[Thoracic surgery following prophylactic administration of oxytetracycline].
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Oxytetracycline↗
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Results for “prophylactic surgery”
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Early aneurysm surgery and prophylactic hypervolemic hypertensive therapy for the treatment of aneurysmal subarachnoid hemorrhage.
The prevailing sentiment of North American neurosurgeons is that there is no significant difference in overall morbidity between patients who are treated with early aneurysm surgery and those who are treated with delayed aneurysm surgery. This concept is based primarily on the high incidence of ischemic events after early intervention. Recent experience, however, indicates that prophylactic hypervolemic hypertensive therapy may be beneficial in reducing delayed ischemia after early aneurysm surgery. During the preceding 21 months, we have performed 125 operations for intracranial aneurysms. Fifty-six patients in this group presented less than 7 days after subarachnoid hemorrhage (SAH) (47 within 3 days) and were treated by a prospective protocol of urgent aneurysm surgery performed within 24 hours after presentation. In all cases, the aneurysm was clipped with the use of mannitol and spinal drainage for brain relaxation. All patients were then treated with prophylactic volume expansion therapy and induced hypertension with a central venous pressure or a Swan-Ganz catheter until the 14th day after SAH. Preoperatively, 17 patients were Hunt and Hess Grade I, 9 were Grade II, 28 were Grade III, and 2 were Grade IV. In this group of 56 patients at risk for delayed ischemia from vasospasm, 5 patients had significant intraoperative complications. Ten patients (18%) had delayed cerebral ischemia, totally reversible in 6 cases, with small infarcts in 3 cases, and with 1 death (2% mortality from delayed ischemia), there were 5 cases of shunted hydrocephalus, and 3 deaths from other complications. Overall, 41 patients (73%) returned to their premorbid occupations without neurological deficit.(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Pressure↗
[Surgical prevention and therapy of cerebral ischemia].
Surgery for cerebral ischemias has three main purposes: (1) prevention of cerebral infarctions, (2) functional improvement in patients with chronic ischemia, and (3) reduction of morbidity and mortality after complete infarction. The preventive efficiency of carotid endarterectomy has been documented in cases of high-grade symptomatic carotid artery stenosis. Several multicentric randomized studies are still under way whose aim is to define the benefit of surgery in cases of low and medium-grade symptomatic carotid stenosis as well as asymptomatic carotid stenosis. Little data is at present available on the value of prophylactic surgery in the vertebro-basilar system. In contrast to prophylactic surgery, several procedures are used for treatment of chronic hypoperfusion syndromes. In addition to carotid endarterectomy, extra-/intracranial bypass surgery, percutaneous balloon dilatation and transposition of the vertebral artery may improve perfusion. The indication for surgery with the goal of functional improvement is based on the typical symptomatology of a fluctuating neurological deficit and on tests of cerebro-vascular reactivity. In the treatment of established infarctions, neurosurgery may help non-geriatric patients to recover to the greatest possible extent by offering the methods of monitoring and management of intracranial pressure that have been used in neurotraumatology for the last twenty years.
Brain Ischemia↗
[Preventive surgery for familial adenomatous polyposis coli].
Familial adenomatous polyposis coli (FAP) may not be considered a single disease entity with standardized guidelines for operative treatment. However, prophylactic colectomy after the manifestation of polyps but prior to the development of colorectal cancer is essential. The optimal timing of prophylactic surgery remains a clinical decision taken independently of mutation analysis. In case of the classic FAP phenotype, restorative proctocolectomy and ileal pouch-anal anastomosis is the procedure of choice. The development of reliable guidelines for attenuated FAP variants requires further evidence from clinical studies on surgical strategy and the advantages of prophylactic surgery over regular endoscopic screening with removal of polyps.
Adenomatous Polyposis Coli↗
DNA screening for breast/ovarian cancer susceptibility based on linked markers. A family study.
BACKGROUND: Linkage to chromosome 17q has been identified in hereditary breast cancer and hereditary breast/ovarian cancer syndrome. A hereditary breast/ovarian cancer syndrome kindred was identified that yielded a highly significant lod score (4.20) when 17q markers were studied, enabling us to identify those who probably carried the cancer-associated gene among the high-risk members of the family. METHODS: High-risk members of the hereditary breast/ovarian cancer syndrome kindred were offered counselling on the basis of 17q markers. Family members responding positively received one-to-one genetic counseling in a structured setting. Subjects were educated before disclosure, and the immediate impact of this information was assessed after disclosure. RESULTS: We provided genetic counseling on the basis of linkage findings to 32 relatives (four men and 28 women). Women who were told they were linkage positive expressed an increased motivation for surveillance and prophylactic surgery. Most women who were told they were linkage negative indicated that they would not proceed with prophylactic surgery but would continue careful surveillance. To date, there has been no evidence of serious emotional disturbances resulting from this disclosure. We believe that this experience can be used by cancer geneticists and physicians in developing protocols for genetic counseling in cancer-associated hereditary disorders. CONCLUSIONS: Physicians must understand current developments in cancer genetics and linkage so that they can be applied to genetic counseling and treatment of high-risk patients.
