Radiomics predict the WHO/ISUP nuclear grade and survival in clear cell renal cell carcinoma.

OBJECTIVES: This study aimed to assess the predictive value of radiomics derived from intratumoral and peritumoral regions and to develop a radiomics nomogram to predict preoperative nuclear grade and overall survival (OS) in patients with clear cell renal cell carcinoma (ccRCC). METHODS: The study included 395 patients with ccRCC from our institution. The patients in Center A (anonymous) institution were randomly divided into a training cohort (n = 284) and an internal validation cohort (n = 71). An external validation cohort comprising 40 patients from Center B also was included. Computed tomography (CT) radiomics features were extracted from the internal area of the tumor (IAT) and IAT combined peritumoral areas of the tumor at 3 mm (PAT 3 mm) and 5 mm (PAT 5 mm). Independent predictors from both clinical and radiomics scores (Radscore) were used to construct a radiomics nomogram. Kaplan-Meier analysis with a log-rank test was performed to evaluate the correlation between factors and OS. RESULTS: The PAT 5-mm radiomics model (RM) exhibited exceptional predictive capability for grading, achieving an area under the curves of 0.80, 0.80, and 0.90 in the training, internal validation, and external validation cohorts. The nomogram and RM gained from the PAT 5-mm region were more clinically useful than the clinical model. The association between OS and predicted nuclear grade derived from the PAT 5-mm Radscore and the nomogram-predicted score was statistically significant (p < 0.05). CONCLUSION: The CT-based radiomics and nomograms showed valuable predictive capabilities for the World Health Organization/International Society of Urological Pathology grade and OS in patients with ccRCC. CRITICAL RELEVANCE STATEMENT: The intratumoral and peritumoral radiomics are feasible and promising to predict nuclear grade and overall survival in patients with clear cell renal cell carcinoma, which can contribute to the development of personalized preoperative treatment strategies. KEY POINTS: The multi-regional radiomics features are associated with clear cell renal cell carcinoma (ccRCC) grading and prognosis. The combination of intratumoral and peritumoral 5 mm regional features demonstrated superior predictive performance for grading. The nomogram and radiomics models have a broad range of clinical applications.

Development of a CT-assessed adiposity nomogram for predicting outcome in localized ccRCC.

PURPOSE: This study aimed to develop and validate a computed tomography-based nomogram assessing visceral and subcutaneous adiposity for predicting outcomes in localized clear cell renal cell carcinoma (ccRCC). METHODS: A cohort of 364 patients with pathologically confirmed ccRCC participated in this retrospective study, with 254 patients assigned to the training set and 110 to the validation set (a 7:3 distribution ratio). The adipose score (AS) was generated using the least absolute shrinkage and selection operator Cox regression. Subsequently, a nomogram was constructed by integrating the clinical independent predictor with the AS to predict disease-free survival (DFS) in localized ccRCC after surgery. The performance of the nomogram was compared with the University of California, Los Angeles, Integrated Staging System (UISS), and the Stage, Size, Grade, and Necrosis (SSIGN) score. RESULTS: In both the training and validation cohorts, the nomogram exhibited superior discrimination compared to SSIGN and UISS (C-index: 0.897 vs. 0.781 vs. 0.776 in the training cohort, and 0.752 vs. 0.596 vs. 0.686 in the validation cohort; 5 year AUC: 0.907 vs. 0.805 vs. 0.820 in the training cohort, and 0.832 vs. 0.577 vs. 0.726 in the validation cohort). Decision curve analysis (DCA) revealed a superior net benefit across a wider range of threshold probabilities for predicting 5 year DFS compared to UISS and SSIGN scores. CONCLUSIONS: The developed prognostic nomogram demonstrated high accuracy and overall superior performance compared to existing prognostic models.

Can Gender-Specific Renal and Visceral Fat Be Evaluated by CT Predict Fuhrman Nuclear Classification of Clear Cell Renal Cell Carcinoma?

