Journal Article Page
European UrologyVolume 61, issue 5, pages e41-e52, May 2012
Clinical, Molecular, and Genetic Correlates of Lymphatic Spread in Clear Cell Renal Cell Carcinoma
Accepted 9 January 2012, Published online 18 January 2012, pages 888 - 895
While it is well known that clear cell renal cell carcinoma (ccRCC) that presents with lymphatic spread is associated with an extremely poor prognosis, its molecular and genetic biology is poorly understood.
Define the clinicopathologic, molecular, and genetic biological characteristics of these tumors in comparison to nonmetastatic (N0M0) renal cell carcinomas.
Design, setting, and participants
A retrospective study defined clinicopathologic features, expression of 28 molecular markers, and occurrence of chromosomal aberrations for their correlation with lymphatic spread in three cohorts of 502, 196, and 272 patients, respectively.
Fisher exact test or the χ2 test were used to compare categorical variables; continuous variables were compared with the Mann-Whitney U test or student t test. Cut-off values were calculated based on receiver operating characteristic curves and the Youden Index. Uni- and multivariate regression analyses were used to investigate the correlation with lymphatic spread.
Results and limitations
In clinical analyses, a predictive model consisting of smoking history (p = 0.040), T stage (p < 0.0001), Fuhrman grade (p < 0.0001), Eastern Cooperative Oncology Group performance status (p < 0.0001), and microvascular invasion (p < 0.0001) was independently associated with lymphatic spread. After adjustment with these clinical variables, low carbonic anhydrase IX (CAIX) (p = 0.043) and high epithelial vascular endothelial growth factor receptor 2 (p = 0.033) protein expression were associated with a higher risk of lymphatic spread, and loss of chromosome 3p (p < 0.0001) with a lower risk. The current study is limited by its retrospective design, small sample size, and single-center experience.
The low rates of CAIX expression and loss of chromosome 3p suggest that lymphatic spread in ccRCC occurs independently of von Hippel-Lindau tumor suppressor inactivation.
According to the World Health Organization, renal cell carcinoma (RCC) accounted for 116 500 deaths in 2008 . Although the incidence of localized (N0M0) RCCs has risen , 20–30% of patients still present with metastatic disease , and despite the implementation of effective targeted drug treatments, metastatic disease is still associated with a grim prognosis . This is particularly true for RCCs having lymph node involvement, which is an entity reported to have particularly poor survival  and . For example, the US National Institutes of Health reported a median overall survival of 14.7 mo for patients without lymph nodes compared to 8.5 mo for patients with lymph nodes . Likewise, in data from the University of California, Los Angeles (UCLA) , the presence of positive lymph nodes in M1 patients was associated with larger, higher-grade primary tumors that were more commonly associated with sarcomatoid features. Moreover, N + M1 patients had a median survival of 10.5 mo compared with 20.4 mo for N0M1 patients, respectively. The median survival of N0M1 patients was improved to 28 mo in those who received adjunctive immunotherapy, while the median survival of patients with N + M1 disease was the same in those treated with and those treated without adjunctive immunotherapy. While these are well known clinical observations, the biological background that underlies the poor outcomes of lymphatic spread in RCC is still poorly understood. We hypothesized that clear cell RCCs (ccRCCs) with lymphatic spread represent a unique subtype of ccRCC, having their own definable clinical, genetic, and molecular features. To investigate this hypothesis, we analyzed the clinicopathologic features, protein expression profiles, and chromosomal aberrations that were independently associated with node-positive ccRCC.
2. Materials and methods
2.1. Clinical analysis
We first aimed to examine a broad spectrum of clinicopathologic features to identify those associated with lymphatic spread. Therefore, 502 patients treated for RCC between 1989 and 2007 were extracted from the institutional review board-approved UCLA kidney cancer database. Inclusion criteria were a full dataset in terms of age, gender, Eastern Cooperative Oncology Group performance status (ECOG PS) , smoking history, and comorbidities such as hypertension, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and coronary artery disease. Pathologic data included TNM stages , tumor size, Fuhrman grade , and the presence of microvascular invasion (MVI) or macrovascular invasion (MAVI), collecting duct invasion (CDI), multifocality, and sarcomatoid features.
