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Stopsack KH, Gerke T, Zareba P, Pettersson A, Chowdhury D, Ebot EM, Flavin R, Finn S, Kantoff PW, Stampfer MJ, Loda M, Fiorentino M, Mucci LA. Tumor protein expression of the DNA repair gene BRCA1 and lethal prostate cancer. Carcinogenesis 2021; 41:904-908. [PMID: 32556091 DOI: 10.1093/carcin/bgaa061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/26/2020] [Accepted: 06/11/2020] [Indexed: 12/22/2022] Open
Abstract
DNA repair genes are commonly altered in metastatic prostate cancer, but BRCA1 mutations are rare. Preliminary studies suggest that higher tumor expression of the BRCA1 protein may be associated with worse prognosis. We undertook a prospective study among men with prostate cancer in the Health Professionals Follow-up Study and evaluated BRCA1 via immunohistochemical staining on tissue microarrays. BRCA1 was expressed in 60 of 589 tumors. Prevalence of BRCA1 positivity was 43% in the 14 men with metastases at diagnosis compared with 9% in non-metastatic tumors [difference, 33 percentage points; 95% confidence interval (CI), 7-59]. BRCA1-positive tumors had 2.16-fold higher Ki-67 proliferative indices (95% CI, 1.18-3.95), higher tumor aneuploidy as predicted from whole-transcriptome profiling, and higher Gleason scores. Among the 575 patients with non-metastatic disease at diagnosis, we evaluated the association between BRCA1 expression and development of lethal disease (metastasis or cancer-specific death, 69 events) during long-term follow-up (median, 18.3 years). A potential weak association of BRCA1 positivity with lethal disease (hazard ratio, 1.61; 95% CI, 0.82-3.15) was attenuated when adjusting for age, Gleason score and clinical stage (hazard ratio, 1.11; 95% CI, 0.54-2.29). In summary, BRCA1 protein expression is a feature of more proliferative and more aneuploid prostate tumors and is more common in metastatic disease. While not well suited as a prognostic biomarker in primary prostate cancer, BRCA1 protein expression may be most relevant in advanced disease.
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Affiliation(s)
- Konrad H Stopsack
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Travis Gerke
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Piotr Zareba
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Urology, McMaster University, Hamilton, ON, USA
| | - Andreas Pettersson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Medicine, Clinical Epidemiology Unit, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Dipanjan Chowdhury
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ericka M Ebot
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Richard Flavin
- Department of Pathology, St. James's Hospital, Dublin, Ireland.,Trinity College, Dublin, Ireland
| | - Stephen Finn
- Department of Pathology, St. James's Hospital, Dublin, Ireland.,Trinity College, Dublin, Ireland
| | - Philip W Kantoff
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meir J Stampfer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimo Loda
- Department of Pathology, Cornell Medical School, New York, NY, USA
| | - Michelangelo Fiorentino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Pathology Unit, Addarii Institute, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Lorelei A Mucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Ceraolo C, Gerke TA, Zareba P, Pettersson A, Stopsack KH, Chowdhury D, Ebot EM, Flavin R, Finn SP, Kantoff PW, Stampfer MJ, Loda M, Fiorentino M, Mucci LA. Tumor protein expression of BRCA1 and development of lethal prostate cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
65 Background: DNA repair genes including BRCA1 are commonly altered in metastatic prostate tumors. However, mutations and copy number aberrations in these genes are rare in primary tumors. Instead, preliminary studies suggest that higher tumor expression of the BRCA1 protein may be associated with worse prognosis. Methods: We undertook a prospective study of tumor BRCA1 protein expression and lethal prostate cancer among men with clinically localized prostate cancer in the Health Professionals Follow-up Study. We performed immunohistochemical staining for BRCA1 on tumor tissue microarrays using a validated antibody and scored expression as positive or negative. We also assessed tumor proliferation by immunostaining for Ki67, angiogenesis by immunostaining for CD34, and apoptosis using a TUNEL assay. Proportional hazards regression was used to evaluate the association between BRCA1 protein expression and development of lethal prostate cancer (metastasis or cancer-specific death). Results: Ten percent of tumors (60 of 589) stained positive for the BRCA1 protein. BRCA1-positive tumors were characterized by higher Gleason scores, a higher proliferative index, and a higher apoptotic index. During a median follow-up of 14.3 years, 18 men (34%) in the BRCA1-positive group and 74 men (14%) in the BRCA1-negative group developed lethal prostate cancer. There was a strong positive association between BRCA1 protein expression and lethal prostate cancer in both unadjusted analyses (HR 2.71, 95% CI 1.73–4.26) and after adjusting for clinical factors (HR 2.00, 95% CI 1.26–3.18). The positive association with BRCA1 protein expression was also independent of proliferation index. Conclusions: Primary prostate tumors expressing the BRCA1 protein have a highly proliferative phenotype and are more likely to progress to lethal disease, independent of its higher proliferative index. Assessing tumor protein expression of BRCA1 may help elucidate the Janus-faced role of DNA repair pathways in prostate cancer progression.[Table: see text]
