Michaela E McGree

Mayo Clinic - Rochester, Рочестер, Minnesota, United States

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Publications (133)509.98 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: To construct a tool, using computed tomography (CT) imaging and preoperative clinical variables, to estimate successful primary cytoreduction for advanced epithelial ovarian cancer (EOC). Women who underwent primary cytoreductive surgery for stage IIIC/IV EOC at Mayo Clinic between 1/2/2003 and 12/30/2011 and had preoperative CT images of the abdomen and pelvis within 90 days prior to their surgery available for review were included. CT images were reviewed for large-volume ascites, diffuse peritoneal thickening (DPT), omental cake, lymphadenopathy (LP), and spleen or liver involvement. Preoperative factors included age, body mass index (BMI), Eastern Cooperative Oncology Group performance status (ECOG PS), American Society of Anesthesiologists (ASA) score, albumin, CA-125, and thrombocytosis. Two prediction models were developed to estimate the probability of (i) complete and (ii) suboptimal cytoreduction (residual disease (RD) >1 cm) using multivariable logistic analysis with backward and stepwise variable selection methods. Internal validation was assessed using bootstrap resampling to derive an optimism-corrected estimate of the c-index. 279 patients met inclusion criteria: 143 had complete cytoreduction, 26 had suboptimal cytoreduction (RD > 1 cm), and 110 had measurable RD ≤1 cm. On multivariable analysis, age, absence of ascites, omental cake, and DPT on CT imaging independently predicted complete cytoreduction (c-index = 0.748). Conversely, predictors of suboptimal cytoreduction were ECOG PS, DPT, and LP on preoperative CT imaging (c-index = 0.685). The generated models serve as preoperative evaluation tools that may improve counseling and selection for primary surgery, but need to be externally validated. Copyright © 2015. Published by Elsevier Inc.
    Gynecologic Oncology 04/2015; DOI:10.1016/j.ygyno.2015.04.013 · 3.69 Impact Factor
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    ABSTRACT: To reexamine the tenet that advanced age independently impacts progression-free and cause-specific survival in patients with endometrial cancer (EC). Patients undergoing surgery for stage I-IIIC EC between 1999 and 2008 were stratified by age (<70 vs ≥70 years). Three propensity score (PS) methods were utilized to adjust for confounding risk factors. The PS, or conditional probability of being ≥70 years old, given a patient's baseline covariates, was derived using logistic regression. Cox proportional hazards models were fit to estimate the effect of age ≥70 on outcomes. Of 1,182 eligible patients, 822 (69.5%) were <70 and 360 (30.5%) were ≥70. Patients ≥70 were more likely to have multiple adverse risk factors. The total standardized difference of these factors was reduced by 74% and 81%, respectively, using PS-stratification and PS-matching analyses. The nonsignificant trend toward an association between progression-free survival and age ≥70 in unadjusted analysis (hazard ratio [HR], 1.40; 95% CI, 0.95-2.04) was further attenuated in the 3 PS analyses. The unadjusted HR for the association between age ≥70 and cause-specific survival was 2.03 (95% CI, 1.32-3.13). HRs were attenuated in PS analyses but retained significance (except for PS matching), potentially reflecting differences in salvage therapies (P<.001), including a 3-fold greater use of chemotherapy in those <70. When risk-adjusted for the higher prevalence of adverse prognostic factors in elderly EC patients, progression-free survival after primary therapy is not age dependent but the less favorable cause-specific survival in this cohort may reflect age-related postrecurrence treatment differences. Copyright © 2015. Published by Elsevier Inc.
