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Anees B Chagpar

Publications and source records attributed to Anees B Chagpar.

18 recordsLinked to original sources
PubMed2006

Predicting patients at low probability of requiring postmastectomy radiation therapy.

BACKGROUND: Postmastectomy radiation therapy (PMRT) is recommended for patients with four or more positive lymph nodes (LN+). Given the ramifications of PMRT for immediate reconstruction, we sought to create a model using preoperative and intraoperative factors to predict which patients with a positive sentinel lymph node will have less than four LN+. METHODS: The database from a prospective multicenter study of 4,131 patients was used for this analysis. Patients with one to three positive sentinel lymph nodes (SLN) and tumors < 5 cm (n = 1,133) in size were randomly divided into a training set (n = 580) and a test set (n = 553). Multivariate logistic regression was used on the training set to create a prediction rule that was subsequently validated in the test set. RESULTS: Median patient age was 57 (range, 27-100) years, and median tumor size was 2.0 (range, 0.2-4.8) cm. In the training set, factors associated with having four or more LN+ on multivariate analysis were: tumor size [odds ratio (OR) = 2.087; 95% confidence interval (CI): 1.307-3.333, P = 0.002), number of positive SLN (P < 0.0005), and proportion of positive SLN (OR = 3.602; 95% CI: 2.100-6.179, P < 0.005). A predictive model was established with a point assigned to each positive SLN, T2 (vs. T1), and if proportion of positive SLN was > 50%, for a maximum of five points. In both the training and test sets, patients with one point had a low probability of having four or more LN+ (3.8% and 3.3%, respectively). CONCLUSION: Tumor size, number of positive SLN, and the proportion of positive SLN influence whether patients will have four or more LN+. A simple model can predict the probability of requiring PMRT.

Adult↗
PubMed2006

Factors associated with surgical options for breast carcinoma.

BACKGROUND: Breast conservation surgery (BCS) and mastectomy have equivalent survival outcomes for women with breast carcinoma, but treatment decisions are affected by many factors. The current study evaluated the impact of patient and physician factors on surgical decision-making. METHODS: Statistical analyses were performed on a prospective multicenter study of patients with invasive breast carcinoma. Patient, physician, and geographic factors were considered. RESULTS: Of 4086 patients, BCS was performed in 2762 (67.6%) and mastectomy was performed in 1324 (32.4%). The median tumor size was 1.5 cm (range, < 0.1-9.0 cm) in patients undergoing BCS and 1.9 cm (range, 0.1-11.0 cm) in patients undergoing mastectomy (P < 0.00001). The median age of patients undergoing BCS was 59 years (range, 27-100 yrs), whereas patients who underwent mastectomy were older (median age of 63 yrs, range, 27-96 yrs [P < 0.00001]). Physicians in academic practices performed more lumpectomies than those who were not in an academic practice (70.9% vs. 65.7%; P = 0.001). More breast conservation procedures were performed by surgeons with a higher percentage of breast practice (P = 0.012). Geographic location was found to be significant, with the Northeast having the highest rate of breast conservation (70.8%) and the Southeast having the lowest (63.2%; P = 0.002). On multivariate analysis, patient age (odds ratio [OR]: 1.455; 95% confidence interval [95% CI], 1.247-1.699 [P < 0.001]), tumor size (P < 0.001), tumor palpability (OR: 0.613; 95% CI, 0.524-0.716 [P < 0.001]), histologic subtype (P = 0.018), tumor location in the breast (P < 0.001), physician academic affiliation (OR: 1.193; 95% CI: 1.021-1.393 [P = 0.026]), and geographic location (P = 0.045) were found to be significant. CONCLUSIONS: Treatment decisions were found to be related to patient clinicopathologic features, surgeon academic affiliation, and geographic location. Future studies will elucidate the communication and psychosocial factors that may influence patient decision-making.

Academic Medical Centers↗
PubMed2006

Determinants of early distant metastatic disease in elderly patients with breast cancer.

