RESUMO
BACKGROUND: Two RCTs found no survival benefit for completion lymphadenectomy after positive sentinel lymph node biopsy compared with observation with ultrasound in patients with melanoma. Recurrence patterns and regional control are not well described for patients undergoing observation alone. METHODS: All patients with a positive sentinel node biopsy who did not have immediate completion lymphadenectomy were identified from a single-institution database (1995-2018). First recurrences were classified as node only, local and in-transit (LCIT) only, LCIT and nodal, or systemic. Regional control and factors associated with recurrence survival were analysed. RESULTS: Median follow-up was 33 months. Of 370 patients, 158 (42·7 per cent) had a recurrence. The sites of first recurrence were node only (13·2 per cent), LCIT only (11·9 per cent), LCIT and nodal (3·5 per cent), and systemic (13·8 per cent). The 3-year postrecurrence melanoma-specific survival rate was 73 (95 per cent c.i. 54 to 86) per cent for patients with node-only first recurrence, and 51 (31 to 68) per cent for those with initial systemic recurrence. In multivariable analysis, ulceration in the primary lesion (hazard ratio (HR) 2·53, 95 per cent c.i. 1·27 to 5·04), disease-free interval 12 months or less (HR 2·38, 1·28 to 4·35), and systemic (HR 2·57, 1·16 to 5·65) or LCIT and nodal (HR 2·94, 1·11 to 7·79) first recurrence were associated significantly with decreased postrecurrence survival. Maintenance of regional control required therapeutic lymphadenectomy in 13·0 per cent of patients during follow-up. CONCLUSION: Observation after a positive sentinel lymph node biopsy is associated with good regional control, permits assessment of the time to and pattern of recurrence, and spares lymphadenectomy-related morbidity in patients with melanoma.
Assuntos
Melanoma/patologia , Recidiva Local de Neoplasia/patologia , Linfonodo Sentinela/patologia , Neoplasias Cutâneas/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Excisão de Linfonodo , Metástase Linfática , Masculino , Melanoma/mortalidade , Melanoma/cirurgia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/cirurgia , Estudos Retrospectivos , Linfonodo Sentinela/cirurgia , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/cirurgia , Análise de Sobrevida , Conduta Expectante , Adulto JovemRESUMO
BACKGROUND: The complex lymphatic drainage in the head and neck makes sentinel lymph node biopsy (SLNB) for melanomas in this region challenging. This study describes the incidence, and location of additional positive nonsentinel lymph nodes (NSLN) in patients with cutaneous head and neck melanoma following a positive SLNB. METHODS: A retrospective review was performed using a single institution prospective database. Patients with a primary melanoma in the head or neck with a positive cervical SLNB were identified. The lymphadenectomy specimen was divided intraoperatively into lymph node levels I-V, and NSLN status determined for each level. RESULTS: Of 387 patients with melanoma of the head and neck who underwent cervical SLNB, 54 had a positive SLN identified (14%). Thirty six patients (67%) underwent immediate completion lymph node dissection (CLND) of whom eight patients (22%) had a positive NSLN. The remaining 18 patients (33%) did not undergo CLND and were observed. Half of positive NSLNs (50%) were in the same lymph node level as the SLN and 33% were in an immediately adjacent level; only two patients were found to have NSLNs in non-adjacent levels. The only factor predictive of NSLN involvement was the size of the tumor deposit in the SLN>0.2 mm (p = 0.05). Superficial parotidectomy at CLND revealed metastatic melanoma only in patients with a positive parotid SLN. CONCLUSIONS: A positive NLSN was identified in 22% of patients undergoing CLND after a positive SLNB. The majority of positive NSLNs are found within or immediately adjacent to the nodal level containing the SLN.
