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Boncher N.,University Hospitals Case Medical Center | Vricella G.,University Hospitals Case Medical Center | Greene G.,Lakeland Regional Cancer Center | Madi R.,University Hospitals Case Medical Center | Madi R.,University of Arkansas for Medical Sciences
Journal of Endourology | Year: 2010

Introduction: In the era of prostate-specific antigen screening and frequent cross-sectional abdominal imaging, concurrent prostate cancer and renal masses are being identified and treated. Minimizing patient morbidity and cost by avoiding separate surgical procedures is advantageous, provided technical feasibility, and safety data. Our goal was to assess the feasibility and safety of single-setting robotic renal surgery and prostatectomy. We present our initial experience. Purpose: To assess the feasibility and safety of single-setting concurrent robot-assisted renal surgery and radical prostatectomy utilizing the same port access scheme. Patients and Methods: From February 2009 to June 2009, we performed single-setting concurrent robot-assisted radical nephrectomy/partial nephrectomy and radical prostatectomy on two patients with synchronous kidney tumors and prostate cancer. Identical port sites were used during both aspects of the procedure with the exception of one additional port during prostatectomy. Prostate cancer clinical stage and Gleason scores were T1c and 6 and T2a and 7, respectively. Corresponding renal tumors were 5cm, respectively. Results: Both operations were performed, with no conversion to open surgery. There were no intraoperative complications and the postoperative course was uneventful in both patients. Discharge was on postoperative day 2 and 3, respectively. Patient 2 had an episode of delayed bleeding on postoperative day 9, treated by selective angio-embolization. Mean operative time for nephrectomy and prostatectomy (135 and 139 minutes, respectively) and estimated blood loss (75 and 100mL, respectively) were reasonable. We began with the renal portion utilizing a lateral decubitus position before re-positioning into the lithotomy position for the prostatic portion. Clamping time was 34 minutes during partial nephrectomy. Conclusion: Single-setting robotic radical/partial nephrectomy and radical prostatectomy is technically feasible and safe in properly selected patients who present with synchronous primary renal and prostate malignancies. © Copyright 2010, Mary Ann Liebert, Inc.


Giuliano A.E.,The Surgical Center | Giuliano A.E.,Cedars Sinai Medical Center | Hawes D.,University of Southern California | Ballman K.V.,Mayo Medical School | And 9 more authors.
JAMA - Journal of the American Medical Association | Year: 2011

Context: Immunochemical staining of sentinel lymph nodes (SLNs) and bone marrow identifies breast cancer metastases not seen with routine pathological or clinical examination. Objective: To determine the association between survival and metastases detected by immunochemical staining of SLNs and bone marrow specimens from patients with early-stage breast cancer. Design, Setting, and Patients: From May 1999 to May 2003, 126 sites in the American College of Surgeons Oncology Group Z0010 trial enrolled women with clinical T1 to T2N0M0 invasive breast carcinoma in a prospective observational study. Interventions: All 5210 patients underwent breast-conserving surgery and SLN dissection. Bone marrow aspiration at the time of operation was initially optional and subsequently mandatory (March 2001). Sentinel lymph node specimens (hematoxylineosin negative) and bone marrow specimens were sent to a central laboratory for immunochemical staining; treating clinicians were blinded to results. Main Outcome Measures: Overall survival (primary end point) and disease-free survival (a secondary end point). Results: Of 5119 SLN specimens (98.3%), 3904 (76.3%) were tumor-negative by hematoxylin-eosin staining. Of 3326 SLN specimens examined by immunohistochemistry, 349 (10.5%) were positive for tumor. Of 3413 bone marrow specimens examined by immunocytochemistry, 104 (3.0%) were positive for tumors. At a median follow-up of 6.3 years (through April 2010), 435 patients had died and 376 had disease recurrence. Immunohistochemical evidence of SLN metastases was not significantly associated with overall survival (5-year rates: 95.7%; 95% confidence interval [CI], 95.0%-96.5% for immunohistochemical negative and 95.1%; 95% CI, 92.7%-97.5% for immunohistochemical positive disease; P=.64; unadjusted hazard ratio [HR], 0.90; 95% CI, 0.59-1.39; P=.64). Bone marrow metastases were associated with decreased overall survival (unadjusted HR for mortality, 1.94; 95% CI, 1.02-3.67; P=.04), but neither immunohistochemical evidence of tumor in SLNs (adjusted HR, 0.88; 95% CI, 0.45-1.71; P=.70) nor immunocytochemical evidence of tumor in bone marrow (adjusted HR, 1.83; 95% CI, 0.79-4.26; P=.15) was statistically significant on multivariable analysis. Conclusion: Among women receiving breast-conserving therapy and SLN dissection, immunohistochemical evidence of SLN metastasis was not associated with overall survival over a median of 6.3 years, whereas occult bone marrow metastasis, although rare, was associated with decreased survival. Trial Registration: clinicaltrials.gov Identifier: NCT00003854. ©2011 American Medical Association. All rights reserved.


