Endoscopic and Surgical Treatment of Mucosal (T1a) Esophageal Adenocarcinoma in Barrett’s Esophagus

September 9, 2009 – 7:43 am

A Mayo Clinic study published in the September 2009 issue of Gastroenterology found that early stage cancers of the esophagus can be treated as effectively by less-invasive, organ-sparing endoscopic therapy as compared to surgical removal of the esophagus.

Dr. Ganapathy Prasad, gastroenterologist and lead author explains “In 20 percent of esophageal cancer cases in the United States, the cancer is detected in the early stages. Traditionally, esophageal cancer patients undergo surgery to remove the esophagus. Our team compared surgery to the use of endoscopic therapy.  Our results showed the less-invasive therapy was just as effective as surgery for early-stage cancers.”

Abstract
Background & Aims
Endoscopic therapy is emerging as an alternative to surgical therapy in patients with mucosal (T1a) esophageal adenocarcinoma (EAC) given the low likelihood of lymph node metastases. Long-term outcomes of patients treated endoscopically and surgically for mucosal EAC are unknown. We compared long-term outcomes of patients with mucosal EAC treated endoscopically and surgically.

Methods
Patients treated for mucosal EAC between 1998 and 2007 were included. Patients were divided into an endoscopically treated group (ENDO group) and a surgically treated group (SURG group). Vital status information was queried using an institutionally approved internet research and location service. Statistical analysis was performed using Kaplan–Meier curves and Cox proportional hazard ratios.

Results
A total of 178 patients were included, of whom 132 (74%) were in the ENDO group and 46 (26%) were in the SURG group. The mean follow-up period was 64 months (standard error of the mean, 4.8 mo) in the SURG group and 43 months (standard error of the mean, 2.8 mo) in the ENDO group. Cumulative mortality in the ENDO group (17%) was comparable with the SURG group (20%) (P = .75). Overall survival also was comparable using the Kaplan–Meier method. Treatment modality was not a significant predictor of survival on multivariable analysis. Recurrent carcinoma was detected in 12% of patients in the ENDO group, all successfully re-treated without impact on overall survival.

Conclusions
Overall survival in patients with mucosal EAC when treated endoscopically appears to be comparable with that of patients treated surgically. Recurrent carcinoma occurs in a limited proportion of patients, but can be managed endoscopically.

Authors
G. A. Prasad, T. T. Wu, D. A. Wigle, N. S. Buttar, L.–M. Wongkeesong, K. T. Dunagan, L. S. Lutzke, L. S. Borkenhagen, and K. K. Wang all from Mayo Clinic

Esophagectomy at Mayo Clinic

By Carol Lammers | Posted in Gastroenterology | Tagged , , , , , , , | Comments (2)

New Surgical Technique for Treatment of Apical Hypertrophic Cardiomyopathy

August 26, 2009 – 9:00 am

Dr. Hartzell Schaff discusses apical myectomy, a new surgical treatment for patients with severely symptomatic apical hypertrophic cardiomyopathy. Dr. Schaff and colleagues presented a study on apical myectomy at the 2009 Annual Meeting of the American Association for Thoracic Surgery.

 


 

ABSTRACT
Objective: Apical hypertrophic cardiomyopathy (ApHCM) is a morphologic variant in which the hypertrophy is primarily localized to the apex of the left ventricle (LV). A subset of patients develop progressive drug refractory diastolic heart failure with severely limiting symptoms due to a resultant low cardiac output. Heart transplant has been the only therapeutic option available for such patients. This study analyzes clinical and hemodynamic outcomes of a novel surgical technique to improve diastolic filling by LV cavity enlargement.
 

Methods: From 1993 through May, 2008, 43 symptomatic patients with ApHCM underwent apical myectomy to augment LV end-diastolic volume (EDV). Information from a prospective database was supplemented by survey information, patient contact, and review of medical records.
 

