Nora T Kizer

Washington University in St. Louis, San Luis, Missouri, United States

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Publications (27)102.41 Total impact

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    ABSTRACT: This retrospective study evaluates the influence of serum platelet count on chemotherapy response rates among women with endometrial cancer. From 3 separate cancer centers, a total of 318 patients with endometrial cancer who received postoperative chemotherapy between June 1999 and October 2009 were retrospectively identified. Endometrioid, serous, clear cell, and carcinosarcoma histologies were included. Patients were classified as having an elevated platelet count if their serum platelet count was greater than 400 × 10/L at the time of initial diagnosis. Primary outcome was chemotherapy response, classified as either complete or partial/refractory. Secondary outcomes were disease-free and disease-specific survival. χ Test and Student t test were performed as appropriate. Kaplan-Meier curves and Cox proportional hazards models were used to assess serum platelet effect on survival. There were 125 deaths, 76 recurrences, and 48 disease progressions. Of the total group, 53 (16.7%) were categorized as having an elevated platelet count. An elevated platelet count was associated with a lower chemotherapy response rate in univariate analysis (hazard ratio [HR], 2.8; 95% 95% confidence interval [CI], 1.46-5.38; P < 0.01). Multivariate analysis showed elevated platelets to be independently associated with decreased disease-free survival (HR, 2.24; 95% CI, 1.26-3.98; P < 0.01) but not disease-specific survival (HR, 1.03; 95% CI, 0.56-1.88, P = 0.93). Patients with endometrial cancer who have an elevated serum platelet count greater than 400 × 10/L may have lower chemotherapy response rates and are at increased risk for recurrence when compared with patients with a count within the reference range.
    International Journal of Gynecological Cancer 07/2015; 25(6):1015-1022. DOI:10.1097/IGC.0000000000000453 · 1.95 Impact Factor
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    ABSTRACT: Objectives. Obese women have a high incidence of wound separation after gynecologic surgery. We explored the effect of a prospective care pathway on the incidence of wound complications. Methods. Women with a body mass index (BMI) >= 30 kg/m(2) undergoing a gynecologic procedure by a gynecologic oncologist via a vertical abdominal incision were eligible. The surgical protocol required: skin and subcutaneous tissues to be incised using a scalpel or cutting electrocautery, fascial closure using #1 polydioxanone suture, placement of a 7 mm Jackson-Pratt drain below Camper's fascia, closure of Camper's fascia with 3-0 plain catgut suture and skin closure with staples. Wound complication was defined as the presence of either a wound infection or any separation. Demographic and perioperative data were analyzed using contingency tables. Univariable and multivariable regression models were used to identify predictors of wound,complications. Patients were compared using a multivariable model to a historical grdup of obese patients to assess the efficacy of the care pathway. Results. 105 women were enrolled with a median BMI of 38.1. Overall, 39 (37%) had a wound complication. Women with a BMI of 30-39.9 kg/m(2) had a significantly lower risk of wound complication as compared to those with a BMI >40 kg/m(2) (23% vs 59%, p < 0.001). After controlling for factors associated with wound complications the prospective care pathway was associated with a significantly decreased wound complication rate in women with BMI <40 kg/m(2) (OR 0.40, 95% C.I.: 0.18-0.89). Conclusion. This surgical protocol leads to a decreased rate of wound complications among women with a BMI of 30-39.9 kg/m(2).
    Gynecologic Oncology 06/2014; 134(2). DOI:10.1016/j.ygyno.2014.06.012 · 3.69 Impact Factor
  • Gynecologic Oncology 06/2014; 133:161. DOI:10.1016/j.ygyno.2014.03.424 · 3.69 Impact Factor
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    ABSTRACT: Alternative strategies beyond current chemotherapy and radiation therapy regimens are needed in the treatment of advanced stage and recurrent endometrial cancers. There is considerable promise for biologic agents targeting the extracellular signal-regulated kinase (ERK) pathway for treatment of these cancers. Many downstream substrates of the ERK signaling pathway, such as glycogen synthase kinase 3β (GSK3β), and their roles in endometrial carcinogenesis have not yet been investigated. In this study, we tested the importance of GSK3β inhibition in endometrial cancer cell lines and in vivo models. Inhibition of GSK3β by either lithium chloride (LiCl) or specific GSK3β inhibitor VIII showed cytostatic and cytotoxic effects on multiple endometrial cancer cell lines, with little effect on the immortalized normal endometrial cell line. Flow cytometry and immunofluorescence revealed a G2/M cell cycle arrest in both type I (AN3CA, KLE, and RL952) and type II (ARK1) endometrial cancer cell lines. In addition, LiCl pre-treatment sensitized AN3CA cells to the chemotherapy agent paclitaxel. Administration of LiCl to AN3CA tumor-bearing mice resulted in partial or complete regression of some tumors. Thus, GSK3β activity is associated with endometrial cancer tumorigenesis and its pharmacologic inhibition reduces cell proliferation and tumor growth.
