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A J Spillane

Publications and source records attributed to A J Spillane.

At least 19 recordsLinked to original sources
PubMed2005

Extra-axillary sentinel node biopsy in the management of early breast cancer.

AIM: To document of our experience with EAS SNB and evaluate its impact on the staging, management and the associated morbidities of patients with early breast cancer. METHOD: A review of two prospective breast cancer databases identifying all SNB procedures performed at two affiliated breast units from 1998 to 2003. RESULTS: A series of 979 patients underwent lymphatic mapping. Sentinel nodes were successfully identified in 903 patients. There were 142 cases in which lymphoscintigraphy identified EAS. In 17 cases extraaxillary sentinel nodes were identified with lymphoscintigraphy but could not be removed. There were 138 cases where internal mammary nodes (IMN) were removed. Of those IMN removed 25 were positive for metastases and in six of these cases only the IMN was positive. Of the 21 cases where other EAS were identified there was one case in which a supraclavicular sentinel node was positive. Twenty-five of the 26 positive sentinel nodes in EAS were macrometastases and one was a micrometastasis. No significant morbidity resulted from biopsy of EAS SNB. During IMN SNB there were eight pleural breeches, which did not result in pneumothoraces, and one case in which bleeding was difficult to control. CONCLUSION: EAS SNB is technically feasible in the majority of cases. Minimal morbidity occurs after an initial learning phase. IMN SNB was shown to have significant impact on the staging and management in 18% of patients when IMNs were identified with lymphoscintigraphy. The impact of other extraaxillary lymph nodes is more difficult to assess due to small numbers. As there is little morbidity and valuable information is gained in a significant percentage of cases we strongly advocate EAS SNB.

Aged↗
PubMed2005

Evaluation of a breast cancer nomogram for prediction of non-sentinel lymph node positivity.

AIMS: This study evaluates the breast cancer nomogram (BCN), an online tool developed by Memorial Sloan-Kettering Cancer Center to determine the rate of non-SLN positivity, in an independent cohort of SLN positive patients. MATERIAL AND METHODS: Available data between 02/2000 and 06/2004 in two prospective databases, 749 cases had successful SLN biopsy including 149 axillary-SLN metastases study cases. These cases had accurately graded tumours up to 9 cm in size and CAD with a minimum total 10 nodes removed. Histopathological assessment of nodes included hematoxylin and eosin staining and/or immunohistochemistry. Computerized BCN was used to estimate probability of non-SLN positivity and compared with actual probability after grouping into deciles. RESULTS: The trend of actual probability in various decile groups was comparable to the predicted probability. An area under the receiver operating characteristic curve was 0.75 as compared to 0.76 in the original study. CONCLUSION: Although this study is small, the results are encouraging and suggest the nomogram is a useful tool to estimate the likelihood of positive axillary non-SLN. However, variations in pathological assessment between centres are the major impediment to widespread application of BCN. If SLN positive patients decline the standard recommendation of CAD or entry into clinical trials evaluating the significance of CAD then the BCN could help in decision making.

Adult↗
PubMed2001

Retroperitoneal sarcoma: time for a change in attitude?

BACKGROUND: Retroperitoneal sarcoma (RPS) is considered a disease with poor prognosis partly because of the difficulty with diagnosis at an early stage. This review assesses the current best practice principles for RPS and finds evidence suggesting a better outlook for appropriately managed cases. Recommendations are made for improving diagnostic certainty before laparotomy and inappropriate transperitoneal biopsy occur. METHODS: A critical review of the English language literature was conducted using MEDLINE software and searching the terms 'retroperitoneal sarcoma' alone or in combination with 'prognosis', 'surgery' and 'adjuvant therapy'. CONCLUSIONS: Retroperitoneal sarcoma is a rare disease but when appropriately managed the disease-free survival can be improved and may even approach that of extremity soft tissue sarcoma. One of the greatest barriers to improving outcome is the misinterpretation of clinical signs and an over-reliance on ultrasound diagnosis in pelvic presentations, or misinterpretation of clinical signs and/or computer tomography (CT) scans in abdominal masses. Physicians referring patients with a retroperitoneal mass should consider more frequently the less common differential diagnoses of an abdominopelvic mass including retroperitoneal sarcoma. This is especially true in circumstances where there is a circumscribed, predominantly solid tumour, with clinical or radiological signs of vascular or rectal displacement, ureteric obstruction and/or classic renal rotational displacement. The more frequent use of CT scans with intravenous and oral contrast with referral prior to inappropriate transperitoneal biopsy is recommended. In atypical cases where preoperative biopsy is necessary, extraperitoneal routes are preferable. Complete en bloc surgical excision at the first laparotomy is the treatment of choice in RPS. Macroscopic clearance may necessitate resection of adjacent viscera, neurovascular structures or abdominopelvic walls but, if achieved, may lead to long-term survival depending on individual tumour biology.

