Michelle Arnold

Trends in Risk Reduction Practices for the Prevention of Lymphedema in the First 12 Months after Breast Cancer Surgery

BACKGROUND Lymphedema is a feared complication of breast cancer surgery. We evaluated the trends in lymphedema development, patient worry, and risk reduction behaviors. STUDY DESIGN We prospectively enrolled 120 women undergoing sentinel node biopsy (SLNB) or axillary node dissection (ALND) for breast cancer and assessed lymphedema by upper extremity volume preoperatively and at 6 and 12 months postoperatively. We defined lymphedema as a >10% volume change from baseline relative to the contralateral upper extremity. Patients completed a validated instrument evaluating lymphedema worry and risk reducing behaviors. Associations were determined by Fishers exact and signed rank tests. RESULTS At 6 months, lymphedema was similar between ALND and SLNB patients (p = 0.22), but was higher in ALND women at 12 months (19% vs 3%, p = 0.005). A clear relationship exists between relative change in upper extremity volume at 6 and 12 months (Kendall tau coefficient 0.504, p < 0.001). Among the women with 0 to 9% volume change at 6 months, 22% had progressive swelling, and 18% resolved their volume changes at 12 months. Overall, 75% of ALND and 50% of SLNB patients had persistent worry about lymphedema at follow-up, and no difference existed in the number of risk reducing behaviors practiced among the 2 groups (p > 0.34). CONCLUSIONS Upper extremity volumes fluctuate, and there is a period of latency before development of lymphedema. Despite the low risk of lymphedema after SLNB, most women worry about lymphedema and practice risk reducing behaviors. Additional study into early upper extremity volume changes is warranted to allay the fears of most women and better predict which women will progress to lymphedema.

Three‐dimensional tumour volume and cancer‐specific survival for patients undergoing nephrectomy to treat pT1 clear‐cell renal cell carcinoma

Study Type – Prognosis (case series)

Salvage autologous fascial sling after failed synthetic midurethral sling: Greater than 3-year outcomes.

To determine long‐term surgical outcomes of salvage autologous fascial sling placement after a failed synthetic midurethral sling.

Evaluation of awareness of risk factors for kidney cancer among patients presenting to a urology clinic.

Abstract Objective. This study aimed to evaluate awareness of risk factors for kidney cancer among patients presenting to a urology clinic. Smoking, obesity and hypertension are widely accepted as risk factors for kidney cancer; however, there are limited data regarding awareness of these risk factors. Material and methods. The researchers prospectively identified 172 patients presenting to a urology clinic between 1 May 2009 and 31 August 2009. Each patient completed a questionnaire that requested responses to whether certain lifestyle factors increased the risk of a variety of cancers. Information on demographics and other covariates was collected via questionnaires and medical chart abstraction. To estimate and compare risk factor awareness levels for different cancers, 95% confidence intervals (95% CIs) were constructed and Fishers exact tests performed. Logistic regression analysis was used to evaluate covariates associated with risk factor awareness. Results. The percentage reporting that smoking increases the risk of kidney cancer (36%, 95% CI 29–44%) was lower than for lung cancer (96%, 95% CI 92–99%). Similarly, the percentage reporting that obesity increases the risk of kidney cancer (32%, 95% CI 25–40%) was lower than for colon cancer (45%, 95% CI 37–53% CI). Only 18% (95% CI 13–25%) identified hypertension as a risk factor for kidney cancer. Female gender and younger age were associated with increased levels of awareness of the association with smoking and obesity, respectively. Conclusion. The data support a low level of awareness of kidney cancer risk factors and underscore an opportunity for urologists to engage in education efforts.

Evaluation of Pancreatic Damage After Extracorporeal Shock Wave Lithotripsy, Percutaneous Stone Surgery, and Ureteroscopy

