Cytochrome P450 (CYP) enzymes play a crucial role in the human body. These enzymes are responsible for the synthesis of steroid hormones and cholesterol, as well as the metabolism of external substances such as medications. While more than 50 CYP enzymes have been identified, just 6 are credited with metabolizing most drugs. Of note is CYP 3A4, which metabolizes ~34% of medications that use the CYP enzyme system. CYP enzymes are polymorphic, meaning there are different versions of the same enzyme; therefore there is variability from individual to individual in their ability to metabolize medications. In the oncology field tyrosine kinase has been identified as an important target controlling cell regulatory functions and proliferation. Thus, tyrosine kinase inhibitors have become widely used for a variety of malignancies. Many of these tyrosine kinase inhibitors rely on CYP 3A4 for metabolism and are subject to variable toxicities based on an individual patient’s genome. A 62-year-old female was diagnosed with Renal Cell Carcinoma (RCC). After undergoing a left nephrectomy, a surveillance scan 21 months after diagnosis was concerning for metastatic disease, which was then confirmed through biopsy. The patient was started on sunitinib 50 mg on days 1-28 of a six-week cycle for metastatic RCC. The patient suffered from Grade 3 myelosupression/mucositis within two weeks of the initiation of therapy. The early onset and severity of the toxicity lead to CYP 3A4 pharmacogenetic testing. She was subsequently found to have a 3A4 polymorphism (*1/*28). The dose of sunitinib was reduced to 25 mg followed by a further reduction to 12.5 mg due to toxicity. Eighteen months after starting sunitinib, a CT scan showed disease progression and therapy was changed to pazopanib. Due to her 3A4 polymorphism, the starting pazopanib dose was empirically reduced by 50% and was started at 400 mg/daily. Pazopanib was held for episodes of severe diarrhea and was further reduced to 200 mg/daily. Nine months after starting pazopanib, new imaging showed lesions in the patient’s liver, confirming disease progression. The patient was subsequently started on nivolumab but quickly progressed. She was then started on cabozantinib at a dose reduced 20 mg/daily. This initial dosing was tolerated well by the patient, so a decision was made to alternate between 20 and 40 mg/daily to increase to an average of 30 mg/daily. She is currently tolerating the 30 mg/daily and continues treatment for metastatic RCC. As described above, CYP 3A4 polymorphisms can result in severe toxicities that present earlier in the treatment course than traditionally expected. Moving forward there may be a role in testing for these polymorphisms to determine an individual’s optimal dose before initiating therapy with tyrosine kinase inhibitors. The advantage of performing such testing would be to limit the severity of toxicities experienced by this patient population, while retaining the overall benefit of these medications.

BACKGROUND: The incidence and mortality of renal cell carcinoma (RCC) after kidney transplantation (KTx) remain unclear. This study's aims were (1) to investigate the pooled incidence/incidence trends, and (2) to assess the mortality/mortality trends in KTx patients with RCC. METHODS: A literature search was conducted using the MEDLINE, EMBASE and Cochrane databases from inception through October 2018. Studies that reported the incidence or mortality of RCC among kidney transplant recipients were included. The pooled incidence and 95% CI were calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO; no. CRD42018108994. RESULTS: A total of 22 observational studies with a total of 320,190 KTx patients were enrolled. Overall, the pooled estimated incidence of RCC after KTx was 0.7% (95% CI: 0.5-0.8%, = 93%). While the pooled estimated incidence of de novo RCC in the native kidney was 0.7% (95% CI: 0.6-0.9%, = 88%), the pooled estimated incidence of RCC in the allograft kidney was 0.2% (95% CI: 0.1-0.4%, = 64%). The pooled estimated mortality rate in KTx recipients with RCC was 15.0% (95% CI: 7.4-28.1%, = 80%) at a mean follow-up time of 42 months after RCC diagnosis. While meta-regression analysis showed a significant negative correlation between year of study and incidence of de novo RCC post-KTx (slopes = -0.05, = 0.01), there were no significant correlations between the year of study and mortality of patients with RCC ( = 0.50). Egger's regression asymmetry test was performed and showed no publication bias in all analyses. CONCLUSIONS: The overall estimated incidence of RCC after KTX was 0.7%. Although there has been a potential decrease in the incidence of RCC post-KTx, mortality in KTx patients with RCC has not decreased over time.

