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Biomedical subjects

R S Foster

Publications and source records attributed to R S Foster.

At least 55 records · Page 3Linked to original sources
PubMed1998

Is retroperitoneal lymph node dissection necessary for adult paratesticular rhabdomyosarcoma?

PURPOSE: We assess the benefit of retroperitoneal lymph node dissection for adult paratesticular rhabdomyosarcoma. MATERIALS AND METHODS: A total of 19 adults with paratesticular rhabdomyosarcoma who underwent retroperitoneal lymph node dissection between 1980 and 1997 comprise our study population. Postoperative chemotherapy was administered in all patients, including cyclophosphamide, doxorubicin and vincristine with or without consolidation with ifosfamide and etoposide in 17, and vincristine, actinomycin D and cyclophosphamide in 2. Radiation therapy also was administered in 2 patients. Patients were classified into pathological and clinical groups according to the Intergroup Rhabdomyosarcoma Studies. Mean followup was 6.4 years (range 0.5 to 17.6). RESULTS: A total of 17 patients (89%) were disease-free and 2 (1 in pathological group I and 1 in pathological group II) died of disease that recurred outside of the retroperitoneum. Of 16 clinical group I patients 9 were in pathological group II. There were negative nodes in 2 of 3 clinical group II patients. Thus, abdominal computerized tomography correctly staged only 8 of 19 patients (42%). CONCLUSIONS: Retroperitoneal lymph node dissection accurately stages paratesticular rhabdomyosarcoma and eliminates the need for abdominal radiotherapy in patients in pathological group II. Combined modality therapy with retroperitoneal lymph node dissection and postoperative chemotherapy achieves a high cure rate.

Adolescent↗
PubMed1998

Identification of clinical stage A nonseminomatous testis cancer patients at extremely low risk for metastatic disease: a combined approach using quantitive immunohistochemical, histopathologic, and radiologic assessment.

PURPOSE: To evaluate previously determined predictors of metastasis in low-stage testis cancer in a consecutive group of clinical stage A patients. PATIENTS AND METHODS: Ninety-one consecutive clinical stage A nonseminomatous germ cell tumor (NSGCT) patients who underwent primary nerve-sparing retroperitoneal lymph node dissection (NSRPLND) had orchiectomy specimens and computed tomographic (CT) scans evaluated blindly in a quantitative fashion. These scores were then correlated with pathologic stage using previously determined paradigms. RESULTS: Using volume of embryonal carcinoma in the orchiectomy specimen, lymph node diameters in the primary landing zones and MIB-1 staining of the orchiectomy specimen, 41 patients were classified as low risk for metastasis. Forty of these 41 had pathologic stage A disease at RPLND. CONCLUSION: These parameters can identify a low-risk group of patients for metastasis who can be rationally offered surveillance.

Carcinoma, Embryonal↗
PubMed1998

En bloc nephrectomy in patients undergoing post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous testis cancer: indications, implications and outcomes.

PURPOSE: We review the indications for nephrectomy at post-chemotherapy retroperitoneal lymph node dissection, identify patients at risk for nephrectomy and assess the impact of nephrectomy on outcome. MATERIALS AND METHODS: Using a computerized data base and chart review we retrospectively reviewed the records of 848 patients who underwent retroperitoneal lymph node dissection after chemotherapy. RESULTS: En bloc nephrectomy was performed at retroperitoneal lymph node dissection after chemotherapy in 162 of the 848 patients (19%). The indications for nephrectomy included contiguous involvement of perirenal structures in 73% of the cases, renal vein thrombosis in 6%, a poorly functioning or nonfunctioning renal unit in 5% and a combination of these conditions in 16%. Pathological studies of the hilum revealed cancer in 20% of the cases, teratoma in 49% and fibrosis in 31%. Patients requiring nephrectomy had significantly more advanced disease and larger disease volume at presentation and after chemotherapy. There were no significant differences in perioperative morbidity or mortality compared with patients who did not undergo nephrectomy. Only 3 patients required perioperative dialysis and none required long-term renal support. CONCLUSIONS: These findings support en bloc nephrectomy at post-chemotherapy retroperitoneal lymph node dissection in select patients with large volume perihilar retroperitoneal disease.

