Pregnancy and risk of renal cell cancer: a population-based study in Sweden

Kidney cancer in the Middle East and North Africa region: a 30-year analysis (1990-2019)

Kidney cancer, a type of urogenital cancer, imposes a high burden on patients. Despite this, no recent research has evaluated the burden of this type of cancer in the Middle East and North Africa (MENA) region. This study explored the burden of kidney cancer from 1990 to 2019 according to age, sex and socio-demographic index (SDI). The Global Burden of Disease (GBD) 2019 data was utilized to estimate the incidence, death, and disability-adjusted life-years (DALYs) caused by kidney cancer. These estimates were reported as counts and as age-standardised rates with 95% uncertainty intervals (UIs). The estimated age-standardised incidence, mortality, and DALY rates of kidney cancer in 2019 were 3.2 (2.8-3.6), 1.4 (1.2-1.6), and 37.2 (32.0-42.6) per 100,000, respectively. Over the period from 1990 to 2019, these rates have increased by 98.0%, 48.9%, and 37.7%, respectively. In 2019, the United Arab Emirates, Qatar, and Lebanon had the largest age-standardised incidence, mortality, and DALY rates. The smallest age-standardised incidence rates were seen in Yemen, Afghanistan, and the Syrian Arab Republic. Additionally, the smallest age-standardised mortality and DALY rates were observed in the Syrian Arab Republic, Yemen, and Morocco. The highest incidence rates were found among individuals aged 75-79 in both males and females. In 2019, the MENA/Global DALY ratio exceeded one for females aged 5-19 age and males aged 5-14, compared to 1990age groups in males. The burden of kidney cancer consistently rose with increasing SDI levels from 1990 to 2019. The increasing burden of kidney cancer highlights the urgent need for interventions aimed at improving early diagnosis and treatment in the region.

Is hysterectomy associated with kidney cancer risk? A meta-analysis of cohort studies

Introduction

Emerging evidence have suggested a potential relationship between hysterectomy and risk of kidney cancer with inconsistent results. We aimed to investigate the association of hysterectomy with kidney cancer risk based on a meta-analysis of all available cohort studies.

Methods

A comprehensive literature search was performed in the PubMed and Embase database, covering all the papers published by September 2022. The pooled relative risks (RRs) and 95% confidence intervals (CIs) were estimated using a DerSimonian and Laird random effects model.

Results

Overall, our meta-analysis included 10 cohorts from 9 studies with approximately 240 million participants. The pooled RR with its 95% CI showed a significantly positive association between hysterectomy and risk of kidney cancer (RR 1.30, 95% CI 1.19-1.41). No obvious heterogeneity was observed across the studies (P = 0.206 for heterogeneity; I2 = 25.9%).

Conclusion

Findings from this meta-analysis of cohort studies indicated that hysterectomy was positively associated with subsequent kidney cancer risk. Further large prospective studies with long-term follow-up are warranted to verify these findings.

Reproductive and hormonal factors and risk of renal cell carcinoma among women in the European Prospective Investigation into Cancer and Nutrition

BACKGROUND

Renal cell carcinoma (RCC) is twice as common among men compared with women, and hormonal factors have been suggested to partially explain this difference. There is currently little evidence on the roles of reproductive and hormonal risk factors in RCC aetiology.

MATERIALS & METHODS

We investigated associations of age at menarche and age at menopause, pregnancy-related factors, hysterectomy and ovariectomy and exogenous hormone use with RCC risk among 298,042 women in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

RESULTS

During 15 years of follow-up, 438 RCC cases were identified. Parous women had higher rates of RCC compared with nulliparous women (HR = 1.71, 95% CI 1.18, 2.46), and women who were older at age of first pregnancy had lower rates of RCC (30 years + vs. <20 years HR = 0.53, 95% CI 0.34, 0.82). Additionally, we identified a positive association for hysterectomy (HR = 1.43 95% CI 1.09, 1.86) and bilateral ovariectomy (HR = 1.67, 95% CI 1.13, 2.47), but not unilateral ovariectomy (HR = 0.99, 95% CI 0.61, 1.62) with RCC risk. No clear associations were found for age at menarche, age at menopause or exogenous hormone use.

CONCLUSION

Our results suggest that parity and reproductive organ surgeries may play a role in RCC aetiology.

Sex and Gender Differences in Kidney Cancer: Clinical and Experimental Evidence

Simple Summary

Kidney cancer is a frequent malignant tumor that accounts for approximately 5% of all cancer incidences. It affects both males and females, but males are twice as likely to develop kidney cancer than females. Evidence shows that this discrepancy takes root in individual differences, such as genetics or pathologies that affect the patient. It is then reflected in the clinical characteristics of the tumors, as males have larger and more aggressive tumors. Understanding the sex- and gender-based differences in kidney cancer is essential to be able to offer patients individualized medicine that would better cover their needs in terms of prevention, diagnosis and treatment.

Abstract

Sex and gender disparities have been reported for different types of non-reproductive cancers. Males are two times more likely to develop kidney cancer than females and have a higher death rate. These differences can be explained by looking at genetics and genomics, as well as other risk factors such as hypertension and obesity, lifestyle, and female sex hormones. Examination of the hormonal signaling pathways bring further insights into sex-related differences. Sex and gender-based disparities can be observed at the diagnostic, histological and treatment levels, leading to significant outcome difference. This review summarizes the current knowledge about sex and gender-related differences in the clinical presentation of patients with kidney cancer and the possible biological mechanisms that could explain these observations. Underlying sex-based differences may contribute to the development of sex-specific prognostic and diagnostic tools and the improvement of personalized therapies.

The impacts of parity on spirometric parameters: a systematic review

Introduction: The relationship between parity and health outcomes has been debated in the scientific literature in terms of 'selection-pressure'. However, no previous review has raised the impacts of parity on spirometric parameters. This Systematic Review aimed to review the impacts of parity on spirometric parameters.Areas covered: PubMed and Scopus were searched on October 1^st, 2020, using the combination of the following two medical subject headings: 'Parity' and 'Respiratory Function Tests'. Only original articles published in English/French were retained. Ten studies investigated the impacts of parity on spirometric parameters: six included healthy females, three involved unhealthy females [chronic obstructive pulmonary disease, defect in protease inhibitor, and some other conditions] and one included a mixed population of healthy/unhealthy females. The studies reported conflicting results: no impact, positive impact (multiparity is associated with larger forced-expiratory-volume in one second, forced- and slow- vital-capacity, and inspiratory-capacity), or negative impact (multiparous females has lower bronchial flows, higher static volumes, an accelerated lung-aging, a tendency to an obstructive-ventilatory-defect and/or to lung-hyperinflation, and increased protease inhibitor levels).Expert opinion: The ten studies presented some limitations that made data interpretation relatively difficult. Future research to identify the 'real' impact of parity on spirometric parameters are therefore encouraged.