PET/CT with prostate-specific membrane antigen (PSMA)-targeted tracers has been used in the diagnosis and staging of patients with clear cell renal cell carcinoma (ccRCC). For ccRCC primary tumors, PET parameters were shown to predict histologic grade and features. The aim of this study was to correlate PSMA PET/CT with histopathological findings in patients with metastatic recurrence of ccRCC. Patients with ccRCC who underwent PSMA-targeted PET/CT and subsequent histopathological evaluation of suspicious lesions were included. Specimens underwent immunohistochemical marking. Lesion diameter, volume and tracer uptake were correlated with the extent and intensity of molecular PSMA expression and with clinical findings. Twelve PET-positive lesions of nine patients were evaluated. Eleven ccRCC metastases and one prostate carcinoma were detected histopathologically. Molecular PSMA expression was detected in all lesions, which intensity and distribution did not correlate with PET parameters. PSMA-targeted PET/CT is a feasible tool for the evaluation of patients with ccRCC but cannot reliably predict histologic features of metastases. PSMA may also be expressed in malignant lesions other than ccRCC, leading to incidental detection of these tumors.

No description available.

<p>Renal cell carcinoma (RCC) is the most frequently lethal of urological cancers. It arises in the lining of the proximal convoluted tubule of the kidney and is most common in men ages 50–70. Often, partial or radical nephrectomy is needed to effectively treat the disease, leaving patients with reduced kidney function. RCC frequently displays significant radiation resistance, limiting the usefulness of traditional radiation therapy which might spare patients’ normal tissue. The enzyme carbonic anhydrase 9 (CA9), a product of the hypoxia pathway, is found upregulated in the majority of RCC, particularly the clear cell type. It catalyses the dissolution of carbon dioxide into water as bicarbonate and has been linked to increased invasion and migration in RCC tumour cells. The radiation resistance of two RCC cell lines 786-O (human CCRCC) and RAG (murine renal adenocarcinoma) was investigated by the clonogenic assay in the presence of a CA9 inhibitor or silencing RNA. The interference with CA9 by either of these methods significantly sensitizes 786-O cells to the effects of ionizing radiation <em>in vitro</em>. Moreover, fractionation of the dose delivered can increase this sensitization effect. It is hoped that current targeting of CA9 can make radiation therapy a more feasible option in the treatment of RCC.</p> / Master of Science (MSc)

Le cancer du rein papillaire de type 2 (PRCC2) est un cancer très agressif avec un potentiel métastatique élevé et pour lequel il n’y a pas de traitement efficace. La forme héréditaire de PRCC2 est associée au syndrome rare de la léiomyomatose cutanéo-utérine héréditaire (HLRCC). HLRCC est due à une mutation germinale hétérozygote du gène Fumarate Hydratase (FH) qui code l'enzyme du cycle de Krebs, la Fumarase. Le déficit en fumarase induit l’accumulation de fumarate et active les voies de signalisation du facteur de transcription inductible par l’hypoxie (HIF) et des espèces réactives de l’oxygène (ROS). Néanmoins, aucune mutation du gène FH n’a été rapportée dans les cas de PRCC2 sporadiques. Le projet de recherche porte sur la caractérisation moléculaire des PRCC2 héréditaires et sporadiques. Notre analyse du transcriptome a identifié des différences entre les signatures moléculaires des PRCC2 héréditaires et sporadiques. Cependant, l’étude d’immunohistochimie n'a pas révélé de biomarqueurs potentiels. Les analyses bio-informatiques de profils d’expression génique ont révélé que les tumeurs PRCC2 héréditaires et sporadiques partagent une dérégulation de la voie principale NRF2/KEAP1. Il a été montré que la surexpression de AKR1B10 (Aldo-Keto Reductase Family 1 Membre B10) est la conséquence directe de l’activation de l'élément de réponse antioxydant (ARE). Finalement, nous avons établi un nouveau modèle in vitro de lignée cellulaire, NCCFH1 (FH-/-), issue d’un patient HLRCC. NCCFH1 représente une plateforme idéale pour les études fonctionnelles, métaboliques et thérapeutiques. Bortézomib pourrait être la meilleure alternative thérapeutique pour les patients avec PRCC2. / Papillary Renal Cell Carcinoma type 2 (PRCC2) is known to be a very aggressive type of kidney cancer with a high metastatic potential, poor outcome and absence of effective therapy. Hereditary form of PRCC2 is associated with rare hereditary leiomyomatosis and renal cell carcinoma (HLRCC). HLRCC is characterized by germline heterozygous mutations in the Fumarate Hydratase (FH) gene that encodes an enzyme of the Krebs cycle, Fumarase. It has been shown that the accumulation of fumarate induces activation of Hypoxia Inducible Factor (HIF) and ROS (Reactive Oxygen Species) pathways. Nevertheless, no FH gene mutation has been reported in sporadic PRCC2 tumors. The goal of this study is to better characterize hereditary and sporadic PRCC2. Our transcriptome analysis identified the set of genes that are differentially expressed between the two types of PRCC2. Subsequent immunohistochemistry screening did not reveal any potential diagnostics biomarkers. Further, the comprehensive computational analysis of gene profiling data revealed that hereditary and sporadic PRCC2 share the similar molecular signature with NRF2-KEAP1 axis deregulation as one of the major pathway in both forms. We demonstrated that over expression of Aldo-keto reductase family 1 member B10 (AKR1B10) is the direct consequence of the antioxidant response element (ARE) activation shared in hereditary and sporadic tumors. Finally, we have established FH-deficient cell line (NCCFH1) a new preclinical model of hereditary PRCC2. It presents the perfect platform for studying the metabolic features and testing new therapies for hereditary PRCC2, while bortezomib appears to be a potential efficient therapeutic option.

