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1.
J Urol ; : 101097JU0000000000004089, 2024 Jun 20.
Artigo em Inglês | MEDLINE | ID: mdl-38860938

RESUMO

PURPOSE: This study aimed to investigate the prevalence of pathogenic germline variants (PGVs) in hereditary cancer genes utilizing a universal testing approach and to determine the rate of PGVs that would have been missed based on National Comprehensive Cancer Network (NCCN) guidelines in genitourinary (GU) malignancies. MATERIALS AND METHODS: A multisite, single-institution prospective germline genetic test (GGT) was universally offered to patients with new or active diagnoses of GU malignancies (prostate, bladder, and renal) from April 2018 to March 2020 at Mayo Clinic sites. Participants were offered GGT using a next-generation sequencing panel of > 80 genes. Demographic, tumor characteristics, and genetic results were evaluated. NCCN GU cancer guidelines were used to identify whether patients had incremental findings, defined as PGV-positive patients who would not have received testing based on NCCN guidelines. RESULTS: Of 3095 individuals enrolled in the study, 601 patients had GU cancer (prostate = 358, bladder = 106, and renal = 137). The mean enrollment age was 67 years (SD 9.1), 89% were male, and 86% of patients were non-Hispanic White. PGVs were identified in 82 (14%) of all GU patients. PGV prevalence breakdown by cancer type was: 14% prostate, 14% bladder, and 13% renal cancer. Nearly one-third of identified PGVs were high penetrance, and the majority of these (67%) were clinically actionable. Incremental PGVs were identified in 28 (57%) prostate, 15 (100%) bladder, and 14 (78%) renal cancer patients. Of the 82 patients with PGV findings, 29 (35%) had at least 1 relative undergo cascade testing for the familial variant(s) identified. CONCLUSIONS: More than 1 in 8 patients with GU malignancies were found to carry a PGV, with 67% of patients with high-penetrance PGVs undergoing clinically actionable changes. The majority of these PGVs would not have been identified based on current testing criteria. These findings support universal GGT for GU malignancies and underscore its potential to enhance risk assessment and guide precision interventions in urologic oncology.

2.
Clin Med Insights Oncol ; 17: 11795549231161878, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36968334

RESUMO

Background: Radiation necrosis (RN) is a clinically relevant complication of stereotactic radiosurgery (SRS) for intracranial metastasis (ICM) treatments. Radiation necrosis development is variable following SRS. It remains unclear if risk factors for and clinical outcomes following RN may be different for melanoma patients. We reviewed patients with ICM from metastatic melanoma to understand the potential impact of RN in this patient population. Methods: Patients who received SRS for ICM from melanoma at Mayo Clinic Arizona between 2013 and 2018 were retrospectively reviewed. Data collected included demographics, tumor characteristics, radiation parameters, prior surgical and systemic treatments, and patient outcomes. Radiation necrosis was diagnosed by clinical evaluation including brain magnetic resonance imaging (MRI) and, in some cases, tissue evaluation. Results: Radiation necrosis was diagnosed in 7 (27%) of 26 patients at 1.6 to 38 months following initial SRS. Almost 92% of all patients received systemic therapy and 35% had surgical resection prior to SRS. Patients with RN trended toward having larger ICM and a prior history of surgical resection, although statistical significance was not reached. Among patients with resection, those who developed RN had a longer period between surgery and SRS start (mean 44 vs 33 days). Clinical improvement following treatment for RN was noted in 2 (29%) patients. Conclusions: Radiation necrosis is relatively common following SRS for treatment of ICM from metastatic melanoma and clinical outcomes are poor. Further studies aimed at mitigating RN development and identifying novel approaches for treatment are warranted.

3.
Can J Urol ; 29(5): 11284-11290, 2022 10.
Artigo em Inglês | MEDLINE | ID: mdl-36245197

RESUMO

INTRODUCTION: A comprehensive analysis on outcomes in the perioperative and pathological setting in patients with a prior diagnosis of prostate cancer has not been performed. The objective of this study is to describe the effect of prior prostate cancer treatment on perioperative and pathological outcomes after cystectomy. MATERIALS AND METHODS: This was a retrospective review of all male patients who underwent cystectomy at our institution from 01/01/2007-01/01/2020. Patients who were previously diagnosed and treated for prostate cancer were identified and outcomes were assessed. RESULTS: In 525 male patients, 132 (25.1%) had a diagnosis of prostate cancer prior to cystectomy. In the patients with a history of prostate cancer, 59 (46.2%) patients underwent prior radical prostatectomy (RP), 52 (39.4%) underwent some form of radiation therapy and the remaining 21 were managed with other modalities, including 11.4% who were on active surveillance. When comparing perioperative outcomes, there were no significant differences in outcomes. Pathological outcomes revealed that pT4 disease was more common in the RT cohort (19.2%, p = 0.05). In patients with no history of prostate cancer, 151 (40.2%) were found to have incidental prostate cancer at the time of cystectomy. Most (67.5%) patients with incidental prostate cancer had Gleason < 7 disease and only 1.3% developed metastatic prostate cancer on follow up, compared to over 10% of the patients previously treated for prostate cancer (p < 0.05). CONCLUSIONS: Patients who underwent prostate cancer treatment prior to cystectomy may be at increased risk for worse perioperative and pathologic outcomes after cystectomy.


