Biomedical subjects

D S Reintgen

Publications and source records attributed to D S Reintgen.

At least 91 records · Page 5Linked to original sources

PubMed1995

Analysis of residual cancer after diagnostic breast biopsy: an argument for fine-needle aspiration cytology.

BACKGROUND: Diagnostic breast biopsy (DxBx) requires an effective strategy for successful treatment of breast cancer by lumpectomy or mastectomy. Clearance of margins is required to achieve local control. METHODS: We reviewed 844 malignant diagnostic biopsies. The strategy was to perform DxBx on all nonpalpable lesions and fine-needle aspiration (FNA) on all palpable lesions. When FNA was equivocal, DxBx was performed. After positive DxBx, either the biopsy cavity or FNA-positive breast mass was excised, and margins were documented with touch preparation cytology analysis (TPC) and frozen section (FS) as necessary to achieve negative margins. RESULTS: Outside institutions referred 430 excisional biopsies. Two hundred twenty-five (52.3%) were found to have residual cancer at surgical excision. Our institution performed 414 biopsies: 169 were performed on nonpalpable lesions in which 58% had residual tumor at resection; 245 were diagnosed by FNA of palpable lesions. Residual disease was found in 12 (5%). CONCLUSIONS: Of patients who undergo DxBx, > 50% have residual breast cancer. It is recommended that (a) FNA be performed on all palpable masses or DxBx of nonpalpable masses; when cancer is diagnosed, proceed to surgical excision. (b) When lumpectomy is the option, margins should be reexcised and intraoperatively evaluated with TPC and FS at the time of axillary dissection.

Adenocarcinoma↗

PubMed1995

Tumor biology of infiltrating lobular carcinoma. Implications for management.

OBJECTIVE: The purpose of this study was to characterize the biologic determinants that affect the behavior and management of infiltrating lobular cancer. METHODS: A prospectively accrued data base containing 1548 breast cancer cases was queried for specific pathologic and mammographic features. From this data base, 777 patients treated and followed-up at the H. Lee Moffitt Cancer Center were reviewed, and comparisons were made between the following three histologic subgroups: 661 infiltrating ductal (ID), 42 infiltrating ductal plus infiltrating lobular (ID + IL), and 74 infiltrating lobular (IL). RESULTS: Comparisons of the three histologic forms of breast cancer demonstrated the following: 1. At diagnosis tumors with IL components were larger than those with ID components (p < 0.001); in addition, a greater percentage of IL cancers were T3 lesions (14.8%), compared with ID cancers (4.5%). 2. Sizes of IL tumors were underestimated frequently by mammographic examinations when compared with pathologic measurements (p < 0.001). 3. By comparison to ID tumors, increasing IL tumor size is less likely to be associated with an increased number of metastatic lymph nodes per patient (p = 0.09). 4. Infiltrating lobular cancers treated by lumpectomy with cytologic surgical margin analysis more often gave false-negative results than did ID cancers (p < 0.001). 5. Infiltrating lobular cancers treated by lumpectomy required conversion to mastectomy over 2 times more frequently than ID cancers treated by lumpectomy. 6. Mastectomy was performed more frequently than lumpectomy for the treatment of IL versus ID tumors (p = 0.039). CONCLUSIONS: Infiltrating lobular cancers are biologically distinct from ID cancers. Although lumpectomy may be performed safely in selected patients, multiple difficulties exist in the management of IL cancer, particularly when breast conservation is chosen.

Adult↗

PubMed1994

Influence of physician communication on newly diagnosed breast patients' psychologic adjustment and decision-making.

