Plasma and Urine Free Glycosaminoglycans as Monitoring Biomarkers in Nonmetastatic Renal Cell Carcinoma-A Prospective Cohort Study

Abstract

Background: No liquid biomarkers are approved in renal cell carcinoma (RCC), making early detection of recurrence in surgically treated nonmetastatic (M0) patients dependent on radiological imaging. Urine- and plasma free glycosaminoglycan profiles-or free GAGomes-are promising biomarkers reflective of RCC metabolism.

Objective: To explore whether free GAGomes could detect M0 RCC recurrence noninvasively.

Design setting and participants: Between June 2016 and February 2021, we enrolled a prospective consecutive series of patients elected for (1) partial or radical nephrectomy for clinical M0 RCC (cohort 1) or (2) first-line therapy following RCC metachronous metastatic recurrence (cohort 2) at Sahlgrenska University Hospital, Gothenburg, Sweden. The study population included M0 RCC patients with recurrent disease (RD) versus no evidence of disease (NED) in at least one follow-up visit. Plasma and urine free GAGomes-consisting of 40 chondroitin sulfate (CS), heparan sulfate, and hyaluronic acid (HA) features-were measured in a blinded central laboratory preoperatively and at each postoperative follow-up visit until recurrence or end of follow-up in cohort 1, or before treatment start in cohort 2.

Outcome measurements and statistical analysis: We used Bayesian logistic regression to correlate GAGome features with RD versus NED and with various histopathological variables. We developed three recurrence scores (plasma, urine, and combined) proportional to the predicted probability of RD. We internally validated the area under the curve (AUC) using bootstrap resampling. We performed a decision curve analysis to select a cutoff and report the corresponding net benefit, sensitivity, and specificity of each score. We used univariable analyses to correlate each preoperative score with recurrence-free survival (RFS).

Results and limitations: Of 127 enrolled patients in total, 62 M0 RCC patients were in the study population (median age: 63 year, 35% female, and 82% clear cell). The median follow-up time was 3 months, totaling 72 postoperative visits -17 RD and 55 NED cases. RD was compatible with alterations in 14 (52%) of the detectable GAGome features, mostly free CS. Eleven (79%) of these correlated with at least one histopathological variable. We developed a plasma, a urine, and a combined free CS RCC recurrence score to diagnose RD versus NED with AUCs 0.91, 0.93, and 0.94, respectively. At a cutoff equivalent to ≥30% predicted probability of RD, the sensitivity and specificity were, respectively, 69% and 84% in plasma, 81% and 80% in urine, and 80% and 82% when combined, and the net benefit was equivalent to finding an extra ten, 13, and 12 cases of RD per hundred patients without any unnecessary imaging for plasma, urine, and combined, respectively. The combined score was prognostic of RFS in univariable analysis (hazard ratio = 1.90, p = 0.02). Limitations include a lack of external validation.

Conclusions: Free CS scores detected postsurgical recurrence noninvasively in M0 RCC with substantial net benefit. External validity is required before wider clinical implementation.

Patient summary: In this study, we examined a new noninvasive blood and urine test to detect whether renal cell carcinoma recurred after surgery.

Keywords: Glycosaminoglycans; Liquid biopsy; Renal cell carcinoma; Tumor biomarkers.

© 2022 The Author(s).

Figures

Fig. 1

Study design: (A) patient flow and (B) workflow used to select free GAGome features correlated with recurrence and to develop GAGome-based recurrence scores. GAG = glycosaminoglycan; GAGome = glycosaminoglycan profile; NED = no evidence of disease; RCC = renal cell carcinoma; RD = recurrent disease; UHPLC-MS/MS = ultra-high-performance liquid chromatography and triple-quadrupole mass spectrometry.

Fig. 2

(A) Correlation of detectable plasma and urine free GAGome features in 72 postoperative visits with RD (N = 17) versus NED (N = 55) from 62 patients in the study population. The posterior probability density of the log-odds ratio for RD per unit of change of the free GAGome feature (in standard deviations from the mean value) is plotted together with the mean log-odds ratio and the 95% credible interval (CI; thick black line). The region of practical equivalence (ROPE) is marked by the two vertical dashed lines. A free GAGome feature is deemed compatible with RD or NED if its 95% CI does not fall inside the ROPE by >5%. (B) Correlation between plasma and urine free GAGome features compatible with RD and histopathological variables from 67 patients in the total population with preoperative samples in terms of log-odds ratio and 95% CI (horizontal line). CS = chondroitin sulfate; GAGome = glycosaminoglycan profile; HS = heparan sulfate; NED = no evidence of disease; RD = recurrent disease; TNM = tumor, node, metastasis.

Fig. 3

Plasma, urine, and combined free CS RCC recurrence scores in the study population (M0 RCC at postoperative visits) and their corresponding receiver operating characteristic curves (N = 62 patients across 72 visits: 16 RD vs 55 NED in 61 patients for plasma, 16 RD vs 51 NED for urine in 58 patients for urine, and 15 RD vs 51 NED in 57 patients for combined). CS = chondroitin sulfate; NED = no evidence of disease; RCC = renal cell carcinoma; RD = recurrent disease.