A 27-Year-Old Primigravida with a Right Renal Cell Carcinoma Removed at 30 Weeks of Gestation by Robot-Assisted Retroperitoneoscopic Partial Nephrectomy

BACKGROUND Large renal tumors during pregnancy are rare findings (0.07-0.1%). Current guidelines recommend surgical removal. This surgery should be carefully planned in an interdisciplinary team and involves special risks for mother and fetus. This report describes a case of a 27-year-old primigravida woman with a right renal cell carcinoma involving the lower pole of the kidney, which was removed at 30 weeks of gestation by robot-assisted retroperitoneoscopic partial nephrectomy (RARPN). CASE REPORT The patient was referred by the treating obstetrician with a newly diagnosed right lower pole renal mass of 6×4 cm in greatest diameter extending deeply into the parenchyma. No metastasis or enlarged lymph nodes were described in subsequent magnetic resonance tomography. Clinical and laboratory examinations documented a healthy mother and fetus. A right-sided RARPN was advised and planned by an interdisciplinary team of treating physicians (gynecologists, oncologists, and urologists). The surgery was conducted under general anesthesia with an obstetrician on stand-by. Surgery was performed without any complications (operation time 95 min, renal-ischemia time 15 min, and negligible blood loss) and histopathology confirmed the diagnosis of a chromophobe renal cell carcinoma. Further follow-up consultations showed regular wound healing and normal progression of pregnancy, and the patient gave birth to a healthy child at term. Follow-up examinations of the patient were uneventful. CONCLUSIONS This case shows that RARPN can be a safe and effective surgical procedure for partial nephrectomy during pregnancy, where surgery is performed in a specialist center and by an interdisciplinary experienced surgical team. It seems to offer advantages and better risk profile over the laparoscopic approach.

Hysterectomy, Oophorectomy, and Risk of Renal Cell Carcinoma

BACKGROUND

Female hormones may play roles during renal cell carcinoma (RCC) carcinogenesis. The aims of this study were to investigate associations between hysterectomy, oophorectomy, and risk of RCC and to assess whether the associations were modified by exogenous estrogen, commonly used among women who have undergone hysterectomy.

METHODS

Postmenopausal women (n = 144,599) ages 50-79 years at enrollment (1993-1998) in the Women's Health Initiative were followed for a mean of 15.9 years. Hysterectomy and oophorectomy were self-reported. Incident RCC cases were confirmed by physician review of medical records and pathology reports. Multivariable Cox proportional hazards modeling was used to estimate hazard ratios (HR) and 95% confidence intervals (CI), adjusting for potential confounders.

RESULTS

A total of 583 women developed RCC during follow-up. We observed that hysterectomy, regardless of oophorectomy status, was significantly associated with an increased risk of RCC (HR, 1.28; 95% CI, 1.03-1.60). The association appeared to be more pronounced in women with age at hysterectomy younger than 40 years (HR, 1.34; 95% CI, 1.01-1.80) or older than 55 years (HR, 1.52; 95% CI, 1.01-2.29). Oophorectomy was not significantly associated with risk of RCC. There was no evidence that exogenous estrogen use modified the association between hysterectomy and risk of RCC.

CONCLUSIONS

In this large prospective study, we showed that women with a history of hysterectomy had 28% increased risk of RCC, and this finding was not modified by exogenous hormone use.

IMPACT

If our findings are confirmed, women should be made aware of increased risk of RCC when considering hysterectomy.

Renal Cell Carcinoma Metastases to the Oral Cavity: Report of 2 Cases and Review of Literature

The localization of renal cell carcinoma (RCC) metastases in the oral cavity has been reported, accounting for about 15% of patients with metastasizing renal disease. In this work, we report 2 cases of oral metastases of renal carcinoma and provide a review of the current literature on the occurrence of oral metastases of renal origin. The first patient (a 61-year-old man) presented with a tumefaction of the body of the tongue. The second patient (a 71-year-old man) showed a large mass localized in the buccal mucosa. In both patients, incisional biopsy was performed to better characterize the nature of the lesions. Histologic evaluation showed the metastatic origin of the 2 lesions, which were distant metastases of clear cell RCC. After systemic evaluation, a second surgical procedure was performed to obtain a wider resection of the mass to reduce the development of complications and improve the patients' quality-of-life. After the second surgical treatment, both patients showed an improvement in symptoms, and no further complications and/or signs of recurrence were detected. At present, 132 cases of oral metastases of RCC have been described in the literature. This article reviews and discusses the clinical, diagnostic, and pathologic features and the treatment options reported in the literature. Localization of renal metastases to the tongue was the most frequently described localization in the literature. In general, surgical treatment appears to be effective in controlling metastasis development and associated symptoms. Although relatively rare, renal metastases to the oral cavity should be taken into account when creating the differential diagnosis of oral lesions of unknown origin.

The Association of Multiparity with Lung Function and Chronic Obstructive Pulmonary Disease-Related Phenotypes

BACKGROUND

Apparent increased female susceptibility to chronic obstructive pulmonary disease (COPD) suggests sex hormones modulate disease pathogenesis. Little is known about associations between multiparity and lung function in smokers.

RESEARCH QUESTION

We hypothesized that multiparity is associated with lung function and measures of emphysema and airway disease.

STUDY DESIGN AND METHODS

Utilizing female participants from the 5-year follow up of the COPD Genetic Epidemiology (COPDGene^®) study we performed multivariable linear regressions to assess the effect of multiparity and number of pregnancies on forced expiratory volume in 1 second (FEV₁) percentage of predicted (% predicted), FEV₁/forced vital capacity (FVC), percent emphysema on computed tomography (CT) scans, and Pi10, a measure of airway thickening. We sampled never smokers and those with lower smoking exposure from the National Health and Nutrition Examination Survey (NHANES) 2011-2012 dataset.

