Surgical Strategy for the Management of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus

The hallmark of renal cell carcinoma is its biological characteristic of invading the renal vein and/or inferior vena cava (IVC), which occurs in 4–10% of patients. Radical nephrectomy (RN) with tumor thrombectomy is the standard approach for treating such challenging cases. Except tumor thrombus height, several factors can determine the surgical strategy, including the effect of targeted molecular therapy (TMT), invasion of the IVC wall, venous occlusion, establishment of collateral circulation, IVC thromboembolism, and primary tumor location. The surgical strategy for patients with retrohepatic vena cava tumor thrombi depends on the upper extent of the tumor thrombus. In addition, the first porta hepatis and hepatic veins are important anatomical boundaries. Based on previous studies, the effect of pre-surgical TMT is limited. The safety of IVC venography, an imaging modality that can observe congestion of the tumor thrombus and show the collateral circulation, has considerably improved. IVC interruption plays an important role in tumor thrombectomy for patients with invasion of the venous walls, complete occlusion of the vena cava, and the presence of distal thrombus. A series of retrospective and prospective studies are needed to be conducted, which will provide our clinical work with more powerful reference and basis

Sequential everolimus for angiomyolipoma associated with tuberous sclerosis complex: a prospective cohort study

Abstract Background To evaluate the efficacy, safety and health economics of sequential everolimus in treating angiomyolipoma (AML) associated with tuberous sclerosis complex (TSC). Methods In this prospective cohort study, patients met the inclusion criteria received standard or sequential treatment according to their willingness. All patients received an initial dose of everolimus (10 mg oral, once a day) for 3 months. The standard treatment group maintained 10 mg QD for 12 months, while the sequential treatment group reduced the dose to 5 mg QD from the 4th month. The efficacy, serum everolimus concentration and safety were evaluated at 1, 3, 6, 9 and 12 months after treatment. The primary efficacy endpoint was the proportion of patients with confirmed angiomyolipoma response of at least a 50% reduction in the total volume of target AML relative to baseline. Results Between June 1, 2016 and June 1, 2017, a total of 53 patients were included. Twenty-three patients received standard treatment, 30 patients received sequential treatment. At 1, 3, 6, 9 and 12 months after treatment, the proportion of patients whose total target tumor volume decreased by ≥ 50% from baseline was 39.1% versus 36.7%, 43.5% versus 56.7%, 47.8% versus 50%, 47.8% versus 60% and 47.8% versus 23.3% respectively (P > 0.05 for all). The overall response rate of skin lesions in the two groups was 40.4%, and the response rates of skin lesions at different times were similar for two groups (P > 0.05 for all). Major adverse effects (AEs) included mouth ulceration, hypertriglyceridemia, hypercholesterolemia, menstrual disorders. There was no significant difference between the two groups in the incidence of AEs at 3 months after treatment. The incidence of overall and grade 3/4 AEs at 12 months after treatment were significantly lower in the sequential treatment group. The average direct cost of the two groups in 12 months was $15,466 and$11,120, respectively. Conclusions Compared to standard treatment, sequential treatment was equally effective, with a lower incidence of adverse events and a lower direct cost, suggesting that it may be an alternative treatment for AML associated with TSC

Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Localized and Advanced Prostate Cancer: A Systematic Review and Meta-Analysis.

OBJECTIVE AND BACKGROUND:Increasing evidence suggests that inflammation plays an essential role in cancer development and progression. The inflammation marker neutrophil-lymphocyte ratio (NLR) is correlated with prognosis across a wide variety of tumor types, but its prognostic value in prostate cancer (PCa) remains controversial. In the present meta-analysis, the prognostic value of NLR in PCa patients is investigated. METHODS:We performed a meta-analysis to determine the predictive value of NLR for overall survival (OS), recurrence-free survival (RFS), and clinical features in patients with PCa. We systematically searched PubMed, ISI Web of Science, and Embase for relevant studies published up to October 2015. RESULTS:A total of 9418 patients from 18 studies were included in the meta-analysis. Elevated pretreatment NLR predicted poor OS (HR 1.628, 95% CI 1.410-1.879) and RFS (HR 1.357, 95% CI 1.126-1.636) in all patients with PCa. However, NLR was insignificantly associated with OS in the subgroup of patients with localized PCa (HR 1.439, 95% CI 0.753-2.75). Increased NLR was also significantly correlated with lymph node involvement (OR 1.616, 95% CI 1.167-2.239) but not with pathological stage (OR 0.827, 95% CI 0.637-1.074) or Gleason score (OR 0.761, 95% CI 0.555-1.044). CONCLUSIONS:The present meta-analysis indicated that NLR could predict the prognosis for patients with locally advanced or castration-resistant PCa. Patients with higher NLR are more likely to have poorer prognosis than those with lower NLR

