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1.
Surgery ; 168(3): 518-526, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32669204

RESUMO

BACKGROUND: It is unknown whether all thick melanomas share the same prognostic features. We present a large, multi-institutional study on thick melanoma, evaluating for factors prognostic of survival. METHODS: We queried the database of the Sentinel Lymph Node Working Group for patients with thick melanoma (>4 mm) who had a sentinel lymph node biopsy from 1993 to 2018. Clinicopathologic characteristics were correlated with overall survival. RESULTS: There were 1,235 patients with a median follow-up of 28 months. Median thickness was 5.9 mm, with 713, 356, and 166 cases having a thickness of >4 to 6, >6 to 10, and >10 mm, respectively. Ulceration was seen in 51.2% of cases, while sentinel lymph node metastases were seen in 439 of 1,235 (35.5%) cases. For melanomas >4 to 6 mm, age, thickness, ulceration, lymphovascular invasion, and sentinel lymph node metastasis were correlated with overall survival (all P < .05), but for melanomas >6 to 10 mm, only sex and sentinel lymph node metastasis were prognostic of overall survival (both P < .05). For melanomas >10 mm, only sentinel lymph node metastasis predicted overall survival on multivariable analyses (P < .05). CONCLUSION: Prognostic markers of overall survival for thick melanoma include thickness, ulceration, and sentinel lymph node metastasis, but also include other unique factors such as lymphovascular invasion. Moreover, certain prognostic markers for survival are associated with different subgroups of thick melanoma, which vary based on thickness group.


Assuntos
Procedimentos Cirúrgicos Dermatológicos , Melanoma/mortalidade , Recidiva Local de Neoplasia/epidemiologia , Neoplasias Cutâneas/mortalidade , Pele/patologia , Idoso , Vasos Sanguíneos/patologia , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática/patologia , Vasos Linfáticos/patologia , Masculino , Melanoma/patologia , Melanoma/cirurgia , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Recidiva Local de Neoplasia/patologia , Prognóstico , Estudos Retrospectivos , Linfonodo Sentinela/patologia , Biópsia de Linfonodo Sentinela/estatística & dados numéricos , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Carga Tumoral
2.
Ann Surg Oncol ; 2020 Jun 10.
Artigo em Inglês | MEDLINE | ID: mdl-32524460

RESUMO

BACKGROUND: Sentinel lymph node biopsy (SLNB) is recommended for intermediate thickness melanoma, but for thick melanoma, guidelines are less definitive about the use of SLNB in this population. We present a study on thick melanoma evaluating for prognostic factors. PATIENTS AND METHODS: The Sentinel Lymph Node Working Group database was queried for thick (> 4 mm) melanoma cases that had a SLNB from 1993 to 2018. Clinicopathologic characteristics were correlated with SLN status and melanoma-specific survival (MSS). RESULTS: There were 1235 patients. Median follow-up was 28 months. Median thickness was 5.9 mm, with 956, 175, and 104 cases presenting thickness > 4-8, > 8-12, and > 12 mm, respectively. SLN metastases were seen in 439 of 1235 (35.5%) cases and in 33.9%, 40.6%, and 42.3% of melanomas > 4-8, > 8-12, and > 12 mm, respectively. In each thickness group, MSS was significantly worse for SLN-positive compared with SLN-negative cases (all P < 0.005). Multivariable analysis showed that SLN metastasis, male gender, increasing thickness, lymphovascular invasion, and microsatellitosis significantly predicted worse MSS for melanomas > 4-8 mm, with SLN metastasis showing the greatest risk (HR 2.17, 95% CI 1.64-2.87, P < 0.0001). For melanomas > 8 mm, only SLN metastasis significantly predicted MSS (> 8-12 mm: HR 3.93, 95% CI 2.00-7.73, P < 0.0001; > 12 mm: HR 3.58, 95% CI 1.56-8.22, p < 0.0027). CONCLUSIONS: Thick melanoma patients with SLN metastasis have significantly worse MSS compared with SLN-negative patients, even in the thickest cases, and SLN status is the most powerful and/or only predictor of MSS. Given these results, SLNB shows important prognostic value in this population and is indicated for clinically localized thick melanoma.

