David P. Jaques

Decision making on surgical palliation based on patient outcome data

BACKGROUND Strategies for the effective application of palliative procedures are infrequently standardized and incompletely understood. The effect on patient outcome as determined by elements such as resolution of chief complaints, quality of life, pain control, morbidity of therapy, and resource utilization should predominate decisions regarding surgical palliative care. METHODS Articles published between 1990 and 1996 on the surgical palliation of cancer were identified by a MEDLINE search and reviewed for designated parameters considered important for good palliative care. RESULTS A total of 348 citations were included. Entries considered these fundamental elements: cost (2%); pain control (12%); quality of life (17%); need to repeat the intervention (59%); morbidity and mortality (61 %); survival (64%); and physiologic response (69%). Established methods for quality of life and pain assessment were sporadically utilized. CONCLUSIONS In the current surgical literature, there is uncommon reporting of the range of data required to recommend sound palliative surgical choices.

Guidelines for the Safe Use of Radioactive Materials During Localization and Resection of the Sentinel Lymph Node

Background: Several reports have demonstrated accurate prediction of nodal metastasis with radiolocalization and selective resection of the radiolocalized sentinel lymph node (SLN) in patients with breast cancer and melanoma. As reliance on this technique grows, its use by those without experience in radiation safety will increase.Methods: Tissue obtained during radioguided SLN biopsies was examined for residual radioactivity. Specimens with a specific activity greater than the radiologic control level (RCL) of 0.002μCi/g were considered radioactive. Radiation exposure to the surgical team was measured.Results: A total of 24 primary tissue specimens and 318 lymph nodes were obtained during 57 operations (37 for breast cancer, 20 for melanoma). All 24 (100%) of the specimens injected with radiopharmaceutical and 89 of 98 (91%) of the localized nodes were radioactive after surgery. Activity fell below the RCL 71 ± 3.6 hours in primary tissue specimens, 46 ± 1.7 hours in nodes from melanoma patients, and 33 ± 3.5 hours in nodes from breast cancer patients (P = .037). The hands of the surgical team (n = 22 cases) were exposed to 9.4 ± 3.6 mrem/case.Conclusion: Although low levels of radiation exposure are associated with radiolocalization and resection of the SLN, the presented guidelines ensure conformity to existing regulations and allow timely pathologic analysis.

Ultrasonographically guided injection improves localization of the radiolabeled sentinel lymph node in breast cancer

AbstractBackground: Several reports have demonstrated the accurate prediction of axillary nodal status (ANS) with radiolocalization and selective resection of sentinel lymph nodes (SLN) in breast cancer. To date, no technique has proven to be superior in localizing the SLN. Methods: 1.0 mCi of clear unfiltered99mtechnetium sulfur colloid was injected under ultraso-nographic (US) guidance around the perimeter of the breast lesion (palpable and nonpalpable) or previous biopsy site. Resection of the radiolocalized nodes was performed, followed by complete axillary lymph node dissection (AXLND). Results: Forty-two breast cancer patients underwent SLN biopsy after US-guided radiopharmaceutical injection. The SLN was localized in 41 patients (98%). The type of previously performed diagnostic biopsy did not influence the ability to localize the sentinel lymph node. Pathology revealed nodal metastasis in 7 of the 41 evaluable patients (17%). ANS was accurately predicted in 40 of 41 patients (98%). Conclusions: Early experience with radiologicalization and selective resection of SLN in breast cancer remains promising. Use of US-guided injection facilitates localization of the SLN, perhaps as a result of more accurate placement of the radionuclide marker. Use of this technique allowed for effective management of patients regardless of tumor size or the extent of prior biopsy, thereby expanding the potential number of eligible patients for SLN biopsy.

Suture granuloma masquerading as malignancy of the biliary tract.

SummaryEighteen years after having a duodenal leiomyosarcoma resected, a patient presented with weight loss, pruritus, and abdominal pain. ERCP was consistent with a cholangiocarcinoma with proximal hepatic duct stricture and nonfilling of the cystic duct. CAT scan revealed no extrinsic masses compressing the gallbladder or biliary tract. At surgical exploration, the patient was found to have a suture granuloma with surrounding fibrosis within the common bile duct. There was no evidence of malignancy.