    Gynecologic Oncology 04/2015; DOI:10.1016/j.ygyno.2015.04.010 · 3.69 Impact Factor
  • Journal of Minimally Invasive Gynecology 03/2015; 22(3):S45. DOI:10.1016/j.jmig.2014.12.094 · 1.58 Impact Factor
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    ABSTRACT: To identify patients at risk for postoperative morbidities, we evaluated indications and factors associated with 30-day readmission after epithelial ovarian cancer surgery. Patients undergoing primary surgery for epithelial ovarian cancer between January 2, 2003, and December 29, 2008, were evaluated. Univariable and multivariable logistic regression models were fit to identify factors associated with 30-day readmission. A parsimonious multivariable model was identified using backward and stepwise variable selection. In total, 324 (60.2%) patients were stage III and 91 (16.9%) were stage IV. Of all 538 eligible patients, 104 (19.3%) were readmitted within 30 days. Cytoreduction to no residual disease was achieved in 300 (55.8%) patients, and 167 (31.0%) had measurable disease (≤1 cm residual disease). The most common indications for readmission were surgical site infection (SSI; 21.2%), pleural effusion/ascites management (14.4%), and thromboembolic events (12.5%). Multivariate analysis identified American Society of Anesthesiologists score of 3 or higher (odds ratio, 1.85; 95% confidence interval, 1.18-2.89; P = 0.007), ascites [1.76 (1.11-2.81); P = 0.02], and postoperative complications during initial admission [grade 3-5 vs none, 2.47 (1.19-5.16); grade 1 vs none, 2.19 (0.98-4.85); grade 2 vs none, 1.28 (0.74-2.21); P = 0.048] to be independently associated with 30-day readmission (c-index = 0.625). Chronic obstructive pulmonary disease was the sole predictor of readmission for SSI (odds ratio, 3.92; 95% confidence interval, 1.07-4.33; P = 0.04). Clinically significant risk factors for 30-day readmission include American Society of Anesthesiologists score of 3 or higher, ascites and postoperative complications at initial admission. The SSI and pleural effusions/ascites are common indications for readmission. Systems can be developed to predict patients needing outpatient management, improve care, and reduce costs.
    International Journal of Gynecological Cancer 02/2015; 25(2):193-202. DOI:10.1097/IGC.0000000000000339 · 1.95 Impact Factor
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    ABSTRACT: Our objective was to understand the relationship between optimal diabetes control, as defined by Minnesota Community Measurement (MCM), and adverse health outcomes including emergency department (ED) visits, hospitalizations, 30-day rehospitalization, intensive care unit (ICU) stay, and mortality. In 2009, we conducted a retrospective cohort study of empaneled Employee and Community Health patients with diabetes mellitus. We followed patients from 1 September 2009 until 30 June 2011 for hospitalization and until 5 January 2014 for mortality. Optimal control of diabetes mellitus was defined as achieving the following three measures: low-density lipoprotein (LDL) cholesterol <100 mg/mL, blood pressure <140/90 mmHg, and hemoglobin A1c <8%. Using the electronic medical record, we assessed hospitalizations, ED visits, ICU stays, 30-day rehospitalizations, and mortality. The chi-square or Wilcoxon rank-sum tests were used to compare those with and without optimal control. We used Cox proportional hazard models to estimate the associations between optimal diabetes mellitus status and each outcome. We identified 5,731 empaneled patients with diabetes mellitus; 2,842 (49.6%) were in the optimal control category. After adjustment, we observed that non-optimally controlled patients had higher risks for hospitalization (hazard ratio [HR] 1.11; 95% confidence interval [CI] 1.00-1.23), ED visits (HR 1.15; 95% CI 1.06-1.25), and mortality (HR 1.29; 95% CI 1.09-1.53) than diabetic patients with optimal control. No differences were observed in ICU stay or 30-day rehospitalization. Diabetic patients without optimal control had higher risks of adverse health outcomes than those with optimal control. Patients with optimal control defined by the MCM were associated with decreased morbidity and mortality.
    Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 01/2015; 8:1-8. DOI:10.2147/DMSO.S71726
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    ABSTRACT: Surgical site infection (SSI) following epithelial ovarian cancer (EOC) primary surgery (PS) occurs in 10-15% of women. Perioperative factors associated with SSI and impact of SSI on survival were determined. EOC cases that underwent PS from 1/2/2003-12/30/2011 were retrospectively reviewed. SSIs were defined according to ACS NSQIP. Logistic regression models were fit to identify factors associated with SSI. Cox proportional hazards models were utilized to evaluate the association of patient and perioperative characteristics with overall survival (OS) and disease-free survival (DFS). Among 888 cases, 96 (10.8%) developed SSI: 32 superficial, 2 deep, and 62 organ/space. Factors independently associated with superficial SSI were increasing BMI (odds ratio 1.41 [95% confidence interval, 1.12, 1.76] per 5kg/m(2)), increasing operative time (1.24 [1.02, 1.50] per hour), and advanced stage (III/IV) (10.22 [1.37, 76.20]). Factors independently associated with organ/space SSI were history of gastroesophageal reflux disease (2.13 [1.23, 3.71]), surgical complexity (intermediate 3.11 [1.02, 9.49]; high 8.07 [2.60, 25.09]; referent: low), and residual disease (RD) (measureable ≤1cm 1.77 [0.96, 3.27]; suboptimal >1cm (3.36 [1.48, 7.61]; referent: microscopic). Occurrence of superficial (hazard ratio 1.69 [1.12, 2.57]) or organ/space (1.46 [1.07, 2.00]) SSI was independently associated with worse OS. SSI occurrence was not independently associated with DFS. SSI after PS is associated with decreased OS. Most risk factors for SSI are not modifiable. Alternative measures to lower rates of SSIs are needed as this may improve OS. Preoperative identification of SSI risk factors may assist in risk-assessment and operative planning. Copyright © 2014. Published by Elsevier Inc.
