Thomas J. Miner

Long-term Survival Following Treatment of Pseudomyxoma Peritonei: An Analysis of Surgical Therapy

Summary Background Data:Pseudomyxoma peritonei (PMP) is a clinical syndrome with a poorly defined natural history. Relative contributions of tumor biology, patient selection, and the extent of treatment on ultimate outcome are not well characterized. Methods:Patients treated at the Memorial Sloan-Kettering Cancer Center between 1980 and 2002 with a diagnosis of PMP were identified. Patient characteristics, pathologic features, and details of treatment were analyzed retrospectively. Results:The 97 patients included in this study underwent a mean 2.2 ± 0.1 operations (range, 1–6). Although complete cytoreduction was achieved in 55% (53/97), disease recurred in 91% (48/53) of patients. The median disease-free interval after complete cytoreduction was 24 months. The median overall survival was 9.8 years and was independently associated with low-grade pathologic subtype (P < 0.001) and the ability to achieve complete cytoreduction (P < 0.001). Ten-year survival was attained in 21% (20/97) of the patients, of which 90% (18/20) had low-grade pathologic features. At the time of death or completion of follow-up, only 12% (12/97) of the patients were disease free. Conclusions:Outcome in patients with PMP is strongly associated with tumor biology. Although improved survival is associated with low-grade pathology and tumors amenable to complete cytoreduction, recurrence of PMP is common. Treatment may be beneficial, particularly in controlling symptoms, but absolute cure, defined as a prolonged disease-free state, is uncommon.

A Prospective, Symptom Related, Outcomes Analysis of 1022 Palliative Procedures for Advanced Cancer

Objective:To prospectively evaluate surgical procedures performed with palliative intent. Summary Background Data:There is a paucity of outcomes data necessary to allow sound surgical decision-making and informed consent for palliative procedures. Methods:Procedures to palliate symptoms of advanced cancer were identified prospectively from all operations performed. Patients were observed for >90 days or until death. Resutls:There were 1022 palliative procedures performed in 823 patients from July 2002 to June 2003. Operative (713/1022) or endoscopic (309/1022) procedures were performed for gastrointestinal obstruction (34%), neurologic symptoms (23%), pain (12%), dyspnea (9%), jaundice (7%) or other symptoms (15%). Symptom improvement or resolution within 30 days was achieved in 80% (659/823). Median duration of symptom control was 135 days. Recurrence of the primary symptom occurred in 25% (165/659) while treatment of debilitating additional symptoms was required in 29% (191/659). Palliative procedures were associated with 30-day postoperative morbidity (29%) and mortality (11%). A major postoperative complication reduced the probability of symptom improvement to 17%. Median survival was 194 days from the time of the palliative procedure and was adversely associated with poor performance status (ECOG ≥ 2 [P < 0.001] or NCI fatigue score of ≥1 [P < 0.001]), poor nutrition (albumin <3.5 [P = 0.005] or significant weight loss [P = 0.003]), and no previous cancer therapy (P = 0.002). Conclusions:In carefully selected patients, relief of symptoms following palliative procedures can be expected, but new or recurrent symptoms limit durability. Potential benefits are minimized by postoperative complications and are less predictable for patients with poor performance status, malnutrition and no prior cancer therapy.

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.

Clinical outcomes with laparoscopic stage M1, unresected gastric adenocarcinoma.

Objective:For patients with laparoscopic stage M1 gastric adenocarcinoma, no resection of the primary tumor, and systemic chemotherapy, this study investigated the incidence of subsequent palliative intervention and survival. Summary Background Data:Laparoscopy was performed for patients with computed tomography scan stage M0 disease and no significant obstruction or bleeding. Methods:A prospectively maintained database for 1993 to 2002 was used to identify 165 patients (median age, 63 years) with laparoscopic M1 disease in the peritoneum (P1, adjacent to stomach, 9%; P2, few distant sites, 35%; or P3, disseminated, 30%) or liver (10%) or both (16%). Functional performance status (FPS, Eastern Cooperative Oncology Group) was 0 to 1 (84%) or 2 (16%). Results:Subsequent intervention was performed on 50% of patients, at median interval of 4 months (range, 1–35 months) after laparoscopy. Intervention was performed on the stomach for obstruction (33%), bleeding (8%), or perforation (1%) or on a distant site for a metastasis-related complication (20%). More than one intervention (maximum, 4) was performed in 21%. Laparotomy was necessary in 12%; the remainder had endoscopic or radiologic procedures or radiation therapy only. There was one intervention-related death. Median survival was 10 months, with 1-year survival of 39%. On multivariate analysis, better FPS (0–1; odds ratio, 4; P = 0.001) and limited peritoneal metastasis (P1 or P2; 2; P = 0.01) were independently associated with improved survival. Conclusions:The incidence of subsequent intervention was 50%, but few patients had laparotomy. Intervention-related mortality was minimal. The burden of metastatic disease and functional performance status were important prognostic factors.

Surgical vampires and rising health care expenditure: reducing the cost of daily phlebotomy.

OBJECTIVE To determine whether simply being made continually aware of the hospital costs of daily phlebotomy would reduce the amount of phlebotomy ordered for nonintensive care unit surgical patients. DESIGN Prospective observational study. SETTING Tertiary care hospital in an urban setting. PARTICIPANTS All nonintensive care unit patients on 3 general surgical services. INTERVENTION A weekly announcement to surgical house staff and attending physicians of the dollar amount charged to nonintensive care unit patients for laboratory services during the previous week. MAIN OUTCOME MEASURE Dollars charged per patient per day for routine blood work. RESULTS At baseline, the charges for daily phlebotomy were

Palliative surgery for advanced cancer: lessons learned in patient selection and outcome assessment.

147.73/patient/d. After 11 weeks of residents being made aware of the daily charges for phlebotomy, the charges dropped as low as

Lapatinib/gemcitabine and lapatinib/gemcitabine/oxaliplatin: a phase I study for advanced pancreaticobiliary cancer.

108.11/patient/d. This had a correlation coefficient of -0.76 and significance of P = .002. Over 11 weeks of intervention, the dollar amount saved was

Optimal management of gastric cancer: results from an international RAND/UCLA expert panel.

54,967. CONCLUSION Health care providers being made aware of the cost of phlebotomy can decrease the amount of these tests ordered and result in significant savings for the hospital.