BACKGROUND: The purpose of this analysis was to determine predictors of early distant metastasis in elderly breast cancer patients receiving hormonal therapy. METHODS: We analyzed data from 938 patients in the North American Fareston Tamoxifen Adjuvant Trial>or=65 years old to determine predictors of early metastatic disease. RESULTS: The median patient age was 73 (range 65 to 100). With a median follow-up of 34 months, 17 patients (1.8%) developed distant metastases. The median time to distant metastasis was 21 months. On univariate analysis, significant predictors of distant metastatic disease were as follows: progesterone receptor status (P=.032), lymphovascular invasion (P=.020), tumor grade (P=.007), tumor size (P<.01), and number of metastatic nodes (P<.01). On multivariate analysis, only the number of positive nodes (P=.029) remained significant. Patients with >or=4 positive nodes were more likely to develop early metastases than those with 0 to 3 positive nodes (odds ration 20.304; 95% confidence interval 2.777-148.456, P=.003). CONCLUSIONS: Lymph node status in the elderly breast cancer patient treated with hormonal therapy alone is a strong predictor of early distant recurrence.

Aged↗
PubMed2006

Prediction of sentinel lymph node-only disease in women with invasive breast cancer.

BACKGROUND: The purpose of this study was to create a model that predicts which breast cancer patients will have sentinel lymph node (SLN)-only metastasis. METHODS: SLN-positive breast cancer patients (N = 1,253) were analyzed. Multivariate analysis was performed to identify factors predicting SLN-only disease; a prediction rule was created. RESULTS: Median tumor size was 2 cm. The median number of SLNs removed was 2; the median number of positive SLNs was 1. Multivariate analysis found tumor size, number of positive SLN, and proportion of SLN positive were significant predictors of SLN-only disease (P < .001). A prediction rule with 1 point being given for >1 positive SLN, 1 point for >50% of SLN positive, and up to 4 points for tumor size (T1a = 1, T1b or T1c = 2, T2 = 3, and T3 = 4) was established. Ninety-five percent of patients with 1 point had SLN-only disease (P < .0001). CONCLUSION: An integer-based model may predict SLN-only disease and may be useful in determining whether completion axillary lymph node dissection is required.

Adult↗
PubMed2006

Accuracy of physical examination, ultrasonography, and mammography in predicting residual pathologic tumor size in patients treated with neoadjuvant chemotherapy.

OBJECTIVE: To assess the accuracy of physical examination, ultrasonography, and mammography in predicting residual size of breast tumors following neoadjuvant chemotherapy. BACKGROUND: Neoadjuvant chemotherapy is an accepted part of the management of stage II and III breast cancer. Accurate prediction of residual pathologic tumor size after neoadjuvant chemotherapy is critical in guiding surgical therapy. Although physical examination, ultrasonography, and mammography have all been used to predict residual tumor size, there have been conflicting reports about the accuracy of these methods in the neoadjuvant setting. METHODS: We reviewed the records of 189 patients who participated in 1 of 2 protocols using doxorubicin-containing neoadjuvant chemotherapy, and who had assessment by physical examination, ultrasonography, and/or mammography no more than 60 days before their surgical resection. Size correlations were performed using Spearman rho analysis. Clinical and pathologic measurements were also compared categorically using the weighted kappa statistic. RESULTS: Size estimates by physical examination, ultrasonography, and mammography were only moderately correlated with residual pathologic tumor size after neoadjuvant chemotherapy (correlation coefficients: 0.42, 0.42, and 0.41, respectively), with an accuracy of +/-1 cm in 66% of patients by physical examination, 75% by ultrasonography, and 70% by mammography. Kappa values (0.24-0.35) indicated poor agreement between clinical and pathologic measurements. CONCLUSION: Physical examination, ultrasonography, and mammography were only moderately useful for predicting residual pathologic tumor size after neoadjuvant chemotherapy.

Adult↗
PubMed2006

Gender-related differences in outcome for melanoma patients.

