence of severe complications and postoperative mortality rate in RCC patients with tumor venous thrombosis who have undergone nephrectomy and thrombectomy were 15.1 and 6.4 %, respectively. Risk factors for perioperative mortality included ascites, preoperative pulmonary embolism, and supradiaphragmatic thrombosis.

Crystalcryoglobulinemia as a manifestation of monoclonal gammopathy of renal significance in a patient with renal cell carcinoma

Crystalcryoglobulinemia refers to the extracellular deposition of crystals in the systemic vasculature, leading to vascular injury, thrombosis, and occlusion. This entity is usually described as a complication of multiple myeloma, although it can also occur in the setting of a monoclonal gammopathy of renal significance. Synchronous presentation of a monoclonal gammopathy and renal cell carcinoma is rare. Hypothetically, as both neoplasms’ growth depends on certain cytokines such as interleukin-6, it is possible that cytokine production from one neoplasm may stimulate the growth of the other. In this report, we describe a case of crystalcryoglobulinemia in a patient with a monoclonal gammopathy of renal significance and concomitant renal cell carcinoma. Additionally, we performed a systematic review of the literature and analyzed data of 61 reported cases of crystalcryoglobulinemia and of 40 reported cases describing the association between multiple myeloma and renal cell carcinoma.

A novel Apigenin derivative suppresses renal cell carcinoma via directly inhibiting wild-type and mutant MET

MET, the receptor of hepatocyte growth factor (HGF), is a driving factor in renal cell carcinoma (RCC) and also a proven drug target for cancer treatment. To improve the activity and to investigate the mechanisms of action of Apigenin (APG), novel derivatives of APG with improved properties were synthesized and their activities against Caki-1 human renal cancer cell line were evaluated. It was found that compound 15e exhibited excellent potency against the growth of multiple RCC cell lines including Caki-1, Caki-2 and ACHN and is superior to APG and Crizotinib. Subsequent investigations demonstrated that compound 15e can inhibit Caki-1 cell proliferation, migration and invasion. Mechanistically, 15e directly targeted the MET kinase domain, decreased its auto-phosphorylation at Y1234/Y1235 and inhibited its kinase activity and downstream signaling. Importantly, 15e had inhibitory activity against mutant MET V1238I and Y1248H which were resistant to approved MET inhibitors Cabozantinib, Crizotinib or Capmatinib. In vivo tumor graft study confirmed that 15e repressed RCC growth through inhibition of MET activation. These results indicate that compound 15e has the potential to be developed as a treatment for RCC, and especially against drug-resistant MET mutations.