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Affiliation(s)
- Carl Ceraolo
- Harvard University T H Chan School of Public Health, Cambridge, MA
| | | | - Piotr Zareba
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Stephen P. Finn
- St. James's Hospital and Trinity College Dublin, Cancer Molecular Diagnostics, Dublin, Ireland
| | - Philip W. Kantoff
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Meir J. Stampfer
- Harvard T.H. Chan School of Public Health, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Massimo Loda
- Center for Molecular Oncologic Pathology, Dana-Farber Cancer Institute, Boston, MA
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Chesnut GT, Zareba P, Sjoberg DD, Mamoor M, Carlsson S, Lee T, Fainberg J, Vertosick E, Manasia M, Schoen M, Ehdaie B. Patient-reported pain, discomfort, and anxiety during magnetic resonance imaging-targeted prostate biopsy. Can Urol Assoc J 2019; 14:E202-E208. [PMID: 31793867 DOI: 10.5489/cuaj.6102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The addition of targeted prostate biopsy to systemic biopsy impacts patient experience. We examined patient-reported pain, discomfort, anxiety, and tolerability among men undergoing magnetic resonance imaging (MRI)-targeted prostate biopsy in addition to transrectal ultrasound-guided systematic biopsy compared to those undergoing systematic biopsy alone. METHODS All patients underwent transrectal systematic 14-core biopsies. Patients with regions of interest on MRI underwent additional targeted biopsies. All patients received equivalent periprostatic nerve block. Four single-item, standard, 11-point numerical rating scales evaluating pain, discomfort, anxiety, and tolerability were completed immediately after biopsy. Differences in means were compared using t-tests. Correlation between rated domains was tested using Spearman's correlation coefficient. RESULTS Of 273 consecutive patients, 195 (71%) underwent targeted biopsy and 188 (69%) had undergone prior biopsy. In all men, the median score for pain and tolerability was 3, while the median score for discomfort and anxiety was 4. Pain was rated at 7 or above by 15% of patients. Moderate correlation between pain, discomfort, anxiety, and tolerability of repeat biopsy was observed (Spearman's ρ between 0.48 and 0.76). Compared to patients undergoing systematic biopsy alone, men who received both targeted and systematic biopsies reported higher anxiety scores (difference 1.2; 95% confidence interval [CI] 0.4-2.0; p=0.004) and discomfort (difference 1.0; 95% CI 0.3-1.7; p<0.001). CONCLUSIONS Patients undergoing targeted and systematic biopsies report more discomfort and anxiety than patients undergoing systematic biopsies alone. Absolute differences are small, and patients are willing to undergo repeat biopsy if advised. Interventions to reduce biopsy-related anxiety are needed.
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Affiliation(s)
- Gregory T Chesnut
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Piotr Zareba
- Department of Surgery, Urology Division, McMaster University, Hamilton, ON, Canada
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Maha Mamoor
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sigrid Carlsson
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Taehyoung Lee
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jonathan Fainberg
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Emily Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Michael Manasia
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Mary Schoen
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Behfar Ehdaie
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Zareba P, Pinthus JH, Russo P. The contemporary role of lymph node dissection in the management of renal cell carcinoma. Ther Adv Urol 2018; 10:335-342. [PMID: 30344645 DOI: 10.1177/1756287218794094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 06/22/2018] [Indexed: 01/19/2023] Open
Abstract
The appropriate role of lymph node dissection (LND) in the management of patients with renal cell carcinoma (RCC) is still a matter of debate. There is ample evidence that LND is the most accurate modality for staging the regional lymph nodes (LNs), which may harbor metastatic disease in greater than one-third of patients with high-risk RCC. The presence of LN metastases is an independent negative prognostic factor in this disease and accurate determination of LN status not only helps with patient counselling regarding prognosis and tailoring of postoperative surveillance schedules, but it also identifies patients at high risk of systemic disease recurrence who may qualify for clinical trials of adjuvant systemic therapies. Meanwhile, the therapeutic value of LND has been brought into question by a randomized trial (European Organisation for Research and Treatment of Cancer; EORTC 30881) that showed no difference in progression-free or overall survival between patients who were treated with radical nephrectomy (RN) and LND and those treated with RN alone. Given that most patients enrolled in this trial had small renal masses and therefore were at low risk for LN metastases, the question of whether patients with high-risk tumors derive a therapeutic benefit from a standardized, extended LND remains unanswered.
