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Biomedical subjects

D P Winchester

Publications and source records attributed to D P Winchester.

At least 19 recordsLinked to original sources
PubMed1992

Physical examination of the breast.

Despite the increasing emphasis in physicians' use of screening mammography, primary care physicians continue to appropriately perform physical examination of the breast. Several screening programs have reported that mammography will miss at least 10% of breast cancers, physical examination can independently detect breast cancer, the combination of mammography and physical examination is superior to either modality alone, and biopsy of a palpable dominant mass should not be deferred because the results of the mammogram are normal. Optimal breast cancer screening should include both mammography and physical examination of the breast.

Breast Neoplasms↗
PubMed1992

Patient characteristics, methods of diagnosis and treatment of melanoma in the United States.

The American College of Surgeons performed a patient care and evaluation study of melanoma for 1981 and 1987 to determine the presenting symptoms, methods of evaluation, clinical management and resulting outcome. Melanomas of the skin, eye, mucous membrane, metastases with unknown primary site and miscellaneous sites were included. Details concerning 5,004 patients from 681 hospitals in the study in 1981 and 6,900 patients from 844 hospitals in the study in 1987 were obtained--most melanomas were located in the skin; a decline in symptoms occurred at initial diagnosis; an increase in age at first diagnosis was reported; most melanomas were in Caucasian patients; slightly more melanomas occurred in men than women; more melanomas occurred in men on the head and neck and trunk, and more in the lower extremity in women; most tumors were not large in diameter; a significant shift was reported to lower levels of Clark's invasion, and a significant amount of unknowns existed in the Breslow's thickness of invasion. The large number of unknowns makes analysis difficult, but there seems to be some shift toward thinner levels of Breslow's in tumors in which it was known, from 1981 to 1987. Only a small proportion of patients in the current series was known to have node involvement or known distant metastases. An overall decline in diagnostic studies occurred between 1981 and 1987.

Adult↗
PubMed1991

Adjuvant therapy for node-negative breast cancer. The use of prognostic factors in selecting patients.

Patients with invasive breast cancer and pathologically negative lymph nodes (NO) have a favorable 10-year survival rate, particularly with small (less than 1 cm) primary tumors. Overall, however, 20% to 35% will experience recurrence with local therapy only. Adjuvant chemotherapy or tamoxifen have prolonged disease-free survival (DFS), but not overall survival (OS). Unanswered questions of optimal end point (DFS or OS) and the risk of treating many to benefit few have prompted clinicians to use prognostic indicators to facilitate treatment recommendations. Currently, the most readily available and accurate information comes from TNM staging, pathologic features, and hormone receptors. Ploidy, S-phase fraction, HER-2-neu amplification or over-expression, and cathepsin-D may be useful prognostic indices. Until a more precise system of weighing several prognostic variables is developed, the decision to recommend adjuvant systemic therapy in this generally good prognosis group will have to be thoughtfully considered by patient and physician. Whenever possible, patients should be encouraged to enter clinical trials.

Breast Neoplasms↗
PubMed1990

Evaluation and management of breast abnormalities.

The increasing use of screening mammography, liability risks, and volume control legislation by the federal government pose a major challenge to clinicians to safely select patients for breast biopsy. Despite a normal mammogram, a palpable breast mass often requires aspiration or excisional biopsy. Careful clinical judgement must prevail if observation is elected. A biopsy should be performed on a clinically suspicious mass whether the mammogram is suspicious or not. Management of the patient with a nonpalpable mammographic abnormality requires a close working relationship among the surgeon, pathologist, and radiologist. Thoughtful clinical judgement and interdisciplinary cooperation promote an acceptable benign to malignant ratio for breast biopsies.

Breast Diseases↗
PubMed1990

The assurance of quality care for the cancer patient.

Quality assurance is receiving increasing attention in a changing health care delivery system dominated by cost containment. Quality is being defined by health professionals, patients, hospitals, the purchasers of care, and government. None seem to agree entirely. A meaningful future for assurance of quality of care for the patient with cancer will require thoughtful program development by a widely diverse group of organizations dedicated to this goal.

Delivery of Health Care↗
PubMed1990

The importance of DNA flow cytometry in node-negative breast cancer.

DNA flow cytometric analysis and conventional clinical factors were compared with disease outcome in 257 patients with node-negative infiltrating ductal carcinoma who had been treated between 1976 and 1983. Median follow-up was 80 months; none of the patients received adjuvant therapy. The relative prognostic importance of clinical variables, ploidy, and S-phase fraction was analyzed by Cox multivariate analysis. Ploidy was analyzable for 198 tumors and did not predict survival. Nuclear grade predicted disease-free survival for all patients. For 71 patients with diploid tumors, only high S-phase had a statistically significant association with relapse. For 127 patients with aneuploid tumors, tumor diameter predicted both disease-free survival and cancer death; histologic grade was also significant for predicting disease-free survival. In conclusion, flow cytometric determination of ploidy and S-phase fraction can provide valuable predictive information in node-negative breast cancer in addition to conventional variables.

Breast Neoplasms↗
PubMed1990

National survey of the pattern of care for carcinoma of the lung.

