The prognostic value of p53 has been shown in many organs but there is still controversy regarding its value in Renal Cell Carcinoma (RCC). This study was aimed to investigate the prognostic and clinicopathological significance of p53 protein expression in RCC and its histological subtypes.

1. Clinics of Oncology
Research Article ISSN: 2640-1037 Volume 4
Celik B*
Department of Pathology, Antalya Hospital, Health Science University, Turkey
Correlation of p53 Expression with the Clinicopathological Parameters and Prognosis of
Renal Cell Carcinoma. A Revival of an Old-Topic
*
Corresponding author:
Betul Celik,
Department of Pathology, Antalya Hospital,
Health Science University, SBU Antalya Egitim
Arastirma hastanesi, patoloji Bölümü 07000
Antalya/Turkey, E-mail: bet_celik@yahoo.com
Received: 26 Mar 2021
Accepted: 07 Apr 2021
Published: 12 Apr 2021
Copyright:
©2021 Celik B, et al. This is an open access article distrib-
uted under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and
build upon your work non-commercially.
Citation:
Celik B, Correlation of p53 Expression with the Clinico-
pathological Parameters and Prognosis of Renal Cell Car-
cinoma. A Revival of an Old-Topic. Clin Onco. 2021; 4(4):
1-5
Keywords:
Renal cell carcinoma; Clear cell; Prognosis; p53;
Expression
clinicsofoncology.com 1
1. Abstract
1.1. Background: The prognostic value of p53 has been shown
in many organs but there is still controversy regarding its value in
Renal Cell Carcinoma (RCC). This study was aimed to investigate
the prognostic and clinicopathological significance of p53 protein
expression in RCC and its histological subtypes.
1.2. Materials and Methods: Tissues obtained from patients who
undergone nephrectomy for RCC was included for the study at
a single academic center. Anti-p53 antibody was applied to the
tumor area immunohistochemically. The relationships of this an-
tibody with prognostic factors and survival rates were evaluated
with statistical analyses.
1.3. Results: The overall p53 expression was observed in 16.36%
of cases. This rate was 19.5% for clear cell RCC. Chromophobe
and papillary RCC cases were not hosted p53 expression. Our re-
sults showed that p53 positive expression was associated with low
Fhurman (G1+G2) and high Fhurman (G3+G4) nuclear grades
(p=0.031) but not the patient age (p=0.623), sex (p=0.131), tumor
size (p=0.943), capsular invasion (p=0.720), sarcomatoid histolo-
gy (p=0.321), Fhurman nuclear grades (p=0.220), Stage (p=0.135),
and survival (p=0.1495) statistically. Albeit not statistically signif-
icant there was a tendency for p53 expression (p=0.060) in the
clear cell type RCC and patients who died.
1.4. Conclusions: The p53 expression is correlated with higher
grade tumors. Its expression is proportionally common in clear cell
RCC than papillary or chromophobe RCC. Its presence can be ad-
junct to grading RCC.
2. Introduction
A few decades have been passed since the discovery of the protein
p53. It had been first detected by virtue of its association with the
SV40 large T cell antigen [1]. It has a protective effect that results
in sustained proliferation, ie: acts as tumor suppressor protein and
is the guardian of the genome. Since its discovery, thousands of
articles have been published in nearly all disciplines [2, 3].
Non-mutated, wild-type p53 has a relatively short half-life. It is
under the control of Murine Double Minute 2 (MDM2) [4]. While
N-terminal domain of MDM2 binds to p53, promotes its transloca-
tion from the nucleus to the cytoplasm which leads to suppression
of its activity, C-terminal domain targets proteasomal-mediated
degradation of p53. Targeting the p53-MDM2 pathway and mu-
tant p53 is the major goal in cancer treatment nowadays [5, 6].
Investigation of p53 in Renal Cell Carcinoma (RCC) dates back to
the early 1990s. Earlier studies reported a very low level of p53 in
RCC [7, 8, 9]. Recent studies, on the other hand, reveal different
results [10, 11].