OBJECTIVES To complete a prospective evaluation of serum amylase and lipase levels before and after shock wave lithotripsy (SWL) for renal stones. We also compared these serum levels to those of patients undergoing percutaneous and ureteroscopic stone surgery. SWL injury to the pancreas should be noted by an increase in serum amylase and lipase. METHODS A prospective evaluation of 38 patients (16 who underwent SWL, 15 who underwent percutaneous nephrostolithotomy, and 7 who underwent ureteroscopic stone manipulation) who underwent treatment of renal calculi at our institution was completed. The control group was the combined group of patients who had undergone percutaneous nephrostolithotomy or ureteroscopic stone manipulation. The serum amylase and lipase levels were measured before the procedure, immediately after the procedure (2 hours), and ≥30 days after the procedure. RESULTS No statistically significant difference was found in the change from before to immediately after the procedure between the SWL group and the controls in amylase (median decrease 6 U/L vs 11 U/L, P = .45) or lipase (median decrease 4 U/L vs 9 U/L, P = .31). Also, no statistically significant evidence was seen in the change from before to >30 days after the procedure between the SWL group and controls in the amylase level (median increase 0 U/L vs 2 U/L, P = 1.00) or lipase (median change 2 U/L increase vs 1 U/L decrease, P = .96). CONCLUSIONS SWL does not appear to noticeably increase the serum amylase and lipase level directly postoperatively or >30 days after the procedure compared with baseline or compared with the controls.

Correlation of radiographic renal cell carcinoma tumor volume utilizing computed tomography and magnetic resonance imaging compared with pathological tumor volume.

Abstract Objective. New evidence suggests that three-dimensional pathological tumor volume (TV) provides additional prognostic information in renal cell carcinoma (RCC) to that provided by tumor size alone. The aim of this study was to assess the correlation between radiographic TV, by computed tomography (CT) and magnetic resonance imaging (MRI), and pathological tumor volume (TV). Material and methods. Pathological TV from 143 patients treated with surgical removal for unilateral RCC was compared with radiographic TV. Measurements were taken by one central pathologist and one radiologist, who were blinded to each others findings. The TV for each modality was calculated using the equation for measuring the volume of an ellipsoid: π/6(Length × Width × Height). Results. No statistical differences were noted for relevant clinicopathological covariates between patients who had CT scan or MRI. The correlation coefficient for pathological TV was similar for MRI (0.97) and CT (0.98), although the correlation was lowest for those patients with the smallest tumors (0.82 for pT1a). The TV correlation was weaker among non-obese patients [0.99 for body mass index (BMI) >30 vs 0.89 for BMI <30]. Gender, tumor grade and tumor subtype did not affect TV correlation. Incongruence between radiographic TV and pathological TV is due to overestimation of TV by radiographic imaging. Conclusions. There was a strong correlation between RCC TV on preoperative images (CT and MRI) compared with pathological TV. This correlation was diminished for patients with smaller tumors. Future investigations are needed to validate this observation and more directly explore the ability of radiographic TV to predict RCC progression and patient outcome.

Comparison of baseline quality of life measures between renal cell carcinoma patients undergoing partial versus radical nephrectomy

BackgroundTo compare demographics, pathologic features, performance scores, comorbidities, symptoms and responses to quality of life (QoL) surveys between nephron-sparing surgery (NSS) and radical nephrectomy (RN) patients prior to surgical intervention. Previous investigators have compared QoL outcomes for patients undergoing RN and NSS; however, there are limited data comparing QoL-related characteristics at baseline between these groups.MethodsWe identified 144 patients with localized RCC who underwent either NSS (n = 71) or RN (n = 73) between May ‘07-November ‘12. We abstracted baseline data on demographic and clinic-pathologic variables as well as responses to the SF-36 and FACT-G surveys from our prospective registry. We amended the FACT-G with 8 additional questions designed to address RCC-specific QoL. For comparisons between the two groups, we employed Wilcoxon rank-sum and Fishers Exact tests where appropriate.ResultsWe observed RN patients to have more aggressive pathology. We noted no difference in performance scores between the two groups; however, RN patients were more likely to have higher Charlson scores (p = 0.022) and various symptoms at presentation (all p <0.001). For the QoL surveys, we did not observe differences on the FACT-G; however, we noted evidence of differential scores between the two groups on specific domains of the SF-36 (e.g. Mental Health; p 0.022) and the RCC-specific QoL questions added to the FACT-G.ConclusionsWe report baseline differences between RN and NSS patients on clinico-pathologic as well as QoL-related metrics. As issues of survivorship become increasingly important, our results underscore the need to consider baseline status in evaluations of QoL-related outcomes for patients undergoing surgery for RCC.

