Publications (19)48.78 Total impact
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Chapter: Molecular and surgical advances in pediatric tumors
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ABSTRACT: Before the 1950s, less than a third of children with Wilms’ tumor, rhabdomyosarcoma (RMS), or neuroblastoma survived. Because of the rarity of these tumors, no single institution could collect enough patients for randomized trials. In the United States, the pediatric cancer study groups joined forces to create the National Wilms’ Tumor Study Group (NWTS) in 1969 and the Intergroup Rhabdomyosarcoma Study Committee (IRS) in 1972. Protocols to treat neuroblastoma have been developed by both the Children’s Cancer Group (CCG) and the Pediatric Oncology Group (POG). The multinational Société Internationale d’Oncologie Pédiatrique (SIOP) studies form a European counterpart to these groups. The protocols used by these groups that employ multimodality therapy including multiagent chemotherapy, have led to the current long-term survival approaching 40% in neuroblastoma [1], 70% in RMS [2], and 95% in Wilms’ tumor [3]. Each group continues to modify risk-adapted therapy based on identified prognostic factors. Recent identifications of molecular level differences may allow for further stratification of risk and adaptation of therapy to maximize survival while minimizing therapy.07/2011: pages 51-69; -
Article: Location of pulmonary metastasis in pediatric osteosarcoma is predictive of outcome.
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ABSTRACT: The 3-year survival after pulmonary metastasectomy for osteosarcoma (OS) is approximately 30%. Resection of metastatic disease can prolong life in pediatric patients with OS. Our objective is to assess the outcome of pediatric patients with pulmonary metastases located centrally as compared with peripheral lesions. A retrospective review of patients 0 to 21 years old with a diagnosis of OS with pulmonary metastases on computed tomographic scan between 1985 and 2000 was completed. Demographics, metastasis location, survival, morbidity, and mortality were evaluated. Of 115 patients who had pulmonary metastasis secondary to OS, there were 96 wedge resections and 13 lobectomy/pneumonectomies in 84 patients. The morbidity of wedge resection was 9% and lobectomy/pneumonectomy was 8%. There were no deaths from surgery. The median survival for patients undergoing lobectomy compared with wedge resection was 0.61 and 1.14 years, respectively, but did not reach statistical significance. The median overall survival for the entire cohort was 0.75 years. The median overall survival after initial detection of metastatic disease was 1.06 years among the patients with peripheral disease, compared with 0.38 years in patients with central disease (P = .008). Patients with central pulmonary metastases in OS have a very poor prognosis, even after operative treatment, compared with those with peripheral disease. Patients with central lesions may benefit from other nonsurgical treatment options.Journal of Pediatric Surgery 07/2011; 46(7):1333-7. · 1.45 Impact Factor -
Article: Results of the Intergroup Rhabdomyosarcoma Study Group D9602 protocol, using vincristine and dactinomycin with or without cyclophosphamide and radiation therapy, for newly diagnosed patients with low-risk embryonal rhabdomyosarcoma: a report from the Soft Tissue Sarcoma Committee of the Children's Oncology Group.
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ABSTRACT: Patients with localized, grossly resected, or gross residual (orbital only) embryonal rhabdomyosarcoma (ERMS) had 5-year failure-free survival (FFS) rates of 83% and overall survival rates of 95% on Intergroup Rhabdomyosarcoma Study Group (IRSG) protocols III/IV. IRSG D9602 protocol (1997 to 2004) objectives were to decrease toxicity in similar patients by reducing radiotherapy (RT) doses and eliminating cyclophosphamide for the lowest-risk patients. Subgroup A patients (lowest risk, with ERMS, stage 1 group I/IIA, stage 1 group III orbit, stage 2 group I) received vincristine plus dactinomycin (VA). Subgroup B patients (ERMS, stage 1 group IIB/C, stage I group III nonorbit, stage 2 group II, stage 3 group I/II) received VA plus cyclophosphamide. Patients in group II/III received RT. Compared with IRS-IV, doses were reduced from 41.4 to 36 Gy for stage 1 group IIA patients and from 50 or 59 to 45 Gy for group III orbit patients. Estimated 5-year FFS rates were 89% (95% CI, 84% to 92%) for subgroup A patients (n = 264) and 85% (95% CI, 74%, 91%) for subgroup B patients (n = 78); median follow-up: 5.1 years. Estimated 5-year FFS rates were 81% (95% CI, 68% to 90%) for patients with stage 1 group IIA tumors (n = 62) and 86% (95% CI, 76% to 92%) for patients with group III orbit tumors (n = 77). Five-year FFS and OS rates were similar to those observed in comparable IRS-III patients, including patients receiving reduced RT doses, but were lower than in comparable IRS-IV patients receiving VA plus cyclophosphamide. Five-year FFS rates were similar among subgroups A and B patients.Journal of Clinical Oncology 02/2011; 29(10):1312-8. · 18.37 Impact Factor -
Article: Outcomes of truncal vascular injuries in children.
