Farhood Iranparvar Alamdari

Follow-up guidelines for nonmetastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy

To define guidelines for the follow‐up management of nonmetastatic renal cell carcinoma (RCC), by assessing tumour recurrences and the clinical course in patients who had undergone radical nephrectomy.

Prognostic significance of the Heidelberg classification of renal cell carcinoma.

Objective: The specific genetic alterations characterising renal cell carcinoma (RCC) have lead to the recognition of distinctive types of tumours. In a large material of patients, the prognostic and clinical information of these different tumour types were evaluated. Methods: Tumours from 186 patients were evaluated retrospectively according to the guidelines given by the Heidelberg Classification Conference. All patients were primarily nephrectomised and TNM staged, and the follow-up times for alive patients varied between 44 and 174 months. Results: The material consisted of 145 conventional (non-papillary), 25 papillary, 12 chromophobe and 4 unclassified RCCs. There was no difference in tumour size between the different RCC types. Among patients with conventional RCC, 37% had distant metastases at the time of diagnosis, significantly more frequently than 16% in patients with papillary and 8% in chromophobe RCC (p = 0.044 and 0.048, respectively). Conventional RCC more frequently had vein invasion compared with papillary RCC (p = 0.009). Patients with chromophobe and papillary RCC survived significantly longer than patients with conventional RCC (p = 0.017 and 0.031, respectively). Conclusions: A significant difference in clinical behaviour between the different RCC types was found. Patients with conventional RCC had a higher incidence of metastases, vein invasion and had adverse survival compared with papillary and chromophobe RCCs. Thus, the RCC types recognised by specific genetic alterations seem to represent different malignant phenotypes.

Factors of Importance for Prediction of Survival in Patients with Metastatic Renal Cell Carcinoma, Treated with or without Nephrectomy

Objective: The indications for nephrectomy in patients with metastatic renal cell carcinoma remain controversial. A number of variables were analysed to identify factors that might predict the survival time, and these factors were used to obtain guidance as to which patients might benefit from palliative nephrectomy. Material and Methods: We reviewed the medical records for 106 consecutive patients with primary metastatic renal cell carcinoma, including clinicopathological factors, routine laboratory data and metastatic spread. The association of the different factors to survival time was evaluated by univariate and multivariate analysis. Results: A number of factors correlated to survival time in univariate analysis, including solitary versus multiple metastases, serum albumin and DNA ploidy, but after Cox multivariate analysis their significance was lost. The remaining independent prognostic factors were performance status, number of metastatic sites, erythrocyte sedimentation rate (ESR), calcium in serum and vein invasion with tumour thrombus formation. The factors with no association to survival time were the metastatic sites, tumour size and nuclear grade. Patients treated with nephrectomy had a significantly longer survival time than those who did not undergo nephrectomy (p < 0.001). None of the 28 patients who did not undergo nephrectomy survived for 2 years, compared with 38 of the 78 patients who were nephrectomized. Conclusions: Patients who can be expected to survive longer, and who might be recommended for nephrectomy despite metastatic disease, would have the following independent factors: a good performance status, metastases limited to one organ, low ESR, normal calcium in serum and no tumour thrombus formation.

Radical Nephrectomy Is Still Preferable in the Treatment of Localized Renal Cell Carcinoma

Objectives: Due to the advances of radiological methods, an increased number of incidentally detected renal cell carcinomas is diagnosed. The reported excellent results of nephron-sparing surgery have promoted its application in patients with a normal contralateral kidney. However, the risk of local tumor recurrence and surgical complications after nephron-sparing surgery might be higher compared with radical nephrectomy. Methods: In 89 patients with localized renal cell carcinoma treated with radical nephrectomy, long-term renal function, morbidity, and survival were evaluated. The renal function was followed up regularly with serum creatinine measurements. Results: The cause-specific 5-year survival rate was 91.6%. There was neither local nor contralateral kidney tumor recurrence in any patient. Surgical complications were observed in 3% of the patients. Mean serum creatinine after the nephrectomy was 123 µmol/l without further increase during 10 years of follow-up. Conclusions: Radical nephrectomy of localized renal cell carcinoma has low morbidity, excellent local tumor control, and a high survival rate. For patients with a normally functioning contralateral kidney the long-term renal function remained adequate. Based on these data, there is no convincing evidence justifying nephron-sparing surgery to be used routinely for patients with a normally functioning contralateral kidney.

Adrenal metastasis in renal cell carcinoma: a recommendation for adjustment of the TNM staging system.

