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Biomedical subjects

Merrick I Ross

Publications and source records attributed to Merrick I Ross.

At least 109 records · Page 6Linked to original sources
PubMed2002

Adjuvant irradiation for axillary metastases from malignant melanoma.

PURPOSE: To evaluate the outcome and treatment-related toxicity for patients with axillary lymph node metastases from malignant melanoma treated with surgery and radiation, with or without systemic therapy. MATERIALS AND METHODS: The medical records of 89 consecutive patients with axillary lymph node metastases from malignant melanoma were retrospectively reviewed. All patients underwent axillary dissection and postoperative radiation to a median dose of 30 Gy at 6 Gy/fraction delivered twice weekly. In 3 patients referred with microscopic residual disease, a single boost (4-6 Gy) was given to a reduced field. All but 2 patients were referred because their axillary dissections revealed features believed to predict a 30-50% risk of subsequent axillary recurrence: lymph nodes >/=3 cm in size (54 patients), >/=4 lymph nodes positive (44), the presence of extracapsular extension (69), recurrent disease after initial surgical resection (23), or multiple risk factors (77). Fifty-one patients received systemic therapy before or after radiation therapy. RESULTS: At a median follow-up of 63 months, 47 patients had relapsed and 43 patients had died. The actuarial overall and disease-free survival rates at 5 years were 50% and 46%, respectively. The actuarial axillary control and distant metastasis-free survival rates at 5 years were 87% and 49%, respectively. Univariate analysis revealed that the probability of axillary control was inferior when the axillary disease measured >6 cm in size (72% vs. 93%, p = 0.02), the location of the primary tumor was unknown (74% vs. 93%, p = 0.02), the axillary failure occurred within 18 months from diagnosis of the primary melanoma (84% vs. 100%, p = 0.04), or the Breslow thickness was >4 mm (80% vs. 96%, p = 0.04). Additionally, there was an inferior distant metastasis-free and disease-free survival when there were >2 nodes positive for metastatic disease, the primary lesion had a Breslow thickness >4 mm, or the axillary failure occurred within 18 months from diagnosis of the primary melanoma. On multivariate analysis, the significantly inferior distant metastasis-free and disease-free survival seen when >2 nodes were positive or the recurrence occurred within 18 months remained significant. The small number of axillary failures precluded multivariate analysis for axillary control; however, stratified analysis suggested that size >6 cm was the factor most closely associated with subsequent axillary failure. Twenty-six patients developed treatment-related arm edema. Classification according to the severity of edema yielded 5-year actuarial arm edema rates of 21%, 19%, and 1%, for Grade 1 (transient or asymptomatic), Grade 2 (requiring medical intervention), or Grade 3 (requiring surgical intervention) edema, respectively. CONCLUSION: Adjuvant radiation therapy using a hypofractionated regimen resulted in an 87% 5-year axillary control rate, superior to the 50-70% local control achieved with surgery alone for lymph node metastases from melanoma when high-risk features are present. Improvements are needed for patients with bulky nodal masses >6 cm in size. Mild-to-moderate arm edema was common, but manageable. The degree to which radiotherapy adds to the risk of arm edema after axillary dissection alone cannot be addressed in the present analysis.

Adult↗
PubMed2002

Breast cancer on the world wide web: cross sectional survey of quality of information and popularity of websites.

OBJECTIVES: To determine the characteristics of popular breast cancer related websites and whether more popular sites are of higher quality. DESIGN: The search engine Google was used to generate a list of websites about breast cancer. Google ranks search results by measures of link popularity---the number of links to a site from other sites. The top 200 sites returned in response to the query "breast cancer" were divided into "more popular" and "less popular" subgroups by three different measures of link popularity: Google rank and number of links reported independently by Google and by AltaVista (another search engine). MAIN OUTCOME MEASURES: Type and quality of content. RESULTS: More popular sites according to Google rank were more likely than less popular ones to contain information on ongoing clinical trials (27% v 12%, P=0.01 ), results of trials (12% v 3%, P=0.02), and opportunities for psychosocial adjustment (48% v 23%, P<0.01). These characteristics were also associated with higher number of links as reported by Google and AltaVista. More popular sites by number of linking sites were also more likely to provide updates on other breast cancer research, information on legislation and advocacy, and a message board service. Measures of quality such as display of authorship, attribution or references, currency of information, and disclosure did not differ between groups. CONCLUSIONS: Popularity of websites is associated with type rather than quality of content. Sites that include content correlated with popularity may best meet the public's desire for information about breast cancer.