Wilke L.G.,Duke University | Ballman K.V.,Mayo Medical School | McCall L.M.,Mayo Medical School | Giuliano A.E.,John Wayne Cancer Institute | And 6 more authors.
Annals of Surgical Oncology | Year: 2010

Background: In 2007, the National Quality Forum (NQF) released four performance measures for the treatment of breast cancer. We proposed to study the degree of adherence with these measures among participating institutions in a multi-institutional trial. Methods: American College of Surgeons Oncology Group (ACOSOG) Z0010 enrolled breast cancer patients onto a phase II trial studying the prognostic significance of bone marrow and sentinel node micrometastases. The current study used v2 analyses to determine the degree of adherence with four NQF measures among three institution types: academic, community, and teaching affiliate. Results: The study revealed small but important differences in two measures. Ninety-five percent of patients from teaching affiliated institutions received whole-breast radiation compared to 92% at academic and 91% at community hospitals. Among patients who were underinsured or uninsured, a marked decrease in radiation use was noted in comparison to patients with insurance-85 versus 93%, respectively. The study also revealed a difference among institutional types in patients undergoing excisional biopsy for diagnosis. In teaching-affiliated hospitals, 28.6% underwent excisional biopsy as compared to 36.8 and 37.4% in academic and community hospitals, respectively. There was no statistically significant difference between adherence rates with the remaining two measures. Adjuvant chemotherapy was administered to patients with hormone receptor negative tumors C1 cm in size in 79-85% of institutions. Tamoxifen was administered to 79-82% of those patients with hormone receptor-positive cancers. Conclusions: Among breast cancer patients enrolled onto a multi-institutional clinical trial, we found a high degree of adherence with current consensus standards for adjuvant treatment, despite varied practice environments. © Society of Surgical Oncology 2010.


Mays M.P.,University of Louisville | Martin R.C.G.,University of Louisville | Burton A.,University of Louisville | Ginter B.,University of Louisville | And 7 more authors.
Cancer | Year: 2010

BACKGROUND: Sentinel lymph node (SLN) biopsy generally is recommended for patients who have melanoma with a Breslow thickness ≥1 mm. Most patients with melanoma between 1 mm and 2 mm thick have tumor-negative SLNs and an excellent long-term prognosis. The objective of the current study was to evaluate prognostic factors in this subset of patients and determine whether all such patients require SLN biopsy. METHODS: Patients with melanoma between 1 mm and 2 mm in Breslow thickness were evaluated from a prospective multi-institutional study of SLN biopsy for melanoma. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis to compare patients with melanoma that measured from 1.0 mm to 1.59 mm (Group A) versus patients with melanoma that measured from ≥1.6 mm to 2.0 mm thick (Group B). Univariate and multivariate analyses were performed to evaluate factors predictive of tumor-positive SLN status, DFS, and OS. RESULTS: The current analysis included 1110 patients with a median follow-up of 69 months. SLN status was tumor-positive in 133 of 1110 patients (12%) including 66 of 762 patients (8.7%) in Group A and 67 of 348 patients (19.3%) in Group B (P < .0001). On multivariate analysis, age, Breslow thickness, and lymphovascular invasion were independently predictive of a tumor-positive SLN (P < .05). DFS (P < .0001) and OS (P = .0001) were significantly better for Group A than for Group B. When tumor thickness was treated as either a continuous variable (P < 0.0001) or a categorical variable (P < .0001), it was significantly predictive of DFS and OS. On multivariate analysis, Breslow thickness, age, ulceration, histologic subtype, regression, Clark level, and SLN status were significant factors predicting DFS; and Breslow thickness, age, primary tumor location, sex, ulceration, and SLN status were significant factors predicting OS (P < .05). A subgroup of patients who had tumors <1.6 mm in Breslow thickness, had no lymphovascular invasion, and were aged ≥59 years had a low risk (5%) of tumor-positive SLN. CONCLUSIONS: The current findings indicated that there is significant diversity in the biologic behavior of melanoma between 1 mm and 2 mm in Breslow thickness. SLN biopsy is recommended for all such patients to identify those with lymph node metastasis who are at the greatest risk of recurrence and mortality. © 2010 American Cancer Society.