Combined Modality Therapy↗
PubMed2001

Screen-detected breast cancer compared to symptomatic presentation: an analysis of surgical treatment and end-points of effective mammographic screening.

BACKGROUND: Mammographic screening has been shown to reduce mortality from breast cancer and to offer more opportunity for breast conservation surgery (BCS). The minimum standards (or surrogate end-points) that need to be achieved by a screening programme if it is to reduce mortality have been derived from the Two County Study. Three surrogate end-points that can be used to gauge the quality of the screening service are that 50% of the identified infiltrating cancers should be < 15 mm; at least 30% of grade 3 cancers should be < 15 mm; and 70% of screen-detected cancers should have a negative axillary dissection. The present study assesses these end-points of effective screening in an urban population referred to The Strathfield Breast Centre (TSBC). The screening end-points and surgical treatment of one group of women referred with a BreastScreen New South Wales (NSW)-detected breast cancer (screen group) were compared to all the other, mostly symptomatic, breast cancer referrals (symptom group). The problems with the current pattern of acceptance of mammographic screening in TSBC's referral area are discussed. METHODS: A prospective non-randomized study was done via analysis of the prospective database at The Strathfield Breast Centre (TSBC). RESULTS: There were 224 women in the screen group and 657 women in the symptom group. The mean tumour size was 18.1 mm in the screen group and 22.1 mm in the symptom group. There were significantly more small invasive cancers (< 15 mm) in the screen group (58%) compared with the symptom group (33%; P < 0.001). In the screen group there were more low-grade tumours but 30% of grade 3 tumours were < 15 mm compared with 16% in the symptom group (P = 0.009). In patients with invasive cancers who underwent axillary dissection, there was a significant difference in axillary node negativity, being 72% in the screen group and 59% in the symptom group (P = 0.003). In the screen group 64% of women had BCS compared with 51% in the symptom group (P = 0.002). CONCLUSIONS: These end-points of effective mammographic screening were met in the BreastScreen NSW group of women who were referred to TSBC despite the biases involved which could lessen the effectiveness of the screening programme. This crudely translated into a significant reduction in breast cancer mortality but selection and lead time bias has to be taken into account in evaluation of these data. There was a significantly greater chance of BCS in the screen group.

Breast Neoplasms↗
PubMed2000

Synovial sarcoma: a clinicopathologic, staging, and prognostic assessment.

PURPOSE: Synovial sarcoma (SS) is a common soft tissue sarcoma (STS) with a propensity for young adults and notable sensitivity to chemotherapy (CT). This study provides a current clinicopathologic, staging, and prognostic assessment for SS. The problems with the current American Joint Committee for Cancer (AJCC) Staging System in relation to SS are discussed. METHODS: Review of a prospective database supplemented by retrospective data. RESULTS: One hundred fifty patients were assessed; median age was 30 years and median follow-up was 52 months. Overall actuarial 5-year survival rate was 57%. Size trend, but not a cutoff of less than 5 cm versus > or = 5 cm, was a prognostic indicator (P <.001). The current AJCC/International Union Against Cancer Staging System differentiated prognosis less well than the recently proposed Royal Marsden Hospital Staging System. Age greater than 20 years at diagnosis implied worse prognosis. A local recurrence event was associated with a worse survival (P <.001). Therapeutic CT was administered to 55 patients. Eleven of 19 patients had an objective response to a combination of ifosfamide and doxorubicin. Four cases had complete response after CT. Twenty-one patients had pulmonary metastasectomy, with an actuarial 5-year survival rate of 23%. CONCLUSION: SS tends to affect young people. In this subtype of STS, size trend is the most significant influence on stage and hence survival; however, smaller SSs have an unexpectedly poor prognosis. Adequate local control may affect survival. SS is often chemosensitive, and given its poor prognosis, multicenter trials of adjuvant therapy are warranted.

