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ABSTRACT: Objectives Non-Hodgkin lymphoma is a hematologic malignancy associated with the more aggressive behavior of some forms of skin cancer. An association between sebaceous carcinoma and immunosuppression has been identified, but the behavior of sebaceous carcinoma in the setting of non-Hodgkin lymphoma has not been studied. This study aimed to increase understanding of the behavior of sebaceous carcinoma in patients with concomitant non-Hodgkin lymphoma. Methods Six patients diagnosed with sebaceous carcinoma and non-Hodgkin lymphoma from 1976 to 2008 were identified at the Mayo Clinic in Rochester, Minnesota. Their charts were reviewed retrospectively. Results All six patients were male and White and presented with sebaceous carcinoma on non-eyelid regions of the head and neck. Two patients had Muir-Torre syndrome; four had secondary cancers that included colon, prostate, transitional cell, and urothelial cancers. Skin cancers other than sebaceous carcinoma included basal cell carcinoma and squamous cell carcinoma. Three patients died of causes unrelated to sebaceous carcinoma; one died of an unknown cause and two were alive at the time of the study. Conclusions Sebaceous carcinoma does not appear to behave more aggressively in the setting of non-Hodgkin lymphoma. Larger studies are needed to definitively understand how sebaceous carcinoma behaves in patients with lymphoma.
International journal of dermatology 05/2013; · 1.18 Impact Factor
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ABSTRACT: : To compare the risk of subsequent oophorectomy among women who underwent hysterectomy for benign indications and those who did not.
: Using Rochester Epidemiology Project resources, we compared the risk of oophorectomy through December 31, 2008, among 4,931 women in Olmsted County, Minnesota, who underwent ovary-sparing hysterectomy for benign indications (case group) between 1965 and 2002, with 4,931 age-matched women who did not undergo hysterectomy (referent group). The cumulative incidence of subsequent oophorectomy was estimated by the Kaplan-Meier method, and comparisons were evaluated by Cox proportional hazard models using age as the time scale to allow for complete age adjustment.
: The median follow-up times for case group and referent group participants were 19.6 and 19.4 years, respectively. At 10, 20, and 30 years after hysterectomy, the respective cumulative incidences of subsequent oophorectomy were 3.5%, 6.2%, and 9.2% among case group participants and 1.9%, 4.8%, and 7.3% among referent group participants. The overall risk of subsequent oophorectomy among case group participants was significantly higher than among referent group participants (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.02-1.42; P=.03). Furthermore, among case group participants, the risk of subsequent oophorectomy was significantly higher (HR 2.15, 95% CI 1.51-3.07; P<.001) in women who had both ovaries preserved compared with those who initially had one ovary preserved.
: The incidence of oophorectomy after hysterectomy is only 9.2% at 30-year follow-up and is only 1.9 percentage points higher than the incidence of oophorectomy in referent women with intact reproductive organs.
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Obstetrics and Gynecology 05/2013; 121(5):1069-74. · 4.73 Impact Factor
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ABSTRACT: OBJECTIVES: Identify risk factors of anastomotic leak (AL) after large bowel resection (LBR) for ovarian cancer (OC) and compare outcomes between AL and no AL. METHODS: All cases of AL after LBR for OC between 01/01/1994-05/20/2011 were identified and matched 1:2 with controls for age (+/-5years), sub-stage (IIIA/IIIB;IIIC;IV), and date of surgery (+/-4years). Patient-specific and intraoperative risk factors, use of protective stomas, and outcomes were abstracted. A stratified conditional logistic regression model was fit to determine the association between each factor and AL. RESULTS: 42 AL cases were evaluable and matched with 84 controls. Two-thirds of the AL had stage IIIC disease and >90% of both cases and controls were cytoreduced to <1cm residual disease. No patient-specific risk factors were associated with AL (pre-operative albumin was not available for most patients). Rectosigmoid resection coupled with additional LBR was associated with AL (OR=2.73, 95%CI 1.13-6.59, P=0.025), and protective stomas were associated with decreased risk of AL (0% vs. 10.7%, P=0.024). AL had longer length of stay (P<0.001), were less likely to start chemotherapy (P=0.020), and had longer time to chemotherapy (P=0.007). Cases tended to have higher 90-day mortality (P=0.061) and were more likely to have poorer overall survival (HR=2.05, 95%CI 1.18-3.57, P=0.011). CONCLUSIONS: Multiple LBRs appear to be associated with increased risk of AL and protective stomas with decreased risk. Since AL after OC cytoreduction significantly delays chemotherapy and negatively impacts survival, surgeons should strongly consider temporary diversion in selected patients (poor nutritional status, multiple LBRs, previous pelvic radiation, very low anterior resection, steroid use).