RESULTS

We included 1820 participants from COPDGene^® and 418 participants from NHANES (321 never smokers, 97 ever smokers). In COPDGene^®, multiparity (beta coefficient [β] = -3.8, 95% confidence interval [CI]: [-6.5, -1.1], p = 0.005) and higher number of pregnancies were associated with lower FEV₁ % predicted. Multiparity was not associated with percent emphysema or Pi10. In individuals with no or mild obstruction, multiparity was associated with lower FEV₁ % predicted. There was an interaction with multiparity and age on FEV₁ % predicted (p = 0.025). In NHANES, there was no association between multiparity and FEV₁ % predicted in never smokers or the lower smoking exposure group.

INTERPRETATION

Multiparity was associated with lower FEV₁ % predicted in current and former smokers in COPDGene^® study participants. These preliminary results emphasize the importance of smoking abstinence in women of child-bearing age.

The impacts of parity on lung function data (LFD) of healthy females aged 40 years and more issued from an upper middle income country (Algeria): A comparative study

BACKGROUND

Studies evaluating the impacts of parity on LFD of healthy females presented controversial conclusions.

AIM

To compare the LFD of healthy females broken down according to their parities.

METHODS

A medical questionnaire was administered and anthropometric data were determined. Two groups [G1 (n = 34): ≤ 6; G2 (n = 32): > 6] and three classes [C1 (n = 15): 1-4; C2 (n = 28): 5-8; C3 (n = 23): 9-14] of parities were identified. LFD (plethysmography, specific airway resistance (sRaw)] were determined. Student's t-test and ANOVA test with post-Hoc test were used to compare the two groups' and the three classes' data.

RESULTS

G1 and G2 were age and height matched; however, compared to G1, G2 had a lower body mass index (BMI). C1, C2 and C3 were height, weight and BMI matched; however, compared to C2, C3 was older. G1 and G2 had similar values of FEV1, forced- and slow- vital capacities (FVC, SVC), maximal mid-expiratory flow (MMEF), forced expiratory flow at x% of FVC (FEFx%), peak expiratory flow (PEF), expiratory and inspiratory reserve volumes (ERV, IRV, respectively), inspiratory capacity (IC), sRaw, FEV1/FVC, FEV1/SVC, and residual volume/total lung capacity (RV/TLC). The three classes had similar values of MMEF, FEFx%, PEF, thoracic gas volume (TGV), ERV, IRV, FEV1/FVC, FEV1/SVC and RV/TLC. Compared to G1, G2 had higher TGV (2.68±0.43 vs. 3.00±0.47 L), RV (1.80±0.29 vs. 2.04±0.33 L) and TLC (4.77±0.62 vs. 5.11±0.67 L). Compared to C1, C2 had higher FEV1 (2.14±0.56 vs. 2.47±0.33 L), FVC (2.72±0.65 vs. 3.19±0.41 L), SVC (2.74±0.61 vs. 3.24±0.41 L), TLC (4.47±0.59 vs. 5.10±0.58 L), IC (1.92±0.41 vs. 2.34±0.39 L) and sRaw (4.70±1.32 vs. 5.75±1.18 kPa*s). Compared to C1, C3 had higher TLC (4.47±0.59 vs. 5.05±0.68 L) and RV (1.75±0.29 vs. 2.04±0.30 L).

CONCLUSION

Increasing parity induced a tendency towards lung-hyperinflation.

Laparoscopic Approach in Management of Renal Cell Carcinoma During Pregnancy: State of the Art

Renal cell carcinoma (RCC) is extremely rare in pregnant women. However, this is one of the most reported urologic tumors during pregnancy. The aim of this review was to evaluate RCC during pregnancy in terms of epidemiology, risk factors, diagnosis, natural history of disease, and the safety of laparoscopic approach in the management of this tumor. RCC presentation is frequently made incidentally during an ultrasonography performed for other reasons, such as hydronephrosis owing to non-neoplastic causes. The optimal time for surgery during pregnancy and the consequences of surgery on the maternal and fetal well-being are major considerations. Risks for adverse pregnancy outcomes should be explained, and the patient's decision about pregnancy termination should be considered. Ultrasound is good in diagnosing renal masses, with a sensitivity comparable to that of computed tomography only for exophytic masses larger than 3 cm. Magnetic resonance imaging is reproducible and a good, though expensive, alternative to computed tomography scans for the evaluation of renal lesions in pregnant women. Radical nephrectomy or nephron-sparing surgery are essential treatments for management of RCC. Laparoscopic surgery has historically been considered dangerous during pregnancy and avoided whenever possible, because of concerns regarding surgery-related risks, such as uterine injury, miscarriage, teratogenesis, preterm birth, and hypercapnia. The laparoscopic treatment during pregnancy is becoming increasingly accepted where feasible with low morbidity. However, the combination of a multidisciplinary approach, multi-specialty communication, and skilled surgeons can give the best possible outcomes for mother and fetus.

Epidemiology of Renal Cell Carcinoma

CONTEXT

Despite the improvement in renal cell carcinoma (RCC) diagnosis and management observed during the last 2 decades, RCC remains one of the most lethal urological malignancies. With the expansion of routine imaging for many disorders, an increasing number of patients who harbour RCC are identified incidentally.

OBJECTIVE

To summarise and compare RCC incidence and mortality rates, analyse the magnitude of risk factors, and interpret these epidemiological observations in the context of screening and disease management.

EVIDENCE ACQUISITION

The primary objective of the current review was to retrieve and describe worldwide RCC incidence/mortality rates. Secondly, a narrative literature review about the magnitude of the known risk factors was performed. Finally, data retrieved from the first two steps were elaborated to define the clinical implications for RCC screening.

EVIDENCE SYNTHESIS

RCC incidence and mortality significantly differ among individual countries and world regions. Potential RCC risk factors include behavioural and environmental factors, comorbidities, and analgesics. Smoking, obesity, hypertension, and chronic kidney disease represent established risk factors. Other factors have been associated with an increased RCC risk, although selection biases may be present and controversial results have been reported.

CONCLUSIONS

Incidence of RCC varies worldwide. Within the several RCC risk factors identified, smoking, obesity, and hypertension are most strongly associated with RCC. In individuals at a higher risk of RCC, the cost effectiveness of a screening programme needs to be assessed on a country-specific level due to geographic heterogeneity in incidence and mortality rates, costs, and management implications. Owing to the low rates of RCC, implementation of accurate biomarkers appears to be mandatory.