    International Journal of Molecular Sciences 08/2013; 14(8):16617-37. DOI:10.3390/ijms140816617 · 2.34 Impact Factor
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    ABSTRACT: OBJECTIVE: Our study evaluated whether buffering reduces pain from lidocaine injection for loop electrosurgical excisional procedures (LEEPs) of the cervix when compared to unbuffered lidocaine. METHODS: Women undergoing outpatient LEEPs were randomized to receive either buffered or unbuffered lidocaine. Participants, caregivers, and statisticians were blinded to treatment allocation. Pain was categorized as injection, procedure, or cramping pain. Severity of pain was reported using a Likert visual analog scale and compared using Mann-Whitney tests. RESULTS: Twenty-eight subjects received buffered lidocaine and 24 subjects received unbuffered lidocaine. The 2 groups were similar in regard to age, race, previous LEEP, anesthetic volume used, and loop size. Mean scores were similar between the nonbuffered and buffered groups for injection pain (25 vs 19, p = .13), procedure pain (27 vs 19, p = .08), and cramping pain (19 vs 18, p = .86). CONCLUSIONS: Pain scores with subepithelial lidocaine plus epinephrine for LEEP are low and are not significantly reduced by buffering the anesthetic.
    Journal of Lower Genital Tract Disease 06/2013; 18(1). DOI:10.1097/LGT.0b013e31828deffd · 1.11 Impact Factor
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    ABSTRACT: The article below summarizes a roundtable discussion of a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Baranoski AS, Tandon R, Weinberg J, et al. Risk factors for abnormal anal cytology over time in HIV-infected women. Am J Obstet Gynecol 2012;207:107.e1-8.
    American journal of obstetrics and gynecology 08/2012; 207(2):142-3. DOI:10.1016/j.ajog.2012.06.025 · 3.97 Impact Factor
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    ABSTRACT: In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Baranoski AS, Tandon R, Weinberg J, et al. Risk factors for abnormal anal cytology over time in HIV-infected women. Am J Obstet Gynecol 2012;207:107.e1-8.
    American Journal of Obstetrics and Gynecology 08/2012; 207(2):e1–e3. DOI:10.1016/j.ajog.2012.06.034 · 3.97 Impact Factor
  • Nora Kizer, Jeffrey F Peipert
    Annals of internal medicine 06/2012; 156(12):896-7, W315. DOI:10.7326/0003-4819-156-12-201206190-00425 · 16.10 Impact Factor
  • Gynecologic Oncology 03/2012; 125:S147. DOI:10.1016/j.ygyno.2011.12.361 · 3.69 Impact Factor
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    ABSTRACT: Serous uterine cancer is not a feature of any known hereditary cancer syndrome. This study evaluated familial risk of cancers for patients with serous uterine carcinoma, focusing on Lynch syndrome malignancies. Fifty serous or mixed serous endometrial carcinoma cases were prospectively enrolled. Pedigrees were developed for 29 probands and tumors were assessed for DNA mismatch repair (MMR) abnormalities. Standardized incidence ratios for cancers in relatives were estimated. A second-stage analysis was undertaken using data from Gynecologic Oncology Group (GOG)-210. Incidence data for cancers reported in relatives of 348 patients with serous and mixed epithelial and 624 patients with endometrioid carcinoma were compared. Nineteen of 29 (65.5%) patients in the single-institution series reported a Lynch-related cancer in relatives. Endometrial and ovarian cancers were significantly overrepresented and a high number of probands (6 of 29, 20.7%) reported pancreatic cancers. None of the probands' tumors had DNA MMR abnormalities. There was no difference in endometrial or ovarian cancer incidence in relatives of serous and endometrioid cancer probands in the case-control study. Pancreatic cancers were, however, significantly more common in relatives of patients with serous cancer [OR, 2.39; 95% confidence interval (CI), 1.06-5.38]. We identified an excess of endometrial, ovarian, and pancreatic cancers in relatives of patients with serous cancer in a single-institution study. Follow-up studies suggest that only pancreatic cancers are overrepresented in relatives. DNA MMR defects in familial clustering of pancreatic and other Lynch-associated malignancies are unlikely. The excess of pancreatic cancers in relatives may reflect an as yet unidentified hereditary syndrome that includes uterine serous cancers.
