A plea for role models.
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Education, Medical, Undergraduate↗
Biomedical subjects
L I Goldman
Publications and source records attributed to L I Goldman.
Narrowing resection margins for patients with low-risk melanoma.
Surgeons hesitate to accept lesser cancer operations for several reasons. Paramount, however, is the fear that they might jeopardize cure rates by inadvertently leaving residual tumor behind. In cutaneous melanoma, for example, wide excision of the primary tumor site, usually in combination with skin grafting, has been the standard for years. Recently, as the biologic characteristics of this neoplastic system have become better understood, a subset of patients has been identified who can be cured readily by surgical excision alone. It is in this low-risk group of patients that lesser margins of excisions have been advocated. To date, a majority of surgeons have not accepted this thesis. In an effort to study this further, one of us prospectively treated 45 patients with thin, low-risk melanomas by conservative excision of their primary tumor sites. The margins invariably were 2 cm or less, and two thirds of the patients were operated on as out-patients utilizing local anesthesia. After a mean follow-up period of 36 months, no recurrences of melanoma developed. Acceptance of this treatment appears appropriate in this subset of patients.
Ambulatory Surgical Procedures↗
Nonocclusive ischemic colitis secondary to hemorrhagic shock.
A young male with a penetrating chest wound suffered modest and transitory hemorrhagic shock. Nonocclusive right-sided ischemic colonic necrosis developed secondarily. This became obvious on serial follow-up examinations, prompting exploration and curative surgical resection. This case represents ischemic colitis secondary to hemorrhagic shock following trauma. Upon review of the literature, only five other such cases have been reported. Although shock-associated ischemic colitis is well documented, it is extremely uncommon to see gangrenous changes of the bowel in young, otherwise healthy, trauma victims. Mesenteric vasospasm is believed to be the causative factor in these cases. For unknown reasons, the right colon seems to be the favored site of ischemic damage. Nonocclusive intestinal ischemia should be considered in patients who have abdominal pain after a hypotensive episode.
Adult↗
Assessment of survival rates with metastatic malignant melanomas.
Ten patients who survived for at least five years after the development of metastatic melanoma were compared with 45 other patients who died of disseminated disease. The difference between the groups was the persistent absence of internal organ involvement in the first group and its invariable presence in the latter group. In addition, it appeared that several of the primary tumors from the nonlethal group were thinner, located in a more favorable location and occurred with greater frequency in women. All of these features tend to be indicative of a lesser degree of biologic aggressiveness of these tumors. They may prove helpful in identifying those patients with metastatic disease who are potential long term survivors and, therefore, require continued aggressive treatment.
Adult↗
The role of lymph node dissection for clinical stage I malignant melanoma of intermediate thickness (1.51-3.99 mm).
The survival times of patients who had an elective regional lymph node dissection was compared with that of those who did not undergo the procedure in a database of 72 patients with clinical Stage I melanoma of intermediate thickness (1.51-3.99 mm). All of the patients had been followed for 5 years or longer or until death. No significant differences were found in other reported prognostic factors, suggesting that the two groups were comparable. By multivariate analysis, a low mitotic rate, intermediate patient age, and the presence of an infiltrative lymphocytic response were found to be associated with favorable survival. There did not appear to be any association of elective regional lymph node dissection with survival; and it was concluded that such therapy should not be regarded as "standard" for clinical Stage I melanoma of intermediate thickness.
Actuarial Analysis↗
Screening for occult blood in selected patients. The potential for false-negatives.
Seventy-one patients presenting for elective hernia repair without gastrointestinal symptoms were screened for occult blood in their stools. All patients had stools negative for occult blood and were studied with proctosigmoidoscopy and barium enema. Polyps were found in 10% of the study population. The potential for missing polyps definitely exists if patients are selected for further studies only on the basis of tests for occult stool blood.
Barium Sulfate↗
Preoperative nuclear scans in patients with melanoma.
One hundred forty-one liver scans, 137 brain scans, and 112 bone scans were performed in 192 patients with clinical Stage 1 melanoma. One liver scan was interpreted as abnormal; liver biopsy of that patient showed no metastasis. There were 11 suggestive liver scans; three of the patients with suggestive liver scans had negative liver biopsies. The remaining eight patients were followed from 4 to 6 years and none of those patients developed clinical evidence of hepatic metastases. All of the brain scans were normal. Five patients had suggestive bone scans and none of those patients had manifested symptoms of osseous metastases with a follow-up of 2 to 4.5 years. This study demonstrates that the use of preoperative liver, brain and bone scan in the evaluation of patients with clinical Stage 1 melanoma is virtually unproductive.
