Gwen M. Grimsby

Is there concordance of invasive breast cancer pathologic tumor size with magnetic resonance imaging

BACKGROUND In the era of breast conservation therapy, preoperative imaging is imperative in planning a single definitive surgical treatment. METHODS We performed a retrospective review of a prospectively collected database of patients treated at a single institution for invasive breast cancer over 5 years. Clinical and pathologic variables were analyzed with respect to magnetic resonance imaging (MRI) and pathologic tumor size using analysis of variance F tests and chi-square tests. RESULTS Of 190 patients, 53% had concordance of MRI and pathologic cancer size within .5 cm. MRI overestimated 33% and underestimated 15% of tumors. Neoadjuvant chemotherapy and lymph node status were associated with discordance. Among tumors overestimated by MRI, 65% had additional significant findings in the breast tissue around the main lesion: satellite lesions, ductal carcinoma in situ, and/or lymphovascular invasion. CONCLUSIONS Breast MRI is concordant with pathologic tumor size within .5 cm among 53% of patients. Most patients with tumors overestimated by MRI have significant findings in the surrounding breast tissue, the excision of which would be expected to benefit the patient.

Scientific Presentation Award: The impact of magnetic resonance imaging on surgical treatment of invasive breast cancer

BACKGROUND The purpose of this study was to examine the relationship between magnetic resonance imaging (MRI) and surgical treatment of invasive breast cancer (IBC). METHOD The IBC patients treated from January 2003-June 2008 were reviewed by a single institution. RESULTS A total of 814 patients were treated, out of which 562 (69%) underwent breast conservation therapy (BCT), 151 (19%) chose mastectomy alone (M), and 101 (12%) chose mastectomy with reconstruction (M+ R). The mean age was comparatively low in M + R patients (P <or= 0.001). The mean tumor size was the lowest in BCT patients (P <or= 0.001). MRI use increased with no significant difference in type of surgery as noted by year. In multivariate analysis, type of surgery was significantly associated with tumor size, multifocality, age, and MRI use. The factors associated with MRI performance were: multifocality, younger age, tumor size, lobular histology, body mass index, and genetic testing. CONCLUSIONS The use of MRI in IBC patients has increased over the past 5 years, without any observable impact on surgical treatment. Similar factors are associated with mastectomy and MRI performance.

Bladder capacity on preoperative urodynamics may impact outcomes on transobturator male slings.

Stress incontinence is frequently seen after prostate surgery. We sought to evaluate preoperative urodynamic (UDS) parameters on functional outcomes after transobturator male sling placement.

A Double-Blind Randomized Controlled Trial of Continuous Intravenous Ketorolac vs Placebo for Adjuvant Pain Control After Renal Surgery

OBJECTIVE To evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control. PATIENTS AND METHODS A prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level. RESULTS The study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13). CONCLUSION Although continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control. TRIAL REGISTRATION clinicaltrials.gov Identifiers: NCT00765128 and NCT00765232.

Does magnetic resonance imaging accurately predict residual disease in breast cancer

BACKGROUND The accuracy of magnetic resonance imaging (MRI) in identifying residual disease after breast conservation therapy (BCT) is unclear. METHOD Review of an institutional database identified patients with positive or close (<or=2 mm) margins undergoing MRI before re-excision. Histopathologic correlation was performed. RESULTS Forty-three women underwent MRI after BCT. MRI suggested residual disease in 29 patients, of whom 20 (69%) had residual carcinoma pathologically. Nine patients had false-positive MRI as seen by benign pathology findings. Fourteen MRIs indicated no residual disease, of which 6 had residual disease pathologically. The sensitivity and positive predictive value of MRI was 77% and 69%, respectively. MRI conducted within 28 days of the original surgery was 85% sensitive. MRI performed after 28 days was 69% sensitive. CONCLUSIONS MRI is able to detect residual disease among most patients undergoing re-excision. False-positive results may be caused by inflammatory processes that resemble residual disease.

