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Biomedical subjects

M Morris

Publications and source records attributed to M Morris.

At least 163 records · Page 9Linked to original sources
PubMed1996

Implementation of guidelines and paths in oncology.

At the M.D. Anderson Cancer Center, we initiated a disease management program to reduce the variability of practice and increase its effectiveness, using a model that was familiar to the faculty. Professional staff members, including physicians, nurses, and allied health professionals, were divided into groups according to disease site. Each group developed practice guidelines and collaborative care paths based on evidence in the literature and expert opinion. Desired outcomes were defined. The faculty participated in developing and implementing the program, which was viewed as a means of achieving efficient, productive management of care. Nearly 1,000 patients have been entered on the 98 paths outlined to date. Integrated information systems have been an important tool for instituting the guidelines at the point of patient care and for measuring clinical and financial outcomes. A physician-led outcomes management program should permit us to deliver high-quality care and support outcomes research while decreasing costs.

Critical Pathways↗
PubMed1996

Management of stage IA cervical carcinoma.

Approximately 10%-15% of women with stage I cervical cancer have microinvasive lesions (stage IA). In studying these patients, we aim to identify the cancers that have little or no chance of harboring metastatic disease from the primary site. These patients may be treated by more conservative means, thereby lowering morbidity and cost and preserving the women's fertility. The diagnosis of stage I cervical cancer is surrounded by controversies concerning the diagnostic criteria, the low level of agreement among pathologists interpreting the same material, and the limited evidence in the literature for definitions of risk factors. The available information suggests that women with squamous cell lesions that invade at a 3-mm depth or less and who have no evidence of lymph-vascular invasion may be successfully treated with cervical conization. Women with a depth of invasion of more than 3 mm or with lymph-vascular invasion should be treated with methods that address the potential for disease in the lymph nodes and paravaginal tissues.

Carcinoma, Squamous Cell↗
PubMed1995

Oxytocin antisense reduces salt intake in the baroreceptor-denervated rat.

Experiments were performed to evaluate the role of central oxytocin (OT) in the inhibition of salt intake produced by sinoartic denervation (SAD). The effect of OT antisense treatment on 24 h intake of 2% NaCl in SAD and sham-operated (SO) rats was determined. PVN injection of unmodified antisense oligodeoxynucleotides (ODNs) to OT mRNA decreased intake of 2% NaCl in SAD, but not SO rats. Salt consumption was 22 +/- 4 ml after the injection of control ODN as compared to 8 +/- 4 ml after the OT antisense injection (P < 0.05). SAD animals also demonstrated an increased plasma OT response to salt loading, an elevation from 3.2 +/- 0.7 to 6.9 +/- 0.8 pg/ml. In contrast, salt ingestion produced no significant change in plasma OT in the SO group. The increased endocrine response in the SADs occurred even though salt intake was lower in this group. There were no group differences in plasma electrolytes or posterior pituitary OT content. Results show that OT antisense specifically inhibits salt intake in the denervated rat, suggesting that the central oxytocinergic axis stimulates sodium drive in this experimental model.

Animals↗
PubMed1995

Effect of age on postmyocardial infarction ventricular arrhythmias (Holter Registry data from CAST I and CAST II). Cardiovascular Arrhythmia Suppression Trials.

Holter data from the 17,609 postmyocardial infarction patients in the CAST Registry were analyzed to study the effect of age on VPC and VT incidence and frequency. Multivariable analysis demonstrated that age is an important independent predictor of increased ventricular ectopy, with the median rate of VPCs/hour increasing from 0.4 (patients aged < 50 years) to 4.0 (patients aged 75 to 80 years), and the prevalence of VT increasing from 7.3% (patients aged < 50 years) to 15.3% (patients aged 75 to 80 years).

Age Factors↗
PubMed1995

Infusion site soft-tissue injury after paclitaxel administration.

