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W J Temple

Publications and source records attributed to W J Temple.

At least 19 recordsLinked to original sources
PubMed2001

Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas.

BACKGROUND: The Intergroup Melanoma Surgical Trial began in 1983 to examine the optimal surgical margins of excision for primary melanomas of intermediate thickness (i.e., 1-4 mm). There is now a median 10-year follow-up. METHODS: There were two cohorts entered into a prospective multi-institutional trial: (1) 468 patients with melanomas on the trunk or proximal extremity who randomly received a 2 cm or 4 cm radial excision margin and (2) 272 patients with melanomas on the head, neck, or distal extremities who received a 2 cm radial excision margin. RESULTS: A local recurrence (LR) was associated with a high mortality rate, with a 5-year survival rate of only 9% (as a first relapse) or 11% (anytime) compared with an 86% survival for those patients who did not have a LR (P < .0001). The 10-year survival for all patients with a LR was 5%. The 10-year survival rates were not significantly different when comparing 2 cm vs. 4 cm margins of excision (70% vs. 77%) or comparing the management of the regional lymph nodes (observation vs. elective node dissection). The incidences of LR were the same for patients having a 2 cm vs. 4 cm excision margin regardless of whether the comparisons were made as first relapse (0.4% vs. 0.9%) or at anytime (2.1% vs. 2.6%). When analyzed by anatomic site, the LR rates were 1.1% for melanomas arising on the proximal extremity, 3.1% for the trunk, 5.3% for the distal extremities, and 9.4% for the head and neck. The most profound influence on LR rates was the presence or absence of ulceration; it was 6.6% vs. 1.1% in the randomized group involving the trunk and proximal extremity and was 16.2% vs. 2.1% in the non-randomized group involving the distal extremity and head and neck (P < .001). A multivariate (Cox) regression analysis showed that ulceration was an adverse and independent factor (P = .0001) as was head and neck melanoma site (P = .01), while the remaining factors were not significant (all with P > .12). CONCLUSION: For this group of melanoma patients, a local recurrence is associated with a high mortality rate, a 2-cm margin of excision is safe and ulceration of the primary melanoma is the most significant prognostic factor heralding an increased risk for a local recurrence.

Humans↗
PubMed2000

Locally recurrent rectal cancer: role of composite resection of extensive pelvic tumors with strategies for minimizing risk of recurrence.

Locally recurrent cancer of the rectum has been under-recognized as a complication, although it affects up to 40% of patients treated with surgery alone. Even in the best centers, rates average 25%. While radiotherapy may reduce recurrence, it is now apparent that total mesorectal excision is the most effective modality, with rates as low as 5%. The dramatic decrease in local recurrence can also be linked to increased survival in prospective studies, an effect more significant than any adjuvant therapy. The options, however, for patients with locally recurrent cancer are limited. Fifteen percent of patients with this complication die without systemic spread. Salvage by surgery offers potential cure. Other than anastomotic recurrences that can be locally resected, the best approach for long-term survival is an extensive surgical procedure requiring en bloc removal of adjacent organs and pelvic structures-so-called composite resection. With careful selection, 30% 5-year survival can be achieved and palliation is considerable, with 50% long-term local control. Intraoperative radiotherapy and brachytherapy, and/or preoperative chemoradiation may provide better results in future. Newer techniques of coloanal anastomosis, improved urinary diversion, and myocutaneous flaps for perineal reconstruction radically reduce the morbidity of these procedures. The approach to recurrent rectal cancer requires a sophisticated multidisciplinary team to obtain optimum results.

Brachytherapy↗
PubMed2000

Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial.