Metastatic malignant melanoma to the bladder: A case series

Background: Metastatic melanoma to the bladder is rarely reported, and the role of surgery is still largely unknown. We review 4 such cases and highlight their management and outcomes. We also review the relevant literature. Methods: The Mayo Clinic tumor database was searched and 4 such cases were found. Results: All 4 patients were treated locally with transurethral resection. The only patient who had a solitary metastasis did relatively well, having no evidence of disease 10 months after his presentation, while the other 3 died within 6 months. The literature highlights various approaches to management, but there is no definitive evidence that radical cystectomy offers any benefit over transurethral resection. Conclusion: Resection may improve survival in the setting of a solitary metastasis, but there is no evidence that radical cystectomy offers any benefit over local resection. With diffuse disease, however, resection is likely only beneficial for treatment of hematuria.

Urologic surgical simulation: an endoscopic bladder model.

Introduction: With the explosion of endoscopic techniques in urology as well as the increasing work restrictions with resident duty hours, training programs are faced with the challenges of how to adequately train residents while still being proficient and safe in the operating room. Surgical simulation with models is an excellent tool to help bridge the gap between practice and experience and allow residents to learn basic skills in a low stress environment that can be later transferred to the operating room. Methods: We present a high-fidelity endoscopic boar bladder model for first-year urology resident training in preparation for real-time experience in the operating room. Results: The boar bladder model held up for the residents to complete six separate tasks. In each of the six assigned tasks, both residents had a percent improvement ranging from 13% to 97% when comparing an average of the first attempts with the final attempt. Conclusions: The novel simulation model we describe demonstrates is a high-fidelity tissue surrogate that can be used for simulation training for improvement in core urologic skills by novice residents. This model may be a useful tool in documenting proficiency-based competence of cystoscopic skills.

Bladder outlet obstruction secondary to a Brunn's cyst

Introduction: Bladder outlet obstruction in younger men is often secondary to urethral stricture disease. In the older population it is often a result of benign prostatic hypertrophy. Materials and Methods: We describe the diagnosis, treatment, and outcome of a rare case of a Brunn’s cyst causing bladder outlet obstruction in a 43-year-old male who was evaluated for obstructive urinary complaints. Results: Ultrasound and cystoscopy revealed a cystic lesion at the bladder neck. Transurethral unroofing of the cyst resulted in resolution of the obstructive symptoms and resumption of normal voiding. Final pathology revealed a cystic structure with predominately denuded urothelium with multiple submucosal cystically dilated von Brunn’s nests, most consistent with a Brunn’s cyst. A search of the literate reveals only one similar case. Conclusions: We present the rare case of a Brunn’s cyst causing bladder outlet obstruction in a young man.

Long-term renal function after donor nephrectomy: secondary follow-up analysis of the randomized trial of ketorolac vs placebo.

OBJECTIVE To evaluate the long-term safety of a novel continuous infusion of ketorolac vs placebo after laparoscopic donor nephrectomy. METHODS We performed a secondary analysis of a previously reported randomized controlled trial conducted from October 7, 2008, to July 21, 2010. Patients aged 18-75 years received a continuous infusion of either ketorolac (treatment [n=57]) or normal saline (control [n=54]) for 24 hours immediately after laparoscopic donor nephrectomy. Serum creatinine levels were measured at 1- and 1.5-year follow-ups. Glomerular filtration rate was calculated preoperatively, postoperatively, and at 1- and 1.5-year follow-ups using the Chronic Kidney Disease Epidemiology Collaboration equation. Glomerular filtration rates were compared between treatment and control groups using 2-sample t tests. RESULTS Data analysis for the 111 donor nephrectomy patients showed that glomerular filtration rates decreased in both groups over time, but changes were not clinically significant. No difference was found in glomerular filtration rates (in mL/min/1.73 m2) between treatment and control groups at 1-year follow-up (89.29 vs 87.94 mL/min/1.73 m2; P=.58) or at 1.5-year follow-up (88.54 vs 90.25 mL/min/1.73 m2; P=.51). CONCLUSION The novel provision of continuous steady-state ketorolac is safe for postoperative pain control in patients after donor nephrectomy, with no change in glomerular filtration rates between treatment and control groups acutely and at up to 1.5-year follow-up.