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ABSTRACT: Pediatric truncal vascular injuries occur infrequently and have a reported mortality rate of 30% to 50%. This report examines the demographics, mechanisms of injury, associated trauma, and outcome of patients presenting for the past 10 years at a single institution with truncal vascular injuries. A retrospective review (1997-2006) of a pediatric trauma registry at a single institution was undertaken. Seventy-five truncal vascular injuries occurred in 57 patients (age, 12 +/- 3 years); the injury mechanisms were penetrating in 37%. Concomitant injuries occurred with 76%, 62%, and 43% of abdominal, thoracic, and neck vascular injuries, respectively. Nonvascular complications occurred more frequently in patients with abdominal vascular injuries who were hemodynamically unstable on presentation. All patients with thoracic vascular injuries presenting with hemodynamic instability died. In patients with neck vascular injuries, 1 of 2 patients who were hemodynamically unstable died, compared to 1 of 12 patients who died in those who presented hemodynamically stable. Overall survival was 75%. Survival and complications of pediatric truncal vascular injury are related to hemodynamic status at the time of presentation. Associated injuries are higher with trauma involving the abdomen.Journal of Pediatric Surgery 10/2009; 44(10):1958-64. · 1.45 Impact Factor -
Article: Melanoma growth and tumorigenicity in models of microgravity.
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ABSTRACT: Spaceflight involves numerous biological stressors that could affect long-term cancer incidence and tumor behavior. Ground-based models of microgravity can be used to investigate in vitro and in vivo tumor growth as a preparation for later work in space. The incidence of tumor growth and carcinogenesis in microgravity is as yet unknown. Hence, we investigated the effects of modeled microgravity on tumor growth and tumorigenicity using ground-based in vitro and in vivo models. Murine B16-F10 melanoma cells were cultured in a tissue culture flask (FL) and in a rotating-wall vessel bioreactor (BIO) designed by NASA to simulate some aspects of microgravity. We then measured cell growth, melanin production, and apoptosis. After 48 h of cultures in FL and BIO, cells were inoculated subcutaneously in C57BL/6 mice, syngeneic hosts for B16-F10 tumor cells. Tumor sizes were then measured every other day. BIO cultures had 50% decreases in growth when compared with FL cultures while demonstrating an inversely proportional increase in doubling time. Melanin production (a marker of differentiation) increased at 24 and 48 h in BIO. Flow cytometry analysis demonstrated that there was an increase in the percentage of apoptotic cells in the BIO when compared with that in the FL. When BIO-cultured melanoma cells were inoculated subcutaneously in mice, there was a significant increase in tumorigenicity as compared with FL-cultured cells. Our results indicate that simulated microgravity may have altered the tumor cell characteristics and enhanced the invasive property. It is possible that the microgravity analogue culture environment may have selected highly tumorigenic cells for survival despite the decreased overall growth in the microgravity analogue.Aviation Space and Environmental Medicine 12/2006; 77(11):1113-6. · 0.88 Impact Factor -
Article: Outcome after surgical resection of recurrent rhabdomyosarcoma.