BACKGROUND: Paclitaxel is a diterpenic plant product that has significant activity in several solid tumors, including epithelial ovarian cancer. After promising results in Phase I and II studies, its use has increased dramatically. With this increased use, isolated reports of local tissue reactions to paclitaxel have been described. The purpose of this study was to characterize further the presentation and clinical course of this toxic effect. METHODS: Nine hundred fifty-five courses of paclitaxel were administered to patients with gynecologic malignancies at M. D. Anderson Cancer Center during a 13-month period. Nineteen (2%) local infusion-site injuries in 17 patients were observed. RESULTS: The primary disease site was the ovary in 13 patients, the peritoneum in 2, and the endometrium in 2. Paclitaxel was administered as initial therapy in 6 patients and as salvage therapy in 11. Clinical evidence of infiltration was documented during infusion in 8 of 19 (42%) reported episodes. Immediate reactions consisting of mild discomfort, erythema, and edema were observed in six patients, three of whom had complete resolution of the lesion within 1 month. The remaining patients noted initial development of injury between 3 and 13 days after paclitaxel infusion. The typical injury was a discolored, raised, rounded, and indurated lesion that was moderately painful. Two patients (11%) had Grade 1 lesions, 13 (68%) had Grade 2 lesions, and four (21%) had Grade 3 lesions with central ulceration. Cellulitis requiring intravenous antibiotic therapy was associated with two lesions. At last follow-up, 13 injuries had persistent discoloration and induration; one patient had persistent ulceration present at the time of her death 6 months after presentation and one patient underwent excision of a persistent lesion at 12 months. CONCLUSIONS: Given the incidence of Grade 2 and Grade 3 local reactions, it appears that paclitaxel should be considered a vesicant.

Extravasation of Diagnostic and Therapeutic Materi↗
PubMed1995

Salvage chemotherapy for refractory transitional cell carcinoma of the ovary (TCC).

OBJECTIVE: Transitional cell carcinoma (TCC) of the ovary is reportedly more sensitive to first-line chemotherapy and has a better prognosis than the more common serous carcinoma. The purpose of this study was to determine the responsiveness of refractory ovarian TCC to salvage chemotherapy. METHODS: Thirty-three patients with refractory TCC who received either platinum drugs or taxanes as salvage chemotherapy at our institution were identified through a retrospective review. Clinical information was abstracted from the medical records, and patient characteristics and response rates were determined. Pathologic sections from all cases were reviewed. RESULTS: The median age of the 33 patients was 53 years (range, 39-71 years). FIGO stage distribution among patients included 1 stage II and 32 stage III. Twenty-six tumors (79%) were classified as TCC-predominant (> 50% of the tumor having the TCC pattern), and seven tumors (21%) were classified as non-TCC predominant (< 50% of the tumor having the TCC pattern). Twenty-four platinum-sensitive patients received salvage platinum therapy (cisplatin, carboplatin, or other platinum analogs) on 27 separate occasions (three patients were treated twice) either as single agents (n = 20) or in combination (n = 7). In 21 of the 27 instances, patients had measurable disease and were evaluable for response. There were nine (43%) complete responses and six (29%) partial responses; in six instances, no response was observed. The overall response rate was therefore 72%. Thirteen patients, of whom 12 had measurable disease, received taxanes (paclitaxel in 10, docetaxel in 2, and paclitaxel+cisplatin in 1). There were partial responses in six (50%) and no response in six. Only one of the responders received high-dose paclitaxel (250 mg/m2). CONCLUSIONS: Our findings suggest that TCC may remain more chemosensitive than more common epithelial tumors in the refractory setting. The relative influences of tumor biology and treatment, however, remain undetermined.

Adult↗
PubMed1995

Potential applications of intraoperative lymphatic mapping in vulvar cancer.