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Affiliation(s)
- Piotr Zareba
- Juravinski Hospital and Cancer Centre, B3-146, 711 Concession Street, Hamilton, Ontario, Canada, L8V 1C3
| | - Jehonathan H Pinthus
- Division of Urology, McMaster University, Hamilton, Ontario, Canada Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
| | - Paul Russo
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Abstract
Patients with bladder cancer are at high risk of developing both venous and arterial thromboembolic events. Factors that contribute to this phenomenon include the hypercoagulable state induced by the malignancy itself, medical comorbidities that are common in this predominantly elderly patient population as well as treatments such as prolonged pelvic surgery and cisplatin-based chemotherapy. While formal guidelines address prevention of venous thromboembolism in patients undergoing radical cystectomy, consensus regarding the role of pharmacologic prophylaxis in patients with bladder cancer being treated with chemotherapy, either with neoadjuvant or adjuvant intent in conjunction with radical cystectomy, as part of bladder preservation protocols or for metastatic disease, has proved elusive. The present narrative review was undertaken to define the incidence of and identify risk factors for thromboembolism among patients with bladder cancer, as well as to assess the efficacy of pharmacologic prophylaxis in reducing the risk of thromboembolism in this patient population.
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Affiliation(s)
- Piotr Zareba
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
| | | | - Jehonathan H. Pinthus
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
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Zareba P, Eastham J, Scardino PT, Touijer K. Contemporary Patterns of Care and Outcomes of Men Found to Have Lymph Node Metastases at the Time of Radical Prostatectomy. J Urol 2017. [PMID: 28625507 DOI: 10.1016/j.juro.2017.06.062] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE A thorough understanding of the natural history and consensus regarding the optimal management of pathological lymph node positive (pN1) prostate cancer are lacking. Our objective was to describe patterns of care and outcomes of a contemporary cohort of men with pN1 prostate cancer. MATERIALS AND METHODS We used the National Cancer Database to identify 7,791 men who were found to have lymph node metastases at radical prostatectomy. Multinomial logistic regression and Cox proportional hazards regression were used to identify patient, tumor and facility characteristics associated with the choice of management strategy after radical prostatectomy and overall survival, respectively. RESULTS Initial post-prostatectomy management was observation in 63% of the men, androgen deprivation therapy alone in 20%, radiation therapy alone in 5%, and androgen deprivation therapy and radiation therapy in 13%. Younger age, lower comorbidity burden, higher grade and stage, and positive surgical margins were associated with a higher likelihood of receiving combination therapy. Grade group 4-5 disease, pT3b-T4 disease, positive surgical margins and a higher number of positive lymph nodes were independent predictors of worse overall survival. The adjusted 10-year overall survival probability decreased from 84% to 32% with the presence of an increasing number of adverse prognostic factors. Treatment with combined androgen deprivation therapy and radiation therapy was associated with better overall survival (multivariable HR 0.69, 95% CI 0.52-0.92, p = 0.010 for combination therapy vs observation). CONCLUSIONS Patient and tumor characteristics are associated with the choice of management strategy after radical prostatectomy and survival in men with pN1 prostate cancer. Multimodal therapy may be of benefit in this patient population.
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Affiliation(s)
- Piotr Zareba
- Division of Urology, McMaster University, Hamilton, Ontario, Canada.
