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Biomedical subjects

Richard J Bold

Publications and source records attributed to Richard J Bold.

28 records · Page 2Linked to original sources
PubMed2003

Dermatofibrosarcoma protuberans: reappraisal of wide local excision and impact of inadequate initial treatment.

BACKGROUND: The extent of local invasion in dermatofibrosarcoma protuberans (DFSP) is often clinically difficult to appreciate, and this leads to inadequate resections. We examined the effect of inadequate initial treatment and the efficacy of wide resection. METHODS: We performed a retrospective analysis of the records of 35 patients with DFSP treated at our institution (1985 and 2001). Data were analyzed with Wilcoxon's ranked sum test and Fisher's exact test. RESULTS: Of the 24 patients eligible for analysis, 11 had definitive wide resection after diagnostic excisions elsewhere (primary group), and 13 had recurrent tumors after previous surgical treatment elsewhere (recurrent group). Twenty-three patients were treated with wide resection only, and adjuvant radiation was administered to one patient who had a fibrosarcoma. At a median follow-up of 54 months, patients definitively treated at our institution had a 100% local recurrence-free survival. In comparison to the primary group, recurrent DFSPs were significantly larger and deeper and occurred in the head and neck region. Five cases had bone involvement, and of these, 80% occurred in the recurrent group. CONCLUSIONS: Inadequate initial treatment results in larger, deeper recurrent lesions, but these can be managed by appropriate wide excision. Wide resection of DFSP (whether recurrent or primary) with negative histological margins predicts a superior local recurrence-free survival.

Adolescent↗
PubMed2002

Multimodality management of a giant cell tumor arising in the proximal sacrum: case report.

STUDY DESIGN: Descriptive. OBJECTIVE: To outline a novel multimodality approach for a difficult surgical resection of a giant cell tumor in the cephalad portion of the sacrum. SUMMARY OF BACKGROUND DATA: Giant cell tumors of the sacrum are rare primary bone tumors. Recent reports have demonstrated diminished giant cell tumor recurrence with cryosurgery by using a "direct pour" technique with liquid nitrogen. Although successful in decreasing tumor recurrence, this technique is accompanied by a 4%-8% rate of skin necrosis and high rates of pathologic fracture. The authors describe resection and a novel, controlled method of argon-based cryotherapy (followed by a unique pelvic reconstruction) for a large, difficult giant cell tumor of the sacrum. METHODS: A 29-year-old woman presented with complaints of right foot drop and decreased sensation of the right buttock, posterior thigh, posterior calf, and lateral aspect of the right foot. Radiographic evaluation revealed a mass in the right sacrum; histologic examination of CT-guided biopsy revealed a giant cell tumor. A combined anterior abdominal and posterior sacral approach was performed, the tumor was resected, and the margin of the cavity was treated with controlled argon-based cryotherapy. The combination of thermocouples, electromyographic monitoring, and rapid freeze-thaw cycles allowed a controlled ablation of the tumor margin while ensuring that surrounding structures, such as the rectal wall, sacral nerves, and gluteal muscles, were not damaged. Posterior spinal fusion L4 to sacrum, posterior spinal instrumentation L4 to pelvis, and allograft reconstruction of the right sacrum were performed. RESULTS: The patient recovered well without skin necrosis or pathologic fracture. Urinary and fecal continence were preserved. At the 20-month follow-up the patient has no evidence of local tumor recurrence and is fully ambulatory without a brace or narcotic medication. CONCLUSION: A novel multimodality approach, consisting of resection, controlled cryosurgery, and a unique lumbopelvic reconstruction, was safe and successful in managing a challenging proximal sacral giant cell tumor. Twenty months after surgery the patient has excellent bowel and bladder control, no tumor recurrence, and functional ambulation without a brace or pain.

Adult↗
PubMed2002

Modern parathyroid surgery: a cost-benefit analysis of localizing strategies.

