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Biomedical subjects

H Gutman

Publications and source records attributed to H Gutman.

At least 19 recordsLinked to original sources
PubMed2001

Surgery for abdominal metastases of cutaneous melanoma.

The objective of this study was to support our hypothesis that surgical resection of abdominal metastases of melanoma, regardless of symptomatology, could provide prolonged palliation and improved survival. We performed a retrospective chart review at M.D. Anderson Cancer Center. A series of 251 melanoma patients (stages I, II, or III at registration) who developed intraabdominal metastases during follow-up were studied. Altogether, 96 patients underwent 119 laparotomies; 51 underwent endoscopic or percutaneous procedures; and 116 patients were treated medically. Surgery was associated with a median survival of 11 months, significantly longer than that with other treatment (p < 0.001). Tumor was extirpated during 37% of the first laparotomies, and in an additional 33% very good palliation was achieved with incomplete resection. Tumor extirpation was associated with 10-month symptom-free survival (SFS), significantly longer than that with any other approach (p < 0.0001). In the nonsurgically treated patients, good palliation was achieved in 8% to 17% of patients with no complete response. The median SFS after surgery was 5 months, but 23% of patients were symptom-free more than 12 months; 87 patients with minimal symptoms; and 72 severely symptomatic patients underwent surgery. Complete resection was feasible in 42% and 34%, respectively. Surgery was associated with 12 months median survival in both groups. There was a significant survival benefit from surgery in patients with gastrointestinal (GI) tract metastases in contrast to those who had non-GI metastases. For the 96 surgically treated patients, a time interval of more than 4 years between diagnosis of the primary lesion and the abdominal recurrence predicted decreased risk of death (p = 0.038). The 30-day postoperative complication and mortality rates were 19.0% and 3.3%, respectively. Complete surgical resection of melanoma metastases in the abdomen is associated with median and symptom-free survival benefits. Symptomatic and asymptomatic patients benefit equally, especially if abdominal metastases appear more than 4 years after the initial diagnosis and do not involve non-GI viscera. Less than complete resection can provide durable palliation.

Abdominal Neoplasms↗
PubMed2000

Standard and nonstandard applications of sentinel node-guided melanoma surgery.

Identification and histologic study of the sentinel node (SN) is an acceptable, yet not firmly established, guide for treating intermediate-thickness melanoma. This study widens the range of applications of this technique. We included 97 patients with intermediate-thickness melanoma lesions or lesions for which there is no standard treatment. Fifty-six underwent preoperative lymphoscintigraphy, and all underwent intraoperative lymphatic mapping (IOLM) using blue dye, followed by frozen section study and total node processing by serial sections. Elective lymph node dissection was performed in cases of metastasis to the sentinel node or technical failures with high risk. Four categories were defined: (A) intermediate-thickness lesions (mean 2.27 mm) (n = 45); (B) thin lesions (mean 1.14 mm) with risk factors of regional failure (n = 27); (C) lesion thickness close to but more than 4 mm (n = 10); and (D) lesions of undetermined thickness (n = 15). Median follow-up was 30 months (range 13-51 months). Intraoperative lymphatic mapping successfully identified the sentinel node (SN) in 93% of basins explored. Metastases were detected in 11 SNs. There were three lymph basin recurrences in patients with previously negative SNs, all salvaged by therapeutic lymph basin dissection and are NED (no evidence of disease). Two SN(+) patients had systemic recurrences; one died of his disease, and the other is alive with disease. One SN(-) patient died NED owing to other cause. This technique spared 83% of category A patients from lymph node dissection. It allowed better staging and better decision making for treatment in categories B and D; and it prevented early regional recurrences in category C patients. Intraoperative lymphatic mapping with SN guidance is a novel, lo

Adult↗
PubMed2000

Applicability of the sentinel node technique to Merkel cell carcinoma.

BACKGROUND: Merkel cell carcinoma (MCC) resembles malignant melanoma in several ways. Both are cutaneous lesions of the same embryonic origin. Both have an unpredictable biologic behavior, early regional lymph node involvement, early distant metastases, and high recurrence rate. OBJECTIVE: To apply the sentinel node technique described for melanoma to MCC in light of the common biologic features of these two tumors. METHODS: Preoperative lymphoscintigraphy, intraoperative lymphatic mapping, and sentinel node biopsy and frozen section histology were performed to guide the surgical treatment of three patients with MCC. RESULTS: Application of this approach in patients with MCC is feasible, reproducible, and seems reliable. CONCLUSION: The use of the sentinel node technique for MCC will reduce the number of unnecessary lymphadenectomies, will enable identification of microscopic metastases to lymph nodes, and will improve the stratification and accrual of patients into adjuvant treatment protocols. It may even lead to a survival benefit.