PATIENT SUMMARY

The probability of harbouring kidney cancer is higher in developed countries and among smokers, obese individuals, and individuals with hypertension.

Renal Cell Carcinoma in a Pregnant Woman With Horseshoe Kidney

To our knowledge, this is the first reported case of renal cell carcinoma in kidney horseshoe diagnosed in the second trimester of pregnancy. We performed open radical nephrectomy when the pregnancy was completed. Kidney cancer is rare during pregnancy and the symptoms can be mimic urinary infection. The diagnosis and its management can be a challenge.

Epidemiology of Renal Cell Carcinoma

The increasing incidence of RCC in most populations may in part be due to increasing numbers of incidentally detected cancers with new imaging methods. Further, the increase is not only limited to small local tumours but also includes more advanced tumours, which may to some part explain the still high mortality rates. The variation in incidence between populations may have several other explanations. Traditionally the starting point has included thoughts of environmental exposures, which so far have only in part explained the causes of RCC, by means of cigarette smoking and obesity, which may account for approximately 40% of cases in high-risk countries (Table 2). Further, the genetic variations may be of importance as a cause of the difference between populations. Continued research in RCC is needed with the knowledge that nearly 50% of patients die within 5 years after diagnosis. The further search for environmental exposures should take in account the knowledge that RCC consists of different types with specific genetic molecular characteristics. These genetic alterations have in some cases been suggested to be associated with specific exposures. Furthermore, there might exist a modulating effect of genetic polymorphisms among metabolic activation and detoxification enzymes. Hence, a further understanding of the genetic and molecular processes involved in RCC will hopefully give us a better knowledge how to analyse and interpret exposure associations that have importance for both initiation and progression of RCC.

Review on renal cell carcinoma and pregnancy: A challenging situation

Renal cell carcinoma is rarely diagnosed during pregnancy. Its management is a real challenge due to the sparse literature and lack of standard guidelines. In this situation, the diagnosis is often delayed as the clinical presentation might resemble other pregnancy-related disorders but it should be one of the diagnostic possibilities in women with recurrent or refractory urinary tract symptoms, renal pain, or mass that could be palpated. Diagnostic approach may include ultrasound examination and sometimes magnetic resonance imaging. If localized, surgery would be the preferred line of treatment. Other treatment modalities, end results of treatment, and review of literature of this rare association will be presented.

Incidence of cancer among grand multiparous women in Finland with special focus on non-gynaecological cancers: A population-based cohort study

BACKGROUND

Many studies have previously revealed evidence of an association between grand multiparity (five or more deliveries) and gynaecological cancer. Oestrogen has an impact on cancer formation and the amount of circulating oestrogen is significantly higher during pregnancy. Also the lifestyle of grand multiparous women differs somewhat from the average population. Considering these factors it is plausible that also non-gynaecological cancers are associated with multiparity. The aim of our study was to determine cancer incidence among grand multiparous women, with special attention to non-gynaecological cancers.

MATERIAL AND METHODS

All 102 541 women alive in 1974-2011 and having had at least five deliveries were identified in the Finnish Population Register and followed up for cancer incidence through the Finnish Cancer Registry to the end of 2011. Standardised incidence ratios (SIRs) were defined as ratios between observed and expected numbers of cases, the latter ones based on incidence in the entire Finnish female population.

RESULTS

The overall incidence of non-gynaecological cancers was the same as in the reference population (SIR 0.98, 95% confidence interval 0.90-1.06). The incidence of cancers of the gall-bladder (SIR 1.42, 1.26-1.58), biliary tract (1.19, 1.04-1.35) and kidney (1.22, 1.14-1.31) was increased. There were significantly fewer cases than expected of urinary bladder cancer (SIR 0.70, 0.61-0.78), lung cancer (0.87, 0.81-0.92), colon cancer (0.94, 0.89-0.99) and all types of skin cancers. As a consequence of the decreased incidence of gynaecological cancers (SIR 0.74, 0.71-0.77) and breast cancer (0.60, 0.58-0.61), the SIR for cancer overall was 0.84 (0.83-0.85).

CONCLUSION

The study demonstrated that grand multiparous women have a similar overall risk of non-gynaecological cancers as other women, despite significant differences in some specific forms of cancer.

Cancer risk in women with 10 or more deliveries

OBJECTIVE

To determine cancer incidence among Finnish women with 10 or more deliveries.

METHODS

Finnish women with at least 10 childbirths before December 31, 2010 (n=4,967) were identified from the Finnish Population Register and followed for cancer incidence through the Finnish Cancer Registry to the end of 2010. Cancer risks in this cohort were expressed as ratios between observed and expected numbers of cases (standardized incidence ratios), both drawn from the Finnish Cancer Registry, with 95% confidence intervals (CIs).

RESULTS

Total cancer incidence was markedly lower than in the reference population (656 cases, standardized incidence ratio 0.76, 95% CI 0.73-0.79). There was clearly less breast (0.44, 0.35-0.53), ovarian (0.49, 0.28-0.80), endometrial (0.31, 0.17-0.44), and basal cell skin cancer (0.72, 0.60-0.85) than in the reference population. The incidence of thyroid cancer (2.33, 1.59-3.29), lip cancer (2.87, 1.05-6.24), and uterine sarcoma (3.41, 1.47-6.72) was markedly increased.

CONCLUSION

Women with 10 or more deliveries show a decreased overall cancer incidence as a result of decreased risks of cancers of the ovary, endometrium, and breast and basal cell carcinoma of the skin. The increased risks were observed in thyroid cancer and some rare cancer types.

Parity and kidney cancer risk: evidence from epidemiologic studies

BACKGROUND

Observational studies have reported conflicting results between parity and kidney cancer risk. To our knowledge, a comprehensive and quantitative assessment of the association between parity and kidney cancer has not been reported. Thus, we conducted a systematic review and dose-response meta-analysis of published epidemiologic studies to summarize the evidence of this association.

METHODS

Relevant published studies of parity and kidney cancer were identified using MEDLINE (PubMed) database through end of June 2013. Two authors independently assessed eligibility and extracted data. Six prospective and eight case-control studies reported relative risk (RR) estimates and 95% confidence intervals (CI) of kidney cancer associated with parity or parity number. Fixed- or random-effects models were used to estimate summary relative risk.