Results: The mean age was 50±17yr and 65% were female. All patients were severely limited with dyspnea, 63% had angina, and 60% had syncope or pre-syncope. Ninety-one percent of patients were in New York Heart Association (NYHA) class III or IV. Myectomy was performed through an apical incision, and the LV cavity was augmented by excision of hypertrophic muscle at the apex and mid ventricle; a mean of 16±7 g of muscle was removed. In 14 patients who underwent pre- and postoperative hemodynamic catheterization, the LV end-diastolic pressure decreased from 28±9 to 24±7 mmHg (P=0.002) and the EDV index increased from 55±17 to 68±18 cc/m2 (P=0.003). Invasive measurements of stroke volume increased from of 56±17 cc to 63±19 cc (p=0.007). Forty of forty-one hospital survivors had improvement in symptoms after operation. The mean peak maximum oxygen consumption on exercise testing (n=5) increased from 13.5±4.4 to 15.8±4.6 mL/kg per minute. Survival at 1, 3, and 5 years was 95%, 81%, and 81%, respectively. At an average follow-up of 2.6±3.1years, 23 patients (74%) were in NYHA class I or II. One patient underwent heart transplant 5 years after apical myectomy.

Conclusion: For patients with ApHCM who have limiting symptoms despite optimal medical treatment, apical myectomy can improve functional status by decreasing LV end-diastolic pressure, thus improving the effective operative compliance of the LV and increasing stroke volume. This procedure may be of value in other patients with HCM who have severe hypertrophy and small LV end-diastolic volumes.

Authors
Hartzell V. Schaff1, Morgan L. Brown1, Steve R. Ommen1, Joseph A. Dearani1, Martin D. Abel1, A. J. Tajik2, Rick A. Nishimura1; 1Mayo Clinic, Rochester, MN; 2Mayo Clinic, Scottsdale, AZ

By Carol Lammers | Posted in Cardiovascular | Tagged , , , | Leave a Comment

Laparoscopic Colectomy Demonstration

August 13, 2009 – 2:50 pm

Dr. Robert R. Cima provides a surgical demonstration of laparoscopic colectomy and robotically assisted rectal cancer surgery.

A minimally invasive approach is Mayo’s preferred operative approach for both malignant and benign conditions as there are numerous benefits for patients without any compromise in their surgical outcome.

The first laparoscopic colectomy was reported in the literature in 1991. However, it still accounts for less than 12% of the colectomies performed nationally. The reasons for this are many but the most common explanation is that it requires a higher level of technical skill in order for it to be performed safely and efficiently. There also was a concern about performing laparoscopic colectomy for patients with colorectal cancer.

Fortunately, a national randomized clinical trial led by a Mayo Clinic physician demonstrated that in expert hands the cancer outcomes were the same. More importantly, there were a number of short-term benefits for the patients. These benefits include shorter hospitalizations, less pain and fewer complications. This has been demonstrated in multiple studies including a meta-analysis performed at Mayo Clinic. The Division of Colon and Rectal Surgery at Mayo Clinic in Minnesota has performed over 3,000 minimally invasive colorectal procedures ranging from segmental colectomies to total proctocolectomies with ileal pouch construction.

Colon Cancer Clinical trials

By Carol Lammers | Posted in Colon and rectal surgery | Tagged , , , , , | Comments (3)

A Randomized Controlled Trial of Vertebroplasty for Osteoporotic Spine Fractures

August 10, 2009 – 10:35 am

Dr. David Kallmes discusses a new study that found relief of pain from vertebral compression fractures, as well as improvement in pain-related dysfunction, were similar in patients treated with vertebroplasty and those treated with simulated vertebroplasty without cement injections. The article was published in the New England Journal of Medicine.

 

ABSTRACT
Background: Vertebroplasty is used commonly to treat painful, osteoporotic vertebral compression fractures.

Methods: In this multi-center trial, we randomly assigned patients with 1-3 painful, osteoporotic vertebral compression fractures to vertebroplasty or to a simulated vertebroplasty without cement. The primary outcomes were modified Roland-Morris Disability Questionnaire (RDQ) scores (range, 0-23) and patient ratings of average pain intensity in the preceding 24 hours (0-10 numerical rating scale) at one month. Patients were allowed to cross over after one month.

Results: All patients received their assigned interventions (68 vertebroplasty and 63 simulated vertebroplasty). The baseline characteristics were similar in the two groups. At one month, the vertebroplasty and control groups did not differ significantly on either the RDQ (treatment difference: 0.7; 95% CI: -1.3, 2.8; P = 0.49) or the pain rating (treatment difference: 0.7; 95% CI: -0.3, 1.7; P = 0.19). Both groups showed immediate improvement in disability and pain after the intervention. Although the groups did not differ significantly on any secondary outcome at one month, there was a trend toward a higher rate of clinically meaningful improvement in pain (30% decrease from baseline) in the vertebroplasty group (64% versus 48%, P = 0.06). At three months, there was a higher crossover rate in the control group (43% versus 12%, P<0.001)). There was one serious adverse event in each group.

