Estudo da expressão imunoistoquímica e do valor prognóstico de sintases do óxido nítrico (NOS), metaloproteinases da matriz extracelular (MMP), fator de crescimento endotelial vascular (VEGF), caderina e, densidade de microvasos (DMV) e da densidade de vasos linfáticos (DVL) em pacientes portadores de carcinoma de células renais / Study of immunohistochemical expression and value prognosis of nitric oxide synthases (NOS), metalloproteinases of extracellular matrix (MMP), vascular endothelial growth factor (VEGF), cadherin e, microvessel density (DMV) and the density of lymphatic vessels (DVL) in patients with carcinoma of renal cells

RESUMO

Introdução: O carcinoma de células renais (CCR) é neoplasia altamente letal, com evolução incerta. Novos fatores prognósticos biomoleculares em CCR são necessários. ... Dados epidemiológicos clínicos e patológicos foram coletados. Empregaram-se classificações de performance status da Eastern Cooperative Oncologic Group (ECOG), Karnofsky Performance Status (KPS) e a classificação da American Society of Anesthesiology (ASA) ... A partir da análise univariada, criou-se um Modelo Multivariado Hierárquico (MMH), que submetido à análise multivariada, permitiu a elaboração de um escore com as variáveis prognósticas mais significativas para SG e SLD. Resultados: Na análise univariada, dentre os marcadores biomoleculares, apenas a NOS-3 (p=0,047) e DMV (p=0, 052) tiveram impacto na SG. .... Na análise univariada de SLD para os 94 pacientes sem metástases, nenhum marcador biomolecular teve impacto significativo (p>0,05). Na análise multivariada para SLD, apenas o estádio Clínico foi fator independente. O estádio III (ajustado pelo estádio I) teve HR de 9,5 vezes para recidiva. Conclusão: Fatores clínicos usuais permaneceram como os fatores preditivos mais significativos em CCR e permitiram a elaboração de um escore prognóstico, no qual pacientes com mais de 4 pontos tiveram chance de óbito de mais de 50%. Este escore deve ser testado em outras casuísticas. Futuros estudos sobre as correlações da NOS-3 e seu papel prognóstico no CCR devem ser realizados.

ABSTRACT

Introduction: Renal cell carcinoma (RCC) is a tumor with high mortality rate and uncertain evolution. Therefore, new molecular factors in RCC are necessary. This study aims: to evaluate the expression of Nitric Oxide Sintases types 1, 2 and 3 (NOS-1, NO-2, NOS-3), matrix metalloproteases types 2 and 9 (MMP-2 and MMP-9), E-Cadherin and vascular endothelial growth factor (VEGF) through imunohistochemical analysis; to evaluate microvessel density (MVD) and lymphatic vessel density (LVD); to verify the association among biomarkers expression and epidemiological, clinic and pathological variables; to verify the impact of the variables as prognostic factors in 5 years overall survival (OS) and disease free survival (DFS). Material and Methods: One-hundred and ten patients with RCC were included. Clinical, epidemiological and pathological data were collected from medical charts. Performance status classifications used were Eastern Cooperative Oncologic Group Classification (ECOG) and Karnofsky Performance Status (KPS) and the American Society of Anesthesiology Classification (ASA). The Tissue Microarray (TMA) was used and a digital microscopy program (ACIS III) was empregated. To predict recurrence, progression our death, the variables selected by univariate analysis were included in a Hierarchic Multivariate Model (HMM), to estimate the odds of deaths or disease progression or recurrence. Results: In the univariate analysis, NOS-3 (p=0.047) and MVD (p=0.052) had impact in OS. Patients with low expression of NOS-3 had an OS of 79% versus 58.1% for patients with high expression of NOS-3. The MVD showed direct correlation with OS rates patients with high MVD had higher OS (79.9%) than the patients with low MVD (58%). E-cadherin, the VEGF, the MMP-2, MMP-9 and DVL expression were not correlated with OS and DFS. NOS expression (NOS- 1, NOS - 2 and NOS - 3) were directly correlated with tumor size patients with low NOS expression had tumors 2.0 to 3.0cm smaller than patients with high NOS expression. High expression of NOS-3 was correlated with lymph node metastasis (31% versus 9.7%, p=0.029), with renal pelvis and ureter invasion (16% versus 3.3%, p= 0.0041) and with a higher rate of radical nephrectomies (88% versus 63.3%, p=0.003). The high expression of the MMP-2 and the MMP-9 were correlated with high grade tumors (p=0.046 and p=0.009 respectively) and with histological type not clear cell (p=0.029 and p=0.009, respectively). In the OS multivariate analysis, the significant prognostic factors were TNM clinical staging (HR=4.5), grade (HR=2.9), KPS (HR=2.5), the occurrence of post-nephrectomy progression (HR = 5.3) and/or recurrence (HR= 6.5), all of them adjusted by the age (HR=1.1). The HMM score ranged of 0 the 7 points. There were no deaths among patients with 0 point and all patients with 7 points have died. According to the HMM score, the probability to be alive for 0, 1-2, 3-4, 5-7 score levels was respectively 100%, 83.5%, 53,5 and 13.5%. In the univariate DFS analysis for the 94 patients without metastases (16 of the 110 patients had metastasis at diagnosis), no molecular marker had significant impact. In the multivariate analysis for DFS, only the TNM clinical staging was an independent prognostic factor. Clinical staging III had HR of 9.5 times for recurrence. Conclusions: Usual clinical factors remained as most important prognostic factors in RCC and had allowed the elaboration of one score, in which patients with more than 4 points has a death probability rate higher than 50%. This MMH score must be validated for other groups. Future studies regarding the correlations and the prognostic role of NOS-3 in RCC must be conducted.