Objectives To study the incidence of adrenal metastasis in patients with renal cell carcinoma (RCC) of all stages, its correlation with clinicopathological variables and its impact on survival. Furthermore, the need for adrenalectomy as part of the routine radical nephrectomy was assessed. Material and methods The medical records of 321 patients with RCC of all stages who were operated on with the aim of performing adrenalectomy combined with radical nephrectomy between 1982 and 2000 were reviewed. The accuracy of the available preoperative radiological examinations was evaluated and any adrenal involvement was compared with other clinical and histopathological findings.Results Ipsilateral adrenal tumour involvement was detected in 17/321 patients (5.3%). In four of these patients, the adrenal gland was the only preoperatively found metastatic site. Factors predicting the presence of ipsilateral adrenal metastases were male gender, tumour size, vein invasion, renal capsule and perirenal fat invasion. Tumour location within the kidney and tumour side had no predictive value for the presence of adrenal metastasis. The presence of ipsilateral adrenal involvement was a significant adverse prognostic variable, indicating a short survival time (p<0.001). Conclusions Ipsilateral adrenal metastasis is a highly adverse prognostic factor. In the TNM staging system, adrenal gland involvement should be staged as M1a. Ipsilateral adrenalectomy in conjunction with radical nephrectomy should be performed if an adrenal lesion cannot be cleared of suspicion after preoperative radiological imaging, as in locally advanced tumours. The adrenal gland can be left in situ if the ipsilateral adrenal gland is assessed as normal at the preoperative investigation and perioperatively by the surgeon.

Angiogenesis and other markers for prediction of survival in metastatic renal cell carcinoma.

Objective. The treatment of metastatic renal cell carcinoma (RCC) remains a clinical challenge. Factors predicting any benefit of different therapies would therefore be useful. Angiogenesis is important in tumor progression and the development of metastases. The aim of this study in patients with distant metastases at diagnosis was to evaluate possible outcome information obtained with a number of soluble angiogenic variables in serum. Material and methods. Serum samples were taken at diagnosis from 120 consecutive patients with metastatic RCC who were operated on with radical nephrectomy. Different clinicopathological variables and vascular endothelial growth factor (VEGF), vascular endothelial growth factor receptor-1 (VEGFR-1), basic fibroblast growth factor (bFGF) and erythropoietin levels in serum were compared with the clinical course. Results. The median survival time for all patients was 9 months. Six patients (5%) died during the postoperative period, all of whom had a performance status (PS) of 2 or 3. None of the angiogenic factors (VEGF, VEGFR-1, bFGF, erythropoietin) gave any prognostic information, except that VEGF was associated with survival (p=0.0234) in patients with a good PS. A number of other variables gave prognostic information in univariate analysis but, after multivariate analysis, only PS (p=0.002), the number of metastatic sites (p=0.003) and capsule invasion (p=0.017) remained as independent predictive factors. Conclusions. Among predictive factors, only PS, the number of metastatic sites and capsule invasion independently predicted survival in patients with metastatic RCC, while soluble angiogenic factors in serum gave no prognostic information. Nephrectomy in patients with metastatic RCC remains controversial but long-term survival can be achieved in selected patients, especially those with a good PS.

Detection of micrometastases by flow cytometry in sentinel lymph nodes from patients with renal tumours

Background:Stage is an important prognostic factor in renal tumours and dissemination to regional lymph nodes is associated with poor outcomes. Lymph nodes are routinely assessed by immunohistochemistry and microscopic evaluation, a time-consuming process where micrometastases might go undiagnosed. We evaluate an alternative method for detecting metastatic cells in sentinel nodes (SNs) by flow cytometry.Methods:A total of 15 nodes from 5 patients diagnosed with renal tumours were analysed by flow cytometry. Staining for the intracellular marker cytokeratin 18 (CK18) with the surface markers carbonic anhydrase IX (CA9) and Cadherin 6 were used in flow cytometry analysis. Peripheral blood mononuclear cells (PBMCs) with the addition of known concentrations of cancer cell lines were analysed to investigate the sensitivity of micrometastasis detection.Results:Stability of the assay was marked by low intra-assay variability (coefficient of variance ⩽16%) and low inter-assay variability (R2=0.9996–1). Eight nodes in four patients were positive for metastasis; six of them were considered being micrometastatic. These metastases were undetected by routine pathology and the patients were restaged from pN0 to pN1.Conclusions:Flow cytometry is able to detect micrometastases in lymph nodes of renal tumour patients that were undetected under H&E examination.

