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Biomedical subjects

Vijay P Khatri

Publications and source records attributed to Vijay P Khatri.

17 recordsLinked to original sources
PubMed2006

Upstaging and improved survival of early breast cancer patients after implementation of sentinel node biopsy for axillary staging.

BACKGROUND: Sentinel lymph node biopsy (SLNB) has become a standard for axillary staging for early breast cancer patients. Prior studies suggest that SLNB may be more sensitive for the identification of lymph node disease than axillary lymph node dissection (ALND). We hypothesized that SLNB use increases the incidence of node-positivity in early breast cancer patients compared to ALND. Furthermore, survival improves due to more accurate staging (stage migration). METHODS: Registry data from an NCI-designated cancer center was reviewed for breast cancer patients with T1 and T2 tumors for two 5-year periods: before (1993-1997) and after (2000-2004) SLNB implementation (1998). TNM staging was updated to conform to American Joint Committee on Cancer (AJCC) 2003 guidelines. RESULTS: There were no differences in tumor size or stage groupings between the two time periods (n = 316 and 577). There was a non-significant increase in the proportion of patients with lymph node involvement (32 vs. 27%; P = .16) after SLNB implementation; though a trend of increased incidence of single-node positive patients was observed (13 vs. 8%; P = .07). This was significant in patients with T1A/T1B tumors (10 vs. 3%; P = .04), though not seen in T1C or T2 tumors. Stage II survival improved in the later time period (P = .02). CONCLUSIONS: The increase in single-node positivity after SLNB implementation supports the theory that SLNB is more sensitive than ALND. Improvements in survival are likely due to the stage migration of patients who would have been node-negative by ALND (but were found to be node-positive by SLNB) in addition to improvements in adjuvant therapy.

Adult↗
PubMed2006

Type-2 dominant cytokine gene expression following hepatic surgery.

BACKGROUND/PURPOSE: Hemorrhage and ischemic liver injuries associated with hepatic resection are thought to play a role in postoperative complications, possibly through altered cytokine production. The current study was performed to investigate the effects of hepatectomy on cytokine gene expression. METHODS: We collected blood preoperatively, at completion of operation, and on postoperative days 1 and 5 from ten patients undergoing hepatic resection. The peripheral blood mononuclear cells were evaluated with real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR) for gene expression of interleukin-10 (IL-10), proinflammatory cytokines (interferon-gamma [IFNgamma], IL-15, tumor necrosis factor alpha [TNFalpha], and chemokines regulated on activation, normal T expressed and secreted [RANTES], macrophage inflammatory protein 1 alpha [MIP-1alpha], [MIP-1beta]). Wilcoxon Rank and paired t-tests were used for statistical analysis. RESULTS: Immediately following hepatectomy there was a significant (31.4 +/- 60.5-fold; P < 0.05) increase in IL-10 gene expression that was sustained until the first postoperative day. In contrast, there was a significant downregulation (38 +/- 71 eight fold lower than preoperative; P < 0.05) of IFNgamma gene expression on day 1. By postoperative day 5, the changes in gene transcript levels of both IL-10 and IFNgamma had returned to the preoperative baselines. This contrasting change in IL-10 and IFNgamma gene expression in response to hepatic resection was statistically significant (P = 0.02). CONCLUSIONS: Hepatectomy elicits an imbalance towards the immunosuppressive type-2 cytokine profile in the early postoperative period. Measurement of cytokine gene transcripts following hepatic resection may have predictive value for clinical outcome, and deserves further study.

Chemokines↗
PubMed2006

Staging and prognosis of colon cancer.

Significant advances have been made in all aspects of care relating to colorectal cancer. Although surgery will likely remain the mainstay of definitive treatment for the majority of colorectal malignancies, a better understanding of tumor progression and biology will help guide the choice of surgical therapy to best achieve a curative resection. Additionally, advances in the use of neoadjuvant and adjuvant therapies should continue to increase disease-free and overall survival when combined with appropriate operative resection. Although TNM staging remains our strongest tool at this point for establishing prognosis and directing therapy, expansion of our knowledge of the molecular events underlying colorectal tumorigenesis undoubtedly will lead to the refinement of our current staging and prognostic systems.

Colonic Neoplasms↗
PubMed2005

Extending the frontiers of surgical therapy for hepatic colorectal metastases: is there a limit?