There are several clinicopathologic parameters which are use-
ful in the evaluation of the prognosis of RCC. Besides cell type,
nuclear grade, capsular invasion, stage, and tumor size, there are
molecular biomarkers yet to be implemented in clinical practice
such as Von Hippel Lindau (VHL), Vascular Endothelial Growth
Factor (VEGF) and Carbonic Anhydrase IX (CAIX) [12]. Here
in the present study, we aimed to examine p53 immunoreactivity

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Volume 4 Issue 4 -2021 Research Article
in tissues obtained from patients with a diagnosis of RCC and to
determine its relationship with the clinicopathological parameters
and its potential for patient’s outcome.
3. Materials and Methods
Fifty-five cases of renal cell carcinoma, obtained from the files
of Gazi University School of Medicine were examined retrospec-
tively. All patients were treated by complete nephrectomy. The
follow-up was available for 31 cases and ranged from 3 to 104
months. Tumor classification was made on the basis of guidelines
from the 2016 WHO classification of tumors of the urinary system
[13]. Histologic diagnosis, renal vein and renal sinus invasion or
extension to fat were retracted from the pathology reports as well
as re-evaluating the slides. Tumors with sarcomatoid features were
also noted separately. Fhurman system for nuclear grading and
Robson staging were employed [14]. For immunohistochemical
detection of p53 gene, the formalin-fixed, paraffin-embedded tis-
sues were taken on slides and de-waxed in xylene and rehydrated
in graded alcohol. Antigen retrieval procedure was done by heat-
ing the sections in citrate buffer (pH 6.0) in a microwave oven after
the endogenous peroxidase blocking. Anti-p53 monoclonal anti-
body (DO7, Dako) was applied, followed by a Streptavidin-Bio-
tin complex. DAB (3'3-diaminobenzidine tetrahydrochloride) was
used as the chromogen. P53 immunostaining status was scored as
positive if more than 10% of the nuclei of neoplastic cells were
positive and it was considered negative if less than 10% of the
nuclei were stained.
The relationship of p53 protein with clinicopathologic parameters
was analyzed using a chi­
square test. Univariate analysis was per-
formed with the Kaplan-Meier method and the log-rank test was
used to assess the difference between subgroups.
4. Results
There were 21 female (%38) and 34 male (%62) aged 37 to
79 years (Mean 59.98). The range of tumor size was 1.4 to 19
cm (Mean 7,28 cm) and capsular invasions was observed in 32
(58.2%) of cases and vein invasions were seen in none cases.
There were 20 (36.4%) Stage I, 17 (30.9%) Stage II, 16 (29.1%)
Stage II, and 2 (3.6%) Stage IV cases. All cases we lost belonged
to Stage III and patient loss was not related to metastatic disease.
Distribution of cases based on stage, grade, and the results of the
p53 staining in relation to clinicopathological parameters were
presented in Table-1. Positive p53 staining was observed in 9
(19.5%) of the 46 clear cell RCC (ccRCC) (Figure 1). Positive p53
staining was not observed in none of 4 chromophobe and 5 papil-
lary RCC. Each Fhurman nuclear grades had no statistical relation-
ship with p53 (p=0.220) but when we subgroup cases as low and
high grade, low (Fhurman G1+G2) and high (Fhurman G3+G4)
nuclear grades were found to be correlated statistically with p53
staining (p=0.031). Patient age (p=0.623), sex (p=0.131), tumor
size (p=0.943), capsular invasion (p=0.720), co-existed sarcoma-
toid histology (p=0.321), and Stage (p=0.135) were found not to
be correlated with p53 staining statistically. Albeit not statistically
significant, there was a tendency for frequent p53 expression in
clear cell vs non-clear cell RCC (p=0.060).
Figure 1: Diffuse p53 immunostaining in a Fhurman grade II tumor. Note the absence of p53 in the peritumoral kidney (right) and one obsolescence
glomerulus (bottom right) (Anti-p53x20).
