Method for prediction of oncological survival rate in patients with nonmetastatic renal cell carcinoma after malignant nephrectomy or partial nephrectomy

FIELD: medicine.

SUBSTANCE: surgery material is subject to immunohistochemical and pathomorphological analysis. A Ki-67 antigen expression level and a mutant p53 oncogene expression level are determined. An average diameter of malignant cell nuclei, or the presence or the absence of nucleoli in the malignant cell nuclei are evaluated with the presence or the absence of the nucleoli in the malignant cell nuclei are stated at various magnifications, while cariometry is enabled with a certain minimum count of renal cell carcinoma cell nuclei. The predicted oncological survival rate is calculated by formula: Ymbv=1.83X1+1.45X2+1.18X3, where Ymbv is a morphobiomolecular value; X1 is a histological malignancy degree in points; X2 is the Ki-67 expression level in points; X3 is the p53 expression level in points. The histological malignancy degree is shown by the average diameter of the malignant cell nuclei, or the presence or the absence of the nucleoli in the malignant cell nuclei. The Ymbv value ≤6.29 shows a favourable prognosis for the oncological survival rate in the patients; the Ymbv value 6.82-8.92 provides a relatively favourable prognosis, while the Ymbv value 9.19-11.55 enables to state a relatively unfavourable prognosis, and an unfavourable prognosis is given by the Ymbv value > 11.55.

EFFECT: higher prediction accuracy.

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The invention relates to the field of medicine: Oncology, pathology and urology, may be used to predict cancer 3-, 5 - and 7-year survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor.

Methods for estimating cancer patient survival in renal cell cancer can be divided according to their structure assessed by clinical and pathological criteria (Galfano A., G. Novara, Lafrate M. et at. Mathematical models for prognostic prediction in patients with renal cell carcinoma // Urol. Int. - 2008. - Vol.80. - P.113-123). All without exception method is multifactorial (multivariable) analysis of certain parameters (independent factors). There are two main ways of assessing prognosis of a cancer - mathematical algorithm and the nomogram. The latter is a graphic model of the results of the multivariate analysis, which allows to calculate the probability of survival for each individual patient. Methods, including mathematical algorithms (or integrated system), allow to divide patients into groups according to prognostic categories and are used not only for planning post-operative monitoring of patients, but also for interpreting the results of various studies. Major Crete is the criteria for the selection of these ways - the number of patients and the index concordancia (CI) or agreement coefficient Kendall, which allows to determine the accuracy of the method. If CI is in the range between 0.5 and 0.7, the predictive accuracy is low, in the range from 0.71 to 0.9 - moderate and higher than 0.9 high (Galfano A., G. Novara, Lafrate M. et al. Mathematical models for prognostic prediction in patients with renal cell carcinoma // Urol. Int. - 2008. - Vol.80. - P.113-123; Harrell F.E., Jr., Califf R., Pryor D.B. et al. Evaluating the yield of medical tests // JAMA. - 1982. - Vol.247. - P.2543-2546).

Prognostic methods based on clinical parameters

1. In 2001 .Yaycioglu et al. proposed method for calculating the risk of recurrence (PRetz) after radical nephrectomy depending on the clinical manifestations of the disease and clinical tumor size. PRetzrepresented by the following formula: RRetz=1,55 × symptoms (0 = no symptoms; 1 = presence of symptoms)+0,19 × clinical tumor size (in cm). According to this formula, the patients were divided into 2 risk groups: 1) low - with a score of ≤3 (5-year cancer survival rate is 92%); 2) high - score >3 (5-year cancer survival rate - 57%) (Yaycioglu O., Roberts W.W., Chan, T. et al. Prognostic assessment of nonmetastatic renal cell carcinoma: a clinically based model // Urol. - 2001. - Vol.58. - P.141-145).

2. L.Cindolo et al. (2003) developed a method to assess relapse-free survival (VWD) patients after Radik the school nephrectomy. It RRetz=1,28 × symptoms (0 = no symptoms; 1 = presence of symptoms)+0,13 × clinical tumor size (in cm). The low risk - with a score of ≤1,2 (5-year relapse-free survival rate is 93%); high - score >1,2 (5-year relapse-free survival rate of 68%) (Cindolo L., de la Taille A., Messina G. et al. A preoperative clinical prognostic model for non-metastatic renal cell carcinoma // BJU Int. - 2003. - Vol.92. - P.901-905).

Meanwhile, the proposed methods, the first based only on clinical parameters, i.e. inherently subjective, and secondly, have low predictive accuracy for the model Yaycioglu O. et al. CI in the evaluation of relapse-free survival rate was 0.65, cancer survival rates - 0.63 and overall survival is 0.59, and the model Cindolo L. et al. CI in the evaluation of relapse-free survival rate is 0.67, the cancer survival rate is 0.65 and overall survival - of 0.62 (Galfano A., G. Novara, Lafrate M. et al. Mathematical models for prognostic prediction in patients with renal cell carcinoma // Urol. Int. - 2008. - Vol.80. - P.113-123).