OBJECTIVE: We describe early results of and potentially important anatomic findings with intraoperative lymphatic mapping in patients with vulvar cancer. METHODS: Isosulfan blue was injected into the dermis at the leading edge of the vulvar lesion in 21 patients. One to five minutes later a standard groin incision was made and carried to the superficial fascia. After gentle dissection, the afferent lymphatic channel and/or sentinel lymph node was identified by its bright blue color. The sentinel node was removed and then the superficial inguinal lymphadenectomy was completed. RESULTS: The 21 patients, ranging in age from 23 to 85 years (median, 52 years), underwent intraoperative lymphatic mapping. The clinical stages were as follows: T1 in 9, T2 in 10, T3 in 1, and unknown in 1 patient with a prior wide local excision. Two patients had palpably suspicious nodes. Ten patients had lateral lesions, and 11 had midline tumors. Eight of the 11 patients had bilateral groin dissections, making a total of 29 groins dissected. The sentinel node was identified in 18 patients (86%) and in 19 groins (66%). Five patients had unilateral node metastases, and one patient had bilateral node metastases. A sentinel node was found in five of these seven groins. A total of 238 nodes were removed (median, 8.2 nodes per groin). In no case was a nonsentinel node positive if the sentinel node was negative. In one patient the only metastasis was microscopic tumor in the sentinel lymph node. In one case, the sentinel node was found below the cribriform fascia. The sentinel node could not be identified in either groin in one patient with a clitoral primary; however, dye was seen in lymphatic channels passing under the symphysis pubis. The sentinel node was identified in various sites within the superficial compartment including lateral to the femoral artery and at the extreme medial border of the dissection. No complication related to the injection of isosulfan blue was seen. CONCLUSION: Intraoperative lymphatic mapping is safe and simple to perform and may help identify the sentinel node, define the extent of superficial inguinal lymphadenectomy, and identify uncommon anatomic variations.

Adult↗
PubMed1995

Surveillance for recurrent endometrial carcinoma: development of a follow-up scheme.

We examined the method of diagnosis for a group of women who developed recurrent endometrial carcinoma after being rendered clinically disease-free by primary therapy. We then used this information to develop a follow-up protocol that maximizes the chances for detecting recurrence while minimizing surveillance costs. In brief, we evaluated all women with clinical stage I endometrial carcinoma who were treated with curative intent during a 7-year period. Medical records were examined to identify patients who had tumor recurrence diagnosed during follow-up in our clinic. Clinical presentation, time to diagnosis, method of diagnosis, and subsequent outcome were analyzed. This information was used to design a surveillance protocol for further clinical testing. Ninety-six percent of 412 women treated between 1985 and 1992 were clinically disease-free after primary surgery with or without adjuvant treatment. Median follow-up is 64 months. Overall, 44 patients (11%) developed recurrent cancer after a median interval of 14.8 months. Complete follow-up data were available for the 39 patients who had their recurrence diagnosed in our clinic. The cumulative percentages of diagnosed recurrences were 51, 82, and 95% at 12, 24, and 36 months, respectively. Sixteen women (41%) had symptoms that led to the identification of recurrent disease. Recurrences in the 23 asymptomatic women (59%) were diagnosed by physical examination in 13, chest radiograph in 1, serum CA-125 level in 6, vaginal cytology in 1, and computed tomography in 2. Only 1 patient with a grade 1 adenocarcinoma had treatment failure. At the time of analysis, 30 patients with recurrent cancer had died of disease, 6 were alive with disease, and 3 were free of disease. A surveillance scheme consisting of an examination, vaginal cytology, and serum CA-125, combined with immediate evaluation of symptomatic women, could be expected to identify 95% of recurrences. Such an approach, performed at 6- to 12-month intervals for 3 years, could be limited to patients with grade 2-3 adenocarcinomas or variant cell types. However, given the high failure rate of salvage therapy, the prompt detection of recurrence may not convey a survival advantage.

Endometrial Neoplasms↗
PubMed1995

Staging laparotomy for endometrial carcinoma: assessment of peritoneal spread.