Urothelial bladder cancer may suppress perforin expression in CD8+ T cells by an ICAM-1/TGFβ2 mediated pathway

The immune system plays a significant role in urothelial bladder cancer (UBC) progression, with CD8+ T cells being capable to directly kill tumor cells using perforin and granzymes. However, tumors avoid immune recognition by escape mechanisms. In this study, we aim to demonstrate tumor immune escape mechanisms that suppress CD8+ T cells cytotoxicity. 42 patients diagnosed with UBC were recruited. CD8+ T cells from peripheral blood (PB), sentinel nodes (SN), and tumor were analyzed in steady state and in vitro-stimulated conditions by flow cytometry, RT-qPCR, and ELISA. Mass spectrometry (MS) was used for identification of proteins from UBC cell line culture supernatants. Perforin was surprisingly found to be low in CD8+ T cells from SN, marked by 1.8-fold decrease of PRF1 expression, with maintained expression of granzyme B. The majority of perforin-deficient CD8+ T cells are effector memory T (TEM) cells with exhausted Tc2 cell phenotype, judged by the presence of PD-1 and GATA-3. Consequently, perforin-deficient CD8+ T cells from SN are low in T-bet expression. Supernatant from muscle invasive UBC induces perforin deficiency, a mechanism identified by MS where ICAM-1 and TGFβ2 signaling were causatively validated to decrease perforin expression in vitro. Thus, we demonstrate a novel tumor escape suppressing perforin expression in CD8+ T cells mediated by ICAM-1 and TGFβ2, which can be targeted in combination for cancer immunotherapy.

Neoadjuvant Chemotherapy Reinforces Antitumour T cell Response in Urothelial Urinary Bladder Cancer

Evidence indicates that neoadjuvant chemotherapy (NAC) may promote antitumour immune responses by activating T cells. The tumour-draining sentinel node (SN) is a key site to study tumour-specific T cell activation, being the primary immunological barrier against the tumour. In this prospective study, we set out to elucidate the effects of NAC on T cell subsets in the SNs of patients with muscle-invasive urothelial bladder cancer. We found that CD8+ effector T (Teff) cell exhaustion was reduced after NAC treatment, while cytotoxicity was increased. Additionally, in complete responders (CR patients), these cells were functionally committed effectors, as displayed by epigenetic analysis. In CD4+ Teffs, NAC treatment was associated with increased clonal expansion of tumour-specific SN-derived cells, as demonstrated by a specific cell reactivity assay. In contrast, we observed an attenuating effect of NAC on regulatory T cells (Tregs) with a dose-dependent decrease in Treg frequency and reduced effector molecule expression in the remaining Tregs. In addition, multicolour flow cytometry analysis revealed that CR patients had higher Teff to activated Treg ratio, promoting antitumoural T cell activation. These results suggest that NAC reinforces the antitumour immune response by activating the effector arm of the T cell compartment and diminishing the influence of suppressive Tregs. PATIENT SUMMARY: In this report, we analysed the effect of chemotherapy on immune cell subsets of 40 patients with advanced bladder cancer. We found that chemotherapy has a positive effect on immune effector T cells, whereas an opposite, diminishing effect was observed for immune-suppressive regulatory T cells. We conclude that chemotherapy reinforces the antitumour immune response in bladder cancer patients.

Tissue-resident memory T cells are epigenetically cytotoxic with signs of exhaustion in human urinary bladder cancer

Tissue‐resident memory T (TRM) cells are CD8+ T lymphocytes that reside in the tissues, including tumours. This T cell subset possesses a magnitude of cytotoxicity, but its epigenetic regulation has not been studied. Here, we investigate the impact of perforin DNA methylation in TRM cells and correlate it with their functional potential. Fifty‐three urothelial urinary bladder cancer (UBC) patients were recruited prospectively. The DNA methylation status of the perforin gene (PRF1) locus in TRM cells was investigated by pyrosequencing. Flow cytometry with ViSNE analysis and in‐vitro stimulation were used to evaluate TRM cell phenotypes. We discovered that tumour TRM cells have low DNA methylation in the PRF1 locus (32·9% methylation), which corresponds to increased numbers of perforin‐expressing TRM cells. Surprisingly, programmed cell death 1 (PD‐1) expression is high in tumour TRM cells, suggesting exhaustion. Following interleukin‐15 and T cell receptor stimulation, perforin and T‐bet expressions are enhanced, indicating that TRM cells from tumours are not terminally exhausted. Moreover, a high number of TRM cells infiltrating the tumours corresponds to lower tumour stage in patients. In conclusion, TRM cells from UBC tumours are epigenetically cytotoxic with signs of exhaustion. This finding identifies TRM cells as potential new targets for cancer immunotherapy.