| | - James Eastham
- Urology Service, Memorial Sloan Kettering Cancer Center and Department of Urology, Weill Cornell Medical College, New York, New York
| | - Peter T Scardino
- Urology Service, Memorial Sloan Kettering Cancer Center and Department of Urology, Weill Cornell Medical College, New York, New York
| | - Karim Touijer
- Urology Service, Memorial Sloan Kettering Cancer Center and Department of Urology, Weill Cornell Medical College, New York, New York
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Rosenzweig B, Rubinstein ND, Reznik E, Zareba P, Shingarev R, Juluru K, Akin O, Hsieh JJ, Jaimes E, Russo P, Susztak K, Coleman JA, Hakimi AA. MP73-17 BENIGN AND TUMOR PARENCHYMA METABOLOMIC PROFILES AFFECT COMPENSATORY RENAL GROWTH IN RENAL CELL CARCINOMA SURGICAL PATIENTS. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.3362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Rosenzweig B, Rubinstein ND, Reznik E, Zareba P, Shingarev R, Juluru K, Akin O, Hsieh J, Jaimes EA, Russo P, Susztak K, Coleman J, Hakimi AA. Effect of benign and tumor parenchyma metabolomic profiles on compensatory renal growth in renal cell carcinoma surgical patients. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.6_suppl.446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
446 Background: Pre-operative kidney volume is an independent predictor of glomerular filtration rate in renal cell carcinoma patients. Compensatory renal growth (CRG) can ensue prior to nephrectomy in parallel to tumor growth and benign parenchyma loss. We aimed to test whether renal metabolite abundances significantly associate with CRG, suggesting a causative relationship. Methods: Tissue metabolomics data from 49 patients, with a median age of 60 years, were previously collected and the pre-operative fold-change of their contra to ipsi-lateral benign kidney volume served as a surrogate for their CRG. Contra-lateral kidney volume fold-change within a 3.3 +/- 2.1 years follow-up interval was used as a surrogate for long-term CRG. Using a multivariable statistical model we identified metabolites whose abundances significantly associate with CRG. Results: We identified 13 metabolites in the benign (e.g. L-urobilin) and 163 metabolites in the malignant (e.g. 3-indoxyl-sulfate) tissues to significantly associate with CRG. Benign/tumor fold change in metabolite abundances revealed three additional metabolites with a significant positive association with CRG (e.g. p-cresol sulfate). At the pathway level, we show that fatty-acid oxidation is highly enriched with metabolites whose benign tissue abundances strongly positively associate with CRG, whereas in the tumor tissue significant enrichment of dipeptides (positive association) and benzoate, glycolysis/gluconeogenesis, lysolipid and nucleotide sugar pentose (negative associations) sub-pathways were observed. The effect of metabolite abundances in the benign tissue on long term CRG provided further support for positive association of fatty-acid metabolism sub-pathway enrichment, where sphingolipid, monoacylglycerol, long chain fatty acids, and mid chain fatty acids were enriched for a negative association. Conclusions: These data suggest that specific biological processes in the benign as well as in the tumor parenchyma strongly influence compensatory renal growth.
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Affiliation(s)
| | | | - Eduard Reznik
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Piotr Zareba
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Oguz Akin
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - James Hsieh
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Paul Russo
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - A. Ari Hakimi
- Memorial Sloan Kettering Cancer Center, New York, NY
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Zareba P, Rosenzweig B, Winer AG, Coleman JA. Association between lymph node yield and survival among patients undergoing radical nephroureterectomy for urothelial carcinoma of the upper tract. Cancer 2017; 123:1741-1750. [PMID: 28152158 DOI: 10.1002/cncr.30516] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 11/07/2016] [Accepted: 11/21/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Prior studies examining the value of lymph node (LN) dissection (LND) in patients with urothelial carcinoma of the upper urinary tract (UTUC) have produced conflicting results. The objective of the current study was to assess the relationship between LN yield and survival among patients undergoing radical nephroureterectomy (RNU). METHODS The National Cancer Data Base was used to identify patients with non-metastatic UTUC who were treated with RNU between 2004 and 2012. The association between LN yield and overall survival (OS) was assessed using Cox proportional hazards regression, with adjustment for patient, tumor, and facility characteristics. RESULTS Of the 14,472 patients, 2926 (20%) underwent LND. The median yield was 2 LNs (interquartile range 1-6 LNs). Among the entire cohort and the LN-negative (pN0) subgroup, a higher LN yield was associated with lower all-cause mortality (multivariable hazard ratio [HR] 0.94 per 5 LNs removed, 95% confidence interval [95% CI] 0.89-1.00 [P = .034] for the entire cohort and HR 0.86, 95% CI 0.79-0.94 [P = .001] for the pN0 subgroup). Among patients with positive LNs (pN+), there was no association noted between LN yield and OS; however, positive and negative LN counts were found to be independent predictors of OS (HR 1.27 per 5 positive LNs, 95% CI 1.16-1.39 [P<.001] and HR 0.90 per 5 negative LNs, 95% CI 0.82-1.00 [P = .049]). CONCLUSIONS In this large, contemporary cohort of patients with UTUC, LND was found to be used infrequently despite evidence that a higher LN yield is associated with lower all-cause mortality. Cancer 2017;123:1741-1750. © 2017 American Cancer Society.
