Christina Weltz

A phase I clinical trial of immunotherapy with interferon‐γ gene‐modified autologous melanoma cells

Tumor cells transduced with cytokine genes provide immunogenic vaccines for cancer immunotherapy.

Conducting Molecular Epidemiological Research in the Age of HIPAA: A Multi-Institutional Case-Control Study of Breast Cancer in African-American and European-American Women

Breast cancer in African-American (AA) women occurs at an earlier age than in European-American (EA) women and is more likely to have aggressive features associated with poorer prognosis, such as high-grade and negative estrogen receptor (ER) status. The mechanisms underlying these differences are unknown. To address this, we conducted a case-control study to evaluate risk factors for high-grade ER- disease in both AA and EA women. With the onset of the Health Insurance Portability and Accountability Act of 1996, creative measures were needed to adapt case ascertainment and contact procedures to this new environment of patient privacy. In this paper, we report on our approach to establishing a multicenter study of breast cancer in New York and New Jersey, provide preliminary distributions of demographic and pathologic characteristics among case and control participants by race, and contrast participation rates by approaches to case ascertainment, with discussion of strengths and weaknesses.

Paravertebral block anesthesia for inguinal hernia repair.

Choice of anesthesia for inguinal hernia repair remains a controversial topic. Local anesthesia has been described in the literature as the optimal technique, however general and spinal anesthesia are commonly used in practice despite well-known complications and side effects. The regional technique of paravertebral block has been successfully used at our institution for the operative treatment of breast cancer. Its attributes are prolonged sensory block with minimization of postoperative pain, reduction of nausea and vomiting, shortened hospital stay, patient satisfaction, and rapid return to normal activities. These features are desirable in the practice of ambulatory hernia surgery; hence we initiated the use of thoracic/lumbar paravertebral block for that surgical procedure. Paravertebral block anesthesia was performed on 30 consecutive patients. Block placement took an average of 12.3 minutes, in six cases repeat injection at one or two spinal levels was required due to incomplete blockade. Paravertebral block achieved effective anesthesia in 28 of 30 cases; conversion to general anesthesia was performed for two failed blocks. We are reporting postoperative data on the 28 completed blocks. Supplementation of intravenous sedation or injection of local anesthesia successfully treated transient intraoperative pain in 10 cases. Epidural extension of anesthesia resulting in lower limb numbness and motor weakness delayed the discharge of two patients. There were no other complications of anesthesia and no cases of urinary retention. Time to onset of pain averaged 15 hours, while duration of sensory block was 13 hours. Patients were prescribed a standing order of naproxen 500 mg b.i.d. for 4 days regardless of pain; supplemental oral narcotic use during the 48 hours following surgery averaged 3.5 tablets, with 6 patients not requiring any narcotic. Ninety-six percent of patients scheduled for ambulatory surgery were discharged from the postanesthesia care unit, with an average stay of 2.5 hours. Employed patients returned to work on day 5.5 (range 3–10 days); patients who were not employed returned to regular activities in 5.8 days (range 1–14 days). Eighty-two percent of patients reported being “very satisfied” with the anesthetic technique.

Sources of anticipatory distress among breast surgery patients.

Surgical consultation concerning the possibility of breast cancer is a distressing experience, and having to take the next step of breast surgery even more so for many women. However, the sources of variability in such presurgical distress are not well understood. Sixty-one women (mean age = 51) were recruited immediately following surgical consultation in which a recommendation of breast surgery (excisional biopsy/lumpectomy); was made. Patients completed measures of distress, worry about cancer and surgery, trait anxiety, optimism and pessimism prior to surgery. Surprisingly, results revealed no effect of surgeon-provided information concerning preliminary diagnosis on patient distress. Rather, worry about what the surgeon might find concerning the breast mass during surgery, worry about having to go through the operative procedures, and patient optimism were the only factors that uniquely contributed to patient distress (ps < 0.05). This study provides a foundation for future clinical interventions to reduce presurgery distress.