A national survey of the patterns of care for carcinoma of the lung sponsored by the Commission on Cancer of the American College of Surgeons has documented continuing changes in epidemiology, treatment, and outcome. The project consisted of a long-term study of 15,219 patients whose diagnosis was made in 1981 and a short-term study of 19,074 patients whose diagnosis was made in 1986. The male/female incidence ratios have continued to decrease and the decrease has moved into the older age groups. Although the percentage of adenocarcinoma is increasing at the expense of squamous carcinoma, the latter is still the most prevalent histologic type. The accuracy of percutaneous needle biopsy and transbronchial biopsy of lung nodules reported from this group of 941 hospitals was high and equal to that reported by single institutions. The percentage of patients having a resection did not increase from 1981 to 1986, but for smaller lesions a move was apparent toward more lung-sparing resections. Little change has occurred in the use of adjuvant radiotherapy, particularly in stage III disease, where approximately 50% of the patients received postoperative irradiation. An improvement in the overall 5-year survival when compared with Surveillance, Epidemiology, and End Results data was noted. Whether this is a true improvement in survival or is the result of selection because of an unrecognized change in the pattern of care for patients with a carcinoma of the lung is unknown.

Adult↗
PubMed1989

Technique and complications of reconstruction of the pelvic floor with polyglactin mesh.

A polyglactin mesh sling was used to reconstruct the pelvis in eight patients after colorectal or urologic resections in preparation for postoperative radiation therapy. There were three perioperative complications--a pelvic abscess requiring percutaneous drainage, a wound dehiscence and a herniation of the small intestine between the pelvic sidewall and mesh requiring small intestinal resection. There were two delayed complications, both partial small intestinal obstructions. One occurred just after the conclusion of radiation treatment and the other occurred five months after the conclusion of radiation therapy. Both obstructions responded to conservative management. None of the common acute radiation effects occurred during radiotherapy. One patient with delayed partial small intestinal obstruction had possible late radiation effects. The median follow-up period after radiation therapy was 12.5 months. Despite the complications described in this report, the use of a polyglactin mesh sling as an adjunct to resection of carcinoma of the pelvis has merit and should be studied further.

Aged↗
PubMed1988

Limitations of mammography in the identification of noninfiltrating carcinoma of the breast.

A retrospective study of 321 patients who underwent localizing mammography and excisional biopsy of the breast from 1984 to 1985 was performed. The study was undertaken to refine selection criteria for biopsy in women with nonpalpable mammographic abnormalities by comparing mammographic features and impression with histologic findings. Twenty-eight of 36 (78 per cent) noninfiltrating carcinomas presented with microcalcifications alone; in contrast, 27 of 39 (69 per cent) infiltrating carcinomas presented with a mass alone. As the number of microcalcifications increased, so did the incidence of carcinoma. The size of the mass was not a guide for predicting carcinoma. Although only 11 of 75 carcinomas presented as a mass with microcalcifications, 11 of 21 calcified masses were carcinoma. There were no significant differences in the mammographic presentation between ductal and lobular carcinoma. The sensitivity of the mammographic impression was 48/75 (0.64), and the specificity was 221/246 (0.898). The false-positive rate was 25/73 (0.34), and the false-negative rate was 10/141 (0.07). From this study, we concluded 1, the incidence of noninfiltrating carcinoma was significantly higher and the incidence of positive nodes was significantly lower in nonpalpable abnormalities than in palpable masses; 2, noninfiltrating carcinomas were generally associated with microcalcifications alone, but infiltrating carcinomas were generally associated with a mass alone, and 3, the diagnostic accuracy of mammography was limited by under-interpretation of the subtler signs of noninfiltrating carcinoma and by over-interpretation of mammographic findings generally accepted as criteria for carcinoma.

Biopsy↗
PubMed1979

Symptomatology as an indicator of recurrent or metastatic breast cancer.

Eighty-seven patients with recurrent breast cancer after mastectomy were analyzed for patterns of recurrence and methods of detection. After an average disease-free interval of 30 months, 38% developed osseous metastases, 16% recurred locally, 10% had local plus systemic disease, 10% showed pulmonary metastases and the remainder were distributed among liver, brain, and remaining breast disease. In 79 patients recurrence was heralded by symptoms. Physical examination in five asymptomatic patients revealed local or supraclavicular recurrence. In only three asymptomatic patients was recurrence documented by "routine" chest x-rays (in two), or liver enzymes/liver scan (in one). No asymptomatic disease was found by bone scan. It is concluded that periodic history, physical examination, and chest x-rays are the most important components in the follow-up of breast cancer patients. Radioisotope scans and other radiographs are valuable in confirming symptomatic disease and detecting additional diseases, but cannot be recommended routinely in the asymptomatic patient because of low yield and cost.

Bone Neoplasms↗
PubMed1978

Cytologic findings of aspiration of tumors of the breast.

Fine needle aspiration biopsy for cytologic diagnosis has been shown to be an effective adjunct to the clinical evaluation of masses of the breast by physical examination and mammography. In addition to adequately decompressing cystic masses, the procedure has been beneficial in obtaining a pathologic interpretation of any mass that is to be observed. Preoperative knowledge of the malignant nature of a mass of the breast allows the physician to investigate more selectively the possibility of metastatic disease and to consider more intelligently treatment options. Furthermore, the psychologic agony of the unknown for the patient and her family is avoided. Although histologic confirmation is always recommended before proceeding with mastectomy, a positive cytologic diagnosis can suffice when clinically advanced carcinoma is present or when there are medical contraindications to surgical treatment. Because of the false-negative rate of aspiration cytologic diagnosis, all clinically malignant or suspicious masses should have a biopsy in the face of benign cytology. This point cannot be over emphasized and is particularly pertinent to those patients in whom high risk factors of carcinoma of the breast are present. Inconclusive aspirates should be repeated or a biopsy of the mass should be done.

Adult↗