Assuntos
Neoplasias de Cabeça e Pescoço/patologia , Linfonodos/patologia , Melanoma/secundário , Biópsia de Linfonodo Sentinela/métodos , Neoplasias Cutâneas/patologia , Adulto , Idoso , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Incidência , Estimativa de Kaplan-Meier , Excisão de Linfonodo/métodos , Excisão de Linfonodo/estatística & dados numéricos , Linfonodos/cirurgia , Masculino , Melanoma/mortalidade , Melanoma/cirurgia , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Estudos Retrospectivos , Medição de Risco , Biópsia de Linfonodo Sentinela/estatística & dados numéricos , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/cirurgia , Estatísticas não Paramétricas , Análise de SobrevidaRESUMO
PURPOSE: To examine the association between positive resection margins and survival and local recurrence in patients with gastric cancer undergoing resection with curative intent. METHODS: Patients who underwent curative intent resection for gastric carcinoma from 1985 to 2010 were identified from a prospectively maintained database. Positive margins were defined as disease present at the line of luminal transection. Clinicopathological features and outcome of patients undergoing gastrectomy with negative and positive margins were compared. RESULTS: Among 2384 patients undergoing curative intent resection, 108 (4.5 %) had positive margins. Positive margins were associated with higher American Joint Committee on Cancer (AJCC) stage, T stage, N stage, median number of positive nodes, diffuse Lauren type, and poorly differentiated tumors. Treatment of positive margins consisted of: observation (39 %), chemoradiotherapy (26 %), chemotherapy (20 %), repeat resection (10 %), radiotherapy (4 %), and unknown (1 %). Multivariate analysis of the entire cohort demonstrated margin status, T stage, N stage, grade, and perineural invasion to be independent predictors of survival. Margin status was an independent predictor of survival in patients with ≤3 positive nodes or T1-2 disease but was not in patients with >3 positive nodes or T3-4 disease. Local recurrence occurred in 16 % of patients with a positive margin. We identified no factors predictive of local recurrence in patients with positive margins. CONCLUSIONS: Positive resection margin is associated with advanced AJCC stage and aggressive tumor biology but remains an independent predictor of worse survival. The significance of a positive margin in gastric cancer is confined to patients with nontransmural disease and/or limited nodal involvement.
Assuntos
Carcinoma/secundário , Carcinoma/terapia , Recidiva Local de Neoplasia/etiologia , Neoplasias Gástricas/patologia , Neoplasias Gástricas/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Quimiorradioterapia Adjuvante , Quimioterapia Adjuvante , Feminino , Gastrectomia , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Gradação de Tumores , Invasividade Neoplásica , Estadiamento de Neoplasias , Neoplasia Residual , Modelos de Riscos Proporcionais , Radioterapia Adjuvante , Reoperação , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Splenectomy is performed for a variety of indications in haematological disorders. This study was undertaken to analyse outcomes, and morbidity and mortality rates associated with this procedure. METHODS: Patients undergoing splenectomy for the treatment or diagnosis of haematological disease were included. Indications for operation, preoperative risk, intraoperative variables and short-term outcomes were evaluated. RESULTS: From January 1997 to December 2010, 381 patients underwent splenectomy for diagnosis or treatment of haematological disease. Some 288 operations were performed by an open approach, 83 laparoscopically, and there were ten conversions. Overall 136 patients (35·7 per cent) experienced complications. Postoperative morbidity was predicted by age more than 65 years (odds ratio (OR) 1·63, 95 per cent confidence interval 1·05 to 2·55), a Karnofsky performance status (KPS) score lower than 60 (OR 2·74, 1·35 to 5·57) and a haemoglobin level of 9 g/dl or less (OR 1·74, 1·09 to 2·77). Twenty-four patients (6·3 per cent) died within 30 days of surgery. Postoperative mortality was predicted by a KPS score lower than 60 (OR 16·20, 6·10 to 42·92) and a platelet count of 50,000/µl or less (OR 3·34, 1·25 to 8·86). The objective of the operation was achieved in 309 patients (81·1 per cent). The success rate varied for each indication: diagnosis (106 of 110 patients, 96·4 per cent), thrombocytopenia (76 of 115, 66·1 per cent), anaemia (10 of 16, 63 per cent), to allow further treatment (46 of 59, 78 per cent) and primary treatment (16 of 18, 89 per cent). CONCLUSION: Splenectomy is an effective procedure in the diagnosis and treatment of haematological disease in selected patients.