3.
Ann Surg ; 2019 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-31188198

RESUMO

OBJECTIVE: To assess whether preoperative ultrasound (US) assessment of regional lymph nodes in patients who present with primary cutaneous melanoma provides accurate staging. BACKGROUND: It has been suggested that preoperative US could avoid the need for sentinel node (SN) biopsy, but in most single-institution reports, the sensitivity of preoperative US has been low. METHODS: Preoperative US data and SNB results were analyzed for patients enrolled at 20 centers participating in the screening phase of the second Multicenter Selective Lymphadenectomy Trial. Excised SNs were histopathologically assessed and considered positive if any melanoma was seen. RESULTS: SNs were identified and removed from 2859 patients who had preoperative US evaluation. Among those patients, 548 had SN metastases. US was positive (abnormal) in 87 patients (3.0%). Among SN-positive patients, 39 (7.1%) had an abnormal US. When analyzed by lymph node basin, 3302 basins were evaluated, and 38 were true positive (1.2%). By basin, the sensitivity of US was 6.6% (95% confidence interval: 4.6-8.7) and the specificity 98.0% (95% CI: 97.5-98.5). Median cross-sectional area of all SN metastases was 0.13 mm; in US true-positive nodes, it was 6.8 mm. US sensitivity increased with increasing Breslow thickness of the primary melanoma (0% for ≤1 mm thickness, 11.9% for >4 mm thickness). US sensitivity was not significantly greater with higher trial center volume or with pre-US lymphoscintigraphy. CONCLUSION: In the MSLT-II screening phase population, SN tumor volume was usually too small to be reliably detected by US. For accurate nodal staging to guide the management of melanoma patients, US is not an effective substitute for SN biopsy.

4.
Ann Surg Oncol ; 26(7): 2254-2262, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31011906

RESUMO

BACKGROUND: Factors that predict melanoma recurrence after a negative sentinel lymph node biopsy (SLNB) are not well-defined. We evaluated melanoma recurrence patterns, factors prognostic for recurrence, and the impact of recurrence on outcomes after a negative SLNB. METHODS: The Sentinel Lymph Node Working Group database was evaluated from 1996 to 2016 for negative SLNB melanoma patients. Clinicopathologic characteristics were correlated with recurrence, overall survival (OS), and melanoma-specific survival (MSS). RESULTS: Median follow-up was 32.1 months. Recurrences developed in 558 of 5351 negative SLN patients (10.4%). First-site of recurrence included a local or in-transit recurrence (LITR) in 221 cases (4.1%), nodal recurrence (NR) in 109 cases (2%), and distant recurrence (DR) in 220 cases (4.1%). On multivariable analysis, age, thickness, head/neck or lower extremity primary, and microsatellitosis significantly predicted for an LITR as first-site. Having an LITR as first-site significantly predicted for a subsequent NR and DR, and significantly predicted for worse OS and MSS. Furthermore, thickness and head/neck or lower extremity primary significantly predicted for an NR as first-site, while a prior LITR significantly predicted for a subsequent NR. Factors significantly predictive for a DR included thickness, head/neck or trunk primary, ulceration, and lymphovascular invasion. Patients with any type of locoregional recurrence were at higher risk for a DR. CONCLUSIONS: Recurrences occur in 10.4% of negative SLN patients, with LITR and DR being the most common types. Importantly, having an LITR significantly predicts for a subsequent NR and DR, and is prognostic for worse survival after a negative SLNB.


Assuntos
Neoplasias de Cabeça e Pescoço/patologia , Excisão de Linfonodo/mortalidade , Melanoma/patologia , Recidiva Local de Neoplasia/patologia , Biópsia de Linfonodo Sentinela/mortalidade , Linfonodo Sentinela/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Seguimentos , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Masculino , Melanoma/cirurgia , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/cirurgia , Valor Preditivo dos Testes , Estudos Retrospectivos , Linfonodo Sentinela/cirurgia , Taxa de Sobrevida , Adulto Jovem
5.
J Surg Oncol ; 119(8): 1053-1059, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30883771

RESUMO

BACKGROUND: Completion lymph node dissection (CLND) for sentinel lymph node (SLN) disease in melanoma patients is debated. We evaluated the impact of CLND on survival and assessed for predictors of nonsentinel node metastasis (positive CLND). METHODS: Positive SLN melanoma patients were retrospectively identified in the Sentinel Lymph Node Working Group database. Clinicopathological factors were correlated with CLND status, overall survival (OS), and melanoma-specific survival (MSS). RESULTS: There were 953 positive SLN patients of whom 831 (87%) had CLND. Positive CLND was seen in 141 (17%) cases and was associated with worse OS and MSS (both P < 0.001). CLND was not performed (No-CLND) in 122 of 953 positive SLN cases (13%), of whom 100 had follow-up and 18 (18%) developed a nodal recurrence (NR). No significant differences in OS and MSS were seen comparing CLND with No-CLND (P = 0.084, P = 0.161, respectively) and comparing positive CLND with No-CLND NR patients (P = 0.565, P = 0.998, respectively). Gender, primary site, ulceration, and number of positive SLNs were correlated with nonsentinel node metastasis. CONCLUSIONS: Performance of CLND provides prognostic information but is not associated with a survival benefit. Clinical variables can predict a positive CLND in patients who may be at high risk of recurrence.