Paravertebral somatic nerve block for outpatient inguinal herniorrhaphy: an expanded case report of 22 patients.

Background and Objectives. Inguinal herniorrhaphy is a common outpatient surgical procedure. However, anesthetic techniques for inguinal herniorrhaphy are still associated with numerous side effects. Paravertebral somatic nerve block (PSNB) has the potential advantage to offer unilateral abdominal wall anesthesia and longlasting pain relief with minimal side effects. We report our initial trial of PSNB for outpatient inguinal herniorrhaphy. Methods. Twenty‐two patients received a PSNB at T10 to L2 using 5 mL of 0.5% bupivacaine with epinephrine 1:400,000 at each of the five levels. The onset of surgical anesthesia, duration of analgesia, side effects, and patient satisfaction with the technique were documented. Results. Surgical anesthesia occurred 15‐30 minutes after injection. Two patients had a failed block. The mean ± SD time to onset of discomfort was 14 ± 11 hours. Time until first narcotic requirement was 22 ± 18 hours. Thirteen patients (n = 20) had no incisional discomfort 10 hours or longer after their blocks. Three patients had epidural spread. Most patients were very satisfied with their anesthetic technique. Conclusions. The results of our initial experience suggest that PSNB is a potentially safe and effective technique. In general, the block provided long‐lasting pain relief in most patients with few side effects. A randomized study comparing paravertebral blocks with conventional anesthesia choices is suggested given the findings in this initial series of patients.

Hypnosis Decreases Presurgical Distress in Excisional Breast Biopsy Patients

BACKGROUND:Excisional breast biopsy is associated with presurgical psychological distress. Such distress is emotionally taxing, and may have negative implications for postsurgical side effects and satisfaction with anesthesia. We investigated the ability of a brief hypnosis session to reduce presurgical psychological distress in excisional breast biopsy patients. METHODS:Ninety patients presenting for excisional breast biopsy were randomly assigned to receive either a 15-minute presurgery hypnosis session (n = 49, mean age: 46.4 (95% CI: 42.3–50.4)) or a 15-minute presurgery attention control session (n = 41, mean age: 45.0 (95% CI: 40.8–49.2)). The hypnosis session involved suggestions for increased relaxation and decreased distress. The attention control session involved nondirective empathic listening. Presurgery distress was measured using visual analog scales (VAS) and the short version of the Profile of Mood States (SV-POMS). Data were analyzed using analysis of variance and &khgr;2 procedures. RESULTS:Groups did not differ in terms of the following: demographics (age, education, ethnicity, marital status, all P’s > 0.28); medical variables (presurgery diagnosis, previous excisional biopsy, previous breast cancer, all P’s > 0.11); or preintervention distress (SV-POMS P > 0.74) assessed on the day of surgery. Postintervention, and before surgery, patients in the hypnosis group had significantly lower mean values for presurgery VAS emotional upset (16.5 vs 38.2, P < 0.0001, d = .85), VAS depressed mood (6.6 vs 19.9, P < 0.02, d = .67), and SV-POMS anxiety (10.0 vs 5.0, P < 0.0001, d = 0.85); and significantly higher levels for VAS relaxation (75.7 vs 54.2, P < 0.001, d = −0.76) than attention controls. CONCLUSIONS:The study results indicate that a brief presurgery hypnosis intervention can be an effective means of controlling presurgical distress in women awaiting diagnostic breast cancer surgery.

Anticipatory psychological distress in women scheduled for diagnostic and curative breast cancer surgery.

Background: Psychological distress is a central experience for women facing diagnostic and curative breast cancer surgery. Purpose: The present study was designed to predict anticipatory distress in 187 women scheduled to undergo excisional breast biopsy or lumpectomy. Method: Participants completed questionnaires assessing emotional distress and predictors of this distress (surgery type, worry about the surgical procedure, and worry about what the surgeon will find). Results: The study found that lumpectomy patients experienced greater anticipatory distress than excisional breast biopsy patients on three of the four distress measures (all ps < 0.05) and that worry about what the surgeon might find partially mediated these effects. Conclusion: The results suggest that although women awaiting lumpectomy are more distressed than women awaiting biopsy, both groups report substantial distress, and, consequently, psychosocial interventions are recommended for both groups.