BACKGROUND: Evidence of the association between obesity and renal cell carcinoma progression is contradictory. The effects of renal cell carcinoma on fat distribution are still unknown. OBJECTIVE: The goal of this study was to determine the ability of various forms of fat deposition to predict the Fuhrman nuclear grade of clear cell renal cell carcinoma [ccRCC]. METHODS: This retrospective study included 320 patients with pathologically proven ccRCC [215 men and 105 women; 263 low-grade ccRCC and 57 highgrade ccRCC]. Based on computed tomography scans, adipose tissue in various body regions was classified into the perirenal fat area [PFA], visceral fat area [VFA], total fat area [TFA], subcutaneous fat area [SFA], and hepatic steatosis [HS]. Subsequently, the relative VFA [rVFA] was computed. Age, sex, body mass index, and maximal tumor diameter were also regarded as clinical factors. Univariate and multivariate logistic regression studies were conducted to evaluate whether there was an association between body fat composition and the Fuhrman classification and whether it was related to gender. RESULTS: After correcting for age, males with low-grade ccRCC exhibited higher TFA [257.6 vs. 203.0, p = 0.002], VFA [151.6 vs.115.5, p = 0.007], SFA [106.0 vs. 87.5, p = 0.015], PFA [55.1 vs. 30.4, p < 0.001], and HS [18% vs. 0%, p = 0.031] than those with high-grade ccRCC. There was no significant difference among rVFA in males. In females, there was no significant difference in any of the parameters. VFA and PFA remained independent predictors for high-grade ccRCC in males in both the monovariate [VFA: odds ratio [OR] 0.992, 95% confidence interval [CI] 0.987-0.997, p = 0.004; PFA: OR 0.949, 95% CI 0.930-0.970, p < 0.001] and multivariate [VFA: OR 1.028, 95% CI 1.001-1.074, p < 0.001; PFA: OR 0.878, 95% CI 0.833-0.926, p < 0.001] models. CONCLUSION: Gender-specific adipose tissue in different locations demonstrated varied values for predicting high-grade ccRCC and may be utilized as an independent predictor of high-grade ccRCC in male patients.

Development and validation of a nomogram to evaluate the therapeutic effects of second-line axitinib in patients with metastatic renal cell carcinoma.

The unpredictable biological behavior and tumor heterogeneity of metastatic renal cell carcinoma (mRCC) cause significant differences in axitinib efficacy. The aim of this study is to establish a predictive model based on clinicopathological features to screen patients with mRCC who can benefit from axitinib treatment. A total of 44 patients with mRCC were enrolled and divided into the training set and validation set. In the training set, variables related with the therapeutic efficacy of second-line treatment with axitinib were screened through univariate Cox proportional hazards regression and least absolute shrinkage and selection operator analyses. A predictive model was subsequently established to assess the therapeutic efficacy of second-line treatment with axitinib. The predictive performance of the model was evaluated by analyzing the concordance index and time-dependent receiver operating characteristic, calibration, and decision curves. The accuracy of the model was similarly verified in the validation set. The International Metastatic RCC Database Consortium (IMDC) grade, albumin, calcium, and adverse reaction grade were identified as the best predictors of the efficacy of second-line axitinib treatment. Adverse reaction grade was an independent prognostic index that correlated with the therapeutic effects of second-line treatment with axitinib. Concordance index value of the model was 0.84. Area under curve values for the prediction of 3-, 6-, and 12-month progression-free survival after axitinib treatment were 0.975, 0.909, and 0.911, respectively. The calibration curve showed a good fit between the predicted and actual probabilities of progression-free survival at 3, 6, and 12 months. The results were verified in the validation set. Decision curve analysis revealed that the nomogram based on a combination of four clinical parameters (IMDC grade, albumin, calcium, and adverse reaction grade) had more net benefit than adverse reaction grade alone. Our predictive model can be useful for clinicians to identify patients with mRCC who can benefit from second-line treatment with axitinib.

Genomic Profiling and Response to Immune Checkpoint Inhibition plus Tyrosine Kinase Inhibition in FH-Deficient Renal Cell Carcinoma.