Conclusions: Improvement in osteoporotic compression fracture pain and pain-related disability was similar in patients treated with vertebroplasty and patients treated with simulated vertebroplasty without cement. (ClinicalTrials.gov NCT00068822)

AUTHORS
D.F. Kallmes1, B.A.Comstock2, P.J. Heagerty2, J.A. Turner, Ph.D.2, D.J. Wilson4, T.H. Diamond5, R. Edwards6, L.A. Gray1, L. Stout2, S. Owen4, W. Hollingworth3, B. Ghdoke2, D.J. Annesley-Williams7, S.H. Ralston,8 J.G. Jarvik2

1Mayo Clinic, Rochester, MN/US, 2University of Washington, Seattle, WA/US 3Department of Social Medicine, Bristol/UK, 4Nuffield Orthopaedic Centre NHS Trust, Oxford/UK, 5St George Hospital, University of New South Wales, Sydney/AU, 6Gartnavel General Hospital, Glasgow/UK, 7Nottingham University Hospital NHS Trust, Nottingham/UK, 8Western General Hospital, University of Edinburgh, Edinburgh/UK

By Carol Lammers | Posted in Neurology, Radiology | Tagged , , , | Comments (2)

Disease Associations With Monoclonal Gammopathy of Undetermined Significance: A Population-Based Study of 17,398 Patients

August 5, 2009 – 3:22 pm

Dr. S. Vincent Rajkumar, Mayo Clinic hematologist, discusses the first systematic study to determine association of Monoclonal Gammopathy of Undetermined Significance (MGUS) with all diseases in 17,398 patients, published in Mayo Clinic Proceedings.

Abstract
OBJECTIVE: To systematically study the association of monoclonal gammopathy of undetermined significance (MGUS) with all diseases in a population-based cohort of 17,398 patients, all of whom were uniformly tested for the presence or absence of MGUS.

PATIENTS AND METHODS: Serum samples were obtained from 77% (21,463) of the 28,038 enumerated residents in Olmsted County, Minnesota. Informed consent was obtained from patients to study 17,398 samples. Among 17,398 samples tested, 605 cases of MGUS and 16,793 negative controls were identified. The computerized Mayo Medical Index was used to obtain information on all diagnoses entered between January 1, 1975, and May 31, 2006, for a total of 422,663 person-years of observations. To identify and confirm previously reported associations, these diagnostic codes were analyzed using stratified Poisson regression, adjusting for age, sex, and total person-years of observation.

RESULTS: We confirmed a significant association in 14 (19%) of 75 previously reported disease associations with MGUS, including vertebral and hip fractures and osteoporosis. Systematic analysis of all 16,062 diagnostic disease codes found additional previously unreported associations, including mycobacterium infection and superficial thrombophlebitis.

CONCLUSION: These results have major implications both for confirmed associations and for 61 diseases in which the association with MGUS is likely coincidental.

Footnotes
This study was supported in part by grants CA62242, CA107476, and AR30582 from the National Institutes of Health, US

AUTHORS: John P. Bida, MA, Robert A. Kyle, MD, Terry M. Therneau, PhD, L. Joseph Melton III, MD, Matthew F. Plevak, MS, Dirk R. Larson, MS, Angela Dispenzieri, MD, Jerry A. Katzmann, PhD and S. Vincent Rajkumar, MD all from Mayo Clinic

By Carol Lammers | Posted in Uncategorized | Tagged , , | Leave a Comment

Racial Differences in Primary Central Nervous System Lymphoma Incidence and Survival Rates

July 31, 2009 – 8:53 am

Dr. Brian P. O’Neill discusses a new study that shows the incidence of primary central nervous system lymphoma (PCNSL) is two times higher in black Americans, ages 20 to 49, than in white Americans. This study was published in the June issue of Journal of Neuro-Oncology.