Assuntos
Doenças Hematológicas/cirurgia , Esplenectomia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Criança , Pré-Escolar , Conversão para Cirurgia Aberta/estatística & dados numéricos , Feminino , Hemoglobinas/metabolismo , Humanos , Lactente , Laparotomia/métodos , Laparotomia/mortalidade , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Contagem de Plaquetas , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Esplenectomia/mortalidade , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: While it is suggested that more than 15 lymph nodes (LNs) should be evaluated for accurate staging of gastric cancer, LN yield in western countries is generally low. The effect of preoperative chemotherapy on LN yield in gastric cancer is unknown. The aim of the present study is to determine whether preoperative chemotherapy is associated with any difference in the number of LNs obtained from specimens of patients who underwent curative surgery for gastric adenocarcinoma. PATIENTS AND METHODS: In 1205 patients from Memorial Sloan-Kettering Cancer Center (MSKCC) and 1220 patients from the Netherlands Cancer Registry (NCR) who underwent a gastrectomy with curative intent for gastric adenocarcinoma without receiving preoperative radiotherapy, LN yield was analyzed, comparing patients who received preoperative chemotherapy and patients who received no preoperative therapy. RESULTS: Of the 2425 patients who underwent a gastrectomy, 14% received preoperative chemotherapy. Median LN yields were 23 at MSKCC and 10 in the NCR. Despite this twofold difference in LN yield between the two populations, with multivariate Poisson regression, chemotherapy was not associated with LN yield of either population. Variables associated with increased LN yield were institution, female sex, lower age, total (versus distal) gastrectomy and increasing T-stage. CONCLUSIONS: In this patient series, treatment at MSKCC, female sex, lower age, total gastrectomy and increasing primary tumor stage were associated with a higher number of evaluated LNs. Preoperative chemotherapy was not associated with a decrease in LN yield. Evaluating more than 15 LNs after gastrectomy is feasible, with or without preoperative chemotherapy.
Assuntos
Adenocarcinoma/tratamento farmacológico , Terapia Neoadjuvante , Biópsia de Linfonodo Sentinela , Neoplasias Gástricas/tratamento farmacológico , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Quimioterapia Adjuvante , Feminino , Humanos , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Estadiamento de Neoplasias , Países Baixos , Cidade de Nova Iorque , Sistema de Registros , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: To characterise recurrence patterns and survival following pathologic complete response (pCR) in patients who received preoperative therapy for localised gastric or gastrooesophageal junction (GEJ) adenocarcinoma. METHODS: A retrospective review of a prospective database identified patients with pCR after preoperative chemotherapy for gastric or preoperative chemoradiation for GEJ (Siewert II/III) adenocarcinoma. Recurrence patterns, overall survival, recurrence-free survival, and disease-specific survival were analysed. RESULTS: From 1985 to 2009, 714 patients received preoperative therapy for localised gastric/GEJ adenocarcinoma, and 609 (85%) underwent a subsequent R0 resection. There were 60 patients (8.4%) with a pCR. Median follow-up was 46 months. Recurrence at 5 years was significantly lower for pCR vs non-pCR patients (27% and 51%, respectively, P=0.01). The probability of recurrence for patients with pCR was similar to non-pCR patients with pathologic stage I or II disease. Although the overall pattern of local/regional (LR) vs distant recurrence was comparable (43% LR vs 57% distant) between pCR and non-pCR groups, there was a significantly higher incidence of central nervous system (CNS) first recurrences in pCR patients (36 vs 4%, P=0.01). CONCLUSION: Patients with gastric or GEJ adenocarcinoma who achieve a pCR following preoperative therapy still have a significant risk of recurrence and cancer-specific death following resection. One third of the recurrences in the pCR group were symptomatic CNS recurrences. Increased awareness of the risk of CNS metastases and selective brain imaging in patients who achieve a pCR following preoperative therapy for gastric/GEJ adenocarcinoma is warranted.
Assuntos
Adenocarcinoma/mortalidade , Neoplasias Esofágicas/mortalidade , Junção Esofagogástrica , Recidiva Local de Neoplasia/epidemiologia , Neoplasias Gástricas/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Idoso , Neoplasias Encefálicas/secundário , Terapia Combinada , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias Gástricas/patologia , Neoplasias Gástricas/terapiaRESUMO
BACKGROUND: We treated melanoma patients with temozolomide (TMZ) in the neoadjuvant setting and collected cryopreserved tumor samples before and after treatment. The primary objective was to determine whether the response proportion was higher than previously reported in widely metastatic patients. A secondary objective was to test the feasibility of obtaining adequate tissue before and after treatment for genetic testing. MATERIALS AND METHODS: Chemotherapy-naive melanoma patients who were candidates for surgical resection were eligible. TMZ was administered orally at 75 mg/m(2)/day for 6 weeks of every 8-week cycle. Cycles were repeated until complete response (CR), progression, or stable disease (SD) for two cycles. RESULTS: Of 19 assessable patients, 2 had CRs and 1 had partial response. Four patients had SD; 12 progressed. Tumor O-6-methylguanine-DNA methyltransferase (MGMT) promoter was unmethylated in all nine patients analyzed including from the two CR patients. Pretreatment tumor microarray results were obtained in 16 of 19 patients. CONCLUSIONS: The response proportion to TMZ in the neoadjuvant setting was 16%, not different than in the metastatic setting. Responses were seen even in tumors with a methylated MGMT promoter. Pretreatment cryopreserved tumor adequate for microarray analysis could be obtained in most, but not all, patients. Post-treatment tumor was unavailable in complete responders.
