Kari Thompson

Attaining Negative Margins in Breast-Conservation Operations: Is There a Consensus among Breast Surgeons?

BACKGROUND The purpose of this survey was to ascertain the most common surgical practices for attaining negative (tumor-free) surgical margins in patients desiring breast-conservation treatment for breast cancer to see if a consensus exists for optimal treatment of patients. STUDY DESIGN We sent a survey to 1,000 surgeons interested in the treatment of breast cancer. Three hundred eighty-one surgeons responded to this survey and 351 were used for the analysis (response rate of 38%). RESULTS Answers showed a large variety in clinical practices among breast surgeons across the country. There was little intraoperative margin analysis; only 48% of surgeons examine the margins grossly with a pathologist and even fewer used frozen sections or imprint cytology. Decisions to reexcise specific margins varied greatly. For example, 57% of surgeons would never reexcise for a positive deep margin, but 53% would always reexcise for a positive anterior margin. Most importantly, there was a large range in answers about acceptable margins with ductal carcinoma in situ and invasive carcinoma. Fifteen percent of surgeons would accept any negative margin, 28% would accept a 1-mm negative margin, 50% would accept a 2-mm negative margin, 12% would accept a 5-mm negative margin, and 3% would accept a 10-mm negative margin. CONCLUSIONS Results of this survey highlight the wide variety of practice patterns in the US for handling surgical margins in breast-conservation treatment. This issue remains controversial, with no prevailing standard of care. Consequently, additional study is needed in the modern era of multimodality treatment to examine the minimal amount of surgical treatment necessary, in conjunction with chemotherapy and radiation, to attain adequate local control rates in breast-conservation treatment.

Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results.

BACKGROUND Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset. METHODS The patients who had regained significant weight >or=2 years after RYGB after losing >or=50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up. RESULTS A total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds. CONCLUSIONS Incisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

Transrectal Endoscopic Retrorectal Access (TERA): A Novel NOTES Approach to the Peritoneal Cavity

BACKGROUND As the field of natural orifice translumenal endoscopic surgery (NOTES) expands, new access sites are being investigated. One access site to the peritoneal cavity, which has not been the subject of much investigation, is transrectal access. The aim of this article is to describe a new method to peritoneal access: transrectal endoscopic retrorectal access (TERA). MATERIALS AND METHODS Three pigs were placed in the supine position under general anesthesia, and an umbilical port was placed for the pneumoperitoneum, as well as visualization of the pelvic dissection and access. A rectotomy was made under direct vision above the dentate line posteriorly. The flexible endoscope was introduced into the retrorectal space, balloon dilation was used to open and dissect the retrorectal plane, and the peritoneal cavity was entered with a needle knife. After peritoneal exploration, the endoscope was withdrawn and the rectotomy was closed under direct vision. RESULTS Each of the 3 cases was successful with entry into the peritoneal cavity to the right of the sacral promontory. Direct visualization allowed the avoidance of injury to the ureter, vessels, and nervous structures of the pelvis. The flexible endoscope allowed an easy direct visualization of the upper abdominal organs. In addition, retroflexion allowed a view of the pelvic organs. Mean operative time was 40 minutes. CONCLUSIONS TERA is a novel access route to the peritoneal cavity that can be performed by using readily available instrumentation. When performed under direct view, injury to the adjacent structures can be avoided while obtaining access. Unresolved issues include sterility of the procedure and reproducibility, and future survival studies will delineate long-term safety.

Robotic single-incision transabdominal and transvaginal surgery: initial experience with intersecting robotic arms

Single‐incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology.

