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PubMed2006

Aggressive multimodality treatment in transitional cell carcinoma of the parafallopian tube: report of 2 cases and review of the literature.

BACKGROUND: Primary carcinoma of the fallopian tube is a rare and aggressive cancer. Information regarding its epidemiologic, biologic, and prognostic characteristics is limited; consequently, no standard treatment has been developed. We report the case histories of 2 women with transitional cell carcinoma (TCC) of the parafallopian tube treated with aggressive multimodality therapy, and the literature is reviewed. CASES: Two women presented with stage IIB TCC of the parafallopian tube. Both were treated with cytoreductive surgery followed by adjuvant intravenous chemotherapy with cisplatin, gemcitabine, and paclitaxel. Our consolidation treatment consisted of intraperitoneal chemotherapy using the same agents, and 1 patient also received additional hyperthermic chemotherapy with docetaxel. Both patients remain free of disease. CONCLUSION: In these 2 cases, an aggressive, multimodality regimen proved to be feasible and effective in treating TCC of the parafallopian tube.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2006

Synovial cell sarcoma of the vulva: multimodality treatment incorporating preoperative external-beam radiation, hemivulvectomy, flap reconstruction, interstitial brachytherapy, and chemotherapy.

BACKGROUND: Vulvar synovial cell sarcomas are rare, with only four previously published cases in the literature. Traditionally, the primary management for these tumors has been surgery alone. CASE: We report a case of a large vulvar synovial cell sarcoma in a 50-year-old woman treated with comprehensive combined multimodality management, including preoperative intensity-modulated radiation therapy, radical hemivulvectomy, flap reconstruction, interstitial low-dose-rate brachytherapy boost, and adjuvant chemotherapy. CONCLUSION: Based on this case and the limited data in the literature, multimodality treatment of advanced soft tissue sarcoma of the vulva may optimize local control and minimize toxicity while preserving sexual function.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1994

Bone scintigraphy and multimodality imaging in bone neoplasia: strategies for imaging in the new health care climate.

The integration of multiple imaging modalities in the assessment of musculoskeletal neoplasia is complex. Although no two instances are identical, certain guidelines can be gleaned from our experience as well as that reported in the literature. Assessment of most soft tissue masses is best carried forth with a combination of conventional radiography and magnetic resonance imaging (MRI). Screening skeletal scintigraphy without localizing symptomatology that includes axial and appendicular skeleton is best carried out initially with bone scintigraphy. Screening the axial skeleton in the presence of clinical symptomatology or a strong suspicion of axial skeletal metastases or pathology is best implemented as a total spine screening examination with MRI and specialized pulsing sequences. Computed tomography is reserved primarily for assessment of cortical and juxtacortical lesions, fracture fragment positioning and/or configuration, and characterization of lesion matrix calcification or ossification when conventional radiographs are indeterminate. Although physical examination and conventional radiography still remain the initial medical algorithms used to evaluate possible musculoskeletal neoplasia, primary skeletal tumors may require multimodality imaging to segregate aggressive and nonaggressive processes. In this multimodality scenario, bone scintigraphy has a critical role in assisting with differentiation between malignant and benign neoplasms.

Bone Neoplasms↗
PubMed2002

Effect of a multimodality natural medicine program on carotid atherosclerosis in older subjects: a pilot trial of Maharishi Vedic Medicine.

Although the onset and progression of coronary heart disease (CHD) involve multiple risk factors, few intervention studies have attempted to modify these factors simultaneously. This pilot study tested the effect of a multimodality intervention involving dietary, exercise, herbal food supplement, and stress reduction approaches from a traditional system of natural medicine, Maharishi Vedic Medicine (MVM). The primary outcome measure was carotid intima-media thickness (IMT), a noninvasive measure of peripheral atherosclerosis and surrogate measure of coronary atherosclerosis. Comparison groups included modern medicine (conventional dietary, exercise, and multivitamin approaches) and usual care (no added intervention). Of 57 healthy seniors (mean age 74 years) randomized to the 3 treatment groups, 46 completed IMT post-testing. Carotid IMT was determined by B-mode ultrasound before and after 1 year of treatment. IMT decreased in a larger fraction of MVM subjects (16 of 20) than in the modern (5 of 9) and usual care (7 of 14) groups combined (i.e., 12 of 23; odds ratio 3.7, p = 0.05). For subjects with multiple CHD risk factors ("high-risk" subjects, n = 15), IMT decreased more in the MVM (-0.32 +/- 0.23 mm, mean +/- SD) than in the usual care (+0.022 +/- 0.085; p = 0.009) or modern (-0.082 +/- 0.095, p = 0.10) groups. Within-group reductions in IMT were significant for all MVM subjects (-0.15 +/- 0.21, n = 20, p = 0.004) and for high-risk MVM subjects (n = 6, p = 0.01). These results show that this multimodality traditional approach can attenuate atherosclerosis in older subjects, particularly those with marked CHD risk.

