Norman B. Halpern

A multifactorial analysis of melanoma: prognostic histopathological features comparing Clark's and Breslow's staging methods.

A multifactorial analysis was used to identify the dominant prognostic variables affecting survival from a computerized data base of 339 melanoma patients treated at this institution during the past 17 years. Five of the 13 parameters examined simultaneously were found to independently influence five year survival rates: 1) pathological stage (I vs II, p = 0.0014), 2) lesion ulceration (present vs absent, p = 0.006), 3) surgical treatment (wide excision vs wide excision plus lymphadenectomy, p = 0.024), 4) melanoma thickness (p = 0.032), and 5) location (upper extremity vs lower extremity vs trunk vs head and neck, p = 0.038). Additional factors considered that had either indirect or no influence on survival rates were clinical stage of disease, age, sex, level of invasion, pigmentation, lymphocyte infiltration, growth pattern, and regression. Most of these latter variables derived their prognostic value from correlation with melanoma thickness, except sex which correlated with location (extremity lesions were more frequent on females, trunk lesions on males). This statistical analysis enabled us to derive a mathematical equation for predicting an individual patients probability of five year survival. Three categories of risk were delineated by measuring tumor thickness (Breslow microstaging) in Stage I patients: 1) thin melanomas (<0.76 mm) were associated with localized disease and a 100% cure rate: 2) intermediate thickness melanomas (0.76–4.00 mm) had an increasing risk (up to 80%) of harboring regional and/or distant metastases and 3) thick melanomas (≤4.00 mm) had a 80% risk of occult distant metastases at the time of initial presentation. The level of invasion (Clarks microstaging) correlated with survival, but was less predictive than measuring tumor thickness. Within each of Clarks Level II, III and IV groups, there were gradations of thickness with statistically different survival rates. Both microstaging methods (Breslow and Clark) were less predictive factors in patients with lymph node or distant metastases. Clinical trials evaluating alternative surgical treatments or adjunctive therapy modalities for melanoma patients should incorporate these parameters into their assessment, especially in Stage I (localized) disease where tumor thickness and the anatomical site of the primary melanoma are dominant prognostic factors.

Choledochoduodenostomy. Analysis of 71 cases followed for 5 to 15 years.

To investigate the long-term effectiveness of choledochoduodenostomy (CDD), the experience with 71 patients followed for 5 or more years after CDD was analyzed retrospectively. From 1968 to 1984, 134 patients underwent CDD. Eight patients (6%) died in the immediate postoperative period, 55 left the hospital, 8 of them were lost to follow-up, and 47 were followed but died before 5 years elapsed after CDD. The remaining 71 patients form the data base for this analysis: 38 were followed for more than 5 years, 25 were followed for more than 10 years, and 8 were followed for more than 15 years (mean 12.1 years +/- 1.3 SEM). Choledocholithiasis, chronic pancreatitis, and postoperative stricture were the indications for CDD. Cholangitis was observed in only three patients. The diameter of the common bile duct (CBD) was large in most patients (mean 18 mm +/- 0.9 SEM). These results infer that CDD is effective to treat non-neoplastic obstructing lesions of the distal CBD on a long-term basis and that the presence of a dilated CBD (more than 16 mm) that allows the construction of a CDD more than 14 mm is essential to obtain good results.

Paraganglioma of the duodenum in association with congenital neurofibromatosis possible relationship

A case of a duodenal paraganglioma in a patient with von Recklinghausens disease is presented, along with a review of the common clinical features of the 26 cases of duodenal paraganglioma and related neurogenic tumors reported in the literature. There was no reported evidence of recurrence or metastasis. Local excision was the most commonly employed method of treatment. It is proposed that duodenal paraganglioma with its admixed components and variable histologic features may represent hamartomatous hyperplasia of the paraganglia and the supporting neuroid tissue in this area. This would explain the benign behavior of these tumors as compared with carcinoids. Its association, in this case, with neurofibromatosis supports the neural crest origin of duodenal paragangliomas.

Pancreaticoduodenectomy for metastatic tumors to the periampullary region

Although operative resection of metastatic lesions to the liver, lung, and brain has proved to be useful, only recently have there been a few reports of pancreaticoduodenectomies in selected cases of metastases to the periampullary region. In this report we present four cases of proven metastatic disease to the periampullary region in which the lesions were treated by pancreaticoduodenectomy. Metastatic tumors corresponded to a melanoma of unknown primary site, choriocarcinoma, high-grade liposarcoma of the leg, and a small cell cancer of the lung. All four patients survived the operation and had no major complications. Two patients died of recurrence of their tumors, 6 and 63 months, respectively, after operation; the other two patients are alive 21 and 12 months, respectively, after operation. It can be inferred from this small but documented experience, as well as a review of the literature, that pancreaticoduodenectomy for metastatic disease can be considered in selected patients, as long as this operation is performed by experienced surgeons who have achieved minimal or no morbidity and mortality with it.

Economics of pancreatoduodenectomy in the elderly

BACKGROUND Managed care and the increasing percentage of surgical procedures performed in the elderly have renewed the focus on hospital charges and expenditures. The objective of this study was to determine whether septuagenarians and octogenarians accrue more hospital charges or have a higher risk of morbidity and death. METHODS We retrospectively reviewed the charges and pertinent clinical outcomes data that were available on 70 of the last 100 pancreatoduodenectomies performed at our institution (1989 to 1994). Charges from four cost centers were analyzed and normalized to 1995 dollars by using the Consumer Price Index and Wilcoxon rank sum test. Patients were divided into two groups: group 1, 70 years of age or older (n = 21); group 2, younger than 70 years of age (n = 49). RESULTS Anesthetic charges were

Acute Chylous Peritonitis

2657 +/-

Factors influencing mortality and morbidity from injuries to the abdominal aorta and inferior vena cava

835 for group 1 versus

Evaluation and Treatment of Acute and Chronic Pancreatitis: A Review of 380 Cases

2815 +/-

Peritoneovenous shunt for intractable ascites of hepatic, nephrogenic, and malignant causes

826 for group 2, which was not a statistically significant difference. Laboratory charges were

Predicting the risk of abdominal disease in Hodgkin's lymphoma. A multifactorial analysis of staging laparotomy results in 255 patients.

4650 +/-