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Affiliation(s)
- Piotr Zareba
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Barak Rosenzweig
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew G Winer
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A Coleman
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York
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Zareba P, Flavin R, Isikbay M, Rider JR, Gerke TA, Finn S, Pettersson A, Giunchi F, Unger RH, Tinianow AM, Andersson SO, Andrén O, Fall K, Fiorentino M, Mucci LA. Perineural Invasion and Risk of Lethal Prostate Cancer. Cancer Epidemiol Biomarkers Prev 2017; 26:719-726. [PMID: 28062398 DOI: 10.1158/1055-9965.epi-16-0237] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 12/07/2016] [Accepted: 12/08/2016] [Indexed: 12/12/2022] Open
Abstract
Background: Prostate cancer has a propensity to invade and grow along nerves, a phenomenon called perineural invasion (PNI). Recent studies suggest that the presence of PNI in prostate cancer has been associated with cancer aggressiveness.Methods: We investigated the association between PNI and lethal prostate cancer in untreated and treated prostate cancer cohorts: the Swedish Watchful Waiting Cohort of 615 men who underwent watchful waiting, and the U.S. Health Professionals Follow-Up Study of 849 men treated with radical prostatectomy. One pathologist performed a standardized histopathologic review assessing PNI and Gleason grade. Patients were followed from diagnosis until metastasis or death.Results: The prevalence of PNI was 7% and 44% in the untreated and treated cohorts, respectively. PNI was more common in high Gleason grade tumors in both cohorts. PNI was associated with enhanced tumor angiogenesis, but not tumor proliferation or apoptosis. In the Swedish study, PNI was associated with lethal prostate cancer [OR 7.4; 95% confidence interval (CI), 3.6-16.6; P < 0.001]. A positive, although not statistically significant, association persisted after adjustment for age, Gleason grade, and tumor volume (OR 1.9; 95% CI, 0.8-5.1; P = 0.17). In the U.S. study, PNI predicted lethal prostate cancer independent of clinical factors (HR 1.8; 95% CI, 1.0, 3.3; P =0.04).Conclusions: These data support the hypothesis that perineural invasion creates a microenvironment that promotes cancer aggressiveness.Impact: Our findings suggest that PNI should be a standardized component of histopathologic review, and highlights a mechanism underlying prostate cancer metastasis. Cancer Epidemiol Biomarkers Prev; 26(5); 719-26. ©2017 AACR.
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Affiliation(s)
- Piotr Zareba
- Division of Urology, McMaster University, Hamilton, Ontario, Canada
| | - Richard Flavin
- Department of Pathology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Trinity College Dublin, Dublin, Ireland
| | | | - Jennifer R Rider
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Travis A Gerke
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - Stephen Finn
- Department of Pathology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Trinity College Dublin, Dublin, Ireland
| | - Andreas Pettersson
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Clinical Epidemiology Unit, Department of Medicine, Solna, Stockholm, Sweden
| | - Francesca Giunchi
- Pathology Unit, Addarii Institute, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Robert H Unger
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Alex M Tinianow
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Swen-Olof Andersson
- Department of Urology, Örebro University Hospital, Örebro, Sweden.,School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Ove Andrén
- Department of Urology, Örebro University Hospital, Örebro, Sweden.,School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Katja Fall
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Michelangelo Fiorentino
- Department of Pathology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Pathology Unit, Addarii Institute, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Lorelei A Mucci
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts. .,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Public Health Sciences, University of Iceland, Reykjavik, Iceland
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11
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Duivenvoorden WC, Daneshmand S, Canter D, Lotan Y, Black PC, Abdi H, van Rhijn BW, Fransen van de Putte EE, Zareba P, Koskinen I, Kassouf W, Traboulsi SL, Kukreja JE, Boström PJ, Shayegan B, Pinthus JH. Incidence, Characteristics and Implications of Thromboembolic Events in Patients with Muscle Invasive Urothelial Carcinoma of the Bladder Undergoing Neoadjuvant Chemotherapy. J Urol 2016; 196:1627-1633. [DOI: 10.1016/j.juro.2016.06.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 11/15/2022]
Affiliation(s)
| | - Siamak Daneshmand
- University of Southern California-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Daniel Canter
- Fox Chase Cancer Center, Einstein Health Network and Urologic Institute of Southeastern Pennsylvania, Philadelphia, Pennsylvania
| | - Yair Lotan
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Peter C. Black
- Vancouver Prostate Centre, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hamidreza Abdi
- Vancouver Prostate Centre, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bas W.G. van Rhijn