Adenoid Cystic Breast Carcinoma: Is Axillary Staging Necessary in All Cases? Results from the California Cancer Registry

Abstract:  Adenoid cystic carcinoma (ACC) is an uncommon type of breast cancer. There are limited data about its epidemiology, tumor characteristics, and outcomes. Using a large, population‐based data base, this study aimed to identify specific characteristics of patients with adenoid cystic breast cancer, investigate its natural history, and determine its long‐term prognosis. The California Cancer Registry, a population‐based registry, was reviewed from the years 1988 to 2006. The data were analyzed with relation to patient age, tumor size and stage, and overall survival. Relative cumulative actuarial survival was determined using the Berkson‐Gage life table method. A total of 244 cases of invasive adenoid cystic cancer were identified in women during this time period. The patients’ median age was 61.9 years. Most cases were diagnosed in non‐Hispanic White women (82%, n = 200), followed by African American (6%, n = 15), Asian/Pacific‐Islander (5.7%, n = 14) and Hispanic women (4.4%, n = 12). The remainder of the patients was of unknown or other ethnicity. Tumors were between 1 and 140 mm in size. At the time of diagnosis, 92% (n = 225) of patients had localized disease, 5% (n = 12) of patients had regional disease, and even fewer (n = 7) had either distant or unknown staged disease. Lymph node involvement was not present in any tumors smaller than 1.4 cm. The relative cumulative survival of patients with adenoid cystic breast carcinoma was 95.6% at 5 years and 94.9% at 10 years. ACC of the breast is a rare disease with an overall good prognosis. Knowing that this cancer usually presents as localized disease, with lymph node involvement seen only with larger tumors, can help clinicians plan the operative management of these tumors.

Internal iliac artery angioplasty and stenting: an underutilized therapy.

BACKGROUND Internal iliac artery (IIA) stenosis is a common finding in patients undergoing angiography. In patients with localized thigh and buttock claudication, endovascular treatment of an isolated IIA stenosis may lead to symptomatic improvement. METHODS We retrospectively reviewed the records of nine patients who underwent IIA intervention for symptomatic thigh/buttock claudication. Patient demographics, angiographic status of both IIAs, and technical success were assessed by chart and angiogram review. Symptom relief was considered a successful outcome. RESULTS Nine patients underwent unilateral or bilateral IIA angioplasty and/or stenting. There was a 100% technical success rate, and there were no complications. Six patients underwent a bilateral intervention and three underwent unilateral intervention. Fifteen arteries were treated. Seven arteries were treated with angioplasty, two with angioplasty and stenting, and six with primary stenting. Of the nine patients treated, seven had symptomatic relief from their claudication. Mean follow-up was 1 month. CONCLUSION Percutaneous angioplasty and stenting of the IIA is technically feasible and safe. In patients who present with isolated proximal thigh and buttock claudication, IIA occlusive disease should be considered as an etiology. A majority of patients undergoing intervention report symptomatic improvement. Percutaneous intervention of the IIA has not been reported previously and should be an endovascular treatment option given its low morbidity and success rate. Also, there may be a beneficial role for IIA intervention in those patients undergoing unilateral IIA embolization during the course of endovascular aneurysmorrhaphy.

Early Ambulation after Percutaneous Femoral Access with Use of Closure Devices and Hemostatic Agents

BACKGROUND Patient satisfaction after percutaneous endovascular procedures is significantly influenced by the amount of time to ambulation postprocedure. The purpose of this study was to assess the complication rates of early ambulation after use of closure devices or topical hemostatic agents for femoral access sites for endovascular procedures. METHODS A retrospective review was performed of all patients who underwent an endovascular procedure from a femoral access site between January 2004 and March 2008. The access site was closed with an Angio-Seal, StarClose, or D-Stat Dry with pressure. Patients ambulated 2 hr postprocedure when a closure device was used and 4 hr postprocedure when a D-Stat pad was applied. Access-site bleeding complications were assessed. Sheath size, closure method, patient characteristics, and antiplatelet status were analyzed. RESULTS A total of 245 patients with a mean age of 70 years were identified. Of these, 154 (63%) patients were treated with a D-Stat pad with pressure, Angio-Seal was used on 83 (34%), and StarClose was used on eight (3%). The overall complication rate was 5.7%. Complications increased with increasing age (p = 0.003) and use of StarClose (p = 0.0001). The D-Stat pad was associated with a decreased complication rate (p = 0.03). Sheath size did not influence the incidence of bleeding. There was no significant increase in complications in patients taking an antiplatelet agent. CONCLUSION With a protocol using closure devices and hemostatic agents, early ambulation after percutaneous femoral access can be achieved safely with an acceptable complication rate in patients with peripheral vascular disease.