N-stage status was defined according to pathologic findings or by clinical data when applicable. Clinically, lymphadenopathy was defined as enlarged (≥1 cm3) hilar or retroperitoneal lymph nodes on preoperative computerized tomography or magnetic resonance imaging. All patients underwent a minimum of an ipsilateral hilar lymph node dissection (LND) in the absence of clinically suspicious nodes. The decision to perform an extended LND was based on the finding of abnormal lymph nodes detected on preoperative imaging or at the time of surgery, a practice that historically has resulted in only an 8% incidental positive lymph node rate . The extent of LND was determined by individual surgeon practice without a standardized institutional template. All positive lymph nodes were confirmed by histologic examination. Data on number of lymph nodes removed and their rate of positivity are not available in our database.
2.2. Molecular analysis
Secondary investigation using a tissue microarray (TMA) was performed to evaluate molecular characteristics. The study subcohort consisted of 196 randomly selected ccRCC patients who underwent nephrectomy at UCLA between 1989 and 2000. For molecular analysis, we chose markers relevant to RCC biology as part of the hypoxia-inducible factor (HIF) pathway (HIF-1α, carbonic anhydrase IX [CAIX], vascular endothelial growth factor [VEGF]-A, VEGF-C, VEGF-D, and VEGF-R1-3) and the mammalian target of rapamycin (mTOR) pathway (p27, pAkt, pS6, phosphatase and tensin homolog [PTEN]) or have otherwise been demonstrated to be important prognostic markers (CAXII, Ki67, p53, p21, Gelsolin, EpCam, Vimentin, and chemokine (C-X-C motif) receptor 3 [CXCR3]) in RCC.
Three core-tissue biopsies, 0.6 mm in diameter, were taken from selected morphologically representative regions of formalin-fixed, paraffin-embedded, primary tumor specimens and arrayed using methods described previously . Immunohistochemical staining was performed as described previously  using appropriate positive and negative controls. A single pathologist (D.B.S.) blinded to clinicopathologic variables and clinical outcome performed quantitative assessment for each antibody. The extent of expression (staining frequency) was recorded as a percentage of the entire tumor sample that stained positive as a pooled mean of three spots. Staining intensity was not considered because in prior experience using our TMA, staining intensity appears to be a subjective variable influenced by fixation protocols, tissue types, and storage time of tissue specimens .
2.3. Cytogenetic analysis
Tumor samples were collected immediately after nephrectomy from 272 ccRCC tumors treated between 1989 and 2007 and aseptically minced into 2- to 3-mm pieces. The detailed tissue preparation protocol was described previously . From each tumor, 20 metaphases were analyzed in accordance with the International System for Human Cytogenetic Nomenclature  by one clinical cytogeneticist (P.N.R.).
2.4. Statistical analysis
The clinicopathologic features and chromosomal aberrations in a single group of lymph node–positive ccRCCs (N + M0) (26, 8, and 6 in the clinical, molecular, and cytogenetic analyses respectively) or N + M1 (73, 30, and 22 in the clinical, molecular, and cytogenetic analyses, respectively) were compared to another group of lymph node–negative (N0M0) tumors using the χ2 test and Fisher exact test for categorical variables and student t test for continuous variables. In TMA analysis, protein expressions of lymphatic RCCs were compared to those for N0M0 tumors using the Mann-Whitney U test. Cut-off values were calculated based on receiver operating characteristic (ROC) curves and the Youden Index.
Univariate and multiple logistic regression analyses were used to test the independent association of clinical, molecular, and cytogenetic variables with lymphatic spread. For univariate analysis, only those variables that occurred in N+ patients with significant differences or had statistically different expression compared to N0M0 patients were investigated. Clinicopathologic features that demonstrated an independent correlation in univariate logistic regression analysis were further evaluated by adjustment in multiple logistic regression analysis including molecular and cytogenetic variables. For calculation of multiple logistic regression models, a backward stepwise selection with the likelihood ratio criterion (including and exclusion criteria were p≤ 0.05 and p≥ 0.10, respectively) was used. The rank of elimination was given when a variable was removed from the equation, and the odds ratio (OR), 95% confidence interval (CI), and the p value for the removed variable were obtained during the removal step. All variables were investigated as continuous variables to avoid overfitting of the models. The statistical tests were two-sided and performed at a significance level of 0.05 using the PASW (SPSS) v.18.0 software package (IBM Corp., Armonk, NY, USA).