BACKGROUND: Physician-patient communication is of critical importance when a breast cancer diagnosis is made, because the emotionally overwhelmed patient must be educated about her disease and available treatments so she can participate in decisions about her care. A research study addressed the hypothesis that patients whose surgeons used psychotherapeutic techniques during the cancer diagnostic interview would have better psychologic adjustment to their cancer. METHODS: One hundred women surveyed 6 months after surgery completed the Cancer Diagnostic Interview Scale (CDIS) and the SCL-90-R, a measure of psychologic well being. RESULTS: Factor analysis of the CDIS revealed that the physician's caring attitude was perceived by the women as most important, with information-giving as a much weaker component. Multiple regression analysis supported the hypothesis that psychologic adjustment was predicted by physician behavior during the cancer diagnostic interview. Other significant predictors of adjustment were a history of psychiatric problems and premorbid life stressors. CONCLUSIONS: Provision of information needed for decision-making appears to be valued largely within the context of a caring physician-patient relationship. Specific surgeons' behaviors believed to facilitate patient adjustment include expressing empathy, allowing sufficient time for patients to absorb the cancer diagnosis, providing information, and engaging the patient in treatment decision-making.

Adaptation, Psychological↗

PubMed1994

Age as a prognostic factor in the malignant melanoma population.

BACKGROUND: The incidence of malignant melanoma is increasing faster than any other cancer, and the state of Florida has one of the highest incidence of melanoma in the United States. This increased incidence is thought to be due to the intense sunlight exposure and ultraviolet radiation exposure in the elderly population. With the increased emphasis on issues of aging, it is appropriate to study the role of age as a prognostic factor for malignant melanoma in the Florida population. METHODS: A retrospective, computer-aided search identified 442 consecutively registered patients with malignant melanoma at the Cutaneous Oncology Program. All patients had stage 1 or 2 disease (cutaneous disease only) at diagnosis. Prognostic variables analyzed included the most powerful factors for stage 1 and 2 melanoma, tumor thickness, ulceration, and Clark level of invasion. Other prognostic variables included in the analysis were the clinical variables of sex and primary site (axial vs. extremity). The population was divided into patients < or = 65 and > 65 years of age. RESULTS: Significant disease-free survival differences were encountered in the older population, with only 55% of the elderly population being disease free at 5 years compared with 65% for the younger population (p = 0.0073). However, a greater percentage of patients with melanoma who were > 65 years of age had ulcerated lesions (17.5% vs. 12.9%) and a greater percentage of thick lesions at diagnosis (67.2% vs. 62.7%). Both of these prognostic factors would bias the older population with a poorer survival. A stepwise regression analysis of the entire population was performed, treating age as a continuous variable. Surprisingly, increasing age along with tumor thickness were the only significant predictors for disease-free survival. After inclusion of these two prognostic variables, none of the other prognostic factors, including Clark level, ulceration, sex, and primary site, added to the prognostic model. CONCLUSIONS: From this analysis, it is apparent that geriatric patients with melanoma have a worse prognosis than a younger control population, even after the correction for the more commonly cited prognostic factors. This information should be used in mathematical modeling to identify high-risk populations who are candidates for perhaps more aggressive primary or adjuvant therapies.

Adult↗

PubMed1994

The use of lymphoscintigraphy in melanoma of the head and neck.

Lymphoscintigraphy has been shown to be of assistance in defining the lymphatic drainage pattern of melanoma. In this study, lymphoscintigraphy was performed on 25 patients with primary melanoma (stages I and II at diagnosis) of the head and neck to determine whether the lymphatic drainage seen on lymphoscintigram was the same as the surgeon's expected lymphatic drainage. The lymphoscintigrams were discordant in 21 of the patients (84 percent) with drainage to a lymphatic basin not predicted clinically. Based on the discordant lymphoscintigram, a change in surgical therapy occurred in 13 of 21 patients (62 percent). Of the 25 patients, 18 underwent prophylactic node dissections and 7 did not. Of the nodal basins removed, 27 of 38 nodal bases (71 percent) were seen on lymphoscintigraphy. Melanoma metastatic to lymph nodes was removed from nodal basins identified by the lymphoscintigram, but not predicted clinically, in two patients (8 percent). Historical anatomical patterns of lymph drainage and the clinical impression of experienced surgeons cannot reliably predict the pattern of lymphatic drainage in patients with melanoma of the head and neck.