BACKGROUND: Ten- to 15-year survival results were analyzed from a prospective multi-institutional randomized surgical trial that involved 740 stages I and II melanoma patients with intermediate thickness melanomas (1.0 to 4.0 mm) and compared elective (immediate) lymph node dissection (ELND) with clinical observation of the lymph nodes as well as prognostic factors that independently predict outcomes. METHODS: Eligible patients were stratified according to tumor thickness, anatomical site, and ulceration, and then prerandomized to either ELND or nodal observation. By using Cox stepwise multivariate regression analysis, the independent predictors of outcome were tumor thickness (P < .001), the presence of tumor ulceration (P < .001), trunk site (P = .003), and patient age more than 60 years (P = .01). RESULTS: Overall 10-year survival was not significantly different for patients who received ELND or nodal observation (77% vs. 73%; P = .12). Among the prospectively stratified subgroups of patients, 10-year survival rates favored those patients with ELND, with a 30% reduction in mortality rate for the 543 patients with nonulcerated melanomas (84% vs. 77%; P = .03), a 30% reduction in mortality rate for the 446 patients with tumor thickness of 1.0 to 2.0 mm (86% vs. 80%; P = .03), and a 27% reduction in mortality rate for 385 patients with limb melanomas (84% vs. 78%; P = .05). Of these subgroups, the presence or absence of ulceration should be the key factor for making treatment recommendations with regard to ELND for patients with intermediate thickness melanomas. CONCLUSIONS: These long-term survival rates from patients treated at 77 institutions demonstrate that ulceration and tumor thickness are dominant predictive factors that should be used in the staging of stages I and II melanomas, and confer a survival advantage for these subgroups of prospectively defined melanoma patients.

Extremities↗
PubMed2000

Quality of cancer surgery: challenges and controversies.

It is generally accepted that the quality of cancer surgery delivered to a patient impacts the patient's overall prognosis significantly. Often, the fact that all surgery and surgeons are not equal is not considered. Furthermore, it should not be assumed that surgeons who perform a particular operation frequently perform it better. Using breast cancer, melanoma, and colorectal cancer as examples, this article illustrates that proper surgical education and training are paramount in assuring that both the selection and delivery of a particular procedure is appropriate in the management of cancer.

Breast Neoplasms↗
PubMed2000

The surgeon as a prognostic factor in the management of pancreatic cancer.

Improved results for pancreatic resection have been attributed to the concentration of pancreatic surgery in high-volume centers. The evidence supporting a relationship between hospital case volume and operative mortality for pancreatectomy is reviewed. The surgeon's case volume does not appear to influence mortality independently, but other surgeon-related characteristics, like specialized training, have not been examined. More research is needed to elucidate the factors that have contributed to reduced mortality for this complex surgery.

Clinical Competence↗
PubMed1996

Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger.

OBJECTIVE: A prospective multi-institutional randomized surgical trial involving 740 stage I and II melanoma patients was conducted by the Intergroup Melanoma Surgical Program to determine whether elective (immediate) lymph node dissection (ELND) for intermediate-thickness melanoma (1-4 mm) improves survival rates compared with clinical observation of the lymph nodes. A second objective was to define subgroups of melanoma patients who would have a higher survival with ELND. METHODS: The eligible patients were stratified according to tumor thickness, anatomic site, and ulceration, and then were prerandomized to either ELND or nodal observation. Femoral, axillary, or modified neck dissections were performed using standardized surgical guidelines. RESULTS: The median follow-up was 7.4 years. A multifactorial (Cox regression) analysis showed that the following factors independently influenced survival: tumor ulceration, trunk site, tumor thickness, and patient age. Surgical treatment results were first compared based on randomized intent. Overall 5-year survival was not significantly different for patients who received ELND or nodal observation. However, the 552 patients 60 years of age or younger (75% of total group) with ELND has a significantly better 5-year survival. Among these patients, 5-year survival was better with ELND versus nodal observation for the 335 patients with tumors 1 to 2 mm thick, the 403 patients without tumor ulceration, and the 284 patients with tumors 1 to 2 mm thick and no ulceration. In contrast, patients older than 60 years of age who had ELND actually had a lower survival trend than those who had nodal observation. When survival rates were compared based on treatment actually received (i.e., including crossover patients), the patients with significantly improved 5-year survival rates after ELND included those with tumors 1 to 2 mm thick, those without tumor ulceration, and those 60 years of age or younger with tumors 1 to 2 mm thick or without ulceration. CONCLUSION: This is the first randomized study to prove the value of surgical treatment for clinically occult regional metastases. Patients 60 years or age or younger with intermediate-thickness melanomas, especially with nonulcerative melanoma and those with tumors 1 to 2 mm thick, may benefit from ELND. However, because some patients still are developing distant disease, these results should be considered an interim analysis.