    Gynecologic Oncology 12/2014; 136(2). DOI:10.1016/j.ygyno.2014.12.007 · 3.69 Impact Factor
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    ABSTRACT: Minimally invasive surgery (MIS) is the preferred technique for managing endometrial cancer. Given that uterine serous carcinoma (USC) has a predilection for multiquadrant peritoneal dissemination, our objective was to estimate the potential risk for overlooking occult peritoneal spread with the use of MIS. A single-institution, retrospective review was conducted of patients who underwent primary surgical staging for endometrial cancer via laparotomy between 1999 and 2008. Patterns of metastases were analyzed to estimate the potential risk for understaging via MIS. A total of 202 USC cases met inclusion criteria. Pelvic and para-aortic nodes were positive in 59 (36%) of 166 and 43 (31%) of 138, respectively. Stage IVb disease was diagnosed in 77 (38%) of 202 patients. The majority (86%, 66/77) harbored bulky and/or multisite macroscopic abdominal implants. Isolated microscopic peritoneal disease was present in 5 of 77 cases (6% of stage IV, 2% of the entire cohort) but, in all cases, was limited to the omentum; 6 of 77 cases (8% of stage IV, 3% of the cohort) harbored a single implant in the context of a negative omentum but, in all cases, were macroscopic (locations included the ileum, the diaphragm, and the base of the mesentery). For providers who aim to remove all visible disease in patients with USC, the rate of extrauterine disease escaping detection using MIS is low (<3%) provided an omentectomy is performed together with staging.
    International Journal of Gynecological Cancer 12/2014; 25(1). DOI:10.1097/IGC.0000000000000326 · 1.95 Impact Factor
  • Journal of the American College of Surgeons 10/2014; 219(4):e25. DOI:10.1016/j.jamcollsurg.2014.07.450 · 4.45 Impact Factor
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    ABSTRACT: Objectives. The aim of this study is to determine the impact of obesity on surgical and oncologic outcomes after primary debulking surgery (PDS) in advanced epithelial ovarian cancer (EOC). Methods. Women with stage IIIC/IV EOC who underwent PDS with curative intent between 1/2/2003 and 12/30/2011 were included. Patient characteristics, intraoperative and postoperative outcomes, recurrence and status were abstracted. Complications were graded according to the 4-point Accordion classification. For analyses, patients were divided into three groups according to body mass index (BMI): group 1-BMI <25.0 kg/m(2); group 2-BMI 25.0-39.9 kg/m(2); and group 3-BMI >= 40.0 kg/m(2). Results. Of the 620 patients included in the study, 36.6%, 56.9%, and 6.5% were in weight groups 1, 2, and 3, respectively. Weight group 3 was an independent predictor of severe complications after adjusting for confounders (adjusted odds ratio (95% CI): 2.93 (1.38, 6.20) for group 3 vs. group 2). Weight group was not associated with differences in residual disease (p = 0.80). The 90-day mortality rates were 11.9%, 6.7%, and 15.7%, respectively, in weight group 1, 2, and 3 (p = 0.049 unadjusted, p = 0.01 adjusted). There was no difference in OS (p = 0.52) or PFS (p = 0.23) between weight groups. Conclusions. BMI >= 40.0 kg/m(2) is an independent predictor of severe 30-day postoperative morbidity and 90-day mortality after PDS for EOC information useful in preoperative counseling. BMI does not appear to impact long-term oncologic outcomes including residual disease at PDS, although we had limited power at the extremes of BMI. BMI may be an important factor to consider in risk-adjustment models and reimbursement strategies.