ABSTRACT:
To determine racial and ethnic differences in incidence and survival in patients with primary central nervous system lymphoma (PCNSL), NCI Surveillance, Epidemiology, and End Results (SEER) program data from 1992 to 2002 were queried. Data were substratified by age (20–49 years vs. 50 or above) and race (White, Black, Asian/Pacific Islander [A/PI], American Indian/Alaskan Native [AI/AN]). Incidence of PCNSL and survival were calculated by SEER*Stat software. The incidence rates were 0.94 per 100,000 per year (95% confidence interval [CI] 0.90–0.98) for Whites, 1.10 (95% CI 0.98–1.22) for Blacks, 0.51 (95% CI 0.28–0.74) for AI/AN, and 0.64 (95% CI 0.56–0.72) for A/PI. In patients aged 20–49 years the rates were 0.72 (95% CI 0.68–0.76) for Whites, 1.43 (95% CI 1.27–1.59) for Blacks, 0.58 (95% CI 0.30–0.86) for AI/AN, and 0.21 (CI 0.15–0.27) for A/PI. In patients over 49 years, the rates were 1.30 (95% CI 1.22–1.38) for Whites, 0.56 (95% CI 0.40–0.72) for Blacks, 0.34 (95% CI 0–0.70) for AI/AN, and 1.31 (95% CI 1.00–1.53) for A/PI. PCNSL incidence for ages 20–49 years for Black patients was twice that for Whites. Incidence for ages over 49 years for Whites was twice that for Blacks. Survival at 12 months, 24 months, and 60 months was higher among Whites than Blacks. Research is needed to determine the origin of these differences.

Authors:
Jose S. Pulido, Robert A. Vierkant, Janet E. Olson, Lauren Abrey, David Schiff and Brian Patrick O’Neill

Departments of Ophthalmology, Health Sciences Research, and Neurology, Mayo Clinic and Foundation and the Mayo Clinic Cancer Center, Rochester, MN (J.S.P., R.A.V., J.E.O., B.P.O.); Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (L.A.); Departments of Neurology and Neurosurgery, University of Virginia Health System, Charlottesville, VA (D.S.); USA

By Carol Lammers | Posted in Neurology, Uncategorized | Tagged , , , | Comments (1)

Signs and Symptoms of Bladder Cancer

July 21, 2009 – 8:50 am

Dr. Jeffery Karnes discusses bladder cancer.

The signs and symptoms of bladder cancer, how the diagnosis is made, and how grade and stage (the depth of invasion) is interpreted which dictates the next step in treatment are explained.

By Carol Lammers | Posted in Urology | Tagged | Comments (2)

Diffusion Tensor Imaging Characteristics of Amnestic and Non-Amnestic Mild Cognitive Impairment

July 17, 2009 – 9:22 am

Dr. Kejal Kantarci discusses diffusion tensor MR imaging (DTI) that provides information on the tissue microstructure in the brain. The data generated by this imaging technology may be helpful in differentiating between various forms of dementias and cognitive impairment in the future. This study was presented at the Alzheimer’s Association International Conference on Alzheimer’s Disease in Vienna.

 

ABSTRACT
Background: The broad clinical definition of mild cognitive impairment (MCI) includes amnestic MCI (aMCI) with impairment in memory domain and non-amnestic MCI (naMCI) with impairment(s) in cognitive domains other than memory such as attention/executive functioning, language, and visuospatial processing. While people with the aMCI subtype most commonly progress to Alzheimer’s disease (AD), the natural history, imaging characteristics and the pathological underpinnings of naMCI are less clear. Non-invasive imaging markers for underlying pathologies in MCI may be useful in identifying patients who may benefit from disease specific treatments at the prodromal stage of dementia. Diffusion tensor MR imaging (DTI) provides information on the integrity of tissue microstructure. The magnitude of diffusivity measured with the apparent diffusion coefficient (ADC) increases, and the directionality of diffusivity measured with fractional anisotropy (FA) decreases with neurodegeneration. Our objective was to determine the characteristic DTI profiles of the MCI subtypes.

Methods: We studied clinically diagnosed age, gender and education matched patients with aMCI (n=28), naMCI (n=28), and cognitively normal (CN) (n=28) at 3Tesla using parallel imaging with an acceleration factor of two. 3DMPRAGE was performed for anatomical segmentation and labeling. In order to avoid partial volume averaging of tissue diffusivity with CSF, we used an EPI-FLAIR-DTI sequence (which nulls CSF) with 21 diffusion sensitive gradient directions (b=1000 s/mm2). We measured the ADC from segmented cortical gray matter in regions derived from the automated anatomic labeling atlas. Color FA maps generated in DTIStudio were used for measuring tract-based FA and ADC by manual placement of tract-based regions of interest.

Results: Patients with aMCI had elevated ADC in the hippocampus (p<0.05), and decreased posterior cingulum tract FA (p<0.01) compared to CN subjects. Patients with naMCI had decreased posterior cingulum tract FA (p<0.01), but normal hippocampal ADC compared to CN subjects.