Assuntos
Antineoplásicos/uso terapêutico , Dacarbazina/análogos & derivados , Melanoma/tratamento farmacológico , Adulto , Idoso , Antineoplásicos/efeitos adversos , Quimioterapia Adjuvante , Metilação de DNA , Metilases de Modificação do DNA/genética , Enzimas Reparadoras do DNA/genética , Dacarbazina/efeitos adversos , Dacarbazina/uso terapêutico , Feminino , Humanos , Masculino , Melanoma/patologia , Melanoma/cirurgia , Pessoa de Meia-Idade , Regiões Promotoras Genéticas , Temozolomida , Proteínas Supressoras de Tumor/genéticaRESUMO
BACKGROUND: The clinical significance of immunohistochemically detected isolated tumor cells (ITC) in lymph nodes of gastric cancer patients is controversial. This study examined the prognostic impact of ITC on patients with early-stage gastric cancer in two large volume centers in the United States and Japan. METHODS: Fifty-seven patients with T2N0M0 gastric carcinoma who underwent gastric resection between January 1987 and January 1997 at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York and 107 patients resected at National Cancer Center Hospital (NCCH) in Tokyo between January 1984 and December 1990 were studied. The sections were newly prepared from each lymph node for immunohistochemical staining for cytokeratin. Lymph nodes and original specimens from MSKCC were examined by pathologists in NCCH. The prognostic significance of the presence of ITC in lymph nodes was investigated in patients of both institutions. RESULTS: ITC were identified in 30 of 57 patients (52.6%) at MSKCC and in 38 of 107 patients (35.5%) at NCCH. In both institutions, there was no significant difference in the prognosis of the studied patients with or without ITC (P= .22, .86 respectively). CONCLUSIONS: The presence of ITC detected by immunohistochemistry in the regional lymph nodes did not affect the prognosis of American and Japanese patients with T2N0M0 gastric carcinoma who underwent gastrectomy with D2 lymph node dissection.
Assuntos
Adenocarcinoma/secundário , Linfonodos/patologia , Células Neoplásicas Circulantes/patologia , Neoplasias Gástricas/patologia , Adenocarcinoma/sangue , Adenocarcinoma/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/metabolismo , Diferenciação Celular , Feminino , Seguimentos , Gastrectomia , Humanos , Técnicas Imunoenzimáticas , Japão , Queratinas/análise , Excisão de Linfonodo , Linfonodos/cirurgia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Estadiamento de Neoplasias , Prognóstico , Fatores de Risco , Biópsia de Linfonodo Sentinela , Neoplasias Gástricas/sangue , Neoplasias Gástricas/cirurgia , Taxa de Sobrevida , Estados UnidosRESUMO
BACKGROUND: The aim of the study was to evaluate the efficacy and toxicity of neoadjuvant chemotherapy with intravenous (i.v.) cisplatin and fluorouracil (5-FU), surgery and postoperative intraperitoneal (i.p.) floxuridine (FUdR) and leucovorin (LV) in patients with locally advanced gastric cancer. PATIENTS AND METHODS: Preoperative staging was confirmed by laparoscopy (LAP). Two cycles of i.v. cisplatin (20 mg/m(2)/day, rapid infusion) and 5-FU (1000 mg/m(2), continuous 24-h infusion), given on days 1-5 and 29-34, were followed by a radical gastrectomy and a D2 lymphadenectomy. Patients having R0 resections were to receive three cycles of i.p. FUdR (1000 mg/m(2)) and LV (240 mg/m(2)), given on days 1-3, 15-17 and 29-31. Intraperitoneal chemotherapy was begun 5-10 days from surgery. RESULTS: Thirty-eight patients were treated. Both preoperative and postoperative chemotherapy were well tolerated. T stage downstaging (pretreatment LAP versus surgical pathological stage) was seen in 23% of patients. The R0 resection rate was 84%. Neither an increase in postoperative morbidity nor operative mortality was noted. With a median follow-up of 43.0 months, 15 patients (39.5%) are still alive (median survival 30.3 months). Good pathologic response, seen in five patients (15%), was associated with better survival (P = 0.053). Peritoneal and hepatic failures were found in 22% and 9% of patients, respectively. Quality of life seemed to be preserved. CONCLUSIONS: Neoadjuvant cisplatin/5-FU followed by postoperative i.p. FUdR/LV can be safely delivered to patients undergoing radical gastrectomy and D2 lymphadenectomy. The R0 resection and the survival rates are encouraging. An association between pathologic response and patient outcome was suggested.