Assuntos
Excisão de Linfonodo/estatística & dados numéricos , Melanoma/mortalidade , Melanoma/cirurgia , Adulto , Idoso , Bases de Dados Factuais , Feminino , Humanos , Metástase Linfática , Masculino , Melanoma/patologia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Biópsia de Linfonodo Sentinela , Taxa de Sobrevida
6.
Ann Surg Oncol ; 26(1): 33-41, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30421045

RESUMO

BACKGROUND: Microsatellitosis (mS) in melanoma has been considered a marker of unfavorable tumor biology, leading to the current American Joint Committee on Cancer staging of IIIB/C/D disease, despite few investigative studies of this entity limited by the small sample sizes and incomplete nodal microstaging. We sought to better characterize outcomes and prognostic factors in a multi-institutional cohort of patients with mS and nodal microstaging. METHODS: The Sentinel Lymph Node Working Group cohort included 414 mS patients who underwent sentinel lymph node (SLN) biopsy. Cox regression analysis was used to evaluate the prognostic significance of established clinicopathologic characteristics. Melanoma-specific survival (MSS) of patients with mS was compared with 3002 similarly staged patients from the Surveillance, Epidemiology, and End Results (SEER) Program registry. RESULTS: The median age of the mS cohort was 64.9 years; 39.6% were female. Median thickness was 3 mm, 40.6% of cases were ulcerated, and the SLN positivity rate was 46.7%. Increasing thickness, male sex, and SLN positivity were significantly associated with poorer MSS. Stage IIIB/C/D 5-year MSS rates were 86.3% (95% confidence interval [CI] 79.4-93.3%), 54.1% (95% CI 45.4-59.7%), and 44.2% (95% CI 25.4-63.0%), respectively. MSS survival for the stage IIIB mS cohort was significantly better than a similarly staged SEER cohort (5-year MSS of 70.1%, 95% CI 66.0-74.2%), while no significant difference was observed for the stage IIIC or D cohorts. CONCLUSIONS: SLN metastases are common and are a significant prognostic factor in patients with mS. Survival in stage IIIB patients with mS was considerably more favorable than their stage would otherwise suggest, which has important implications for decisions regarding adjuvant therapy for patients with mS.


Assuntos
Melanoma/patologia , Repetições de Microssatélites , Biópsia de Linfonodo Sentinela/mortalidade , Linfonodo Sentinela/patologia , Neoplasias Cutâneas/patologia , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Melanoma/mortalidade , Melanoma/cirurgia , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Programa de SEER , Linfonodo Sentinela/cirurgia , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/cirurgia , Taxa de Sobrevida
7.
J Surg Oncol ; 116(7): 856-861, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28650570

RESUMO

BACKGROUND AND OBJECTIVES: Stage III malignant melanoma is a heterogeneous disease where those cases deemed marginally resectable or irresecatble are frequently incurable by surgery alone. Targeted therapy takes advantage of the high incidence of BRAF mutations in melanomas, most notably the V600E mutation. These agents have rarely been used in a neoadjuvant setting prior to surgery. METHODS: Thirteen consecutive patients with confirmed BRAFV600E regionally advanced melanoma deemed marginally resectable or irrresectable, were treated with BRAF inhibiting agents, prior to undergoing surgery. The primary outcome measures were a successful resection and pathological response. Disease-free survival was a secondary outcome measure. RESULTS: Overall, 12/13 patients showed a marked clinical responsiveness to medical treatment, enabling a macroscopically successful resection in all cases. Four patients had a complete pathological response with no viable tumor evident in the resected specimens and eight patients showed evidence of minimally residual tumor with extensive tumoral necrosis and fibrosis. One patient progressed and died before surgery. At a median follow up of 20 months, 10 patients remain free of disease. CONCLUSIONS: Perioperative treatment with BRAF inhibiting agents in BRAFV600E mutated Stage III melanoma patients facilitates surgical resection and affords satisfactory disease free survival.