Background Renal cell carcinoma (RCC) is the most common type of kidney cancer. Patients diagnosed with metastatic RCC (mRCC) have shorter overall survival compared to those diagnosed at earlier stages. Several targeted therapies, which cost from $7,000 - $16,000 per month have been approved since 2005 to treat mRCC. In addition, there is a growing interest in the use of cytoreductive nephrectomy (CN) with targeted therapies among mRCC patients. However, little is known regarding the economic burden of RCC and role of CN and prescribing patterns of targeted therapies among older mRCC patients. Objectives 1) To assess the economic burden of RCC among older adults in the targeted therapy era 2) To compare the overall survival (OS) and total healthcare cost (THC) among older mRCC patients receiving CN and targeted therapy versus patients receiving targeted therapy alone 3) To describe prescribing patterns of targeted therapies and associated OS and THC among older mRCC patients. Methods This dissertation was conducted using the Surveillance Epidemiology and End Results (SEER) - Medicare linked data. For the first objective, the study included a prevalent cohort of RCC patients from 2013, diagnosed during 2005 - 2013 and continuously enrolled in Medicare. RCC patients were matched to non-cancer beneficiaries using propensity score matching. Generalized linear models estimated the incremental healthcare costs. Incremental total healthcare cost (THC) was multiplied by the estimated number of RCC patients on Medicare to calculate the total economic burden of RCC. For the second objective, we included patients diagnosed with mRCC between 2007-2014 and compared overall survival (OS), and THC between patients who received CN + targeted therapy and targeted therapy alone. A propensity score based inverse probability of treatment weighting (IPTW) method was used to balance the two treatment groups. A Cox proportional hazard model assessed the risk for death and a GLM compared healthcare costs between the groups. For the third objective, patients with mRCC were defined as patients who were diagnosed at stage-IV or at earlier stages but were currently using targeted therapies. Further, we restricted our sample to patients who initiated targeted therapy. We described the frequencies of the most common first and second line targeted therapies. We also described OS and THC per month for clear-cell and non-clear cell mRCC for each therapy and line of therapy. Results The first study included 10,392 each of RCC and control patients. The average THC associated with RCC was $7,419. The average THC was $4,584 for patients diagnosed at stage-I, $4,727 for stage-II, $9,331 for stage-III, and $31,637 for stage-IV. The annual economic burden of RCC on Medicare was estimated to be $1.5 billion. The second study included 471 mRCC patients that received CN + targeted therapy or targeted therapy alone. The median OS from the adjusted survival curves was significantly higher (p Conclusions The economic burden of RCC varied substantially between early stage and metastatic patients. Among mRCC patients, use of CN among targeted therapy users was associated with a higher median OS and similar monthly THC over a lifetime. Sunitinib and everolimus were the most common first and second line targeted therapies among mRCC patients. The descriptive analysis suggested that OS and THC were similar across types of targeted therapy sequences.