Gynecologic Oncology 04/2013; · 3.89 Impact Factor
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ABSTRACT: OBJECTIVE: Technological advances in surgical management of endometrial cancer (EC) may allow for novel risk modification in surgical site infection (SSI). METHODS: Perioperative variables were abstracted from EC cases surgically staged between January 1, 1999, and December 31, 2008. Primary outcome was SSI, as defined by American College of Surgeons National Surgical Quality Improvement Program. Counseling and global models were built to assess perioperative predictors of superficial incisional SSI and organ/space SSI. Thirty-day cost of SSI was calculated. RESULTS: Among 1,369 EC patients, 136 (9.9%) had SSI. In the counseling model, significant predictors of superficial incisional SSI were obesity, American Society of Anesthesiologists (ASA) score >2, preoperative anemia (hematocrit <36%), and laparotomy. In the global model, significant predictors of superficial incisional SSI were obesity, ASA score >2, smoking, laparotomy, and intraoperative transfusion. Counseling model predictors of organ/space SSI were older age, smoking, preoperative glucose >110 mg/dL, and prior methicillin-resistant Staphylococcus aureus (MRSA) infection. Global predictors of organ/space SSI were older age, smoking, vascular disease, prior MRSA infection, greater estimated blood loss, and lymphadenectomy or bowel resection. SSI resulted in a $5,447 median increase in 30-day cost. CONCLUSIONS: Our findings are useful to individualize preoperative risk counseling. Hyperglycemia and smoking are modifiable, and minimally invasive surgical approaches should be the preferred surgical route because they decrease SSI events. Judicious use of lymphadenectomy may decrease SSI. Thirty-day postoperative costs are considerably increased when SSI occurs.
Gynecologic Oncology 04/2013; · 3.89 Impact Factor
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ABSTRACT: OBJECTIVE: To assess effects of clinicopathologic risk factors and contemporary therapeutic interventions on high-risk uterine epithelial carcinoma outcomes. METHODS: Patient-, disease-, and treatment-specific variables were annotated. Survival was estimated via the Kaplan-Meier method. Associations were evaluated with Cox proportional hazards regression and summarized using hazard ratios. RESULTS: From 1999 through 2008, therapy with curative intent was initiated for 119 grade 3 endometrioid (G3EC), 211 serous (USC), and 40 clear cell (CCC) carcinomas. Although clinicopathologic risk factors varied among the histologic subtypes, overall survival (OS) did not differ statistically between subtypes (P=.10) or in stage-for-stage comparative analyses (stage I/II, P=.45; stage III, P=.46; stage IV, P=.65). The 5-year cause-specific survival in stage I/II was 84.8%, 89.8%, and 83.9% for G3EC, USC, and CCC, respectively; multivariable modeling identified lymphovascular space involvement (LVSI) as the only independent prognostic factor (P=.02). For stage III, 5-year OS was 49.2% and 40.0% for G3EC and USC, respectively; multivariable modeling identified age (P<.001), LVSI (P<.001), unresectable nodal disease (P=.03), and regional radiotherapy (P=.01) as independent prognostic factors. For stage IV, 5-year OS was 8.7% and 12.1% for G3EC and USC, respectively; multivariable modeling identified LVSI (P=.002), cervical stromal invasion (P=.02), and adjuvant chemotherapy (P=.02) but not residual disease as independent prognostic factors. CONCLUSIONS: When controlled for disease stage, outcomes did not differ among high-risk histologic subtypes. LVSI was a significant adverse prognostic factor within all stages. The lack of improved outcomes with contemporary therapy suggests that more innovative therapeutic approaches should be given higher priority.