Adult↗
PubMed1998

Clinical stage I nonseminoma: surgery versus surveillance.

The presentation of nonseminomatous germ cell tumor confined clinically to the testicle (clinical stage I) is associated with a 30% incidence of occult retroperitoneal metastases. For decades, the standard of care in these patients has been a retroperitoneal lymph node dissection (RPLND), both for staging purposes, and, in the pre-modern chemotherapy era, it was performed with curative intent. The improvements in combination chemotherapy during the past 20 years have resulted in the cure of most individuals with small volume recurrent disease, calling into question the continued need for RPLND. The strategy of surveillance and chemotherapy for the 30% who relapse has gained acceptance, and, with meticulous follow-up, can result in the same excellent cure rates seen in patients treated with the surgical option. Although primary chemotherapy has also been suggested as a treatment option, the majority of patients will receive that chemotherapy unnecessarily, and cure rates with this strategy will not surpass those for surveillance or RPLND. Prognostic factors have been developed that can successfully identify a group of patients who are at an extremely low risk of relapse, thus potentially sparing these individuals any additional therapy. However, attempts to define a very high risk population have been unsuccessful to date, and we await the development of newer biologic markers able to predict which patients are most likely to have occult retroperitoneal disease and therefore most likely to benefit from additional "adjuvant" therapy post-orchiectomy.

Germinoma↗
PubMed1998

Integration of surgery and systemic therapy: results and principles of integration.

Eight hundred seventy patients with metastatic nonseminomatous germ cell cancer underwent postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for resection of residual disease. Several risk factors for relapse and survival were identified as highly significant (P = .00001), namely, presence of residual cancer in the specimen before salvage chemotherapy programs, tumor marker elevation, need for "re-do" PC-RPLND, or unresectability. Although more than half of the entire group (52.5%) had one or more of these risk factors, 67.5% are long-term survivors following PC-RPLND. The remaining 47.5% were referred after primary chemotherapy, without risk factors. Only 9.8% relapsed and 95.5% survived.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1997

Urethral catheter removal prior to hospital discharge following radical prostatectomy.

OBJECTIVES: To investigate the feasibility of early catheter removal following radical prostatectomy. METHODS: Fifty-eight consecutive patients underwent radical prostatectomy, with intent of early catheter removal. Catheter removal was based on postoperative cystograms performed on postoperative day (POD) 3 or 4. Charts were retrospectively reviewed and patients were contacted by phone and specifically questioned regarding continence and bladder control. RESULTS: Fifty-one patients (87.9%) had a cystogram performed on POD 3 or 4. In 43 patients (74.1%), the catheter was successfully removed prior to hospital discharge. Eight patients experienced either early or late complications (excluding incontinence); these included 3 patients with a superficial wound infection, 2 patients with hematuria requiring reinsertion of a urethral catheter, 1 patient with a spontaneous pneumothorax, 1 patient who developed a deep vein thrombosis and lymphocele, and 1 patient with a bladder neck contracture. Urinary continence was reported as excellent to good in 86% of the patients at a mean follow-up of 17.4 months. Three patients (5%) underwent placement of an artificial urinary sphincter. CONCLUSIONS: Catheter removal prior to hospital discharge after radical prostatectomy is feasible without any increase in morbidity.

Adult↗
PubMed1997

Postchemotherapy retroperitoneal lymph node dissection is effective therapy in selected patients with elevated tumor markers after primary chemotherapy alone.