Methods based on pathological criteria

.Leibovich et al. (2003)to estimate relapse-free survival of patients with non-metastatic clear with kidney cancer who underwent radical nephrectomy, has created a slightly different way, in which lay the same criteria, but based on the pTNM classification 2002 (table 1): allocated 8 categories of patients with various spare parts is offered by the cancer survival (table 2) (Leibovich Century, Blute M.L, J.C. Cheville et al. Prediction of progression after radical nephrectomy for patients with clear cell renal cell carcinoma // Cancer. - 2003. - Vol.97. - P.1663-1671).

Although the model .Leibovich et al. (2003) the value of CI was 0.82 (Galfano A., G. Novara, Lafrate M. et al. Mathematical models for prognostic prediction in patients with renal cell carcinoma // Urol. Int. - 2008. - Vol.80. - P.113-123), the algorithm .Leibovich et al. (2003), intended to form clear kidney cancer without distant metastases, only describes relapse-free survival (Galfano A., G. Novara, Lafrate M. et al. Mathematical models for prognostic prediction in patients with renal cell carcinoma // Urol. Int. - 2008. - Vol.80. - P.113-123), a whether there are significant differences in the indicators of the specific cancer survival rates have described eight categories of patients, not shown.

Combined methods

Most of the existing prediction methods cancer survival of patients undergoing radical nephrectomy for cancer of the kidney, are, in fact, combined with the relatively arbitrary choice of those or other clinical, laboratory, pathological and molecular biological parameters associated with the forecast.

H.G. van der Poel et al. (1993) (Van der Poel H.G., P.F.A. Mulders, Oosterhof G.O.N. et al. Prognostic value of karyometric and clinical characteristics in renal cell carcinoma // Cancer. - 1993. - Vol.72. - P.2667-2674) proposed a method, based on multivariate regression analysis of survival 121 patient with renal cell the cancer (according to the method of Coke). H.G. van der Poel et al. (1993) showed that the stage of the disease (according to the classification of the International Union Against Cancer, 1987) (p=0.001), somatic status (Karnofsky scale from 0 to 100) (p=0.006), lower body mass of the patient (p=0.008), as well as anisocoria (p=0,018) are independent prognostic factors. The proposed method includes the regression equation: XBeta = (0,875 × stage)+(-0,04 × indicator of somatic status)+(-0,74 × the rate of decrease in weight)+(0,044 × the difference between the maximum and minimum standard deviations square nuclei in the tumor). Depending on the values of XBeta were demonstrated differences in the functions of the three-year survival rate of patients (according to the method of Kaplan-Meier): patients with a value ≤-2,3 had a good prognosis (cancer survival rate is 80%), from -2,3 to -1 - "intermediate" (cancer survival rate - 41%) and > -2,3 - bad (cancer survival rate - 21%) (Van der Poel H.G, Mulders P.F.A, Oosterhof G.O.N. et al. Prognostic value of karyometric and clinical characteristics in renal cell carcinoma // Cancer. - 1993. - Vol.72. - P.2667-2674).

Meanwhile, the authors evaluated only 3-year cancer survival rate, while 65 (54%) patients were receiving immuno - and/or chemotherapy, 7 (6%) - radiation therapy, which may affect the quality of the proposed model assessment of patients ' survival. No prognostic evaluation of 5 - and 7-year-old cancer patient survival. In addition, tadia cancer of the kidney was determined by obsolete (today) systems C.J. Robson et al. (1969) (Robson C.J., B.M. Churchill, Anderson W. The results of radical nephrectomy for renal cell carcinoma // J. Urol. - 1969. - Vol.101. - P.297-301) and UICC (1987) (Hermanek p, Sobin L.H. TNM classification of malignant tumours. UICC International Union Against Cancer. - Berlin: Springer-Verlag, 1987). The authors took into account the histological structure (histotype) tumors, which had no prognostic significance not only for multifactorial, but in univariate Cox regression analysis, however, since 1993, histological classification of renal cell carcinoma evolved several times (Yurin A.G. tumors of the kidney (working standards postmortem studies: the Library of the pathologist. - SPb., 2006. - VIP. - 84 C.), which may also affect the accuracy of predictive models. The method is not sufficiently specific that there are no criteria for determining cancer survival it with non-metastatic clear of cancer of the kidneys, as the method-prototype includes all cases of kidney cancer. Unknown and accuracy of predictive models.

