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Summary: William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine. This paper dissects how his innovative multi-tier residency program helped him hide his addiction while simultaneously providing outstanding patient care and academic training.
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Hospitais Universitários/história , Internato e Residência/história , Especialidades Cirúrgicas/história , Transtornos Relacionados ao Uso de Substâncias , Cirurgiões/história , Anestesia/história , História do Século XIX , História do Século XX , Humanos , Internato e Residência/organização & administração , América do Norte , Especialidades Cirúrgicas/educaçãoRESUMO
BACKGROUND AND OBJECTIVES: Currently, standard treatment of soft tissue sarcoma (STS) is wide local excision and adjuvant radiation, but radiation may be unnecessary in superficial STS. The primary objective is to assess local recurrence rates in patients treated with surgical management alone for superficial STS. METHODS: A retrospective cancer registry review of patients treated with surgery alone for superficial STS at the Tom Baker Cancer Center (TBCC) was performed. Patient and tumor characteristics as well as recurrence data were collected. RESULTS: Sixty-one patients met study criteria. Local and overall recurrence rates were 7/61 (11.5%) and 12/61 (19.7%), respectively. The proportion with a T2 tumor was 38.8% versus 33.3% (P = 0.69), with Grade 2 or 3 tumors was 59.2% versus 83.3% (P = 0.14), and with resection margins <1 cm was 28.6% versus 75.0% (P = 0.008) for patients without and with recurrence, respectively. Median time to recurrence was 1.7 (0.4-5.2) years. CONCLUSIONS: Surgical resection alone appears to be a viable option for superficial STS that can save patients from potential side effects of radiation. The association between recurrence and inadequate margins (<1 cm) requires additional treatment be offered to this subset of patients.
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Sarcoma/patologia , Sarcoma/cirurgia , Adulto , Idoso , Alberta/epidemiologia , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia/epidemiologia , Seleção de Pacientes , Sistema de Registros , Estudos Retrospectivos , Sarcoma/epidemiologia , Sarcoma/mortalidade , Resultado do TratamentoRESUMO
INTRODUCTION: Using a preoperative neoadjuvant chemoradiation protocol, followed by complete excision, we have achieved local control rates exceeding that found in most large series. METHODS: From October 1990 through May 2008, resectable desmoids were initially treated with a preoperative protocol using Adriamycin 30 mg x 3 days continuous intravenous infusion followed by 3,000 cGy of radiation (300 cGy fractions over 10 days). Resection was performed 4-6 weeks later. After 2001, all patients were initially offered Tamoxifen 120 mg/day and Celebrex 400 mg/day for 1 year. Patients who progressed on Tamox/Celeb were treated with protocol and those with stabilization or regression were observed. Patient demographics, tumor size, history of previous recurrences, and follow-up status were recorded prospectively. RESULTS: There were 40 females and 12 males with a mean follow-up of 45 months. Forty patients presented with primary tumors and eight presented with recurrent disease. Thirty-nine patients had surgical resection and 13 were observed. Thirty patients underwent the neoadjuvant protocol. Tamoxifen and Celebrex were used in 16 patients, 6 had stabilization in growth, 1 had a 50% reduction in the size of the tumor, there was 1 complete regression, and 8 progressed. Of the patients who had resectable disease Tamoxifen and Celebrex obviated surgery in 30%. Overall 13% (5) of patients developed a recurrence. There were three recurrences among the protocol group for a local control rate of 90%. CONCLUSION: Although our neoadjuvant protocol demonstrates the best results to date in eradication of disease, an initial conservative approach is reasonable to determine who would most benefit from surgery.
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Antineoplásicos/administração & dosagem , Fibromatose Agressiva/terapia , Recidiva Local de Neoplasia/terapia , Neoplasias de Tecidos Moles/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Celecoxib , Quimioterapia Adjuvante , Doxorrubicina/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Pirazóis/administração & dosagem , Radioterapia Adjuvante , Sulfonamidas/administração & dosagem , Tamoxifeno/administração & dosagem , Adulto JovemRESUMO
BACKGROUND: Local recurrence rates of 15% to 30% after treatment of soft tissue sarcoma (STS) are still common but unacceptable. Our hypothesis was that a refined neoadjuvant chemotherapy and radiation protocol (modified Eilber protocol) improves local control rates while minimizing major morbidity. METHODS: Consecutive patients with STS deep to the fascia of the extremity or trunk during 1984 to 1996 were treated with 3 days of doxorubicin (30 mg/day) and sequential radiation (300 cGy/day for 10 days). Wide excision with limb preservation was performed 4 to 8 weeks after radiation completion. Treatment complications, margins, local recurrence, and survival were prospectively documented. RESULTS: Of 75 patients, 66% had tumors >5 cm, and 71% were grade 2/3. In eight patients, negative margins were not achieved, and four of these had amputation (95% limb salvage). Three of the remaining four had local recurrence with a 5- and 7-year actuarial local control rate of 50% and 25%, respectively. In contrast, of the 67 patients with negative margins, a local control rate of 97% at 5 years and 94% at 7 years and an overall survival of 63% were achieved. Although margin (P = .001) and stage (P = .035) were correlated, these were not significant on multivariate Cox regression analysis. Risk factors for death included tumor stage (hazard ratio, 1.54; P = .001) and tumor grade (hazard ratio, 1.4; P = .02). Three patients (4%) required reoperation for tissue loss, and eight patients (10.6%) developed minor wound complications. CONCLUSIONS: This modified Eilber protocol seems to maximize local control and minimize major wound complications for extremity/truncal STS.