OBJECTIVES: Elevated tumor markers after primary chemotherapy for metastatic testis cancer are usually an indication of persistent cancer. Subsequent treatment has usually been salvage chemotherapy. This article examines the possibility that selected patients can achieve long-term disease-free survival with surgery alone. METHODS: Using a computerized data base of 627 postinduction chemotherapy retroperitoneal lymph node dissections (PC-RPLND), 23 patients with elevated tumor markers who have undergone PC-RPLND after induction chemotherapy alone were identified. Of the 23 patients, 15 were considered candidates for salvage chemotherapy, but instead underwent salvage surgery. Case histories were reviewed to establish selection criteria for PC-RPLND. RESULTS: Eight patients originally presented as clinical Stage C, 6 as clinical Stage B-3, and 1 as clinical Stage B-2. All patients initially received cisplatin combination chemotherapy. Twelve patients had an elevated alpha-fetoprotein level and 3 patients had an elevated beta human chorionic gonadotropin level prior to PC-RPLND. Seven patients had rising markers at the time of PC-RPLND. Seven patients had teratoma only in their resected specimen and all have no evidence of disease (NED) at a median of 35 months. Two patients had necrosis only in their RPLND specimen and both are NED at 10 and 42 months. Six patients had cancer in their resected specimen and 2 are NED, 1 is alive with disease, and 3 are dead of disease. Five of the 6 patients with cancer in their resected specimen were the only patients who received postoperative chemotherapy. CONCLUSIONS: Some patients with modest elevations of tumor markers after induction chemotherapy may only have teratoma or necrosis in the postchemotherapy resected specimen. These patients (n = 9) remain continuously NED. Patients who undergo salvage surgery and have cancer in the resected specimen do less well, but selected patients can be cured with this modality and thus avoid the morbidity of salvage chemotherapy.

Adolescent↗
PubMed1997

Vertical muscle transposition augmented with lateral fixation.

INTRODUCTION: Full vertical rectus muscle transpositions have been shown to be an effective treatment for lateral rectus palsies and type I Duane syndrome. This operation is usually accompanied by mechanical or botulinum toxin treatment of one or both medial rectus muscles. This series evaluates the effect of augmenting the transposed muscles with lateral fixation sutures. METHODS: Transposition of the vertical rectus muscles to the lateral rectus muscle was performed in 23 eyes of 21 patients; transposition to the medial rectus muscle was performed in one eye of one of these 21 patients. A lateral fixation suture of 5-0 Dacron polyester filament was placed in the sclera 16 mm posterior to the limbus and adjacent to the lateral rectus muscle, incorporating one fourth of the transposed vertical rectus muscle. Of the 21 patients, five had type I Duane syndrome with a face turn and esotropia in the primary position, seven had a unilateral lateral rectus palsy, two had bilateral lateral rectus palsy, four had an ipsilateral lateral rectus palsy combined with a contralateral lateral rectus paresis (a recess resect procedure was performed on the paretic eye along with the augmented transposition on the paralyzed eye), two had gaze palsies, and one had a unilateral lateral rectus palsy with recurrent esotropia after a transposition procedure performed 16 years previously. Lateral fixation sutures alone were used in the last case listed. Postoperative diplopia-free fields were measured when possible (10 cases). RESULTS: In most cases (19/23 eyes), alignment was achieved in the primary position with the use of the augmented transposition procedure alone. On average,20 degrees of binocular fusion into the abducted field was obtained. No postoperative limitation of adduction in the transposed eye was noted. Among the patients with Duane syndrome, 80% had elimination of the face turn; one patient had 5 degrees of residual face turn. The one patient with previous transposition surgery alone had an 80% (16 PD) reduction of the recurrent esotropia after placement of lateral fixation sutures. After augmented transpositions, induced vertical deviations in the primary position were uncommon (4/20 patients) and not greater than 2 PD. Significant lid fissure changes were not seen. CONCLUSIONS: The addition of lateral fixation sutures to full vertical rectus muscle transpositions improves the tonic abducting force of the procedure for patients with lateral rectus palsy and type I Duane syndrome without compromising adduction.