OBJECTIVE: To better understand the factors associated with the well-established gender difference in survival for patients with melanoma. SUMMARY BACKGROUND DATA: Gender is an important factor in patients with cutaneous melanoma. Male patients have a worse outcome when compared with females. The reasons for this difference are poorly understood. METHODS: This prospective multi-institutional study included patients aged 18 to 70 years with melanomas > or =1.0 mm Breslow thickness. Wide excision and sentinel lymph node (SLN) biopsy was performed in all patients. Clinicopathologic factors, including gender, were assessed and correlated with disease-free survival (DFS), distant disease-free survival (DDFS), and overall survival (OS). RESULTS: A total of 3324 patients were included in the covariate analyses; 1829 patients had follow-up data available and were included in the survival analyses. Median follow-up was 30 months. On univariate analysis, men (n = 1906) were more likely than women to be older than 60 years (P < 0.0001), have thicker melanomas (P < 0.0001), have primary tumor regression (P = 0.0054), ulceration (P < 0.0001), and axial primary tumor location (P < 0.0001). On multivariate analysis, age (P = 0.0002), thickness (P < 0.0001), ulceration (P = 0.015), and location (P < 0.0001) remained significant in the model. There was no difference in the rate of SLN metastasis between men and women (P = 0.37) on multivariate analysis. When factors affecting survival were considered, the prognosis was worse for men as validated by lower DFS (P = 0.0005), DDFS (P < 0.0001), and OS (P < 0.0001). CONCLUSIONS: Male gender is associated with a greater incidence of unfavorable primary tumor characteristics without an increased risk for nodal metastasis. Nonetheless, gender is an independent factor affecting survival.

Adolescent↗
PubMed2006

Treatment of sentinel node-positive breast cancer.

Sentinel node biopsy has become well accepted as a minimally invasive means of accurately staging the axilla in breast cancer patients. Patients with metastases in the sentinel node(s) have traditionally proceeded to completion of axillary node dissection, whereas patients who are node negative can be spared the morbidity of this procedure. Recently, there has been some debate as to what constitutes node-positive disease and whether patients with metastasis in the sentinel node(s) require completion axillary dissection. This review addresses the controversies regarding the management of sentinel node-positive breast cancer patients.

Biopsy↗
PubMed2005

Biopsy type does not influence sentinel lymph node status.

BACKGROUND: This study sought to determine whether the type of biopsy examination independently affects sentinel lymph node (SLN) status in breast cancer patients. METHODS: A prospective multicenter study of patients who had SLN biopsy examination followed by axillary node dissection was analyzed to determine whether the type of biopsy examination influenced SLN status. RESULTS: Of the 3853 patients studied, 32% had a positive SLN. Patients were diagnosed by fine-needle (N = 293), core-needle (N = 2154), excisional (N = 1386), or incisional (N = 20) biopsy procedures. The rates of SLN positivity for these groups were 45%, 32%, 29%, and 65%, respectively (P < .001). Other factors predictive of SLN status included: patient age (P < .001), tumor size (P < .001), tumor palpability (P < .001), number of SLN removed (P < .001), type of surgery (mastectomy vs. lumpectomy) (P < .001), histologic subtype (P = .048), and the use of immunohistochemistry (P < .001). All of these factors remained significant in the multivariate model except for histologic subtype and biopsy examination type. CONCLUSIONS: Biopsy examination type does not independently influence the risk for nodal metastasis.

Adult↗
PubMed2005

Effect of lymphoscintigraphy drainage patterns on sentinel lymph node biopsy in patients with breast cancer.

BACKGROUND: Sentinel lymph node (SLN) biopsy examination is an accepted method of staging breast cancer patients. SLN biopsy examination in patients with drainage to the internal mammary chain (IMC) nodes is controversial. METHODS: A prospective study of SLN biopsy examination followed by axillary dissection was analyzed to determine how surgeons manage patients with IMC drainage and the rates of axillary SLN identification and positivity in these cases. RESULTS: Lymphoscintigraphy was performed in 2196 (53.2%) of the 4131 patients in this study. IMC drainage was noted in 80 patients (3.6%). An axillary SLN was identified in 29 of the 40 patients with IMC drainage alone (72.5%). The rate of finding a positive axillary lymph node did not differ based on the lymphoscintigraphic pattern (P = .470). CONCLUSIONS: Most surgeons do not perform IMC SLN biopsy procedures. Even when lymphoscintigraphy shows isolated drainage to IMC nodes, axillary SLNs usually are identified. Lymphoscintigraphy therefore has limited usefulness.

Adult↗
PubMed2005

Surgeon and community factors affecting breast cancer sentinel lymph node biopsy.