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ABSTRACT: Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children. Patients with localized disease have a cure rate of 50% to 90%; however, there has been little evidence that aggressive surgical resection for recurrent disease is of benefit. We reviewed our experience with aggressive surgical resection for recurrent RMS. A retrospective review of the records for patients with RMS was performed. Data extracted included tumor site, histology, initial therapy, time to recurrence, treatment, and outcomes. From 1991 to 2002, 122 patients with RMS (3 months-18 years) were treated at the MD Anderson Cancer Center. Of 32 patients with recurrent RMS, 19 had surgical resection and 13 had biopsy only or no resection. The common primary sites included extremity (12), genitourinary nonbladder/prostate (7), and retroperitoneal/trunk (7). In the resection group, 33 operations were performed with 5 (15%) major complications and no deaths. Seventeen (52%) of these procedures (7 pelvic, 5 thoracic, 3 amputations, and 2 cranial) were classified as aggressive. After a mean follow-up period of 4.9 years, 7 patients (37%) had no evidence of disease, 8 (42%) died, and 4 were lost to follow-up. There was no correlation between survival and the type of resection. In the no-resection group only, 1 (8%) of 13 patients survived. Despite morbidity, aggressive surgical resection is warranted to improve survival in patients with recurrent RMS.Journal of Pediatric Surgery 05/2006; 41(4):633-8; discussion 633-8. · 1.45 Impact Factor -
Article: Long-term survival after aggressive resection of pulmonary metastases among children and adolescents with osteosarcoma.
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ABSTRACT: Although survival without resection of pulmonary metastases from osteosarcoma is unlikely, not all surgeons agree on an aggressive surgical approach. We have taken an approach to attempt surgical resection if at all feasible regardless of number of metastases and disease-free interval (DFI). This study presents information on long-term follow-up after this aggressive approach to resection. A single-institution retrospective cohort study of osteosarcoma patients younger than 21 years with pulmonary metastases, limited to the contemporary chemotherapeutic period (1980-2000), was conducted. In 137 patients, synchronous (23.4%) or metachronous (76.6%) pulmonary nodules were identified. The median follow-up was 2.0 years (5 days to 20.1 years) for all patients. Overall survival among patients who had pulmonary nodules was 40.2% and 22.6% at 3 and 5 years, respectively. Ninety-nine patients underwent attempted pulmonary metastasectomy (mean survival, 33.6 months; 95% confidence interval, 25.1-42.1) and 38 patients did not (mean survival, 10.1 months; 95% confidence interval, 6.5-13.6; P < .001, t test). Characteristics that were associated with an increased likelihood of 5-year overall survival after pulmonary resection were primary tumor necrosis greater than 98% after neoadjuvant chemotherapy (P < .05) and DFI before developing lung metastases more than 1 year (P < .001). No statistically significant difference in overall survival or disease-free survival was found based on the number of pulmonary metastases resected. Characteristics including primary tumor size, site, or extension; chemotherapy; early vs late metastases; unilateral vs bilateral metastases; and resection margins did not significantly affect survival. Most patient and tumor characteristics commonly used by surgeons to determine utility of resection of pulmonary metastases among patients with osteosarcoma are not associated with outcome. Biology of the particular tumor (response to preoperative chemotherapy, measured by tumor necrosis percentage, and DFI), as opposed to tumor burden, appears to influence survival more significantly. We would advocate considering repeat pulmonary resection for patients with recurrent metastases from osteosarcoma.Journal of Pediatric Surgery 02/2006; 41(1):194-9. · 1.45 Impact Factor -
Article: Treatment issues in pediatric gastric adenocarcinoma.
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ABSTRACT: Gastric adenocarcinoma is a rare diagnosis in children. Modern treatment includes chemotherapy, radiotherapy, and surgery and has evolved over the past decade. The authors report a case of an 8-year-old girl with gastric adenocarcinoma. The case will be followed by a brief discussion of the presentation, current management guidelines, and prognosis of this rare pediatric entity.Journal of Pediatric Surgery 09/2004; 39(8):e8-10. · 1.45 Impact Factor -
Article: Results of treatment of fifty-six patients with localized retroperitoneal and pelvic rhabdomyosarcoma: a report from The Intergroup Rhabdomyosarcoma Study-IV, 1991-1997.