McMasters K.M.,University of Louisville | Edwards M.J.,University of Cincinnati | Ross M.I.,University of Texas M. D. Anderson Cancer Center | Reintgen D.S.,Lakeland Regional Cancer Center | And 6 more authors.
Annals of Surgery | Year: 2010

Objective: This analysis was performed to investigate the hypothesis that ulceration predicts improved response to adjuvant interferon (IFN) therapy. Summary Background Data: Several studies have demonstrated that adjuvant therapy for high-risk melanoma patients with IFN alfa-2b improves disease-free survival (DFS), although the impact on overall survival (OS) is controversial. Recent data have suggested that IFN therapy may preferentially benefit patients with ulcerated primary melanomas. Methods: Post hoc analysis was performed by a prospective multi-institutional randomized study of observation versus adjuvant IFN therapy for melanoma. All patients underwent sentinel lymph node biopsy; completion lymphadenectomy was performed for patients with sentinel lymph node metastasis. Patients were stratified by Breslow thickness, ulceration, and nodal status. Kaplan-Meier analysis of DFS and OS was performed and included univariate and multivariate analyses. Results: A total of 1769 patients were analyzed (1311 without ulceration, 458 with ulceration) with a median follow-up of 71 months. Ulceration was associated with significantly worse DFS and OS in both node-negative and node-positive patients. Kaplan-Meier analysis of node-negative and node-positive patients by ulceration status revealed that the only significant impact of interferon was improved DFS in the ulcerated node-positive patients (P = 0.0169). IFN therapy had no significant impact on OS regardless of ulceration status, however. On multivariate analysis, IFN treatment was a significant independent predictor of DFS among ulcerated patients (odds ratio, 0.51; 95% confidence interval, 0.30-0.83; P = 0.0053), but not among patients without ulceration. Conclusions: These data support the conclusion that ulceration is a predictive marker for response to adjuvant IFN therapy. Future studies to evaluate specifically the differential effect of IFN on patients with ulcerated melanomas may allow us to focus this therapy on patients most likely to benefit from it. © 2010 by Lippincott Williams & Wilkins.


Scoggins C.R.,University of Louisville | Bowen A.L.,University of Louisville | Martin II R.C.,University of Louisville | Edwards M.J.,University of Cincinnati | And 6 more authors.
Archives of Surgery | Year: 2010

Hypothesis: Sentinel lymph node (SLN) biopsy provides valuable prognostic information for patients with thick (T4) melanoma. Design: Post hoc analysis of data from a prospective, randomized trial. Setting: Academic and private hospitals. Patients: Data of 240 patients with melanoma thicker than 4 mm were analyzed. Patients with tumor-positive SLNs underwent completion lymphadenectomy. Diseasefree and overall survival were evaluated by Kaplan-Meier analysis. Univariate and multivariate analyses were performed to evaluate factors predictive of tumorpositive SLNs and disease-free and overall survival. Results: Median thickness of melanoma was 5.6 mm, and patients were followed up for amedian of 50 months. The SLNs were tumor positive in 100 patients (41.7%); 18% of these had additional positive nodes on completion lymphadenectomy. Extremity tumor location (risk ratio, 1.66; 95% confidence interval, 1.24-2.24; P=.001), Clark level (1.95; 1.33-2.87; P=.02), and lymphovascular invasion (1.57; 1.13-2.17; P=.01) were associated with a greater risk of tumor-positive SLNs. The patients with tumor-negative SLNs had significantly better median disease-free survival (46.5 vs 31.0 months; P=.04) and overall survival (55.5 vs 43.0 months; P=.004) compared with patients with tumor-positive SLNs. On multivariate analysis, male sex (risk ratio, 1.59; 95% confidence interval, 1.05-2.50; P=.02), increasing Breslow thickness (1.58; 1.10- 2.30; P=.03), ulceration (1.73; 1.18-2.59; P=.02), and tumor-positive SLNs (1.68; 1.17-2.43; P=.009) were associated with worse overall survival. Conclusion: The SLN biopsy provides useful prognostic information for patients with T4 melanoma. ©2010 American Medical Association. All rights reserved.