    Gynecologic Oncology 08/2014; 135(1). DOI:10.1016/j.ygyno.2014.07.103 · 3.69 Impact Factor
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    ABSTRACT: OBJECTIVE: To estimate lower extremity lymphedema prevalence in patients surgically treated for endometrial cancer, identify predictors of lymphedema, and evaluate the effects of lymphedema on quality of life. METHODS: One thousand forty-eight consecutive patients who were operated on between 1999 and 2008 at the Mayo Clinic were mailed a survey, which included our validated 13-item lymphedema screening questionnaire and two validated quality-of-life measures. Logistic regression models were fit to identify factors associated with prevalent lymphedema; a multivariable model was obtained using stepwise and backward variable selection methods. The relationship between lymphedema and obesity with each quality-of-life score was evaluated separate multivariable linear models. RESULTS: There were 591 responders (56%) after exclusions. Our questionnaire revealed a previous self-reported lymphedema diagnosis in 103 (17%) patients and identified undiagnosed lymphedema in 175 (30%) (overall prevalence 47.0%, median 6.2 years follow-up). Lymphedema prevalence in patients treated with hysterectomy alone compared with lymphadenectomy was 36.1% and 52.3%, respectively (attributable risk 23%). Lymphedema risk was not associated with the number of nodes removed or the extent of lymphadenectomy after adjusting for other factors. On multivariable analysis, higher body mass index, congestive heart failure, performance of lymphadenectomy, and radiation therapy were associated with prevalent lymphedema. Multiple quality-of-life scores were worse in women with lymphedema. CONCLUSION: The attributable risk of developing lower extremity lymphedema was 23% for patients with endometrial cancer who underwent lymphadenectomy compared with hysterectomy alone with an overall prevalence of 47%. Lymphedema was associated with reductions in multiple quality-of-life domains.
    Obstetrics and Gynecology 07/2014; DOI:10.1097/AOG.0000000000000372 · 4.37 Impact Factor
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    ABSTRACT: Objective Estimate the overall rates of significant incontinent conduit-related complications and compare rates between conduit types. Methods This was a retrospective review of 166 patients who underwent incontinent urinary diversion from April 1993 through April 2013. Patients were categorized by conduit type – ileal, sigmoid colon, and transverse colon. Significant conduit-related complications were assessed at 30 and 90 days after surgery. Significant conduit-related complication was defined as any of the following: ureteral stricture, conduit leak, conduit obstruction, conduit ischemia, ureteral anastomotic leak, stent obstruction requiring intervention via interventional radiology procedure or reoperation, and renal failure. Results A total of 166 patients underwent formation of an incontinent urinary conduit, most commonly during exenteration for gynecologic malignancy. There were 129 ileal, 11 transverse colon, and 26 sigmoid conduits. The overall significant conduit-related complication rate within 30 days was 15.1%. Complications rates for ileal, transverse and sigmoid conduits were 14.7%, 0%, and 23.1%, respectively (Fisher’s exact test,p = 0.24). By 90 days, the Kaplan-Meier estimated rates of significant complications were 21.8% overall, and 22.3%, 0%, and 28.9%, respectively, by conduit type (log-rank test,p = 0.19). The most common significant conduit-related complications were conduit or ureteral anastomotic leaks and conduit obstructions. By 1 and 2 years following surgery, the Kaplan-Meier estimated overall rate of significant conduit-related complication increased to 26.5% and 30.1%, respectively. Conclusions Our study suggests that there are multiple appropriate tissue sites for use in incontinent conduit formation, and surgical approach should be individualized. Most significant conduit-related complications occur within 90 days after surgery.