In clinical practice, as a rule, when carrying out various multicenter studies, the most widespread prognostic algorithm integrated staging UISS (UCLA (University of California at Los Angeles) Integrated Staging System), proposed in 2001 A.Zisman et al. (Zisman a, Pantuck AJ, Dorey f, et al. Improved prognostication of renal cell carcinoma using an Integrated Staging System // J. Clin. Oncol - 2001. - Vol.19. - P.1649-1657). This system was created based on the analysis of the overall 5-year survival 661 patient who underwent radical nephrectomy about renal cell cancer (all histological subtypes). Estimated TNM stage (1997), somatic status ECOG PS (table 3) and histological grade of malignancy on S.A.Fuhrman et al. (1982). All patients depending on the overall 5-year survival were divided into 5 groups: in group I, the overall survival was 95%, in group II - 67%, in the group III - 39%, in the group IV - 23% and in group V - 0%. Applying this system for prognosis after radical nephrectomy in 814 patients with renal cell carcinoma, of which 468 were non-metastatic kidney cancer, and 346 - metastatic tumor shapes, A.Zisman et al. (2002) identified 3 groups of patients with low, moderate, and high risk of disease progression and death (Zisman a, Pantuck AJ, J. Wieder et al. Risk group assessment and clinical outcome algorithm to predict the natural history of patients with surgically resected renal cell carcinoma // J. Clin. Oncol. - 2002. - Vol.20. - P.4559-4566). Both systems UISS for risk assessment in patients with cancer of the kidneys in the absence or presence of metastases (lymphogenous and/or remote) are presented in table 4 and 5, and data on projected 5 - and 2-year survival in table 6 and 7.

Although K.R.Han et al. (2003), applying the algorithm UISS to assess the risk of progression and death in PA is antov with non-metastatic renal cell cancer at a fairly representative material, figured CI of this method for estimating cancer survival rates ranging from 0.79 to 0.84 (Han K.R., Bleumer I., A.J. Pantuck et al. Validation of an integrated staging system toward improved prognostication of patients with localized renal cell carcinoma in an international population // J. Urol. - 2003. - Vol.170. - P.2221-2224). The proposed method also does not take into account variant renal cell carcinoma, and, in addition, based on the assessment of physical status of the patient, therefore, its use in pathological practice in the study by pathomorphology operational material difficult.

As a prototype for closest to the technical nature of the selected method I.Frank et al. (2002)that to determine cancer survival rates in patients after radical nephrectomy for patients with clear cancer of the kidneys proposed method, based on pathological criteria that had statistical significance in multivariate analysis, such as stage (pTNM, 1997) (p<0,001), tumor size ≥5 cm (p<0,001), histological grade of malignancy on S.A.Fuhrman et al. (1982) (Fuhrman SA, Lasky L.C., Limas C. Prognostic significance of morphologic parameters in renal cell carcinoma // Am. J. Surg. Pathol. - 1982. - Vol.6. - P.655-663) (p<0.001) and the presence of micronecrosis in tumors (p<0,001) - SSIGN (Stage, Size, Grade and Necrosis) (Frank I, Blute M.L, J.C. Cheville et al. An outcome prediction model for patients with clear cell renal cell carcinoma treated with radical nephrectomy based on tumor stage, size, grade and necrosis: the SSIGN score // J. Urol. - 2002. - Vol.168. - P.23952400) (table 8). In accordance with this has been allocated 10 categories of patients with different cancer survival (table).

The method selected as the prototype, has the following disadvantages:

- Unknown levels of differences in rates of cancer survival at ten of the described categories of patients, which undoubtedly affects the accuracy of the prediction.

The algorithm described I.Frank et al. (2002), dependent on TNM-stage 1997, outdated today.

- I.Frank et al. (2002) used the method for determining histological grade, developed S.A.Fuhrman et al. (1982). According to the author of the proposed method, magnification ×100 to determine III histological grade of the tumor in the way S.A.Fuhrman et al. not enough, as this increase is not all nuclei are visualized. So, according to its own data, magnification ×100 more than half of the nucleoli was not determined. To determine IV histological grade of the tumor by the authors of this work do not specify a value increase of the microscope.

In the way S.A.Fuhrman et al. there is also no clear data on average size of nuclei of cells clear variant renal cell cancers of various histological grade in normal (routine) processing of the material, as well as karyometric is their indicators of clear cells kidney cancer, as the diameter, perimeter, area, volume, indexes, forms and elongation of the nuclei of tumor cells.

In addition, S.A.Fuhrman et al. (1982) there is no description techniques of fixation and staining, while the long-established fact is a nuclear-cytoplasmic retraction of from 10 to 70% in all tissues, depending on the application of those or other methods of material processing (Tasca K. Introduction to quantitative cytohistologic morphology. - Bucharest: Publishing house of the Academy, 1980. - P.26-28). You must take into account the fact that paraffin or celloidin sections should not be measured nuclei in the outer zone of the preparation of a width of 0.5 mm, since here the cells more compressed during histological processing, and between the volumes of the nuclei of the peripheral and Central zones there is a difference of 70% when filling in paraffin and 35% in celloidin (Tasca K. Introduction to quantitative cytohistologic morphology. - Bucharest: Publishing house of the Academy, 1980. - P.26-28).

- It is important to note that the study S.A.Fuhrman et al. (1982) of the 103 cases of renal cell carcinoma accounting for its clear variant had only 2/3 (other forms of cancer - papillary, "mixed structure" and sarcomatoid component). Other forms of cancer, in which kariometrijskih parameters and the presence or absence of nucleoli at different magnifications of the microscope which may be significantly different from the clear option. Thus, this method lacks specificity, i.e. there are no criteria for determining histological grade it is non-metastatic clear of cancer of the kidney.