Breast Neoplasms↗
PubMed2002

Interval sentinel lymph nodes in melanoma.

HYPOTHESIS: For patients with melanoma, interval or in-transit sentinel lymph nodes (SLNs) have the same risk for nodal metastasis as SLN in traditional (ie, cervical, axillary, and inguinal) nodal basins. DESIGN: Prospective clinical trial. SETTING: Multicenter study. PATIENTS: Eligible patients were aged 18 to 70 years with melanomas of at least 1.0-mm Breslow thickness and nodes with clinically negative findings. INTERVENTION: Sentinel lymph node biopsy was guided by preoperative lymphoscintigraphy to identify all SLNs. MAIN OUTCOME MEASURES: We evaluated interval nodal sites, including epitrochlear, popliteal, and subcutaneous or intramuscular nodes outside of traditional basins, for the presence of metastases. RESULTS: The SLNs were identified in 2332 nodal basins from 2000 patients. In 62 patients (3.1%), interval SLNs were identified. We found SLN metastases in 442 (19.5%) of 2270 conventional nodal basins and 13 (21.0%) of 62 interval sites. In 11 (84.6%) of the 13 cases in which we found an interval node that was positive for metastatic disease, it was the only site of nodal metastasis. CONCLUSIONS: Although interval SLNs are identified infrequently, they contain metastatic disease at nearly the same frequency as SLNs in cervical, axillary, and inguinal nodal basins. Positive interval SLNs are likely to be the only site of nodal metastasis. Therefore, detailed preoperative lymphoscintigraphy and meticulous intraoperative search for interval nodes should be performed.

Adult↗
PubMed2002

Frequency of nonsentinel lymph node metastasis in melanoma.

BACKGROUND: Completion lymph node dissection (CLND) may not be necessary for some patients because nodal metastasis is rarely detected beyond the sentinel lymph nodes (SLNs). This analysis was performed to determine, among patients with positive SLNs, the rate of nodal metastasis found in nonsentinel nodes (NSNs). METHODS: This analysis includes patients with positive sentinel nodes, detected by hematoxylin and eosin (H&E) staining or immunohistochemistry (IHC), who then underwent CLND. RESULTS: This analysis included 274 patients with at least one positive SLN who underwent CLND of 282 involved regional nodal basins. Of the 282 SLN-positive nodal basins, 45 (16%) were found to have positive NSNs in the CLND specimen. Breslow thickness, Clark level, presence of ulceration, histological subtype, presence of vertical growth phase, evidence of regression, presence of lymphovascular invasion, number of positive SLNs, age, sex, and presence of multiple draining nodal basins were not predictive of positive nodes in the CLND specimen. Patients with SLN metastases detected only by IHC had an equal likelihood of having positive NSNs as those patients with positive SLNs on H&E examination. CONCLUSIONS: No patient population could be identified with minimal risk of non-SLN metastasis. When a positive SLN is identified on either H&E staining or IHC, CLND should be performed routinely.

Adult↗
PubMed2002

Breast-conservation therapy in early-stage breast cancer patients with a positive family history.

BACKGROUND: Our goal was to evaluate the role of breast-conservation therapy in early-stage breast cancer patients with a family history (FH) of breast cancer. METHODS: Between 1970 and 1994, 1324 female patients with breast cancer were treated with breast-conservation therapy at our institution. From these, we identified 985 patients with stage 0-II breast cancer and who had available information on FH status. FH was considered positive in any patient who had a relative who had been previously diagnosed with breast cancer. Disease-specific survival was calculated from the date of initial diagnosis using the Kaplan-Meier method. RESULTS: The stage distribution for the 985 patients was as follows: 0 in 65 (7%), I in 500 (51%), and II in 420 (43%). The median age was 50 years (range, 21-88), with a median follow-up time of 8.8 years (range,.25-29). The median tumor size was 1.5 cm. FH was positive in 31%. There were no significant differences in locoregional recurrence, distant recurrence, disease-specific survival, or incidence of contralateral breast cancer in patients with a positive FH versus patients with a negative FH. CONCLUSIONS: Breast-conservation therapy is not contraindicated in early-stage breast cancer patients with a positive FH.

Adult↗
PubMed2002

A prospective trial of preoperative chemotherapy in resectable breast cancer: predictors of breast-conservation therapy feasibility.