Hepatic resection for colorectal metastases, limited to the liver, has become the standard of care, and currently remains the only potentially curative therapy. Numerous single institutional reports have demonstrated long-term survival, and there are no other treatment options that have shown a survival plateau. However, curative resection is possible in less than 25% of patients with disease limited to the liver, which consequently translates into only 5% to 10% of the original group developing colorectal cancer. To increase the number of patients who could benefit from hepatic resection, the last decade has seen considerable effort directed towards the following areas, (1) refining prognostic factors that would improve patient selection, (2) advancements in surgical technique such as, use of intraoperative ultrasonography, controlling hemorrhage through use of vascular clamping techniques supplemented with low central venous pressure anesthesia, availability of novel devices for parenchymal transection, and controlled anatomic hepatectomy with Glissonian technique, and (3) novel approaches to permit curative hepatic resection such as, preoperative portal vein embolization for hypertrophy of future liver remnant and staged hepatic resection. This article reviews development of these innovative multidisciplinary modalities and the aggressive surgical approach that has been adopted to extend the frontiers of surgical therapy for colorectal hepatic metastases.

Colorectal Neoplasms↗
PubMed2005

Experience and attitudes of surgeons toward palliation in cancer.

BACKGROUND: Surgery can effectively palliate symptoms in patients with advanced malignancy and thereby maintain quality of life. However, the goal of surgical palliation should be balanced with the associated risks, and the decision to operate can be challenging for even the most experienced surgeon. HYPOTHESIS: There are significant deficiencies in training during residency and in continuing medical education in palliative surgical care leading to a lack of agreement for treatment recommendations. DESIGN AND SETTING: A survey of general surgeons involving 4 clinical vignettes of patients with advanced malignancies and varying degrees of symptoms. Respondents were asked to select the best treatment option for each patient from a list of 6 alternatives. Furthermore, respondents identified the clinical factors that most influenced the decision, as well as the major goal of the palliative intervention. SUBJECTS: Surgeons in a midsized urban setting and its surrounding region. RESULTS: Of 124 surveys sent out, 70 (56%) were completed. Significant deficiencies in education were identified; 59 (84%) of the respondents did not receive any education in palliative surgical care during residency and 28 (44%) lacked continuing medical education. A consensus treatment recommendation was not selected in 3 of the 4 clinical vignettes, but the respondents used similar clinical factors and goals of treatment for selection of the specific recommendation. CONCLUSIONS: Palliative care is a major deficiency of postgraduate surgical training. A more focused effort in training surgeons in palliative care may allow for the more uniform and standard provision of palliative surgical care to patients with advanced cancer.

Adult↗
PubMed2005

Tumors of the retrorectal space.

PURPOSE: Retrorectal tumors are a diverse group of masses derived from a variety of embryologic origins. Because of this, some confusion is associated with their diagnosis and management. Although rare, a basic understanding of the etiology, presentation, work-up, and treatment of retrorectal masses is essential. METHODS: The incidence, classification, diagnosis, treatment, and prognosis of these masses are presented. A comprehensive review of the literature is included in our analysis. RESULTS: Retrorectal lesions can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. Benign and malignant lesions behave similarly. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history. Biopsy of these lesions should be avoided to prevent tumor seeding, fecal fistula, meningitis, and abscess formation. Complete surgical resection, usually after appropriate specialized imaging, remains the cornerstone of their treatment. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primarily to local control, which often is difficult to achieve for malignant lesions. CONCLUSIONS: Retrorectal masses present a challenging surgical problem from diagnosis to treatment. A high index of suspicion and resultant early diagnosis, followed by thorough preoperative planning, is required for optimal management and outcome.

Humans↗
PubMed2005

Extremity soft tissue sarcoma: controversial management issues.

Unlike common malignancies, such as breast and colorectal carcinoma, where treatment modalities can be investigated with large prospective randomized trials, such an endeavor has been hampered with soft tissue sarcomas (STS) due to its rarity. In absence of such randomized clinical trials, controversy exists with regards to numerous clinically relevant questions and clinicians are left with single institutional experiences gathered either in a retrospective or prospective fashion. Some of these frequently encountered issues in the management of STS include (1) whether poorly executed biopsies affect outcome? (2) Do all unplanned excisions require re-excisions? (3) Is MRI a superior imaging modality? (4) Whether radiation should be provided pre- or post-operatively? (5) Does extent of surgical margin influence local control? (6) Is adjuvant radiation therapy necessary for stage IIB STS? (7) Does adjuvant chemotherapy influence local control? (8) Does local recurrence influence survival? We will address these topics in this review.

Antineoplastic Agents↗
PubMed2004

D2.5 dissection for gastric carcinoma.