RESULTS

The summary relative risk of kidney cancer for the parity versus nulliparous was 1.23 (95% CI, 1.10-1.36; Q = 12.41; P = 0.413; I(2) = 3.3%). In addition, significant association was also found for the highest versus lowest parity number, with summary RR = 1.36 (95% CI, 1.19-1.56; Q = 8.24; P = 0.766; I(2) = 0%). In the dose-response analysis, the summary per one live birth relative risk was 1.08 (95% CI: 1.05-1.10; Q = 9.34; P = 0.500; I(2) = 0%), also indicating the positive effect of parity on kidney cancer risk. No evidence of publication bias and significant heterogeneity between subgroups was detected by meta-regression analyses.

CONCLUSIONS

In summary, findings from this meta-analysis suggest that ever parity and higher parity number is significantly associated with increased risk of kidney cancer.

IMPACT

The present results suggest a positive association between parity and kidney cancer risk.

Reproductive factors and kidney cancer risk in 2 US cohort studies, 1993-2010

Clinical and experimental findings suggest that female hormonal and reproductive factors could influence kidney cancer development. To evaluate this association, we conducted analyses in 2 large prospective cohorts (the National Institutes of Health-AARP Diet and Health Study (NIH-AARP), 1995-2006, and the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO), 1993-2010). Cohort-specific and aggregated hazard ratios and 95% confidence intervals relating reproductive factors and kidney cancer risk were computed by Cox regression. The analysis included 792 incident kidney cancer cases among 283,952 postmenopausal women. Women who had undergone a hysterectomy were at a significantly elevated kidney cancer risk in both NIH-AARP (hazard ratio = 1.28, 95% confidence interval: 1.09, 1.50) and PLCO (hazard ratio = 1.41, 95% confidence interval: 1.06, 1.88). Similar results were observed for both cohorts after analyses were restricted to women who had undergone a hysterectomy with or without an oophorectomy. For the NIH-AARP cohort, an inverse association was observed with increasing age at menarche (P for trend = 0.02) and increasing years of oral contraceptive use (P for trend = 0.02). No clear evidence of an association with parity or other reproductive factors was found. Our results suggest that hysterectomy is associated with increased risk of kidney cancer. The observed associations with age at menarche and oral contraceptive use warrant further investigation.

Antiblastic treatment, for solid tumors, during pregnancy: a crucial decision

Cancer is the second leading cause of death during the reproductive years complicating between 0.02 percent and 0.1 percent of pregnancies. The incidence is expected to rise with the increase in age of childbearing. The most common types of pregnancy-associated cancers are: cervical cancer, breast cancer, malignant melanoma, Hodgkin's lymphoma, non-Hodgkin's lymphoma and ovarian cancer. The relatively rare occurrence of pregnancy-associated cancer precludes conducting large, prospective studies to examine diagnostic, management and outcome issues. The treatment of pregnancy-associated cancer is complex since it may be associated with adverse fatal effects. In pregnant patients diagnosed with cancer during the first trimester, treatment with multidrug anti-cancer chemotherapy is associated with an increased risk of congenital malformations, spontaneous abortions or fetal death, and therefore, should follow a strong recommendation for pregnancy termination. Second and third trimester exposure is not associated with teratogenic effect but increases the risk of intrauterine growth retardation and low birth weight. There are no sufficient data regarding the teratogenicity of most cytotoxic drugs. Almost all chemotherapeutic agents were found to be teratogenic in animals and for some drugs only experimental data exist. Moreover, no pharmacokinetic studies have been conducted in pregnant women receiving chemotherapy in order to understand whether pregnant women should be treated with different doses of chemotherapy. This article reviews the available data regarding the different aspects of the treatment of cancer during pregnancy.

[Renal masses in pregnancy. Diagnostics and therapeutic management]

Cancer is the second most common cause of death in women of childbearing age. However, renal cell carcinoma (RCC) is a rare tumor in this collective with an incidence far below 5/100,000 cases per year. Therefore, medical experience with respect to diagnostics and therapeutic management of newly diagnosed RCC in pregnant women is scarce and the number of published cases low. However, recent studies indicated that higher estrogen levels and multigravidity could be associated with a higher risk of RCC. The aim of this article is to summarize the clinical experience in treating pregnant women with renal cancer against the background of those cases published in the literature.

A case-control study of reproductive factors and renal cell carcinoma among black and white women in the United States

OBJECTIVE

Renal cell carcinoma (RCC) incidence is higher among blacks than whites in the United States and has been associated with the frequency and timing of childbirth among women in some epidemiologic studies. We investigated whether reproductive factors are associated with RCC, overall and by race, within a population-based case-control study.

METHODS

Between 2002 and 2007, 497 female cases of incident RCC (136 black, 361 white) and 546 female controls (273 black, 273 white) within the Detroit and Chicago metropolitan areas were enrolled. Information on reproductive history and other factors was collected through in-person interviews. Multivariate-adjusted odds ratios (OR) and 95% confidence intervals (CI) were computed using unconditional logistic regression.

RESULTS

Reduced RCC risk was observed among women aged ≥30 years at first live birth, relative to an age of <20 years (OR 0.5, 95% CI 0.3-0.9). This association was present among both white (OR 0.4, 95% CI 0.2-0.9) and, though not statistically significant, black women (OR 0.6, 95% CI 0.2-1.8). In analyses restricted to clear cell adenocarcinoma, the most common RCC histological subtype, the association was particularly strong (OR 0.3, 95% CI 0.2-0.8). We did not observe clear evidence of association with RCC for other reproductive factors.

CONCLUSIONS

Our findings further support an association between late maternal age at first birth and reduced RCC risk, and suggest that the association may be particularly strong for clear cell adenocarcinoma.

Renal cell cancer among African Americans: an epidemiologic review

Incidence rates for renal cell cancer, which accounts for 85% of kidney cancers, have been rising more rapidly among blacks than whites, almost entirely accounted for by an excess of localized disease. This excess dates back to the 1970s, despite less access among blacks to imaging procedures in the past. In contrast, mortality rates for this cancer have been virtually identical among blacks and whites since the early 1990s, despite the fact that nephrectomy rates, regardless of stage, are lower among blacks than among whites. These observations suggest that renal cell cancer may be a less aggressive tumor in blacks. We have reviewed the epidemiology of renal cell cancer, with emphasis on factors which may potentially play a role in the observed differences in incidence and mortality patterns of renal cell cancer among blacks and whites. To date, the factors most consistently, albeit modestly, associated with increased renal cell cancer risk in epidemiologic studies among whites--obesity, hypertension, cigarette smoking--likely account for less than half of these cancers, and there is virtually no epidemiologic evidence in the literature pertaining to their association with renal cell cancer among blacks. There is a long overdue need for detailed etiologic cohort and case-control studies of renal cell cancer among blacks, as they now represent the population at highest risk in the United States. In particular, investigation of the influence on renal cell cancer development of hypertension and chronic kidney disease, both of which occur substantially more frequently among blacks, is warranted, as well as investigations into the biology and natural history of this cancer among blacks.