Follow-up data for a minimum of 3 months and maximum of 104
months were available for 31 cases. The median time from opera-
tion to the end of study or to death was 44.0 months (mean:39.43).
One patient died of acute myocardial infarction and was excluded
from the survival analysis. Ten patients died of RCC at the end
of clinical follow-up and median survival time was 8.3 months
for these 10 patients (range 3 to 15). Although survival times be-
tween p53 positive and p53 negative groups were striking (31.88
vs 81.51 months respectively), the p53 gene expression was not
found to be a significant predictor of survival (p=0.1495) statis-
tically (Table 1). We also observed that p53 mutations were less
common among survivors [5 out of 21 (23.8%) vs 4 out of 10
(40%) patients respectively] but it was not significant statistically.

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Table 1: Patient and tumor characteristics in relation to the results of the p53 staining.
Clinicopathological characteristics n
p53
p
Positive (%) Negative (%)
Sex
0.131
Male 34 8 (23.5) 26 (76.5)
Female 21 1 (4.76) 20 (95.24)
Age ≤ 50 34 3 (8.8) 31 (91.2)
0.623
>50 16 5 (31.2) 11 (68.8)
Size ≤ 7 cm 32 6 (18.75) 26 (81.25)
0.943
> 7 cm 20 3 (15.0) 17 (85.0)
Histological Type*
0.06
clear 46 9 (19.5) 37 (80.5)
Non-clear 9 -- 6 (100)
Sarcomatoid areas
0.321
present 7 2 (28,6) 5 (71.4)
absent 48 7 (14,6) 41 (85.4)
Grade
0.22
I 4 4 (100)
II 32 3 (9.4) 29 (90.6)
III 14 4 (28.6) 10 (71.4)
IV 5 2 (40) 3 (60)
Low grade (GI+GII) 36 3 (8.3) 33 (91.7)
0.031
High grade (GIII+GIV) 19 6 (31.6) 13 (68.4)
Stage
0.135
I 20 2 (10) 18 (90)
II 17 2 (13.3) 13 (86.7)
III 16 4 (25) 12 (75)
IV 2 1 (50) 1 (50)
*p=0.17 for overall cases.
5. Discussion
Mutation of p53 gene leads to tumor formation and acts as an ini-
tiating factor in carcinogenesis as well as having influences on the
prognosis of various malignant tumors. One well known tumor
pathway is colon carcinogenesis. Studies in the 1990s observed
a low level of p53 mutation in RCC [9, 15, 16]. In recent years,
contrary findings have been observed: Gene expression profiles
and mutation analyzes in RCC from Vinylidene chloride-exposed
mice indicate dysregulation of the p53 pathway [17]. An in vitro
study found that the regulatory role of the von Hippel-Lindau tu-
mor suppressor gene (VHL) in which the knockdown of VHL in-
creases chemo-resistance in the renal cancer cell lines (ACHN) is
dependent on the activation of p53 [18]. Renal cancer cells escape
death by p53 depletion and increasing p53 stability by transgluta-
minase 2 inhibition reduces tumor volume with the administration
of a DNA-damaging anti-cancer drug such as doxorubicin [19].
Another in-vitro study confirms that inhibition of mTOR-induced
apoptosis promotes RCC cell apoptosis through concurrent activa-
tion of p53 [20]. Indeed, more recent studies investigated the rela-
tion between treatment sensitivity and p53, and made p53 popular
research interest for RCC again [10, 21, 22].
In the present study each Fhurman nuclear grade is not correlat-
ed with P53 expression. However, when we sub-grouped cases as
low (Fhurman grade I+II) and high (Fhurman grade III+IV) grade,
a statistically significant difference in p53 staining was noted
(p<0.05). Kankaya et al grouped their cases as low and high grade
and found similar results [23]. In the study of Mombini et al., the
cases were not classified as low and high grade but the calculation
was made between these 2 grades because there was no grade 1
and grade 4 cases. They found statistically significant results be-
tween grade 2 and 3 in terms of p53 mutation [24]. Although the
Fuhrman nuclear grading is applied in pathology practice widely,
the utility of it has been questioned. When ccRRC was analysed,
significant differences in survival were demonstrated between
grade 1+2 and grade 3+4 [25]. As can be seen in our study modifi-
cation of Fhurman grade (two- or three- tiered) may be more reli-
able for evaluating the pathologic status and prognosis of ccRCC.
