Upper urinary tract urothelial carcinoma with loco‐regional nodal metastases: insights from the Upper Tract Urothelial Carcinoma Collaboration

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/86906/1/j.1464-410X.2011.10075.x.pd

Advanced patient age is associated with inferior cancer-specific survival after radical nephroureterectomy

Study Type – Prognosis (case series) Level of Evidence 4To assess the impact of patient age on outcomes after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).Data were collected on 1453 patients treated with RNU at 13 centres. Pathological slides were reviewed by dedicated genitourinary pathologists according to standardized criteria. Age at RNU was analysed both as a continuous and categorical variable (70 years were less likely to undergo lymphadenectomy and to receive adjuvant chemotherapy ( P  ≤ 0.026). In multivariable analyses, being older was associated with decreased all-cause (AC) survival (>60 years) and cancer-specific survival (CSS; >80 years) after controlling for the effects of standard pathological features ( P  ≤ 0.006). However, addition of age did not improve the predictive accuracy of a base model that included standard pathological features for prediction of either disease recurrence, AC survival or CSS.Being older at the time of RNU was associated with decreased survival. This finding could be due to a change in the biological potential of the tumour cell, a decrease in the host’s defence mechanisms, or differences in care patterns. Further work is needed to improve our understanding of UTUC outcomes in this growing segment of the population and to develop strategies to improve cancer control in the elderly.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78588/1/j.1464-410X.2009.09072.x.pd

Tumour architecture is an independent predictor of outcomes after nephroureterectomy: a multi-institutional analysis of 1363 patients

To assess whether tumour architecture can help to refine the prognosis of patients treated with nephroureterectomy (NU) for urothelial carcinoma (UC) of the upper urinary tract (UT), as the prognostic value of tumour architecture (papillary vs sessile) in UTUC remains elusive. PATIENTS AND METHODS The study included 1363 patients with UTUC and treated with radical NU at 12 centres worldwide. All slides were re-reviewed according to strict criteria by genitourinary pathologists who were unaware of the findings of the original pathology slides and clinical outcomes. Gross tumour architecture was categorized as sessile vs papillary. RESULTS Papillary growth was identified in 983 patients (72.2%) and sessile growth in 380 (27.8%). The sessile growth pattern was associated with higher tumour grade, more advanced stage, lymphovascular invasion, and metastasis to lymph nodes (all P  < 0.001). In multivariable Cox regression analyses that adjusted for the effects of pathological stage, grade and lymph node status, tumour architecture (sessile or papillary) was an independent predictor of cancer recurrence (hazard ratio 1.5, P  = 0.002) and cancer-specific mortality (1.6, P  = 0.001). Adding tumour architecture increased the predictive accuracy of a model that comprised pathological stage, grade and lymph node status for predicting cancer recurrence and cancer-specific death by a minimal but statistically significant margin (gain in predictive accuracy 1% and 0.5%, both P  < 0.001). CONCLUSION The tumour architecture of UTUC is associated with established features of biologically aggressive disease, and more importantly, with prognosis after radical NU. Including tumour architecture in predictive models for disease progression should be considered, aiming to identify patients who might benefit from early systemic therapeutic intervention.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72257/1/j.1464-410X.2008.08003.x.pd

Fatores de risco para prolongamento do tempo de permanência após cirurgia colorretal