Adolescent↗

PubMed1993

Fine needle aspiration biopsy of palpable breast lesions. Review and statistical analysis of 1875 cases.

Fine needle aspiration biopsy (FNAB) is an increasingly accepted method for investigating palpable breast nodules. We reviewed our experience with a consecutive series of 1875 FNABs performed using 21 or 23 gauge butterfly needles. Correlation was made with histology (524 cases) or clinical follow-up (2-70 months). Cytological diagnoses utilized histopathological terminology and were categorized as: unsatisfactory (93 or 4.96%); no evidence of malignancy (1295 or 69.07%); atypical (183 or 9.76%); suspicious (42 or 2.24%); malignant (262 or 13.97%). Of the 1571 benign aspirates, 220 or 14% were followed by excisional biopsy because of clinical suspicion, atypia or hypocellularity. Of these aspirates, 198 were benign while 22 proved to be malignant (one in situ ductal, one intracystic papillary, two tubular, one cribriform, seven ductal nos, three in situ and five infiltrating lobular carcinomas, two large cell lymphomas). Malignancy was detected histologically in 12.9% of unsatisfactory, 3.06% of benign but often hypocellular, 8.16% of atypical, 97.62% of suspicious and 100% of malignant aspirates. Considering only histologically verified breast aspirates and including suspicious cytodiagnoses, FNAB had a sensitivity of 93.23%, a specificity of 99.50%, positive and negative predictive values of 99.62% and 90%, and an overall diagnostic accuracy of 95.61%. This series clearly shows that FNAB effectively evaluates palpable breast lesions when careful consideration is given to clinical judgement, specimen procurement, diagnostic criteria and a clinically relevant reporting style.

Adolescent↗

PubMed1992

Psychosocial aspects of melanoma.

Seventy-five patients with melanoma were surveyed for recent history of major stress, coping styles, and psychiatric disturbance. Recurrence of disease was strongly related to biological variables (stage and Breslow depths) but not to psychological measures. Major life stress was not related to stage, Breslow, Clark level, or estimates of lymphocytic infiltration of tumor. Coping styles were paradoxically related to major life stress such that history of major stresses was associated with greater confrontation of the melanoma diagnosis, greater will to fight the disease, and less avoidance of its frightening aspects. Experience with fewer major life stresses was associated with a defeatist attitude characterized by an expectation of a poor prognosis and little control over outcomes. More than 50% of the sample had experienced at least one major life stress in the past 5 years. This figure is consistent with prior work and indicative of a higher than normal rate of major life stress in the years before diagnosis.

Adaptation, Psychological↗

PubMed1992

Treatment of the primary in malignant melanoma of the skin.

Surgical excisional therapy of malignant melanoma is the primary method of treatment for malignant melanoma. The exact size of the excisional therapy depends on the depth and location of the tumor. At the University of South Florida (Tampa, FL), tumors less than 0.76 mm in depth are resected with a 1-cm margin and tumors greater than 0.76 mm in depth are resected with a 3-cm margin. The location of the tumor also determines the exact margin of excision. Maximal reconstructive efforts following general principles of plastic and reconstructive surgery are noted and used for producing an optimal functional and aesthetic result.

Esthetics↗

PubMed1992

Etiology and prognosis of local recurrence in malignant melanoma of the skin.

All patients with stage I and stage II malignant melanoma of the skin were analyzed for stage; time of local, regional, or systemic recurrence, or two or more of these events; presence or absence of ulceration of the primary tumor; thickness of the primary tumor; level of invasion according to Clark; and margins of resection. Local recurrence had a significant negative impact on the long-term survival of patients. Our data revealed that local recurrence had the same poor prognostic effect as regional or systemic recurrence, or both. Factors significant in predicting local recurrence included the primary tumor characteristics of ulceration of the primary tumor and thickness of the primary tumor. Margins of resection and level of invasion were not noted significant in predicting local recurrence.