Aged↗
PubMed1999

Role of radiotherapy in sarcoma of the breast--a retrospective review of the M.D. Anderson experience.

BACKGROUND: The role of adjuvant radiotherapy for sarcoma of the breast, based on local extension of disease and patterns of failure, remains undefined because of the rarity of the disease presentation. METHODS: Fifty-nine cases of soft tissue sarcoma of the breast were retrospectively reviewed. Cystosarcoma phylloides was excluded from analysis. Surgical intervention consisted of segmental resection (n = 16) or mastectomy (n = 38); five patients underwent excisional biopsy. Adjuvant radiotherapy was administered in four patients following segmental resection and in 13 patients after mastectomy. Doses totaled 50 Gy in the majority of patients, and conventional criteria and radiotherapy techniques for adjuvant breast irradiation were used. RESULTS: None of the dissected axillary nodes contained metastatic tumor on pathologic review. Patterns of failure were evaluated. Tumor size (P < 0.03) and surgical margins (P < 0.002) were predictive of local failure (LF). Due to limited patient numbers, no statistical significance was identified with any treatment modality. Following mastectomy alone, LF occurred in 13 patients (34%) versus the 13% rate of LF with mastectomy and radiotherapy (P = NS). Distant metastases developed concurrently with the two local failures in the group that underwent mastectomy and radiation. After segmental mastectomy, LF occurred in 3 cases (25%) concurrent with distant metastases: no LF were noted after segmental mastectomy and radiation (P = 0.27). For all treatment groups, local recurrences were characterized as multiple and involved the chest wall. Local failure occurred in 60% of patients with positive surgical margins who did not receive adjuvant irradiation. Irrespective of surgical margins, over 75% of local recurrences developed among patients treated by surgery alone. CONCLUSIONS: The role of radiotherapy for breast sarcoma remains undefined due to the rarity of this disease presentation. This retrospective review failed to demonstrate a statistical benefit for the administration of adjuvant irradiation in sarcoma of the breast, probably because of limited patient numbers. Because large tumor size and positive surgical margins incur a higher risk for LF, radiotherapy is probably indicated in these cases. Axillary dissection obligates the radiotherapist to treat the axilla in order to include all tissues in the surgical bed, and should be avoided to reduce potential treatment related morbidity. Established therapeutic principles and techniques used for both soft tissue sarcoma and breast cancer should continue to be applied.

Adolescent↗
PubMed1999

Sentinel-node guided lymph-node dissection for merkel cell carcinoma.

Merkel cell carcinoma is an aggressive neuroendocrine skin tumour. Treatment is still debatable. Merkel cell carcinoma resembles malignant melanoma in its cutaneous presentation and its embryonic origin; both have unpredictable biological behaviour, early regional lymph node involvement, early distant metastases and a high recurrence rate. In light of these common features, we used pre-operative lymphoscintigraphy, intraoperative lymph-node mapping and sentinel-node biopsy-a well-described technique for the treatment of melanoma-in a 60-year-old man with Merkel cell carcinoma in the right buttock. Following frozen section identification of a metastatic first-order sentinel node, radical right groin dissection was performed. All the other lymph nodes in this basin proved to be disease-free, including the second-order sentinel node and Cloquet node. The patient is now being treated with adjuvant chemotherapy and radiotherapy. This case shows that sentinel-node guided dissection is applicable to Merkel cell carcinoma.

Carcinoma, Merkel Cell↗
PubMed1999

Role of radiation therapy in the management of cutaneous malignant melanoma.

Traditionally, cutaneous malignant melanoma is regarded as a radioresistant tumor. Recently, however, an increasing number of clinical studies have refuted this notion. The authors examined the role of radiation therapy in the palliative and/or adjuvant treatment of cutaneous malignant melanoma. The records of 69 patients with cutaneous malignant melanoma were reviewed. Twenty-five patients with extensive regional lymph node involvement received adjuvant radiation therapy after primary surgical treatment, and the remainder received palliative radiation therapy. The therapeutic significance of fraction size was analyzed. In the palliative radiation therapy group, the response rate was 52% with a fraction size < or = 300 cGy and 35% with a larger fraction size (p > 0.05, NS). Local regional control rates after adjuvant radiation therapy using conventional fractionation and larger fraction size were 87% and 82%, respectively (p > 0.05, NS). Radiation therapy is effective in the management of cutaneous malignant melanoma. It plays an important role in the palliation of metastatic disease and as an adjuvant treatment. No advantage in using a large fraction size over conventional dose schedules was found.

Adult↗
PubMed1999

Usefulness of serological determinations of soluble 53 kDa protein in follow-up of melanoma patients.