Aged↗
PubMed1996

Reliability of multimodal evaluation of abnormal screening mammogram results.

OBJECTIVE: Our purpose was to evaluate the effectiveness and reliability of the multimodal evaluation of suspicious or equivocal screening mammogram results by use of ancillary imaging studies and needle biopsies. STUDY DESIGN: This article reports on the experience of the Breast Evaluation Center at Long Beach Memorial Medical Center between 1989 and 1993 where 43,125 screening mammograms were performed. RESULTS: A total of 2866 patients were called back for additional evaluation, which consisted of magnification views and ultrasonography. Since 1990 fine-needle biopsies have been done on selected patients and since 1992 core biopsies have been available. Needle localization excisional biopsies were performed on 344 patients, and 158 cancers were diagnosed. This represents a 46% positive predictive value. Careful follow-up was obtained on the patients seen in 1990 to attempt to determine whether any cancers developed within a year of the time the patients with abnormal screening mammogram results had been evaluated with imaging modalities but no tissue diagnosis made. One cancer may have been missed. The cost savings of this protocol are also examined. CONCLUSION: Multimodal evaluation of patients with suspicious screening mammogram results appears to be a cost effective approach with adequate sensitivity and specificity.

Biopsy, Needle↗
PubMed2002

Multimodal strategies to improve surgical outcome.

OBJECTIVE: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures. BACKGROUND: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated. METHODS: We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach. RESULTS: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs. CONCLUSIONS: Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

Anesthesia, Epidural↗
PubMed2001

Aggressive multimodal treatment of pleuropulmonary blastoma.

Pleuropulmonary blastoma is a rare intrathoracic neoplasm almost solely confined to childhood. Survival is poor. The authors report 2 children with extensive intrathoracic disease who are long term survivors after multimodal therapy. Both children received multiagent neoadjuvant chemotherapy, followed by surgical resection to remove all gross tumor. Postoperative chemotherapy was given to both children; radiotherapy was also given in the second case because of a question of positive tumor margins. Experience supports the use of multimodal therapy, including an aggressive surgical approach in the potentially curative treatment of this tumor.

Child↗
PubMed1994

The impact of adjuvant nephrectomy on multimodality treatment of metastatic renal cell carcinoma.

Multimodality treatment of metastatic renal cell carcinoma with biological response modifiers and cytoreductive surgery has produced durable responses. The timing and impact of cytoreductive surgery on the success of immunotherapy require further study. We reviewed the treatment of 62 patients with metastatic renal cell carcinoma and primary tumors in place who qualified for multimodality treatment comprising adjuvant nephrectomy and biological response modifier protocols at our institution between 1987 and 1992. Of the patients 37 were scheduled to undergo initial adjuvant nephrectomy followed by biological response modifier therapy. A total of 25 patients underwent initial biological response modifier therapy with planned delayed adjuvant nephrectomy if a response to treatment was demonstrated. Of the 37 patients undergoing initial adjuvant nephrectomy, 8 (22%) were unable to enter induction of immunotherapy because of perioperative complications (1), medical contraindications (2), tumor progression (4) or death (1). Three patients in the initial adjuvant nephrectomy group (8%) had a partial response and the median survival in this group was 12 months (range 1 to 57). In the initial biological response modifier group 3 patients (12%) with an objective response (2 complete and 1 partial) to biological response modifier therapy underwent nephrectomy. The median survival for the initial biological response modifier group was 14 months (range 1 to 48). These results add to our understanding of the impact of adjuvant nephrectomy on patients with metastatic renal cell carcinoma considered for immunotherapy protocols.

Adult↗
PubMed2002

Multimodality management of locally recurrent colorectal cancer.