To evaluate surgical staging procedures in women with endometrial carcinoma, we examined the techniques used to assess the peritoneal cavity in 295 clinical stage I patients treated between 1985 and 1993. These patients were felt to be at increased risk for extrauterine disease because of significant myometrial invasion, high-grade (2 or 3), or variant histology (papillary serous, clear cell, or mixed). Patients had a mean of two intraperitoneal samples taken: 224 patients (76%) had at least an omental biopsy and peritoneal cytology. Additional peritoneal biopsy sites included pericolic gutters (50), pelvic peritoneum (45), bowel serosa/mesentery (24), diaphragm (22), appendix (11), and adhesions (7). At the time of staging laparotomy, 22 patients (7.5%) had gross evidence of peritoneal spread, which was readily confirmed by directed biopsy. In the 273 women without gross peritoneal disease, 3 (1%) had occult metastases detected by routine biopsy, 3 (1%) had microscopic metastases in palpably abnormal biopsies, and 22 had positive cytology as the only evidence of peritoneal disease. Only three operative complications were potentially attributable to peritoneal assessment: cystotomy (1), partial small bowel obstruction (1), and ileus (1). Peritoneal failures have been noted in 12 patients over a mean follow-up interval of 39 months. Seven of these patients had obvious peritoneal disease at laparotomy. Two of the remaining 5 had optimal peritoneal sampling and represent false-negative cases. A staging laparotomy that included total abdominal hysterectomy with adnexal resection, cytology, omental biopsy, and biopsy of grossly abnormal sites would have potentially identified all patients with known peritoneal disease. Routine biopsy of other grossly normal peritoneal sites is associated with extremely low yield and is not recommended.

Adult↗
PubMed1995

Intestinal fistulae formation following pelvic exenteration: a review of the University of Texas M. D. Anderson Cancer Center experience, 1957-1990.

Intestinal fistulae are an uncommon but serious complication of pelvic exenteration. To characterize factors leading to fistula formation and to define optimal management of this complication, we reviewed 533 cases of patients who underwent pelvic exenteration at the University of Texas M. D. Anderson Cancer Center between 1957 and 1990. Forty-two of those patients developed an intestinal fistula following total (n = 29), anterior (n = 12), or posterior (n = 1) exenteration which was not tumor related. Prior to routine pelvic floor reconstruction, the fistula rate was 16%. With the advent of omental pedicle grafts and gracilis flaps, the rate decreased to 4.5%. The fistulae described included those from the small bowel to the pelvic cavity (n = 15) or the neovagina (n = 8), and from the large bowel to the neovagina (n = 8). Complex fistulae were noted in 11 patients. Early fistulae, those that developed during initial hospitalization, occurred in 25 patients and were mainly related to infectious complications. Twenty-three patients underwent attempted surgical repair of fistulae. Eleven died during their hospitalization of sepsis, recurrent wound complications, or fistula. Late fistulae, those that developed after discharge, occurred in 17 patients and were mainly related to delayed healing. Early and late fistulae did not differ in location. Only two patients with late fistula formation died from complications of therapy. Significant long-term morbidity, however, included short bowel syndrome. Based on our review, we conclude the following: (1) Pelvic floor reconstruction, careful attention to surgical technique and aggressive treatment of infections reduces the risk of early fistula formation; (2) in cases associated with significant infection, treatment should be surgical; and (3) in stable patients, conservative management with hyperalimentation and bowel should be considered.

Female↗
PubMed1995

Treatment of locally advanced cervical cancer with concurrent radiation and intra-arterial chemotherapy.