Adolescent↗
PubMed2000

Epithelioid sarcoma: the clinicopathological complexities of this rare soft tissue sarcoma.

BACKGROUND: Epithelioid sarcoma is a rare high grade soft tissue sarcoma with a known propensity for locoregional recurrence. The literature is limited on other characteristics such as frequency of multifocal disease at presentation, the relationship of presenting size of the primary lesion to prognosis, and the ability of current staging systems to predict prognosis. METHODS: Review of the Royal Marsden National Health Service Trust (RMH) experience of 37 cases over 21 years. RESULTS: The mean age was 29 years, with male predominance (2.7:1), and distal limb locations were most common (56%). Five patients presented with multifocal local disease. Median follow-up was 88 months in the 19 patients still alive. The 5- and 10-year actuarial overall survival was 70% and 42%, respectively. Tumors deep to the investing fascia had a worse prognosis than superficial tumors. Regional metastasis events were also associated with significantly worse overall survival. Local recurrence, size of 5 cm or larger, and regional metastasis events were predictive of worse distant metastasis-free survival. Tumor size (<5 cm vs. > or =5 cm), local recurrence events, sex, and site were not significant predictors of survival. The American Joint Committee on Cancer/International Union Against Cancer staging systems and the recently proposed RMH staging system of the Royal Marsden National Health Service Trust provided poor differentiation of prognosis in epithelioid sarcoma. The 5-year actuarial local recurrence rate was 35%. The 5-year actuarial regional nodal metastasis rate was 23%. The actuarial 5-year distant metastasis rate was 40%, with pleuropulmonary metastases the most common site of metastatic disease, and 35% of pleuropulmonary metastases presented with pleural effusion. Median post-distant metastasis survival was 8 months. CONCLUSIONS: Epithelioid sarcoma has unusual clinical behavior compared with other high grade soft tissue sarcoma. It has a propensity for multifocal disease at presentation, local recurrence, regional metastasis, and particularly poor prognosis after regional or distant metastatic disease. Size and stage according to the American Joint Committee on Cancer/International Union Against Cancer are unreliable predictors of prognosis.

Adolescent↗
PubMed2000

Role of axillary surgery in early breast cancer: review of the current evidence.

BACKGROUND: Controversy continues to surround the best practice for management of the axilla in patients with early breast cancer (EBC), particularly the clinically negative axilla. The balance between therapeutic and staging roles of axillary surgery (with the consequent morbidity of the procedures utilized) has altered. This is due to the increasing frequency of women presenting with early stage disease, the more widespread utilization of adjuvant chemoendocrine therapy and, more recently, the advent of alternative staging procedures, principally sentinel node biopsy (SNB). The aim of the present review is to critically analyse the current literature concerning the preferred management of the axilla in early breast cancer and make evidence-based recommendations on current management. METHODS: A review was undertaken of the English language medical literature, using MEDLINE database software and cross-referencing major articles on the subject, focusing on the last 10 years. The following combinations of key words have been searched: breast neoplasms, axilla, axillary dissection, survival, prognosis, and sentinel node biopsy. RESULTS: Despite the trend to more frequent earlier stage diagnosis, levels I and II axillary dissection remain the treatment of choice in the majority of women with EBC and a clinically negative axilla. CONCLUSIONS: Sentinel node biopsy has no proven superiority over axillary dissection because no randomized controlled trials have been completed to date. Despite this, SNB will become increasingly utilized due to encouraging results from major centres responsible for its development, and patient demand. Therefore if patients are not being enrolled in clinical trials strict quality controls need to be established at a local level before SNB is allowed to replace standard treatment of the axilla. Unless this is strictly adhered to there is a significant risk of an increase in the frequency of axillary relapse and possible increased understaging and resultant inadequate treatment of patients.

