Vito Mancini

Current insights in renal cell cancer pathology

In recent years molecular biologists and pathologists have described new entities of renal cell cancer (RCC) with a totally different morphology and biology among the histotypes of renal carcinoma, but always referring to the same renal cancer disease. The evidence of a distinct biological behavior and long-term prognosis among these makes the correct pathological diagnosis of renal cancer critically important for the clinician. Advances in understanding of the pathogenesis, behavior, and importance of prognostic factors for RCC have paved the way for a revision of its classification and staging. We reviewed the role of histological classification, microscopic tumor necrosis, microscopic venous invasion, lymph node involvement and, particularly, pathological stage. In our series of patients who underwent renal surgery for neoplasm, a retrospective study established the predictive role of tumor size on recurrence rate, compared with other known prognostic factors, and we conclude that histological grade, pathological stage and tumor size remain relevant prognosticators in early stage RCC patients. In order to optimize the management of patients with RCC it is necessary to develop an interdisciplinary approach (surgeon, radiologist, pathologist, oncologist) and find new prognostic parameters at molecular and cellular levels. Many efforts are ongoing to integrate molecular data (from tissue microarrays) and clinical data (traditional prognosticators) into a molecular integrated staging system. In the postgenomic era, new tumor-associated antigens and molecules can be identified at the protein level using proteomics, providing a major opportunity for screening and finding novel targets that are the basis of new emerging therapies for RCC.

Interferon-alpha (IFN-α)-conditioned DC Preferentially Stimulate Type-1 and Limit Treg-type In Vitro T-cell Responses From RCC Patients

Dendritic cells (DCs) are potent antigen presenting cells and represent attractive candidates for use in novel immunotherapies for patients with renal cell carcinoma (RCC), a disease that has proven refractory to conventional treatment modalities, such as chemotherapy and radiotherapy. Given the perceived need to augment antitumor type-1 immunity (TC1 and Th1) as a therapeutic end point, and the known functional plasticity of DC populations that may display heterogeneous capacity to promote T-cell responses, we sought to identify a preferred DC preparation with this capacity. We compared 2 different preparations of monocyte-derived DC using interferon-alpha (IFN-α) (IFN-DC and αDC1) with classic DCs “matured” (mDCs) using interleukin-1β/interleukin-6/tumor necrosis factor-α/prostaglandin E2, for their ability to promote autologous TC1 antitumor responses from RCC patients in vitro. IFN-α–conditioned DC promoted significantly higher numbers of RCC-specific CD8+ T cells exhibiting a cytotoxic phenotype after in vitro stimulation (IVS) than cytokine cocktail-mDCs. Furthermore, IVS using IFN-DCs was able to diminish regulatory-type T cells among CD4+ T-cell responder populations versus IVS using conventional mDC-based vaccines. These data emphasize an important role for IFN-α in modulating the immunologic functions of DCs toward a polarized DC1-type capable of coordinately promoting TH1-type and TC1-type T-cell mediated immunity and supports the translational development of patient-derived IFN-α–conditioned DC for use in novel immunotherapies for patients with RCC, and in whom, endogenous tumor-specific TC1 effector cells may be dysfunctional, anergic, or prone to undergo apoptosis.

Dysfunctional DC subsets in RCC patients: Ex vivo correction to yield an effective anti-cancer vaccine

Dendritic cells (DCs) are potent antigen-presenting cells responsible for the activation and functional polarization of specific T cells. In patients with renal cell carcinoma (RCC) and other cancers, coordinate DC and T cell defects have been reported. In particular, DC and T cell functional subsets that are not conducive to tumor clearance are hypothesized to predominate in patients with advanced-stage disease. Two major peripheral blood DC subsets have been identified in humans: myeloid dendritic cells (mDCs) and plasmacytoid dendritic cells (pDCs) that are believed to mediate contrasting effects on cancer immunity. Given the lack of information regarding DC subsets in patients with RCC, in the present study we have investigated the comparative frequencies and activation states of mDC and pDC in peripheral blood, cancer tissues and lymph nodes of patients with RCC using flow cytometry and immunohistochemistry. Three monoclonal antibodies (mAbs) reactive against specific DC subsets (BDCA-2 or BDCA-4 for pDC and BDCA-1 and BDCA-3 which represent two distinct subsets of mDC, mDC1 and mDC2, respectively) were employed. We observed a significant reduction of both DC subsets in the peripheral blood of patients as compared to normal donors. Similarly, both mDC and pDC were recruited in large numbers into RCC tumor tissues, where they displayed an immature phenotype (DC-LAMP(-)) and appeared unable to differentiate into mature DC (CD83(+)) that were competent to migrate to draining lymph nodes. However, we were readily able to generate ex vivo mDC from RCC patients. These DC stimulated robust anti-tumor CTL in vitro and would be envisioned for use in DC-based vaccines applied in patients with RCC whose existing immune system is judged dysfunctional, anergic or prone to undergo apoptosis.