BACKGROUND: The role of preoperative chemotherapy for breast cancer is evolving. We initiated a prospective trial of sequential preoperative paclitaxel and doxorubicin-based combination chemotherapy in patients with stage I (tumor >1 cm), II, or IIIA disease and evaluated its effect on breast-conservation therapy (BCT) eligibility. METHODS: Pathology findings for the initial 100 consecutive patients who underwent surgery were analyzed. RESULTS: The median tumor size at presentation was 2.4 cm, and 39% of patients were deemed eligible for BCT. After chemotherapy, the median tumor size decreased to 1.0 cm (P <.001), and 59% of patients seemed BCT eligible (BCT conversion rate 34% among patients initially assessed as BCT ineligible; P <.001). Final pathology confirmed BCT feasibility in 90% of patients assessed as BCT candidates before surgery. The pathology from mastectomy specimens revealed BCT feasibility in 11 (27%) of 41 patients deemed BCT ineligible. Multivariate analysis revealed lobular histology, multicentricity, and calcifications, but not age, initial tumor size, or nodal status to predict final pathology indicating BCT ineligibility. CONCLUSIONS: Induction chemotherapy improves BCT eligibility for breast cancer patients. Improved breast imaging methods after chemotherapy are necessary to improve accuracy in predicting the feasibility of BCT, especially in patients presenting with diffuse calcifications or multicentricity.

Adult↗
PubMed2002

Predictors of locoregional recurrence among patients with early-stage breast cancer treated with breast-conserving therapy.

BACKGROUND: Our aim was to identify predictors of locoregional recurrence (LRR) in patients with early-stage breast cancer treated with breast-conserving therapy (BCT) and long-term follow-up. METHODS: From 1970 to 1994, 1153 patients with stage I to II breast cancer underwent BCT and radiotherapy at our institution. Patients with prior breast cancer or other primary malignancies were excluded. Clinical and pathologic characteristics evaluated were age, race, tumor size, stage, pathologic tumor margins, axillary nodal involvement, estrogen and progesterone receptor status, Black's nuclear grade, type of surgery, and use of adjuvant therapy. RESULTS: Of 1083 patients, 54% presented with stage I disease and 46% with stage II disease. Median age was 50 years, and median follow-up was 9 years. Axillary nodes were positive in 31% of the patients who underwent axillary dissection. LRR developed in 6%, LRR followed by systemic recurrence in 5%, and systemic recurrence alone in 13%; 76% had no evidence of recurrence at last follow-up. Age, tumor size, positive lymph nodes, and not receiving chemotherapy or hormonal therapy were independent predictors of LRR. Disease-specific survival among patients with LRR was similar to that among patients with no recurrence. CONCLUSIONS: Multidisciplinary treatment strategies should be used to accomplish durable locoregional control after BCT.

Adult↗
PubMed2002

Long-term complications associated with breast-conservation surgery and radiotherapy.

BACKGROUND: Breast-conservation surgery plus radiotherapy has become the standard of care for early-stage breast cancer; we evaluated its long-term complications. METHODS: We selected patients treated with surgery and radiotherapy between January 1990 and December 1992 (an era in which standard radiation dosages were used) with follow-up for at least 1 year. Patients were prospectively monitored for treatment-related complications. Median follow-up time was 89 months. RESULTS: A total of 294 patients met the selection criteria. Grade 2 or higher late complications were identified in 29 patients and included arm edema in 13 patients, breast skin fibrosis in 12, decreased range of motion in 4, pneumonitis in 2, neuropathy in 2, fat necrosis in 1, and rib fracture in 1. Arm edema was more common after lumpectomy plus axillary node dissection than after lumpectomy alone. Arm edema occurred in 18% of patients who underwent surgery plus irradiation of the lymph nodes and 10% who underwent surgery without nodal irradiation. CONCLUSIONS: Breast-conservation surgery plus radiotherapy was associated with grade 2 or higher complications in only 9.9% of patients. Half of these complications were attributable to axillary dissection, it is hoped that lower complication rates can be achieved with sentinel lymph node biopsy. Breast-conservation surgery and radiotherapy is associated with grade 2 or greater complications in only 9.9% of patients. Nearly half of these complications are attributable to axillary dissection.

Adult↗
PubMed2002

Presence of the human leukocyte antigen class II gene DRB1*1101 predicts interferon gamma levels and disease recurrence in melanoma patients.