    Cancer Prevention Research 03/2012; 5(3):435-43. DOI:10.1158/1940-6207.CAPR-11-0499 · 5.27 Impact Factor
  • Gynecologic Oncology 03/2012; 125:S77-S78. DOI:10.1016/j.ygyno.2011.12.186 · 3.69 Impact Factor
  • Gynecologic Oncology 03/2012; 125:S17. DOI:10.1016/j.ygyno.2011.12.040 · 3.69 Impact Factor
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    ABSTRACT: Adjuvant radiotherapy improves local control but not survival in women with endometrial cancer. This benefit was shown in staged patients with "high intermediate risk" (HIR) disease. Other studies have challenged the need for systematic staging including lymphadenectomy. We sought to determine whether LVSI alone or in combination with other histologic factors predicts lymph node (LN) metastasis in patients with endometrioid endometrial cancer. A retrospective review was conducted of patients with endometrioid endometrial carcinoma who had confirmed presence/absence of LVSI and clinicopathologic data necessary to identify HIR criteria. Kaplan-Meier curves were generated and univariate and multivariate analyses performed as appropriate. We identified 757 eligible patients and 628 underwent systematic lymphadenectomy for staging purposes. In the surgically staged group, 242 (38%) patients met uterine HIR criteria and 196 (31%) had LVSI. Both HIR and LVSI were significantly associated with LN metastasis. Among the HIR positive group, 59 had LN metastasis (OR 4.46, 95% CI 2.72-7.32, P<0.0001). Sixty-six LVSI positive patients had nodal metastasis (OR 11.04, 95% CI 6.39-19.07, P<0.0001). The NPV of LVSI and HIR negative specimens was 95.6% and 93.4% respectively. In multivariate analysis, PFS and OS were significantly reduced in both LVSI positive (P<0.0001) and HIR patients (P<0.0001) when compared to patients who were LVSI and HIR negative. HIR status and LVSI are highly associated with LN metastasis. These features are useful in assessing risk of metastatic disease and may serve as a surrogate for prediction of extrauterine disease.
    Gynecologic Oncology 01/2012; 124(1):31-5. DOI:10.1016/j.ygyno.2011.09.017 · 3.69 Impact Factor
  • Nora T Kizer, Matthew A Powell
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    ABSTRACT: The key pregnancy-related physiological maternal and fetal changes that occur and the modifications to standard surgical approaches that can impact surgical outcomes are important to recognize. Surgery during pregnancy can be safe and effective. Laparoscopy has become an acceptable alternative to the standard laparotomy and should be considered when surgeons with appropriate skills and experience are available. Care of these patients should always involve a multidisciplinary team with the goal to optimize outcomes for both the mother and the fetus.