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Terapia Neoadjuvante/métodos , Sarcoma/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibióticos Antineoplásicos/administração & dosagem , Quimioterapia Adjuvante , Doxorrubicina/administração & dosagem , Feminino , Histiocitoma Fibroso Benigno/patologia , Histiocitoma Fibroso Benigno/cirurgia , Histiocitoma Fibroso Benigno/terapia , Humanos , Leiomiossarcoma/patologia , Leiomiossarcoma/cirurgia , Leiomiossarcoma/terapia , Lipossarcoma/patologia , Lipossarcoma/cirurgia , Lipossarcoma/terapia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/prevenção & controle , Dosagem Radioterapêutica , Radioterapia Adjuvante , Estudos Retrospectivos , Sarcoma/tratamento farmacológico , Sarcoma/patologia , Sarcoma/radioterapiaRESUMO
Unicameral bone cysts of the pelvis are extremely rare. A 19-year old man presented with a pathologic fracture through a pelvic unicameral bone cyst. He was treated with computed tomography-guided percutaneous curettage, biopsy, and demineralized bone matrix injection. Treatment has proven successful in short-term follow-up.
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Cistos Ósseos/cirurgia , Matriz Óssea/transplante , Curetagem , Fraturas Espontâneas/cirurgia , Ísquio/lesões , Radiografia Intervencionista , Tomografia Computadorizada por Raios X , Adulto , Biópsia por Agulha , Seguimentos , Humanos , MasculinoRESUMO
OBJECTIVE: To compare the prognosis of patients undergoing a hemipelvectomy (HP) in the treatment of pelvic sarcomas and carcinomas and to review the morbidity and mortality associated with HP. DESIGN: Retrospective chart review. SETTING: The Foothills Hospital, University of Calgary, Calgary, Alberta. PATIENTS: Thirteen patients with clinically and radiographically isolated malignancies involving the bony pelvis and adjacent structures. INTERVENTIONS: Patients were treated with either an external HP (9 patients) or internal HP (4) in 1983-2001. OUTCOME MEASURES: Survival and recurrence rates for patients in 2 histopathologic groups (sarcoma v. carcinoma); morbidity and mortality associated with HP. RESULTS: Hemipelvectomy was performed for 7 sarcomas (4 primary bone and 3 soft tissue) and 6 carcinomas (5 genital tract and 1 unknown primary). Seven of the 9 external HPs involved composite resection of other pelvic structures, including other pelvic viscera (3 patients), sacrum (3) and portions of lumbar vertebrae and nerves (1). There were no additional resections among the 4 internal HPs, but 3 patients had allograft reconstruction. Length of stay averaged 30 days (range 14-70 d). At least 1 complication occurred in 10 of 13 cases. The most common complication was flap necrosis occurring in 5 patients (38%). There was 1 perioperative death (8%). The survival of patients treated for sarcomas was better than for carcinomas, which were primarily of the genital tract. Only 1 of the patients with a pelvic sarcoma died of disease (86% disease-specific survival), with a median follow-up of 12 months (range 9-108 mo). Of the 7 sarcoma patients 5 were disease-free at last follow-up. One of 6 pelvic carcinoma patients died perioperatively, with another dying of unknown causes 4 months after surgery. Of the 4 remaining patients 3 died of disease, resulting in a median survival of 9 months (range 4-20 mo). Four of 6 patients with pelvic carcinomas developed recurrent disease, none local. CONCLUSIONS: HP has considerable morbidity but is a viable and potentially curative treatment for patients with pelvic sarcomas. With pelvic carcinomas HP was not curative, but did provide short-term local disease control. Future improvements in imaging techniques and quality-of-life studies may help with patient selection. The role of HP in recurrent carcinoma remains to be determined.
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Carcinoma/cirurgia , Hemipelvectomia/efeitos adversos , Hemipelvectomia/mortalidade , Neoplasias Pélvicas/cirurgia , Sarcoma/cirurgia , Adolescente , Adulto , Idoso , Carcinoma/mortalidade , Carcinoma/patologia , Mortalidade Hospitalar , Humanos , Pessoa de Meia-Idade , Neoplasias Pélvicas/mortalidade , Neoplasias Pélvicas/patologia , Complicações Pós-Operatórias , Prognóstico , Estudos Retrospectivos , Sarcoma/mortalidade , Sarcoma/patologia , Taxa de Sobrevida , Fatores de TempoRESUMO
BACKGROUND AND OBJECTIVES: After resection, desmoid tumors are associated with a recurrence rate that is typically 25-50%. Although this is an unusual problem, we instituted a prospective cohort study with neoadjuvant chemotherapy and radiation, followed by surgical resection, in an effort to improve local control. METHODS: Between 1985 and 1999, 13 patients with potentially resectable disease were managed with a treatment protocol of preoperative doxorubicin (30 mg continuous infusion daily for 3 days) and radiotherapy (10 x 300 cGy). Resection was performed 4-6 weeks later. All lesions were resected with an intended margin of 1 cm, but clear adventitial margins were accepted in order to preserve critical structures. RESULTS: The median follow-up was 71 months (range, 22-109). Six patients (46%) presented after failure of a previous surgery. Clear microscopic margins were obtained in 11 patients, and 2 patients had positive margins. There were two local recurrences (15% local recurrence). Both recurrences followed resection of large thigh lesions, which appeared at 30 and 49 months of follow-up. In one patient with a chest wall tumor, two new primary desmoid tumors developed outside the treatment area, in the ipsilateral arm and forearm. Eleven patients have been disease free for a median of 71 months (range, 22-109). CONCLUSIONS: For potentially resectable lesions, this protocol provides excellent local control, even in those with recurrent disease. Neoadjuvant treatment with doxorubicin and radiotherapy appears to be a better option than surgery alone, or surgery and adjuvant radiotherapy. These results need to be confirmed in larger, prospective randomized trials.