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ABSTRACT: We reviewed 56 IRS-IV patients with localized rhabdomyosarcoma [RMS] of the retroperitoneum/pelvis to assess outcome and prognostic factors, including the value of initially excising >or=50% of the tumor (debulking) before chemotherapy. Patients had embryonal RMS [N=38], alveolar RMS [N = 7], RMS not otherwise specified [NOS, N = 7], or undifferentiated sarcoma [N = 4]. Fifteen patients were debulked; 41 patients were biopsied. All received VAC; most received radiotherapy. Estimated 5-year failure-free survival [FFS] and overall survival rates were 70 and 75%, respectively. FFS rates were better for patients <10 years old and those with embryonal RMS compared to alveolar RMS/undifferentiated sarcoma. After adjusting for age and histological differences, FFS was better for patients whose tumor was debulked prior to beginning therapy [P = 0.02]. These results are superior to those of previous protocols for patients with RMS of the retroperitoneum/pelvis. Initial excision of >or=50% of the tumor may be associated with increased FFS.Pediatric Blood & Cancer 07/2004; 42(7):618-25. · 1.89 Impact Factor -
Article: Surgical management of gynecologic rhabdomyosarcoma.
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ABSTRACT: The multidisciplinary treatment strategy for rhabdomyosarcoma (RMS) of the female gynecologic system is evidence of the progress made in the management of many childhood cancers. Previously, initial radical surgery (eg, complete vaginectomy, hysterectomy, and pelvic exenteration) and less effective single-agent chemotherapeutic agents were used with suboptimal results. Over the past 30 years, there has been an increase in overall survival with gynecologic RMS and a significant decrease in the hysterectomy and vaginectomy rates. The usual recommended treatment strategy for gynecologic RMS is initial biopsy to establish the diagnosis, followed by neoadjuvant chemotherapy. The specific chemotherapy regimen is selected based on the risk stratification of the particular patient, and this will often allow a more conservative surgical approach to be used, with the goal of complete tumor resection. Radiation therapy is considered before definitive surgical resection with minimal response to chemotherapy or after definitive surgical resection with positive margins. Recurrent or persistent RMS, including RMS of the female gynecologic system, represents a very aggressive disease with poor outcome. In these cases, aggressive management, including experimental chemotherapy agents and organ-sacrificing surgery, is often indicated to afford any chance of long-term survival. Continued enrollment of a high proportion of these patients into ongoing prospective clinical trials should allow the outcomes to continue to improve.Current Treatment Options in Oncology 05/2004; 5(2):109-18. · 2.68 Impact Factor -
Article: Complications in pediatric surgical oncology.
Journal of the American College of Surgeons 12/2003; 197(5):832-7. · 4.55 Impact Factor -
Article: Prognostic factors and surgical treatment guidelines for children with rhabdomyosarcoma of the perineum or anus: a report of Intergroup Rhabdomyosarcoma Studies I through IV, 1972 through 1997.
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ABSTRACT: Rhabdomyosarcoma (RMS) of the perineum or anus is a rare sarcoma of childhood with a poor prognosis. This study reviews the Intergroup Rhabdomyosarcoma Study Group (IRSG) studies I through IV to identify determinants of patient outcome and to refine surgical treatment guidelines. From 1972 through 1997, 71 eligible patients were treated and studied. The median patient age was 6 years. The majority (64%) were at an advanced stage (clinical group III and IV) at initial presentation and 50% had positive regional lymph node (LN) involvement. The 5-year failure-free survival rate (FFS) for all patients was 45% and the overall survival rate (OS) was 49%. Characteristics that were associated with significantly improved survival rate were primary tumor size less than 5 cm, lower (less advanced) clinical group and stage, negative regional lymph node status, and age less than 10 years. When the extent of disease was controlled for in multivariate analysis, only age less than 10 predicted an improved outcome. The 5-year overall survival rate for patients less than 10 years of age was 71% versus 20% in older patients (P <.001). Histology (alveolar versus embryonal) and primary site (perineal versus anal) did not significantly affect outcome. Because of the high incidence of regional LN involvement in these patients, a strategy of routine surgical evaluation of ilioinguinal lymph nodes in all patients with perineal or anal RMS is recommended.Journal of Pediatric Surgery 03/2003; 38(3):347-53. · 1.45 Impact Factor -
Article: Advances in the surgical management of sarcomas in children.