Assuntos
Melanoma/tratamento farmacológico , Melanoma/cirurgia , Inibidores de Proteínas Quinases/administração & dosagem , Proteínas Proto-Oncogênicas B-raf/antagonistas & inibidores , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Quimioterapia Adjuvante , Intervalo Livre de Doença , Feminino , Humanos , Imidazóis/administração & dosagem , Indóis/administração & dosagem , Masculino , Melanoma/enzimologia , Melanoma/genética , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Oximas/administração & dosagem , Assistência Perioperatória/métodos , Proteínas Proto-Oncogênicas B-raf/genética , Piridonas/administração & dosagem , Pirimidinonas/administração & dosagem , Sulfonamidas/administração & dosagem , Vemurafenib
8.
N Engl J Med ; 376(23): 2211-2222, 2017 06 08.
Artigo em Inglês | MEDLINE | ID: mdl-28591523

RESUMO

BACKGROUND: Sentinel-lymph-node biopsy is associated with increased melanoma-specific survival (i.e., survival until death from melanoma) among patients with node-positive intermediate-thickness melanomas (1.2 to 3.5 mm). The value of completion lymph-node dissection for patients with sentinel-node metastases is not clear. METHODS: In an international trial, we randomly assigned patients with sentinel-node metastases detected by means of standard pathological assessment or a multimarker molecular assay to immediate completion lymph-node dissection (dissection group) or nodal observation with ultrasonography (observation group). The primary end point was melanoma-specific survival. Secondary end points included disease-free survival and the cumulative rate of nonsentinel-node metastasis. RESULTS: Immediate completion lymph-node dissection was not associated with increased melanoma-specific survival among 1934 patients with data that could be evaluated in an intention-to-treat analysis or among 1755 patients in the per-protocol analysis. In the per-protocol analysis, the mean (±SE) 3-year rate of melanoma-specific survival was similar in the dissection group and the observation group (86±1.3% and 86±1.2%, respectively; P=0.42 by the log-rank test) at a median follow-up of 43 months. The rate of disease-free survival was slightly higher in the dissection group than in the observation group (68±1.7% and 63±1.7%, respectively; P=0.05 by the log-rank test) at 3 years, based on an increased rate of disease control in the regional nodes at 3 years (92±1.0% vs. 77±1.5%; P<0.001 by the log-rank test); these results must be interpreted with caution. Nonsentinel-node metastases, identified in 11.5% of the patients in the dissection group, were a strong, independent prognostic factor for recurrence (hazard ratio, 1.78; P=0.005). Lymphedema was observed in 24.1% of the patients in the dissection group and in 6.3% of those in the observation group. CONCLUSIONS: Immediate completion lymph-node dissection increased the rate of regional disease control and provided prognostic information but did not increase melanoma-specific survival among patients with melanoma and sentinel-node metastases. (Funded by the National Cancer Institute and others; MSLT-II ClinicalTrials.gov number, NCT00297895 .).


Assuntos
Excisão de Linfonodo , Melanoma/secundário , Biópsia de Linfonodo Sentinela , Linfonodo Sentinela/cirurgia , Conduta Expectante , Adulto , Idoso , Intervalo Livre de Doença , Feminino , Humanos , Análise de Intenção de Tratamento , Excisão de Linfonodo/efeitos adversos , Linfonodos/diagnóstico por imagem , Linfonodos/patologia , Metástase Linfática/diagnóstico , Linfedema/etiologia , Masculino , Melanoma/mortalidade , Melanoma/patologia , Melanoma/cirurgia , Pessoa de Meia-Idade , Estadiamento de Neoplasias/métodos , Complicações Pós-Operatórias , Prognóstico , Modelos de Riscos Proporcionais , Linfonodo Sentinela/patologia , Biópsia de Linfonodo Sentinela/efeitos adversos , Análise de Sobrevida , Ultrassonografia , Adulto Jovem
9.
Ann Surg Oncol ; 24(8): 2089-2094, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28224364

RESUMO

BACKGROUND: Although a well-established causative relationship exists between smoking and several epithelial cancers, the association of smoking with metastatic progression in melanoma is not well studied. We hypothesized that smokers would be at increased risk for melanoma metastasis as assessed by sentinel lymph node (SLN) biopsy. METHODS: Data from the first international Multicenter Selective Lymphadenectomy Trial (MSLT-I) and the screening-phase of the second trial (MSLT-II) were analyzed to determine the association of smoking with clinicopathologic variables and SLN metastasis. RESULTS: Current smoking was strongly associated with SLN metastasis (p = 0.004), even after adjusting for other predictors of metastasis. Among 4231 patients (1025 in MSLT-I and 3206 in MSLT-II), current or former smoking was also independently associated with ulceration (p < 0.001 and p < 0.001, respectively). Compared with current smoking, never smoking was independently associated with decreased Breslow thickness in multivariate analysis (p = 0.002) and with a 0.25 mm predicted decrease in thickness. CONCLUSION: The direct correlation between current smoking and SLN metastasis of primary cutaneous melanoma was independent of its correlation with tumor thickness and ulceration. Smoking cessation should be strongly encouraged among patients with or at risk for melanoma.