The combined management of locally recurrent colorectal cancer shows considerable promise, but the best way to incorporate the different treatment modalities and the potential benefits remain uncertain. The case series mentioned here were derived from highly selected groups from a much larger population of patients with recurrent disease; thus fully combined management may be only appropriate for a minority of people with recurrent disease. There is a need for multicenter randomized trials to better delineate the real benefits from the combined approach. Multimodality management of recurrent colorectal cancer, however, involves more than the combination of surgery, radiation therapy, and chemotherapy for a select minority of resectable patients. It involves the use of each modality to its greatest advantage for all patients, as determined by a multidisciplinary team of specialists. We should also not confine our attention to the treatment aspects of recurrent disease alone, as the greatest promise for improved survival could be with a more general application of total mesorectal excision. Because most people who develop local recurrence of colorectal cancer will die from their disease, the main contribution of a multimodality approach may be towards palliation.

Chemotherapy, Adjuvant↗
PubMed1995

Nuclear morphometric analysis of metastasis in Wilms' tumor after multimodal therapy: comparison with primary tumor.

OBJECTIVES: The outlook for children with Wilms' tumor has improved with the use of multimodal therapy, and survival rates now exceed 85%. Yet, 15% of children with tumors with favorable histologic findings continue to recur unpredictably. We previously reported that nuclear morphometry (the distribution of nuclear roundness factor [NRF], lowest values for ellipticity, and age) when combined in a multivariate analysis accurately predicted response to therapy for patients with histologically favorable Wilms' tumors. METHODS: To investigate further the nuclear shape changes associated with disease recurrence, we analyzed histologic sections taken from primary tumors and postmultimodal therapy metastatic lesions for 7 children who had a recurrence with initially histologically favorable primary tumors. RESULTS: Mean NRF was significantly lower (P = 0.0001) in the metastatic lesion (35 +/- 5) group when compared with the primary tumor group (50 +/- 5). The percent coefficient of variation for NRF was also significantly lower (P = 0.006) in the metastatic lesion when compared with the primary tumor. Nuclear area was increased (P = 0.02), although the nuclear perimeter was unchanged (P = 0.1). CONCLUSIONS: (1) Nuclei in metastatic lesions from Wilms' tumors with favorable histologic findings after multimodal therapy are more round and exhibit less variable distribution, suggesting clonal homogeneity within the metastatic lesion. (2) Nuclei in the metastatic lesions have greater area than in the primary tumors yet have an unchanged perimeter, which may be due to internal nuclear expansion secondary to increased cellular deoxyribonucleic acid (DNA) ploidy. Although the results of this study are promising, we are currently extending this hypothesis to a larger group of patients.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1999

A multimodal approach in the diagnosis of patients with hematopoietic disorders.

Myelodysplastic syndromes (MDS) are a group of relatively ill-defined hematopoietic disorders in which both qualitative and quantitative defects of the hematopoietic cells cause bone marrow dysfunction. With an incidence estimated to be approximately 1 per 100,000 persons per year, MDS mainly affects the elderly. Myelodysplastic syndromes share many features with acute nonlymphocytic leukemia; in fact, a proportion of patients with MDS eventually develop acute myeloid leukemia. To illustrate a multimodal approach in the diagnosis of patients with hematopoietic disorders, we describe a 66-year-old patient with a question of myelodysplastic syndrome, leukemia, and two translocations involving chromosome 10:t(5;10) and t(7;10). These structural rearrangements effectively gave rise to monosomy for part of the long arm of chromosome 5 and for the long arm of chromosome 7. Findings of del(5q) and del(7) in MDS have been reported in the literature. The results of chromosome morphometry, which was conducted to compare the lengths of all relevant chromosome segments, are consistent with the hypothesized chromosomal abnormalities. The investigational technique of fluorescence in situ hybridization (FISH), using both painting and alpha-satellite probes, was used as an adjunct to conventional cytogenetics to further delineate the nature of the chromosome abnormalities observed in the GTG-banded studies. Confirmatory studies utilizing the new technique of spectral karyotyping (SKY) were also carried out. Thus, the multimodal approach of hematopathology, GTG-banding, chromosome morphometry, FISH, and SKY can be very useful for delineating complex cytogenetic cases.

Bone Marrow↗
PubMed2001

Hypothyroidism incidence after multimodality treatment for stage III and IV squamous cell carcinomas of the head and neck.