Scoggins C.R.,University of Louisville | Martin R.C.G.,University of Louisville | Ross M.I.,University of Texas M. D. Anderson Cancer Center | Edwards M.J.,University of Cincinnati | And 11 more authors.
Annals of Surgical Oncology | Year: 2010

Introduction: Some melanoma patients who undergo sentinel lymph node (SLN) biopsy will have false-negative (FN) results. We sought to determine the factors and outcomes associated with FN SLN biopsy. Methods: Analysis was performed of a prospective multi-institutional study that included patients with melanoma of thickness > 1.0 mm who underwent SLN biopsy. FN results were defined as the proportion of node-positive patients who had a tumor-negative sentinel node biopsy. Kaplan-Meier survival analysis and univariate and multivariate analyses were performed. Results: This analysis included 2,451 patients with median follow-up of 61 months. FN, true-positive (TP), and true-negative (TN) SLN results were found in 59 (10.8%), 486 (19.8%), and 1,906 (77.8%) patients, respectively. On univariate analysis comparing the FN with TP groups, respectively, the following factors were significantly different: age (52.6 vs. 47.6 years, p = 0.004), thickness (mean 2.1 vs. 3.1 mm, p = 0.003), lymphovascular invasion (LVI; 3.7 vs. 13.7%, p = 0.037), and local/in-transit recurrence (LITR; 32.2 vs. 12.4%, p < 0.0001); these factors remained significant on multivariate analysis. Overall 5-year survival was greater in the TN group (86.7%) compared with the TP (62.3%) and FN (51.3%) groups (p < 0.0001); however, there was no significant difference in overall survival comparing the TP and FN groups (p = 0.32). Conclusions: This is the largest study to evaluate FN SLN results in melanoma, with a FN rate of 10.8%. FN results are associated with greater patient age, lower mean thickness, less frequent LVI, and greater risk of LITR. However, survival of patients with FN SLN is not statistically worse than that of patients with TP SLN. © 2009 Society of Surgical Oncology.


Brown R.E.,University of Louisville | Ross M.I.,The Surgical Center | Edwards M.J.,University of Cincinnati | Noyes R.D.,LDS Hospital | And 6 more authors.
Annals of Surgical Oncology | Year: 2010

Background: We hypothesized that metastasis beyond the sentinel lymph nodes (SLN) to the nonsentinel nodes (NSN) is an important predictor of survival. Materials and methods: Analysis was performed of a prospective multi-institutional study that included patients with melanoma ≥1.0 mm in Breslow thickness. All patients underwent SLN biopsy; completion lymphadenectomy was performed for all SLN metastases. Disease-free survival (DFS) and overall survival (OS) were computed by Kaplan-Meier analysis; univariate and multivariate analyses were performed to identify factors associated with differences in survival among groups. Results: A total of 2335 patients were analyzed over a median follow-up of 68 months. We compared 3 groups: SLN negative (n = 1988), SLN-only positive (n = 296), and both SLN and NSN positive (n = 51). The 5-year DFS rates were 85.5, 64.8, and 42.6% for groups 1, 2, and 3, respectively (P < 0.001). The 5-year OS rates were 85.5, 64.9, and 49.4%, respectively (P < 0.001). On univariate analysis, predictors of decreased OS included: SLN metastasis, NSN metastasis, increased total number of positive LN, increased ratio of positive LN to total LN, increased age, male gender, increased Breslow thickness, presence of ulceration, Clark level ≥ IV, and axial primary site (in all cases, P < 0.01). When the total number of positive LN and NSN status were evaluated using multivariate analysis, NSN status remained statistically significant (P < 0.01), while the total number of positive LN and LN ratio did not. Conclusions: NSN melanoma metastasis is an independent prognostic factor for DFS and OS, which is distinct from the number of positive lymph nodes or the lymph node ratio. © 2010 Society of Surgical Oncology.


Lynne Anderson J.,Lakeland Regional Cancer Center
Clinical Journal of Oncology Nursing | Year: 2013

Female sexual dysfunction (FSD) is a common side effect of cancer and cancer treatments. Assessing for sexual dysfunctions in women with cancer is a vital component of helping women to have better, more satisfying sexual experiences. FSD is not widely addressed in most healthcare facilities or by healthcare providers, but it is a topic that all providers should be discussing with their female patients. © Oncology Nursing Society.


PubMed | Lakeland Regional Cancer Center
Type: Journal Article | Journal: Cancers | Year: 2013

Melanoma patients with recurrent disease confined to an extremity can be offered one of two regional therapies that both give high complete response rates. Isolated limb infusion (ILI) is a newer technique performed with catheters and tourniquets that has a reduced potential morbidity, decreased efficacy and does not treat the regional nodal basin. Hyperthermic Isolated Limb Perfusion (HILP) is an open surgical technique that includes removal of the regional nodal basin as part of the surgical procedure. An analysis was performed of the rates of regional nodal disease in this patient population to determine the percentage of patients with stage III metastatic disease to the lymph nodes that would be under treated with the ILI technique. A total of 229 patients underwent a HILP for melanoma with regional lymph node dissection as is our standard between July 1987 and December 2009. Ninty-two of the 229 patients (40%) had metastatic regional nodal disease documented at the time of the HILP procedure. HILP is the only technique that addresses all micrometastatic disease on the extremity.

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