Robotic Donor Nephrectomy

Renal transplantation remains the standard of care for end-stage renal disease (ESRD). Unfortunately, as the demand for donor kidneys has increased this has not been followed by an increase in organ availability. Thus, patients must wait for a long time for an organ with the appropriate blood type and tissue type. Live donor renal transplant allows a superior outcome and typically a shorter waiting time for transplant in comparison to cadaveric renal transplant.1 According to the Organ Procurement and Transplantation Network, approximately 6,000 living donor renal transplants have been performed annually in the United States since 2000. Murray 2 performed the first successful living donor transplant between identical twins in 1954.

Transesophageal Endoscopic Myotomy (TEEM) for the Treatment of Achalasia – The United States Human Experience

The stem cell spheroids were infected with NV1066, a third-generation herpesvirus, or NDV-F3aa-GFP, a Newcastle Disease virus mutant. Both viruses carried the marker gene green fluorescent protein (GFP), which allowed monitoring by fluorescent microscopy. Cell cycle analysis and cell migration assay were also performed. Results: Viral infection of cancer stem cells was rapid (GFP expression was seen by 24 hours). The viruses from both families each produced efficient infection and killing of cancer. At doses of multiplicity of infection (MOI, number of viruses per tumor cell) of 0.5 or 1, >95% of cells were dead by day 6. Infection with virus also produced decreased migratory capacity of the cancer stem cells and shifted the population to a higher fraction in S phase. Conclusion: Multiple types of oncolytic viruses effectively target the stem cell subpopulation of pancreatic cancer cells. Infection decreases metastatic potential and effects killing of such stem cells. These data support clinical studies of oncolytic viruses in the treatment of chemoand radioresistant tumors.

Abstract 4336: Fluorescence laparoscopy for high-resolution pancreatic tumor imaging in an orthotopic mouse model

Proceedings: AACR 101st Annual Meeting 2010‐‐ Apr 17‐21, 2010; Washington, DC We report here the development of fluorescence laparoscopy to image green fluorescent protein (GFP)-expressing pancreatic tumors in an orthotopic mouse model. An orthotopic mouse model of human pancreatic cancer was established by injecting GFP-expressing MiaPaca-2 human pancreatic cancer cells into the pancreas of 6-week old female athymic mice. On post-operative day 14, the animals underwent a diagnostic laparoscopy using both white and fluorescent light. The fluorescence laparoscope was constructed by modifying a standard laparoscopic system in the following manner: a 480-nm short pass excitation filter was placed between the light cable and the laparoscope, and a 2-mm thick emission filter that allows leakage of 1% of the background light was placed between the laparoscope and the camera. The camera and recording system were replaced with a MultiCam 310C (UVP, Upland, CA) that allows variable exposure time and gain setting in the controlling software. The exposure time was set to 110 msec and the gain to 97. A 3-mm 0-degree laparoscope was used in the mice. The mouses abdomen was gently insufflated to 2 mm Hg via a 22-gauge angiocatheter that was secured via a suture. After fluorescence laparoscopy, the animals were sacrificed, and the identified tumors were collected and processed for histology. The experiments were performed in triplicate. Fluorescence laparoscopy allowed facile and rapid identification of the bright fluorescent tumors in the pancreatic body. By employing the specific parameters above mentioned, a clear background was visible along with the fluorescent tumor under the fluorescent light mode. This could proffer an advantage in allowing exact localization of the lesions, eliminating the need to flip back and forth between white and fluorescent lighting, under which the background is usually so darkened that it is difficult to maintain spatial orientation. In summary, the use of fluorescence laparoscopy permits the facile, clear, and rapid identification and localization of tumors that are labeled with fluorescent proteins or other fluorophores. Fluorescence laparoscopy may thus play a useful role in the diagnosis and staging of pancreatic and other aggressive gastrointestinal cancers. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4336.