Worldwide, gastric cancer ranks second only to lung cancer in mortality and accounts for 500 000 deaths annually. Since 1930, the incidence of gastric carcinoma in the United States has been declining steadily and plateaued during the 1980-1990 decade. Mortality rates for white males in the United States were approximately 40 per 100000 in 1930, compared with 5.4 per 100000 in 1994. For nonwhite males the rates were 23.7 per 100 000 in 1955 and 12 per 100 000 in 1985. In the United States in 2002, an estimated 21 600 new cases and 12 400 deaths were attributable to gastric carcinoma.

Anastomosis, Surgical↗
PubMed2004

Immediate breast reconstruction after mastectomy increases wound complications: however, initiation of adjuvant chemotherapy is not delayed.

BACKGROUND: Immediate breast reconstruction is being increasingly used after mastectomy, although it may increase the incidence of wound complications. The indications for chemotherapy in breast cancer are expanding and wound complications following mastectomy may delay the initiation of adjuvant chemotherapy. HYPOTHESIS: Immediate breast reconstruction after mastectomy for breast cancer does not lead to an increased incidence of wound complications nor delay the initiation of systemic chemotherapy. DESIGN AND SETTING: Retrospective medical record review at a tertiary care center. PATIENTS: One hundred twenty-eight women treated with a mastectomy for breast cancer over an 8-year period (January 1, 1995, through December 31, 2002). MAIN OUTCOME MEASURES: Surgical site complications (infectious and noninfectious) and time to initiation of postoperative chemotherapy. RESULTS: One hundred forty-eight mastectomy procedures in 128 women with breast cancer were evaluated. We analyzed 4 subgroups according to whether or not immediate breast reconstruction was part of the surgical procedure (76 or 72 procedures, respectively) and whether or not postoperative adjuvant chemotherapy was administered (81 or 47 patients, respectively). There was an increased incidence of wound complications in patients who underwent immediate breast reconstruction compared with those who did not (6/72 [8.3%] vs 17/76 [22.3%]; P = .02). However, these complications did not delay initiation of postoperative chemotherapy. CONCLUSIONS: Although we observed an increased incidence of wound complications when immediate breast reconstruction was combined with mastectomy, there was no delay in the initiation of adjuvant therapy. Immediate breast reconstruction should remain an important treatment option after mastectomy even when postoperative chemotherapy is anticipated.

Adult↗
PubMed2004

Clinical presentation, imaging, and staging of anal cancer.

Perianal symptoms are common, and benign anorectal conditions have clinical features not too dissimilar to those associated with anal canal carcinoma. To avoid delayed diagnosis, physicians need to be cognizant of the possibility of anal canal carcinoma, which can be effectively treated with chemoradiation therapy without the need for mutilating surgery. Appropriate imaging studies should be obtained for accurate staging of the disease and for follow-up examinations after definitive treatment.

Anus Diseases↗
PubMed2004

Non-resection approaches for colorectal liver metastases.

The field of in situ destruction of liver tumors has expanded rapidly with various institutions' results suggesting that these methods represent viable palliative options, primarily because of the low associated morbidity and mortality. Despite this enthusiasm, clinical trials are needed to determine the true nature and degree of palliation. Treating a systemic disease such as colorectal liver metastases with local therapy strategies alone is of dubious value. In fact, it has been shown by most reports that the limiting factor inpatient outcome is disease progression rather than technical failure. For optimal results, physicians performing in situ ablation of liver lesions should be familiar with tumor biology and the natural history of the malignancy, and possess expertise in proper integration of other therapeutic modalities (eg, systemic chemotherapy and hepatic artery chemotherapy). Patients with liver metastases from colorectal carcinoma should therefore be evaluated for curability by a surgical oncologist within the context of a multidisciplinary team, as surgical resection remains the best treatment to achieve long-term survival. Such an assessment offers the patient the opportunity of a tailored therapy that may consist of hepatic resection, intravenous or regional chemotherapy, and local ablative therapy. Furthermore, results of RF ablation should be reported in terms of well-established oncological outcomes (eg, overall survival, disease-free survival, progression-free survival) that are more meaningful to the patient, rather than lesion-oriented outcomes. Because most of the ablative techniques have not yet been validated, it is imperative that well-designed clinical trials are conducted under the auspices of national cooperative groups. To consider them standard independent therapies otherwise would be premature.

Administration, Cutaneous↗
PubMed2003

Dermatofibrosarcoma protuberans: reappraisal of wide local excision and impact of inadequate initial treatment.