HYPOTHESIS: Preoperative and intraoperative localizing techniques are more cost-effective than a nondirected bilateral neck exploration in the initial treatment of primary hyperparathyroidism (HPT). DESIGN: A clinical outcome model was developed to simulate the surgical management of primary HPT. Clinical scenarios modeled included a nondirected bilateral neck exploration and surgery using the following localizing strategies: preoperative technetium Tc 99m sestamibi scanning, intraoperative "quick" intact parathyroid hormone assay, or intraoperative radioguidance. Average total charges based on intent to treat were estimated from our practice and from the literature. MAIN OUTCOME MEASURES: Average total charges per patient (for the primary operation and for reexploration for persistent HPT, if needed), incidence of surgical failure (ie, persistent HPT), and risk of recurrent laryngeal nerve injury (cumulative risk of the primary procedure and a subsequent operation for persistent HPT). RESULTS: The use of any localizing strategy reduced total charges, risk of persistent HPT, and cumulative risk of recurrent laryngeal nerve injury compared with a nondirected bilateral neck exploration. The greatest cost savings and the lowest risk of recurrent laryngeal nerve injury were achieved when technetium Tc 99m sestamibi scanning was combined with intraoperative radioguidance. The lowest rate of persistent HPT was found when technetium Tc 99m sestamibi scanning was combined with an intraoperative parathyroid hormone assay. CONCLUSIONS: Limited parathyroid surgery using any localizing strategy is cost-effective, safe, and efficacious in the management of primary HPT. The cost benefit was primarily achieved by reduced operative charges and immediate hospital discharge rather than a lower need for reexploration for persistent HPT.

Cost Savings↗
PubMed2002

Controlled tamponade of severe presacral venous hemorrhage: use of a breast implant sizer.

Hemorrhage from the presacral venous plexus is a potentially life-threatening complication of pelvic operations. The morbidity and mortality that stems from severe hemorrhage has led to the development of various hemostatic techniques. Although suture ligature, packing, and placement of tacks can be very effective, they can often be unsuccessful. When these conventional hemostatic techniques fail, alternative approaches are required. We describe the successful use of an expandable breast implant sizer and outline the practical, theoretical, and financial advantages of applying this technique when more conservative approaches have failed.

Balloon Occlusion↗
PubMed2002

Morbidity, mortality, and technical factors of distal pancreatectomy.

BACKGROUND: Pancreatic leak is a major source of morbidity associated with pancreatic surgery. We sought to identify disease and technique-dependent factors associated with morbidity and mortality after distal pancreatectomy. METHODS: Retrospective review of patients who underwent distal pancreatectomy during a 5-year period. Clinical, technical, and pathologic data were correlated with operative morbidity or mortality. RESULTS: Fifty-one patients underwent distal pancreatectomy for primary pancreatic disease, extrapancreatic malignancy, or trauma. Overall perioperative mortality and morbidity rates were 4% and 47%, respectively. Pancreatic leak was the most common complication, occurring in 26% of patients. Overall complications and pancreatic leaks occurred more often after distal pancreatectomy for trauma and in patients with a sutured pancreatic stump closure. CONCLUSIONS: Distal pancreatectomy can be performed with a low rate of mortality, though pancreatic leak is a common cause of morbidity. The urgency of the procedure and the method of pancreatic stump closure may influence postoperative morbidity.

Adolescent↗
PubMed2002

Percutaneous transhepatic portography with intravascular ultrasonography for evaluation of venous involvement of hepatobiliary and pancreatic tumors.

PURPOSE: To determine the safety and utility of percutaneous transhepatic portography (PTP) with intravascular ultrasonography (IVUS) for preoperative evaluation of major spleno-mesenteric-portal venous invasion by tumors of the pancreas, porta hepatis, or liver. MATERIALS AND METHODS: This is a 2-year prospective observational study including 15 consecutive patients (five men, 10 women; mean age, 63.3 y +/- 10.2) with tumors of the pancreas (n = 8), liver (n = 3), or porta hepatis (n = 4) who underwent PTP/IVUS after computed tomography indicated possible tumor invasion into a major portal radical. Transhepatic portal access was created under fluoroscopic guidance with an 8-F vascular sheath and IVUS was performed with an 8-F, 10-MHz system. When appropriate, operative exploration was performed (nine of 15) and findings were correlated with imaging data from PTP/IVUS. RESULTS: PTP/IVUS was performed successfully in all patients and good visualization of the major portal radicals was achieved. There were no complications from PTP/IVUS, which was performed as an outpatient procedure in most (n = 14) patients. PTP/IVUS provided precise anatomic data regarding the longitudinal and circumferential extent of major portal venous invasion by these tumors. There was excellent correlation between PTP/IVUS and operative findings. CONCLUSIONS: PTP/IVUS can be performed safely in a preoperative outpatient setting and accurately defines the extent of major portal venous invasion by tumors of the pancreas, porta hepatis, and liver.