Assuntos
Melanoma/patologia , Linfonodo Sentinela/patologia , Neoplasias Cutâneas/secundário , Fumar/efeitos adversos , Feminino , Seguimentos , Humanos , Agências Internacionais , Excisão de Linfonodo , Metástase Linfática , Masculino , Melanoma/etiologia , Melanoma/cirurgia , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Linfonodo Sentinela/cirurgia , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/etiologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia
10.
Clin Breast Cancer ; 16(5): 389-395, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27282845

RESUMO

BACKGROUND: Assessment of residual disease after neoadjuvant therapy for breast cancer is an ongoing challenge of breast imaging. This study evaluates the accuracy of a novel dedicated system for molecular breast imaging (MBI) composed of the new generation of cadmium zinc telluride detectors in assessing residual disease after neoadjuvant therapy in patients with breast cancer. PATIENTS AND METHODS: Clinical data, imaging, surgical, and pathological findings of 51 women with breast cancer undergoing neoadjuvant therapy were recorded. MBI findings were correlated with surgical pathology results. Accuracy of MBI in predicting complete pathological response and size of residual disease was assessed according to molecular subtypes. RESULTS: The size of the largest focus of uptake on MBI correlated with the largest dimension measured on pathology (r = 0.55; P < .001). This correlation was stronger for triple negative and HER2/neu positive subtypes (r = 0.92 and 0.62, respectively). Sixteen patients (31%) had complete pathological response. The sensitivity and specificity of MBI for detecting residual disease were 83% (95% confidence interval [CI], 66-93) and 69% (95% CI, 42-88), respectively. For triple negative or HER2/neu positive disease the sensitivity and specificity were 88% (95% CI, 62-98) and 75% (95% CI, 43-93), respectively. CONCLUSION: The accuracy of MBI in assessing residual disease after neoadjuvant treatment might be related to the molecular subtype. Accuracy is highest in the triple negative and HER2/neu positive subtypes.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/tratamento farmacológico , Neoplasias de Mama Triplo Negativas/diagnóstico por imagem , Neoplasias de Mama Triplo Negativas/tratamento farmacológico , Adulto , Idoso , Antineoplásicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Mama/diagnóstico por imagem , Mama/patologia , Neoplasias da Mama/metabolismo , Neoplasias da Mama/patologia , Feminino , Humanos , Imagem por Ressonância Magnética , Mamografia , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Neoplasia Residual , Receptor ErbB-2/metabolismo , Receptores Estrogênicos/metabolismo , Sensibilidade e Especificidade , Resultado do Tratamento , Neoplasias de Mama Triplo Negativas/patologia , Ultrassonografia Mamária
11.
Can J Surg ; 57(4): E134-40, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25078939

RESUMO

BACKGROUND: Oncoplastic breast reduction in women with medium to large breasts has reportedly benefitted them both oncologically and cosmetically. We present our experience with an oncoplastic breast reduction technique using a vertical scar superior-medial pedicle pattern for immediate partial breast reconstruction. METHODS: All patients with breast tumours who underwent vertical scar superior-medial pedicle reduction pattern oncoplastic surgery at our centre between September 2006 and June 2010 were retrospectively studied. Follow-up continued from 12 months to 6 years. RESULTS: Twenty women (age 28-72 yr) were enrolled: 16 with invasive carcinoma and 4 with benign tumours. They all had tumour-free surgical margins, and no further oncological operations were required. The patients expressed a high degree of satisfaction from the surgical outcome in terms of improved quality of life and a good cosmetic result. CONCLUSION: The vertical scar superior-medial pedicle reduction pattern is a versatile oncoplastic technique that allows breast tissue rearrangement for various tumour locations. It is oncologically beneficial and is associated with high patient satisfaction.


Assuntos
Neoplasias da Mama/cirurgia , Mama/anormalidades , Hipertrofia/cirurgia , Mamoplastia/métodos , Mastectomia Segmentar , Retalhos Cirúrgicos , Adulto , Idoso , Mama/cirurgia , Neoplasias da Mama/complicações , Cicatriz/etiologia , Feminino , Seguimentos , Humanos , Hipertrofia/complicações , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do Tratamento
12.
Isr Med Assoc J ; 16(2): 101-5, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24645229