Assuntos
Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/cirurgia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Floxuridina/administração & dosagem , Leucovorina/administração & dosagem , Terapia Neoadjuvante/métodos , Neoplasias Gástricas/tratamento farmacológico , Neoplasias Gástricas/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Quimioterapia Adjuvante/efeitos adversos , Quimioterapia Adjuvante/métodos , Cisplatino/administração & dosagem , Cisplatino/efeitos adversos , Terapia Combinada/métodos , Intervalo Livre de Doença , Endoscopia do Sistema Digestório/efeitos adversos , Estudos de Viabilidade , Feminino , Floxuridina/efeitos adversos , Fluoruracila/administração & dosagem , Fluoruracila/efeitos adversos , Humanos , Injeções Intraperitoneais , Leucovorina/efeitos adversos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Estadiamento de Neoplasias , Período Pós-Operatório , Qualidade de Vida , Neoplasias Gástricas/mortalidade , Neoplasias Gástricas/patologia , Análise de Sobrevida , Falha de TratamentoRESUMO
BACKGROUND: Immunohistochemical analysis of sentinel lymph nodes from patients with breast carcinoma and melanoma has been shown to increase the sensitivity for detecting lymph node metastases. To the authors' knowledge, this technique has not been described in patients with Merkel cell carcinoma. METHODS: Lymphatic mapping and sentinel lymph node biopsy was performed on 26 patients with Merkel cell carcinoma between 1997 and 1999. All sentinel lymph nodes were analyzed with conventional hematoxylin and eosin (H&E) staining and then analyzed with immunohistochemical staining to evaluate whether this additional technique would increase the number of patients found to have lymph node metastasis. RESULTS: The median age of the patients in the current study was 67 years and the median tumor size at the time of presentation was 2 cm. Lymph node metastases were identified in 5 of the 26 patients (19%). Three of these five lymph node positive patients were identified with H&E staining. The remaining two patients were identified only after immunohistochemical analysis. The median follow-up in this group of lymph node positive patients was 14 months, with 2 of the 5 lymph node positive patients developing a recurrence. The median follow-up in the 21 patients who were lymph node negative was 19 months, with only 1 patient having developed a recurrence at the time of last follow-up. CONCLUSIONS: Immunohistochemical analysis of sentinel lymph nodes from patients with Merkel cell carcinoma appears to increase the sensitivity of detecting clinically occult lymph node metastases.
Assuntos
Carcinoma de Célula de Merkel/patologia , Linfonodos/patologia , Metástase Linfática/patologia , Neoplasias Cutâneas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Biópsia de Linfonodo SentinelaRESUMO
Merkel cell carcinoma is an unusual cutaneous malignancy with a propensity for spreading to regional lymph nodes, either at presentation or as a first site of relapse. Complete surgical resection is the mainstay of treatment of the primary tumor. Because the nodotrophic behavior of the tumor is recognized, lymphatic mapping with sentinel lymph node biopsy is becoming increasingly popular in the initial surgical staging of these patients. The role of elective lymphadenectomy in patients with clinically negative regional nodal basins is unknown. The role of adjuvant radiotherapy, either to the primary site or regional nodal basin, remains undefined. The role of adjuvant chemotherapy in diminishing the risk of subsequent systemic recurrence in patients with positive nodes remains undefined. Overall response rates to combination chemotherapy for surgically unresectable distant metastatic disease are generally high, although responses are transient.