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Piotr Zareba
- McMaster University and Juravinski Hospital, Hamilton, Ontario, Canada
| | - Ilmari Koskinen
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | | | | | - Peter J. Boström
- Turku University Hospital and University of Turku, Turku, Finland
| | - Bobby Shayegan
- McMaster University and Juravinski Hospital, Hamilton, Ontario, Canada
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12
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Duivenvoorden W, Daneshmand S, Canter D, Lotan Y, Black P, Abdi H, van Rhijn B, Fransen van de Putte E, Boström P, Koskinen I, Zareba P, Baack Kukreja J, Kassouf W, Traboulsi S, Pinthus J. PD27-09 INCIDENCE AND SIGNIFICANCE OF THROMBO-EMBOLIC EVENTS IN BLADDER UROTHELIAL CARCINOMA PATIENTS UNDERGOING NEO-ADJUVANT CHEMOTHERAPY AND RADICAL CYSTECTOMY: RESULTS FROM MULTI-CENTRE NORTH-AMERICAN AND EUROPEAN CONTEMPORARY DATA. J Urol 2016. [DOI: 10.1016/j.juro.2016.02.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Duivenvoorden WCM, Daneshmand S, Canter DJ, Lotan Y, Black PC, Abdi H, Van Rhijn BW, Fransen van de Putte EE, Bostrom PJ, Koskinen I, Zareba P, Baack Kukreja JE, Kassouf W, Traboulsi S, Pinthus JH. Incidence, characteristics, and implications of thrombo-embolic events in patients with urothelial carcinoma of the bladder undergoing neoadjuvant chemotherapy. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.2_suppl.393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
393 Background: Neoadjuvant chemotherapy (NAC), in combination with radical cystectomy (RC), is associated with a significant survival advantage for patients with muscle-invasive bladder cancer. Chemotherapy as well as pelvic surgery are significant risk factors for thrombo-embolic events (TEE). The objectives of this study were to investigate the incidence and characteristics of TEE during and after NAC and subsequent RC for urothelial bladder cancer patients. Methods: A retrospective study was carried out on 827 consecutive patients who underwent NAC and cystectomy for urothelial bladder carcinoma from 2002 to 2014 at ten different tertiary centers across North America and Europe. The median time of follow-up from bladder cancer diagnosis was 13 months (range 1-119 months). The incidence (venous, arterial, port-site or deep vein thrombosis, thrombosis, clinical or incidentally detected pulmonary embolism) and timing of TEE (before or after ( < or > 30 days) RC) and Khorana score (based on baseline hemoglobin, platelet and leukocyte counts, BMI and tumor site, which was established for cancer patients treated with chemotherapy) was determined for all patients. Multivariate analysis was performed on 827 patients. Kaplan Meier survival curves and log rank test were used to compare survival between patients who developed TEE and those who did not. Results: The Khorana criteria indicated intermediate TEE risk in most patients. Khorana risk score was 1 or 2 in 88% of patients. Nevertheless, the incidence of TEE in patients undergoing NAC was 15%. 59 TEE were detected pre-operatively (7.1%), 21 early within 30 days of RC (2.5%) and 36 late post-operatively (4.3%). 32% of the TEE events were detected incidentally by imaging, 68% were detected clinically. Median overall survival of patients who developed TEE was 28 months compared to 71 months for those who did not develop TEE (p = 0.012). Conclusions: This multi-centre retrospective study suggests that TEE are very common in bladder cancer patients undergoing NAC followed by RC and is associated with poorer survival. Further investigation with a prospective prevention trial is warranted.
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Affiliation(s)
| | - Siamak Daneshmand
- Institute of Urology, University of Southern California, Los Angeles, CA
| | | | - Yair Lotan
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Hamidreza Abdi
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Bas W.G. Van Rhijn
- Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Badhoevedorp, Netherlands
| | | | - Peter J. Bostrom
- University Health Network, Princess Margaret Hospital, Toronto, ON, Canada
| | | | | | | | - Wassim Kassouf
- McGill University Health Centre, McGill University, Montreal, QC, Canada
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14
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Zareba P, Duivenvoorden W, Leong DP, Pinthus JH. Androgen deprivation therapy and cardiovascular disease: what is the linking mechanism? Ther Adv Urol 2015; 8:118-29. [PMID: 27034724 DOI: 10.1177/1756287215617872] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The past decade has brought increased awareness of the potential adverse effects of androgen deprivation therapy (ADT) in men with prostate cancer. Arguably the most important and controversial of these is the increased risk of cardiovascular morbidity and mortality. Although multiple observational studies have shown that men treated with ADT are at increased risk of developing atherosclerotic cardiovascular disease, our understanding of the biological mechanisms that might underlie this phenomenon is still evolving. In this review, we discuss some of the mechanisms that have been proposed to date, including ADT-induced metabolic changes that promote the development and progression of atherosclerotic plaques as well as direct local effects of hormonal factors on plaque growth, rupture and thrombosis.