    Clinical obstetrics and gynecology 12/2011; 54(4):633-41. DOI:10.1097/GRF.0b013e318236eb0d · 1.53 Impact Factor
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    ABSTRACT: The effect of body mass index (BMI) on treatment outcomes for patients with locally advanced cervical carcinoma who receive definitive chemoradiation is unclear. The cohort in this study included all patients with cervical carcinoma (n = 404) who had stage IB(1) disease and positive lymph nodes or stage ≥IB(2) disease and received treatment at the authors' facility between January 1998 and January 2008. The mean follow-up was 47.2 months. BMI was calculated using the National Institute of Health online calculator. BMI categories were created according to the World Health Organization classification system. Primary outcomes were overall survival, disease-free survival, and complication rate. Univariate and multivariate analyses were performed. Kaplan-Meier survival curves were generated and compared using Cox proportional hazard models. On multivariate analysis, compared with normal weight (BMI 18.5-24.9 kg/m(2) ), a BMI <18.5 kg/m(2) was associated with decreased overall survival (hazard ratio, 2.37; 95% confidence interval, 1.28-4.38; P < .01). The 5-year overall survival rate was 33%, 60%, and 68% for a of BMI <18.5 kg/m(2) , a BMI from 18.5 kg/m(2) to 24.9 kg/m(2) , and a BMI >24.9 kg/m(2) , respectively. A BMI <18.5 kg/m(2) was associated with increased risk of grade 3 or 4 complications compared with a BMI >24.9 kg/m(2) (radiation enteritis: 16.7% vs 13.6%, respectively; P = .03; fistula: 11.1% vs 8.8%, respectively; P = .05; bowel obstruction: 33.3% vs 4.4%, respectively; P < .001; lymphedema: 5.6% vs 1.2%, respectively; P = .02). Underweight patients (BMI <18.5 kg/m(2) ) with locally advanced cervical cancer had diminished overall survival and more complications than normal weight and obese patients.
    Cancer 03/2011; 117(5):948-56. DOI:10.1002/cncr.25544 · 4.90 Impact Factor
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    ABSTRACT: The clinicopathologic significance of lower uterine segment involvement (LUSI) in endometrial cancer patients remains unclear. Although LUSI has been reported to be a prognostic indicator, literature is limited. We studied 481 surgically staged endometrioid endometrial cancers with disease confined to the uterus (FIGO 1988 stage I or II). Primary outcomes were overall survival (OS) and disease-free survival (DFS). The relationships between LUSI and OS and DFS were assessed using the Kaplan-Meier method and Cox proportional hazard models. The t test or Fisher exact test was used for evaluating relationships between variables of interest. LUSI was present in 223 cases (46.4%), and was associated with both decreased disease free survival (P = 0.02) and overall survival (P = 0.01) in univariate analysis. Multivariate analysis confirmed the association between LUSI and increased risk for recurrence [hazard ratio (HR) 2.27; 95% confidence interval (95% CI) 1.09-4.7; P = 0.03] and increased mortality (HR 1.76; 95% CI 1.12-2.78; P = 0.01). LUSI in patients with early-stage endometrioid endometrial cancer is associated with decreased survival.
    Annals of Surgical Oncology 12/2010; 18(5):1419-24. DOI:10.1245/s10434-010-1454-9 · 3.94 Impact Factor
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    ABSTRACT: Recent randomized controlled data suggest that neoadjuvant chemotherapy (NACT) with interval debulking (ID) may produce similar overall survival and progression free survival compared to standard primary cytoreduction followed by chemotherapy. The object of our study was to assess current patterns of care among members of the Society of Gynecologic Oncologists (SGO), specifically collating their opinions on and use of NACT for advanced stage ovarian cancer. A 20-item questionnaire was sent to all working e-mail addresses of SGO members (n=1137). The data was collected and analyzed using descriptive statistics with commercially available online survey software. The Chi-square test for independence was used to determine differences in responses between groups. Of 339 (30%) responding members, most rarely employ NACT, with 60% of respondents using NACT in less than 10% of advanced stage ovarian cancer cases. Respondents did not consider available evidence sufficient to justify NACT followed by ID (82%), nor did most think it should be preferred (74%). Sixty-two percent of respondents thought it was impossible to accurately predict preoperatively whether an optimal cytoreduction is possible. Thirty-nine percent believed that women with bulky upper abdominal disease on preoperative imaging would benefit from NACT versus primary debulking. If gross disease were found at ID, 43% would continue to treat with IV chemotherapy, and 42% would place an IP port if optimally cytoreduced. When ID reveals microscopic disease, 51% would continue IV treatment and the remaining IP therapy. Eighty-six percent of the respondents believed that both biological and surgical factors determine patient outcomes. The majority of responding SGO members do not treat patients with NACT followed by ID. Currently available studies of NACT/ID have been insufficient to convince most gynecologic oncologists to incorporate it into practice. Our results provide a benchmark against which further research can assess the penetration of NACT/ID into clinical practice.