Adult↗
ASCO/SSO review of current role of risk-reducing surgery in common hereditary cancer syndromes.
Although the etiology of solid cancers is multifactorial, with environmental and genetic factors playing a variable role, a significant portion of the burden of cancer is accounted for by a heritable component. Increasingly, the heritable component of cancer predispositions has been linked to mutations in specific genes, and clinical interventions have been formulated for mutation carriers within affected families. The primary interventions for mutations carriers for highly penetrant syndromes such as multiple endocrine neoplasias, familial adenomatous polyposis, hereditary nonpolyposis colon cancer, and hereditary breast and ovarian cancer syndromes are primarily surgical. For that reason, the American Society of Clinical Oncology (ASCO) and the Society of Surgical Oncology (SSO) have undertaken an educational effort within the oncology community. A joint ASCO/SSO Task Force was charged with presenting an educational symposium on the surgical management of hereditary cancer syndromes at the annual ASCO and SSO meetings, resulting in an educational position article on this topic. Both the content of the symposium and the article were developed as a consensus statement by the Task Force, with the intent of summarizing the current standard of care. This article is divided into four sections addressing breast, colorectal, ovarian and endometrial cancers, and multiple endocrine neoplasia. For each, a brief introduction on the genetics and natural history of the disease is provided, followed by a detailed description of modern surgical approaches, including a description of the clinical and genetic indications and timing of prophylactic surgery, and the efficacy of prophylactic surgery when known. Although a number of recent reviews have addressed the role of genetic testing for cancer susceptibility, including the richly illustrated Cancer Genetics and Cancer Predisposition Testing curriculum by the ASCO Cancer Genetics Working Group (available through http://www.asco.org), this article focuses on the issues surrounding the why, how, and when of surgical prophylaxis for inherited forms of cancer. This is a complex process, which requires a clear understanding of the natural history of the disease and variance of penetrance, a realistic appreciation of the potential benefit and risk of a risk-reducing procedure in a potentially otherwise healthy individual, the long-term sequelae of such surgical intervention, as well as the individual patient and family's perception of surgical risk and anticipated benefit.
Female↗
Selective use of sentinel lymph node surgery during prophylactic mastectomy.
BACKGROUND: Patients with invasive cancer identified at the time of prophylactic mastectomy (PM) will require axillary lymph node dissection for staging; therefore, many surgeons advocate sentinel lymph node (SLN) surgery at the time of PM. The current study investigates the invasive cancer rate in PM and evaluates factors associated with invasive cancer to guide SLN surgery use. METHODS: Patients undergoing PM at the M. D. Anderson Cancer Center between January 2000 and July 2005 were identified from a prospective database. Clinical, radiographic, and pathologic data were collected. RESULTS: A total of 409 patients (436 PM cases) were identified; 382 underwent contralateral PM (CPM) and 27 underwent bilateral PM (BPM). Cancer was identified in 22 of 436 PM cases (5%). Of these, 14 patients (64%) had ductal carcinoma in situ (DCIS). Only 8 patients (1.8%) had invasive cancer, with a mean tumor size of 5 mm (range, 2-9 mm). There was no difference in the occult cancer rate between CPM and BPM. No cases of invasive cancer were identified in the 23 patients with BRCA mutations. Significantly increased risk of invasive cancer in the PM breast was seen in postmenopausal patients (3.7%; P = .007), patients age >60 years (7.5%; P = .008), and patients with history of invasive lobular carcinoma (9.7%; P = .0002) or lobular carcinoma in situ (LCIS) (7.7%; P = .008). CONCLUSIONS: The frequency of cancer in PM is very low and the majority represents DCIS. Therefore, routine use of SLN surgery in all patients undergoing PM is not warranted. However, patients at higher risk for whom SLN surgery should be considered include older women and patients with a history of lobular cancer or LCIS.
Adult↗
Minor skin surgery. Are prophylactic antibiotics ever needed for curettage?
