Peritonectomy and intraperitoneal chemotherapy.
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Antineoplastic Agents↗
Biomedical subjects
John T Vetto
Publications and source records attributed to John T Vetto.
Outcomes among women younger than age 40 in a state breast cancer screening program.
BACKGROUND: The value of entering women younger than age 40 in breast cancer screening programs (SPs) remains unclear. METHODS: Data from the Oregon Breast and Cervical Cancer Program (BCCP) for the period December 31, 2000 through July 1, 2003 were reviewed with a focus on women 39 years of age or younger. Information on cancers detected in this group was extracted from The Oregon State Cancer Registry. RESULTS: Of the 13,636 women screened, 797 (5.8%) were younger than 40 (mean age 31.9 years). A total of 20.6% of the women were asymptomatic and therefore represented true incidence screening, while 79.4% were referred to the program for symptoms (prevalence screen). A total of 125 biopsies were done out of 797 women, which yielded 5 cancers. All 5 of these patients were symptomatic at presentation and had a negative family history. CONCLUSIONS: There are as yet no data in our state breast cancer SP to support screening of asymptomatic women younger than 40.
Adolescent↗
Breast fine-needle aspirates with scant cellularity are clinically useful.
INTRODUCTION: Fine-needle aspirates (FNAs) with scant cellularity are considered inadequate by current cytopathology standards. We hypothesized that such aspirates are clinically useful. METHODS: A 10-year database of palpable breast lumps evaluated by FNA-based triple test (TT; FNA, breast imaging studies, and clinical breast examination) and triple test scores (TTSs; 3-9) was examined to identify FNAs with scant cellularity but without evidence of malignancy (negative SC-FNAs). These FNAs were correlated with the occurrence of any subsequent cancers (false-negative SC-FNAs) and with TTSs. RESULTS: Among a total of 324 negative SC-FNAs, 9 cancers were subsequently found at sampled sites. Seven were associated with a suspicious or malignant TTS (scores of 5 or greater) and therefore still correctly diagnosed as malignant or suspicious for malignancy. The remaining two cancers were missed by both SC-FNA and TTS (false-negative rate for TTS of 0.6%); both had scores of 4 because of suspicious imaging. CONCLUSIONS: Scantly cellular but negative FNAs are useful (can avoid unnecessary invasive breast biopsy) in the evaluation of palpable breast masses, especially when interpreted in the context of the TT and TTS.
Adolescent↗
Sidney L. Saltzstein, MD, MPH receives 2004 Margaret Hay Edwards Achievement medal.
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Awards and Prizes↗
Impact of the recent reduction in working hours (the 80 hour work week) on surgical resident cancer education.
BACKGROUND: Resident work hours were recently reduced to 80 hours per week by a mandate from the Accreditation Council for Graduate Medical Education and subsequent Federal law (HR 3236). This mandate became effective July 1st, 2003. We sought to determine any impact this change had on perceived and real resident cancer education and knowledge. METHODS: Of the total 85 residents in our large, university-based surgical training program, we focused on the 40 who had been in the clinical program (rather than research) before and after the work hour reduction. Perceived impact on cancer education was determined by survey, and real impact by before (2002) and after (2004) scores on the overall and cancer-specific portion of the annual American Board of Surgery In-Training Examination (ABSITE). RESULTS: All eligible residents responded to the survey. The majority (83% to 85%) indicated that exposure to cancer patients on wards and in clinics remained the same. Thirty percent felt that their exposure to cancer operations and tumor boards had decreased; 60% to 65% felt that exposure to these activities were unchanged. Approximately half of residents reported an increase in their cancer-related reading and Internet learning activities--the other half felt they had not changed. The majority (88%) reported no change in their participation in extraprogrammatic cancer-related continuing medical education activities. Of the survey responders, 23 had completed the ABSITE in both 2002 and 2004; their mean scores between the 2 time periods increased by 7% for the overall test and decreased by 3% for the cancer-specific portion. CONCLUSIONS: Overall, the recent reduction in work hours does not appear to have changed residents' experience with cancer patient care, although possible early reductions in attendance at cancer operations and tumor boards merits further study and possibly future schedule changes. The reported perceived increase in cancer-related reading and Internet learning has not yet translated into improved test scores.
Educational Measurement↗
Fine-needle aspiration diagnosis of plasmacytoma presenting as breast masses in a patient on estrogen therapy for prostate cancer.
We describe a 79-yr-old man with a history of androgen-independent metastatic prostate cancer treated with exogenous estrogens presenting with bilateral breast masses associated with bilateral axillary lymphadenopathy. Although the findings on physical examination with the concomitant history of estrogen therapy for metastatic prostate cancer raised the clinical suspicion of breast cancer, fine-needle aspiration (FNA) cytology identified the lesions as multiple myeloma.