The role of the soluble 53 kDa antigen (s53) determinations in follow-up of melanoma patient was studied. high performance liquid chromatography (HPLC) was used to measure serum levels of s53 antigen after its partial isolation on gel fiberglass (GFG) affinity chromatography columns. Two main proteins were isolated from these columns as representatives of soluble tumor-associated antigens (TAA) with molecular masses of 64 and 53 kDa. In a Western immunoblot analysis, the 53 kDa protein exhibited a strong positive reaction to the commercial p53 antibody. HPLC isolated both antigens with individual variations and significant differences in their concentrations in patients from different groups. The presence of metastases was manifested by a significant increase in the serum levels of both isolated TAA. This finding is in accordance with our previous observations on the role of the soluble 53 kDa protein in the development of colon and uterine cancers. We conclude that the determination of the serum level of the s53 antigen is of diagnostic significance in the monitoring of melanoma patients.

Antigens, Neoplasm↗
PubMed1999

Tailoring treatment for classical Kaposi's sarcoma: comprehensive clinical guidelines.

Classical Kaposi's sarcoma (CKS) is a rare indolent proliferative disease which is particularly prevalent among Jews of Ashkenazi and Mediterranean origin. To define guidelines for its comprehensive management, we conducted a retrospective analysis of 123 patients, focusing mainly on treatment modalities. The CKS-related mortality was 4% (5 patients). Of the 39 patients for whom observation only was the primary approach, 15 (38%) remained progression-free for 1-83 months (median, 4 months). Twenty-nine of the 52 (56%) patients who underwent surgery as the primary approach remained recurrence-free for 1-162 months (median, 15 months). Radiotherapy achieved an objective response in 74 courses (85%), including 50 (58%) complete responses. Symptomatic relief was reported in 95% of the patients. Vinblastine (27 series) achieved an objective response in 73% of series, including 22% complete responses. Multivariate analysis of time to progression with observation alone identified immunosuppression as the only significant independent factor that predicted disease progression. Our study suggests that observation alone may be sufficient for immunocompetent asymptomatic patients; symptomatic resectable lesions are suitable for simple excision; and more advanced disease or unresectable lesions require radiotherapy. If disease is extensive or the other approaches fail, chemotherapy is appropriate. Tailoring the treatment for CKS is an integrative process, requiring good understanding of the role of each available modality in the different clinical disease settings.

Adult↗
PubMed1995

Biologic distinctions and therapeutic implications of sarcomatoid metaplasia of epithelial carcinoma of the breast.

BACKGROUND: Malignant sarcomatoid metaplasia of epithelial carcinoma of the breast (carcinosarcoma) is diagnosed at an annual rate of two cases per 107 women in the United States of America. It seems that these tumors behave differently than other carcinomas or sarcomas of the breast. STUDY DESIGN: The University of Texas M. D. Anderson Cancer Center experience (1947 to 1991) treating 50 patients (mean age of 50 years, range of 25 to 76 years) was retrospectively reviewed. The five-year overall survival and disease-free survival rates were compared and prognostic factors were identified. RESULTS: The overall survival rate of 43 percent was lower than had been expected for carcinoma of the breast. No patient with stage IV disease survived five years. Tumor size and stage at diagnosis had the strongest impact on outcome. The impact of axillary lymph node status on prognosis was less than expected. Hormonal receptor levels were positive in only 12.5 percent of the tumors tested. Mastectomy with adjuvant chemotherapy or radiotherapy, or both, was superior to mastectomy alone and to wide local excision with or without adjuvant therapy, particularly for patients with stage II disease. If complete surgical resection is possible, the surgical approach for treatment of recurrent disease is better than any other modality. CONCLUSIONS: Carcinosarcoma behave biologically differently than conventional carcinoma of the breast in that sarcomatoid characteristics dominate the clinical course. These biologic distinctions should direct the treatment toward a multimodality approach that includes mastectomy and sarcoma-oriented adjuvant chemotherapy and radiotherapy.

Adult↗
PubMed1994

Sarcoma of the breast: implications for extent of therapy. The M. D. Anderson experience.