Curettage of skin lesions was not followed by bacteraemia in 22 patients. The risk of bacterial endocarditis after curettage and other minor skin surgery is small but should not be overlooked in those with a prosthetic heart valve, a history of other cardiac surgery, a previous episode of infective endocarditis, drug addiction, diabetes, alcoholism, immunosuppression, or renal failure--especially where the skin lesion might be infected.
Anti-Bacterial Agents↗
Advances in the management of hereditary medullary thyroid cancer.
This work draws on recent advances during the era of codon-oriented prophylactic surgery for hereditary medullary thyroid cancer (MTC). Milestones included identification of RET (REarranged during Transfection) as the susceptibility gene, introduction of prophylactic surgery on evidence of a RET germline mutation, revelation of genotype-phenotype correlations within the MEN 2 spectrum and demonstration of age-related progression of MTC. Novel surgical techniques, notably systemic microdissection and compartment-oriented surgery, have greatly enhanced surgical cure. Uncovering molecular pathways from RET genotype to MEN 2 phenotype should provide treatment options for RET mutation carriers whose MTC currently is too advanced for cure.
Age Factors↗
Tamoxifen and breast cancer risk in women harboring a BRCA1 germline mutation: computed efficacy, effectiveness and impact.
The management of breast cancer prone women remains a tough issue despite the release of institutional guidelines. Currently, only the anti-estrogen agent Tamoxifen and prophylactic surgery are claimed to decrease breast cancer incidence. However, efficacy of Tamoxifen, particularly in BRCA1 gene carriers, remains controversial and acceptability of prophylactic surgery is low. To evaluate the expected impact of Tamoxifen in preventing hereditary breast cancers, a modelling was made according to the efficacy of the treatment with respect to biological predictors of response: estrogen receptor (ER) and pS2 status of a series of 33 BRCA1-related breast cancers (BRCA1-BCs), and using data on BRCA1-BCs penetrance, as well as compliance and acceptability of the strategy. Although, 88% of BRCA1-BCs are ER negative in our series, 30% of cases are pS2 positive, implying a potential hormonal sensitivity of a proportion of these cancers. From our modelling, the expected impact of Tamoxifen in BRCA1 gene carriers is a reduction of breast cancer incidence of about 10% according to acceptability and compliance, close to that of 5% and of 13.5% for prophylactic mastectomy, according to acceptability rates from US and French surveys respectively. Since autonomy of choice is the root of western ethics, cancer prone women should be informed about the low but valuable expected reduction of incidence of breast cancer using Tamoxifen preventive therapy.
Antineoplastic Agents, Hormonal↗
[The concept of "microsurgical" technique in medullary thyroid carcinoma].
Medullary thyroid carcinomas (MTC) metastasize early into the regional lymph nodes. Calcitonin is a highly specific and sensitive marker for these tumors, which is feasible for follow-up and for screening. Additionally, in families with hereditary MTC the responsible mutations of the RET-proto-oncogene can be identified, and prophylactic surgery can be provided. We operated on 127 patients for MTC, 114 of whom had diagnosed carcinomas; 13 operations were performed with prophylactic intention. A total of 101 patients needed microsurgical dissection of the cervical compartments. Of these, 31% could be cured, and a further 46% showed postoperatively normalized basal calcitonin concentrations. Thirteen patients who needed mediastinal dissection had persistent increased levels of pentagastrin-stimulated or basal calcitonin values. All patients who underwent prophylactic surgery could be cured.
Adult↗
Unexpected gynecologic neoplasms in patients with proven or suspected BRCA-1 or -2 mutations: implications for gross examination, cytology, and clinical follow-up.
Identification of inheritable mutations associated with the development of malignancy has led to prophylactic surgeries to remove tissues at risk. We report seven unrelated patients with family histories of breast and/or ovarian cancer, five of whom underwent prophylactic salpingo-oophorectomy with hysterectomy. Four had proven BRCA-1 or -2 mutations. Malignant cells were found unexpectedly in the peritoneal washings of two patients, leading to the discovery of early-stage fallopian tube carcinoma. After changing the sampling technique at our institution, two more cases of unexpected fallopian tube carcinoma in situ were discovered. Another patient had a significant family history and underwent hysterectomy for uterine fibroids, leading to the discovery of fallopian tube carcinoma. Another patient with BRCA-1 mutation had unexpected widespread primary peritoneal papillary serous adenocarcinoma. The final patient had a borderline malignant clear cell adenofibroma. These cases underscore the importance of peritoneal cytology and thorough sampling in the management of patients undergoing hysterectomy with a family history of breast/ovarian cancer and/or known BRCA-1/BRCA-2 mutations. As prophylactic surgeries are becoming more common secondary to advances in molecular diagnostics, pathologists need to be aware that surgical specimens from these patients may require more rigorous examination to uncover early neoplastic changes.