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Affiliation(s)
- Piotr Zareba
- Division of Urology, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Wilhelmina Duivenvoorden
- Division of Urology, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Darryl P Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jehonathan H Pinthus
- Department of Surgery, Juravinski Hospital and Cancer Centre, 711 Concession St, Hamilton, Ontario L8V 1C3, Canada
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15
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Zareba P, Wu C, Agzarian J, Rodriguez D, Kearon C. Meta-analysis of randomized trials comparing combined compression and anticoagulation with either modality alone for prevention of venous thromboembolism after surgery. Br J Surg 2014; 101:1053-62. [DOI: 10.1002/bjs.9527] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2014] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Although venous thromboembolism (VTE) is an important cause of postoperative morbidity and mortality, there is still no consensus on the optimal strategy for VTE prevention after major surgery. The objective of this review was to determine the benefits and risks of thromboprophylaxis with both compression and anticoagulation, compared with either modality alone.
Methods
A systematic review of MEDLINE, CENTRAL and Embase databases was performed to identify eligible randomized trials. The literature search and data extraction were carried out independently by two reviewers. Outcomes of interest were deep vein thrombosis (DVT), pulmonary embolism, bleeding, limb injury and mortality.
Results
Twenty-five studies were eligible for inclusion. Adding compression to anticoagulation decreased the risk of DVT by 49 per cent (risk ratio (RR) 0·51, 95 per cent confidence interval 0·36 to 0·73). The corresponding funnel plot suggested publication bias and, overall, the evidence for this comparison was judged to be of low quality. Adding anticoagulation to compression decreased the risk of DVT by 44 per cent (RR 0·56, 0·45 to 0·69) while increasing the risk of bleeding (RR 1·74, 1·29 to 2·34). There was no suggestion of publication bias and the evidence for this comparison was judged to be of moderate quality.
Conclusion
Combined compression and anticoagulation is more effective at preventing postoperative DVT than either modality alone. However, adding anticoagulation to compression increases the risk of bleeding, and the evidence that adding compression to anticoagulation reduces VTE risk is of low quality.
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Affiliation(s)
- P Zareba
- Division of Urology, McMaster University, Hamilton, Ontario, Canada
| | - C Wu
- Division of Urology, McMaster University, Hamilton, Ontario, Canada
| | - J Agzarian
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - D Rodriguez
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - C Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Zareba P, Lorenzo AJ, Braga LH. Risk Factors for Febrile Urinary Tract Infection in Infants with Prenatal Hydronephrosis: Comprehensive Single Center Analysis. J Urol 2014; 191:1614-8. [DOI: 10.1016/j.juro.2013.10.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Piotr Zareba
- Division of Urology, McMaster University, Hamilton, Ontario, Canada
| | - Armando J. Lorenzo
- Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luis H. Braga
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada
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Zareba P, Colaci DS, Afeiche M, Gaskins AJ, Jørgensen N, Mendiola J, Swan SH, Chavarro JE. Semen quality in relation to antioxidant intake in a healthy male population. Fertil Steril 2013; 100:1572-9. [PMID: 24094424 PMCID: PMC3843991 DOI: 10.1016/j.fertnstert.2013.08.032] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 08/20/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the relationship between dietary antioxidant intake and semen quality in young healthy males. DESIGN Cross-sectional study. SETTING University and college campuses in the Rochester, New York, area. PATIENT(S) One hundred eighty-nine university-aged men. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Semen volume, total sperm count, concentration, motility, total motile count, and morphology. RESULT(S) Progressive motility was 6.5 (95% confidence interval [CI], 0.6, 12.3) percentage units higher among men in the highest quartile of β-carotene intake compared with men in the lowest quartile. Similar results were observed for lutein intake. Lycopene intake was positively related to sperm morphology. The adjusted percentages (95% CI) of morphologically normal sperm in increasing quartiles of lycopene intake were 8.0 (6.7, 9.3), 7.7 (6.4, 9.0), 9.2 (7.9, 10.5), and 9.7 (8.4, 11.0). There was a nonlinear relationship between vitamin C intake and sperm concentration, with men in the second quartile of intake having, on average, the highest sperm concentrations and men in the top quartile of intake having the lowest concentrations. CONCLUSION(S) In a population of healthy young men, carotenoid intake was associated with higher sperm motility and, in the case of lycopene, better sperm morphology. Our data suggest that dietary carotenoids may have a positive impact on semen quality.