In addition, 17% of patients with renal cell cancer included in the study, conducted radiation and/or chemotherapy, which probably may also affect the size of the nuclei (Fuhrman SA, Lasky L.C., Limas C. Prognostic significance of morphologic parameters in renal cell carcinoma // Am. J. Surg. Pathol. - 1982. - Vol.6. - P.655-663).

The technical result of the invention is the development levels of different measures of forecasting 3-, 5 - and 7-year cancer survival rates of patients with non-metastatic clear of cancer of the kidneys, which will increase the accuracy of the prediction.

The technical result of the invention is achieved by the fact that determine the histological grade of malignancy of non-metastatic renal clear cell carcinoma patients after nephrectomy or resection of the kidney with the tumor: when the value of the average diameter of the nuclei of tumor cells ≤6 μm or absence of nucleoli in the nuclei of tumor cells, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 10, I define the histological grade of malignancy.

When the average diameter of the nuclei of tumor cells 6,1-7 μm or defined the research Institute of nucleoli at magnification ×400, if karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 20, define II histological grade of malignancy.

When the average diameter of the nuclei of tumor cells 7,1-8 μm or determination of nucleoli at magnification ×125, if karyometry minimum number of nuclei of cells clear of kidney cancer, 30, III determine the histological grade of malignancy.

When the average diameter of the nuclei of tumor cells >8 or determination of nucleoli at magnification ×100, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 40 determine IV histological grade of malignancy.

Immunohistochemical study to determine the level of expression of the antigen Ki-67: the level of expression of the antigen Ki-67≤3% assign 1 point, 3,1-10% - 2 points, >10% - 3 points.

Immunohistochemical study also identifies the level of expression of mutant-type p53 oncogene: the expression level of p53≤12%, assign 1 point, 12,1-35% - 2 points, >35% - 3 points.

Prediction of cancer survivability is performed using the formula:

TheIBE=1,83X1+1,H2+1,18X3,

where X1histological grade of malignancy of the tumor (1, 2, 3, or 4; X2the level of expression of Ki-67 points (1, 2 or 3); X3level exp is ASCII p53 in points (1, 2 or 3).

When the value of YIBE≤6,29 predict cancer 7-year survival in patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor in 100% of cases, when the value of YIBE6,82-8,92 predict cancer 3-, 5 - and 7-year survival in these patients in 96,5%, 75% and 71.2% of cases, respectively, when the value of YIBE9,19-11,55 predict cancer 3-, 5 - and 7-year survival in these patients in 81.8%, and 54.5 per cent and 42.4% of cases, respectively, when the value of YIBE>11,55 predict cancer 3-, 5 - and 7-year survival in these patients is 20%, 10% and 10% of cases, respectively.

When the value of YIBE≤6,29 forecast cancer survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor regarded as favorable, if the value ofIBE=6,82-8,92 as relatively favorable, when the value of YIBE=9,19-11,55 - as a relatively unfavorable, when the value of YIBE>11,55 as unfavorable.

The method is as follows.

From each tumor cut out at least 10 pieces from different departments at random. Material fixed in 10% neutral buffered formalin, followed by pouring in the wax,make a slice thickness of 7 μm and stained them with hematoxylin and eosin. In the study does not include clear cases of cancer of the kidney with the presence sarcomatoid component. Do not measure core in the outer zone of the preparation of a width up to 500 microns.

On the basis of criteria developed on the basis of the St. Petersburg state institution "City postmortem Bureau" (Yurin A.G., Kowalski G.B. Histological grade of malignancy of kidney cancer: cario and stereometric analysis // Arch. Pat. - 2009. - V.2. - S-18), for assessment of histological grade determine parameters such as the absence or presence of nucleoli at different magnification (×100, ×125 ×400) or the average diameter of the nuclei of tumor cells. When careonecredit.com study can be limited by a certain minimum number of nuclei of cells clear of kidney cancer.

When the average diameter of the nuclei of tumor cells ≤6 μm or absence of nucleoli in the nuclei of tumor cells, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 10, I define the histological grade of malignancy.

When the average diameter of the nuclei of tumor cells 6,1-7 μm or determination of nucleoli at magnification ×400, if karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 20, define II histological grade of malignancy.

When the average diameter is tra nuclei of tumor cells 7,1-8 μm or determination of nucleoli at magnification ×125, if karyometry minimum number of nuclei of cells clear of kidney cancer, 30, III determine the histological grade of malignancy.

When the average diameter of the nuclei of tumor cells >8 or determination of nucleoli at magnification ×100, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 40 determine IV histological grade of malignancy.

Immunohistochemistry tumors performed using the monoclonal antibody Ki-67 (Dako), and p53 ("NovoCastra") after treatment (slice thickness of 5 μm, placed on high adhesive glass) in a pressure cooker in order to restore antigenic reactivity, and detectional system (secondary system) "EnVizion" ("Dako"), Are control reactions: for a positive control is used adenocarcinoma of the colon; a negative reaction is without primary antibodies.

Immunohistochemical study of the proportion of cells with stained nuclei determine among 1000 cells in the areas with the highest content of "positive" cells, in percent:

1) when the expression level of the antigen Ki-67≤3% assign 1 point, 3,1-10% - 2 points, >10% - 3 points;

2) when the level of expression of the oncogene p53≤12% assign 1 point, 12,1-35% - 2 points, >35% - 3 points.