BACKGROUND: FH-deficient renal cell carcinoma (RCC) is a rare and exceptionally aggressive RCC subtype. There is currently limited understanding of the molecular alterations, pathogenesis, survival outcomes, and systemic therapy efficacy for this cancer. OBJECTIVE: To perform a retrospective multicenter analysis of molecular profiling and clinical outcomes for patients with FH-deficient RCC, with an emphasis on treatment response to first-line immune checkpoint inhibitor plus tyrosine kinase inhibitor (ICI/TKI) versus bevacizumab plus erlotinib (Bev/Erlo) combination therapy in patients with advanced disease. DESIGN, SETTING, AND PARTICIPANTS: The study included 77 cases of FH-deficient RCC from 15 centers across China. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinical characteristics, molecular correlates, 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging, and treatment outcomes were analyzed. RESULTS AND LIMITATIONS: A total of 77 patients were identified, including 70 cases with a germline FH alteration (hereditary leiomyomatosis RCC syndrome [HLRCC]-associated RCC) and seven patients with somatic FH loss. Recurrent pathogenic alterations were found in NF2 (six/57, 11%), CDH1 (six/57, 11%), PIK3CA (six/57, 11%), and TP53 (five/57, 8.8%). Sixty-seven patients were evaluable for response to first-line systemic therapy with Bev/Erlo (n = 12), TKI monotherapy (n = 29), or ICI/TKI (n = 26). ICI/TKI combination therapy was associated with more favorable overall survival on systemic treatment (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.04-0.90) and progression-free survival on first-line therapy (HR 0.22, 95% CI 0.07-0.71) compared to Bev/Erlo combination therapy. The main limitation is the retrospective study design. CONCLUSIONS: We described the genomic characteristics of FH-deficient RCC in an Asian population and observed a favorable response to ICI/TKI combinational therapy among patients with advanced disease. PATIENT SUMMARY: This real-world study provides evidence supporting the antitumour activity of combining molecular targeted therapy plus immunotherapy for kidney cancer deficient in fumarate hydratase. Further studies are needed to investigate the efficacy of this combination strategy in this rare cancer.

Preoperative prognostic nomogram for prophylactic steroid treatment of patients with subclinical Cushing's syndrome.

BACKGROUND: Subclinical Cushing's syndrome (SCS) is incidentally detected in a growing number of patients by advanced imaging technology. However, there is no consensus on the clinical management of SCS, especially in terms of whether prophylactic steroid treatment is necessary following adrenalectomy. In this study we developed a model based on preoperative indices for predicting postoperative adrenal insufficiency (AI) that can guide therapeutic decision-making. METHODS: A total of 27 patients with SCS who underwent adrenalectomy between August 2016 and August 2019 were enrolled and divided into AI and non-AI groups. Cox proportional hazards regression and least absolute shrinkage and selection operator analyses were performed to select relevant clinical parameters. The predictive performance of our model was evaluated by time-dependent receiver operating characteristic (ROC) curve and calibration curve analyses. RESULTS: Five clinical parameters (apolipoprotein A1, neutrophil-lymphocyte ratio, total cholesterol, platelet count, and homocysteine) were identified as the best predictors of replacement therapy (RT). The areas under the ROC curve for our prognostic model were 0.833, 0.945, and 0.967 for 3-, 4-, and 5-day non-(N)RT, respectively. The calibration curve of the 5 independent RT-related markers showed a good fit between nomogram-predicted probability of NRT and actual NRT, suggesting that our model has good predictive value. CONCLUSIONS: Our prognostic nomogram can help clinicians identify patients with AI who would benefit from RT so that timely treatment can be initiated. KEYWORDS: Subclinical Cushing's syndrome (SCS); Replacement therapy (RT); Adrenal insufficiency (AI); Nomogram; Receiver operating characteristic (ROC).

The Identification of Differentially Expressed Genes Showing Aberrant Methylation Patterns in Pheochromocytoma by Integrated Bioinformatics Analysis.

Malignant pheochromocytoma (PHEO) can only be fully diagnosed when metastatic foci develop. However, at this point in time, patients gain little benefit from traditional therapeutic methods. Methylation plays an important role in the pathogenesis of PHEO. The aim of this research was to use integrated bioinformatics analysis to identify differentially expressed genes (DEGs) showing aberrant methylation patterns in PHEO and therefore provide further understanding of the molecular mechanisms underlying this condition. Aberrantly methylated DEGs were first identified by using R software (version 3.6) to combine gene expression microarray data (GSE19422) with gene methylation microarray data (GSE43293). An online bioinformatics database (DAVID) was then used to identify all overlapping DEGs showing aberrant methylation; these were annotated and then functional enrichment was ascertained by gene ontology (GO) analysis. The online STRING tool was then used to analyze interactions between all overlapping DEGs showing aberrant methylation; these results were then visualized by Cytoscape (version 3.61). Next, using the cytoHubba plugin within Cytoscape, we identified the top 10 hub genes and found that these were predominantly enriched in pathways related to cancer. Reference to The Cancer Genome Atlas (TCGA) further confirmed our results and further identified an upregulated hypomethylated gene (SCN2A) and a downregulated hypermethylated gene (KCNQ1). Logistic regression analysis and receiver operating characteristic (ROC) curve analysis indicated that KCNQ1 and SCN2A represent promising differential diagnostic biomarkers between benign and malignant PHEO. Finally, clinical data showed that there were significant differences in the concentrations of potassium and sodium when compared between pre-surgery and post-surgery day 1. These suggest that KCNQ1 and SCN2A, genes that encode potassium and sodium channels, respectively, may serve as putative diagnostic targets for the diagnosis and prognosis of PHEO and therefore facilitate the clinical management of PHEO.