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Affiliation(s)
- Piotr Zareba
- MPH Program, Harvard School of Public Health, Boston, MA
- Division of Urology, McMaster University, Hamilton, Ontario, Canada
| | - Daniela S. Colaci
- Department of Nutrition, Harvard School of Public Health, Boston, MA
| | - Myriam Afeiche
- Department of Nutrition, Harvard School of Public Health, Boston, MA
| | - Audrey J. Gaskins
- Department of Nutrition, Harvard School of Public Health, Boston, MA
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
| | - Niels Jørgensen
- University Department of Growth and Reproduction, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Jaime Mendiola
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, Murcia, Spain
| | - Shanna H. Swan
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine, Rochester, NY
- Department of Preventive Medicine, Mount Sinai School of Medicine, New York, NY
| | - Jorge E. Chavarro
- Department of Nutrition, Harvard School of Public Health, Boston, MA
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Zareba P, Colaci DS, Afeiche M, Gaskins AJ, Jørgensen N, Mendiola J, Swan SH, Chavarro JE. Semen quality in relation to antioxidant intake in a healthy male population. Fertil Steril 2013. [PMID: 24094424 DOI: 10.1016/j.fertnstert.2013.08.032.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the relationship between dietary antioxidant intake and semen quality in young healthy males. DESIGN Cross-sectional study. SETTING University and college campuses in the Rochester, New York, area. PATIENT(S) One hundred eighty-nine university-aged men. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Semen volume, total sperm count, concentration, motility, total motile count, and morphology. RESULT(S) Progressive motility was 6.5 (95% confidence interval [CI], 0.6, 12.3) percentage units higher among men in the highest quartile of β-carotene intake compared with men in the lowest quartile. Similar results were observed for lutein intake. Lycopene intake was positively related to sperm morphology. The adjusted percentages (95% CI) of morphologically normal sperm in increasing quartiles of lycopene intake were 8.0 (6.7, 9.3), 7.7 (6.4, 9.0), 9.2 (7.9, 10.5), and 9.7 (8.4, 11.0). There was a nonlinear relationship between vitamin C intake and sperm concentration, with men in the second quartile of intake having, on average, the highest sperm concentrations and men in the top quartile of intake having the lowest concentrations. CONCLUSION(S) In a population of healthy young men, carotenoid intake was associated with higher sperm motility and, in the case of lycopene, better sperm morphology. Our data suggest that dietary carotenoids may have a positive impact on semen quality.
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Affiliation(s)
- Piotr Zareba
- Masters of Public Health Program, Harvard School of Public Health, Boston, Massachusetts; Division of Urology, McMaster University, Hamilton, Ontario, Canada
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Zareba P, Abdulla A, Bowen J, Hopkins R, Tarride JE, Whelan JP. 2015 CHANGES IN ERECTILE FUNCTION AFTER PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE FOR BENIGN PROSTATIC HYPERPLASIA. J Urol 2012. [DOI: 10.1016/j.juro.2012.02.2178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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20
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Zareba P, Zhang J, Yilmaz A, Trpkov K. The impact of the 2005 International Society of Urological Pathology (ISUP) consensus on Gleason grading in contemporary practice. Histopathology 2010; 55:384-91. [PMID: 19817888 DOI: 10.1111/j.1365-2559.2009.03405.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
AIMS To investigate the impact of the 2005 International Society of Urological Pathology (ISUP) Gleason grading consensus in contemporary practice. METHODS AND RESULTS The Gleason scores (GS) were compared in two consecutive patient cohorts with matched biopsies and prostatectomies: (i) 908 patients evaluated before the ISUP consensus (July 2000-June 2004) and (ii) 423 patients evaluated after the ISUP consensus (October 2005-June 2007). All biopsies and prostatectomies were performed and scored in one institution and were sampled and processed identically. There was a higher percentage of biopsy and prostatectomy specimens with GS > or = 7 after the ISUP consensus (GS > or = 7 on biopsy in 32% before ISUP versus 46% after ISUP; GS > or = 7 on prostatectomy in 53% before ISUP versus 68% after ISUP; P < 0.001). No significant difference in the complete and + or -1 unit Gleason agreement was found before and after the ISUP consensus. There was a trend towards better complete agreement for GS > or = 7 after the ISUP consensus. CONCLUSIONS There was a shift towards higher GS on biopsy and prostatectomy in our practice after the ISUP consensus, although - there was no significant impact on the biopsy-prostatectomy Gleason agreement. The significance of this shift for patient management and prognosis is uncertain.
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Affiliation(s)
- Piotr Zareba
- Department of Pathology and Laboratory Medicine, Calgary Laboratory Services and University of Calgary, Calgary, Canada
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