OBJETIVO: Os cirurgiões proctologistas muitas vezes enfrentam dificuldades para explicar aos administradores/contribuintes as razões para o prolongamento do tempo de internação hospitalar (TIH). O objetivo deste estudo foi identificar os fatores associados ao aumento do TIH após cirurgia colorretal. MÉTODO: A população do estudo incluiu pacientes que constam do banco de dados do American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) no ano de 2007 e que foram submetidos à ressecção ileocólica, colectomia segmentar ou ressecção anterior. A população do estudo foi dividida em normal (abaixo do percentil 75) e TIH prolongado (acima do percentil 75). A análise multivariada foi realizada usando o TIH prolongado como variável dependente e as variáveis do ACS-NSQIP como preditivas. Um valor de p < 0,01 foi considerado significativo. RESULTADOS: No total, 12.269 pacientes com um TIH mediano de 6 dias (intervalo interquartil, 4-9) foram incluídos. Havia 2.617 pacientes (21,3%) com TIH prolongado (mediana, 15 dias; intervalo interquartil, 13-22). A idade média dos pacientes era de 69 anos (intervalo interquartil, 57-79) e 1.308 (50%) eram do sexo feminino. Os fatores de risco para TIH prolongado foram sexo masculino, insuficiência cardíaca congestiva, perda de peso, doença de Crohn, albumina < 3,5 g/dL e hematócrito < 47% no pré-operatório, sepse basal, classe ASA ≥ 3, cirurgia aberta, tempo cirúrgico ≥ 190 minutos, pneumonia no pós-operatório, falha no desmame da ventilação mecânica, trombose venosa profunda, infecção do trato urinário, sepse sistêmica, infecção do sítio cirúrgico e reoperação dentro de 30 dias da cirurgia primária. CONCLUSÃO: Vários fatores estão associados ao aumento do TIH após a cirurgia colorretal. Nossos resultados são úteis para que os cirurgiões possam explicar os TIH prolongados aos administradores/contribuintes que são críticos dessa métrica.OBJECTIVE: Colorectal surgeons often struggle to explain to administrators/payers reasons for prolonged length of stay (LOS). This study aim was to identify factors associated with increased LOS after colorectal surgery. DESIGN: The study population included patients from the 2007 American-College-of-Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database undergoing ileocolic resection, segmental colectomy, or anterior resection. The study population was divided into normal (below 75th percentile) and prolonged LOS (above the 75th percentile). A multivariate analysis was performed using prolonged LOS as dependent variable and ACS-NSQIP variables as predictive variables. P-value < 0.01 was considered significant. RESULTS: 12,269 patients with a median LOS of 6 (inter-quartile range 4-9) days were included. There were 2,617 (21.3%) patients with prolonged LOS (median 15 days, inter-quartile range 13-22). 1,308 (50%) were female, and the median age was 69 (inter-quartile range 57-79) years. Risk factors for prolonged LOS were male gender, congestive heart failure, weight loss, Crohn's disease, preoperative albumin < 3.5 g/dL and hematocrit < 47%, baseline sepsis, ASA class ≥ 3, open surgery, surgical time ≥ 190 min, postoperative pneumonia, failure to wean from mechanical ventilation, deep venous thrombosis, urinary-tract infection, systemic sepsis, surgical site infection and reoperation within 30-days from the primary surgery. CONCLUSION: Multiple factors are associated with increased LOS after colorectal surgery. Our results are useful for surgeons to explain prolonged LOS to administrators/payers who are critical of this metric

Racial differences in the outcome of patients with urothelial carcinoma of the upper urinary tract: an international study

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/86897/1/j.1464-410X.2011.10188.x.pd

Obstructive sleep apnea and its malajemente in patients with atrial fibrillation: An International Collaboration of Sleep Apnea Cardiovascular Trialists (INCOSACT) global survey of practicing cardiologists

Background: Among international cardiologists it is unclear whether equipoise exists regarding the benefit of diagnosing and managing obstructive sleep apnea (OSA) to improve atrial fibrillation (AF) outcomes and whether clinical practice and equipoise are linked. Methods: Between January 2019 and June 2020 we distributed a web-based 12-question survey regarding OSA and AF management to practicing cardiologists in 16 countries. Results: The United States, Japan, Sweden, and Turkey accounted for two-thirds of responses. 863 cardiologists responded; half were general cardiologists, a quarter electrophysiologists. Responses regarding treating OSA with CPAP to improve AF endpoints were mixed. 33% of respondents referred AF patients for OSA screening. OSA was diagnosed in 48% of referred patients and continuous positive airway pressure (CPAP) was prescribed for 59% of them. Nearly 70% of respondents believed randomized controlled trials (RCTs) of OSA treatment in AF patients were necessary and indicated willingness to contribute to such trials. Conclusions: There was no clinical equipoise among surveyed cardiologists; a majority expressed certainty that combined OSA and AF treatment is superior to AF treatment alone for improving AF outcomes. However, a minority of surveyed cardiologists referred AF patients for OSA testing, and while half of screened AF patients had OSA, CPAP was prescribed in little more than half of them, reflecting the view that better clinical trial evidence is needed to support this practice. Our results underscore the need for larger, multi-national prospective studies of OSA treatment and AF outcomes to inform more uniform society guideline recommendations

Hypothalamic-pituitary-gonadal axis hormones and cortisol in both menstrual phases of women with chronic fatigue syndrome and effect of depressive mood on these hormones