Assuntos
Carcinoma de Célula de Merkel/patologia , Neoplasias Cutâneas/patologia , Carcinoma de Célula de Merkel/secundário , Carcinoma de Célula de Merkel/cirurgia , Cromograninas/análise , Feminino , Humanos , Queratinas/análise , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Biópsia de Linfonodo Sentinela/métodos , Neoplasias Cutâneas/cirurgiaRESUMO
OBJECTIVE: To test the hypothesis that routine intraperitoneal drainage is not required after pancreatic resection. SUMMARY BACKGROUND DATA: The use of surgically placed intraperitoneal drains has been considered routine after pancreatic resection. Recent studies have suggested that for other major upper abdominal resections, routine postoperative drainage is not required and may be associated with an increased complication rate. METHODS: After informed consent, eligible patients with peripancreatic tumors were randomized during surgery either to have no drains placed or to have closed suction drainage placed in a standardized fashion after pancreatic resection. Clinical, pathologic, and surgical details were recorded. RESULTS: One hundred seventy-nine patients were enrolled in the study, 90 women and 89 men. Mean age was 65.4 years (range 23-87). The pancreas was the tumor site in 142 (79%) patients, with the ampulla (n = 24), duodenum (n = 10), and distal common bile duct (n = 3) accounting for the remainder. A pancreaticoduodenectomy was performed in 139 patients and a distal pancreatectomy in 40 cases. Eighty-eight patients were randomized to have drains placed. Demographic, surgical, and pathologic details were similar between both groups. The overall 30-day death rate was 2% (n = 4). A postoperative complication occurred during the initial admission in 107 patients (59%). There was no significant difference in the number or type of complications between groups. In the drained group, 11 patients (12.5%) developed a pancreatic fistula. Patients with a drain were more likely to develop a significant intraabdominal abscess, collection, or fistula. CONCLUSION: This randomized prospective clinical trial failed to show a reduction in the number of deaths or complications with the addition of surgical intraperitoneal closed suction drainage after pancreatic resection. The data suggest that the presence of drains failed to reduce either the need for interventional radiologic drainage or surgical exploration for intraabdominal sepsis. Based on these results, closed suction drainage should not be considered mandatory or standard after pancreatic resection.
Assuntos
Drenagem/métodos , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/mortalidade , Cavidade Peritoneal , Período Pós-Operatório , Prevalência , Probabilidade , Estudos Prospectivos , Valores de Referência , Sensibilidade e Especificidade , Análise de Sobrevida , Resultado do TratamentoRESUMO
PURPOSE: The American Joint Committee on Cancer (AJCC) recently proposed major revisions of the tumor-node-metastases (TNM) categories and stage groupings for cutaneous melanoma. Thirteen cancer centers and cancer cooperative groups contributed staging and survival data from a total of 30,450 melanoma patients from their databases in order to validate this staging proposal. PATIENTS AND METHODS: There were 17,600 melanoma patients with complete clinical, pathologic, and follow-up information. Factors predicting melanoma-specific survival rates were analyzed using the Cox proportional hazards regression model. Follow-up survival data for 5 years or longer were available for 73% of the patients. RESULTS: This analysis demonstrated that (1) in the T category, tumor thickness and ulceration were the most powerful predictors of survival, and the level of invasion had a significant impact only within the subgroup of thin (< or = 1 mm) melanomas; (2) in the N category, the following three independent factors were identified: the number of metastatic nodes, whether nodal metastases were clinically occult or clinically apparent, and the presence or absence of primary tumor ulceration; and (3) in the M category, nonvisceral metastases was associated with a better survival compared with visceral metastases. A marked diversity in the natural history of pathologic stage III melanoma was demonstrated by five-fold differences in 5-year survival rates for defined subgroups. This analysis also demonstrated that large and complex data sets could be used effectively to examine prognosis and survival outcome in melanoma patients. CONCLUSION: The results of this evidence-based methodology were incorporated into the AJCC melanoma staging as described in the companion publication.
Assuntos
Melanoma/mortalidade , Melanoma/patologia , Estadiamento de Neoplasias/normas , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/secundário , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Análise de Sobrevida , Estados Unidos/epidemiologiaRESUMO
PURPOSE: To revise the staging system for cutaneous melanoma under the auspices of the American Joint Committee on Cancer (AJCC). MATERIALS AND METHODS: The prognostic factors analysis described in the companion publication (this issue), as well as evidence from the published literature, was used to assemble the tumor-node-metastasis criteria and stage grouping for the melanoma staging system. RESULTS: Major changes include (1) melanoma thickness and ulceration but not level of invasion to be used in the T category (except for T1 melanomas); (2) the number of metastatic lymph nodes rather than their gross dimensions and the delineation of clinically occult (ie, microscopic) versus clinically apparent (ie, macroscopic) nodal metastases to be used in the N category; (3) the site of distant metastases and the presence of elevated serum lactic dehydrogenase to be used in the M category; (4) an upstaging of all patients with stage I, II, and III disease when a primary melanoma is ulcerated; (5) a merging of satellite metastases around a primary melanoma and in-transit metastases into a single staging entity that is grouped into stage III disease; and (6) a new convention for defining clinical and pathologic staging so as to take into account the staging information gained from intraoperative lymphatic mapping and sentinel node biopsy. CONCLUSION: This revision will become official with publication of the sixth edition of the AJCC Cancer Staging Manual in the year 2002.