BACKGROUND: Increased interferon gamma (IFN-gamma) levels are an independent predictor of melanoma recurrence. Human leukocyte antigen (HLA) class II genes can regulate cytokine production; we investigated whether these genes would predict IFN-gamma levels and recurrence in melanoma patients. METHODS: Of 591 patients who presented with localized melanoma, 579 underwent identification of HLA class II alleles; 233 melanoma patients and 90 controls underwent determination of plasma IFN-gamma levels. HLA class II genes were examined for association with IFN-gamma levels and disease recurrence. RESULTS: After a median follow-up of 60 months, melanoma patients with IFN-gamma levels above the mean control value were more likely to have developed disease recurrence compared with patients with levels below the mean. The HLA class II gene HLA-DRB1*1101 was the strongest predictor of recurrence, and HLA-DRB1*1101-positive melanoma patients had increased levels of IFN-gamma compared with patients lacking the gene. CONCLUSIONS: Among patients with localized melanoma, both HLA-DRB1*1101 and increased IFN-gamma levels were associated with an increased risk for recurrence; HLA-DRB1*1101-positive patients had relatively increased levels of IFN-gamma. HLA class II genes may mediate cytokine production in melanoma patients, and this mechanism may help determine the risk of disease recurrence.

Adolescent↗
PubMed2002

Surgery for inoperable breast cancer.

Neoadjuvant chemotherapy has the potential to convert inoperable breast cancer into operable disease; however, patients may remain inoperable by the classic criteria after neoadjuvant chemotherapy. In such cases, palliative surgical therapy to promote comfort and hygiene and to control wound breakdown may need to be considered. This report documents this clinical scenario in a patient with a large exophytic breast cancer who had a partial response with neoadjuvant chemotherapy and required an extended radical mastectomy with extensive reconstruction for coverage. The decision to undertake such a surgical procedure is complicated when the patient's life expectancy may be extremely limited and both patient and treatment team must carefully weigh the risks and potential benefits of a highly complex but technically feasible operation.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2002

Treatment and outcome of patients with intracystic papillary carcinoma of the breast.

BACKGROUND: Intracystic papillary carcinoma (IPC) of the breast is a rare form of noninvasive breast cancer. An appreciation of associated pathology with IPC may be critical in surgical decision-making. METHODS: The medical records of all patients with IPC treated between 1985 and 2001 were retrospectively reviewed. Three patient groups were identified according to the pathologic features of the primary tumor: IPC alone, IPC with associated ductal carcinoma in situ (DCIS), and IPC with associated invasion with or without DCIS. Types of treatment and outcomes were compared between groups. RESULTS: Forty patients were treated for IPC during the study period. Fourteen had pure IPC, 13 had IPC with DCIS, and 13 had IPC with invasion. The incidence of recurrence and the likelihood of dying of IPC did not differ between the three groups regardless of the type of surgery (mastectomy or segmental mastectomy) performed and whether radiation therapy was administered. The disease-specific survival rate was 100%. CONCLUSIONS: When IPC is identified, it is frequently associated with DCIS and or invasion. Standard therapy should be based on associated pathology. The role of radiation therapy in pure IPC remains to be determined.

Adult↗
PubMed2002

Patterns of early recurrence after sentinel lymph node biopsy for melanoma.

BACKGROUND: Patterns of early recurrence after sentinel lymph node (SLN) biopsy for melanoma was determined from the Sunbelt Melanoma Trial, which includes patients with Breslow thickness > or =1.0 mm and nonpalpable regional lymph nodes. METHODS: SLN were evaluated by routine histology and S-100 protein stain. Overall, there were 1,183 patients with a median follow-up of 16 months. RESULTS: SLN were positive in 233 of 1,183 patients (20%). The recurrence rate was greater among patients with histologically positive SLN than those with negative SLN (15.5% versus 6.0%, respectively, P <0.05). Patients with positive SLN were more likely to have distant metastases (as opposed to locoregional recurrence) than those with negative SLN (67% versus 46%, respectively, P <0.05). By multivariate analysis, SLN status, Breslow thickness, Clark level, and ulceration were significant independent factors associated with early recurrence. Of patients with negative SLN, 14 of 950 (1.5%) experienced metastatic disease in lymph node basins which were staged as negative for tumor by SLN biopsy initially. CONCLUSIONS: Early regional lymph node recurrence was very uncommon after positive SLN biopsy and completion lymphadenectomy. Patients with positive SLN are more likely than those with negative SLN to develop both local/in-transit recurrence and distant metastases within a short follow-up period.

Female↗
PubMed2002

Implications of axillary sentinel lymph node biopsy in immediate autologous breast reconstruction.