Clinical Characteristics of Aldosterone- and Cortisol-Coproducing Adrenal Adenoma in Primary Aldosteronism

Aldosterone- and cortisol-coproducing adrenal adenoma (A/CPA) cases have been observed in patients with primary aldosteronism (PA). This study investigated the incidence, clinical characteristics, and molecular biological features of patients with A/CPAs. We retrospectively identified 22 A/CPA patients from 555 PA patients who visited the Chinese People’s Liberation Army General Hospital between 2004 and 2015. Analysis of clinical parameters revealed that patients with A/CPAs had larger tumors than those with pure APAs (P<0.05). Moreover, they had higher proportions of cardiovascular complications, glucose intolerance/diabetes, and osteopenia/osteoporosis compared to the pure APA patients (P<0.001). In the molecular biological findings, quantitative real-time PCR analysis revealed similar CYP11B1 and CYP17A1 mRNA expressions in resected A/CPA specimens and in pure APA specimens. Western blot and immunochemical analyses showed CYP11B1, CYP11B2, and CYP17A1 expressions in both A/CPAs and pure APAs. Seventeen cases with KCNJ5 mutations were detected among the 22 A/CPA DNA samples, but no PRKACA or other causative mutations were observed. Each patient improved following adrenalectomy. In conclusion, A/CPAs were not rare among PA patients. These patients associated with high incidences of cardiovascular events and metabolic disorders. Screening for excess cortisol secretion is necessary for PA patients

The values of neutrophil-lymphocyte ratio and/or prostate-specific antigen in discriminating real Gleason score ≥ 7 prostate cancer from group of biopsy-based Gleason score ≤ 6

Abstract Background The discrepant concordance between biopsy and radical prostatectomy (RP) specimen are well reported. To validate the clinical usefulness of neutrophil-lymphocyte ratio (NLR) in discriminating real GS ≥ 7 PCa from biopsy-based GS ≤ 6 PCa in comparison with serum total prostate-specific antigen (tPSA) and value of their combination. Methods One hundred one patients who underwent physical examinations incidentally found elevated tPSA and subsequently received biopsy with a conclusion of GS ≤ 6 and RP with an interval of 4-6 weeks after biopsy were enrolled. NLR and tPSA were obtained within 15 days prior to biopsy. Logistic regression model was applied appropriately; McNemar tests and AUC model were performed to evaluate differences among tPSA, NLR and their combination and corresponding diagnostic power respectively. Results The pathological results from RP specimen comprised 61 patients with GS ≤ 6 and 100 patients with GS ≥ 7. Higher tPSA and NLR were significantly associated with patients with actual GS ≥ 7 (All P < 0.05) concurrently. Multivariate logistic regression indicated that tPSA (OR = 1.088, 95% C.I. = 1.029-1.151, P = 0.003) and NLR (OR = 1.807, 95% C.I. = 1.021-3.200, P = 0.042) could be independent predictors for GS groupings. Under cutoff value of 14.09 ng/ml for tPSA and 2.25 for NLR, the sensitivity, specificity and accuracy were 60.0%, 80.3% and 67.7% for tPSA, 42%, 88.5% and 59.6% for NLR, and 71.0%, 75.4% and 72.7% for combination of tPSA and NLR (tPSA + NLR) respectively. The sensitivity of tPSA + NLR was significantly higher in comparison with tPSA (P = 0.001) and NLR (P < 0.001). Except for sensitivity, no significant difference was found between tPSA and NLR in specificity (P = 0.227) and accuracy (P = 0.132). tPSA got the largest AUC with 0.732 (p < 0.001, 95% C.I.: 0.651-0.813). Conclusions Serum tPSA and NLR were significantly elevated among GS ≥ 7 PCa concurrently. The combination of tPSA and NLR might have additional benefit to biopsy on discriminating real GS ≥ 7 Pca from biopsy-based GS ≤ 6 PCa. More stratification models and prospectively multicenter studies are necessary

