Background:Prepectoral breast reconstruction is increasingly popular. This study compares complications between 2 subpectoral and 1 prepectoral breast reconstruction technique.Methods:Between 2008 and 2015, 294 two-staged expander breast reconstructions in 213 patients were performed with 1 of 3 surgical techniques: (1) Prepectoral, (2) subpectoral with acellular dermal matrix (ADM) sling (“Classic”), or (3) subpectoral/subserratus expander placement without ADM (“No ADM”). Demographics, comorbidities, radiation therapy, and chemotherapy were assessed for correlation with Clavien IIIb score outcomes. Follow-up was a minimum of 6 months.Results:Surgical cohorts (n = 165 Prepectoral; n = 77 Classic; n = 52 No ADM) had comparable demographics except Classic had more cardiac disease (P = 0.03), No ADM had higher body mass index (BMI) (P = 0.01), and the Prepectoral group had more nipple-sparing mastectomies (P < 0.001). Univariate analysis showed higher expander complications with BMI ≥ 40 (P = 0.05), stage 4 breast cancer (P = 0.01), and contralateral prophylactic mastectomy (P = 0.1), whereas implant complications were associated with prior history of radiation (P < 0.01). There was more skin necrosis (P = 0.05) and overall expander complications (P = 0.01) in the Classic cohort, whereas the No ADM group trended toward the lowest expander complications among the 3. Multivariate analysis showed no difference in overall expander complication rates between the 3 groups matching demographics, mastectomy surgery, risks, and surgical technique.Conclusions:Prepectoral and subpectoral Classic and No ADM breast reconstructions demonstrated comparable grade IIIb Clavien score complications. BMI > 40, stage 4 cancer, and contralateral prophylactic mastectomy were associated with adverse expander outcomes and a prior history of radiation therapy adversely impacted implant outcomes. Ninety-day follow-up for expander and implant complications may be a better National Surgical Quality Improvement Program measure.
ObjectivesTo evaluate the relationship between surgeon volume of radical cystectomy (RC) and postoperative morbidity, and to assess the economic burden of bladder cancer in the USA. MethodsWe captured all patients who underwent RC (International Classification of Diseases, ninth revision, code 57.71) between 2003 and 2010, using a nationwide hospital discharge database. Patient, hospital and surgical characteristics were evaluated. The annual volume of RCs performed by the surgeons was divided into quintiles. Multivariable regression models were developed, adjusting for clustering and survey weighting, to evaluate the outcomes, including 90-day major complications (Clavien grade III-V) and direct patient costs. We adjusted for clustering and weighting to achieve a nationally representative analysis. ResultsThe weighted cohort included 49 792 patients who underwent RC, with an overall 90-day major complication rate of 16.2%. Compared with surgeons performing one RC annually, surgeons performing ≥7 RCs each year had 45% lower odds of major complications (odds ratio [OR] 0.55; P < 0.001) and lower costs by $1690 (P = 0.02). Results were consistent when we analysed surgeon volume as a continuous variable and when we examined the surgeons with the highest volumes (≥28 cases annually), which showed markedly lower odds of major complications compared with the surgeons with the lowest volumes (OR 0.45, 95% CI 0.31-0.67; P < 0.001). Compared with patients who did not have any complications, those who had a major complication were associated with significantly higher 90-day median direct hospital costs ($43 965 vs $24 341; P < 0.001). ConclusionsWe showed that there was an inverse relationship between surgeon volume and the development of postoperative 90-day major complication rates as well as direct hospital costs. Centralisation of RC to surgeons with higher volumes may reduce the development of postoperative major complications, thereby decreasing the burden of bladder cancer on the healthcare system.