I hope morphological and biomolecular indicators is ü (U IBE) according to this formula: if valueIBE≤6,29 predict cancer 7-year survival in 100% of cases, when the value of YIBE=6,82-8,92 predict cancer 3-, 5 - and 7-year survival in these patients in 96,5%, 75% and 71.2% of cases, respectively, when the value of YIBE=9,19-11,55 predict cancer 3-, 5 - and 7-year survival in these patients in 81.8%, and 54.5 per cent and 42.4% of cases, respectively, when the value of YIBE>11,55 predict cancer 3-, 5 - and 7-year survival in patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor in 20%, 10% and 10% of cases, respectively.

When the value of YIBE≤6,29 forecast cancer survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor regarded as favorable, if the value ofIBE=6,82-8,92 as relatively favorable, when the value of YIBE=9,19-11,55 - as a relatively unfavorable, when the value of YIBE>11,55 as unfavorable.

The main features of the proposed method are:

1. When determining histological grade non-metastatic renal clear cell carcinoma patients after nephrectomy and or resection of the kidney with the tumor determine the average diameter of the nuclei of tumor cells or the presence (or absence) of nucleoli in the nuclei of tumor cells.

2. The presence or absence of nucleoli in the nuclei of tumor cells is determined at different magnifications of the microscope.

3. Karyometry provide for a minimum number of core cells clear of kidney cancer: 10 nuclei of cells clear of kidney cancer when I histological grade, 20 - by II, 30 - III-and 40 - when IV histological grade.

4. When the average diameter of the nuclei of tumor cells ≤6 μm or absence of nucleoli in the nuclei of tumor cells, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 10, I define the histological grade of malignancy.

5. When the average diameter of the nuclei of tumor cells 6,1-7 μm or determination of nucleoli at magnification ×400, if karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 20, define II histological grade of malignancy.

6. When the average diameter of the nuclei of tumor cells 7,1-8 μm or determination of nucleoli at magnification ×125, if karyometry minimum number of nuclei of cells clear of kidney cancer, 30, III determine the histological grade of malignancy.

7. When the average diameter of the nuclei of tumor cells >8 or determination of nucleoli at magnification ×100, p is and karyometry minimum number of nuclei of cells clear of kidney cancer, equal to 40 determine IV histological grade of malignancy.

8. Perform immunohistochemistry, which determine the levels of expression of antigens Ki-67 and p53.

When the level of expression of the antigen Ki-67≤3% assign 1 point, 3,1-10% - 2 points, >10% - 3 points.

When the level of expression of the oncogene p53≤12% assign 1 point, 12,1-35% - 2 points, >35% - 3 points.

9. I hope morphological and biomolecular indicator (YIBE) by the formula:

TheIBE=1,83X1+1,H2+1,18X3,

where X1histological grade of malignancy of the tumor (1 to 4); X2the level of expression of Ki-67 (in points 1, 2 or 3); X3the level of p53 expression (in points 1, 2 or 3).

10. When the value of YIBE≤6,29 predict cancer 7-year survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor in 100% of cases.

When the value of YIBE=6,82-8,92 predict cancer 3-, 5 - and 7-year survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor in 96,5%, 75% and 71.2% of cases, respectively.

When the value of YIBE=9,19-11,55 predict cancer 3-, 5 - and 7-year survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or through the functions of the kidney with the tumor in 81.8%, and 54,5% and 42.4% of cases, respectively.

When the value of YIBE>11,55 predict cancer 3-, 5 - and 7-year survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor in 20%, 10% and 10% of cases, respectively.

11. When the value of YIBE≤6,29 forecast cancer survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor regarded as favorable.

When the value of YIBE=6,82-8,92 forecast regarded as relatively favorable.

When the value of YIBE=9,19-11,55 forecast regarded as relatively unfavorable.

When the value of YIBE>11,55 forecast regarded as unfavorable.

A causal relationship between significant distinctive features and achieve the effect:

A significant direct significant correlation between the average diameter of the nuclei of tumor cells and the presence or absence of nucleoli in the nuclei of tumor cells at different magnifications of the microscope (r=0,88; p<0,0001). We used different zoom microscope: when magnification ×100 was clearly visualized nuclei only in tumors IV histological grade, tumor III histological degree is Yeni malignancy clear visualization of the nucleoli in the nuclei of tumor cells was observed only under magnification ×125, while increasing ×100 more than half of the nucleoli was not determined.

To obtain reliable results possible karyometry minimum number of cores: 10 nuclei of cells clear of kidney cancer when I histological grade, 20 - by II, 30 - III-and 40 - when IV histological grade.