Adolescent↗
Minimal deviation melanoma.
Minimal deviation melanoma is a recent concept of uncertain biologic significance. Minimally deviant melanocytes are not seen in metastases, suggesting they do not have the same biologic behavior as clearly malignant cells. Therefore, the Breslow and Clark prognostic criteria may not be applicable. Eight patients with MDM are presented. All were treated by scar re-excision and primary closure. Lesions ranged from 0.31 to 1.65 millimeters thick and four were Clark's level IV. Median follow-up study has been 19 months without evidence of local recurrence or distant metastasis. We concluded that MDM has a low likelihood for aggressive behavior in spite of tumor penetration which might suggest otherwise and that radical surgical therapy appears unnecessary.
Adult↗
Hemoccult screening in selected patients. The hernia patient older than age fifty years.
Two hundred and forty patients, asymptomatic relative to gastrointestinal disease, who applied for elective hernia repair, were tested as outpatients for occult blood in the stool. Thirty-eight patients had one or more positive specimens. Significant pathologic characteristics were identified by lower gastrointestinal evaluation in 23 of these patients. One patient had an adenocarcinoma (Dukes' Stage B). Eight patients had polyps of various types, 11 patients had colonic diverticula, and three patients had anorectal disease. Patient compliance was excellent and the cost-benefit ratio appeared to be acceptable.
Age Factors↗
Optimal resection margin for cutaneous malignant melanoma.
Cutaneous malignant melanoma has traditionally been treated by "wide" local excision with a 5-cm margin of normal skin about the tumor. The rationale of wide excision for melanoma has never been clearly defined, but the procedure is known to be effective in preventing local recurrence. We studied 105 patients who had 109 primary melanomas in 1977 and related margin width of the definitive excision to the presence of satellites, to the subsequent development of local recurrence and in-transit metastases, and to survival. Survival was not dependent on margin width, and there were no incidences of local recurrence. Satellitosis and in-transit cutaneous metastasis indicate that a melanoma is capable of local recurrence; these phenomena occurred only in tumors whose thickness (Breslow) was greater than 2.0 mm. These data provide a rationale for wide excision of "thick" melanomas and support more modest local therapy for thin cutaneous melanoma.
Adult↗
The significance of lymph node involvement in patients with medullary carcinoma of the breast.
Sixty-two patients with medullary carcinoma of the breast were studied. Mean survival time was 105 months. When identical stages are compared, the five and ten year survival rates for patients with medullary carcinoma of the breast parallel those for patients with infiltrating ductal carcinoma. Age, duration of symptoms, site of the primary lesion, size of the primary lesion, menopausal status and postoperative radiotherapy and the number of positive axillary lymph nodes were all evaluated for independent effects upon survival. The number of involved axillary nodes appeared to be the only worthwhile prognostic indicator. We believe that patients with medullary carcinoma of the breast and positive axillary lymph nodes should receive adjuvant chemotherapy.
Adult↗
Interval cholecystectomy: an appraisal.
Interval cholecystectomy (IC), the removal of a diseased gallbladder after drainage for acute infection, is considered an appropriate procedure in suitable patients. While increased technical problems can be expected, other potentially serious complications are frequently overlooked. This review, prompted by difficulties during IC, compares multiple parameters (eg, technical difficulties, morbidity, postoperative convalescence) between this group and "routine" gallbladder operations (RC). During the period between 1970 and 1979, 224 patients with gallbladder disease were operated upon at this Veterans Administration Medical Center. Included among these were seven patients who required cholecystostomy, five of whom were treated by subsequent IC. When compared to the RC group, IC was usually done in older patients and was technically more difficult, as evidenced by longer operating times and increased operative blood loss. In addition, this group's postoperative convalescent period was significantly prolonged because of an increased rate of complications, wound infections being the most common. These were believed to be responsible for the two deaths in this group (the only deaths in the entire RC-IC group.
Acute Disease↗
Hemoccult screening in selected patients.
One hundred patients, asymptomatic relative to gastrointestinal disease, who applied for elective hernia repair were tested as outpatients for occult blood in the stool. Twenty-six had one or more positive specimens. Among this group colonic disease was found in seven, including adenocarcinoma (Dukes' stage A) in one, adenomatous polyps in three, and colonic diverticula in the remainder. The unexpectedly high false-positive rate (33%) was reduced markedly by giving a meat-free diet before stool collection. Patient compliance was excellent and the cost-benefit ratio appeared to be acceptable.