Monoamine oxidase A (MAO-A) expression is associated with high-grade prostate cancer. Immunohistochemistry showed that MAO-A is also expressed in the basal epithelial cells of normal prostate glands. Using cultured primary prostatic epithelial cells as a model, we showed that MAO-A prevents basal epithelial cells from differentiating into secretory cells. Under differentiationpromoting conditions, clorgyline, an irreversible MAO-A inhibitor, induced secretory cell-like morphology and repressed expression of cytokeratin 14, a basal cell marker. More importantly, clorgyline induced mRNA and protein expression of androgen receptor (AR), a hallmark of secretory epithelial cells. In clorgyline-treated cells, androgen induced luciferase activity controlled by the promoter of prostate-specific antigen, an AR target gene, in a dose-dependent manner. This activity was blocked by the AR antagonist Casodex, showing that AR is functional. In turn, androgen decreased MAO-A expression in clorgyline-treated, secretory-like cells. Our results demonstrated that cultured basal epithelial cells have the potential to differentiate into secretory cells, and that inhibition of MAO-A is a key factor in promoting this process. Increased expression of MAO-A in high-grade prostate cancer may be an important contributor to its de-differentiated phenotype, raising the possibility that MAO-A inhibition may restore differentiation and reverse the aggressive behavior of high-grade cancer.
Purpose-Gleason grade 4/5 prostate cancer is a determinant for recurrence following radical prostatectomy. Monoamine oxidase-A is over expressed in grade 4/5 compared to grade 3 cancer. Monoamine oxidase-A is also expressed by normal basal cells and in vitro studies suggest that its function is to repress secretory differentiation. Therefore, monoamine oxidase-A in grade 4/5 cancer might reflect dedifferentiation to a basal cell-like phenotype. We investigated whether monoamine oxidase-A expression correlates with another basal cell protein, CD44, in high grade cancer and whether either is associated with an aggressive phenotype.Materials and Methods-A total of 133 grade 4/5 archival cancers from a cohort previously used to evaluate the prognostic significance of histomorphological variables were scored for monoamine oxidase-A and CD44 immunohistochemical labeling. Spearman rank correlations of the proteins, and histomorphological and clinical variables were determined. The univariate and multivariate value of each variable as a determinant of biochemical recurrence was assessed by logistic regression.Results-Monoamine oxidase-A expression correlated with CD44. Neither was prognostic for biochemical recurrence. However, monoamine oxidase-A expression positively correlated with preoperative serum prostate specific antigen and the percent of grade 4/5 cancer.Conclusions-Concurrent expression of monoamine oxidase-A and CD44 suggests that grade 4/5 cancer may be basal cell-like in nature, despite the absence of other classic basal cell biomarkers such as cytokeratins 5 and 14, and p63. The correlation of monoamine oxidase-A expression with prostate specific antigen and the percent of grade 4/5 cancer suggests that monoamine oxidase-A may contribute to growth of high grade cancer and that antidepressant drugs that target monoamine oxidase-A may have applications in treating prostate cancer. Keywordsprostate; monoamine oxidase; neoplasm recurrence, local; adenocarcinoma; CD44 protein, humanThe presence of Gleason grades 4 and/or 5 cancer in primary adenocarcinoma of the prostate is associated with a poor outcome following radical prostatectomy. 1 The primary determinant of failure to cure prostate cancer by surgery is the percent of Gleason grade 4/5 present in the largest (index) cancer. 2 Individuals in whom cancer is composed entirely of Gleason grade 3 have a greater than 95% chance of being cured by surgery. In contrast, for approximately every 10% increase in the percent of grade 4/5 cancer present at surgery there is a 10% biochemical The functions of MAO-A in the nervous system have been extensively studied and inhibitors of its activity have therapeutic value in neurological diseases. 4 However, MAO-A actions in other tissues are not as well understood. In studies to reveal the biological role of MAO-A in prostate cancer we observed that MAO-A is also highly expressed in basal but not in secretory cells of the normal prostatic epithelium. 5 Furthermore, using a primary cell culture model we noted that...
The AR-V1 or V7 transcript level does not predict recurrence in patients with high grade prostate cancer at indeterminate risk for progression. Grade 3 cancer in mixed grade tumors may differ from 100% grade 3 cancer, at least in AR-V1 expression.
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