Postoperative Adjuvant Sorafenib or Sunitinib for Nonmetastatic Renal Cell Carcinoma with Venous Tumor Thrombus: a Prospective Cohort Study

PURPOSE: To evaluate the efficacy and safety of antiangiogenic agents (sorafenib and sunitinib) as postoperative adjuvant therapy in patients with nonmetastatic renal cell carcinoma (RCC) and venous tumor thrombus (VTT). MATERIAL AND METHODS: From March 2006 to January 2016, 147 patients who met the inclusion criteria were enrolled; 27 patients received sorafenib, and 17 patients received sunitinib. After radical nephrectomy and thrombectomy, the duration of maintenance targeted medication treatment was approximately 1 year. The primary objective was to compare disease-free survival (DFS) between each experimental group and control. Secondary end points included overall survival (OS) and toxic effects. RESULTS: The three groups were well balanced in terms of age, body mass index, gender, performance status, medical history, American Society of Anesthesiologists score, surgical approach, and tumor side and size. However, more patients receiving adjuvant therapy had inferior vena cava tumor thrombus. DFS and OS did not differ significantly between groups (P = .459 and .871, respectively). After adjusting for potential confounding factors, results of multivariate analysis proved that postoperative adjuvant therapy was not an independent factor for predicting DFS and OS (P > .05 for both). The subgroup analyses for inferior vena cava tumor thrombus found similar results. The common adverse events were hand-foot syndrome, diarrhea, fatigue, and neutropenia. The adverse effects were mild in both groups, and the incidence was not significantly different between sorafenib and sunitinib. CONCLUSIONS: Adjuvant treatment postoperatively with sorafenib or sunitinib showed no survival benefit relative to control for patients with nonmetastatic RCC and VTT in a prospective cohort study

Influence of tumor size on oncological outcomes of pathological T3aN0M0 renal cell carcinoma treated by radical nephrectomy

<div><p>Objective</p><p>To evaluate the prognostic significance of tumor size in pathological T3aN0M0 renal cell carcinoma (RCC) treated by radical nephrectomy.</p><p>Materials and methods</p><p>Patients who underwent radical nephrectomy for sporadic RCC with pathological T3aN0M0 RCC at our institution between January 2006 and June 2015 were identified. The entire cohort was divided into two groups according to the cutoff of tumor size obtained from receiver operating characteristic (ROC) curve. Clinicopathological variables were retrospectively collected and compared. Kaplan-Meier analysis and multivariate Cox regression were conducted to evaluate the effect of tumor size on survival outcomes.</p><p>Results</p><p>163 pT3aN0M0 RCC patients were included with a median follow-up period of 31 months. The optimal cutoff for tumor size was 7 cm according to the ROC curve. 90 cases (55.2%) presented tumors which measured 7 cm or less, and 73 cases (44.8%) showed tumor size greater than 7 cm. Patients with larger tumors tended to exhibit higher rates of symptoms and higher Fuhrman grades; they also indicated more necrosis features, and were more likely to invade the collecting system and renal vein. Compared with patients who exhibited tumor size of≤7 cm, those with tumor size>7 cm were associated with shorter estimated five-year cancer-specific survival (CSS, 46.6% versus 75.0%, <i>P</i> = 0.003) and five-year recurrence-free survival (RFS, 35.6% versus 62.7%, <i>P</i> = 0.011). Multivariate Cox analysis revealed that tumor size was retained as an independent factor for CSS (HR = 2.506, 95% CI 1.169–5.373, <i>P</i> = 0.018).</p><p>Conclusions</p><p>The tumor size significantly affected the survival outcomes of pT3aN0M0 RCC treated by radical nephrectomy, and a cutoff size of 7 cm can help enhance the prognostic discrimination. Thus, the tumor size may be considered in the future TNM classification of stage pT3a.</p></div