Adenocarcinoma↗
Recommendations for follow-up care of individuals with an inherited predisposition to cancer. II. BRCA1 and BRCA2. Cancer Genetics Studies Consortium.
OBJECTIVE: To provide recommendations for cancer surveillance and risk reduction for individuals carrying mutations in the BRCA1 or BRCA2 genes. PARTICIPANTS: A task force with expertise in medical genetics, oncology, primary care, gastroenterology, and epidemiology convened by the Cancer Genetics Studies Consortium (CGSC), organized by National Human Genome Research Institute (previously the National Center for Human Genome Research). EVIDENCE: Studies evaluating cancer risk, surveillance, and risk reduction in individuals genetically susceptible to breast and ovarian cancer were identified using MEDLINE (National Library of Medicine) and from bibliographies of articles thus identified. Indexing terms used were "genetics" in combination with "breast cancer," "ovarian cancer," and "screening," or "surveillance" in combination with "cancer family" and "BRCA1" and "BRCA2." For studies evaluating specific interventions, quality of evidence was assessed using criteria of the US Preventive Services Task Force. CONSENSUS PROCESS: The task force developed recommendations through discussions over a 14-month period. CONCLUSIONS: Efficacy of cancer surveillance or other measures to reduce risk in individuals who carry cancer-predisposing mutations is unknown. Based on expert opinion concerning presumptive benefit, early breast cancer and ovarian cancer screening are recommended for individuals with BRCA1 mutations and early breast cancer screening for those with BRCA2 mutations. No recommendation is made for or against prophylactic surgery (eg, mastectomy, oophorectomy); these surgeries are an option for mutation carriers, but evidence of benefit is lacking, and case reports have documented the occurrence of cancer following prophylactic surgery. It is recommended that individuals considering genetic testing be counseled regarding the unknown efficacy of measures to reduce risk and that care for individuals with cancer-predisposing mutations be provided whenever possible within the context of research protocols designed to evaluate clinical outcomes.
Antineoplastic Agents, Hormonal↗
Public health aspects of breast cancer gene testing in Canada. Part 1: risks and interventions.
The risks (penetrance) of breast and ovarian cancer in carriers of the BRCA1 or BRCA2 genes are high, but it is likely that estimates based on selected large multicase families are inflated by selection bias. Estimates based on a population survey of Ashkenazi Jews are lower, but other population-based estimates are still not available. The proportion of breast or ovarian cancers related to the genes is similarly lower in population-based samples than in referred selected families, and, even for subjects with cancer onset at young ages or with a family history, it is quite small. Other genes with lower prevalence are also important, and there is evidence of some gene environmental interactions. The management of female BRCA gene carriers includes intensive surveillance, prophylactic surgery and the use of tamoxifen. Apart from screening justified by randomized trials in the general community, such as mammography, recommendations for surveillance and prophylactic surgery are based only on expert opinion, and there has been little consideration of risk-benefit or cost-benefit comparisons. Tamoxifen reduced breast cancer incidence in one trial of high-risk women, but not in two other smaller trials, and the effect on mortality has not been determined. The limitations of genetic testing, and particularly of intervention strategies, deserve close scrutiny.
Adult↗
The course of distress in women at increased risk of breast and ovarian cancer due to an (identified) genetic susceptibility who opt for prophylactic mastectomy and/or salpingo-oophorectomy.
The levels and course of psychological distress before and after prophylactic mastectomy (PM) and/or prophylactic salpingo-oophorectomy (PSO) were studied in a group of 78 women. General distress was measured through the hospital anxiety and depression scale (HADS), cancer-related distress using the impact of events scale (IES). Measurement moments were baseline (2-4 weeks prior to prophylactic surgery), and 6 and 12 months post-surgery. After PM, anxiety and cancer-related distress were significantly reduced, whereas no significant changes in distress scores were observed after PSO. At one year after prophylactic surgery, a substantial amount of women remained at clinically relevant increased levels of cancer-related distress and anxiety. We conclude that most women can undergo PM and/or PSO without developing major emotional distress. More research is needed to further define the characteristics of the women who continue to have clinically relevant increased scores after surgery, in order to offer them additional counselling.
Adult↗
Single center experience in primary surgery for medullary thyroid carcinoma.