Female↗
PubMed2002

Surgical management of breast cancer: today and tomorrow.

The surgeon continues to play a key role in the initial local/regional management of breast cancer. Breast conserving therapy (BCT) utilizing segmental mastectomy has been developed as an alternative to total mastectomy to improve cosmetic and psychosocial outcomes while retaining oncologic benefits. Developments in the surgical treatment of breast cancer have changed the way breast cancer is diagnosed and treated, and will likely continue to evolve in the future. This review highlights aspects of breast cancer treatment in which the surgical approach has evolved or is evolving, and comments on how the surgeon may participate in breast cancer care in the future.

Breast Neoplasms↗
PubMed2002

Symptomatic pancreatic polypeptide-secreting tumor of the distal pancreas (PPoma).

Our report describes a 46-yr-old woman who presented with watery diarrhea in the presence of multiple endocrine neoplasia type I (MEN I) syndrome. Of various potential pancreatic endocrine hormones, only serum levels of pancreatic polypeptide were elevated. Radiologic imaging failed to identify a pancreatic tumor; her diarrhea was therefore managed with subcutaneous administration of somatostatin. Three years later she developed gallstone pancreatitis with the subsequent development of a pancreatic pseudocyst. At exploration for drainage of the pseudocyst, intraoperative ultrasound identified a 6-mm tumor in the distal pancreas that was resected. Final pathology documented a pancreatic endocrine tumor with immunohistochemical staining demonstrating the presence of pancreatic polypeptide. The present case illustrates the symptomatology that may be associated with pancreatic polypeptide-secreting endocrine tumors of the pancreas.

Cholelithiasis↗
PubMed2002

Effects of the proteasome inhibitor PS-341 on apoptosis and angiogenesis in orthotopic human pancreatic tumor xenografts.

Recent studies have shown that the transcription factor, nuclear factor kappaB (NF-kappaB), regulates critical survival pathways in a variety of different cell types, including human pancreatic cancer cells. The activation of NF-kappaB is controlled by proteasome-mediated degradation of its endogenous polypeptide inhibitor, inhibitor of nuclear factor kappaBalpha. We investigated the effects of PS-341, a peptide boronate inhibitor of the proteasome in human pancreatic cancer cells in vitro and in vivo. Comparison of PS-341's effects on the growth of eight different human pancreatic cancer cell lines revealed marked heterogeneity in drug responsiveness, ranging from highly resistant (IC50 > 10 microM; Panc-48, HS766T, and Mia-PaCa-2) to extremely sensitive (IC50 < 40 nM; L3.6pl, Hpaf2, and BxPC3). However, these effects did not correlate with differential inhibition of NF-kappaB activation. Direct quantification of apoptosis revealed that PS-341's effects on cell growth largely correlated with sensitivity to programmed cell death. Evaluation of PS-341's effects on established orthotopic tumor xenografts demonstrated that biweekly intravenous administration of the maximum-tolerated dose of the drug (1 mg/kg) led to significant reductions in the volumes of L3.6pl tumors but not Mia-PaCa-2 tumors. Laser scanning cytometer-mediated quantification of drug-induced apoptosis in the xenografts confirmed that PS-341 induced DNA fragmentation and activation of caspase-3 in L3.6pl tumors but not in Mia-PaCa-2 tumors. However, histological examination of drug-treated tumors revealed extensive central necrosis and reductions in microvessel density and VEGF expression in both tumor types. Taken together, our results demonstrate that PS-341 inhibits the growth of human pancreatic tumors via direct effects on tumor cells and indirect effects on the tumor vasculature.

Animals↗