When the average diameter of the nuclei of tumor cells ≤6 μm or absence of nucleoli in the nuclei of tumor cells, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 10, I define the degree of malignancy, when the average diameter of the cores is equal to 6.1 to 7 μm, or the definition of nucleoli at magnification ×400, if karyometry minimum number of nuclei of cells clear of kidney cancer, equal to 20 - second degree if the value of the average diameter of the cores, equal to 7.1-8 microns, or determination of the nucleoli at magnification ×125, if karyometry minimum number of cores the clear cells of kidney cancer, 30 - III degree, and when the average diameter of the cores >8 μm or determination of nucleoli at magnification ×100, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 40, determine the IV degree of malignancy (Histological grade of malignancy of kidney cancer: cario and stereometric analysis // Arch. Pat. - 2009. - up. - S-18).

Based on multivariate Cox regression analysis of survival of patients with non-metastatic clear cancer kidney identified the following independent prognostic factors (in descending order of significance of the topic): histological grade of malignancy (p<is 0.0002), the level of expression of Ki-67 (p<0.007), and the level of p53 expression (p<0,05), which are shown in table 10. Such clinical-anatomical predictors such as sex, age, body mass index, pTN0M0-stage, maximum tumor size, presence/absence of infection in the last okolopochechnuyu fibre and/or renal vein, had no prognostic significance in evaluating adjusted patient survival (p>0,05).

Based on the results of multivariable analysis of Coke (table 10) was obtained by the formula above, which includes factors that have prognostic value for non-metastatic renal clear cell carcinoma.

In accordance with the equation were calculated morphological and biomolecular indicators (YIBEfor each of the 100 cases of non-metastatic clear kidney cancer. The average value of YIBEfor all neoplasms was 8,15±0,28 (M±m; with limits of fluctuations from 4,46 to 15,21); median - 7,74. A moderate direct linear correlation between the InIBEand pTN0M0-hundred what their disease (r=0,34, p=0.001), maximum tumor size (r=0,3, p=0.002), invasion of cancer in perirenal tissue (r=0.31, p=0.004) and renal vein (r=0,34, p=0,0006)and tumor invasion into the capsule of the kidney (r=0,3, p=0.003).

The strength and significance of Association between the analyzed traits were assessed using correlation and regression analysis. For survival analysis (by the method of Kaplan-Meier) were used regression model Cox proportional (SOH D.R., 1972) (Borovikov Century Statistica. The art of data analysis on the computer: for professionals. - 2nd ed. - SPb.: Peter, 2003. - 688 S.).

The survival function (according to the method of Kaplan-Meier) was estimated by the formula:

S(t)=P[(n-j)/(n-j+1)δ(j)],

where S(t) is the estimation of the survival function, n is the total number of events (sample size), j - sequence (chronologically) number of individual events, δ(j)=1 if the event indicates a failure (death), δ(j)=0 if the event refers to the loss of follow-up (censoring indicator), P is the product of all observations j ended to the moment t.

For survival analysis we used a regression model Cox proportional in the form:

h(t)=h0(t)y(z1,...,zm),

where h(t) is a function of the intensity (risk), h0(t) is a basic function of intensity, z - variables (covariates).

The significance of differences between survival curves was confirmed using Cree is a series of Gehenna and the log-rank test using the software package Statistica for Microsoft Windows, version 6.0, StatSoft Inc., USA.

To determine the accuracy of the prediction model used a modified coefficient concordancia:

,

where n is the sample size, k is the maximum characteristic value, m is the minimum possible value of the attribute.

Univariate Cox regression analysis showed a significant influence on the survival of patients with non-metastatic clear of cancer of the kidney such factor as morphological and biomolecular indicator (YIBE) (x2=40,8, β=0,439 to be+0.07, t=6,34, p<0,000001).

Depending on the values of YIBEon the basis of the log-rank test and the criterion of Gehenna identified four groups of patients were significant differences in survival rates (table; Appendix 5) which, in turn, became the basis (according to the results of multivariate Cox regression analysis) to create a combined biomolekulare-morphometric model for the calculation of survival rates of patients with non-metastatic clear of cancer of the kidney.

Index (coefficient) concordancia (CI) of the proposed biomolekulare-morphometric model for the assessment of prognosis in patients with non-metastatic clear of cancer of the kidney in the comparative analysis of the three-year cancer survival rates with the control group ("internal validation") of 30 Bo is inih (after nephrectomy about non-metastatic clear kidney cancer, performed for the period from 28.11.2003, 28.11.2005,) was 0.84 (p<0,05), which is closer to the high level of predictive accuracy (F.E. Harrell, Jr., Califf R., Pryor D.B. et al. Evaluating the yield of medical tests // JAMA. - 1982. - Vol.247. - P.2543-2546).

The distinctive set of essential features is new and has allowed the development levels of different measures of forecasting 3-, 5 - and 7-year cancer survival rates of patients with non-metastatic clear of cancer of the kidneys, which will increase the accuracy of the prediction.

In the present method are not used constantly moving TNM classification for kidney cancer, which, undoubtedly, will also improve the accuracy of the prediction.

Examples of specific implementation method.

Example 1: a Histological study No. 20461. Patient P., aged 63.

On post-mortem examination after nephrectomy delivered to the right kidney (education) with a clinical diagnosis of tumor of the upper pole of the right kidney. Microreport: kidney education (3×3×2.5 cm) in the top pole and perinephral fatty tissue overall dimensions 12×6×5.5 to see

Conclusion pathological studies.