BACKGROUND: Chronic fatigue syndrome (CFS) is a disease which defined as medically unexplained, disabling fatigue of 6 months or more duration and often accompanied by several of a long list of physical complaints. We aimed to investigate abnormalities of hypothalamic-pituitary-gonadal (HPG) axis hormones and cortisol concentrations in premenopausal women with CFS and find out effects of depression rate on these hormones. METHODS: We examined follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone and cortisol concentrations in 43 premenopausal women (mean age: 32.86 ± 7.11) with CFS and compared matched 35 healthy controls (mean age: 31.14 ± 6.19). Patients were divided according to menstrual cycle phases (follicular and luteal) and compared with matched phase controls. Depression rate was assessed by Beck Depression Inventory (BDI), and patients with high BDI scores were compared to patients with low BDI scores. RESULTS: There were no significant differences in FSH, LH, estradiol and progesterone levels in both of menstrual phases of patients versus controls. Cortisol levels were significantly lower in patients compared to controls. There were no significant differences in all hormone levels in patients with high depression scores versus patients with low depression scores. CONCLUSION: In spite of high depression rate, low cortisol concentration and normal HPG axis hormones of both menstrual phases are detected in premenopausal women with CFS. There is no differentiation between patients with high and low depression rate in all hormone levels. Depression condition of CFS may be different from classical depression and evaluation of HPG and HPA axis should be performed for understanding of pathophysiology of CFS and planning of treatment

Discrepancy between radiological and pathological size of renal masses

<p>Abstract</p> <p>Background</p> <p>Tumor size is a critical variable in staging for renal cell carcinoma. Clinicians rely on radiological estimates of pathological tumor size to guide patient counseling regarding prognosis, choice of treatment strategy and entry into clinical trials. If there is a discrepancy between radiological and pathological measurements of renal tumor size, this could have implications for clinical practice. Our study aimed to compare the radiological size of solid renal tumors on computed tomography (CT) to the pathological size in an Australian population.</p> <p>Methods</p> <p>We identified 157 patients in the Westmead Renal Tumor Database, for whom data was available for both radiological tumor size on CT and pathological tumor size. The paired Student's <it>t</it>-test was used to compare the mean radiological tumor size and the mean pathological tumor size. Statistical significance was defined as <it>P </it>< 0.05. We also identified all cases in which post-operative down-staging or up-staging occurred due to discrepancy between radiological and pathological tumor sizes. Additionally, we examined the relationship between Fuhrman grade and radiological tumor size and pathological T stage.</p> <p>Results</p> <p>Overall, the mean radiological tumor size on CT was 58.3 mm and the mean pathological size was 55.2 mm. On average, CT overestimated pathological size by 3.1 mm (<it>P </it>= 0.012). CT overestimated pathological tumor size in 92 (58.6%) patients, underestimated in 44 (28.0%) patients and equaled pathological size in 21 (31.4%) patients. Among the 122 patients with pT1 or pT2 tumors, there was a discrepancy between clinical and pathological staging in 35 (29%) patients. Of these, 21 (17%) patients were down-staged post-operatively and 14 (11.5%) were up-staged. Fuhrman grade correlated positively with radiological tumor size (<it>P </it>= 0.039) and pathological tumor stage (<it>P </it>= 0.003).</p> <p>Conclusions</p> <p>There was a statistically significant but small difference (3.1 mm) between mean radiological and mean pathological tumor size, but this is of uncertain clinical significance. For some patients, the difference leads to a discrepancy between clinical and pathological staging, which may have implications for pre-operative patient counseling regarding prognosis and management.</p

High-Level Expression of Notch1 Increased the Risk of Metastasis in T1 Stage Clear Cell Renal Cell Carcinoma

Background: Although metastasis of clear cell renal cell carcinoma (ccRCC) is basically observed in late stage tumors, T1 stage metastasis of ccRCC can also be found with no definite molecular cause resulting inappropriate selection of surgery method and poor prognosis. Notch signaling is a conserved, widely expressed signal pathway that mediates various cellular processes in normal development and tumorigenesis. This study aims to explore the potential role and mechanism of Notch signaling in the metastasis of T1 stage ccRCC. Methodology/Principal Findings: The expression of Notch1 and Jagged1 were analyzed in tumor tissues and matched normal adjacent tissues obtained from 51 ccRCC patients. Compared to non-tumor tissues, Notch1 and Jagged1 expression was significantly elevated both in mRNA and protein levels in tumors. Tissue samples of localized and metastatic tumors were divided into three groups based on their tumor stages and the relative mRNA expression of Notch1 and Jagged1 were analyzed. Compared to localized tumors, Notch1 expression was significantly elevated in metastatic tumors in T1 stage while Jagged1 expression was not statistically different between localized and metastatic tumors of all stages. The average size of metastatic tumors was significantly larger than localized tumors in T1 stage ccRCC and the elevated expression of Notch1 was significantly positive correlated with the tumor diameter. The functional significance of Notch signaling was studied by transfection of 786-O, Caki-1 and HKC cell lines with full-length expression plasmids of Notch1 and Jagged1