Final trial report of sentinel-node biopsy versus nodal observation in melanoma.

Background: Sentinel-node biopsy, a minimally invasive procedure for regional melanoma staging, was evaluated in a phase 3 trial.

Methods: We evaluated outcomes in 2001 patients with primary cutaneous melanomas randomly assigned to undergo wide excision and nodal observation, with lymphadenectomy for nodal relapse (observation group), or wide excision and sentinel-node biopsy, with immediate lymphadenectomy for nodal metastases detected on biopsy (biopsy group). Results No significant treatment-related difference in the 10-year melanoma-specific survival rate was seen in the overall study population (20.

Metastasectomy for distant metastatic melanoma: analysis of data from the first Multicenter Selective Lymphadenectomy Trial (MSLT-I).

Background: For stage IV melanoma, systemic medical therapy (SMT) is used most frequently; surgery is considered an adjunct in selected patients. We retrospectively compared survival after surgery with or without SMT versus SMT alone for melanoma patients developing distant metastases while enrolled in the first Multicenter Selective Lymphadenectomy Trial.

Methods: Patients were randomized to wide excision and sentinel node biopsy, or wide excision and nodal observation.

The impact on morbidity and length of stay of early versus delayed complete lymphadenectomy in melanoma: results of the Multicenter Selective Lymphadenectomy Trial (I).

Background: Complete lymph node dissection, the current standard treatment for nodal metastasis in melanoma, carries the risk of significant morbidity. Clinically apparent nodal tumor is likely to impact both preoperative lymphatic function and extent of soft tissue dissection required to clear the basin. We hypothesized that early dissection would be associated with less morbidity than delayed dissection at the time of clinical recurrence.

Refinements of surgical technique in soft tissue sarcomas.

The primary modality of treatment for a localized soft tissue sarcoma is surgical resection. Adjuvant or neoadjuvant radiation helps reduce the rate of local recurrence. The rate of limb preserving resection is 94% in our series.

Cutdowns for totally implantable access ports to central veins.

For insertion of totally implantable access ports, with the catheter end in the superior vena cava, the percutaneous (Seldinger) technique is commonly used. Of cutdowns, the cephalic vein cutdown is the most popular one (success rate about 80%), followed by the external jugular vein cutdown. Our preliminary experience suggests that internal jugular vein and basilic vein cutdowns have the anatomic features to prove both of them superior to the cephalic vein cutdown.

Large gaps of midline abdominal incisions and their management.

The operative management of midline full-thickness abdominal wall gaps is difficult, often requires several surgical procedures and is associated with significant short- and long-term complications. A rectus abdominis-posterior sheath (RAPS) flap with skin grafting provides a tension-free one-step repair which was used in three patients successfully with midline abdominal wall (including the skin) gaps who had multiple previous operations related to intra-abdominal malignancy. No complications occurred in these patients in relation to this procedure.

Modified anterior compartment resection of the thigh.

For large soft tissue sarcomas of the anterior thigh, an anterior compartment resection is often performed. This may leave the patient with the inability to extend the knee. In our practice, we find that it is usually possible to preserve one of the heads of the quadriceps, usually the vastus medialis, with intact innervation, and thus preserve significant extension function of the knee joint, while the requirements for a radical oncologic procedure are being met.

Quantitative aspects of the relationship between the tumor and host response.

Background: It is generally assumed that the immune response by a host to the tumor depends on their antigenic differences. Whether quantitative aspects in this relationship play any role remains unclear.

Materials And Methods: Observation of tumor growth and regression in allogeneic murine models under various experimental conditions.

Is immunosuppression at the tumor site mechanism of evasion of a systemic response?

Background: Some of the questions still open to investigation are: 1) Does the clinical appearance of a tumor nodule require a prior overwhelming of a systemic host response? 2) Does a palpable growing tumor cause host immunosuppression?

Materials And Methods: Observation of tumor growth and regression in syngeneic and allogeneic murine models under various experimental conditions. Autopsy studies of allogeneic mice with terminal progressive tumor growth.

Results: In syngeneic systems, the take of a threshold tumor inoculum is not facilitated by the contralateral take and growth of a simultaneously injected ten-fold larger inoculum.

Sentinel-node biopsy or nodal observation in melanoma.

Background: We evaluated the contribution of sentinel-node biopsy to outcomes in patients with newly diagnosed melanoma.