Antineoplastic Agents, Hormonal↗
PubMed2000

Gynaecological presentation of retroperitoneal tumours.

OBJECTIVE: To illustrate the problems associated with mistaken pre-operative diagnosis following gynaecological presentation of patients with retroperitoneal tumours. DESIGN: A case series of five referrals. RESULTS: Non-gynaecological tumours were not suspected in each case and hence there was a failure to undertake further pre-operative investigation and referral to a specialised soft tissue sarcoma service. This resulted in four of the patients having an unnecessary laparotomy with an inappropriate transperitoneal biopsy undertaken when the retroperitoneal tumour was discovered. The mistaken diagnosis of ovarian malignancy lead to increased morbidity, compromise of potential for a long disease free interval and/or possibly lessened the chance of cure in each case. CONCLUSIONS: Misinterpretation of clinical signs and an over-reliance on ultrasound diagnosis were the commonest causes of inappropriate management of these patients. Gynaecologists should consider more frequently the other, less common differential diagnoses of a pelvic mass. This is especially true in circumstances with a predominantly solid tumour, where there are clinical signs of vascular or rectal displacement, or where there is ultrasound evidence of ureteric obstruction. The more frequent utilisation of a computerised tomography scan with intravenous and oral contrast with referral before inappropriate transperitoneal biopsy are recommended as complete en bloc surgical excision at the first laparotomy is the treatment of choice in virtually all primary retroperitoneal tumours.

Adult↗
PubMed1999

Myxoid liposarcoma--the frequency and the natural history of nonpulmonary soft tissue metastases.

BACKGROUND: Myxoid liposarcomas (ML) make up the major subset of liposarcomas, which in most series represent the second or third most common type of soft tissue sarcoma. The tendency for ML to metastasize to other soft tissues (STM) in preference to lung parenchyma has been previously described; however, the natural history of this tumor's behavior is poorly documented. Our intent was to analyze the natural history of ML and further quantify the incidence of STM, concentrating on their significance in terms of survival. METHODS: We reviewed the experience at the Royal Marsden Hospital over a 10-year period, documenting the clinicopathological behavior of ML, including the frequency of STM. RESULTS: There were 50 patients, with a median follow-up of 43 months. The actuarial 5-year soft tissue metastasis rate was 31%, and the most common sites of STM were the retroperitoneum, abdominal wall, and abdominal cavity. In those 12 patients who had STM there was a median interval of 23 months after original diagnosis to the time the first metastasis became apparent (range, 0-142 months). Median survival following first metastasis was 35 months; 6 of the 12 patients died between 6 and 50 months. Four patients who had STM remain disease free at 15 to 59 months after their first STM. Any round cell component of the ML was associated with a significantly greater chance of metastatic disease (P = .02). In this series, the overall 5-year and 7-year survival rates were 85% and 68%. Patients with STM had an 11 times greater chance of dying than those who did not. CONCLUSIONS: ML usually is an indolent disease, but there is a subset of patients who develop STM and have a significantly worse prognosis. STM can occur years after the initial diagnosis and can be associated with medium-long-term survival after they occur. STM should be managed aggressively because of this.

Abdominal Neoplasms↗
PubMed1999

Which patients with early breast cancer need axillary clearance?

The role of axillary surgery in the management of early breast cancer is currently the topic of intense debate in the literature. There are strong indications that women are presenting with earlier tumours and hence the majority have negative axillary nodes making axillary dissection less beneficial both in terms of disease control and less likely to result in an alteration of management. Alternative less morbid axillary staging and non-axillary staging methods are being investigated, but sentinel node biopsy shows the most promise for reliable assessment of the axilla. This review aims to assess the current literature regarding the role of axillary surgery in breast cancer management. The reasoning why axillary dissection is still the gold standard in breast cancer management is explained and related to the other methods of axillary assessment and therapy. Suggested guidelines for current optimal management are made.