Contributions from surgeons to clinical trials and research on the management of soft tissue sarcoma

AbstractBackground: Surgical resection is the primary treatment for soft tissue sarcoma. Surgeons are in a position to develop and define appropriate treatment strategies for this disease. In an effort to define the contributions of surgeons to the management of sarcoma, the surgical and clinical oncology literature from January 1983 through June 1996 was reviewed. Methods: A computerized literature search of the Cancerlit database for January 1983 to June 1996 was performed. The search was limited to the topic of soft tissue sarcoma and was further confined to 15 journals that publish articles relevant to surgical management. These studies were then categorized by multiple parameters and analyzed. Results: The Cancerlit file contained 4478 articles in which sarcoma was the primary topic. When the search was limited to 15 journals frequently read by surgeons, 479 references (11%) were retrieved. Within the surgical literature, 95 of the 479 articles (20%) described prospective studies, of which 33 were prospective and randomized. These studies represent all but three of the prospective randomized trials within the literature during the time period reviewed. The management of patients with sarcoma was evaluated in 26 of the prospective randomized trials; of these, 13 trials evaluated adjuvant chemotherapy, three evaluated adjuvant radiotherapy, and ten evaluated the chemotherapeutic treatment of metastatic disease. Surgical oncologists were the first or senior author on 10 of the 16 prospective randomized studies regarding adjuvant radiation or chemotherapy. Four of the 16 trials evaluating adjuvant therapy contained more than 100 patients, and three of those four were from cooperative group efforts. All but one of the studies of adjuvant therapy with less than 100 patients were from single institutional trials. Conclusions: Although the surgical and clinical oncology literature on soft tissue sarcoma is composed primarily of retrospective reviews, the prospective randomized trials reported represent almost all of the randomized trials in the literature and have significant contributions from surgeons. Surgeons can guide and design clinical trials, but overall patient accrual as represented by soft tissue sarcoma is low, and may be improved through cooperative group efforts.

Death and dollars : the cost of dying in the surgical intensive care unit

INTRODUCTION The effect of resuscitation status on the use of laboratory and radiologic studies was analyzed in patients at the Walter Reed Army Medical Centers Surgical Intensive Care Unit. METHODS A retrospective assessment of laboratory and radiologic charges incurred during the last 48 hours of life by 81 patients who died in the Surgical Intensive Care Unit between 1990 and 1992 was performed. Data were analyzed after separation by patients resuscitation status. Each patient was assigned a resuscitation category: no limitation, do not resuscitate (no CPR in event of arrest), or limited therapy (specific order limiting care or monitoring). RESULTS There were 4,095 laboratory tests performed for a total charge of

The utilization of directed clinical evaluation to eliminate routine daily chest X-rays in intensive care unit patients1

191,247. Arterial blood gas testing accounted for over

Death and Dollars

75,000 of these charges. Resuscitation status significantly affected test frequency. CONCLUSIONS During the last 48 hours of life in an intensive care unit, the use of laboratory tests and radiologic exams has a substantial effect on the cost of care and is modified by the patients resuscitation status.

Long-term impact of previous breast biopsy on breast cancer screening modalities

Abstract Purpose T his study was designed to determine whether a directed clinical evaluation could eliminate the need for routine daily chest X-rays (CXRs) in surgical intensive care unit patients. Methods All patients admitted to a 10-bed surgical intensive care unit in a university-affiliated medical center were eligible for evaluation. Patients were evaluated using a 20-point Clinical Evaluation Score (CES) prior to their routine daily CXRs. An evaluation was deemed positive if any parameter was scored as positive. Major CXR findings requiring intervention and minor CXR findings representing changes but not mandating intervention were recorded. Descriptive statistics were used to relate the CES to the CXR findings. Results Fifty-one patients had 216 CESs and CXRs compared. There were 77 positive CESs (36%) and 139 negative CESs (64%). A positive CES predicted 31 of 33 major CXR findings. For major CXR findings requiring intervention, CES had a sensitivity of 94% and a negative predictive value of 98%. Conclusions By utilizing a structured clinical evaluation to determine the need for a morning CXR in this study, we could have eliminated 64% of routine morning CXRs.