Apogossypolone acts as a metastasis inhibitor via up-regulation of E-cadherin dependent on the GSK-3/AKT complex.

Malignant pheochromocytoma is exactly diagnosed only upon the occurrence of metastatic foci. At that point, however, patients are less likely to experience many benefits from traditional chemotherapy. Therefore, a strategy worthy of consideration is inhibition or delay of metastasis with drugs. Recently, numerous studies have indicated that epithelial-to-mesenchymal transition (EMT) is involved in malignant pheochromocytoma, where there is over-expression of metastatic promoting genes and low expression of metastatic suppressor genes. In previous research, we confirmed that apogossypolone (ApoG2) could effectively inhibit tumor movement capabilities, but potential mechanisms for the inhibition were unknown. Here, we initially corroborated that ApoG2 could induce GSK-3/AKT complex formation to down-regulate phosphorylation of the PI3K/AKT pathway. Subsequently, ApoG2 inhibited cell mobilities via promotion of E-cadherin and ß-catenin translocation from cytoplasm to membrane dependent on down-regulate of the PI3K/AKT pathway. Unexpectedly, ApoG2 seemed to promote tumor progression, instead of suppression when there were circulating tumor cells in vivo. Our results indicated that ApoG2 might be an effective target agent early in the disease rather than at the advanced stage where there are a majority of circulating tumor cells. Those cells rely on the mesenchymal-epithelial transition (MET) process to anchor to distant new sites. Hence, the so-called anti-tumor drugs with inhibition of migration and invasion should be carefully distinguished as to whether they are involved in EMT and MET processes or not. Most importantly, we identified that GSK-3 is not only a downstream effector but also an upstream regulator of the PI3K/AKT pathway.

HSP70 inhibitor VER155008 suppresses pheochromocytoma cell and xenograft growth by inhibition of PI3K/AKT/mTOR and MEK/ERK pathways.

According to the most recent World Health Organization classification, all pheochromocytomas have metastatic potential. Up until now there has been an absence of effective therapeutic methods to inhibit tumor growth and metastasis, especially in metastatic foci. Therefore, the discovery of new and effective drugs is urgently needed. Because overexpression of HSP70 frequently occurs in a variety of tumor tissues, VER155008, a new inhibitor targeting HSP70, has shown an anti-tumor effect through inhibition of PI3K/AKT/mTOR and MEK/ERK pathways, both of which are closely connected with pheochromocytoma proliferation, migration, and biologic behaviors. In our research, we reveal that VER155008 can reduce proliferation of the pheochromocytoma cell line PC12 and induce apoptosis at a relatively low dose. Most importantly, VER155008 can effectively suppress cell migration and invasion. Subsequently, drug-effect mechanisms of VER155008 were further detected by western blot, and we found that VER155008 exhibited an anti-tumor effect through down-regulating phosphorylation of the PI3K/AKT/mTOR and MEK/ERK signaling pathways. Finally, the above phenomena were further confirmed in a mouse model in vivo, and the results showed that the drug significantly inhibited xenograft tumor growth. In summary, VER155008 is a potential and promising effective drug for treating patients with pheochromocytoma, and furthermore, it could delay/inhibit tumor metastasis.

Up-regulation of E-cadherin by saRNA inhibits the migration and invasion of renal carcinoma cells.

Previous studies have reported that double stranded RNAs (dsRNAs) have a potent ability to induce gene expression by targeting its promoter in cancer cells, which is called RNA activation (RNAa). In the present study, we have identified that a candidate dsRNA (dsEcad-215) could stimulate E-cadherin mRNA and protein expression via RNAa in renal cell carcinoma (RCC). Because the expression level of E-cadherin was down-regulated in RCC tissues compared to adjacent non-tumor tissues, dsEcad-215 was subsequently transfected into the RCC cell lines ACHN and 786-O. Expectedly, our results indicated that transfection of dsEcad-215 readily inhibited cell migration and invasion. In addition, several critical EMT-promoting genes (ZEB-1 and Vimentin) were down-regulated, while the anti-EMT gene ß-catenin was up-regulated both at the mRNA and protein levels after dsEcad-215 transfection, suggesting that an enhanced E-cadherin level by dsEcad-215 suppressed EMT to inhibit cell motility. Collectively, our findings provide a potential effective therapeutic strategy for RCC, and dsEcad-215 might act as an alternative anti-cancer metastasis drug.