Assuntos
Neoplasias da Próstata , Neoplasias da Bexiga Urinária , Cistectomia , Humanos , Masculino , Próstata/patologia , Prostatectomia , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Neoplasias da Bexiga Urinária/patologia
4.
Ann Vasc Surg ; 76: 80-86, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33901616

RESUMO

PURPOSE: The purpose of this study was to evaluate trends in Medicare reimbursement for common vascular procedures over the last decade. To enrich the context of this analysis, vascular procedure reimbursement is directly compared to inflation-adjusted changes in other surgical specialties. METHODS: The Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary file was utilized to identify the 20 procedures most commonly performed by vascular surgeons from 2011-2021. A similar analysis was performed for orthopedic, general, and neurological surgeons. The Centers for Medicare & Medicaid Services Physician-Fee Schedule Look-Up Tool was queried for each procedure, and reimbursement data was extracted. All monetary data was adjusted for inflation to 2021 dollars utilizing the consumer price index. Average year-over-year and total percentage change in reimbursement were calculated based on adjusted data for included procedures. Comparisons to other specialty data were made with ANOVA. RESULTS: From 2011-2021, the average, unadjusted change in reimbursement for vascular procedures was -7.2%. Accounting for inflation, the average procedural reimbursement declined by 20.1%. The greatest decline was observed in phlebectomy of varicose veins (-50.6%). Open arteriovenous fistula revision was the only vascular procedure with an increase in inflation-adjusted reimbursement (+7.5%). Year-over-year, inflation-adjusted reimbursement for common vascular procedures decreased by 2.0% per year. Venous procedures experienced the largest decrease in average adjusted reimbursement (-42.4%), followed by endovascular (-20.1%) and open procedures (-13.9%). These changes were significantly different across procedural subgroups (P < 0.001). During the same period, the average adjusted change in reimbursement for the 20 most common procedures in orthopedic surgery, general surgery, and neurosurgery was -11.6% vs. -20.1% for vascular surgery (P = 0.004). CONCLUSION: Medicare reimbursement for common surgical procedures has declined over the last decade. While absolute reimbursement has remained relatively stable for several procedures, accounting for a decade of inflation demonstrates the true diminution of buying power for equivalent work. The most alarming observation is that vascular surgeons have faced a disproportionate decrease in inflation-adjusted reimbursement in comparison to other surgical specialists. Awareness of these trends is a crucial first step towards improved advocacy and efforts to ensure the "value" of vascular surgery does not continue to erode.


Assuntos
Centers for Medicare and Medicaid Services, U.S./economia , Comércio/economia , Custos de Cuidados de Saúde , Inflação , Reembolso de Seguro de Saúde/economia , Medicare/economia , Cirurgiões/economia , Procedimentos Cirúrgicos Vasculares/economia , Centers for Medicare and Medicaid Services, U.S./tendências , Comércio/tendências , Economia/tendências , Custos de Cuidados de Saúde/tendências , Humanos , Inflação/tendências , Reembolso de Seguro de Saúde/tendências , Medicare/tendências , Modelos Econômicos , Cirurgiões/tendências , Fatores de Tempo , Estados Unidos , Procedimentos Cirúrgicos Vasculares/tendências
5.
Int Urol Nephrol ; 53(10): 2019-2025, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33905042

RESUMO

PURPOSE: The transversus abdominis plane (TAP) block has been effective in providing adequate pain control, limiting opioid use, and improving perioperative outcomes in patients undergoing major abdominal surgeries. Little is known regarding the efficacy of preoperative (pre-incisional) versus postoperative TAP block in patients who undergo cystectomy. METHODS: This is a retrospective study that reviewed all patients who underwent cystectomy between January 2011 and January 2020 at a single institution. Patients were stratified into three cohorts: preoperative TAP block, postoperative TAP block, no TAP block. A multivariable linear regression model was constructed that assessed factors associated with total morphine milligram equivalents (MME) per hospital stay. RESULTS: In 463 patients, baseline characteristics were similar. There were 66(14.3%) patients who received a perioperative TAP block, 16 (24.2%) of whom received a preoperative TAP block. There were no significant differences in baseline factors. A TAP block was associated with lower MME used per day (41.8 mg vs 53.1 mg, p = 0.009) and per hospital stay (232 mg vs 320.5 mg, p = 0.001). The median MME per hospital stay and per day was lowest in the preoperative TAP cohort (194.0 mg, p = 0.011 and 38.0 mg, p = 0.042, respectively). On multivariable analysis of a subset of patients who received a TAP block, there was no significant difference in MME use in patients who received a preoperative vs postoperative TAP block (- 84.8, p = 0.339). CONCLUSION: The use of TAP blocks was associated with lower MME use in the entire population; however, there was no difference in MME use when comparing preoperative and postoperative TAP blocks.


Assuntos
Cistectomia , Bloqueio Nervoso/métodos , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Músculos Abdominais/inervação , Idoso , Cistectomia/métodos , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
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