Assuntos
Melanoma/mortalidade , Melanoma/patologia , Estadiamento de Neoplasias/normas , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/secundário , Humanos , Metástase Neoplásica , Modelos de Riscos Proporcionais , Análise de Sobrevida , Estados Unidos/epidemiologiaRESUMO
Although sentinel lymph node (SLN) biopsy for melanoma has been adopted throughout the United States and abroad as a standard method of determining the pathologic status of the regional lymph nodes, some controversy still exists regarding the validity and utility of this procedure. SLN biopsy is a minimally invasive procedure, performed on an outpatient basis at the time of wide local excision of the melanoma, with little morbidity. Numerous studies have documented the accuracy of this procedure for identifying nodal metastases. There are four major reasons to perform SLN biopsy. First, SLN biopsy improves the accuracy of staging and provides valuable prognostic information for patients and physicians to guide subsequent treatment decisions. Second, SLN biopsy facilitates early therapeutic lymph node dissection for those patients with nodal metastases. Third, SLN biopsy identifies patients who are candidates for adjuvant therapy with interferon alfa-2b. Fourth, SLN biopsy identifies homogeneous patient populations for entry onto clinical trials of novel adjuvant therapy agents. Overall, the benefit of accurate nodal staging obtained by SLN biopsy far outweighs the risks and has important implications for patient management.
Assuntos
Melanoma/patologia , Estadiamento de Neoplasias/métodos , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/patologia , Quimioterapia Adjuvante , Tomada de Decisões , Humanos , Excisão de Linfonodo , Planejamento de Assistência ao Paciente , PrognósticoRESUMO
INTRODUCTION: Although sentinel node biopsy with completion lymphadenectomy in node-positive patients (SLND) has been widely adopted in the management of patients with early stage melanoma, reports detailing the outcome of patients after SLND are limited. To address this issue, we analyzed our experience with SLND and provided a comparison to patients treated with elective lymph node dissection (ELND). METHODS: All patients who underwent SLND (1991-1998) and ELND (1974-1994) were identified from single institution melanoma databases. RESULTS: A total of 152 and 329 patients with early-stage melanoma of the extremity underwent SLND and ELND, respectively. Nodal metastases were present in 44 of 329 ELND patients (13%) and in 31 of 152 SLND patients (20%). Early relapse-free and disease-specific survivals were similar for the entire population, although in patients at higher risk for recurrence (age >50 years, thickness >3.0 mm), there was an increased rate of relapse in the SLND group (P = .04). Among all sites of early recurrences, locoregional sites were more common in patients undergoing SLND (72%) compared with ELND (39%, P < .01). SLN-negative patients with nodal recurrence had evidence of metastases on retrospective enhanced pathologic analysis in four of seven cases. CONCLUSIONS: Although overall relapse-free and disease-specific survivals are similar, there is a higher rate of relapse in a subset of SLND node-negative patients who are at high risk for nodal metastases. ELND and SLNB should not be thought of as equivalent approaches until studies with longer follow-up are available.
Assuntos
Excisão de Linfonodo , Melanoma/patologia , Recidiva Local de Neoplasia , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/patologia , Adulto , Idoso , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Melanoma/cirurgia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Fatores de Risco , Neoplasias Cutâneas/cirurgiaRESUMO
BACKGROUND: The development of malignant ascites has been associated with a poor prognosis. Previous reports have documented high morbidity rates associated with placement of palliative peritoneovenous shunts (PVS). Most study series have included gynecologic malignancies in their analysis, and wide variations in survival time have been reported. Reported data from nongynecologic malignancies and identification of preoperative factors associated with improved outcome were the concerns of the current study, which attempted to identify patients with malignant ascites who might have benefitted from PVS. METHODS: A retrospective chart review was performed and data including age, gender, weight, preoperative laboratory values, cytology on peritoneal fluid aspirates, and complications within 30 days of the operative procedure were obtained and recorded. Discharge date and follow-up status were obtained for all patients. Statistical analysis was done for categorical values by comparing survival times from date of procedure with follow-up times using the log rank test. Significance for numeric values was determined with Cox regression analysis. Multivariate analysis using Cox regression was performed for those values found to be significant on univariate analysis. RESULTS: Fifty- five patients who had undergone PVS from 1980-1996 for ascites on the Gastric and Mixed Tumor service at the Memorial Sloan-Kettering Cancer Center were identified. Two patients with benign disease and two patients with ovarian malignancies were excluded. The remaining 51 patients underwent placement of 53 PVSs for palliation. Median survival time for the entire group was 52 days. Univariate analysis identified preoperative blood urea nitrogen (BUN), creatinine (Cr), BUN to Cr ratio, and diagnosis as significant factors. Preoperative BUN emerged as an independent predictor of survival by multivariate analysis, and those patients who had a BUN value of < = 17 demonstrated a survival advantage over those with a BUN of > 17. The assessable palliation factors were hospital discharge (80% of patients) and weight loss after shunting (68% of patients lost > 1 kg). Ninety-six percent of patients (24 of 25) with a preoperative BUN of < or = 17 were discharged. CONCLUSIONS: The development of nongynecologic malignant ascites is an end stage event for most patients. The placement of PVS for those patients with nongastrointestinal tumor etiologies, a BUN of < 17, a Cr of < or = 1.1, and a BUN to Cr ratio of < 19 yielded the best results. In the current study, palliation was difficult to assess accurately, although most patients were discharged or lost > 1kg of weight after shunting.