Florida↗

PubMed1992

Lymphoscintigraphy in malignant melanoma.

The development and rationale for the use of lymphoscintigraphy in the preoperative evaluation of patients with malignant melanoma being considered for elective lymph node dissection is reviewed. This overview is updated by an analysis of 135 patients with early stage malignant melanoma involving the head, neck, shoulders, and trunk at Moffitt Cancer Center and Research Institute at the University of South Florida (Tampa, FL). High discordancy rates (overall, 41%) were seen between drainage patterns predicted from historical anatomical guidelines and those revealed by the lymphoscintigraphic examination. The high discordancy rate was most pronounced in the head (64%) and the neck (73%). Surgical management was changed in 33% of the patients, overall. A preoperative lymphoscintigram is recommended for all patients with melanoma with head, neck, and truncal lesions evaluated for elective lymph node dissection as the lymphatic drainage patterns are often unpredictable and variable.

Decision Making↗

PubMed1992

The concept of lymph node dissections in patients with malignant melanoma.

Therapeutic lymph node dissections in patients with grossly palpable metastatic melanoma are performed to control regional disease, to salvage a small percentage of patients, and to obtain staging information. Patients with malignant melanoma may undergo elective lymph node dissections, when the basin is clinically negative, for three reasons. There is some evidence based on large retrospective studies that survival is increased in patients with intermediate thickness melanoma if elective lymph node dissections are performed as part of the initial treatment of the primary melanoma. Second, in a small percentage of patients, a previous elective lymph node dissection may have helped control disease in the regional lymphatics, so that more extensive procedures, including amputations, are not necessary. Another important reason is to obtain staging and prognostic information for the patient because most adjuvant protocols are based on the presence or absence of disease in the regional basin. During a 3-year period, 115 patients have undergone a regional nodal dissection at the Moffitt Cancer Center and James Haley VA Hospital as part of their surgical treatment. With a follow-up of 3 years, patients with 1 node positive do significantly better than those with more than 1 node positive in their dissection (p = 0.06). The percentage of nodes positive is also important. Those patients who have less than 10% of their nodes involved with metastatic melanoma have a better survival than those patients whose percentage is greater than 10% (p = 0.07).

Adolescent↗

PubMed1992

Recurrent malignant melanoma: the identification of prognostic factors to predict survival.

The prognostic factors for stage 1, 2 melanoma have been elucidated. Tumor thickness, ulceration of the primary melanoma, and perhaps, primary site may be used to predict the percentage of patients with regional nodal disease or systemic metastases and the prognosis of patients who have only cutaneous disease at diagnosis. Very little is known about prognosis once there is a recurrence. A retrospective, computer-aided chart review identified 4,185 patients registered at the Duke University Melanoma Database who had stage 1, 2 disease at diagnosis. During a mean follow-up period of 7 years, 35.9% experienced a recurrence. Local regional recurrences explained 62.5% to 85.5% of the recurrences. Even after elective node dissections, local regional recurrences explained most relapses (58.1%). Sixty-five percent of the recurrences occurred within the first 3 years of of follow-up. There was a pronounced difference in 5-year survival in those patients who suffered a recurrence sometime during their clinical course compared with those who never relapsed (p = 0.00001, for trunk primary melanoma). Patients with local or regional recurrence have a better prognosis than patients who relapse systemically, with 5-year survivals from the time of recurrence of 55% for a patient with a local recurrence, 51% for a patient with a regional nodal recurrence, and 20% for a patient with a systemic recurrence. A multivariate regression analysis identified thickness, ulceration of the primary melanoma, and age and location of the primary melanoma on the extremity as variables that predicted prognosis. The only factors concerning the recurrent state that added prognostic information was the disease-free interval and the presence of systemic metastases as the initial recurrence.

Adolescent↗

PubMed1992

Isolated limb perfusion for recurrent melanoma of the extremity.