Adenocarcinoma↗
Dysplastic nevus syndrome: a phenotypic association of sporadic cutaneous melanoma.
Clinical photographs of 79 prospectively studied cases of non-familial cutaneous malignant melanoma were reviewed; special attention was directed to the distribution pattern of coexistent melanocytic lesions. A group of 15 patients had moles on the covered buttock area. Seven of these patients had large clinically atypical nevi, and biopsies of these nevi showed severe melanocytic dysplasia. Residual elements of melanocytic dysplasia were identified in five of the primary melanomas in this group of patients. It is suggested that these patients represent a distinctive syndrome, the Dysplastic Nevus Syndrome (DNS) and that they are at increased risk for development of primary cutaneous malignant melanoma. The clinically and histologically distinctive dysplastic nevi of these patients are identical to the precursor lesion for melanoma that we have previously described in a familial context, the B-K mole syndrome. This paper represents the first description of this form of dysplasia in non-familial melanoma.
Adult↗
Decision in the management of cutaneous malignant melanoma.
Eighty-five percent of the cases of cutaneous malignant melanoma can be identified during a biological stage in which they are incapable of producing metastases and can be cured by surgical excision, alone. Recognition of these cases has major impact for potentially improving survival in this neoplastic system. Once recognized, excisional biopsy of the primary melanoma enables the pathologist to accurately microstage these tumors. The role of surgery, both for the primary site and the regional lymph nodes, continues to undergo refinement as additional information regarding the biology of melanoma becomes available. Adjuvant chemotherapy and/or immunotherapy remains investigational, at present, and awaits the demonstration of its clinical value.
Humans↗
The biology of human malignant melanoma. Preliminary findings in the nude mouse.
The nude mouse model was explored as a means of predicting the behavior of human cutaneous malignant melanoma. Subcutaneous implants from 20 patients were observed for external growth, microscopic appearance, and autoradiographic analyses following tritiated thymidine labeling. Normal epithelial and dermal components were maintained in the six low-risk primary implants, but none had any external growth or tumor cell preservation. Four of the five metastatic implants grew throughout the observation periods, with 30% of the counted tumor cells taking up the radioisotope. There was a slower growth rate in four of nine high-risk primary implants, with tumor cell preservation in eight. Only 6% of the counted tumor cells incorporated tritiated thymidine. This model appears to be capable of discriminating among the behavior of various forms of human malignant melanoma.
Animals↗
The treatment of malignant melanoma of the skin.
This review of 117 melanomas occurring in 115 patients treated by a single surgeon suggests the appropriateness of the therapeutic decisions to be mentioned based upon tumor behavior, determined by microstaging. Local control of level II lentigo maligna melanoma was achieved, in most instances, by local excision with visibly free margins and primary closure. In most of the other instances of melanoma, adequate local control was accomplished by wide three-dimensional excision, 5 centimeter margins--closure usually required grafting. Minor amputation was performed with satisfactory results in those patients with appropriate lesions in the volar-subungual area. Regional lymphadenectomy in patients with level IV and V disease in whom the tumors drained to a single node basin revealed occult metastases in 25 per cent of the patients and, therefore, appears warranted as prophylactic treatment. Preliminary data on recurrences suggest that the frequency of the recurrence paralleled the biologic aggressiveness of the tumor, determined by microstaging in association with the presence or the absence of lymph node metastases.
Adolescent↗
A ten year study of medullary carcinoma of the breast.
In this large series of patients treated for medullary carcinoma of the breast by radical mastectomy, the over-all five year survival rate was 63.7 per cent and the ten year survival rate, 49.5 per cent. Although survival was adversely affected by axillary lymph node involvement, there was an equal incidence of such involvement, there was an equal incidence of such involvement in tumors less than 4 centimeters compared with those greater than 4 centimeters in size; however, patients with tumors greater than 4 centimeters in size fared poorer categorically than did those with smaller lesions. Women in the premenopausal period had one-third of the cancers and had a significantly better survival rate than did those in the postmenopausal period, despite a similar incidence of axillary lymph node involvement. Medullary carcinoma is among the small group of malignant tumors of the breast that have distinctly better five and ten year survival rates than other more common varieties.
Adult↗