PURPOSE: Treatment of head-and-neck cancer patients with surgery, radiotherapy (RT), and chemotherapy has been associated with posttherapy hypothyroidism (HT). We evaluated the rate of posttherapy HT in patients with locally advanced squamous cell carcinoma of the head and neck, treated with multimodality therapy to determine which factors might predict this condition and at what interval the condition developed. METHODS: We reviewed the prospectively collected thyroid function data of patients treated with sequential chemotherapy, RT, and neck dissection. The incidence of posttherapy HT was estimated. The patient, tumor, and treatment factors possibly associated with HT were evaluated. RESULTS: Of 203 patients, 118 had data adequate for evaluation. HT developed in 45% at a median of 24.4 months after therapy. HT occurred in 14% and 27% of patients at 6 months and 1 year after treatment, respectively. Univariate and multivariate analyses of sex, age, RT dose, RT fractionation, T and N stage, tumor site, and neck dissection failed to identify a clinically relevant risk factor. CONCLUSIONS: A high number of patients undergoing aggressive organ-sparing multimodality therapy for advanced squamous cell carcinoma of the head and neck are at risk for subsequent HT. We recommend that all patients definitively irradiated to the head and neck region undergo frequent serum thyroid-stimulating hormone screening for HT, beginning 6 months after RT.

Analysis of Variance↗
PubMed2002

Effects on functional outcome after IORT-containing multimodality treatment for locally advanced primary and locally recurrent rectal cancer.

PURPOSE: In the treatment of patients with locally advanced primary or locally recurrent rectal cancer, much attention is focused on the oncologic outcome. Little is known about the functional outcome. In this study, the functional outcome after a multimodality treatment for locally advanced primary and locally recurrent rectal cancer is analyzed. METHODS AND MATERIALS: Between 1994 and 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with high-dose preoperative external beam irradiation, followed by extended surgery and intraoperative radiotherapy. To assess long-term functional outcome, all patients still alive (n = 97) were asked to complete a questionnaire regarding ongoing morbidity, as well as functional and social impairment. Seventy-six of the 79 patients (96%) returned the questionnaire. The median follow-up was 14 months (range: 4-60 months). RESULTS: The questionnaire revealed fatigue in 44%, perineal pain in 42%, radiating pain in the leg(s) in 21%, walking difficulties in 36%, and voiding dysfunction in 42% of the patients as symptoms of ongoing morbidity. Functional impairment consisted of requiring help with basic activities in 15% and sexual inactivity in 56% of the respondents. Social handicap was demonstrated by loss of former lifestyle in 44% and loss of professional occupation in 40% of patients. CONCLUSIONS: As a result of multimodality treatment, the majority of these patients have to deal with long-term physical morbidity, the need for help with daily care, and considerable social impairment. These consequences must be weighed against the chance of cure if the patient is treated and the disability eventually caused by uncontrolled tumor progression if the patient is not treated. These potential drawbacks should be discussed with the patient preoperatively and taken into account when designing a treatment strategy.

Adult↗
PubMed1998

The importance of postoperative radiation therapy in multimodality management of locally advanced breast cancer: a phase II trial of neoadjuvant MVAC, surgery, and radiation.

PURPOSE: To determine the impact of postoperative radiation on locoregional relapse and overall survival rate in a multimodality protocol for locally advanced breast cancer (LABC). MATERIAL AND METHODS: Of the patients entered in the protocol, 55 were evaluable. Treatment consisted of: neoadjuvant MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) until a maximum response had been achieved; modified radical mastectomy; 6 courses of postoperative adjuvant MVAC chemotherapy, and chest wall irradiation (CWXRT). Multivariate analysis of locoregional response and overall survival was done. RESULTS: Of the total, 42 patients received chest wall radiation; 28 of these also received radiation to regional lymph nodes. Chest wall doses ranged from 45 Gy to 50.4 Gy to the whole chest wall, with 31 patients receiving an additional chest-wall boost. The incidence of locoregional relapse with and without radiation was 7% vs. 31%, respectively (p = 0.026). An overall survival benefit was seen in those receiving radiation, with a mean overall survival of 50 months vs. 20 months, and a 3-year overall survival of 88% vs. 46% with and without radiation, respectively (p = 0.003). Multivariate analysis showed that overall survival was affected by the presence of pathological CR (p = .047), the number of pre-operative chemotherapy cycles (p = .036) and whether or not they received radiation (p = 0.003). Neither the interval between surgery and radiation, technique of radiation, nor radiation modality significantly affected local control. CONCLUSION: The significant improvement in local regional control and overall survival with the addition of radiation suggests that radiation should be an integral part of multimodality management of locally advanced breast cancer.

Adult↗
PubMed2000

Feasibility and first results of multimodality treatment, combining EBRT, extensive surgery, and IOERT in locally advanced primary rectal cancer.