Gynecologic Oncology 03/2013; · 3.89 Impact Factor
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ABSTRACT: OBJECTIVE: Body composition measures (BCMs) are an important predictor of nutritional status in patients with cancer. Poor nutritional status is common in ovarian cancer (OC) and is a well-known variable that influences cancer treatment and outcome. We aim to establish the role of BCMs measured by computed tomography (CT) in predicting outcomes in patients with OC. METHODS: We retrospectively searched our institutional database for patients with stage IIIC/IV OC who underwent surgery as primary treatment at Mayo Clinic between 1996 and 2005 and had adequate presurgical CT images available. For each patient, 1 axial CT image at the level of the 3rd lumbar vertebra was evaluated. Adipose and lean tissues were discriminated using commercially available software. Cox models were fit to evaluate the relationship between patient factors and overall survival (OS). Associations were summarized using hazard ratios (HRs) and corresponding 95% CIs. RESULTS: A total of 82 patients were identified, with a median age of 68.4years. OS at 1 and 5years was 84.1% and 24.1%, respectively. Older age (P=.01), stage IV disease (P<.001), and subcutaneous and muscular fat<77.21cm(2) (P<.001) were independently associated with poor OS. Longer hospital stay was independently predicted by albumin≤3g/dL (P=.03), suboptimal surgery (P=.02), and subcutaneous and muscular fat<77.21cm(2) (P<.001). Surgical complications were independently predicted only by albumin≤3g/dL (P<.01). CONCLUSIONS: CT BCMs, as indicators of nutritional status, are independent predictors of longer hospital stay and poor OS in patients with OC.
Gynecologic Oncology 03/2013; · 3.89 Impact Factor
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ABSTRACT: OBJECTIVE:We examined long-term outcomes of attention-deficit/hyperactivity disorder (ADHD) in a population-based sample of childhood ADHD cases and controls, prospectively assessed as adults.METHODS:Adults with childhood ADHD and non-ADHD controls from the same birth cohort (N = 5718) were invited to participate in a prospective outcome study. Vital status was determined for birth cohort members. Standardized mortality ratios (SMRs) were constructed to compare overall and cause-specific mortality between childhood ADHD cases and controls. Incarceration status was determined for childhood ADHD cases. A standardized neuropsychiatric interview was administered.RESULTS:Vital status for 367 childhood ADHD cases was determined: 7 (1.9%) were deceased, and 10 (2.7%) were currently incarcerated. The SMR for overall survival of childhood ADHD cases versus controls was 1.88 (95% confidence interval [CI], 0.83-4.26; P = .13) and for accidents only was 1.70 (95% CI, 0.49-5.97; P = .41). However, the cause-specific mortality for suicide only was significantly higher among ADHD cases (SMR, 4.83; 95% CI, 1.14-20.46; P = .032). Among the childhood ADHD cases participating in the prospective assessment (N = 232; mean age, 27.0 years), ADHD persisted into adulthood for 29.3% (95% CI, 23.5-35.2). Participating childhood ADHD cases were more likely than controls (N = 335; mean age, 28.6 years) to have ≥1 other psychiatric disorder (56.9% vs 34.9%; odds ratio, 2.6; 95% CI, 1.8-3.8; P < .01).CONCLUSIONS:Childhood ADHD is a chronic health problem, with significant risk for mortality, persistence of ADHD, and long-term morbidity in adulthood.
PEDIATRICS 03/2013; · 4.47 Impact Factor
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ABSTRACT: OBJECTIVE: This study reports the incidence of enuresis and encopresis among children with attention-deficit/hyperactivity disorder (ADHD) versus those without ADHD. METHODS: Subjects included 358 children (74.5% boys) with research-identified ADHD from a 1976 to 1982 population-based birth cohort (n = 5718) and 729 (75.2% boys) non-ADHD control subjects from the same birth cohort, matched by gender and age. All subjects were retrospectively followed from birth until a diagnosis of enuresis or encopresis was made or last follow-up before 18 years of age. The complete medical record for each subject was reviewed to obtain information on age of initial diagnosis of an elimination disorder, frequency and duration of symptoms, and identification of exclusionary criteria specified by DSM-IV, with confirmation of the diagnosis by expert consensus. RESULTS: Children with ADHD were 2.1 (95% confidence interval [CI], 1.3-3.4; P = .002) times more likely to meet DSM-IV criteria for enuresis than non-ADHD controls; they were 1.8 (95% CI, 1.2-2.7; P = .006) times more likely to do so than non-ADHD controls when less stringent criteria for a diagnosis of enuresis were employed. Though not significant, children with ADHD were 1.8 (95% CI, 0.7-4.6; P = .23) times more likely to meet criteria for encopresis than non-ADHD controls. The relative risk was 2.0 (95% CI, 1.0-4.1; P = .05) when a less stringent definition for encopresis was utilized. CONCLUSIONS: Children with ADHD are more likely than their peers without ADHD to develop enuresis with a similar trend for encopresis.