Renal-cell cancer of the upper pole of the right kidney, clear option; without invasion into the capsule of the kidney and metastases in five lymph nodes; stage pT1aN0.

Using an eyepiece micrometer was determined that the average diameter of the cores CL is current tumor was 6 μm; nucleoli are not defined. These figures correspond to I histological grade of the tumor.

Immunohistochemical study of the index of the expression of Ki-67 was 2%, and the mutant-type gene oncosuppressor p53 - 10%, which corresponds to the points 1 and 1 respectively.

Framed data obtained in the equation for calculating morphological and biomolecular indicator (YIBE):

TheIBE=1,83×1+1,45×1+1,18×1=4,46

Thus, the patient has a favourable forecast for your cancer: 7-year survival of patients with such morphological and biomolecular indicator is 100% (in the absence of distant metastases at the time of verification of the diagnosis).

Example 2: Histological study No. 523222. A patient, 54 years of age.

On post-mortem examination after nephrectomy delivered to the right kidney (education) with a clinical diagnosis of tumor of the middle third of the left kidney. Microreport: kidney perinephral fatty tissue and lymph nodes (6 pieces, separately). In the middle third of the kidney, closer to the lateral edge, there is education (6,5×6×5.5 cm), germinating capsule body and growing into perirenal tissue.

Conclusion pathological studies.

Renal-cell cancer of the upper pole of the right kidney, clear option, BP is increased in perirenal adipose tissue; lymph nodes (6 PCs) without metastases; stage pT3aN0.

Using an eyepiece micrometer was determined that the average diameter of the nuclei of the tumor cells was 9.8 μm; large basophilic nucleoli are defined at magnification ×100. These figures correspond IV histological grade of the tumor.

Immunohistochemical study of the index of the expression of Ki-67 was 20%, and the mutant-type gene oncosuppressor p53 - 30%, which corresponds to points 3 and 2, respectively.

Framed data obtained in the equation for calculating morphological and biomolecular indicator (YIBE):

TheIBE=1,83×4+1,45×3+1,18×2=14,03

Thus, the patient has a poor prognosis for your cancer: three-year survival of patients with such morphological and biomolecular indicator is 20%, and five - and seven-year - 10%).

Was investigated 100 cases clear option non-metastatic renal cell cancer stages RTA-T3bN0M0 (pTNM system, 2002), 20 cases, each of these anatomical distribution of lesions after nephrectomy performed in an Urban multi-profile hospital No. 2 for the period from February 4, 1999 and November 28, 2003

Thus, first developed levels of differences in performance prediction 3-, 5 - and 7-year-old cancer survive the minute patients with non-metastatic clear of cancer of the kidneys, which will increase the accuracy of the prediction.

In the present method are not used constantly moving TNM classification for kidney cancer, which, undoubtedly, will also improve the accuracy of the prediction.

The coefficient of concordancia the proposed method was 0.84 (p<0,05), which is closer to the high level of predictive accuracy. The coefficient of concordancia (CI) for the way Frank I. et al. (method-prototype) is 0.83.

Table 1
Prediction of relapse-free survival in patients with non-metastatic clear of cancer of the kidney (Leibovich, B. and et al., 2003)
VariablesPoints
T-stageRTA0
pT1b2
RT3
RTA4
pT3b4
RTS4
RT4
N-stage pNx0
pN00
pN12
pN22
Tumor size (cm)<100
>101
Histological grade of malignancy10
20
31
43
NecrosisNo0
Availability1

Table 2
Assessment of forecast 10-year relapse-free survival of patients with non-metastatic clear of cancer of the kidney (Leibovich, B. and et al., 2003)
Points0-12 34567≥8
Survival (%) 96,188,578,663,2of 54.829,824,710,2

Table 3
The scale of the assessment (General status) patients (ECOG PS)
0Active lifestyle, able to lead the same lifestyle as before the disease
1Unable to perform work requiring great physical effort, but may engage in light work or sedentary work. Does not require a permanent stay in the hospital
2Able to maintain himself, but cannot work. Sitting in a chair or lying in bed less than 50% of waking hours. Does not require a permanent stay in the hospital
3Unable rinse is be yourself. Lying in bed/sitting in the chair more than 50% of waking hours
4Full disability. The complete inability to care for themselves. Bedridden
5Death

Table 4
Risk assessment in patients with non-metastatic cancer of the kidney (UCLA Integrated Staging System)
T-stage1234
Grade1-23-41>1
Somatic status ECOG0≥10≥10≥10
RiskLowIntermediateHigh

Table 5
Risk assessment in patients with metastatic kidney cancer (UCLA Integrated Staging System)
TNMN1M0N2M0/M1
Grade1234
Somatic status ECOG0≥10≥10≥10≥1
RiskLowIntermediateLowIntermediate High

Table 6
The predicted 5-year survival of patients with non-metastatic cancer of the kidney (UCLA Integrated Staging System)
RiskOverall survivalCancer survival rateRelapse-free survival rate
Low83,8%for 91.1%91,4%
Intermediate71,9%80,4%64%
High44%54,7%37,3%