Coffee consumption and risk of renal cell carcinoma

AbstractBackground Studies have suggested an inverse association between coffee consumption and risk of renal cell carcinoma (RCC); however, data regarding decaffeinated coffee are limited.MethodsWe conducted a case–control study of 669 incident RCC cases and 1,001 frequency-matched controls. Participants completed identical risk factor questionnaires that solicited information about usual coffee consumption habits. The study participants were categorized as non-coffee, caffeinated coffee, decaffeinated coffee, or both caffeinated and decaffeinated coffee drinkers. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression, adjusting for multiple risk factors for RCC.ResultsCompared with no coffee consumption, we found an inverse association between caffeinated coffee consumption and RCC risk (OR 0.74; 95% CI 0.57–0.99), whereas we observed a trend toward increased risk of RCC for consumption of decaffeinated coffee (OR 1.47; 95% CI 0.98–2.19). Decaffeinated coffee consumption was associated also with increased risk of the clear cell RCC (ccRCC) subtype, particularly the aggressive form of ccRCC (OR 1.80; 95% CI 1.01–3.22).ConclusionsConsumption of caffeinated coffee is associated with reduced risk of RCC, while decaffeinated coffee consumption is associated with an increase in risk of aggressive ccRCC. Further inquiry is warranted in large prospective studies and should include assessment of dose–response associations.

Prospective evaluation of 24-hour urine profiles following bariatric surgery in a modern comprehensive care bariatric clinic.

AIMS To prospectively examine the effect of modern bariatric surgery on 24-hour urine parameters in a comprehensive care bariatric practice (CCBP). MATERIALS AND METHODS 47 consecutive patients in our CCBP underwent serum and 24-hour urine analysis pre-operatively, and 30 returned at 12 months for repeat testing. Paired comparisons for serum metabolite and 24-hour urine measures were performed using a Wilcoxon signed-rank test for continuous variables and McNemars test for categorical variables. Statistical tests were two-sided, with threshold of significance set at p = 0.05. RESULTS All 30 patients with pre-operative and 12-month follow-up analysis were free of stone events. 20 (67%) had Roux-en-Y gastric bypass (RYGB), 6 (20%) had laparoscopic gastric banding (LGB), and 4 (13%)h ad laparoscopic sleeve gastrectomy (LSG). 24-hour urinary parameters were available for 27 patients. Median urine oxalate (mmol) was 0.29 pre-operatively and 0.21 at 12 months (p = 0.048). Median urine calcium (mg) was 143 pre-operatively and 180 at 12 months (p = 0.11). Median citrate excretion was 527 pre-operatively and 782 at 12 months (p = 0.22). Median serum creatinine was 0.7 pre-operatively and 0.8 at 12 months (p < 0.001). These trends were preserved with the exclusion of LGB and LSG patients. CONCLUSIONS Modern bariatric surgery (RYGB, LGB, and LSG) as part of a CCBP can still demonstrate alterations of select urinary parameters (particularly oxalate and citrate) in select patients associated with an increased risk of urolithiasis at 1 year follow-up.

LOSS OF EXPRESSION OF THE VITAMIN D RECEPTOR IN CLEAR CELL RENAL CELL CARCINOMA

biopsy yielding 91 specimens. Three patients had 2 masses and three more patients underwent rebiopsy. A definitive diagnosis was established in 76 patients (89%). Of the 91 specimens 22 (24%) were benign including 11 oncocytomas, 7 lipid poor angiomyolipomas, 2 abscess/ pyelitis, 1 metanephric adenoma, and 1 benign spindle cell neoplasm. 20 patients (24%) had minor complications including 14 small perinephric hematomas (none required transfusion or admission to the inpatient ward), 2 difficulty voiding, 1 small pneumothorax, 1 rash, 1 shoulder pain, and 1 generalized musculoskeletal pain. The biopsy changed management in 22 patients (26%) with benign lesions or metastatic disease from another primary. Of the remaining 63 patients 24 underwent partial or radical nephrectomy. In all these patients the final pathology of these tumors confirmed the malignant diagnosis derived from biopsy. The remainder of the patients elected needle ablation or observation. CONCLUSIONS: CT guided biopsy of a small solid renal mass is a safe procedure that provides diagnostic information about 90% of the time. Biopsy provides clinically useful information by identification of benign lesions and confirmation of type and grade of malignancy if either resection of needle ablative therapy is a consideration.