Adolescent↗
PubMed1997

Primitive neuroectodermal tumors arising in testicular germ cell neoplasms.

Twenty-nine young men (mean age 29 years) had primitive neuroectodermal tumors (PNETs) arising in germ cell tumors (GCTs). Nine patients had PNETs confined to the testis, eight patients had PNETs in the testis and at metastatic sites, and 12 patients had PNETs identified only at extratesticular sites. Immunohistochemistry was of use in the further classification of these PNETs as neuroblastoma, medulloepithelioma, peripheral neuroepithelioma, or ependymoblastoma. The histologic pattern of PNETs in the testis (neuroblastoma or medulloepithelioma) did not predict which tumors metastasized. PNETs localized to the testis did not affect prognosis. Eight patients with no PNETs outside the testis were free of disease 1 month to 10 years after diagnosis. PNETs in extratesticular sites were an adverse prognostic factor. Nineteen patients with extratesticular PNETs had adequate clinical follow-up. Thirteen are dead of disease from 4 months to 5 1/2 years (mean 26 months) after diagnosis, four are alive with disease 6 months to 2 years after diagnosis, and two have no evidence of disease with short follow-up (6 and 17 months). Mean survival was longer (34 months) for patients whose extratesticular PNET was neuroblastoma than for those with other types of PNETs (13 months). Chemotherapy directed against GCTs was not effective in patients who developed metastatic PNETs of GCT origin. We conclude that extratesticular PNETs in patients with testicular GCTs are usually fatal, but patients with neuroblastomatous metastases may have a more prolonged course.

Adolescent↗
PubMed1996

Preoperative technetium Tc 99m sestamibi imaging. Paving the way to minimal-access parathyroid surgery.

OBJECTIVE: To examine the reliability of technetium Tc 99m sestamibi scanning as a new adjunct to the surgical management of hyperparathyroidism. DESIGN: Preoperative localization of parathyroid adenoma by technetium Tc 99m sestamibi delayed washing-out scanning and high-resolution ultrasound was compared with a historical institutional experience of surgical intervention without preliminary localization studies. A 10-year retrospective review from 1985 to 1995 of patients with surgical hyperparathyroidism was performed. SETTING: Academic tertiary referral medical center. PATIENTS: Thirty-three technetium Tc 99m sestamibi scans in patients with primary hyperparathyroidism were correlated with eventual surgical and pathologic findings. The last 10 patients were also studied with 10-MHz linear transducer ultrasound, and the results were compared with those of the radionuclide scan and eventual surgical and pathologic findings. From 1985 to 1995, 142 patients underwent surgical exploration for primary hyperparathyroidism, and 125 records were available for review. RESULTS: The technetium Tc 99m sestamibi parathyroid scan correctly identified the site and presence of 31 adenomas among 34 confirmed tumors, a sensitivity of 91% and positive predictive value of 97%. The scan detected three anterior mediastinal adenomas that could not be removed through cervical exploration. In each instance median sternotomy was included in the primary surgery and allowed efficient, successful management of these ectopic adenomas. High-resolution ultrasound correctly identified nine of 10 cervical parathyroid adenomas and predicted the volume of each tumor to a statistically significant level. CONCLUSIONS: Hyperthyroidism has traditionally been treated surgically without preliminary localization studies. We found both technetium Tc 99m sestamibi scanning and high-resolution ultrasound to be highly sensitive at detecting parathyroid adenomas at the 90% level. Furthermore, preoperative localization allowed efficient surgical intervention for our group of patients who had high frequency of mediastinal adenomas that required transmediastinal surgery.

Adenoma↗
PubMed1996

Biology of metastases and its clinical implications: testicular germ-cell tumors.