BACKGROUND: We sought to determine whether the results of sentinel lymph node (SLN) biopsy are related to practice and community factors. METHODS: This prospective study included more than 300 surgeons from a variety of practice environments. Most surgeons had minimal experience with SLN biopsy prior to this study. Patients underwent attempted SLN biopsy, followed by completion axillary dissection. Univariate and multivariate analyses were performed to assess factors related to the SLN identification rate and the false negative rate. RESULTS: A total of 4131 patients were enrolled. SLN identification rate was 93%; the false negative (FN) rate was 7.9%. The only factor that was significantly associated with improved SLN identification rate (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.12 to 2.36, P = .0126) and FN rate (OR 2.39, 95% CI 1.32 to 4.79, P = .0073) was surgeon experience (>20 SLN cases). CONCLUSIONS: Surgeon experience is the major factor that contributes to improved SLN biopsy results. SLN biopsy can be performed equally well by community and academic surgeons.

Adult↗
PubMed2005

Factors predicting failure to identify a sentinel lymph node in breast cancer.

BACKGROUND: Although sentinel lymph node (SLN) biopsy is widely accepted as a minimally invasive method of nodal staging, failure to identify an SLN mandates a level I/II axillary node dissection. The purpose of this study was to elucidate factors that independently predict failure to identify an SLN. METHODS: Using a large multicenter prospective study of SLN biopsy for patients with invasive breast cancer, we performed univariate and multivariate regression analyses to determine clinicopathologic factors predictive of failure to identify an SLN. RESULTS: Of the total 4131 patients in the study, an SLN was not identified in 249 (6.0%). Tumor location (P = .409), biopsy type (P = .079), surgery type (P = .380), and histologic subtype (P = .999) were not significant predictors of failure to identify an SLN. On multivariate analysis, age greater than 60 years (OR = 1.469; 95% CI, 1.116-1.934, P = .006), nonpalpable tumors (OR = 0.639; 95% CI, 0.479-0.852, P = .002), injection technique with blue dye alone (OR = 0.389, 95% CI, 0.259-5.86, P < .001), and surgical experience of less than 10 SLN biopsy cases (OR = 1.886; 1.428-2.492, P < .001) were significant independent predictors of failure to identify an SLN. Optimal SLN biopsy technique using an intradermal and/or subareolar injection of radioactive colloid and blue dye can improve SLN identification rates regardless of patient and tumor characteristics. CONCLUSIONS: Patient age and tumor palpability significantly affect the ability to identify an SLN in patients with breast cancer. Optimal injection technique can significantly improve sentinel node identification rate regardless of these factors.

Adult↗
PubMed2005

Should sentinel lymph-node biopsy be used routinely for staging melanoma and breast cancers?

The sentinel lymph node (SLN) is the lymph node that represents the 'gate-keeper' of the lymphatic basin; it is the first node to receive lymphatic drainage from the site of the primary tumor. SLN biopsy is a staging procedure and should be considered as such; it is not meant to be a therapeutic operation. The SLN can be mapped and biopsied using tracer agents (e.g. radiolabelled colloid and/or vital blue dye), which are injected around the primary tumor site. Pathologic analysis of the SLN using a combination of serial sectioning of the node, standard hematoxylin and eosin staining, and immunohistochemistry decreases the false-negative rate compared with traditional nodal processing. SLN biopsy is associated with lower morbidity than full lymphadenectomy. The SLN technique accurately reflects the metastatic status of the regional lymph-node basin; recurrent nodal disease in the mapped basin is rare following a tumor-free SLN biopsy result. The objectives of this review are to provide a current and concise overview of the current literature on SLN biopsy and describe its role in clinical oncology.

Breast Neoplasms↗
PubMed2004

Lumpectomy margins are affected by tumor size and histologic subtype but not by biopsy technique.