Aged↗
Surgical outcomes of a breast cancer-screening program for low-income women.
HYPOTHESIS: Surgical outcomes from a breast cancer-screening program of low-income women are similar to those of other screening programs. DESIGN: Prospective cohort. SETTING: Federally funded screening program. PATIENTS: A total of 15730 women. INTERVENTIONS: A total of 23149 mammograms, 20396 with concomitant clinical breast examination, from January 1, 1997, through December 31, 2001. OUTCOME MEASURES: American College of Radiology scores; associated surgery consultations, biopsies, operations, and pathology results. RESULTS: Most (20868) of the 21296 mammograms assigned an American College of Radiology score were benign; only 428 (2%) were suspicious. Resulting from suspicious clinical breast examinations, the group with American College of Radiology scores of 1 to 3 accounted for 45%, 18%, and 10% of recommended surgical consultations, biopsies, and cancers detected, respectively. A rate of 12.3 cancers per 1000 women was found, greater than with other screening programs. Compliance with therapy was 97%. CONCLUSIONS: This screening program had a higher rate of advanced cancers. Clinical breast examination was an important component, and compliance with surgical recommendations was excellent.
Adult↗
Comparing the cost-effectiveness of the triple test score to traditional methods for evaluating palpable breast masses.
BACKGROUND: Physical examination, mammography, ultrasonography, and fine needle aspiration are traditionally used to guide further management of palpable breast masses, often leading to open biopsy of benign masses. The triple test score (TTS) integrates physical examination, mammography, and fine needle aspiration in the initial evaluation, limiting open biopsy. OBJECTIVE: To compare cost-effectiveness of TTS and traditional methods. METHODS: The primary measure of clinical effectiveness, frequency of missed malignancy, was determined for each strategy using probabilities and outcomes from a systematic literature review. Costs were calculated using the Medicare resource-based relative-value scale. A decision-analytic model compared costs of initial work-up, costs per mass evaluated, and costs per malignancy diagnosed. Sensitivity analyses assessed the influence of variations in model assumptions. RESULTS: In the base case, neither strategy led to undiagnosed breast cancer. However, open biopsy was required in 13% of benign masses using TTS versus 88% using the traditional strategy. The cost of the initial work-up using traditional management was less than TTS (377 US dollars vs. 627 US dollars), but cost per mass evaluated and cost per malignancy diagnosed (1793 US dollars vs. 925 US dollars and 5670 US dollars vs. 2925 US dollars) favored TTS, due to substantially reduced open biopsy.In sensitivity analyses, TTS cost varied most with changes in cost of initial evaluation, whereas the traditional strategy cost varied most with changes in open biopsy cost. CONCLUSIONS: The TTS provides equivalent diagnostic effectiveness but substantially lower cost than traditional management. Cost savings are based on decreased open biopsy, a major contributor to the cost of traditional evaluation in this model.
Biopsy, Needle↗
Looking to our annual meeting and beyond.
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Congresses as Topic↗
Survival in human colorectal cancer correlates with expression of the T-cell costimulatory molecule OX-40 (CD134).
BACKGROUND: The T-cell costimulatory molecule OX-40 (CD134) is expressed on activated CD4(+) ("helper") T cells. Such cells have been detected in human cancers, and engagement of OX-40 improves colon cancer immunity in an animal model. METHODS: Sections of primary colon cancers, normal margins, mesenteric lymph nodes, and metastases were stained for OX-40 by immunohistochemistry. Cancer registry data were reviewed. RESULTS: High levels of OX-40 positive tumor-infiltrating lymphocytes were found in 15 of 72 primary tumors. Thirty-one cases had prominent lymphocytic infiltrates expressing OX-40 at the invasive margin of the tumor. Overall, 50% of primary tumors showed high expression of OX-40. Nearly all mesenteric lymph nodes expressed OX-40, whether tumor was present or not. Normal margins of colon did not show high levels of OX-40. High OX-40 expression in the primary tumor correlated with better survival (mean survival high OX-40, 47 months, low OX-40, 35 months, P <0.05), although this correlation was not stage-independent. CONCLUSIONS: High levels of OX-40 positive lymphocytes are present in half of primary colon cancers, and this expression in primary tumors significantly correlates with better survival. This correlation with survival and our previous preclinical research suggest a basis for an OX-40 immunotherapy trial.
Adenocarcinoma↗
A new score for the evaluation of palpable breast masses in women under age 40.