Adult↗
PubMed1999

Australia's breast surgery workload is changing: comparison of a metropolitan and a rural hospital.

BACKGROUND: Breast cancer is a common disease in our community and its incidence is increasing. As a result of the improvements in community awareness and introduction of screening, patients are being diagnosed with earlier breast cancer and with a higher incidence of pre-invasive disease. Improvements in radiology, often coupled with minimally invasive diagnostic modalities, have lessened the requirement for open diagnostic biopsies and also reduced the number of operations for benign breast disease. METHODS: An audit of the surgical workload at Prince of Wales/Prince Henry Hospitals and Tamworth Base Hospital was conducted to document and compare the above changes in the metropolitan and rural settings. This study was conducted between 1987 and 1996 to assess the effect of screening and improved technology over a 10-year period. RESULTS: The study found that a high percentage of malignant lesions are being diagnosed by fine-needle aspiration biopsy (FNAB) with a corresponding reduction in open biopsy rate at the Prince of Wales Hospital. There is a smaller percentage of benign operations in both settings with a reduction of equal proportion. The reporting of the pathology specimens has markedly improved at both institutions. There has been a reduction in the number of patients having modified radical mastectomy and there has been a corresponding increase in breast conservation surgery especially at the Prince of Wales/Prince Henry Hospitals, although there was an unexpectedly high incidence of breast conservation surgery at Tamworth Base Hospital in 1987. In 1996 the rates of breast conservation surgery were the same in both hospitals. CONCLUSIONS: There are minimal differences in the quality of surgical care being offered to patients at the Tamworth Base Hospital compared with the Prince of Wales Hospital and both institutions are within reach of the accepted best management practices available.

Australia↗
PubMed1999

Surgical aspects of iliopsoas compartment tumours.

AIM: To demonstrate the pathological variety and highlight the surgical principles involved in the management of tumours of the iliopsoas compartment (IPC). METHODS: Review of four clinical cases. RESULTS: Adequate surgical resection or palliation was achieved in each case. CONCLUSION: Resection of IPC tumours is feasible but access to the most superior part of the muscle may be impossible. An extraperitoneal approach is advocated.

Abdominal Neoplasms↗
PubMed1999

Clinical significance of intramammary lymph nodes.

Intramammary lymph nodes (IMLN) are present in up to 47% of breasts and may be involved in metastatic disease in up to 9.8 % of operable breast cancer cases. IMLN are likely to be increasingly recognized with wider acceptance of high quality screening mammography and the use of ultrasound assessment of breast disease. The aim of this study is to demonstrate how IMLN can have an impact on management of breast cancer patients by presenting a case series of three patients. We conclude that IMLN metastases from breast cancer alters the prognosis and hence the management of patients. This will need to be addressed more frequently as sentinel node biopsy is more widely utilized.

Journal Article↗
PubMed1998

The role of the journal club in surgical training.

BACKGROUND: The development of skills in critical appraisal of the medical literature is an important aspect of surgical training. METHODS: At the Prince of Wales Hospital a journal club has been conducted for more than 5 years to improve the registrars' training in this area. A questionnaire was circulated regarding the success of the journal club at achieving adequate review of the important current literature, development of critical appraisal skills by registrars and providing a convivial social gathering. RESULTS: A total of 28 out of 39 current or previous journal club members responded to the questionnaire. Twenty-three of the respondents felt that the journal club provided a good to excellent review of current literature, 26 felt that the journal club facilitated development of critical appraisal skills and all 28 said that the journal club was a convivial social forum. Eight research projects developed from journal club reviews, 19 of the respondents reported that their clinical practice had changed, and 19 had been stimulated to further review a topic as a result of the journal club. Many of the respondents had specific criticisms of the journal club, and these have been used to improve the journal club format. CONCLUSIONS: The present study has highlighted the strengths and weaknesses of our journal club. The journal club is a valuable component of surgical education.

Clinical Competence↗