The purpose of this study was to determine the maximum tolerated dose (MTD) and feasibility of treatment with sequential intra-arterial FUDR and cisplatin administered with concurrent whole pelvis radiation (XRT) to women with advanced cervical cancer. Sixteen patients with squamous carcinoma of the cervix were prospectively treated in a Phase I study. All tumors were stages IIb, IIIb, or IVa with diameters of > or = 7 cm. Patients underwent surgical staging with pelvic and paraortic lymphadenectomy with placement of bilateral intra-arterial catheters in the anterior division of the internal iliac arteries. The catheters terminated in separate subcutaneous ports. No patient had metastasis in the high common iliac or paraortic nodes. Patients received a planned course of 40-50 Gy whole pelvis XRT followed by indicated brachytherapy. During the first 2 weeks of whole pelvis XRT, patients received a 1-hr infusion of FUDR and during the second 2 weeks a 1-hr infusion of cisplatin, each delivered daily by external pump with the daily whole pelviS XRT fraction. Additional cisplatin was infused during brachytherapy. Five dose levels ranging from 6.5 to 27 mg/m2 daily for FUDR and from 2 to 8 mg/m2 daily for cisplatin were used. The MTD of FUDR and CDDP was dose level 4 (22.5 and 6.75 mg/m2, respectively). Dose-limiting toxicity was grade 3/4 nausea seen in three of four patients at dose level 5. No patient had neuro- or ototoxicity. There was no grade 4 myelosuppression. Eight patients had a complete response, and six had a partial response. Disease progressed in two. Mean follow-up was 22.4 months. At this writing, 10 patients had no evidence of disease, 2 were alive with disease, and 4 had died of disease. Median survival has not been reached. This is a well-tolerated regimen with significant activity that warrants further investigation at dose level 4.

Adult↗
PubMed1995

Surgical therapy of T1 and T2 vulvar carcinoma: further experience with radical wide excision and selective inguinal lymphadenectomy.

Radical wide excision and selective inguinal node dissection provide a more conservative and less morbid surgical option for women with vulvar carcinoma than en bloc radical vulvectomy with bilateral inguinofemoral lymphadenectomy. We have expanded our initial experience with this approach to 76 patients with T1 (n = 33) and T2 (n = 43) squamous carcinomas with invasion > 1 mm and clinically negative groin nodes treated between 1978 and 1994. Lateral tumors (n = 53) were more frequent than midline lesions (n = 23). Tumors were excised with a measured gross margin of 2 cm, and dissection was carried to the deep perineal fascia. The mean largest tumor dimension was 26 mm; the mean depth of invasion was 4.4 mm. Superficial inguinal lymphadenectomy, unilateral or bilateral depending on lesion location, was performed. Perioperative complications occurred on the vulva in 8% of cases and in the groin in 11%. Delayed complications, all related to groin treatment, were seen in 29%. The median follow-up interval was 38 months. Seven patients (9%) had inguinal lymph node metastases identified at their primary operation. Most received additional therapy; one has died of disease. Nine women (12%) developed recurrent disease in the vulva: all were controlled by additional resection. Four (5%) developed recurrence in a previously negative groin: three of these are dead of disease. Actuarial 4-year survival is 81%. Radical wide excision and selective inguinal lymphadenectomy can be safely offered to women with T1 and T2 vulvar cancers. Patients with known positive nodes or vulvar failure can be salvaged by further therapy. Women with unanticipated groin failure usually die of disease. These experiences are similar to those observed in more radically resected patients.

Adult↗
PubMed1995

Perineal reconstruction using single gracilis myocutaneous flaps.

Bilateral gracilis myocutaneous flaps were originally used as part of a technique for creating a neovagina following total pelvic exenteration. Based upon this experience, we began using single flaps for primary repair and closure of large surgical defects in the perineal area that require alternate tissue sources to replace lost skin, mucosa, or adjacent deep tissues. Eighteen single gracilis flaps were used for major vulvovaginal reconstructions in 17 women during the past 5 years. Women undergoing unilateral flap reconstructions included 6 with anorectal cancers and 11 with vulvovaginal tumors. Most patients were being treated for recurrence after failed primary therapy (n = 7) or were receiving multimodal treatment for advanced local disease (n = 7). All cases involved complex resections followed by simultaneous reconstruction: mean total operative time was 377 min with a mean estimated blood loss of 1010 cc. Reconstruction involved external flap placement on the vulva or perineum in 7 cases and internal placement to replace excised portions of the vagina in the other 11. Mean flap size was 6.6 x 11.4 cm. Necrosis of flap skin occurred in 3 patients; minor wound separations or flap edge necrosis was seen in 5 cases. Hospital stay averaged 18.4 days. Nine women had recurrent disease and died over 4-30 months; the remaining 8 are alive and disease free with a median follow-up of 25 months. The single gracilis flap provides a versatile method for providing anatomic reconstruction of large perineal defects in women who have undergone extensive resection.