BACKGROUND: The extent of local invasion in dermatofibrosarcoma protuberans (DFSP) is often clinically difficult to appreciate, and this leads to inadequate resections. We examined the effect of inadequate initial treatment and the efficacy of wide resection. METHODS: We performed a retrospective analysis of the records of 35 patients with DFSP treated at our institution (1985 and 2001). Data were analyzed with Wilcoxon's ranked sum test and Fisher's exact test. RESULTS: Of the 24 patients eligible for analysis, 11 had definitive wide resection after diagnostic excisions elsewhere (primary group), and 13 had recurrent tumors after previous surgical treatment elsewhere (recurrent group). Twenty-three patients were treated with wide resection only, and adjuvant radiation was administered to one patient who had a fibrosarcoma. At a median follow-up of 54 months, patients definitively treated at our institution had a 100% local recurrence-free survival. In comparison to the primary group, recurrent DFSPs were significantly larger and deeper and occurred in the head and neck region. Five cases had bone involvement, and of these, 80% occurred in the recurrent group. CONCLUSIONS: Inadequate initial treatment results in larger, deeper recurrent lesions, but these can be managed by appropriate wide excision. Wide resection of DFSP (whether recurrent or primary) with negative histological margins predicts a superior local recurrence-free survival.

Adolescent↗
PubMed2002

Multimodality management of a giant cell tumor arising in the proximal sacrum: case report.

STUDY DESIGN: Descriptive. OBJECTIVE: To outline a novel multimodality approach for a difficult surgical resection of a giant cell tumor in the cephalad portion of the sacrum. SUMMARY OF BACKGROUND DATA: Giant cell tumors of the sacrum are rare primary bone tumors. Recent reports have demonstrated diminished giant cell tumor recurrence with cryosurgery by using a "direct pour" technique with liquid nitrogen. Although successful in decreasing tumor recurrence, this technique is accompanied by a 4%-8% rate of skin necrosis and high rates of pathologic fracture. The authors describe resection and a novel, controlled method of argon-based cryotherapy (followed by a unique pelvic reconstruction) for a large, difficult giant cell tumor of the sacrum. METHODS: A 29-year-old woman presented with complaints of right foot drop and decreased sensation of the right buttock, posterior thigh, posterior calf, and lateral aspect of the right foot. Radiographic evaluation revealed a mass in the right sacrum; histologic examination of CT-guided biopsy revealed a giant cell tumor. A combined anterior abdominal and posterior sacral approach was performed, the tumor was resected, and the margin of the cavity was treated with controlled argon-based cryotherapy. The combination of thermocouples, electromyographic monitoring, and rapid freeze-thaw cycles allowed a controlled ablation of the tumor margin while ensuring that surrounding structures, such as the rectal wall, sacral nerves, and gluteal muscles, were not damaged. Posterior spinal fusion L4 to sacrum, posterior spinal instrumentation L4 to pelvis, and allograft reconstruction of the right sacrum were performed. RESULTS: The patient recovered well without skin necrosis or pathologic fracture. Urinary and fecal continence were preserved. At the 20-month follow-up the patient has no evidence of local tumor recurrence and is fully ambulatory without a brace or narcotic medication. CONCLUSION: A novel multimodality approach, consisting of resection, controlled cryosurgery, and a unique lumbopelvic reconstruction, was safe and successful in managing a challenging proximal sacral giant cell tumor. Twenty months after surgery the patient has excellent bowel and bladder control, no tumor recurrence, and functional ambulation without a brace or pain.

Adult↗
PubMed2002

A logical and stepwise operative approach to radical neck dissection.

A thorough understanding of the anatomy of the neck is essential to avoid injury to vital structures when performing radical neck dissection. The complicated anatomical relations of the various nerves, vessels, and muscles within the confined area of the neck can often be daunting. We outline strategic anatomical landmarks and their relationships to important nerves, arteries, veins, and lymphatics to simplify the complicated and formidable anatomy of the neck. We also delineate key maneuvers that, when combined with the anatomical landmarks, offer a stepwise and logical approach to performing radical neck dissection that confers improved safety.

Humans↗
PubMed2002

Controlled tamponade of severe presacral venous hemorrhage: use of a breast implant sizer.

Hemorrhage from the presacral venous plexus is a potentially life-threatening complication of pelvic operations. The morbidity and mortality that stems from severe hemorrhage has led to the development of various hemostatic techniques. Although suture ligature, packing, and placement of tacks can be very effective, they can often be unsuccessful. When these conventional hemostatic techniques fail, alternative approaches are required. We describe the successful use of an expandable breast implant sizer and outline the practical, theoretical, and financial advantages of applying this technique when more conservative approaches have failed.

Balloon Occlusion↗