Conclusions: The neurodegenerative pathology of AD involves the hippocampus early during the pathological progression. The magnitude of diffusivity measured with ADC increases, and the directionality of diffusivity measured with FA decreases with neurodegeneration. For this reason, elevated hippocampal ADC most likely represent a high frequency of early AD pathology in aMCI patients. Conversely, finding normal hippocampal ADC on avearge in the naMCI subtype suggest that the underlying pathological substrates may include pathologies other than AD in
some proportion of naMCI patients.

Authors: Kejal Kantarci, Ramesh T. Avula, Matthew L. Senjem, Ali R. Samikoglu, Maria M. Shiung, Scott A. Przybelski, Stephen D. Weigand, Heidi A. Ward, Prashanthi Vemuri, David S. Knopman, Bradley F. Boeve, Ronald C. Petersen, Clifford R. Jack, Jr., all from Mayo Clinic

By Carol Lammers | Posted in Neurology | Tagged , , , , , , , , | Leave a Comment

Predicting Alzheimer’s Disease

July 16, 2009 – 10:04 am

Dr. Ronald Petersen discusses a new Mayo Clinic study that found the clinical criteria for mild cognitive impairment are better at predicting who will develop Alzheimer’s disease than a single memory test. This study was presented at the Alzheimer’s Association International Conference on Alzheimer’s Disease on July 14 in Vienna.

ABSTRACT
Background: A great deal of attention is being given to making the diagnosis of dementia and Alzheimer’s disease at an earlier point in the clinical spectrum. However, the clinical features of this point on the spectrum are not well delineated.

Methods: All non-demented subjects from the Mayo Clinic Alzheimer’s Disease Patient Registry were eligible for evaluation. Two prediction models were considered: clinical criteria for mild cognitive impairment (MCI) and a cutoff score on the Free and Cued Selective Reminding Test (FCSRT) (<17). Proportional hazards regression models were used to assess the association between each of the two risk indicators and the onset of dementia. Models were fit to each risk indicator individually. An additional model included both indicators simultaneously. Hazard ratios and 95% confidence intervals were obtained from these models. Additionally, C-statistics were calculated to further compare the ability of the two criteria to discriminate between those who progressed to dementia versus those who did not . The significance of the difference between the two C-statistics was assessed using a bootstrap approach.

Results: 1,261 non-demented subjects were entered into the evaluation. Of these, 193 progressed to dementia. The mean age and education for the total group were 78.8 years and 13.4 years, respectively. The follow-up ranged from 0.9 to 18.1 years, with a median of 5.2. Clinical MCI status was significantly associated with the outcome of dementia. Those classified as MCI had a hazard ratio for risk of dementia onset of 10.15 (95% CI: 7.59-13.57, p<0.001). Those with summed learning scores over three trials on the FCSRT of 17 or less were at an increased risk of progression to dementia (HR = 9.10, 95% CI: 6.72-12.33, p<0.001). When both criteria were included in the same model, both provided independent information for the risk of dementia. The C-statistic calculated for the MCI model (0.78) was 11% higher than that for the FCSRT model (0.70, p<0.001).

Conclusion: Clinical MCI criteria outperformed a single memory test for predicting risk of developing subsequent dementia.

Support for this: Mayo Clinic Alzheimer’s Disease Patient Registry UO1 AG06786, P 50 AG16574, and the Robert H. and Clarice Smith and Abigail Van Buren Alzheimer’s Disease Research Program.

Authors: All from Mayo Clinic, Ronald C. Petersen, David S. Knopman, Bradley F. Boeve, Ruth Cha, V. Shane Pankratz, Yonas E. Geda, Rosebud O. Roberts, Clifford R. Jack, Jr

By Carol Lammers | Posted in Neurology | Tagged , , , , | Leave a Comment

Marfan Syndrome Research, Diagnosis and Treatment Updates

July 15, 2009 – 1:53 pm

Dr. Charles Bruce reviews advances in Marfan Syndrome research and treatment. He also provides details on the upcoming National Marfan Foundation Annual Meeting, including a CME component.

Dr. Bruce’s discussion includes ongoing research on the pathogensis of Marfan Syndrome, which includes insight into the abnormal signaling of transforming growth factor beta and the potential implications of the research. A surgical advance, valve-sparing aortic root replacement, is also being studied and currently shows favorable short-term results.

By Carol Lammers | Posted in Cardiovascular | Tagged , , , | Leave a Comment