RESUMO

BACKGROUND: The surgical approach to breast cancer changed dramatically in the past 20 years. The surgical objective today is to remove the tumor, ensuring negative margins and good cosmetic results, and preserving the breast when possible. Magnetic resonance imaging of the breast has become an essential imaging tool prior to surgery, diagnosing additional tumors and assessing tumor extent. Tumor-to-breast volume ratio, an important predictor of breast conservation, can be measured with MRI and may change the surgical decision. OBJECTIVES: To measure the tumor-to-breast volume ratio using MRI in order to assess whether there is a correlation between this ratio and the type of surgery selected (breast-conserving or mastectomy). METHODS: The volumes of the tumor and the breast and the tumor-to-breast volume ratio were retrospectively calculated using preoperative breast MRI in 76 patients who underwent breast-conserving surgery or mastectomy. RESULTS: Breast-conserving surgery (lumpectomy) was performed in 64 patients and mastectomy in 12. The average tumor-to-breast volume ratio was 0.06 (6%) in the lumpectomy group and 0.30 (30%) in the mastectomy group (P < 0.0001). CONCLUSION: The tumor-to-breast volume ratio correlated with the type of surgery. As measured on MRI, this ratio is an accurate means of determining the type of surgery best suited for a given patient. It is recommended that MRI-determined tumor-to-breast volume ratio become part of the surgical planning protocol for patients diagnosed with breast cancer.


Assuntos
Neoplasias da Mama , Mama , Imagem por Ressonância Magnética , Mastectomia Segmentar , Mastectomia Simples , Adulto , Idoso , Mama/patologia , Mama/cirurgia , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/cirurgia , Técnicas de Apoio para a Decisão , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Imagem por Ressonância Magnética/estatística & dados numéricos , Mastectomia Segmentar/métodos , Mastectomia Segmentar/estatística & dados numéricos , Mastectomia Simples/métodos , Mastectomia Simples/estatística & dados numéricos , Pessoa de Meia-Idade , Tamanho do Órgão , Tratamentos com Preservação do Órgão , Planejamento de Assistência ao Paciente , Valor Preditivo dos Testes , Estudos Retrospectivos , Estatística como Assunto , Carga Tumoral
13.
Ann Surg Oncol ; 20(8): 2590-9, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23504141

RESUMO

BACKGROUND: Sentinel lymph node (SLN) surgery is used worldwide for staging breast cancer patients and helps limit axillary lymph node dissection. [(99m)Tc]Tilmanocept is a novel receptor-targeted radiopharmaceutical evaluated in 2 open-label, nonrandomized, within-patient, phase 3 trials designed to assess the lymphatic mapping performance. METHODS: A total of 13 centers contributed 148 patients with breast cancer. Each patient received [(99m)Tc]tilmanocept and vital blue dye (VBD). Lymph nodes identified intraoperatively as radioactive and/or blue stained were excised and histologically examined. The primary endpoint, concordance (lower boundary set point at 90 %), was the proportion of nodes detected by VBD and [(99m)Tc]tilmanocept. RESULTS: A total of 13 centers contributed 148 patients who were injected with both agents. Intraoperatively, 207 of 209 nodes detected by VBD were also detected by [(99m)Tc]tilmanocept for a concordance rate of 99.04 % (p < 0.0001). [(99m)Tc]tilmanocept detected a total of 320 nodes, of which 207 (64.7 %) were detected by VBD. [(99m)Tc]Tilmanocept detected at least 1 SLN in more patients (146) than did VBD (131, p < 0.0001). In 129 of 131 patients with ≥1 blue node, all blue nodes were radioactive. Of 33 pathology-positive nodes (18.2 % patient pathology rate), [(99m)Tc]tilmanocept detected 31 of 33, whereas VBD detected only 25 of 33 (p = 0.0312). No pathology-positive SLNs were detected exclusively by VBD. No serious adverse events were attributed to [(99m)Tc]tilmanocept. CONCLUSION: [(99m)Tc]Tilmanocept demonstrated success in detecting a SLN while meeting the primary endpoint. Interestingly, [(99m)Tc]tilmanocept was additionally noted to identify more SLNs in more patients. This localization represented a higher number of metastatic breast cancer lymph nodes than that of VBD.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/patologia , Dextranos , Linfonodos/diagnóstico por imagem , Mananas , Compostos Radiofarmacêuticos , Biópsia de Linfonodo Sentinela/métodos , Pentetato de Tecnécio Tc 99m/análogos & derivados , Adulto , Idoso , Idoso de 80 Anos ou mais , Axila , Corantes , Dextranos/efeitos adversos , Feminino , Humanos , Linfonodos/patologia , Linfonodos/cirurgia , Metástase Linfática , Mananas/efeitos adversos , Pessoa de Meia-Idade , Cintilografia , Compostos Radiofarmacêuticos/efeitos adversos , Pentetato de Tecnécio Tc 99m/efeitos adversos
14.
Ann Surg Oncol ; 20(2): 680-8, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23054107