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ABSTRACT: The management of children with soft tissue sarcomas has changed and survival has improved markedly during the past three decades. This is, in large part, due to the multi-modal approach to pediatric malignancies; decreasing the need for radical surgical procedures, while improving survival and decreasing morbidity. The management of patients with rhabdomyosarcomas (RMS) and nonrhabdomyosarcomas soft-tissue sarcomas (NRSTS) as well as neurofibromatosis and related tumors is best accomplished in an organized and systematic fashion with the surgeon involved early in the planning, diagnostic, and treatment phases. Cooperative trials for rhabdomyosarcoma, as part of the Intergroup Rhabdomyosarcoma Study, have led to improved survival with less radical surgery. Ongoing trials of the Soft Tissue Sarcoma Group of the Children's Oncology Group are under way. Since these tumors are rare, cooperative trials are essential to answering the remaining questions regarding extent of surgery and adjuvant therapy.The American Journal of Surgery 01/2003; 184(6):484-91. · 2.78 Impact Factor -
Article: Neurofibromatosis: implications for the general surgeon.
Journal of the American College of Surgeons 11/2002; 195(4):553-63. · 4.55 Impact Factor -
Article: Surgical Principles for Children/Adolescents With Newly Diagnosed Rhabdomyosarcoma: A Report from the Soft Tissue Sarcoma Committee of the Children's Oncology Group.
Sarcoma 01/2002; 6(4):111-22. -
Article: Synovial sarcoma in children: surgical lessons from a single institution and review of the literature
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ABSTRACT: BACKGROUND:Synovial sarcomas are malignant high-grade, soft-tissue neoplasms that account for 7% to 8% of all malignant soft-tissue tumors and are the most common nonrhabdomyosarcoma soft-tissue sarcomas in pediatric patients.STUDY DESIGN:A retrospective review of the records of children younger than 17 years with synovial sarcoma treated at the University of Texas MD Anderson Cancer Center from 1966 until 1999 was undertaken. Primary site, tumor size, tumor margins, surgical treatment, adjuvant therapy, local and distant recurrence, and survival were recorded for 42 patients. Overall survival (OS) and progression-free survival (PFS) rates were calculated by the Kaplan-Meier method. The PFS and OS comparisons were performed using the log-rank test.RESULTS:Forty-four patients were identified, but two patients were excluded because of incomplete records. The median followup duration for the 42 patients was 8.8 years (range 0.2 to 22.4 years). The 5-year progression-free survival and overall survival rates were 75.6% and 87.7%, respectively. Eleven patients were dead and four others had progressed but were alive without evidence of disease after further therapy. Intergroup Rhabdomyosarcoma Study (IRS) grouping and tumor invasiveness were found to be significant prognostic indicators (p < 0.01 and p = 0.02, respectively). Patients with initial gross total resection (IRS Groups I and II) and noninvasive tumors (T1) were most likely to have prolonged PFS and OS. Patients with small tumors (< 5 cm) (p = 0.09) had better PFS and OS. Adjuvant radiation therapy appeared to be of benefit, and chemotherapy did not seem to impact PFS or OS. Tumors ≥ 5 cm are associated with increased risk of local recurrence and distant metastases.CONCLUSIONS:Complete resection with clear, yet not necessarily large, margins remains the treatment of choice for synovial sarcoma in children. Adjuvant radiation therapy should possibly be considered in patients with clear margins (IRS Group I) and in patients with microscopic residual tumor (IRS Group II). Chemotherapy did not seem to impact PFS or OS. Lymph nodes should be evaluated for local regional disease.Journal of the American College of Surgeons. -
Article: Malignant fibrous histiocytoma in children