Academic pediatrics 03/2013;
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ABSTRACT: OBJECTIVE: We report our experience with vulvar (Vu) and vaginal (Va) melanoma, with review of surgical and adjuvant therapy guidelines and description of our use of neoadjuvant therapy in selected cases. METHODS: We reviewed patients seen at Mayo Clinic for management of Vu or Va melanoma, January 1993-February 2012. Surgical treatment, pathologic and outcome data were abstracted. Overall survival (OS) and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method, and compared between subgroups using the log-rank test. RESULTS: 50 patients underwent surgery for primary or recurrent melanoma (Vu=36, Va=14). The 5-year OS rate was 30.9%, with median OS of 3.3years. Adjuvant therapy was given to 30.6% of Vu cases with varying combinations of agents. Among Vu patients, after adjusting for node status and depth of invasion, adjuvant therapy was not associated with improved OS (p=0.39) or RFS (p=0.31). Preoperative chemotherapy was used in 2 Va cases. Despite temozolomide followed by exenteration for a 4cm multi-focal lesion, one patient died within 3months. The second patient, with a 2cm vaginal lesion, demonstrated a partial response to carboplatin and paclitaxel (CP). After local excision and lymphadenectomy she received additional CP with bevacizumab and remains disease free at 5years. CP with bevacizumab was also used in 1 Vu case with a solitary midline of 5cm lesion. She underwent vulvectomy after a partial response, received additional CP and bevacizumab postoperatively, and remains without disease at 2years. CONCLUSION: Preoperative chemotherapy with CP and bevacizumab may improve treatment outcomes, particularly for Va and large Vu lesions.
Gynecologic Oncology 02/2013; · 3.89 Impact Factor
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ABSTRACT: STUDY OBJECTIVE: To compare the long-term outcomes of intrauterine morcellation (IUM) of endometrial polyps vs a traditional operative polypectomy technique, hysteroscopic resection (HSR), and to identify factors predictive of recurrent abnormal uterine bleeding (AUB) after operative polypectomy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Minimally invasive gynecologic surgery practice in a tertiary care center. PATIENTS: Women who underwent operative hysteroscopic polypectomy between January 1, 2004 and December 31, 2009. INTERVENTIONS: Intrauterine morcellation or HSR with evaluation and/or treatment of recurrent AUB after operative polypectomy. MEASUREMENTS AND MAIN RESULTS: Of 311 patients (IUM group, 139; HSR group, 172), 167 (53.7%) had at least 1 gynecologic follow-up visit and 57 (18.4%) had recurrent AUB. Subsequent gynecologic clinic visit rates were similar between the 2 groups (HSR, 58.1%, vs IUM, 48.2%; p = .08). Recurrence of AUB within the first 4 years of follow-up was similar between the IUM and HSR groups (hazard ratio for HSR vs IUM, 1.12; 95% confidence interval, 0.64-1.98; p = .59). However, recurrence of endometrial polyps approached statistical significance (hazard ratio, 3.3; 95% confidence interval, 0.94-11.49; p = .06). Premenopausal status, history of hormone replacement therapy, multiparity, and polycystic ovarian syndrome were independently associated with AUB recurrence. There were no reports of inability to establish a histopathologic diagnosis among all pathology specimens evaluated. CONCLUSION: Compared with HSR, intrauterine morcellation may be associated with lower recurrence of endometrial polyps. However, the incidence of recurrent AUB is independent of polypectomy method.