    Gynecologic Oncology 06/2014; DOI:10.1016/j.ygyno.2014.03.568 · 3.69 Impact Factor
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    ABSTRACT: To describe the short-term perioperative outcomes and overall survival among women with venous thromboembolism (VTE) at initial epithelial ovarian cancer diagnosis. Women presenting with VTE within 30 days of epithelial ovarian cancer diagnosis between January 2, 2003, and December 29, 2011, who had primary debulking surgery or primarily managed with neoadjuvant chemotherapy were included. Descriptive statistics and the Kaplan-Meier method were used to estimate overall survival from the time of epithelial ovarian cancer diagnosis with patient characteristics and process-of-care variables retrospectively abstracted. Of the 37 women with VTE within 30 days before epithelial ovarian cancer diagnosis, 28 (75.7%; mean age 64.2 years) underwent primary debulking surgery and 9 (24.3%; mean age 62.7 years) received neoadjuvant chemotherapy. Eastern Cooperative Oncology Group performance status was 0-1 in 75% (n=21) of patients undergoing primary debulking surgery compared with 44% (n=4) of patients undergoing neoadjuvant chemotherapy. Advanced-stage (III-IV) disease was diagnosed in 71.4% (n=20) of the primary debulking surgery cohort; all patients undergoing neoadjuvant chemotherapy were presumed advanced. Among those who underwent primary debulking surgery, 26 (92.9%) had a preoperative inferior vena cava filter placed; only one (11.1%) in the neoadjuvant chemotherapy cohort received an inferior vena cava filter. Perioperative bleeding complications were rare in the primary debulking surgery cohort. Within the primary debulking surgery cohort, median overall survival was 2.14 years and median overall survival in the neoadjuvant chemotherapy cohort was 8.8 months ().(Figure is included in full-text article.) : Despite preoperative VTE, median overall survival was improved among patients undergoing primary debulking surgery; however, poorer overall survival in the neoadjuvant chemotherapy cohort may reflect a worse performance status or higher proportion of advanced cancer. Preoperative VTE in patients with epithelial ovarian cancer can be safely managed with low rates of bleeding complications.
    Obstetrics and Gynecology 05/2014; 123 Suppl 1:183S-4S. DOI:10.1097/01.AOG.0000447204.35797.4a · 4.37 Impact Factor
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    ABSTRACT: Treatment failures in stage IIIC endometrial carcinoma (EC) are predominantly due to occult extrapelvic metastases (EPM). The impact of chemotherapy on occult EPM was investigated according to grade (G), G1/2EC vs G3EC. All surgical-stage IIIC EC cases from January 1, 1999, through December 31, 2008, from Mayo Clinic were included. Patient-, disease-, treatment-specific risk factors were assessed for association with overall survival, cause-specific survival, and extrapelvic disease-free survival (DFS) using Cox proportional hazards regression. 109 cases met criteria, with 92 (84%) having systematic lymphadenectomy (>10 pelvic and >5 paraaortic lymph nodes resected). In patients with documented recurrence sites, occult EPM accounted for 88%. Among G1/2EC cases (n=48), the sole independent predictor of extrapelvic DFS was grade 2 histology (hazard ratio [HR], 0.28; 95% CI, 0.08-0.91; P=.03) while receipt of adjuvant chemotherapy approached significance (HR 0.13; 95% CI, 0.02, 1.01); P=.0511). The 5-year extrapelvic DFS with and without adjuvant chemotherapy was 93% and 54%, respectively (log-rank, P=.02). Among G3EC (n=61), the sole independent predictor of extrapelvic DFS was lymphovascular space involvement (HR, 2.63; 95% CI, 1.16-5.97; P=.02). Adjuvant chemotherapy did not affect occult EPM in G3EC; the 5-year extrapelvic DFS for G3EC with and without adjuvant chemotherapy was 43% and 42%, respectively (log-rank, P=.91). Chemotherapy improves extrapelvic DFS for stage IIIC G1/2EC but not stage IIIC G3EC. Future efforts should focus on prospectively assessing the impact of chemotherapy on DFS in G3EC and developing innovative phase I and II trials of novel systemic therapies for advanced G3EC.