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ABSTRACT: Because malignant fibrous histiocytoma (MFH) rarely occurs in children, the natural history of this tumor and prognostic factors predictive of outcome have not been well described. The charts of all pediatric patients with MFH seen at M.D. Anderson Cancer Center were reviewed with respect presentation, treatment, and outcome, in an attempt to determine prognostic factors that are predictive of survival. Forty-four pediatric patients were identified. Extremities were the most common tumor site (31 of 44 patients). Five patients presented with angiomatoid histology subtype; all subsequently survived. The estimated 5-year survival rate was 85% for clinical group I patients, 87% for clinical group II, 53% for clinical group III, and 0% for clinical group IV. The estimated 5-year survival rate was 95% for patients with tumors of less than 5 cm in diameter and 45% for those with larger tumors. Overall, the estimated 5-year survival rate was 71%. Significant prognostic factors found to affect survival (by univariate analysis) were clinical group, tumor size, and recurrence. Gender and race were not significant predictors. The use of chemotherapy and radiation was not found to improve the chance of survival, but this most likely reflected the more frequent use of adjuvant therapy in patients with unresectable or high-grade tumors. Although adequate surgical resection continues to be the most effective treatment, investigation of adjuvant chemotherapy and radiation therapy on protocol is warranted.Journal of Pediatric Surgery. -
Article: An evidence-based review of a Lentinula edodes mushroom extract as complementary therapy in the surgical oncology patient.
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ABSTRACT: The purpose of this review is to present the currently published evidence regarding the use, efficacy, potential mechanisms of action, and results of published clinical trials regarding the use of a Lentinula edodes mushroom-derived extract (active hexose correlated compound) as complementary therapy in patients with cancer. The authors explore the current preclinical and clinical evidence as it relates to this topic and its potential use in the surgical oncology patient. There has been a growing interest in stimulation of the immune system in trauma, cancer, and surgical patients in general. Little, however, has been written about some-of the supplements in widely used in Japan and China, but relatively unheard of in the United States.Journal of Parenteral and Enteral Nutrition 35(4):449-58. · 3.29 Impact Factor -
Article: Acute hemodynamic decompensation following patent ductus arteriosus ligation in premature infants.
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ABSTRACT: Patent ductus arteriosus (PDA) ligation can lead to postoperative hemodynamic instability requiring inotropic support, termed hemodynamic decompensation. The purpose of this study was to prospectively determine the incidence, predictors, and clinical impact of hemodynamic decompensation after PDA ligation in preterm infants. All infants undergoing PDA ligation were eligible for this prospective cohort study. After undergoing ligation, patients were followed until 30 days after successful extubation, discharge from the NICU, or death. Data collection included perinatal and preoperative clinical information, operative details, postoperative course, and outcome. Ninety-six preterm infants were enrolled and underwent PDA ligation. Hemodynamic decompensation occurred in 27 patients (28%). Overall in-hospital mortality rate was 18%. Mortality was significantly higher among infants that developed hemodynamic decompensation (33% vs 11%, p = .012). Hemodynamic decompensation was associated with an adjusted odds ratio (OR) for death of 3.1 (95% confidence interval: 1.0-9.5, p = .05). Lower estimated gestational age, lower corrected age, and higher rate of preoperative mechanical ventilation were significant predictors of hemodynamic decompensation. Hemodynamic decompensation occurred in 28% of patients after PDA ligation, resulting in a significantly higher mortality. Younger patients requiring higher ventilator support are most likely to develop hemodynamic decompensation.Journal of Investigative Surgery 21(3):133-8. · 1.09 Impact Factor
Top co-authors
Top Journals
Institutions
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2006
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University of Texas Health Science Center at Houston
- Department of Surgery
Houston, TX, USA
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2002–2006
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University of Texas MD Anderson Cancer Center
- Department of Surgery
Houston, TX, USA
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2003
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University of Texas Medical School
- Department of Surgery
Houston, TX, USA
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