Table 7
The predicted 2-year survival of patients with metastatic kidney cancer (UCLA Integrated Staging System)
RiskOverall survivalCancer survival rate
Low63% 65%
Intermediate40,5%40,9%
High10,1%10,5%

Table 8
Predicting cancer survival in patients with clear cancer of the kidney (Frank I. et al., 2002)
VariablesPoints
T-stageRTA0
pT1b0
RT1
RTA2
pT3b2
RTS2
RT0
N-stagepNx0
pN00
pN1 2
pN22
M-stagepM00
pM14
Tumor size (cm)<50
≥52
Histological grade of malignancy10
20
31
43
Necrosis(-)0
(+)2

Table 9
Assessment of forecast 10-year cancer survival rates of patients with clear cancer of the kidney (Frank I. et al., 2002)
Points0-123 456789≥10
Survival (%) to 97.185,377,966,25038,828,1a 12.714,84,6

Table 10
The influence of morphological and biomolecular factors on survival of patients with non-metastatic clear of cancer of the kidney (results of multivariate regression analysis)
FactorsβStandard errortp
Histological grade of malignancy1,82510,48223,78470,000154
The level of expression of Ki-67 1,45260,53742,70320,006872
The level of p53 expression1,18120,45972,56920,010197
Note.
For all models: χ2=77,28; df=16; p<0,000001

Table 11
The dependence of the survival rate of patients with non-metastatic clear of cancer of the kidneys from the values of morphological and biomolecular indicators
GroupIndicator (YIBE)The proportion surviving (%)p levels between groups
The follow-up period (years)I-III-IIII-IVII-IIIII-IVIII-IV
35 7
I≤6,29100100100*************
II6,82-8,9296,57571,2
III9,19-11,5581,854,542,4
IV>11,55201010
Notes.
1. Stars - the significance of differences: * p<0,05, ** - p<0,01, *** p<0,0001.
2.I - the prognosis is favorable, II - the prognosis is favorable, III - the forecast is unfavorable, IV - the prognosis is poor.

A method for predicting cancer survival of patients with non-metastatic clear cancer SMOS is to after nephrectomy or resection of the kidney with the tumor, consisting in the pathological examination of the surgical material after nephrectomy or resection of the kidney with the tumor, characterized in that it further performed immunohistochemistry to determine the expression level of the antigen Ki-67, and the level of expression of mutant-type p53 oncogene, and if pathological examination of the surgical material determine the average diameter of the nuclei of tumor cells or the presence or absence of nucleoli in the nuclei of tumor cells, and the presence or absence of nucleoli in the nuclei of tumor cells is determined at different magnifications of the microscope, and karyometry provide for a minimum number of core cells clear of kidney cancer, so when the average diameter of the nuclei of tumor cells ≤6 μm or absence of nucleoli in the nuclei of tumor cells, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 10, I define the histological grade of malignancy, when the average diameter of the cores is equal to 6.1 to 7 μm, or the definition of nucleoli at magnification ×400, if karyometry minimum number of nuclei of cells clear of kidney cancer, equal to 20 - second degree if the value of the average diameter of the cores, equal to 7.1-8 microns, or determination of the nucleoli at magnification ×125, if karyometry the minimum number of nuclei of cells clear of kidney cancer, 30 - III degree, and when the average diameter of the cores >8 μm or determination of nucleoli at magnification ×100, when karyometry minimum number of nuclei of cells clear of kidney cancer, is equal to 40, determine the IV degree of histological malignancy; the level of expression of Ki-67≤3% assign 1 point, 3,1-10% - 2 points, >10% - 3 points; the level of expression of p53≤12% assign 1 point, 12,1-35% - 2 points, >35% - 3 points, the prediction of cancer survivability is performed using the formula:
theIBE=1,H1+1,H2+1,18X3,
whereIBE- morphological and biomolecular index; X1histological grade of malignancy of the tumor; X2the level of expression of Ki-67 points; X3the level of p53 expression in points, and histological grade of malignancy of the tumor determine the value of the average diameter of the nuclei of tumor cells or the presence or absence of nucleoli in the nuclei of tumor cells; and when the value of yIBE≤6,29 predict cancer 7-year survival in patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor in 100% of cases, when the value of yIBE6,82-8,92 predict cancer 3-, 5 - and 7-year survival in these patients in 96,5%, 75% and 71.2% of cases, respectively, when the value of yIBE9,19-1155 predict cancer 3-, 5 - and 7-year survival in these patients in 81.8%, and 54.5 per cent and 42.4% of cases, respectively, when the value of yIBE>11,55 predict cancer 3-, 5 - and 7-year survival in these patients is 20%, 10% and 10% of cases, respectively; when the value of yIBE≤6,29 forecast cancer survival of patients with non-metastatic clear of cancer of the kidney after nephrectomy or resection of the kidney with the tumor regarded as favorable, if the value ofIBE=6,82-8,92 as relatively favorable, when the value of yIBE=9,19-11,55 - as a relatively unfavorable, when the value of yIBE>11,55 as unfavorable.



 

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