Does male sex influence the prognosis of patients with renal cancer?

BACKGROUND

The aim of this study was to investigate the influence of sex on stage, grade, subtype, and prognosis of patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

This study included 1,810 patients treated by surgery for RCC at the University Hospitals of Hannover and Marburg between 1990 and 2005. The median follow-up was 54 months.

RESULTS

Of all the patients, 1,167 (64.5%) were men and 643 (35.5%) were women. Men were significantly younger (mean, 61.4 vs. 63.5 years; p < 0.001), and suffered more frequently from advanced tumor stages (45.2 vs. 37.6%; p = 0.002) and higher tumor grades (14.1 vs. 11.1%; p = 0.003). Kaplan Meier curves revealed a significant difference in cancer-specific survival between men and women (5-year survival 64.7 vs. 74.0%; p = 0.002). However, unlike tumor stage, grade, and N/M status, sex could not be retained as a significant independent prognostic marker in multivariate analysis.

CONCLUSIONS

RCC in men is characterized by higher tumor stages and more frequent metastasis at diagnosis along with inferior tumor-specific survival. However, as sex failed to qualify as an independent prognostic marker for cancer-specific survival, delayed diagnosis due to insufficient or neglected (routine) medical check-up and/or more aggressive tumor biology could be concurrently causative for the higher incidence of RCC in men.

Epidemiology and risk factors for kidney cancer

After more than two decades of rising rates, in recent years the total kidney cancer incidence worldwide has shown signs of stabilizing, or even decreasing. In adults, kidney cancer consists of renal cell carcinoma (RCC), the predominant form, and renal transitional cell carcinoma (RTCC); these types primarily arise in the renal parenchyma and renal pelvis, respectively. Although temporal trends by kidney cancer type are not well established worldwide, incidence of RCC in the US has continued to rise, mainly for early-stage tumors, while that of RTCC has declined, and total kidney cancer mortality rates have leveled. Stabilization of kidney cancer mortality rates has also been reported in Europe. These trends are consistent with reports of increasing incidental diagnoses and a downward shift in tumor stage and size in clinical series. The changing prevalence of known risk factors for RCC, including cigarette smoking, obesity, and hypertension, is also likely to affect incidence trends, although their relative impact may differ between populations. Accumulating evidence suggests an etiologic role in RCC for physical activity, alcohol consumption, occupational exposure to trichloroethylene, and high parity among women, but further research is needed into the potential causal effects of these factors. Genetic factors and their interaction with environmental exposures are believed to influence risk of developing RCC, but a limited number of studies using candidate-gene approaches have not produced conclusive results. Large consortium efforts employing genome-wide scanning technology are underway, which hold promise for novel discoveries in renal carcinogenesis.

Epidemiologic characteristics and risk factors for renal cell cancer

Incidence rates of renal cell cancer, which accounts for 85% of kidney cancers, have been rising in the United States and in most European countries for several decades. Family history is associated with a two- to four-fold increase in risk, but the major forms of inherited predisposition together account for less than 4% of renal cell cancers. Cigarette smoking, obesity, and hypertension are the most consistently established risk factors. Analgesics have not been convincingly linked with renal cell cancer risk. A reduced risk of renal cell cancer among statin users has been hypothesized but has not been adequately studied. A possible protective effect of fruit and vegetable consumption is the only moderately consistently reported dietary finding, and, with the exception of a positive association with parity, evidence for a role of hormonal or reproductive factors in the etiology of renal cell cancer in humans is limited. A recent hypothesis that moderate levels of alcohol consumption may be protective for renal cell cancer is not strongly supported by epidemiologic results, which are inconsistent with respect to the categories of alcohol consumption and the amount of alcohol intake reportedly associated with decreased risk. For occupational factors, the weight of the evidence does not provide consistent support for the hypotheses that renal cell cancer may be caused by asbestos, gasoline, or trichloroethylene exposure. The established determinants of renal cell cancer, cigarette smoking, obesity, and hypertension, account for less than half of these cancers. Novel epidemiologic approaches, including evaluation of gene–environment interactions and epigenetic mechanisms of inherited and acquired increased risk, are needed to explain the increasing incidence of renal cell cancer.

Reproductive factors and risk of renal cell cancer: the Nurses' Health Study

Few prospective studies have examined associations between reproductive factors and risk of renal cell cancer (RCC). The authors prospectively examined whether postmenopausal hormone (PMH) use, oral contraceptive use, parity, and other reproductive factors were associated with RCC risk among 118,219 US women in the Nurses' Health Study. A total of 247 RCC cases were confirmed between 1976 and 2004. Multivariate relative risks, adjusted for known risk factors, were calculated using Cox proportional hazards models. Compared with 1 or 2 childbirths, the multivariate relative risks were 1.75 (95% confidence interval (CI): 1.21, 2.53) for 4 childbirths and 1.50 (95% CI: 1.00, 2.23) for > or =5 childbirths (P(trend) = 0.02). Comparing an age at first birth of > or =28 years with an age at first birth of < or =22 years, the multivariate relative risk was 0.66 (95% CI: 0.43, 1.01; P(trend) = 0.01). Compared with 1-3 childbirths and an age at first birth of > or =26 years, the multivariate relative risk was 2.17 (95% CI: 1.49, 3.14) for > or =4 childbirths and an age at first birth of <26 years. No clear associations were observed for PMH use or duration, time since last PMH use, oral contraceptive use or duration, age at menarche, age at menopause, or history of hysterectomy or oophorectomy.

The clinical characteristics of renal cell carcinoma in female patients

OBJECTIVE

To investigate the clinical characteristics of renal cell carcinoma (RCC) in female patients.