Journal of Minimally Invasive Gynecology 01/2013; · 1.74 Impact Factor
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ABSTRACT: BACKGROUND: Patient-reported signs and symptoms are often the first indication of clinically relevant lymphedema. OBJECTIVE: Develop and assess the diagnostic accuracy of a screening questionnaire to detect lower extremity lymphedema (LEL) among normal weight and obese women. DESIGN: Cross-sectional survey study. METHODS: We reviewed existing questionnaires assessing upper extremity lymphedema (UEL) for potential questions and worked with content experts to generate new items. A draft questionnaire with 59 items was reviewed by 5 physicians and 5 physical therapists specialized in lymphedema management and 5 female patients with clinically confirmed secondary LEL. A revised questionnaire with 45 items was administered by mail (n=186) or in a lymphedema clinic waiting area (n=28) to women with clinically confirmed LEL (cases, n=116) or UEL (controls, n=70). A parsimonious subset of items that best discriminated patients with and without LEL was identified using chi-square tests and logistic regression. Sensitivity and specificity for detecting LEL were estimated for the entire sample and for subsamples defined by obesity (BMI ≥30 versus < 30), which may confound the accurate diagnosis of LEL. RESULTS: Questionnaires were completed by 127 women (LEL n=88; UEL n=39). A sum of 13 items (score range 0-52) was the most discriminating. Using a cutoff score of ≥5 points, the sensitivity and specificity for detecting LEL among all participants were 95.5% and 86.5%, respectively and 94.8% and 76.5% for obese participants. LIMITATIONS: By enumerating a sample with a high prevalence of LEL, we may have introduced spectrum bias, which may affect the accuracy of our screening questionnaire. CONCLUSIONS: Our brief, 13-item self-report questionnaire is a sensitive and specific tool for detecting clinically relevant LEL among women, including those with BMI ≥30.
Physical Therapy 01/2013; · 3.11 Impact Factor
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ABSTRACT: : To evaluate the learning curve of robotic hysterectomy using objective, patient-centered outcomes and analytic methods proposed in the literature.
: All cases of robotic hysterectomy performed at Mayo Clinic, Rochester, Minnesota, from January 1, 2007, through December 31, 2009, were collected. Experience was analyzed in 6-month periods. Operative time, complications, and length of stay longer than 1 day were compared between periods for significant change. For learning curve analysis, standard and risk-adjusted cumulative summation charting was used for the two most experienced robotic surgeons (A and B). Outcomes of interest were intraoperative complications and intraoperative or postoperative complications within 6 weeks. Proficiency was defined as the point at which each surgeon's curve crossed H0 based on complication rates of abdominal hysterectomy. Cumulative summation parameters were p0=5.7% and p1=11.4% for outcome 1 and p0=36.0% and p1=50% for outcome 2.
: In 325 cases, operative time decreased significantly from 3.5 to 2.7 hours during the 3-year period. The proportion of patients with length of stay longer than 1 day decreased significantly from 49.2% to 14.7%. Complications did not decrease significantly. The average number of procedures to cross H0 was 91 for outcome 1 and 44 for outcome 2. Observed cumulative summation curves of surgeons A and B differed from the average number of attempts calculated from p0 and p1.
: Operative time and length of stay decrease with 36 months of experience with robotic hysterectomy, whereas complications may not. Cumulative summation analysis provides an objective, individualized tool to evaluate surgical proficiency and suggests this occurs after performing approximately 91 procedures.
: III.
Obstetrics and Gynecology 01/2013; 121(1):87-95. · 4.73 Impact Factor
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ABSTRACT: OBJECTIVE To report our experience with low-dose tissue plasminogen activator in the treatment of calciphylaxis, a rare, usually fatal thrombotic condition that results in ischemia, necrosis, and infarction of adipose and cutaneous tissue. DESIGN Retrospective chart review. SETTING Tertiary care academic medical center. PATIENTS Fifteen patients (4 men and 11 women) with calciphylaxis, treated from January 1, 2002, through December 31, 2010. INTERVENTION Treatment with tissue plasminogen activator, concomitant wound care, and management of calcium-phosphate status. MAIN OUTCOME MEASURES Short-term ulcer healing, long-term survival. RESULTS Patients received daily low-dose infusions of tissue plasminogen activator (mean treatment duration, 11 days). Six patients had no adverse reactions, 3 had minor bleeding, 6 required blood transfusions, and 3 had life-threatening bleeding. No patients died of treatment-related complications. Ten patients died (median time to death, 3.6 months; range, 23 days to 4.2 years). Of the remaining 5 patients, the median duration of follow-up was 36.8 months (range, 70 days to 4.3 years). Patients treated with tissue plasminogen activator had approximately 30% greater survival than controls, but the difference was not significant (P = .14). Our results were limited by the use of concomitant therapies, referral bias for advanced disease, and retrospective case-series design. CONCLUSIONS Thrombolytic tissue plasminogen activator may be a useful adjunctive treatment in the management of patients with calciphylaxis. However, a multidisciplinary approach that includes aggressive wound care, débridement, thrombolytic therapy, restoration of tissue oxygenation, avoidance of infection, and control of calcium-phosphate homeostasis also is essential.