P53 mutation has been seen in conventional, papillary, and chro-
mophobe RCC subtypes and the rate for ccRCC has been similar
to our results: 20% [24]. Their study revealed higher p53 mutation
in papillary and chromophobe tumors compared to ccRCC. Albeit
not statistically significant, we observed opposite result: Frequent
p53 expression in clear cell vs non-clear cell RCC was observed in
our study (p=0.060). Other subtypes had no p53 expression in our
study. This is interesting because instead of the deletion of 3p, seen
in conventional RCC, there is a trisomy of chromosome 17, which
harbors the p53 gene in papillary RCC. This coincidence made us
hypothesized that p53 gene might be responsible in the develop-
ment of papillary RCC. The relationship between papillary and
chromophobe RCC and p53 is limited in the literature and there is
a need to investigate it further [26, 27].
Seven cases in our study had sarcomatoid histology and 2 of them
(28%) showed p53 staining. Oda et al reported that sarcomatoid
areas more frequently showed p53 gene mutations (%79) than

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carcinomatous areas (%14) in RCC [28]. High levels of p53 ex-
pression was also found in our study compared to carcinomatous
histology, but it was not correlated statistically (p>0.05). Same
as our result, Kanamaru et al reported that, in spite of a higher
proliferative index and larger mean nuclear area, no substantial
increase in p53 positivity in sarcomatoid components compared
to basic components was seen [29]. We also observed that patients
who died had more p53 mutations and patients who had p53 mu-
tations had a shorter average survival time compared to others.
The p53 positive cases had a mean survival time of 31.88 months,
while negative cases had a mean survival time of 81,51 months.
Almost same mean survival time (42 months) has been observed
in p53 positive cases in a study: Only one of p53 positive cases
was a survivor [30]. Another study found that p53 had an impact
on disease progression [11]. A meta-analysis also supports these
observations: A total of 2,013 patients from 22 studies showed
that p53 positivity is associated with poor overall survival (HR =
2.17, 95% confidence [CI]: 1.51-3.13) and cancer-specific survival
(HR = 1.59, 95% CI: 1.19-2.12), and was closely correlated with
Fuhrman grade (III/IV vs. I/II: OR = 1.80, 95% CI: 1.24-2.63), not
the sex or tumor size [22].
Our study had limitation. Many isoforms with a different function
in tumor progression are present in RCC [31].Although most com-
mercially available p53 antibody detects the majority of mutations
such as missense mutations, hotspot mutations, somatic mutations,
germ line mutations, the present study didn’t seek all of these p53
mutations. Also case number for papillary and chromophobe RCC
was limited to make a conclusion regarding p53 status. Another
limitation is staging we applied. Our cases were consisted of ar-
chived materials in which American Joint Committee on Cancer
(AJCC) Tumor Node Metastasis (TNM) system was not incorpo-
rated. Even so, the T and N status in the TNM system were eval-
uated separately in our study and revealed no significant result.
Besides, The European Organization for Research and Treatment
of Cancer investigated N status in a randomized phase III trial and
found cancer in about 4% of resected nodes, and no difference in
morbidity or long term outcomes with lymph node resection [32].
In conclusion, p53 expression is correlated with higher grade tu-
mors (Fhurman grade I+II vs III+IV). Although there is no statis-
tical significance, its expression is more common in patients who
had ccRCC than those who had papillary or chromophobe RCC;
p53 mutation is less common in patients who survived, and pa-
tients who had p53 mutation had a shorter survival time. Presence
of p53 in RCC may indicate lower survival and can be used to
predict survival of patients.
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