METHODS

The clinical characteristics including sex, age at diagnosis, histological tumor size, histological subtype, Fuhrman nuclear grade and pathological tumor-node-metastasis (TNM) stage of 881 consecutive patients treated with (partial) nephrectomy for RCC from 1998 to 2006 were analyzed. Characteristics of different gender groups and different female age groups were compared. The one-way anova and t-test were used to compare means. Pearson's chi(2)-test and the likelihood ratio test were used to compare ratios.

RESULTS

Low-grade tumors accounted for 79.3% of female patients and 64.1% of male patients (P < 0.001). The percentage of stage T1-2 was 76.6% in female patients while it was only 68.5% in male patients (P = 0.011). Also, female patients had more T1-2N0M0 tumors (73.0% vs 64.3%, P = 0.009). Once female patients were classified into three groups according to age diagnosis (<or=40, 41-59 and >or=60 years) young female patients seemed to have more tumors with unfavorable histology (8.7% vs 5.1% vs 4.3%), Fuhrman grade 3-4 (23.9% vs 23.1% vs 17.7%) and stage T3-4 (28.3% vs 23.1% vs 22.0%).

CONCLUSION

Compared with male patients, female patients had lower stage and grade tumors. However, younger female patients had more tumors with unfavorable histology, and higher stage and grade compared to older female patients.

Menstrual and reproductive factors and risk of renal cell cancer in the Multiethnic Cohort

A relationship between female reproductive and menstrual factors, including exogenous hormone use, and renal cell cancer (RCC) has been hypothesized, but supporting epidemiologic evidence is limited and inconsistent. Here, the association of reproductive and menstrual factors with RCC risk was examined among 106,036 Hawaii-Los Angeles Multiethnic Cohort female participants who entered the cohort between 1993 and 1996. During an average 10.6 years of follow-up, 229 RCC cases were identified among these women. Data on known and potential risk factors were obtained from the baseline questionnaire. Relative risks and 95% confidence intervals for RCC associated with each factor were estimated using Cox proportional hazard models stratified by race/ethnicity, study center, and menopausal status and adjusted for age and several confounding factors. We found no evidence of association between RCC and parity, age at first birth, age at menarche, age and type of menopause (hysterectomy or bilateral oophorectomy), use and duration of oral contraceptive, and type and duration of postmenopausal hormone use. Our results do not support the hypothesis that hormone-related factors play an etiologic role in RCC among women.

Contemporary epidemiology of renal cell cancer

We analyzed renal cell cancer incidence patterns in the United States and reviewed recent epidemiologic evidence with regard to environmental and host genetic determinants of renal cell cancer risk. Renal cell cancer incidence rates continued to rise among all racial/ethnic groups in the United States, across all age groups, and for all tumor sizes, with the most rapid increases for localized stage disease and small tumors. Recent cohort studies confirmed the association of smoking, excess body weight, and hypertension with an elevated risk of renal cell cancer, and suggested that these factors can be modified to reduce the risk. There is increasing evidence for an inverse association between renal cell cancer risk and physical activity and moderate intake of alcohol. Occupational exposure to trichloroethylene has been positively associated with renal cell cancer risk in several recent studies, but its link with somatic mutations of the von Hippel-Lindau gene has not been confirmed. Studies of genetic polymorphisms in relation to renal cell cancer risk have produced mixed results, but genome-wide association studies with larger sample size and a more comprehensive approach are underway. Few epidemiologic studies have evaluated risk factors by subtypes of renal cell cancer defined by somatic mutations and other tumor markers.

Cancers of the urinary tract among American Indians and Alaska Natives in the United States, 1999-2004

BACKGROUND

Assessment of the kidney parenchyma ("kidney") and urinary bladder ("bladder") cancer burden among American Indians and Alaska Natives (AI/AN) has been limited. Using a database with improved classification for AI/AN, the authors described patterns of these 2 cancers among AI/AN and non-Hispanic whites (NHW) in the United States.

METHODS

Cases diagnosed during 1999 to 2004 were identified through National Program of Cancer Registries and the Surveillance, Epidemiology and End Results program and linked to the Indian Health Service (IHS) registration records. Age-adjusted incidence rates, rate ratios (RR), annual percent change, and stage at diagnosis were stratified by IHS Contract Health Service Delivery Area (CHSDA) counties to adjust for misclassification.

RESULTS

Kidney cancer incidence among AI/AN in CHSDA counties exceeded that among NHW (RR, 1.51; 95% confidence interval [CI], 1.42-1.61), and was highest among AI/AN in the Northern Plains, Southern Plains, Alaska, and Southwest. Average annual increases were highest among AI/AN (5.9%) and NHW (5.9%) males aged 20 to 49 years, although statistically significant only among NHW. Conversely, bladder cancer incidence was significantly lower among AI/AN than NHW (RR, 0.40; 95% CI, 0.37-0.44). For both sites, AI/AN were significantly less likely to be diagnosed at an earlier stage than NHW.

CONCLUSIONS

AI/AN have about 50% greater risk of kidney cancer and half the risk of bladder cancer than NHW. Although reasons for these enigmatic patterns are not known, sustained primary prevention efforts through tobacco cessation and obesity prevention are warranted.

Reproductive, menstrual, and other hormone-related factors and risk of renal cell cancer

A role of hormone-related factors in renal cell cancer (RCC) etiology has been hypothesized, but the epidemiological evidence is inconsistent. The present study aimed at evaluating the effect of reproductive, menstrual and other gender-specific variables on RCC risk among women. This study is part of a larger hospital-based, case-control study on RCC risk, conducted in northern, central and southern Italy. Cases were 273 women, below age 80, with histologically confirmed, incident RCC. Controls were 546 women hospitalized for acute, nonneoplastic conditions, frequency-matched to cases by age and center. Odds ratios (OR) and 95% confidence intervals (CI) were computed using multiple logistic regression models. RCC risk was inversely related to age at first birth (OR = 0.7, 95% CI 0.5-1.0, for >/= 25 years vs. <25 years). Hysterectomy was found to double RCC risk (OR = 2.3, 95% CI 1.3-4.2). A negative association of borderline-statistical significance emerged for age at menarche, whereas, no associations were found between RCC risk and parity, menopausal status, age at menopause and use of hormone replacement therapy or oral contraceptives. Our findings give support to a role of hysterectomy in increasing RCC risk without corroborating, however, a major role of female hormone-related factors.