Recent reports in the literature suggest that hyperthermic isolated limb perfusion (HILP) may be effective in preventing local recurrence in patients with deeply invasive melanoma or in patients with recurrent disease confined to the extremity. It has been used in the past as an adjuvant treatment after resection of the primary melanoma or recurrence, or as a therapeutic measure if all the disease on the extremity cannot be resected. A prospective, nonrandomized trial of 16 patients with melanoma with recurrent disease confined to the extremity underwent HILP. The protocol involved the wide local excision of all recurrent disease when possible, elective or therapeutic node dissection when indicated, and HILP using cisplatin. In 11 patients in whom all recurrent disease could be resected and the HILP was considered prophylactic, only 1 patient's disease has recurred in the perfusion circuit. Before the perfusion, the 11 patients had a total of 19 local or intransit recurrences. Of the 5 patients in whom all recurrent disease could not be resected, disease persisted in 4 patients. When compared with a concurrent control population of patients with extremity melanoma who had a local recurrence and were not perfused, the patients with melanoma who underwent HILP had a significant prolongation of disease-free survival (p less than 0.05), but a similar actuarial survival. In this study, we demonstrate that HILP can prevent local regional recurrences in patients with metastatic melanoma who are at high risk for further recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Arm↗

PubMed1992

The evaluation of putative tumor markers for malignant melanoma.

Biomarkers have long held out the promise that malignancies might be diagnosed early and that patients could be monitored more confidently during their clinical course to more reliably predict recurrence and the effect of therapy. Reliable tumor markers have been described for colon carcinoma, hepatomas, and other tumors, but no reliable marker has been identified to monitor the course of malignant melanoma. Recently, the plasma level of lipid-bound sialic acid (LASA-P) has been described as reflecting an alteration in the surface membrane of cancer cells. An attempt was made to correlate the LASA-P level, along with the serum level of neuron-specific enolase, a glycolytic enzyme specific to cells of neuroectoderm origin including melanocytes, with clinical disease activity with a follow-up to at least 2 years. Two hundred seventy patients had blood samples drawn at various times during their clinical course for assay of LASA-P and neuron-specific enolase. Eighty of the patients (30%) sampled developed a recurrence sometime during their clinical course, whereas another 10 patients had active disease noted at diagnosis with evaluative tumor markers. The sensitivity and specificity of neuron-specific enolase was 27% and 77%, respectively, and cannot be recommended as a marker for melanoma. LASA-P showed a sensitivity of 65%, with 55 patients recurring and having active disease with abnormally high markers and 35 patients recurring or having active disease with normal markers. Specificity of the LASA-P test was 76%. When recurrence was associated with elevated LASA-P levels, the elevated level preceded recurrence by a median of 9.3 months. LASA-P may be a useful marker to follow patients with malignant melanoma.

Biomarkers↗

PubMed1992

Adjuvant chemotherapy in malignant melanoma using dacarbazine, carmustine, cisplatin, and tamoxifen: a University of South Florida and H. Lee Moffitt Melanoma Center Study.

A prospective, nonrandomized trial was performed of the four-drug chemotherapy protocol consisting of dacarbazine, carmustine, cisplatin, and tamoxifen citrate given to high-risk patients for recurrence of melanoma after local regional treatment. The treated patients were consecutively registered and 6 patients who did not elect to be treated served as the control population. Criteria for inclusion in the trial were the presence of four or more lymph nodes positive for metastatic melanoma on regional modal dissection, the presence of metastatic disease in second station lymph node areas such as the iliac basin, greater than 5 cm in maximal diameter tumor burden in the nodal basin, and patients who had resected stage 4 (systemic metastases) disease with clear margins and were rendered free of disease. Actuarial survival curves for the treated group and the control subjects were similar (p = 0.91). There was a definite trend toward an increased disease-free survival for the group receiving adjuvant chemotherapy (p = 0.09). The mean disease-free survival for the control population was 200 days and for the treated group, 600 days. The study suggests a therapeutic benefit for adjuvant chemotherapy treatment of patients with metastatic melanoma who have been rendered free of disease but are at high risk for recurrence.