    Gynecologic Oncology 01/2014; 132(3). DOI:10.1016/j.ygyno.2014.01.007 · 3.69 Impact Factor
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    ABSTRACT: The aim of this study was to determine the incidence and the risk factors of venous thromboembolism (VTE) within 30 days after primary surgery for epithelial ovarian cancer (EOC). In a historical cohort study, we estimated the postoperative 30-day cumulative incidence of VTE among consecutive Mayo Clinic patients undergoing primary cytoreduction for EOC between January 2, 2003, and December 29, 2008. We tested perioperative patient characteristics and process-of-care variables (defined by the National Surgical Quality Improvement Program, >130 variables) as potential predictors of postoperative VTE using the Cox proportional hazards modeling. Among 569 cases of primary EOC cytoreduction and/or staging and no recent VTE, 35 developed symptomatic VTE within 30 days after surgery (cumulative incidence = 6.5%; 95% confidence interval, 4.4%-8.6%). Within the cohort, 95 (16.7%) received graduated compression stockings (GCSs), 367 (64.5%) had sequential compression devices + GCSs, and 69 (12.1%) had sequential compression devices + GCSs + postoperative heparin, with VTE rates of 1.1%, 7.4%, and 5.8%, respectively (P = 0.07, χ test). The remaining 38 (6.7%) received various other chemical and mechanical prophylaxis regimens. In the multivariate analysis, current or past tobacco smoking, longer hospital stay, and a remote history of VTE significantly increased the risk for postoperative VTE. Venous thromboembolism is a substantial postoperative complication among women with EOC, and the high cumulative rate of VTE within 30 days after primary surgery suggests that a more aggressive strategy is needed for VTE prevention. In addition, because longer hospital stay is independently associated with a higher risk for VTE, methods to decrease length of stay and minimize factors that contribute to prolonged hospitalization are warranted.
    International Journal of Gynecological Cancer 11/2013; 23(9):1684-91. DOI:10.1097/IGC.0b013e3182a80aa7 · 1.95 Impact Factor
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    ABSTRACT: Perioperative packed red blood cell transfusion (PRBCT) has been implicated as a negative prognostic marker in surgical oncology. There is a paucity of evidence on the impact of PRBCT on outcomes in epithelial ovarian cancer (EOC). We assessed whether PRBCT is an independent risk factor of recurrence and death from EOC. Perioperative patient characteristics and process-of-care variables (defined by the National Surgical Quality Improvement Program) were retrospectively abstracted from 587 women who underwent primary EOC staging between January 2, 2003, and December 29, 2008. Associations with receipt of PRBCT were evaluated using univariate logistic regression models. The associations between receipt of PRBCT and disease-free survival and overall survival were evaluated using multivariable Cox proportional hazards models and using propensity score matching and stratification, respectively. The rate of PRBCT was 77.0%. The mean ± SD units transfused was 4.1 ± 3.1 U. In the univariate analysis, receipt of PRBCT was significantly associated with older age, advanced stage (≥IIIA), undergoing splenectomy, higher surgical complexity, serous histologic diagnosis, greater estimated blood loss, longer operating time, the presence of residual disease, and lower preoperative albumin and hemoglobin. Perioperative packed red blood cell transfusion was not associated with an increased risk for recurrence or death, in an analysis adjusting for other risk factors in a multivariable model or in an analysis using propensity score matching or stratification to control for differences between the patients with and without PRBCT. Perioperative packed red blood cell transfusion does not seem to be directly associated with recurrence and death in EOC. However, lower preoperative hemoglobin was associated with a higher risk for recurrence. The need for PRBCT seems to be a stronger prognostic indicator than the receipt of PRBCT.
    International Journal of Gynecological Cancer 11/2013; 23(9):1612-9. DOI:10.1097/01.IGC.0000436089.03581.6b · 1.95 Impact Factor
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    ABSTRACT: To study the use of a baseline prostate-specific antigen (PSA) and digital rectal examination in men (aged 40-49 years) in predicting long-term prostate cancer risk in a prospectively followed, representative population cohort. Since 1990, a random sample of men in Olmsted County (aged 40-49 years) has been followed up prospectively (n = 268), with biennial visits, including a urologic questionnaire, PSA screening, and physical examination. The ensuing risk of prostate cancer (CaP) was compared using survival analyses. Median follow-up was 16.3 years (interquartile range 14.0-17.3, max 19.1). For men with a baseline PSA <1.0 ng/mL (n = 195), the risk of subsequent Gleason 6 CaP diagnosis by 55 years was 0.6% (95% confidence interval [CI] 0%-1.7%) and 15.7% (95% CI 6.5%-24.9%) for men with a baseline PSA ≥1.0 ng/mL. No man with a low baseline PSA developed an intermediate or high risk CaP, whereas 2.6% of men with a higher baseline PSA did (95% CI 0.58%-4.6%). Men (aged 40-49 years) can be stratified with a baseline PSA. If it is below 1.0 ng/mL, there is very little risk for developing a lethal CaP, and as many as 75% of men might be able to avoid additional PSA screening until 55 years. Conversely, men aged 40-49 years with a baseline PSA level >1.0 ng/mL had a significant risk of CaP diagnosis and should be monitored more closely.