RESUMO

BACKGROUND: [(99m)Tc]Tilmanocept is a CD206 receptor-targeted radiopharmaceutical designed for sentinel lymph node (SLN) identification. Two nearly identical nonrandomized phase III trials compared [(99m)Tc]tilmanocept to vital blue dye. METHODS: Patients received [(99m)Tc]tilmanocept and blue dye. SLNs identified intraoperatively as radioactive and/or blue were excised and histologically examined. The primary end point, concordance, was the proportion of blue nodes detected by [(99m)Tc]tilmanocept; 90 % concordance was the prespecified minimum concordance level. Reverse concordance, the proportion of radioactive nodes detected by blue dye, was also calculated. The prospective statistical plan combined the data from both trials. RESULTS: Fifteen centers contributed 154 melanoma patients who were injected with both agents and were intraoperatively evaluated. Intraoperatively, 232 of 235 blue nodes were detected by [(99m)Tc]tilmanocept, for 98.7 % concordance (p < 0.001). [(99m)Tc]Tilmanocept detected 364 nodes, for 63.7 % reverse concordance (232 of 364 nodes). [(99m)Tc]Tilmanocept detected at least one node in more patients (n = 150) than blue dye (n = 138, p = 0.002). In 135 of 138 patients with at least one blue node, all blue nodes were radioactive. Melanoma was identified in the SLNs of 22.1 % of patients; all 45 melanoma-positive SLNs were detected by [(99m)Tc]tilmanocept, whereas blue dye detected only 36 (80 %) of 45 (p = 0.004). No positive SLNs were detected exclusively by blue dye. Four of 34 node-positive patients were identified only by [(99m)Tc]tilmanocept, so 4 (2.6 %) of 154 patients were correctly staged only by [(99m)Tc]tilmanocept. No serious adverse events were attributed to [(99m)Tc]tilmanocept. CONCLUSIONS: [(99m)Tc]Tilmanocept met the prespecified concordance primary end point, identifying 98.7 % of blue nodes. It identified more SLNs in more patients, and identified more melanoma-containing nodes than blue dye.


Assuntos
Corantes , Dextranos , Linfonodos/diagnóstico por imagem , Mananas , Melanoma/diagnóstico por imagem , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/diagnóstico por imagem , Pentetato de Tecnécio Tc 99m/análogos & derivados , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Cuidados Intraoperatórios , Linfonodos/patologia , Linfonodos/cirurgia , Metástase Linfática , Masculino , Melanoma/patologia , Melanoma/cirurgia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Cintilografia , Compostos Radiofarmacêuticos , Corantes de Rosanilina , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Adulto Jovem
15.
Am Surg ; 78(4): 451-5, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22472404

RESUMO

The role of routine preoperative magnetic resonance imaging (MRI) in newly diagnosed breast cancer patients planned for breast conserving surgery is presently being debated. In our medical center we practice selective use of preoperative MRI; we sought to examine the yield of MRI in this highly selected group of patients. A retrospective study of all newly diagnosed breast cancer patients presenting between January 2007 and July 2010 to the Tel Aviv Sourasky Medical Center (Tel Aviv, Israel) was completed. Patients planned for breast conserving surgery who underwent preoperative MRI were included in this study. Patients and tumor characteristics, indication for MRI, findings on MRI, consequent workup, and impact on surgical treatment were recorded. Association between preoperative characteristics and yield of MRI was examined. During the study period, 105 patients that were candidates for breast conserving surgery underwent preoperative evaluation with MRI. Use of breast MRI increased over time. Rates of mastectomy were stable throughout the study years. Dense mammogram was the most frequent (51, 68%) indication for MRI. Additional suspicious findings were found in 41 (39%) patients, prompting further workup including 36 biopsies in 25 patients, of which 22 (61%) were with cancer. These additional findings prompted a change in the surgical plan in a third of the patients. In most patients (92; 88%) clear margins were achieved. Limiting the use of MRI in the preoperative workup of breast cancer patients to a selected group of patients can increase the yield of MRI.


Assuntos
Neoplasias da Mama/diagnóstico , Imagem por Ressonância Magnética , Mastectomia Segmentar , Neoplasias Ductais, Lobulares e Medulares/diagnóstico , Cuidados Pré-Operatórios , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/cirurgia , Técnicas de Apoio para a Decisão , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias Ductais, Lobulares e Medulares/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
16.
Am J Surg ; 203(6): 721-5, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22153085

RESUMO

BACKGROUND: Breast borderline lesions are usually diagnosed on needle biopsies of imaging abnormalities. The natural history of these lesions is unclear, and the literature is divided on appropriate management. It was hypothesized that management varies among surgeons and may be associated with surgeon and practice characteristics. METHODS: A survey of 477 members of the American Society of Breast Surgeons was completed. Results were analyzed according to various surgeon and practice characteristics. RESULTS: Most respondents recommended routine excision for atypical ductal and lobular hyperplasia. Excision of radial scars and papillomas was much more variable, with only 50% recommending routine excision. Results differed by surgical dedication to breast surgery and fellowship training. Management of atypical ductal or lobular hyperplasia found at the margin varied significantly. The lack of a routine tumor board, low breast case volume, and low percentage of breast cases were associated with routine excision in these cases. CONCLUSIONS: Breast borderline lesions pose a clinical dilemma, with practice varying greatly among surgeons.