PURPOSE: To assess the outcome of aggressive multimodality treatment with preoperative external beam radiation therapy (EBRT), extended circumferential margin excision (ECME) and intraoperative electron beam radiation therapy (IOERT) in patients with locally advanced primary rectal cancer. METHODS AND MATERIALS: Thirty-eight patients with primary locally advanced rectal cancer, but without distant metastases, received multimodality treatment. CT-scan showed extension to other structures in 15 patients (39%) and definite infiltration into the surrounding structures in 23 patients (61%). All patients received preoperative EBRT (dose range 25-61 Gy) and 82% received 50.4 Gy. The resection types were: 12 low anterior resections (31%), 14 abdomino-perineal resections (37%), 6 abdomino-transsacral resections (16%), and 6 pelvic exenterations (16%). The IOERT dose ranged from 10 to 17.5 Gy depending on the completeness of the resection. RESULTS: There was no perioperative mortality. The resection margins were microscopically negative in 31 patients (82%), microscopically positive in 4 (10%), and positive with gross residual disease in 3 patients (8%). Pelvic recurrences were observed in 5 patients (13%) including 3 IOERT infield failures. The overall 3-year local control, disease-free survival (DFS), and survival rates were 82%, 65%, and 72%, respectively. Negative resection margins were the most significant prognostic factor with regard to DFS (p = 0.0003) and distant control (p = 0.002) compared with cancer involved surgical margins. CONCLUSION: A high percentage of curative resections can be achieved in this group of patients with locally advanced rectal cancers. Adding IOERT to preoperative EBRT and ECME achieves high local control rates and possibly improves survival.

Adult↗
PubMed1997

A three-dimensional multimodality brain map of the nemestrina monkey.

A three-dimensional multimodality computerized map of the nemestrina monkey brain was created with serial sectioning and digital imaging techniques. An adult female Macaca nemestrina (pigtail macaque) weighing 7.2 kg was used in constructing this atlas. CT, PET, and MRI were performed on the monkey before the specimen's head was frozen and cryoplaned. Closely spaced (50 microns) images of the specimen blockface were then digitally acquired and modified to produce whole head and brain-only 3D image sets. The resulting data sets were organized into a digital volume and repositioned into a stereotaxic coordinate system defined by Horsley and Clark in 1908 [7]. Orthogonal images were obtained by digitally resampling the volume in order to produce a full set of coronal, sagittal, and horizontal images. Stereotaxic reference grids were applied to each image indicating the A/P, M/L, or Ho position within the digital volume. Specific anatomic structures were outlined from the cryosection data set and 3D surface models reconstructed. Structural labels indicating nuclei, tracts, and other neuroanatomical features were incorporated into coronally sliced cryosection images spaced at 500 microns. The CT, PET, and MRI data sets were reconstructed into a digital volume and coregistered to the cryosection volume. All images constructed from this 3D map are available for public access via the internet using an anonymous file transfer protocol (FTP) and the World Wide Web (http:@www.loni.ucla.edu). The foremost advantage of this digital map is an integrated multimodality three-dimensional representation of the Macaca nemestrina brain, which is not possible with traditional atlases.

Animals↗
PubMedDate not supplied

Registration, segmentation, and visualization of multimodal brain images.

This paper gives an overview of the studies performed at our institute over the last decade on the processing and visualization of brain images, in the context of international developments in the field. The focus is on multimodal image registration and multimodal visualization, while segmentation is touched upon as a preprocessing step for visualization. The state-of-the-art in these areas is discussed and suggestions for future research are given.

Brain↗
PubMedDate not supplied

Multimodal anatomic, functional, and metabolic brain imaging for tumor resection.

OBJECTIVE: Improvement of neurosurgical techniques with a more detailed description of brain tumors and their functional environment. METHODS: We performed: (1) anatomical magnetic resonance imaging (MRI) for reference, (2) functional sequences dedicated to the adjacent cortical structures (sensorimotor, visual, language paradigms), and (3) thallium 201 cerebral tomoscintigraphy to visualize active tumor invasion. Data were transferred to a workstation for automatic registration. RESULTS: All data were combined into one synthetic image showing the foci of high proliferative activity, which have to be completely resected, and the peritumoral functional structures, which have to be spared in order to minimize postoperative sequelae. This trimodal image is entered into a surgical neuronavigation computer for preoperative planning in order to outline tumoral target and functional risk areas. All this information is displayed in the operative microscope (Zeiss MKM) optically linked to MR images. This multimodality technique diminishes operative time by reducing electrocorticography and improves the operative short-term outcome. CONCLUSION: Multimodal imaging is useful for optimization of neurosurgical tumor resection.

Adult↗