JAMA dermatology (Chicago, Ill.). 01/2013; 149(1):63-7.
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ABSTRACT: : To compare risk of written language disorder (WLD) in children with and without speech-language impairment (S/LI) from a population-based cohort.
: Subjects included all children born between 1976 and 1982 in Rochester, Minnesota, who remained in the community after age 5 years (n = 5718). Records from public and private schools, medical agencies, and tutoring services were abstracted. S/LI was determined based on eligibility criteria for an individualized education plan. Incident cases of WLD were identified by research criteria using regression-based discrepancy, non-regression-based discrepancy, and low-achievement formulas applied to cognitive and academic achievement tests. Incidence of WLD (with or without reading disorder [RD]) was compared between children with and without S/LI. Associations were summarized using hazard ratios.
: Cumulative incidence of WLD by age 19 years was significantly higher in children with S/LI than in children without S/LI. The magnitude of association between S/LI and WLD with RD was significantly higher for girls than for boys. This was not true for the association between S/LI and WLD without RD.
: Risk for WLD is significantly increased among children with S/LI compared with children without S/LI based on this population-based cohort. Early identification and intervention for children at risk for WLD could potentially influence academic outcomes.
Journal of developmental and behavioral pediatrics: JDBP 01/2013; 34(1):38-44. · 2.27 Impact Factor
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ABSTRACT: : To identify patient characteristics and perioperative factors predictive of 30-day morbidity and cost in patients with endometrial carcinoma.
: Data of consecutive patients treated with hysterectomy for endometrial carcinoma between 1999 and 2008 were collected prospectively. Thirty predictors were chosen from more than 130 collected based on anticipated clinical relevance and prevalence (more than 3%). Complications were graded per the Accordion Classification. Multivariable models were developed using stepwise and backward variable selection methods. Thirty-day cost analyses were expressed in 2010 Medicare dollars.
: Of 1,369 patients, significant predictors (P<.01) of grade 2 and higher morbidity included American Society of Anesthesiologists physical status classification system class higher than 2 (odds ratio [OR] 2.1), preoperative white blood count (OR 2.1 per doubling), history of deep vein thrombosis (OR 2.1), pelvic and para-aortic lymphadenectomy (OR 2.3 compared with no lymphadenectomy), laparotomy (OR 2.8 compared with minimally invasive surgery), myometrial invasion more than 50% (OR 2.4), operating time (OR 1.9 per doubling), and grade 4 surgical complexity (OR 2.7 compared with grade 1). After controlling for patient factors in a multivariable model, laparotomy, pelvic, and para-aortic lymphadenectomy were associated with significant increases in cost compared with the use of minimally invasive surgery or hysterectomy alone.
: This analysis identifies patient and perioperative care factors predictive of 30-day morbidity and cost. These data are useful for preoperative counseling, for defining equitable reimbursement and factors critical for risk-adjustment when comparing outcomes, and for identifying areas for quality improvement in patients with endometrial carcinoma. Given the marked increases in morbidity and cost associated with laparotomy and lymphadenectomy, minimally invasive surgery and selective lymphadenectomy should be standard treatment for patients with endometrial carcinoma.