INTODUÇÃO: O carcinoma renal (CR) é uma doença agressiva, e sua incidência vem aumentando. A variante de células claras (CRCC) é a mais comum e apresenta comportamento biológico mais agressivo. Os recentes avanços no conhecimento da biologia molecular do tumor demonstram que a oncogênese dos diversos tipos histológicos é regida por mecanismos celulares diversos. Os modelos prognósticos atuais vêm procurando incorporar os recentes avanços da biologia molecular, com o intuito de melhorar sua capacidade de predizer a evolução e o desfecho destes pacientes. OBJETIVOS: Correlacionar a imunoexpressão dos marcadores selecionados com: 1) sobrevida global e, 2) com parâmetros prognósticos estabelecidos (estadio clínico TNM, tamanho tumoral, grau nuclear de Fuhrman, invasão microvascular e invasão de gordura perirrenal) em portadores de CRCC não metastático. MÉTODOS: Neste estudo de coorte retrospectivo, avaliamos 99 pacientes portadores de CRCC não metastático, quanto à expressão imunoistoquímica das seguintes proteínas: CA-IX, EGF-R, Ki-67, p53, PTEN, VEGF e VEGF-R. Os parâmetros analisados foram: Sobrevida global, estadio TNM, tamanho tumoral, grau nuclear de Fuhrman, invasão microvascular e invasão de gordura perirrenal. Utilizamos um tissue microarray construído exclusivamente para esta finalidade e realizamos a leitura da imunoexpressão por técnica digital utilizando o software Photoshop®. RESULTADOS: O tempo de seguimento médio foi de 7,9 anos. Com relação à sobrevida global, não observamos sua correlação com nenhum dos marcadores avaliados. Quanto à correlação da expressão dos marcadores com os parâmetros prognósticos convencionais, observamos que a expressão do EGF-R se correlacionou com estadio T (p= 0,049) e invasão da gordura perirrenal (p=0,020); e o VEGF-R se correlacionou com grau de Fuhrman (p=0,022) e invasão microvascular (p=0,005). Nos demais marcadores, não foi observada correlação significativa. CONCLUSÃO: Os fatores prognósticos moleculares EGF-R e VEGF-R apresentam-se como ferramentas úteis para avaliação do risco de prognóstico desfavorável em portadores de carcinoma renal de células claras não metastático / INTODUCTION: Renal cell carcinoma is an aggressive disease and its incidence is rising. The clear cell variant is the most common, and also the most aggressive. Recent advances in the understanding of the tumors molecular biology indicate that the oncogenesis of each histologic subtype is controlled by distinct cellular mechanisms. Current prognostic models are gradually incorporating the advances in molecular biology, in the hope to improve their predictive capacity. OBJECTIVES: To correlate the immunoexpression of selected markers with 1) overall survival, and 2) with established prognostic parameters (clinical TNM stage, tumor size, Fuhrman nuclear grade, microvascular invasion and perirenal fat invasion) in patients with non-metastatic ccRCC. METHODS: This is a retrospective cohort study, we evaluated 99 patients with non-metastatic clear cell renal cell carcinoma, as to the expression of the following proteins: CA-IX, EGF-R, Ki-67, p53, PTEN, VEGF e VEGF-R. The analyzed parameters where: overall survival, TNM stage, tumor size, Fuhrman nuclear grade, microvascular invasion, perirenal fat invasion. We utilized a custom built tissue microarray, and the immunoexpression was digitally quantified using the Photoshop® software. RESULTS: The mean follow-up time was 7,9 years. We found no correlation between the expression of the studied molecular markers and overall survival. As for the conventional prognostic parameters, we found the expression of EGF-R to correlate with T stage (p= 0,049) and perirenal fat invasion (p= 0,020), and VEGF-R to correlate with Fuhrman nuclear grade (p= 0,022) and microvascular invasion (p= 0,022). None of the other markers showed correlation with the studied parameters. CONCLUSIONS: The expression of EGF-R and VEGF-R may be useful tools in the prognostic evaluation of unfavorable risk in patients with non metastatic clear cell renal cell carcinoma