    Urology 10/2013; 82(6). DOI:10.1016/j.urology.2013.06.074 · 2.13 Impact Factor
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    ABSTRACT: To prospectively define the prevalence of lymph node metastasis (LNM) in at risk endometrial cancer (EC). From 2004-2008, frozen section based Mayo Criteria prospectively identified patients "not at-risk" of LNM (30% EC population; grade I/II, <50% myometrial invasion and tumor diameter ≤2cm) where lymphadenectomy was not recommended. The remaining 70% EC cohort was considered "at-risk" of LNM; where a systematic pelvic and infrarenal paraaortic lymphadenectomy was recommended. Patients were prospectively followed. The area between renal vein and inferior mesenteric artery (IMA) was labeled as high paraaortic area. For calculating the prevalence of LNM in high paraaortic area, the denominator was the population with known anatomic location of nodal tissue in relation to the IMA. Of the 742 patients, 514 were at risk; of which 89% underwent recommended lymphadenectomy. A mean (± standard deviation) of 36 (±14) pelvic and 18 (±9) paraaortic nodes were harvested. The prevalence of pelvic and paraaortic LNM was 17% and 12%, respectively. In presence of pelvic LNM, 51% had paraaortic LNM. In absence of pelvic LNM, 3% had paraaortic LNM; of which 67% were located exclusively in high paraaortic area. Among patients with paraaortic LNM, 88% had high paraaortic LNM; and 35% had only high paraaortic LNM. The cases of paraaortic LNM with negative pelvic nodes seemed to cluster in moderate to high grade endometrioid EC with ≥50% myometrial invasion. We present reference data for the prevalence of LNM in at-risk EC patients to guide lymphadenectomy decisions for clinical and research purposes.
    Gynecologic Oncology 10/2013; DOI:10.1016/j.ygyno.2013.10.002 · 3.69 Impact Factor
  • Gynecologic Oncology 10/2013; 131(1):275-276. DOI:10.1016/j.ygyno.2013.07.075 · 3.69 Impact Factor
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    ABSTRACT: To develop a risk-scoring system (RSS) for the prediction of lymphatic dissemination after hysterectomy in endometrioid endometrial carcinoma (EC). Patients who underwent surgery from 1/1/1999-12/31/2008 were evaluated. Patients with non-endometrioid histology, stage IV with macroscopic extrauterine disease, or receiving adjuvant therapy (excluding brachytherapy) without pelvic and/or paraaortic (P/PA) lymphadenectomy (LND) were excluded. Lymph node dissemination was defined as nodal metastasis when P/PA LND was performed or P/PA lymph node recurrence after negative LND or when LND was not performed. Logistic regression analysis was used to identify predictors for lymphatic dissemination and develop a RSS and nomogram. The RSS was assessed for calibration and verified for discrimination. Overall, 883 patients were assessed of which 521 (59.0%) underwent P/PA LND and 57 (10.9%) had positive lymph nodes. Of patients who did not undergo P/PA LND (N=362) or had negative nodes (N=464), 10 (1.2%) patients had P/PA lymph node recurrence. Myometrial invasion, tumor diameter (TD), FIGO grade, cervical stromal invasion and lymphovascular space invasion were significant on univariable analysis. All preceding variables were included in a multivariable logistic model. A parsimonious model and an alternative full model not including TD were considered. The full model with TD (illustrated in nomogram) had the highest predictive ability (concordance index 0.88). Our RSS allows accurate quantification of the probability of lymphatic dissemination and can be used as an adjunct to clinical decision-making after hysterectomy in the absence of staging. TD is an important component of the RSS and should be routinely assessed.
    Gynecologic Oncology 07/2013; 131(1). DOI:10.1016/j.ygyno.2013.06.037 · 3.69 Impact Factor
  • Gynecologic Oncology 07/2013; 130(1):e82-e83. DOI:10.1016/j.ygyno.2013.04.253 · 3.69 Impact Factor

Publication Stats

1k Citations
509.98 Total Impact Points

Institutions

  • 2005–2015
    • Mayo Clinic - Rochester
      • • Department of Obstetrics & Gynecology
      • • Department of Health Science Research
      Рочестер, Minnesota, United States
  • 2009
    • All India Institute of Medical Sciences
      • Department of Urology
      New Delhi, NCT, India
  • 2008
    • Permanente Medical Group
      Pasadena, California, United States