For patients with invasive breast cancer, if the results of an axillary sentinel node biopsy are determined to be positive after permanent pathologic examination, the current recommendation is to perform a complete axillary node dissection. Subsequent axillary surgery may compromise the blood supply to an immediate autologous breast reconstruction. The purpose of this study was to determine which clinicopathologic factors in clinically node-negative breast cancer patients may be associated with an increased risk of positive axillary nodes. Identification of these factors will allow surgeons to modify their approach to immediate autologous breast reconstruction in these high-risk patients. The relationship between presenting clinicopathologic characteristics and the incidence of axillary metastases was analyzed by chi-square test and multivariate analysis in 167 patients with invasive breast cancer and a clinically negative axilla who underwent modified radical mastectomy with an immediate free transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. Axillary nodal metastases were found in 35 percent of clinically node-negative breast cancer patients. Multivariate analysis showed that patient age of 50 years or younger (p = 0.019), T2 tumor stage or greater (p = 0.031), and presence of lymphovascular invasion on the initial biopsy specimen (p < 0.001) were independent predictors of axillary metastases in clinically node-negative patients. Based on these results, the authors propose an algorithm for decision making in clinically node-negative breast cancer patients who desire autologous breast reconstruction and sentinel lymph node biopsy. Options for immediate autologous breast reconstruction in patients undergoing mastectomy and axillary sentinel lymph node biopsy that may minimize the risk of vascular damage on reoperation include the use of the internal mammary artery and vein as recipient vessels for a free TRAM flap or a pedicled TRAM flap. If an axillary-based blood supply is used, the authors are considering the use of cadaveric dermis to isolate the pedicle of the flap away from the remaining axillary contents. New developments in breast cancer diagnosis and treatment necessitate a team approach, with increased communication between the breast surgeon and the plastic surgeon in planning surgery for these patients.

Adult↗
PubMedDate not supplied

Breast cancer in reduction mammaplasty specimens: case reports and guidelines.

Increasing numbers of women of all ages are electing to have reduction mammaplasty for very large breasts. Breast cancer can be an incidental finding in reduction mammaplasty specimens. We report here the discovery of breast cancer in specimens from four patients who underwent elective breast reduction, three of whom had not had recent mammograms. All four patients underwent modified radical mastectomy. The role of mammography, surgical options, specimen evaluation, and practical guidelines are discussed.

Adult↗
PubMedDate not supplied

Radiofrequency ablation of early-stage invasive breast tumors: an overview.

As the management of breast cancer evolves toward less invasive treatments, the next step is the possibility of removing the primary tumor without surgery. The most promising of the noninvasive ablation techniques is radiofrequency ablation, which uses frictional heating that is caused when ions in the tissue attempt to follow the changing directions of a high-frequency alternating current. Three pilot studies, including an ongoing study at M.D. Anderson Cancer Center, have demonstrated that radiofrequency ablation is effective for the destruction of small primary breast cancers. The most important factorfor successful radiofrequency ablation is accuracy of the ultrasound evaluation, which is used to estimate tumor size, localize the tumor for treatment, and monitor the progress of the ablation. A study in preparation at M.D. Anderson will determine whether the use of radiofrequency ablation alone for the local treatment of primary breast cancer will result in outcomes equivalent to those obtained with breast conservation therapy.

Breast Neoplasms↗
PubMedDate not supplied

The role of ultrasound in the surgical management of patients diagnosed with ductal carcinoma in situ of the breast.

The purpose of this study was to determine the usefulness of ultrasound (US) as an adjunct to mammography (MMG) in the surgical treatment planning for patients with ductal carcinoma in situ (DCIS) of the breast. A total of 119 patients diagnosed with DCIS, who were treated between 1999 and 2002, were identified from the institutional database. US and MMG size of suspicious abnormalities, pathologic tumor size, and findings of axillary US and surgical axillary evaluation were analyzed. The median size difference of US versus pathologic tumor size and MMG versus pathologic tumor size was 1.0 and 2.0 cm, respectively. Correlation coefficients for US versus pathologic tumor size and MMG versus pathologic tumor size were 0.53 and -0.09, respectively. The negative and positive predictive values of axillary US to predict nodal disease were 93% and 27%, respectively. US evaluation appears to be a useful tool in conjunction with MMG in determining the extent of disease in patients diagnosed with DCIS. However, the low positive predictive value of US for evaluating metastases to axillary lymph nodes does not justify the routine use of this modality for axillary evaluation in patients with DCIS. Therefore the use of US for patients diagnosed with DCIS needs further investigation.

Adult↗