Le cancer du rein (CCR) est une néoplasie immunogène. Le travail présenté ici porte sur les interactions entre les cellules Natural Killer (NK) et les cellules du cancer du rein. Les caractéristiques particulières des cellules tumorales rénales, telles que les mutations de VHL, l’événement phare dans le développement des cancers du rein, ou encore l’expression d’une forme membranaire de la cytokine IL-15 interfèrent avec l’activation des cellules NK. On a identifié une forme membranaire de la cytokine IL-15 particulière sur les cellules tumorales rénales, qui contrôlerait l’homéostasie des cellules NK au sein de la tumeur. Par ailleurs, on montre que certaines mutations de VHL des cellules du cancer du rein favorisent l’activation des cellules NK en diminuant l’expression des molécules HLA de classe I par les cellules tumorales. / Renal cell carcinomas (RCC) are immunogenic. The work presented here describes the interactions between NK cells and RCC. We have investigated particular characteristics of RCC, like the mutation of the VHL gene, the key event in carcinogenesis of kidney cancers of the clear cell type, or a particular expression of IL-15 by the tumor cells. We show that certain RCC cell lines express a unique form of membrane bound IL-15. Our work indicates that the expression of IL-15 by the tumor cells might play a role in the homeostasis of NK cells infiltrating kidney cancers. Furthermore we show that mutations of the VHL gene cause diminished HLA expression favoring thereby the activation of NK.

Background. Angiogenesis is essential for tumour growth. Vascular endothelial growth factor (VEGF) and its isoforms were investigated in relation to the clinical course in a large number of patients with renal cell carcinoma (RCC). Methods. RCC subtypes and behaviour were established by clinicopathological criteria and surveillance. VEGF expression was analysed in serum by enzyme-linked immuno-sorbent assay (ELISA) and in tumour tissue by reverse transcription polymerase chain reaction (RT-PCR), immunohistochemistry (IHC), and Western blot (WB). Results. Serum VEGF (S-VEGF) was increased in RCC compared to control group. S-VEGF correlated with tumour stage and grade and was associated with survival in men but not in women. S-VEGF correlated with blood platelet counts, which were inversely correlated to increasing age in women, and they were decreased in chronically medicated patients, particularly in men. In contrast to S-VEGF, platelet counts associated with survival only in patients free of medication and chronic diseases. RT-PCR showed a correlation between VEGF121/VEGF165 mRNA and between VEGF165/VEGF-R1 mRNA. There was no association between different VEGF mRNA isoforms and S-VEGF. Conventional renal cell carcinoma (CRCC) had higher VEGF165, VEGF121, and VEGF-R1 mRNA levels compared with papillary renal cell carcinoma (PRCC). IHC VEGF staining was strong in kidney cortex. Kidney tumour showed a considerable variation in cytoplasmatic VEGF expression, which correlated with tumour size. Although, there was no difference in VEGF expression between the RCC types, VEGF expression was associated with survival only in CRCC. WB showed a strong protein expression of both VEGF189 and VEGF165 in kidney cortex. In kidney tumour, expression of VEGF189 varied the most, VEGF165 less so, and VEGF121 was rarely detected. Both CRCC and PRCC expressed low levels of VEGF189 and VEGF165 compared with kidney cortex. Chromophobe renal cell carcinoma (ChRCC) expressed VEGF189 levels comparable to those from kidney cortex, while VEGF165 was lower. In PRCC and ChRCC, VEGF189 levels correlated inversely with advancing tumour stage, and in PRCC, VEGF165 levels correlated inversely with increasing tumour size. VEGF189 was an independent prognostic factor for survival in patients with PRCC. Conclusions. S-VEGF has a stronger association to progression in RCC than platelet count. CRCC showed high levels of VEGF mRNA isoforms and VEGF-R1 mRNA compared to PRCC. VEGF mRNA isoforms expression decreased with advancing stage. IHC demonstrated VEGF expression in cell cytoplasm related to tumour growth, particular in CRCC. Different VEGF isoform patterns were found in different RCC types. Protein VEGF189 expression was associated with tumour stage and was an independent prognostic factor in PRCC. Protein VEGF165 expression was generally low and had no prognostic value. The trend for decreasing levels of VEGF isoforms in advanced tumour stages may indicate that angiogenic activity is an early event in tumour growth induced by VEGF, but that during later tumour progression the role of VEGF is less clear.