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Obstetrics and Gynecology 12/2012; 120(6):1419-27. · 4.73 Impact Factor
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Tina I Tarantola,
Laura A Vallow,
Michele Y Halyard,
Roger H Weenig,
Karen E Warschaw,
Travis E Grotz,
James W Jakub,
Randall K Roenigk,
Jerry D Brewer, Amy L Weaver,
Clark C Otley
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ABSTRACT: BACKGROUND: Knowledge regarding behavior of and prognostic factors for Merkel cell carcinoma (MCC) is limited. OBJECTIVE: We sought to further understand the characteristics, behavior, prognostic factors, and optimal treatment of MCC. METHODS: A multicenter, retrospective, consecutive study of patients with known primary MCC was completed. Overall survival and survival free of locoregional recurrence were calculated and statistical analysis of characteristics and outcomes was performed. RESULTS: Among the 240 patients, the mean age at diagnosis was 70.1 years, 168 (70.0%) were male, and the majority was Caucasian. The most common location was head and neck (111, 46.3%). Immunosuppressed patients had significantly worse survival, with an overall 3-year survival of 43.4% compared with 68.1% in immunocompetent patients. In our study, patients with stage II disease had improved overall survival versus those with stage I disease, in a statistically significant manner. Patients with stage III disease had significantly worse survival compared with stage I and with stage II. Primary tumor size did not predict nodal involvement. CONCLUSION: The data presented represent one of the largest series of primary MCC in the literature and confirm that MCC of all sizes has metastatic potential, supporting sentinel lymph node biopsy for all primary MCC. Because of the unpredictable natural history of MCC, we recommend individualization of care based on the details of each patient's tumor and clinical presentation.
Journal of the American Academy of Dermatology 11/2012; · 3.99 Impact Factor
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ABSTRACT: BACKGROUND: Knowledge is limited regarding unknown primary Merkel cell carcinoma (UPMCC). OBJECTIVE: We sought to document the characteristics and behavior of UPMCC, and determine the most appropriate treatment. METHODS: A multicenter, retrospective, consecutive study reviewing patients given a diagnosis of UPMCC between 1981 and 2008 was completed. In addition, a literature review of cases of UPMCC was performed. RESULTS: In all, 23 patients with UPMCC are described and 34 cases from previous reports are compiled. Among the 23 new cases of UPMCC, the average age at diagnosis was 66.0 years; the majority of patients were male (87%) and Caucasian (100% of those reported). One patient was immunosuppressed, and 39% had a history of other cancer. After the initial biopsy, 16 patients had further evaluation of the involved lymph node basin. Half of these had additional positive nodes (8 of 16). The majority of patients had lymph node basin involvement only (78%), whereas 22% had lymph node basin and distant metastasis. The most common lymph node basin involved was inguinal. The median size of the involved lymph node at diagnosis was 5.0 cm. At 2 years, the overall survival of stage IIIB UPMCC was significantly improved versus stage IIIB known primary Merkel cell carcinoma (MCC): 76.9% to 36.4%. LIMITATIONS: Limited number of cases and retrospective review are limitations. CONCLUSION: Our data demonstrate improved overall survival in patients with stage IIIB UPMCC versus those with stage IIIB known primary MCC. Because of the unpredictable natural history of UPMCC, we recommend individualization of care based on the details of each patient's clinical presentation.
Journal of the American Academy of Dermatology 11/2012; · 3.99 Impact Factor
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ABSTRACT: OBJECTIVES: To determine pelvic ultrasound characteristics in women after radiofrequency endometrial ablation (EA) and evaluate the association of those characteristics with symptoms and the need for subsequent therapeutic intervention. METHODS: This retrospective cohort study evaluated patients who underwent transvaginal pelvic ultrasound after radiofrequency EA between July 3, 2006, and November 13, 2009. The presence or absence of postablation symptoms (pelvic pain or vaginal bleeding) at the time of ultrasound defined the 2 groups. Two radiologists evaluated 17 ultrasound parameters. Demographic, clinical, and ultrasound characteristics were compared between symptomatic and asymptomatic patients, and features were assessed for association with subsequent therapeutic interventions. RESULTS: Of the 91 patients who had radiofrequency EA and subsequent ultrasound, 63 patients (69.2%) were symptomatic on evaluation. Symptomatic patients were significantly more likely than asymptomatic patients to have an endometrial thickness of 3 mm or more, a heterogeneous endometrial echotexture, and leiomyomas (P = 0.004, P = 0.008, and P = 0.05, respectively). The most frequent finding in all patients was an indistinct endometrial border (66/79 [83.5%]). In addition, there was a tendency for patients with leiomyomas to have a subsequent intervention (P = 0.07). Although infrequent, all patients (7/91) with cornual hematometra or proximal hydrosalpinx had pain. CONCLUSIONS: Indistinct endometrial border is a common finding after radiofrequency EA and is unrelated to the presence or absence of symptoms. Patients who present with post-radiofrequency EA symptoms seem to have a few specific ultrasound characteristics that differentiate them from asymptomatic patients. The presence of leiomyomas on ultrasound is predictive of the need for therapeutic interventions.