Methods: Patients with a primary cutaneous melanoma were randomly assigned to wide excision and postoperative observation of regional lymph nodes with lymphadenectomy if nodal relapse occurred, or to wide excision and sentinel-node biopsy with immediate lymphadenectomy if nodal micrometastases were detected on biopsy.

Results: Among 1269 patients with an intermediate-thickness primary melanoma, the mean (+/-SE) estimated 5-year disease-free survival rate for the population was 78.

Desmoplastic small round cell tumor of the pleura.

Desmoplastic small round cell tumor (DSRCT) is a rare neoplasm with aggressive behavior. Usually it presents as a peritoneal mass, although other cases in various locations have been described. Since less than 10 cases of primary DSRCT in the pleura have been described, it is of interest to report a pediatric case arising from the pleura.

Surgical procedures and lymphedema of the upper and lower extremity.

Background: Lymphedema occurs in the upper and lower extremity, in a minority of patients, following axillary and groin dissections, respectively. Several technical operative factors have been implicated through the years whose relative significance remains unknown.

Methods: Retrospective review of the author's personal experience with axillary and groin dissections and review of the articles and results written on the author's series of patients.

Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial.

Objective: The objective of this study was to evaluate, in an international multicenter phase III trial, the accuracy, use, and morbidity of intraoperative lymphatic mapping and sentinel node biopsy (LM/SNB) for staging the regional nodal basin of patients with early-stage melanoma.

Summary Background Data: Since our introduction of LM/SNB in 1990, this technique has been widely adopted and has become part of the American Joint Committee on Cancer (AJCC) staging system. Eleven years ago, the authors began the international Multicenter Selective Lymphadenectomy Trial (MSLT-I) to compare 2 treatment approaches: wide excision (WE) plus LM/SNB with immediate complete lymphadenectomy (CLND) for sentinel node (SN) metastases, and WE plus postoperative observation with CLND delayed until the subsequent development of clinically evident nodal metastases.

Internal packing in the control of hemorrhage from large retroperitoneal veins.

Background: Hemorrhage from large retroperitoneal veins is usually controlled by suturing the venous tear. Infrequently, the extent and location of the tear and amount of hemorrhage preclude successful suturing.

Methods: In seven patients with severe hemorrhage from large retroperitoneal veins encountered in association with resection of retroperitoneal sarcoma (6) or repair of a ruptured abdominal aortic aneurysm (1), packing of the area with sufficient amounts of Surgicel (Ethicon, Johnson & Johnson, Somerville, NJ) and pressure for one half hour was used.

Cytokines and chemokines are expressed at different levels in small and large murine colon-26 tumors following intratumoral injections of CpG ODN.

Direct tumor injections of (CpG ODN) into murine colon tumor 26 (CT-26) tumors can induce a potent antitumor response. Tumor size at the beginning of treatment determines the final therapeutic outcome, with smaller tumors responding favorably to CpG ODN therapy whereas large tumors do not. CpG ODN injections in small tumors resulted in tumor necrosis and extensive inflammatory cell infiltration, with average survival that is significantly higher (48.

Surgical treatment of locally progressive stage IIIB carcinoma of the cervix: use of the inverted "T" incision.

Stage III carcinoma of the cervix is treated usually, and often effectively, with the combination of radiation and chemotherapy. For tumors locally recurring, without evidence of distant lymphatic or hematogenous spread, the option of pelvic exenteration rises. The described surgical technique derives from soft tissue sarcoma pelvic surgery.

Technique of forequarter (interscapulothoracic) amputation.

In the anterior approach to forequarter amputation, a segment of clavicle is removed and early dissection and division of the subclavian vessels are done. In the posterior approach after division of the trapezius and muscles attached to the vertebral border of the scapula, the trunks of the brachial plexus and the subclavian vessels are serially ligated and divided, while the pectoral muscles are intact. In both approaches, the dissection around the subclavian vessels can be slow and tedious to avoid bleeding, which could be difficult to control because the vessels have not been cleared circumferentially for application of a vascular clamp.

Reducing toxicity of cisplatin in cancer chemotherapy by extracorporeal removal of excess cisplatin.

Cisplatin and its derivatives are today among the most frequently used agents for treatment of malignancies, the dose, however, is limited by side effects. When an organ or extremity with tumor has a single, well defined artery, cisplatin can be delivered into the tumor, and cisplatin leaving the tumor through the venous drainage can be removed before it empties into the systemic circulation. We developed a hollow fiber device with an immobilized platinum chelator for extracorporeal removal of cisplatin, without the chelator entering the blood.