OBJECTIVE: The effect of the type of biopsy (needle vs. excisional) on lumpectomy margin status has not been well established. The objective of this study was to determine whether needle biopsy is associated with a higher positive margin rate at time of lumpectomy. METHODS: We evaluated this hypothesis in the setting of a prospective multi-institutional study. A total of 3975 patients were enrolled in the University of Louisville Breast Cancer Sentinel Lymph Node Study from May 7, 1998 to June 3, 2003. Patients who underwent lumpectomy at the time of their sentinel lymph node biopsy were the focus of this analysis. Patients with clinical stage T1 N0 and T2 N0breast cancer were eligible; 29 patients were found to have T3 tumors on final pathology. Pathologists at each institution defined margin positivity, and tumor at the inked margin of resection was the study guideline. RESULTS: Median patient age was 59 years, and median tumor size was 1.5 cm. A total of 2658 patients underwent lumpectomy with the following results. The cancer of 1515 patients was diagnosed by fine-needle or core-needle biopsy and of 821 patients was diagnosed by excisional biopsy; in 322 patients the method of diagnosis was unknown. The type of previous biopsy did not significantly affect the positive-margin rate at the time of lumpectomy (13.3% vs. 11.0% for needle and excisional biopsy, respectively, P = 0.107). However, patients with larger tumors were more often found to have a positive margin (11.4% vs. 13.9% vs. 27.6% for T1, T2, and T3 tumors, respectively; P = 0.010). No difference was found in margin status after excision of palpable versus nonpalpable tumors (10.6% vs. 10.9%, respectively, P = 0.743). Histologic subtype, however, did affect margin status (15.8% vs. 9.8% positive margins for lobular vs. ductal type, respectively, P = 0.003). CONCLUSIONS: In this multi-institutional study, increasing tumor size and lobular histologic subtype were associated with a greater likelihood of a positive margin. The type of biopsy, needle or excisional, had no effect on the ability to achieve negative margins.

Adult↗
PubMed2004

Sentinel lymph node biopsy for breast cancer: from investigational procedure to standard practice.

Sentinel lymph node biopsy, popularized in melanoma, has revolutionized the management of breast cancer. While the morbidity associated with axillary node dissection was once thought to be a requisite risk in order to appropriately stage the axilla, large validation studies have demonstrated that sentinel lymph node biopsy is a minimally invasive technique that can accurately predict nodal status. This technique has become an accepted practice in many centers, but there remain many controversies surrounding the technique itself, the pathologic evaluation of the sentinel node and the optimal management of patients with minimal nodal disease. The historic roots of this technique are discussed, along with the controversial issues surrounding the technique and the clinical trials that are currently ongoing.

Breast Neoplasms↗
PubMed2004

Advances in the management of localized breast cancer: an overview.

Over the last few decades, there have been unprecedented advances in the multidisciplinary management of breast cancer. Surgical principles have shifted away from the Halstedian concept of radical surgery towards more cosmetic breast-conserving procedures, and advances have been made in terms of oncologic and plastic surgical techniques for those opting for mastectomy and reconstruction. Sentinel lymph node biopsy has revolutionized the evaluation of patients' nodal status and has become widely accepted as "state of the art." Medical oncology has made tremendous advances and is no longer relegated to the patients with metastatic disease. It is well accepted that chemotherapy may play a role even in patients with small tumors. Certainly the impact of neoadjuvant chemotherapy for downsizing tumors and making them amenable for breast conservation is also widely accepted. The advent of anthracyclines and, more recently, taxane-based regimens has had a substantial impact on the management of breast cancer. In addition, newer hormonal therapies such as the aromatase inhibitors have rivaled the classic cornerstone of tamoxifen. Radiation therapy has evolved from the era of cobalt-based therapy to newer, less morbid, techniques. In addition to advances in external beam radiation, the concept of accelerated partial breast irradiation and intraoperative radiation therapy is evolving and continues to be the focus of research endeavors. The unparalleled advances in the management of breast cancer in the fields of surgical, medical, and radiation oncology over the last half century continue today with ongoing research and clinical trials. As we enter the new millennium, breast cancer management will continue to evolve.

Algorithms↗
PubMed2004

Skin-sparing and nipple-sparing mastectomy: preoperative, intraoperative, and postoperative considerations.

The last several decades have witnessed significant advances in the surgical management of breast cancer. Although many have embraced breast conservation as the procedure of choice, some patients will still opt for mastectomy for a variety of reasons. Recently, the concept of skin sparing mastectomy and immediate breast reconstruction has emerged as an option that provides excellent cosmetic results while being oncologically safe. However, this surgical approach must be considered within a multidisciplinary context, and there are a number of perioperative issues that need to be considered. In addition, newer techniques, which spare the nipple and/or areola, warrant further examination.

Breast Implants↗