Ultrasound quarterly 11/2012;
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ABSTRACT: OBJECTIVE: Abdominal peritoneal implants are characteristic of uterine serous carcinoma (USC). The presumed mechanism of dissemination is retrograde transit via the fallopian tube. We assessed the impact of tubal ligation (TL) on the metastatic profile and survival of USC patients. METHODS: Patient risk factors, process-of-care variables, and disease-specific parameters were annotated. Categorical variables were compared using the χ(2) test. Overall survival (OS) was estimated via the Kaplan-Meier method. RESULTS: Among 211 USC patients, fallopian tube status was documented in 142 patients; 35 had a history of TL and 107 did not. When comparing patients with and without TL, positive peritoneal cytology was present, respectively, in 18.8% vs 45.0% (P=.01) and stage IV disease in 14.3% vs 34.6% (P=.02). Using Cox models, age was the sole significant determinant of OS in stage I/II USC. By contrast, age, lymphovascular space involvement, positive cytology, and TL independently and adversely affected survival in stage III/IV USC. Adjusting for these factors in a multivariable model, the association between TL and OS among patients with advanced disease yielded a hazard ratio of 8.61 (95% CI, 3.08-24.03; P<.001). The prevalence of lymphatic metastasis and nodal tumor burden was significantly greater in patients who underwent ligation. CONCLUSION: Patients with TL had significantly lower rates of positive cytology and stage IV disease than patients without TL. The lymphatic system appeared to be the dominant mode of spread after TL and was associated with a paradoxic worsening of OS, perhaps reflecting a delay in diagnosis.
Gynecologic Oncology 11/2012; · 3.89 Impact Factor
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ABSTRACT: : To identify risk factors for endometrial cancer after benign results of endometrial biopsy or dilation and curettage (D&C).
: Nested case-control study from Rochester Epidemiology Project data. Among 370 Olmsted County, Minnesota, residents who received an endometrial cancer diagnosis between 1970 and 2008, we identified 90 patients (24.5%) who had previous benign endometrial biopsy or D&C results (no atypical hyperplasia). We compared them with 172 matched control group participants who had benign endometrial biopsy or D&C results without subsequent endometrial cancer.
: Using a multivariable conditional logistic regression model, we found that oral contraceptive pill (OCP) use was protective (odds ratio [OR] 0.18, 95% CI [CI] 0.08-0.45; P<.001), and personal history of colorectal cancer (OR 4.44, 95% CI 1.02-19.31; P<.05), endometrial polyp (OR 4.12, 95% CI 1.40-12.17; P=.01), and morbid obesity (OR 3.40, 95% CI 1.18-9.78; P<.03) were independently associated with subsequent endometrial cancer. Compared with the presence of no risk factor, presence of one and two or more risk factors increased the risk of endometrial cancer by 8.12 (95% CI 3.08-21.44) and 17.87 (95% CI 5.57-57.39) times, respectively. Assuming a 2.6% lifetime risk of endometrial cancer, ORs of 8.12 and 17.87 for one and two or more of the four aforementioned risk factors confer a lifetime risk of approximately 18% and 32%, respectively.
: One fourth of patients with endometrial cancer had previous benign endometrial biopsy or D&C results. Personal history of colorectal cancer, presence of endometrial polyps, and morbid obesity are the strongest risk factors for having endometrial cancer after a benign endometrial biopsy or D&C result, and OCP use is the strongest protective factor.
: II.
Obstetrics and Gynecology 11/2012; 120(5):998-1004. · 4.73 Impact Factor