BACKGROUND: The purpose of this study was to develop a rapid and accurate diagnostic test for palpable breast masses in women under age 40. METHODS: Masses were evaluated utilitzing a modified triple test score (MTTS), which assigned scores of 1 point for benign, 2 points for suspicious, or 3 points for malignant findings from physical examination, ultrasonography, and fine needle aspiration. The MTTS was the sum of the three scores and was correlated with biopsy or follow-up. RESULTS: Among 113 masses, 100 scored 3 points, 8 scored 4 points; all were benign. Three scored 5 points; 1 was malignant. Two scored >or=6 points: both were malignant. CONCLUSIONS: The MTTS has 100% diagnostic accuracy when other than 5 points. Masses scoring or=6 points may proceed to definitive therapy. Masses scoring 5 points (3%) require biopsy. This approach avoids open biopsy in the majority of cases, while capturing all malignancies.
Adolescent↗
Beyond doughnuts: tumor board recommendations influence patient care.
BACKGROUND: There is little solid evidence to support the belief that tumor conferences directly impact the care patients receive. This study investigated the recommendations made at tumor conferences and whether these recommendations were enacted. METHODS: Cancer registrars from Oregon-area hospitals with tumor boards that utilized a prospective "working" format were surveyed regarding tumor board characteristics and content. They also recorded the recommendations made for each prospective case presented at each tumor board for one month. Later, they contacted each patient's provider to see which recommendations had been implemented. RESULTS: Information from eight tumor boards in six hospitals was recorded. The institutions varied with regard to size, location, number of tumor boards, number of cases reviewed annually, and types of cancers reviewed. One hundred fifty-three specific, prospective recommendations were made for the care of 97 patients. Of these, 128 (84%) were followed, 2 (1%) were pending, and 5 (3%) were status unknown. Of recommendations followed, 21 (16%) were for diagnosis, 100 (78%) were for therapy, and 7 (5%) were for palliation. CONCLUSION: Recommendations made at tumor conferences are generally implemented into patient care. Tumor boards can play a strategic role in the planning of care for cancer patients.
Education, Medical, Continuing↗
Structured clinical breast examination (CBE) training results in objective improvement in CBE skills.
BACKGROUND: A statewide breast cancer care provider needs assessment had identified CBE training as a target educational need. Accordingly, the authors implemented a one-on-one skills-based course for primary care providers (PCPs) across the state. METHOD: The course had two components: a prerequisite self-study manual, followed by a 1 1/2-hour skills-based practicum. As part of the practicum, pre- and post-course testing were performed on standardized silicone breast models. RESULTS: Pre- and post-testing data were available for 205 PCPs who completed the course. In the pre-test period, 59% of PCPs examined could detect 60-100% of the lumps. In the post-test, that rose to 94% of PCPs detecting 60-100% of the lumps. This improvement reached statistical significance. Further, false-positive lump detection declined in the post-test period to 59% of the pre-test rate (236 to 139). CONCLUSION: Formal CBE training for PCPs significantly improves the sensitivity of lump detection and concurrently reduces false-positive detection. The program is currently being extended to a greater number of providers across the state.
Breast Neoplasms↗
Metastatic breast cancer manifested as refractory anemia and gastric polyps.
Gastric metastasis from breast cancer is uncommon and typically occurs in patients with disseminated disease. The vast majority of patients with gastric lesions have a known preexisting diagnosis of breast cancer. In contrast, we describe a case in which a minimal breast cancer was found to be the primary tumor during the workup of a patient first diagnosed with carcinoma of unknown primary and subsequently presumed to have metastatic gastric cancer. Our case illustrates that a diagnosis of breast cancer metastatic to the stomach may require a high index of suspicion, as well as a meticulous breast workup. It also emphasizes that even tiny breast cancers have a small but real risk of metastatic spread. Determination of the correct primary source in these cases may not be only an academic exercise, since the treatment and prognosis of metastatic breast cancer (especially receptor positive) and metastatic gastric cancer are different.
Anemia, Refractory↗
Sentinel lymph node biopsy.
The introduction of sentinel lymph node biopsy (SLNB) has been an important development in the management of malignant melanoma. Lymph nodes have long been known to play a key role in melanoma metastasis. The importance of nodal staging accounted for the previous surgical practice of elective lymph node dissection (ELND) even with its controversial impact on final outcomes and associated morbidity. Although this morbidity has been reduced with the ability to identify the SLN, numerous questions have subsequently surfaced with respect to this procedure's utility and therapeutic efficacy. This chapter will focus on the indications for SLNB, as well as the current controversies surrounding this procedure.
Humans↗