Assuntos
Neoplasias da Mama/cirurgia , Mama/cirurgia , Neoplasias Ductais, Lobulares e Medulares/cirurgia , Padrões de Prática Médica/estatística & dados numéricos , Lesões Pré-Cancerosas/cirurgia , Mama/patologia , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Hiperplasia/cirurgia , Modelos Logísticos , Análise Multivariada , Papiloma Intraductal/cirurgia , Guias de Prática Clínica como Assunto , Inquéritos e Questionários
17.
J Plast Reconstr Aesthet Surg ; 63(7): 1163-8, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19592319

RESUMO

Malignant melanoma (MM) was considered a hormone-sensitive tumour, and pregnancy was thought to increase its risk and cause faster progression and earlier metastasis. Several controlled studies demonstrated similar survival rates between pregnant and non-pregnant patients and concluded that early reports of advanced MM of pregnancy were probably due to late diagnosis. We retrieved information from our database between 1997 and 2006 on all patients diagnosed as having MM during and up to 6 months after pregnancy (n=11) and compared them to age-matched, non-pregnant, MM patients (n=65, controls) treated by us during that period. The mean Breslow thickness was 4.28mm for the pregnant patients and 1.69mm for the controls (p=0.15). The sentinel nodes were metastatic in five pregnant patients compared to four controls (p<0.0001). Two patients in the pregnancy group and one control died of MM (p=0.0532). Our results indicate a negative effect of pregnancy on the course of MM.


Assuntos
Melanoma/patologia , Complicações Neoplásicas na Gravidez/patologia , Neoplasias Cutâneas/patologia , Adulto , Progressão da Doença , Feminino , Humanos , Metástase Linfática , Melanoma/diagnóstico , Melanoma/secundário , Gravidez , Complicações Neoplásicas na Gravidez/diagnóstico , Neoplasias Cutâneas/diagnóstico
18.
Isr Med Assoc J ; 9(11): 787-90, 2007 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-18085034

RESUMO

BACKGROUND: Peritoneal carcinomatosis is an advanced form of cancer with poor prognosis that in the past was treated mainly palliatively. Today, the definitive approach to peritoneal surface malignancy involves peritonectomy, visceral resection and perioperative intra-abdominal hyperthermic chemotherapy. The anticipated results range from at least palliative to as far as intent to cure. Proper patient selection is mandatory. OBJECTIVES: To determine whether cytoreductive surgery and intraperitoneal hyperthermic chemotherapy can extend survival, and with minor complications only, in patients with peritoneal carcinomatosis. METHODS: Twenty-two IPHP procedures were performed in 17 patients with peritoneal carcinomatosis in our institution between 1998 and 2007: 6 had pseudomyxoma peritonei, 5 had colorectal carcinoma, 3 had ovarian cancer and 3 had mesotheliomas. All patients underwent cytoreductive surgery, leaving only residual metastasis < 1 cm in size. Intraperitoneal chemotherapy was administered through four large catheters (2F) using a closed system of two pumps, a heat exchanger and two filters. After the patient's abdominal temperature reached 41 degrees C, 30-60 mg mitomycin C was circulated intraperitoneally for 1 hour. RESULTS: The patients had a variety of anastomoses. None demonstrated anastomotic leak and none experienced major complications. Six patients had minor complications (pleural effusion, leukopenia, fever, prolonged paralytic ileus, sepsis), two of which may be attributed to chemotherapy toxicity (leukopenia). There was no perioperative mortality. Some patients have survived more than 5 years. CONCLUSIONS: IPHP is a safe treatment modality for patients with peritoneal carcinomatosis. It has an acceptable complications rate and ensures a marked improvement in survival and in the quality of life in selected patients.


Assuntos
Antineoplásicos/administração & dosagem , Quimioterapia do Câncer por Perfusão Regional , Hipertermia Induzida , Neoplasias Peritoneais/terapia , Adenocarcinoma/secundário , Adulto , Idoso , Neoplasias do Colo/patologia , Terapia Combinada , Feminino , Humanos , Masculino , Mesotelioma/secundário , Pessoa de Meia-Idade , Neoplasias Peritoneais/tratamento farmacológico , Neoplasias Peritoneais/secundário , Neoplasias Peritoneais/cirurgia , Resultado do Tratamento
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