Breast Cancer in Male-to-Female Transsexuals: Use of Breast Imaging for Detection

OBJECTIVE The purposes of this article are to describe two cases of breast cancer in male-to-female transsexuals and to review eight cases previously reported in the literature. CONCLUSION Breast cancer occurs in male-to-female transsexuals who receive high doses of exogenous estrogen and develop breast tissue histologically identical to that of a biologically female breast. This exposure to estrogen results in increased risk of breast cancer. The first patient described is a male-to-female transsexual with screening-detected ductal carcinoma in situ and a family history of breast cancer. The other patient is a male-to-female transsexual with invasive ductal carcinoma that was occult on diagnostic digital mammographic and ultrasound findings but visualized on digital breast tomosynthesis and breast MR images. The analysis of the eight previously reported cases showed that breast cancer in male-to-female transsexuals occurs at a younger age and is more frequently estrogen receptor negative than breast cancer in others born biologically male. Screening for breast cancer in male-to-female transsexuals should be undertaken for those with additional risk factors (e.g., family history, BRCA2 mutation, Klinefelter syndrome) and should be available to those who desire screening, preferably in a clinical trial.

Neo-adjuvant therapy with dose-dense docetaxel plus short-term filgrastim rescue for locally advanced breast cancer

Neo-adjuvant, dose-dense docetaxel, 100 mg/m2 every 2 weeks ×4 cycles, was administered to 12 patients with locally advance breast cancer (LABC) (10 stage IIIa and three stage IIIb). Eligibility requirements included a PS 0–2, normal hepatic and renal function, and radiologic absence of metastatic disease. Filgrastim [granulocyte colony stimulating factor (G-CSF)] was started 1 day after chemotherapy and was given for 6 days. Complete blood counts were determined weekly. Surgery was planned upon recovery from the last dose of docetaxel and followed by 4 cycles of adjuvant doxorubicin plus cyclophosphamide (AC) and radiotherapy. Patients with ER+ status received tamoxifen. The median age was 45 (range 34–73) and pre-treatment pathology revealed poorly differentiated infiltrating duct carcinoma in 11 and infiltrating lobular cancer in one, with positive ER/PR status in five. Twelve patients were treated, and all are evaluable for response and toxicity. Nine patients had a major clinical tumor response with five PR and four pathologic complete responses (pCR rate of 33%). Three patients (of whom two with stage IIIb) had progressive disease and went on to receive neo-adjuvant therapy with AC. There was one instance of grade 3 hematologic toxicity (neutropenic fever in one G-CSF non-compliant patient). There were two instances of grade 3 extra-hematologic toxicity: one patient had severe pain and one had treatment-related fatigue. After a median follow-up of 20 months (range 7–49 months) all patients are alive and eight of nine responders remain progression-free. Despite the small size of our study, we believe that dose-dense neo-adjuvant docetaxel is well tolerated and its activity warrants confirmation in a larger number of patients.

Utility of surveillance MRI in women with a personal history of breast cancer

PURPOSE To determine the utility and rate of biopsy in women with a positive history of breast cancer screened with MRI. METHODS Retrospective review of 491 breast MRI screening examinations in women with a personal history of breast cancer. RESULTS In total, 107 biopsies were performed, an average of 0.09 biopsies per person year. The positive predictive value for biopsies prompted by MRI findings was 0.24 (95% C.I. 0.10-0.38). Eight of the nine subsequent cancers were initially identified on screening MRI alone. CONCLUSION Surveillance MRI in breast cancer survivors may increase detection of subsequent cancers while increasing rate of biopsy.