3.1. Clinical analysis
The comparisons of patient and tumor characteristics are summarized in Table 1. Tumor size (OR: 1.176; 95% CI, 1.113–1.243; p < 0.0001); sarcomatoid features (OR: 6.618; 95% CI, 2.741–15.976; p < 0.0001); multifocality (OR: 2.039; 95% CI, 1.153–3.605; p = 0.014); hypertension (OR: 0.588; 95% CI, 0.368–0.939; p = 0.026); smoking history (OR: 2.012; 95% CI, 1.290–3.196; p = 0.002); T stage (OR: 4.427; 95% CI, 3.169–6.138; p < 0.0001); Fuhrman grade (OR: 3.103; 95% CI, 2.267–4.248; p < 0.0001); ECOG PS (OR: 2.521; 95% CI, 1.722–3.689; p < 0.0001); CDI (OR: 1.858; 95% CI, 1.057–3.267; p = 0.031); MAVI (OR: 2.515; 95% CI, 1.502–4.211; p < 0.0001); and MVI (OR: 5.795; 95% CI, 3.032–11.077; p < 0.0001) all showed statistically significantly associations with lymphatic spread in univariate logistic regression analysis. The results of multiple logistic regression analysis are summarized in Table 2.
|Localized Patients, no. (%)||Lymphatic Patients, no. (%)||p value||Test|
|mean ± SD||59.79 ± 12.79||58.15 ± 11.90||0.248||Student t|
|Female||176 (43.7)||38 (38.4)||0.366||Fisher exact|
|Male||227 (56.3)||61 (61.6)|
|No||352 (87.3)||89 (89.9)||0.607||Fisher exact|
|Yes||51 (12.7)||10 (10.1)|
|No||227 (56.3)||68 (68.7)||0.030||Fisher exact|
|Yes||176 (43.7)||31 (31.3)|
|No||352 (87.3)||89 (89.9)||0.607||Fisher exact|
|Yes||51 (12.7)||10 (10.1)|
|No||393 (97.5)||95 (96.0)||0.492||Fisher exact|
|Yes||10 (2.5)||4 (4.0)|
|No||260 (64.5)||47 (47.5)||0.003||Fisher exact|
|Yes||143 (35.5)||52 (52.5)|
|Tumor size, cm, mean ± SD||6.22 ± 3.82||8.93 ± 3.64||<0.0001||Student t|
|T1||230 (57.1)||6 (6.1)|
|T2||63 (15.6)||11 (11.1)||Chi-square|
|T3||104 (25.8)||72 (72.7)||<0.0001|
|T4||6 (1.5)||10 (10.1)|
|Organ-confined (T1 + 2) tumor||293 (72.7)||17 (17.2)||<0.0001||Fisher exact|
|vs advanced (T3 + 4) tumor||110 (27.3)||82 (82.8)|
|I||78 (19.3)||3 (3.0)|
|II||211 (52.4)||34 (34.3)||Chi-square|
|III||102 (25.3)||42 (42.4)||<0.0001|
|IV||12 (3.0)||20 (20.2)|
|0||239 (59.3)||35 (35.4)|
|1||156 (38.7)||56 (56.6)||Chi-square|
|2||8 (2.0)||6 (6.1)||<0.0001|
|3||0 (0.0)||2 (2.0)|
|No||394 (97.8)||86 (86.9)||<0.0001||Fisher exact|
|Yes||9 (2.2)||13 (13.1)|
|No||352 (87.3)||78 (78.8)||0.037||Fisher exact|
|Yes||51 (12.7)||21 (21.2)|
|No||346 (85.9)||70 (70.7)||0.001||Fisher exact|
|Yes||57 (14.1)||29 (29.3)|
|No||383 (95.0)||76 (76.8)||<0.0001||Fisher exact|
|Yes||20 (5.0)||23 (23.2)|
|No||356 (88.3)||78 (78.8)||0.021||Fisher exact|
|Yes||47 (11.7)||21 (21.2)|
SD = standard deviation; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; ECOG PS = Eastern Cooperative Oncology Group performance status; CDI = collecting duct invasion; MAVI = macrovascular invasion; MVI = microvascular invasion.
|Factor||Rank of elimination from analysis||OR||95% CI||p value|
OR = odds ratio; CI = confidence interval; ECOG PS = Eastern Cooperative Oncology Group performance status; MVI = microvascular invasion; CDI = collecting duct invasion; MAVI = macrovascular invasion.