Medullary thyroid carcinoma (MTC) is a rare disease, and most studies are either based on small numbers or multicenter studies with their inherent difficulties. Since 1995, a total of 440 patients with MTC underwent surgery in our clinic. A primary operation was performed in 188 patients (43% of 440). In 60 patients, the primary operation was performed because of a germline RET mutation ("prophylactic surgery"). Most (84%, 158/188) of the patients had pathologic calcitonin levels. Notably, MTC was found in almost 10% (3/30) of patients with normal calcitonin levels. However, all patients with lymph node metastases (LNMs) had elevated calcitonin levels. Total thyroidectomy (TTx) was performed in all patients. Lymph node dissection (LND) was performed at various extensions: one-compartment LND in 35% (66/188), three-compartment LND in 31% (58/188), and four-compartment LND in 29% (22/188). In general, lymph node dissection increased the likelihood of complications. LNM and distant metastases (DM) correlated with the extent of the primary tumor (pT category). The presence of LNM ranged from 17% (pT1 tumor) to 100% (pT4 tumor), whereas the presence of DM ranged from 0% (pT1 tumor) to 81% (pT4 tumor). Biochemical cure (normal calcitonin levels) was obtained in 72% (137/188) of patients. All 60 patients undergoing prophylactic surgery (tumor stage pT0/pT1) were biochemically cured. In contrast, only 60% (77/128) of the remaining patients were cured. The data suggest that primary surgery should be scheduled as soon as possible to treat patients at a node-negative stage. In the case of normal basal and elevated stimulated calcitonin levels, TTx and cervicocentral LND is recommended. If the basal calcitonin level is elevated, LND should include the cervicolateral compartment.
Adolescent↗
Occult cancer of the fallopian tube in a BRCA2 germline mutation carrier at prophylactic salpingo-oophorectomy.
BACKGROUND: Women with a germline BRCA1 or BRCA2 mutation have a significantly increased risk of developing ovarian cancer compared with women in the general population and may consider bilateral prophylactic oophorectomy as a risk-reducing option. CASE: We report a case of occult fallopian tube cancer diagnosed at prophylactic surgery in a patient with a BRCA2 mutation. CONCLUSIONS: This report acts as a reminder of the importance of removing as much of the fallopian tube as possible during prophylactic surgery in BRCA1 and BRCA2 carriers and of the need for careful pathological examination of surgical specimens after surgery.
Fallopian Tube Neoplasms↗
Life expectancy gains from cancer prevention strategies for women with breast cancer and BRCA1 or BRCA2 mutations.
CONTEXT: Women with BRCA1- or BRCA2-associated breast cancer are at increased risk for contralateral breast cancer and ovarian cancer and therefore may consider secondary cancer prevention strategies, such as prophylactic surgery and tamoxifen therapy. It is not proven to what extent these strategies reduce risk of second cancers in such patients. OBJECTIVE: To examine the effect of tamoxifen therapy, bilateral prophylactic oophorectomy (PO), prophylactic contralateral mastectomy (PCM), and combinations of these strategies on life expectancy for women with unilateral breast cancer and a BRCA1 or BRCA2 gene mutation. DESIGN AND SETTING: Decision analysis using a Markov model. Probabilities for developing contralateral breast cancer and ovarian cancer, dying from these cancers, dying from primary breast cancer, and the reduction in cancer incidence and mortality due to prophylactic surgeries and/or tamoxifen were estimated from published studies. PARTICIPANTS: Hypothetical breast cancer patients with BRCA1 or BRCA2 mutations facing decisions about secondary cancer prevention strategies. INTERVENTIONS: Seven strategies, including 5 years of tamoxifen use, PO, PCM, and combinations of these strategies, compared with careful surveillance. MAIN OUTCOME MEASURES: Total and incremental life expectancy (LE) with each intervention strategy. RESULTS: Depending on the assumed penetrance of the BRCA mutation, compared with surveillance alone, 30-year-old early-stage breast cancer patients with BRCA mutations gain in LE 0.4 to 1.3 years from tamoxifen therapy, 0.2 to 1.8 years from PO, and 0.6 to 2.1 years from PCM. The magnitude of these gains is least for women with low-penetrance mutations (assumed contralateral breast cancer risk of 24% and ovarian cancer risk of 6%) and greatest for those with high-penetrance mutations (assumed contralateral breast cancer risk of 65% and ovarian cancer risk of 40%.) Older age and poorer prognosis from primary breast cancer further attenuate these gains. CONCLUSIONS: Interventions to prevent second cancers, particularly PCM, may offer substantial LE gain for young women with BRCA-associated early-stage breast cancer. Estimates of LE gain may help women and their physicians consider the uncertainties, risks, and advantages of these interventions and lead to more informed choices about cancer prevention strategies.
Adult↗