Adult↗

PubMed1992

Treatment of stage IV malignant melanoma with dacarbazine, carmustine, cisplatin, and tamoxifen regimens: a University of South Florida and H. Lee Moffitt Melanoma Center Study.

Fourteen consecutive patients with stage IV metastatic melanoma with measurable disease were treated between January 1989 and August 1990 with combination chemotherapy. The chemotherapy regimen (DBPT) included dacarbazine (DTIC) 200 mg/m2/i.v. on days 1 through 3, carmustine (BCNU) 150 mg/m2/i.v. on day 1, cisplatin 25 mg/m2/i.v. on days 1 through 3, and tamoxifen citrate 10 mg p.o. twice daily. This cycle was repeated every 4 weeks. BCNU was given every other cycle. A total of six cycles of chemotherapy were delivered. Patients were then restaged to assess the response. Six concurrent patients during the study period did not elect to undergo chemotherapeutic approach and served as control subjects. When evaluated at 300 days of follow-up, 4 patients had response (3 complete response and 1 partial response), 3 had stable disease, and 7 showed progression. At 300 days of evaluation after chemotherapy, survival appeared significantly increased between treated and nontreated groups, that is, 48% in the chemotherapy group versus 27% in the control group (p = 0.03). Actuarial survival was significantly increased between those who responded to chemotherapy versus the nonresponders. At 300 days follow-up, survival was at 83% in the responders and 22% in nonresponders (p = 0.0002). This study shows that in stage IV disease, systemic chemotherapy appears to make a difference in survival. Attempts to discover better chemotherapy regimens to improve response in patients with stage IV malignant melanoma should continue to be rewarded.

Adult↗

PubMed1992

Detection of occult lymph node metastases in malignant melanoma.

An accurate prediction of the prognosis of melanoma is dependent on the ability to determine the presence or absence of malignant cells in lymph nodes. Our laboratory has developed a method for screening lymph node sections for the presence of micrometastatic disease. The nodes obtained from regional lymphadenectomies are dissected free from surrounding tissue and divided into halves. One-half is subjected to routine histopathological evaluation and the other one-half is disrupted into a single cell suspension and placed into cell culture. Lymph nodes from 19 patients with malignant melanoma were evaluated by tissue culture. Tumor cells were isolated in 125 of the 173 nodes examined. In contrast, only 14 of these nodes were initially found positive for melanoma by routine pathological evaluation. All lymph nodes positive for melanoma by pathological evaluation were also culture positive. Examination by cell culture has led to an upgrade in the stage of disease in 58% of the histologically node-negative patients. In addition, 43% of the patients who were histologically node negative but culture positive have recurred, suggesting some clinical correlation. These results indicate that the tissue culture method for detecting micrometastatic lymph node disease may prove more reliable and sensitive than current techniques for determining the presence of occult melanoma.

Antigens, Neoplasm↗

PubMed1992

Metastatic melanoma with an unknown primary.

An infrequent initial presentation for malignant melanoma is the diagnosis of metastatic disease without a history of an obvious primary lesion. Confusion exists in the literature concerning the workup, treatment, and prognosis of the unknown primary melanoma. A retrospective, computer-aided chart review of 580 consecutively registered patients with melanoma at the University Treatment Center (Tampa, FL), identified 18 patients with an unknown primary presentation. There were 10 males and 8 females with a mean age of 38.4 years. Ninety-four percent of the patients were diagnosed with metastatic disease in a nodal basin, whereas 1 patient had a resected isolated lung mass as the initial presentation. In the patients who presented after having a biopsy of a single positive node for diagnosis, more disease was recovered in the nodal basin with a formal node dissection in 59% of the patients. Actuarial survival curves were constructed for the group with unknown primary melanoma. As a control population, survival curves were constructed of the subpopulation of patients with melanoma who had a known primary and had stage III (regional nodal disease) at diagnosis. There was no difference in survival between those with known and unknown primary melanoma (p = 0.96).

Adolescent↗