3.2. Molecular analysis
Compared to N0M0 tumors, an expression pattern characterized by low expression of CAIX, CAXII, and endothelial VEGFR-3, and high expression of Ki67, epithelial VEGF-A, epithelial VEGFR-1, epithelial VEGFR-2, and pS6 was associated with lymphatic tumors (Fig. 1), as follows (percentages represent the mean positive staining within each group plus or minus the standard deviation):
- • CAIX: 84.93% ± 32.81% versus 68.59% ± 41.34%; p = 0.005
- • CAXII: 93.80% ± 21.60% versus 81.58% ± 34.02%; p = 0.001
- • Endothelial VEGFR-3: 34.03% ± 27.49% versus 18.05% ± 17.51; p = 0.001
- • Ki67: 6.39% ± 8.07% versus 12.99% ± 14.13%; p = 0.002
- • Epithelial VEGF-A: 33.55% ± 27.72% versus 47.64% ± 30.74%; p = 0.013
- • Epithelial VEGFR-1: 48.98% ± 29.99% versus 67.75% ± 27.78%; p = 0.001
- • Epithelial VEGFR-2: 32.78% ± 29.89% versus 40.38% ± 26.09%; p = 0.041
- • pS6: 35.23% ± 35.24% versus 58.50% ± 32.39%; p = 0.0001.
ROC analyses were conducted to calculate cut-off values that best discriminated between lymphatic and N0M0 tumors. Appropriate cut-off values were CAIX <92%, CAXII <96%, endothelial VEGFR-3 <28%, Ki67 >9%, epithelial VEGF-A >56%, epithelial VEGFR-1 >57%, epithelial VEGFR-2 >17%, and pS6 >28%.
Univariate logistic regression demonstrated an association of low CAIX (OR: 3.656; 95% CI, 1.708–7.829; p = 001); low CAXII (OR: 4.354; 95% CI, 1.908–9.936; p < 0.0001); low endothelial VEGFR-3 (OR: 4.100; 95% CI, 1.769–9.501; p = 0.001); high epithelial VEGF A (OR: 2.841; 95% CI, 1.339–6.026; p = 0.007); high epithelial VEGFR-1 (OR: 3.567; 95% CI, 1.652–7.703; p = 0.001); high epithelial VEGFR-2 (OR: 3.670; 95% CI, 1.451–9.286; p = 0.006); high Ki67 (OR: 3.291; 95% CI, 1.546–7.007; p = 0.002); and high pS6 (OR: 5.117; 95% CI, 2.113–12.392; p < 0.0001) with lymphatic spread. The final logistic regression model is summarized in Table 3.
|Factor||Rank of elimination from analysis||OR||95% CI||p value|
|Low vs high CAIX||–||3.362||1.037||10.906||0.043|
|High vs low VEGFR-2 epithelial||–||4.821||1.137||20.450||0.033|
OR = odds ratio; CI = confidence interval; ECOG PS = Eastern Cooperative Oncology Group performance status; MVI = microvascular invasion; CAIX = carbonic anhydrase IX; VEGFR = vascular endothelial growth factor receptor; CAXII = carbonic anhydrase XII.
3.3. Cytogenetic analysis
An abnormal karyotype was demonstrated by 247 of 272 (90.8%) tumors, (223 of 243 [91.8%] N0M0 tumors; 24 of 28 [85.7%] lymphatic tumors). The comparison of cytogenetic alterations between nonmetastatic and metastatic tumors is summarized in Table 4. Lymphatic metastasized tumors presented significantly less often with chromosome 3p deletion (p < 0.0001) when compared using Fisher exact test. In univariate logistic regression, loss of 3p (OR: 0.123; 95% CI, 0.045–0.334; p < 0.0001) was associated with lymphatic spread. After adjustment for clinical variables, 3p loss remained significantly associated with a lower risk for metastatic lymph node involvement. Multiple logistic regression analysis results of the cytogenetic analyses are summarized in Table 5.