Apogossypolone (ApoG2) induces ROS-dependent apoptosis and reduces invasiveness of PC12 cells in vitro and in vivo.

Malignant pheochromocytoma is accurately diagnosed only at occurrence of metastatic foci. However, at that time, patients are less likely to get many benefits from traditional chemotherapy. Over-expression of BCL-2 family proteins is tightly correlated with progression of pheochromocytoma. ApoG2, as the most potent gossypol derivative, has exhibited anti-tumor activities in various tumors. In the present study, we found that the staining degree of Bcl-2 being stronger than Bax was more frequently observed in pheochromocytoma than adrenocorticohyperplasia, which was possibly related to shorter overall survival. In addition, ApoG2 could induce apoptosis through up-regulation of Bax and down-regulation of Bcl-2, increasing reactive oxygen species (ROS) levels, inducing cytochrome C release and cleaving caspase proteins. Most importantly, those inhibition effects were blocked by caspase activation inhibitor Z-VAD-fmk and antioxidant N-acetyl-L-cysteine. The above results were further confirmed in vivo. Furthermore, ApoG2 could effectively inhibit tumor movement capabilities. Altogether, our results indicated that ApoG2 was a potential effective target drug for pheochromocytoma.

Enhanced wild-type p53 expression by small activating RNA dsP53-285 induces cell cycle arrest and apoptosis in pheochromocytoma cell line PC12.

Malignant pheochromocytoma (PHEO) is diagnosed only when metastasis has occurred, making it less likely for patients to obtain the benefits of traditional chemotherapy. Anti-oncogene TP53 mutation has been detected in PHEO and is possibly related to disease progression. However, whether the upregulation of wild-type TP53 has antitumoral effects on PHEO remains completely unknown. In the present study, we used RNA activation (RNAa) technique to upregulate the expression of wild-type TP53 by transfecting synthetic dsP53­285 into PHEO cell line PC12. We found that the upregulation of wild-type p53 blocked the transition of PC12 cells from the G0/G1 to the S phase, with induction of apoptosis. Additionally, the above-mentioned findings were attested in vivo. Most importantly, dsP53-285-induced antitumoral effects were reversible following co-transfection with siRNA that targeted p53 mRNA. Collectively, our results revealed that the upregulation of p53 and possibly other anti-oncogenes may provide a potential effective therapeutic strategy for PHEO.

NVP-AUY922, a novel HSP90 inhibitor, inhibits the progression of malignant pheochromocytoma in vitro and in vivo.

PURPOSE: Malignant pheochromocytoma (PCC) is a rare tumor with a very poor prognosis and no effective treatments. The aim of this study was to assess the efficacy of a novel second-generation synthetic heat-shock protein 90 (HSP90) inhibitor, NVP-AUY922, to treat malignant PCC in vitro and in vivo. MATERIALS AND METHODS: Cell Counting Kit-8 (CCK-8) and Transwell assays were used to assess the effects of NVP-AUY922 on the proliferation and migration of the PCC cell line PC12. Flow cytometry was used to determine the effects of NVP-AUY922 on apoptosis and cell-cycle progression. Activation of phosphatidylinositol-3-kinase (PI3K)/protein kinase B (PKB/AKT) and mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinase (ERK) signaling was measured using a Western blot analysis. In vivo, a mouse xenograft model was used to test the effects of intraperitoneal injection of NVP-AUY922 on tumor growth. RESULTS: NVP-AUY922 was found to be cytotoxic in PC12 cells at lower concentrations compared with 17-allylamino-17-demethoxygeldanamcyin (17-AAG). NVP-AUY922 inhibited the proliferation of PC12 cells in a time- and concentration-dependent manner and decreased the rate of migration of PC12 cells. Furthermore, we found that HSP90 inhibition induced cell-cycle arrest and apoptosis. In vivo, administration of NVP-AUY922 reduced PCC tumor growth without significant weight loss. Finally, we observed the modulation of MEK/ERK and PI3K/AKT signaling in response to NVP-AUY922 exposure. CONCLUSION: NVP-AUY922 exhibits potent anti-PCC activities in vitro and in vivo and represents a promising therapeutic small molecule for treating malignant PCC.