Assuntos
Ascite/cirurgia , Neoplasias/complicações , Cuidados Paliativos , Derivação Peritoneovenosa , Adulto , Idoso , Idoso de 80 Anos ou mais , Ascite/etiologia , Nitrogênio da Ureia Sanguínea , Creatinina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Neoplasias/mortalidade , Derivação Peritoneovenosa/efeitos adversos , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
OBJECTIVE: To analyze the authors' experience with sentinel lymph node biopsy (SLNB) and the subsequent incidence and pattern of recurrence in patients with positive and negative nodes. SUMMARY BACKGROUND DATA: Lymphatic mapping with SLNB has become widely accepted in the management of patients with melanoma who are at risk for occult regional lymph node metastases. Because this procedure is relatively new, the pattern of recurrence after SLNB is not yet clear. METHODS: All patients with primary cutaneous melanoma who underwent SLNB from 1991 through 1998 were identified from a prospective single-institution melanoma database. RESULTS: Three hundred fifty-seven consecutive patients with localized primary cutaneous melanoma who underwent SLNB were identified. The sentinel node was identified in 332 patients (93%) and was positive in 56 (17%). Fourteen percent of patients had developed a recurrence at a median follow-up of 24 months. The median time to recurrence was 13 months. The 3-year relapse-free survival rates for patients with positive and negative nodes were 56% and 75%, respectively. SLN status was the most important predictor of disease recurrence. The site of first recurrence in patients with negative and positive nodes was more commonly locoregional than distant. Reexamination of the SLN in 11 patients with negative nodes with initial nodal and in-transit recurrence showed evidence of metastases in 7 (64%). CONCLUSIONS: Patients with positive sentinel nodes have a significantly increased risk for recurrence. The early pattern of first recurrence for patients with negative and positive results is characterized by a preponderance of locoregional sites, similar to that reported in previous series of elective lymph node dissection. These data underscore the need for careful pathologic analysis of the SLN as well as a careful, directed locoregional physical examination in the follow-up of these patients.
Assuntos
Melanoma/patologia , Recidiva Local de Neoplasia/patologia , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
The detection of circulating tumor cells (CTC) and bone marrow micrometastases (BMM) by reverse transcriptase polymerase chain reaction (RT-PCR) may help predict recurrence and survival in malignant melanoma (MM). Since the appearance of the original article by Smith et al. in 1991 (Lancet 338:1227), several groups have attempted the detection of CTC and BMM in MM using RT-PCR for melanocytic specific markers, mainly tyrosinase mRNA. Most studies show that tyrosinase is not present in the PB and BM of control individuals without MM. The PCR positivity rates in MM are extremely variable, ranging from 0% to 100%. There was a correlation between RT-PCR and stage in some but not all of the studies. These disparate findings could in part be explained by differences in RNA extraction and blood separation techniques, to unrecognized contamination leading to false positive results, or differences in patient selection. Despite these discrepancies, we and others have shown that RT-PCR for tyrosinase mRNA in PB is able to predict overall survival (OS) and disease-free survival (DFS) in a statistically significant manner. In AJCC stage II-IV patients rendered surgically free of disease, we found that blood tyrosinase positivity was an independent predictor of OS and DFS. We also found that BM tyrosinase positivity is an independent predictor of DFS in the same group of patients. RT-PCR may help identify subgroups of patients at high risk for early relapse for more aggressive adjuvant therapy. Large prospective studies and interlaboratory quality assurance initiatives are necessary to confirm the accuracy and prognostic value of these RT-PCR assays.