|N0M0||Lymphatic spread||p value||Test|
|Yes||156 (63.9)||5 (17.9)||<0.0001||Fisher exact|
|No||88 (36.1)||23 (88.9)|
|Yes||27 (11.1)||6 (21.4)||0.126||Fisher exact|
|No||217 (88.9)||22 (78.6)|
|Yes||25 (10.2)||4 (14.3)||0.517||Fisher exact|
|No||219 (89.8)||24 (85.7)|
|Yes||19 (7.8)||4 (14.3)||0.273||Fisher exact|
|No||225 (92.2)||24 (85.7)|
|Yes||56 (23.0)||9 (32.1)||0.348||Fisher exact|
|No||188 (77.0)||19 (67.9)|
|Yes||75 (30.7)||5 (17.9)||0.192||Fisher exact|
|No||169 (69.3)||23 (82.1)|
|Yes||43 (17.6)||2 (7.1)||0.189||Fisher exact|
|No||201 (82.7)||26 (92.9)|
|Yes||58 (23.8)||8 (28.6)||0.642||Fisher exact|
|No||186 (76.2)||20 (71.4)|
|Yes||45 (18.4)||7 (25.0)||0.446||Fisher exact|
|No||199 (81.6)||21 (75.0)|
|Yes||7 (2.9)||3 (10.7)||0.072||Fisher exact|
|No||237 (97.1)||25 (89.3)|
|Yes||12 (4.9)||1 (3.6)||1.00||Fisher exact|
|No||232 (95.1)||27 (96.4)|
|Rank of elimination from analysis||OR||95% CI||p value|
OR = odds ratio; CI = confidence interval; ECOG = Eastern Cooperative Oncology Group performance status; MVI = microvascular invasion.
The main findings of our current investigation are that RCCs that present with lymphatic spread can be characterized by a unique profile of clinicopathologic, molecular, and genetic alterations. In clinical analysis, a model consisting of smoking history, T stage, Fuhrman grade, ECOG PS, and MVI was correlated with lymphatic spread. Low CAIX and high epithelial VEGFR-2 protein expression on the molecular level, and a low rate of chromosome 3p loss on the genetic level, were further characteristic of lymphatic spread.
Recent reports have demonstrated a link between smoking and advanced tumor stages  and . Our present results similarly demonstrate that smoking is an independent risk factor for lymphatic spread in ccRCC. We have therefore identified a modifiable lifestyle factor that appears to be capable of influencing the biological behavior of ccRCC. Interestingly, advanced primary T stage, but not tumor size, was an independent predictor for lymph nodes. This finding is particularly interesting with regard to active surveillance as a treatment strategy for localized tumors . Our findings suggest that tumor size alone may be insufficient as a selection criterion to exclude subjects for active surveillance. Hypertension was less often observed in patients with lymph node–positive tumors, though hypertension was the weakest covariable in multivariate analysis. We hypothesize that patients with hypertension more often have contact with the health care system and with preventive medical examinations. Thus, it is possible that tumors are diagnosed earlier. Finally, the presence of MVI has been previously reported to be an important predictor of disease recurrence . In the current study, MVI was the most important factor to predict lymphatic spread and, therefore, may serve as a pathologic criterion of paramount importance for postnephrectomy surveillance protocols.
Low CAIX and high epithelial VEGFR-2 expression independently predicted the presence of lymphatic spread. High expression of CAIX in RCC is mainly confined to clear cell tumors, and low CAIX expression has been reported to be associated with worse cancer-specific survival (CSS) . In addition, several reports have shown it to be a marker for poor response to immunotherapy . Clinical analyses have demonstrated that node-positive RCC is likewise associated with worse CSS and diminished response to immunotherapy  and . Therefore, the current data provide a link between these molecular and clinical findings: low CAIX expression is a significant, independent marker for lymphatic spread, and both low CAIX and lymphatic spread are related to poor treatment response and unfavorable survival outcome. In having a low rate of chromosome 3p loss, low expression of CAIX, and poor response to immunotherapy, N+ ccRCC appears to share a number of features with non–clear cell RCC subtypes.