Retroperitoneoscopic radical nephrectomy for renal-cell carcinoma during twin pregnancy

Renal-cell carcinoma (RCC) is rarely reported during pregnancy. Both the open and the laparoscopic approach to nephrectomy have been used effectively and safely in pregnant patients with RCC. We report a unique case of a 52-year-old woman found to have RCC during twin gestation who was treated with retroperitoneoscopic radical nephrectomy, one of the first such cases managed by this approach.

Reproductive characteristics and risk of kidney cancer: Iowa Women's Health Study

OBJECTIVES

Kidney (renal cell) cancer accounts for approximately 3-4% of all new cases of primary cancer diagnosed in the United States. A relationship between kidney cancer and female reproductive factors has been hypothesized but supporting evidence is inconsistent. Our objectives were to explore the relationship between female reproductive factors and kidney cancer and identify independent risk factors related to female reproductive history and its effects on development of kidney cancer.

METHODS

We measured risk factors for kidney cancer and reproductive characteristics in a group of 37,440 postmenopausal women in Iowa. From 1986 to 2003, 165 cases of incident kidney cancer were identified through a statewide cancer registry.

RESULTS

After adjustment for age and other risk factors, past use of estrogen showed an increased risk of renal cancer (RR 1.56; 95% CI 1.13-2.17) when compared to no use. Women with no live birth (RR 1.91, p=0.02) and women with three to four live births (RR 1.62, p=0.02) also had an increased risk of kidney cancer when compared with women who had one to two live births. There was also a lower risk of kidney cancer with greater lifetime duration of ovulation.

CONCLUSION

Although most reproductive variables were not significantly associated with kidney cancer, our study indicates that a greater exposure to estrogens may increase risk for kidney cancer.

Reproductive and hormonal factors and risk of lung cancer in women: a prospective cohort study

Several lines of evidence suggest that endocrine factors may play a role in the development of lung cancer, but the evidence is limited and inconsistent. We investigated the association of reproductive and hormonal factors with risk of lung cancer in the National Breast Screening Study, which included 89,835 Canadian women aged 40-59 years at recruitment between 1980 and 1985. Linkages to national cancer and mortality databases provided data on cancer incidence and deaths from all causes, respectively, with follow-up ending between 1998 and 2000. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between hormonal factors and lung cancer. During a mean of 16.4 years of follow-up, we observed 750 incident lung cancer cases. After adjustment for covariates, parous women were not at increased risk of lung cancer (HR = 1.18, 95% CI 0.94-1.47) relative to nulliparous women; however, there was a modest increase in risk with increasing parity, reaching a HR of 1.42, 95% CI 1.06-1.88 in women who had 5 or more live births (p for trend 0.02). Among parous women, age at first live birth was inversely associated with risk. Women who had their first live birth at age 30 or older were at reduced risk relative to women who had their first live birth below age 23 (HR 0.68, 95% CI 0.50-0.93, p for trend 0.004). These associations did not differ by age at enrollment (40-49 vs. 50-59 years old), but were somewhat strengthened when attention was restricted to never smokers. Ever use of exogenous hormones showed little association with lung cancer risk; however, long-term users of hormone replacement therapy were at slightly increased risk. Our results add to the limited existing evidence that certain reproductive and hormonal factors may be associated with lung cancer risk in women.

Risk factors, classification, and staging of renal cell cancer

Knowledge about renal cell carcinoma (RCC) has increased exponentially over the last decades. A clear understanding of RCC is of utmost importance to prevent the disease and improve the outcomes. Large epidemiologic studies have identified cigarette smoking, chemical agents, obesity, hypertension, and end-stage renal disease as risk factors associated with RCC. Identification and confirmation of risk factors may be projected into preventive strategies. Genetic studies of inherited disorders associated with an enhanced risk of RCC have elucidated many important targets for anticancer therapy. The World Health Organization (WHO) has recently developed a new histologic classification of renal cell tumors that has demonstrated prognostic utility. A refined clinical staging system is improving our ability to prognosticate the outcome of RCC patients. This article provides a practical yet comprehensive review of the risk factors, classification, and staging of RCC focusing on recent updates.

A cohort study of reproductive and hormonal factors and renal cell cancer risk in women

We examined the association of reproductive and hormonal factors with renal cell cancer risk in a cohort study of 89 835 Canadian women. Compared with nulliparous women, parous women were at increased risk (hazard ratio (HR) 1.78, 95% confidence interval (CI) 1.02-3.09), and there was a significant gradient of risk with increasing levels of parity: relative to nulliparous women, women who had > or =5 pregnancies lasting 4 months or more had a 2.4-fold risk (HR=2.41, 95% CI=1.27-4.59, P for trend 0.01). Ever use of oral contraceptives was associated with a modest reduction in risk. No associations were observed for age at first live birth or use of hormone replacement therapy. The present study provides evidence that high parity may be associated with increased risk of renal cell cancer, and that oral contraceptive use may be associated with reduced risk.

Urologic malignancies in pregnancy

Urologic tumors during pregnancy are rare. Presenting symptoms of malignancies may be mistaken as typical symptoms in pregnancy. Evaluation and treatment of tumors of the adrenal gland, kidney, ureter, bladder, and urethra are reviewed based upon stage and type of tumor and stage of pregnancy.

[Factors influencing pulmonary function in Tunisian women aged 45 years and more]

INTRODUCTION

The aim of this study was to analyse the factors influencing pulmonary function and inspiratory muscle strength in healthy Tunisian women aged >or=45 years and in particular to determine the effect of parity.

METHODS

A medical questionnaire together with an evaluation of sporting activity score and 2 levels for schooling and socio-economic status was administered. Parity was introduced as numeric, as dichotomous (G1:<or=3; G2: >or=4) and in 3 classes (C1:<2; C2:=3-4; C3: > 4). Plethysmography with measurement of airway conductance and maximal inspiratory pressure was performed.

RESULTS

108 women were included. According to the ascending multiple linear regression, and in decreasing order, the following influencing factors are noted: Age and height, parity, weight and daily activity, schooling level, and finally leisure activity, body mass index, and physical activity. With high parity, and especially in women aged >or=60 years, there was a decrease in inspiratory muscle strength and an obstructive tendency, without associated restrictive component. Parity effects are age independent.

CONCLUSIONS

Factors influencing the pulmonary function of healthy Tunisian women aged >or=45 years are multiple. Lung function declines with increasing parity.