    Gynecologic Oncology 10/2010; 119(1):18-21. DOI:10.1016/j.ygyno.2010.06.021 · 3.69 Impact Factor
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    ABSTRACT: A 10-point "Surgical Apgar Score" (SAS) for predicting postoperative complications after general and vascular operations has recently been developed and validated. We sought to estimate the ability of this metric to predict major postoperative complications in women undergoing ovarian cancer cytoreductive procedures. All eligible patients with stage III and IV epithelial ovarian, fallopian tube and primary peritoneal cancer undergoing surgical cytoreduction at our institution between 1999 and 2005 were included. Medical records were reviewed and demographic data, clinicopathologic characteristics, comorbidities and intra and postoperative complications were analyzed. The surgical score was calculated from intraoperative blood loss, lowest mean arterial pressure and lowest heart rate as previously described. Descriptive statistics, univariable and multivariable analyses were used as appropriate. Occurrence of major postoperative complications represented the primary outcome. A total of 232 cases were analyzed. Mean age was 62 years. Most patients were Caucasian (92%) and diagnosed with stage III disease (83%). Mean duration of surgical procedure was 171 (70-350) minutes. Median SAS was 6 points (range 1-9). On multivariable analyses, occurrence of major postoperative complications was associated with multiple comorbidities (OR 2.2; 95% CI:1.5-3.1; p<0.0001), stage IV disease (OR 2.5; 95% CI:1.1-5.7; p=0.03), ASA class (OR 2.4; 95% CI:1.2-4.7; p=0.01) and SAS<or=4 (OR 7.4; 95% CI:2.9-18.8; p<0.0001). Lower SAS (<or=4) is the most powerful predictor of postoperative complications in patients undergoing cytoreductive surgery for advanced epithelial ovarian cancer. This prognostic tool may prove helpful for triaging such patients to optimal postoperative levels of care and directing counseling, monitoring and management in the postoperative period.
    Gynecologic Oncology 12/2009; 116(3):370-3. DOI:10.1016/j.ygyno.2009.11.031 · 3.69 Impact Factor
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    ABSTRACT: Heritable polymorphisms modulate metastatic efficiency in Cancer Single nucleotide polymorphisms (SNPs) in MMP9 (rs17576) and SIPA1 (rs746429, rs931127) have been associated with nodal metastases in multiple cancers. We investigated the association of these SNPs with nodal metastases in early-stage cervical cancer. Consecutive patients with stage IB cervical cancer who underwent a pelvic lymph node (LN) dissection were included. Cases (>1 positive LN, n=101) were compared with controls (negative LN pathology, n=273). Genotyping was performed on genomic DNA in the 3 SNPs using a TaqMan assay and correlated with clinical variables. The G allele at SIPA1 rs931127 was associated with an increased risk of nodal disease (OR 1.9, P=0.03) and approached significance at SIPA 1 rs746429 (OR 2.2, P=0.09) and MMP9 rs17576 (OR 1.5, 0.08). In patients with stage Ib1 lesions (n=304), the G allele at both SIPA1 SNPs was associated with LN metastases (rs746429 OR 10.1, P=0.01; rs931127 OR 2.4, P=0.01). In patients with no lymph vascular space invasion, SIPA1 SNPs were again associated with LN metastases, and all patients with nodal disease had at least one G allele at SIPA1 rs746429. In this case-control study, SNPs in SIPA1 varied statistically in cervical cancer patients with and without nodal metastases and in MMP9 after controlling for stage and lymphvascular space invasion. Further work is needed to characterize inherited polymorphisms that provide a permissive background for the metastatic cascade.
    Gynecologic Oncology 11/2009; 116(3):539-43. DOI:10.1016/j.ygyno.2009.09.037 · 3.69 Impact Factor
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    ABSTRACT: In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Nosov V, Su F, Amneus M, et al. Validation of serum biomarkers for detection of early-stage ovarian cancer. Am J Obstet Gynecol 2009;200:639.e1-639.e5.
    American journal of obstetrics and gynecology 07/2009; 200(6):e1-3. DOI:10.1016/j.ajog.2009.04.026 · 3.97 Impact Factor