Adult↗
PubMed1995

Pelvic exenteration for adenocarcinoma of the uterine cervix.

The objective of this study was to describe and compare the outcome of patients with recurrent adenocarcinoma versus squamous cell carcinoma of the uterine cervix who have been treated with pelvic exenteration. All patients undergoing pelvic exenteration for cervical adenocarcinoma from 1955 to 1989 were identified and a retrospective review was conducted. For these 35 patients, we identified 70 controls who had exenteration for squamous cell carcinoma and who were matched for node status, year of procedure, and type of procedure. No significant difference was noted between the control group and the adenocarcinoma group for size of recurrent tumor, status of margins, presence of hydronephrosis prior to exenteration, and the time elapsed from initial diagnosis to exenteration. The two groups were compared for survival and recurrence pattern. Median patient age was 47 years (range 22-70). All patients had prior pelvic radiotherapy. Thirty patients had total pelvic exenteration and 5 had anterior exenteration. There were 3 postoperative deaths (8.6%). Median survival was 38 months for the adenocarcinoma patients and 25 months for the squamous patients (P > 0.99). The overall survival between the two sets of patients was very similar (log rank P = 0.86). There were 23 postexenteration recurrences among the adenocarcinomas (22 in which the site is known) and 32 postexenteration recurrences among the squamous patients (30 with known site). For the adenocarcinoma patients, 14 of 22 had a distant recurrence versus 14 of 30 for the squamous patients (P = 0.27). Patients with central recurrence of cervical adenocarcinoma can be successfully treated with pelvic exenteration and have survival rates similar to squamous carcinoma.

Adenocarcinoma↗
PubMed1995

Staging laparotomy for endometrial carcinoma: assessment of retroperitoneal lymph nodes.

The surgical staging scheme for uterine corpus cancer adopted in 1988 by the International Federation of Gynecology and Obstetrics assigns patients with tumor spread to retroperitoneal lymph nodes to stage IIIC. However, a recommended approach to the detection of lymph node metastasis is not delineated. As part of an ongoing project to assess the value of surgical staging procedures, we reviewed the techniques of lymph node evaluation in 295 at-risk patients. Cases included clinical stage I patients whose preoperative biopsies demonstrated grade 2 or 3 adenocarcinoma or papillary serous, clear cell, or mixed carcinoma. We arbitrarily divided the retroperitoneal space into 10 lymphatic zones: left and right para-aortic, common iliac, external iliac, hypogastric, and obturator. Eighty-two percent of patients had some type of node sampling that involved a mean of three zones. Thirty-three of 244 sampled cases (13.5%) had nodal metastases: 20 had gross involvement and 13 had microscopic. We stratified patients into three groups: (1) those who had no node sampling (n = 51), (2) those with some nodes biopsied (n = 193), and (3) those whose node sampling included a minimum of one para-aortic plus at least one right and left pelvic specimen (n = 51). Retroperitoneal recurrences thought to originate from lymph node sites were identified for the "node-negative" patients in each group: Group 1, 4/51 (8%); Group 2, 9/173 (5%); and Group 3, 0/38 (0%). Lymphatic site failures were seen in 8 of 33 (24%) patients with biopsy-proven metastases. We found that failure to systematically sample pelvic and para-aortic nodes results in a small, but real, risk of undetected extrauterine metastasis. A selective approach to sampling that includes biopsy from both para-aortic and bilateral pelvic lymphatic zones appears to provide an accurate estimate of true node negativity. Further evaluation of this approach is warranted.

Adult↗