Emerging Urinary Markers of Renal Injury in Obstructive Nephropathy

The effects of obstruction on renal function are the consequence of many factors that profoundly alter all components of glomerular function. Besides the acute effects on glomerular filtration rate and tubule function, a chronic obstruction induces tubular and interstitial injury that results from the activation of different pathways. The progression of tubulointerstitial injury leads to chronic renal damage characterized by tubular atrophy, inflammatory cell infiltration, and interstitial fibrosis. Obstructive nephropathy is an evolving disease in which the renal damage continues even after relief of the obstruction. In particular, it has been demonstrated that the time of relief is the most important factor in predicting long-term renal function deterioration. In this setting, the EGF/MCP-1 ratio, urinary NGAL, and urinary KIM-1 are useful early biomarkers of progressive renal damage and could have a potential role in predicting the long-term renal outcome. This minireview summarizes the role of these emerging urinary biomarkers of obstructive nephropathy based on the current understanding of the pathophysiology of renal injury.

JAK3/STAT5/6 Pathway Alterations Are Associated with Immune Deviation in CD8+ T Cells in Renal Cell Carcinoma Patients

To investigate the molecular mechanisms underlying altered T cell response in renal cell carcinoma (RCC) patients, we compared autologous and allogeneic CD8+ T cell responses against RCC line from RCC patients and their HLA-matched donors, using mixed lymphocyte/tumor cell cultures (MLTCs). In addition, we analyzed the expression of molecules associated with cell cycle regulation. Autologous MLTC responder CD8+ T cells showed cytotoxic activity against RCC cell lines; however the analysis of the distribution of CD8+ T-cell subsets revealed that allogenic counterparts mediate superior antitumor efficacy. In RCC patients, a decreased proliferative response to tumor, associated with defects in JAK3/STAT5/6 expression that led to increased p27KIP1 expression and alterations in the cell cycle, was observed. These data define a molecular pathway involved in cell cycle regulation that is associated with the dysfunction of tumor-specific CD8+ effector cells. If validated, this may define a therapeutic target in the setting of patients with RCC.

Unusual solitary metastasis of the ciliary body in renal cell carcinoma

Abstract:  Renal cell carcinoma (RCC) usually metastasizes to the lung, liver, bone; ocular metastasis is uncommon. We describe a rare case of metachronous ciliary RCC metastasis in a 42‐year‐old man who had undergone left radical nephrectomy for conventional RCC (pT3aN0M0, G2 Fuhrman) 6 years earlier. Solitary metastasis of the left eye presented with inflammatory symptoms, but examination of the fundus and bulbar ultrasound revealed a small mass of the ciliary body. Initial radiotherapy was unsuccessful and definitive treatment consisted of ocular enucleation with radical result and no further evidence of local and distant disease. Ocular metastasis of RCC is rare, can appear years after treating the primary tumor and should not be excluded in RCC follow‐up. As for other RCC solitary metastasis, the best option remains the radical surgical approach.

Cystocele Repair by Autologous Rectus Fascia Graft: the Pubovaginal Cystocele Sling

PURPOSE The autologous rectus fascia pubovaginal sling has been a safe and effective means of correcting stress urinary incontinence. We tested the feasibility of using a larger graft to correct cystocele with or without stress urinary incontinence. MATERIALS AND METHODS Between January 2006 and October 2010, 30 patients with symptomatic cystocele underwent the pubovaginal cystocele sling procedure, including 14 with and 16 without concomitant stress urinary incontinence. The technique is a modification of the standard pubovaginal sling procedure. A large trapezoidal (major base 6 cm, minor base 4 cm and height 5 cm) rectus fascia graft is used with 4 instead of 2 sutures to suspend the graft corners. The 2 sutures at the level of the mid urethra are tied above the rectus muscles in a tension-free manner while the 2 sutures at the level of the cervical fold are tied with tension. Data on anatomical outcomes (Baden-Walker classification), functional outcomes (PFIQ-7), post-void residual urine volume and urinary tract infection were prospectively collected. RESULTS At a mean followup of 62.6 months (range 46 to 98) there was no recurrence in the anterior compartment. There was 1 recurrence involving the apical and posterior compartments. All patients reported a statistically significant improvement in PFIQ-7 score. When present preoperatively, post-void residual urine volume, urinary tract infection and stress urinary incontinence ceased in all cases. The only complication was donor site wound dehiscence without fascial involvement. CONCLUSIONS The autologous pubovaginal cystocele sling seems to be a safe, effective technique to correct cystocele with or without stress urinary incontinence.

Absence of Bladder Outlet Obstruction Is an Independent Risk Factor for Prostate Cancer in Men Undergoing Prostate Biopsy.