High expression of epithelial VEGFR-2 was associated with lymphatic spread. As it is well recognized, the VEGF pathway, with its various ligands and associated receptor tyrosine kinases, is of paramount importance for the regulation of angiogenesis and lymphangiogenesis in cancer. VEGF-A is a potent direct-acting angiogenic signal working through the tyrosine kinase receptors VEGFR-1 and VEGFR-2 . While VEGF-mediated lymphangiogenesis is thought to be signaled predominantly through the binding of VEGF-C and VEGF-D to VEGFR-3  and , the lymphangiogenic VEGF ligands C and D can also signal through the VEGFR-2 receptor to promote lymphangiogenesis . In the current study, patients with lymphatic spread had significantly lower VEGFR-3 expression, but higher VEGFR-2 expression; moreover, high epithelial VEGFR-2 was correlated with metastatic lymph nodes. While low VEGFR-3 expression in N+ tumors is an unexpected finding, it must be acknowledged that much is still unknown about the mechanisms of lymphangiogenesis, and the predicted relationships may oversimplify the reality that VEGF receptors can be regulated in both a positive and negative manner by a wide variety of ligands and by an even wider variety of other receptors, including integrins, cadherins, and neuropilins . Clearly there remains much to understand regarding VEGF/VEGFR biochemical and cellular signaling.
In univariate analysis, the current data reveal an association between low incidence of chromosome 3p loss and lymph node involvement that remained consistent after adjustment for clinicopathologic variables. Deletions of chromosome 3p were observed in 18% and 64% of N+ and N0 tumors, respectively, and its loss was correlated with an almost 90% lower risk for lymphatic spread. The chromosome 3p25 contains the von Hippel-Lindau (VHL) tumor suppressor gene , whose loss of function is responsible for the oncogenesis of the majority of clear cell RCCs. Beroukhim et al.  recently compared the different gene expression patterns of wild-type and biallelic VHL-inactivated RCCs, demonstrating that CAIX is the most differently expressed gene measured, with low CAIX expression being confined to a subset of VHL wild-type clear cell tumors. Since low expression of CAIX and a low rate of chromosome 3p loss are characteristic for VHL wild-type tumors, we suggest that ccRCCs that are capable of development of lymphatic spread may develop via a VHL-independent mechanism.
The present study has several limitations, including the retrospective study design, the small sample size (particularly in some subgroups that disallowed certain desired analyses), missing variables in the molecular analyses that did not permit all comparisons to be performed for the entire cohort, and concomitant distant metastases that may have influenced our results. It will be necessary to assess these clinical, molecular, and genetic features in a prospective validation cohort before they should be used in clinical practice for risk group assessment.
Low CAIX and high epithelial VEGFR-2 protein expression, as well as low rate of chromosome 3p loss, are associated with metastatic lymph node spread, suggesting that ccRCCs that spread via the lymphatics develop independently of VHL inactivation. These results may provide a genetic and molecular basis for the poor prognosis and lack of response to interleukin-2 in lymph node–positive ccRCC. These results warrant further investigation into non-VHL-related molecular pathways contributing to the node-positive phenotype in ccRCC.
Author contributions: Allan J. Pantuck had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kroeger, Seligson, Pantuck, Belldegrun.
Acquisition of data: Kroeger, Seligson, Klatte, Rao, Zomorodian, Kabbinavar, Pantuck.
Analysis and interpretation of data: Kroeger, Klatte, Seligson, Birkhäuser, Belldegrun, Pantuck.
Drafting of the manuscript: Kroeger, Klatte, Rampersaud, Birkhäuser, Pantuck.
Critical revision of the manuscript for important intellectual content: Seligson, Rao, Belldegrun.
Statistical analysis: Kroeger, Klatte.
Obtaining funding: None.
Administrative, technical, or material support: Belldegrun, Zomorodian, Kabbinavar, Pantuck.
Supervision: Belldegrun, Pantuck.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: This study was supported in part by the Wissenschaftliche Urologische Gesellschaft e.V. (Germany) (N.K.) and the Swiss National Science Foundation individual fellowship PBBSP3-133403 (F.B.).
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a Institute of Urologic Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
b Department of Urology, University Hospital Greifswald, Greifswald, Germany
c Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
d Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
© 2012 European Association of Urology, Published by Elsevier B.V.
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