This article deals with observations of the clinical behavior of metastatic germ cell cancers of testicular origin. Therefore, when we speak of biology of metastases, we refer to that seen by the clinician as opposed to the laboratory scientist. First, we will review our experience with chemotherapy for metastatic disease. From this we can gain insight into risk factors for relapse and survival. Furthermore, we can infer there are fundamental differences in the biology of germ cell cancers of testicular origin as opposed to primary mediastinal or primary retroperitoneal origin. Some of these differences are further discussed. We also identify "good risk" parameters and suggest criteria for expectant or conservative management postchemotherapy instead of postchemotherapy surgical management. Second, the diversity of metastases as evidenced by a wide histologic spectrum, is discussed in clinical terms. Among topics discussed are non-germ-cell malignant elements found within metastatic germ cell tumors, and possible mechanisms for their emergence. Third, the increasing awareness of long delayed, late relapse and its relative refractoriness to chemotherapy gives further insight into the clinical biology of metastatic germ cell cancer. The multipotential nature of the germ cell results in a wide variety of metastatic subtypes, each with its own clinical behavior. Therefore, a variety of clinical management strategies may be required based upon these different clinical behaviors.

Germinoma↗
PubMed1996

Cost- and risk-benefit considerations in the management of clinical stage I nonseminomatous testicular tumors.

BACKGROUND: The high curability of clinical stage I nonseminomatous germ cell tumors (NSGCTs) and the availability of equally effective management options (retroperitoneal lymph node dissection [RPLND] and surveillance) allows for treatment decisions based on secondary end points, including sort- and long-term toxicity and cost relative to benefit. The purpose of this study was to perform cost-benefit and risk-benefit analyses of management options in clinical stage I NSGCT using data from the literature and Indiana University. METHODS: The overall costs for 100 patients undergoing a primary RPLND were compared with the total costs of 100 patients managed by surveillance for clinical stage I disease. These two options were then analyzed in terms of survival, late relapse, acute and chronic toxicity (including fertility), and perioperative morbidity. RESULTS: The overall costs of these two approaches were essentially identical. The two options were similar in terms of survival, although RPLND demonstrated superiority in terms of fertility, toxicity, and late relapse. CONCLUSIONS: The choice of nerve-sparing RPLND or surveillance in clinical stage I NSGCT patient cannot be made on the basis of cost as a discriminator. Instead, the decision should be made based on patient desires, physician expertise, biological predictors, and short- and long-term toxicity.

Combined Modality Therapy↗
PubMed1996

Tumor proliferative activity is predictive of pathological stage in clinical stage A nonseminomatous testicular germ cell tumors.

PURPOSE: Traditional histopathological features have failed to predict accurately the pathological stage of clinical stage A nonseminomatous germ cell tumors of the testis. Based on pilot studies in nonconsecutive patients at our university, we evaluated nontraditional risk factors (cell cycle analysis by flow cytometry, deoxyribonucleic acid analysis by single cell cytophotometry [image analysis] and assessment of proliferative activity by immunohistochemistry) combined with histopathological features in consecutive patients with clinical stage A nonseminomatous testis cancer. MATERIALS AND METHODS: Orchiectomy specimens from 105 consecutive patients with clinical stage A nonseminomatous germ cell tumors who underwent retroperitoneal lymph node dissection (76 with pathological stage A disease and 29 with proved metastasis) were recut, histopathologically reviewed, immunohistochemically stained with proliferation markers (for example Ki-67/MIB-1), and examined by flow cytometry and image analysis. RESULTS: After multiple logistic regression analysis, the G2M+S cell cycle fraction of the aneuploid tumor stemline was the most predictive parameter of pathological stage (p = 0.0004). Using a cutoff of 41%, patients with metastasis were predicted with a sensitivity of 71%. Of 61 patients with a G2M+S value of less than 41%, 53 had pathological stage A cancer (negative predictive value 87%). A low volume of embryonal carcinoma was predominant in patients at low risk for metastasis and MIB-1 immunohistochemical staining identified 23% of patients with pathological stage A tumor who were at extremely low risk for metastatic disease. CONCLUSIONS: Assessment of tumor cell proliferation cannot classify accurately high risk patients at a clinically applicable level. However, identification of patients at low risk for metastasis by flow cytometry, immunohistochemical proliferation markers and volume of embryonal carcinoma may be possible at the 90% level. MIB-1 staining is able to classify patients at extremely low risk for metastasis. These parameters deserve further study, since identification of patients at extremely low risk for metastasis could potentially decrease overall morbidity in the management of clinical stage A nonseminomatous testis cancer.