AbstractThe purpose of this study was to investigate the relationship between bladder outlet obstruction (BOO) and the risk of being diagnosed with prostate cancer (PCa).Study population consisted of 2673 patients scheduled for the first prostate biopsy (PBx). All patients underwent uroflowmetry before PBx; those with a peak flow rate (PFR) <10 mL/s were considered to have BOO.The incidence of PCa was 41.3% (1104/2673) in the overall population and 34.1% (659/1905) in patients with serum prostate-specific antigen (PSA) ⩽ 10 ng/mL. Univariate and multivariate logistic regression analyses showed that patients with BOO had a significantly (P < 0.0001) lower risk than those without BOO of being diagnosed with PCa (33.1% vs 66.9% in the overall population; 30% vs 70% in patients with PSA ⩽ 10 ng/mL). As the presence of BOO was significantly correlated to a large prostate volume, another independent predictor of PBx outcome, we tested whether these parameters could be used to identify, in the subset of patients with PSA⩽10 ng/mL, those who could potentially be spared from a PBx. If we would have not biopsied patients with BOO and prostate volume ≥60 mL, 14.5% of biopsies could have been avoided while missing only 6% of tumors. Only 10% of the tumors that would have been missed were high-risk cancers.In conclusion, in men undergoing PBx, the absence of BOO, as determined by a PFR ≥10 mL/s, is an independent risk factor for PCa. Our study provides ground for this simple, noninvasive, objective parameter being used, alone or in combination with prostate volume, in the decision-making process of men potentially facing a PBx.

JAK3 in clear cell renal cell carcinoma: Mutational screening and clinical implications

OBJECTIVES Janus Kinase 3 (JAK3) mediates cytokine signaling and T-cell activation. We hypothesized that JAK3 mutations may contribute to the development and progression of clear cell renal cell carcinoma (ccRCC). To test this hypothesis, we performed mutational screening and functional studies. PATIENTS AND METHODS This hospital-based case-control study included 50 patients with ccRCC and 100 age- and gender-matched controls. Both genomic and tumor DNA were extracted. All 23 JAK3 exons were amplified by PCR and analyzed by denaturing high-performance liquid chromatography and automatic sequencing. Effects of JAK3 mutations on interleukin-2-stimulated peripheral T-cells were analyzed by confocal laser-scanning microscopy and immunoprecipitation. RESULTS Four different JAK3 germline missense mutations (p.Gln13Lys; p.Arg925Ser; p.Ala677Thr, p.Val722Ile) were found in a total of 7 ccRCC patients (14%), but in none of the controls (P = 0.0006). All germline mutations were similarly detected in the tumors. An additional somatic missense mutation (p.Tyr238Cys) was found in a patient who had a germline mutation. Four of the mutations have not been previously described (p.Gln13Lys; p.Arg925Ser; p.Ala677Thr, p.Tyr238Cys). Patients with JAK3 mutations more frequently presented with metastases (3 out of 4 [75%] vs. 4 out of 46 [9%]; P = 0.004) and had poorer survival (P = 0.049). In p.Arg925Ser and p.Ala677Thr/p.Val722Ile, functional analyses showed abnormal JAK3 and STAT5 tyrosine phosphorylation and a reduction of JAK3/STAT5 interaction. CONCLUSIONS JAK3 mutations are found in a subset of ccRCC patients and may be associated with ccRCC development and a greater risk of metastases. JAK3 function is compromised in p.Arg925Ser and p.Ala677Thr/p.Val722Ile. Future studies with a larger number of patients need to confirm these findings.

Surgical management of female pelvic organ prolapse with and without urinary incontinence: A single center experience

Abstract The study reports a single center experience with surgical management of female pelvic organ prolapse (POP) with and without urinary incontinence. Between January 2006 and July 2016, 93 consecutive patients with anterior and/or apical symptomatic POP underwent abdominal sacrocolpopexy (ASC) or laparoscopic sacrocolpopexy (LSC) or pubovaginal cystocele sling (PCS); 25 patients had concomitant stress urinary incontinence (SUI). Subjective outcome was assessed by the Pelvic Floor Impact Questionnaire (short form) (PFIQ-7) investigating bladder, bowel and vaginal functions, sexual activity, and daily life. Objective outcomes included the POP anatomic correction by Baden Walker HWS classification, urinary tract infection (UTI) rates, urge urinary incontinence (UUI), and SUI rates. Data were prospectively collected. Forty-three patients underwent PCS, 29 ASC, and 21 LSC. Mean follow-up was 54.88 ± 33.1, 28.89 ± 23.5, and 16.8 ± 11.3 months for PCS, ASC, and LSC, respectively. POP recurrence occurred in 10.5%, 7.5%, and 0% while de novo (ie, in untreated compartment/s) POP occurred in 15.8%, 7.4%, and 4.8% of patients who have undergone PCS, ASC, and LSC, respectively. Kaplan–Meier estimates of POP-free survival showed no difference among the 3 procedures. All procedures significantly reduced PFIQ-7 scores improving quality of life and the rates of recurrent UTIs and concomitant UUI. PCS cured all cases with concomitant SUI; de novo SUI occurred only in 7.4% and 4.8% of patients who have undergone ASC and LSC, respectively. Mean surgical time was significantly shorter for PCS compared to ASC and LSC (P = .0001), and for ASC compared to LSC (P = .004); there was no difference in postoperative pain and hospital stay. Compared to ASC/LSC, PCS involved a higher rate (27.9% vs 6%; P = .01) of minor complications, mainly transient urinary retention, and a lower rate (0% vs 8%; P = .06) of complications requiring surgery. In this single center experience, PCS was not only provided similar subjective and objective results than ASC and LSC but also able to correct concomitant SUI without causing de novo SUI and was safer than other 2 techniques, in female POP repair.