Female↗
PubMed1996

Cooperative hernia study. Pain in the postrepair patient.

BACKGROUND: The Cooperative Hernia Study assessed postoperative pain in a prospective trial as part of a larger study looking at the recurrence rate and other morbidity of the Bassini, McVay, and Shouldice repairs. METHODS: Patients were randomized to one of three surgical hernia repairs. Patients were seen in follow-up at 6, 12, and 24 months and were assessed for the presence of pain, numbness, paresthesia, and recurrence. RESULTS: Three hundred fifteen patients were seen in follow-up, with 276 seen at the 2-year mark. At 1 year, 62.9% of patients had groin or inguinal pain and 11.9% of patients had moderate to severe pain; 53.6% had pain and 10.6% of patients continued to report moderate to severe pain 2 years postoperatively. The predictors for long-term postoperative pain were as follows: absence of a visible bulge before the operation (p < 0.001); presence of numbness in the surgical area postoperatively (p < 0.05); and patient requirement of more than 4 weeks out of work postoperatively (p < 0.004). Three distinct chronic pains were identified. The most common and most severe pain was somatic, localized to the common ligamentous insertion to the public tubercle. The second was neuropathic and was referable to the ilioinguinal or genitofemoral nerve distribution. This was likely because of injury to the genitofemoral nerves, either at surgery or subsequently by encroachment of scar. The third pain was visceral, ejaculatory pain. Twenty-four percent of patients had postoperative numbness at 2 years, independent of the type of repair. Numbness was most common in the distribution of cutaneous branches of the ilioinguinal and iliohypogastric nerves. CONCLUSION: Pain or numbness are common late sequelae of traditional external surgical hernia repairs. Strategies need to be developed to reduce the risk of these complications.

Adult↗
PubMed1996

Cryosurgery for malignant tumours of the liver.

OBJECTIVE: To evaluate the safety and efficacy of ultrasound-guided cryosurgery to treat malignant tumours of the liver. DESIGN: A prospective nonrandomized trial. The follow-up was complete and ranged from 8 to 35 months. SETTING: A university-affiliated hospital. PATIENTS: Ten patients with secondary malignant tumours of the liver; 1 with primary hepatoma. INTERVENTIONS: Computed portography for preoperative staging; laparotomy and ultrasonographic examination of the liver; cryosurgical ablation of liver tumours with or without a concomitant resection. Thirteen procedures were performed on 11 patients. MAIN OUTCOME MEASURES: Preoperative morbidity, disease-free and overall survival. RESULTS: Of 24 lesions frozen, the procedure on 4 lesions was considered a technical failure because of persistent disease. There were no perioperative deaths. One patient had a liver abscess that resolved with percutaneous drainage. One patient had a biliary fistula that resolved spontaneously, and one had a transient rise in the serum creatinine level. Of 11 patients treated, 7 had a recurrence in the liver (persistent disease in 2 and new liver metastases in 5); 2 of these patients died. One patient died of distant disease with no local recurrence. At the time of writing, one patient was alive with extrahepatic disease and no local recurrence and two were free of disease. CONCLUSIONS: Cryosurgery of the liver is a relatively safe procedure that allows treatment of otherwise unresectable malignant disease. Proof of long-term benefit requires further experience and follow-up.

Aged↗
PubMed1995

Preoperative regional therapy for extremity sarcoma. A tricenter update.