Cell Division↗
PubMed1996

The management of patients with clinical stage I nonseminomatous testicular tumors and persistently elevated serologic markers.

PURPOSE: We reviewed our experience with patients who had nonseminomatous germ cell tumors clinically limited to the testis and persistently elevated serum human chorionic gonadotropin (HCG) or alpha-fetoprotein (AFP) levels after orchiectomy. MATERIALS AND METHODS: All patients had clinical stage I disease with persistently elevated tumor markers that were not decreasing in accordance with the expected metabolic decay rate at retroperitoneal lymph node dissection. RESULTS: Of 30 patients identified 3 had elevated AFP, 24 had elevated HCG and 3 had elevation of both markers. Of the 6 patients with elevated AFP with or without concurrent HCG elevation 5 (83%) had relapse and required chemotherapy, as did 6 of 24 (25%) with HCG elevation. CONCLUSIONS: Patients with persistently elevated AFP after orchiectomy should be treated initially with chemotherapy. Although the majority of patients with elevated serum HCG were disease-free after surgery alone, a fourth of these patients still had relapse and required chemotherapy.

Adolescent↗
PubMed1996

Spinal cord ischemia after post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous germ cell cancer.

PURPOSE: We report and analyze several cases of neurological deficit after post-chemotherapy retroperitoneal lymph node dissection that were though to be related to spinal cord ischemia. MATERIALS AND METHODS: We searched the testis cancer data base at our university, which includes 1,447 retroperitoneal lymph node dissections performed from 1982 to 1994, to identify patients who had postoperative neurological complications. The history and clinical course of patients suspected to have spinal cord ischemia were reviewed and potential risk factors were analyzed. RESULTS: The incidence of spinal cord ischemia after post-chemotherapy retroperitoneal lymph node dissection was 0.56% (4 of 712 patients). CONCLUSIONS: Spinal cord ischemia may complicate the course of post-chemotherapy retroperitoneal lymph node dissection in testis cancer patients. Older age, extensive retroperitoneal dissection, prior therapy and certain anesthetic parameters may predispose nonseminomatous germ cell tumor patients to spinal cord ischemia. These risk factors may be used to define a subset of high risk patients, and active measures should be taken in an attempt to minimize the frequency of spinal cord ischemia in these patients.

Adult↗
PubMed1996

Delayed orchiectomy after chemotherapy for metastatic nonseminomatous germ cell tumors.

PURPOSE: We reviewed current experience at our university with delayed orchiectomy after chemotherapy in patients with metastatic nonseminomatous germ cell tumors. MATERIALS AND METHODS: We retrospectively analyzed the records of 160 patients with metastatic germ cell cancer who were given systemic chemotherapy, and subsequently underwent orchiectomy and retroperitoneal lymph node dissection. RESULTS: Analysis of 160 testicular specimens revealed necrosis or scar in 70 (43.7%), pure teratoma in 50 (31.2%) and persistent germ cell cancer in 40 (25%). Corresponding incidences of histopathological findings in the post-chemotherapy retroperitoneal lymph node dissection specimens were significantly different, correlating with less than half of the cases (chi-square, p = 0.002). CONCLUSIONS: Our study confirms the need for delayed orchiectomy after systemic chemotherapy even when there seems to be a partial or complete clinical response at other sites.

Adolescent↗