BACKGROUND: Sarcoma of the breast is a rare clinical entity for which there are no prospective data about extent of surgery indicated or role of multimodality therapy. The purpose of this study was to examine one of the largest single institutional experiences to shed light on these clinical issues. METHODS: This study retrospectively reviewed 60 cases of sarcoma of the breast (cystosarcoma phyllodes excluded). RESULTS: For the entire series there was a median overall survival time (OS) of 67 months and a disease-free survival period (DFS) of 18 months. Tumors smaller than 5 cm were associated with a better DFS (p < 0.04) and OS (p < 0.009). Patients with tumors less than 5 cm in diameter did equally well whether treated by wide local excision or mastectomy. Angiosarcoma histologic characteristics were associated with longer OS than stromal sarcoma (p = 0.017), malignant fibrous histiocytoma (p = 0.075), or fibrosarcoma (p = 0.08). Axillary dissections did not recover any nodal metastasis; moreover, treatment in 75% of the patients with negative nodes subsequently failed. Regional lymph node metastases were always and only in the context of disseminated disease. Adjuvant chemotherapy and/or radiotherapy was associated with prolonged DFS (p = 0.015). There was a trend toward improved local control with adjuvant radiotherapy (p = 0.14). CONCLUSIONS: Lesions less than 5 cm should be treated by breast-preserving wide local excision, and adjuvant radiotherapy should be considered for selected subgroups. For tumors 5 cm or larger, a more aggressive approach seems appropriate; consideration should be given to neoadjuvant chemoradiation followed by margin-negative surgery (if possible). There is no demonstrable staging or therapeutic role for routine axillary dissection.

Adolescent↗
PubMed1993

Effect of surgery on peripheral blood lymphocyte locomotion through type I collagen.

BACKGROUND: Locomotion of peripheral blood lymphocytes (PBL) through peritumoral matrix is obligatory for tumor cell killing. The authors investigated the effect of surgery on lymphocyte locomotion and compared it with the effect on natural killer cell cytotoxicity (NKCC). METHODS: PBL from 12 patients with cancer were assessed for locomotion in Type I rat-tail collagen. Preoperative and postoperative locomotion (after 20 hours of incubation) and NKCC were estimated. RESULTS: Locomotion of lymphocytes through collagen increased significantly after operation in 6 of 12 patients, whereas only 1 of 12 had a decrease (P < 0.001). Short-term (20-hour incubation) exposure of the locomotory HSB cell line to patient plasma samples did not affect their migration. NKCC, as estimated against K562 target cells with the use of the 51Cr-release assay, decreased 5-50% after operation in 9 of 12 patients (P = 0.006). No correlation could be demonstrated between the changes in locomotion and NKCC (regression analyses), nor were identifiable clinical factors associated with these changes. CONCLUSIONS: Locomotion of PBL through collagen increases after operation in patients with cancer, whereas possibly independent factors may decrease postoperative NKCC.

Cell Movement↗
PubMed1993

Locomotion through three-dimensional type I rat tail collagen. A modified mini-assay.

There is an increased application of three-dimensional type I rat tail collagen as an in vitro model for the peritumoral matrix in analysis of lymphocyte migration. The increased demand prompted us to modify the previous methods. We here describe our 'mini'-setup of the collagen model assay, which uses only 1/20 the amount of collagen medium and the number of cells used in the conventional assay. The modified assay was tested for optimal collagen concentration in gel for upward and downward migration, for locomotion from a collagen-gel bead into a collagen overlayer for demonstration of the effect of inhibitors and for differentiation between locomotory properties of lymphocyte subpopulations. The results verify that the mini-assay is an applicable in vitro model, easily read and amenable to limited blood samples such as those obtained from cancer patients, and reflects well known in vivo events.

Animals↗
PubMed1991

[Evaluation of non-occurrence by TI-59 programmable calculator].

A TI-59 programmable calculator program is presented for calculating either risk probability, sample size or confidence level (given 2 of the 3 variables) in cases in which an event of concern did not occur, or as expressed mathematically, had zero numerators. Its main usefulness is as a tool for interpreting previously published data containing no adverse event of concern while contemplating medical alternatives. These conditions are not infrequent in rare medical events--either diseases or complications. However, applicability of the program extends beyond these confines, exemplified in experimental planning for considering expected sample size or in calculating certainty in terms of confidence level.

Mathematical Computing↗
PubMed1991

Choledochoduodenostomy an important surgical tool in the management of common bile duct stones. A review of 126 cases.

Of 2,000 patients who underwent cholecystectomy between 1965-1984, 457 had their common bile ducts explored and of these 126 had choledochoduodenostomies. There were 70 women and 56 men and a third were over 70 years old. Forty-three also had acute cholecystitis or pancreatitis, and 73 had an increased serum concentration of bilirubin. Of the 126, 103 had stones in the common duct, and 16 had benign strictures of the sphincter of Oddi. Morbidity included wound infections in 18 (14%) and bile discharge from the drain for over 14 days in four (3%). Five patients died (4%), and they were all over 70 years old. Ninety-seven of 103 patients followed-up over 1-19 years were symptom free (94%). Two patients required re-operation for a narrow anastomosis. Three patients developed a "sump" syndrome; two were treated with antibiotics, and the third responded to endoscopic sphincterotomy. Choledochoduodenostomies should be considered during operation for benign biliary disease, when stones or a stricture in the common bile duct are anticipated.

Adult↗