BACKGROUND: Preoperative radiation with sensitizing doxorubicin has been popularized in the treatment of high grade sarcoma of the extremity. A multiinstitutional experience with this protocol that was initiated by the Southeastern Cancer Study Group in 1984 and maintained in three institutions was updated by the authors. METHODS: Patients with biopsied sarcoma had intraarterial infusion with doxorubicin hydrochloride (Adriamycin) 30 mg/24 hrs x 3 days and were allocated by the institution to receive radiation 30-35 Gy in 10 fractions or 46 Gy in 23-25 fractions followed by resection. Surgery was performed within 10 days or 30 days depending on the radiation dose. Postoperative chemotherapy was administered to 31 patients. RESULTS: Of 66 patients, 32 were female and 34 were male. The median age was 46 years (range, 14-77 years); 73% had lower and 27% had upper extremity tumors. There were 55 soft-tissue and 9 malignant bone tumors. Common types were malignant fibrous histiocytoma 20%; liposarcoma, 17%; synovial sarcoma 18%; and 14% were osteosarcoma. American Joint Committee on Cancer stages were: I, IIB (17%), IIIA/B (59%), and IIIC/4A (24%). Limb salvage surgery was performed on 60 patients including radical resection in 21 with extensive tumors, wide local excision in 30, and limited excision in 2 patients. Primary amputation was performed on four patients and delayed amputation in two because of wound complications. Three patients had pulmonary metastasectomy in conjunction with primary surgery (2 are long term survivors > 5 years). There were no postoperative deaths, but wound complications occurred in 41% of the patients. Overall survival and disease free survival at 5 years was 59 and 49%. One patient (1.5%) had local recurrence 9 years after resection of an extensive synovial sarcoma of the shoulder. This was resected with limb salvage techniques. Among 23 patients who failed primarily in the lung, the median survival was 7 months with 4 surviving more than 5 years, after demonstration of the pulmonary metastases. Multivariant analysis of prognostic factors showed that extent of disease and stage correlated with disease free survival, whereas only extent of surgical resection correlated with overall surgical survival. CONCLUSION: Combined therapy for extremity sarcoma in a multicenter setting using preoperative radiation with sensitizing chemotherapy and adequate resection was associated with an excellent local control rate (98.5%) and reasonable long term tumor control, although distant metastases continued to be a major challenge.

Adolescent↗
PubMed1995

Perineal wound closure with the rectus abdominis musculocutaneous flap after tumor ablation.

BACKGROUND: We describe the transpelvic rectus abdominis musculocutaneous flap for closing large, often irradiated, perineal defects in patients with cancer. METHODS: We studied 9 men and 17 women who underwent wide excision of advanced T3 and T4 tumors and who had preoperative chemotherapy, radiotherapy, or both. After tumor ablation, we used a transpelvic rectus abdominis musculocutaneous flap to fill pelvic dead space and primarily close the perineal wounds. Twelve simultaneous vaginal reconstructions were performed. RESULTS: Wounds healed promptly in 14 patients. Healing was delayed in the remaining 12 patients due to poor flap adherence to irradiated tissue beds (9), complete flap loss (2), or partial flap loss (1). Delayed healing was associated with the combination of obesity and prior irradiation. Other perioperative complications included localized abdominal wound infection (2), enterocutaneous fistula (1), and abdominal herniation (1). Local disease was controlled in 20 of 26 patients. Mean follow-up was 22 months. CONCLUSION: Transpelvic rotation of the rectus abdominis musculocutaneous flap facilitates healing large, difficult, perineal wounds, resulting from cancer ablation.

Adult↗
PubMed1995

The ultimate modification in the modified neck dissection.

PURPOSE: A study was undertaken to study the potential benefits for function and regional recurrence of preserving the sensory ventral branches of the cervical plexus in modified neck dissections. METHODS: Fifteen cases of squamous cell carcinoma or melanoma of the head and neck in which the sensory nerves were spared were matched to 15 cases in which the nerves were sacrificed. The subjects were examined for sensory loss, questioned regarding acute and chronic dysfunction, and followed for regional recurrence for a minimum of 2 years. RESULTS: The group whose nerves were preserved had significantly less sensory loss and a lower incidence of acute and chronic dysfunction. No subjects in either group had regional recurrence. CONCLUSION: The results of this initial study support a policy of routine preservation of the sensory ventral branches of the cervical plexus when there is no direct tumor involvement.

Carcinoma, Squamous Cell↗