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ABSTRACT: Background: CC49 is a monoclonal antibody directed against a pancarcinoma antigen (TAG-72) expressed by colorectal cancers. The use of
murine CC49 in radioimmunoguided surgery (RIGS) was problematic because of the human anti-mouse antibodies (HAMA) generated.
This study was designed to assess the clearance, safety, and effectiveness of localization of a complimentarity determining
region (CDR)-grafted humanized domain-deleted antitumor CC49 antibody (HuCC49°CH2).
Methods: After thyroid blockade, 1 mg of HuCC49°CH2 radiolabeled with 2 mCi of iodine-125 was administered. All patients subsequently underwent traditional exploration followed
by a survey with the gamma-detecting probe. In five patients, exploration was performed 10 to 24 days after injection, when
precordial counts were sufficiently low (<30 counts per 2 seconds [cp2s]). Traditionally suggestive and probe-positive tissue
was biopsied or excised and examined for the presence of carcinoma, when considered appropriate by the operating surgeon.
Serum was assessed for HAMA.
Results: Seventeen sites were identified as suggestive of carcinoma on traditional exploration and 21 by RIGS. Of these, pathologic
correlation was obtained in 15. The sensitivity of RIGS was 92%, and the positive predictive value was 100%. None of the patients
expressed significant HAMA.
Conclusions: This initial study indicates that the HuCC49°CH2 monoclonal antibody, when used with RIGS, is safe and sensitive in detecting recurrent intra-abdominal colon cancer.
Annals of Surgical Oncology 04/2012; 11(2):197-202. · 4.17 Impact Factor
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ABSTRACT: 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.
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 chi(2) analyses to determine the degree of adherence with four NQF measures among three institution types: academic, community, and teaching affiliate.
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 > or =1 cm in size in 79-85% of institutions. Tamoxifen was administered to 79-82% of those patients with hormone receptor-positive cancers.
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.
Annals of Surgical Oncology 03/2010; 17(8):1989-94. · 4.17 Impact Factor
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Stephen P Povoski,
Johannes O Olsen,
Donn C Young,
Johannah Clarke, William E Burak,
Michael J Walker,
William E Carson,
Lisa D Yee,
Doreen M Agnese,
Rodney V Pozderac,
Nathan C Hall,
William B Farrar
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ABSTRACT: Multiple injection routes, including intradermal (ID), intraparenchymal (IP), and subareolar (SA), are used for 99mTc-sulfur colloid administration for sentinel lymph node (SLN) mapping and biopsy in breast cancer. The aim of this study was to compare localization by ID, IP, and SA injection routes based on preoperative lymphoscintigraphy and intraoperative identification.
Four hundred prospectively randomized breast cancers underwent SLN mapping and biopsy.
Preoperative lymphoscintigraphy demonstrated localization to the axilla in 126/133 (95%) ID, 82/132 (62%) IP, and 96/133 (72%) SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.081 IP vs. SA), with a mean duration of preoperative lymphoscintigraphy of 139 +/- 18 minutes. Mean time to first localization when localization was demonstrated on preoperative lymphoscintigraphy was 8 +/- 14 minutes for ID, 53 +/- 49 for IP, and 22 +/- 29 for SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.003 IP vs. SA). Intraoperative identification of a SLN at the time of SLN biopsy was successful in 133/133 (100%) ID, 121/134 (90%) IP, and 126/133 (95%) SA (P < 0.001 ID vs IP; P = 0.014 ID vs. SA; P = 0.168 IP vs. SA), with a mean time from injection of 99mTc-sulfur colloid to start of SLN biopsy of 288 +/- 71 minutes. Mean intraoperative time to harvest the first SLN was 9 +/- 4 minutes for ID, 13 +/- 6 for IP, and 12 +/- 6 for SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.410 IP vs. SA).
The ID injection route demonstrated a significantly greater frequency of localization, decreased time to first localization on preoperative lymphoscintigraphy, and decreased time to harvest the first SLN. This represents the first prospective randomized clinical trial to confirm superiority of the ID route for administration of 99mTc-sulfur colloid during SLN mapping and biopsy in breast cancer.
Annals of Surgical Oncology 12/2006; 13(11):1412-21. · 4.17 Impact Factor
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Katherine E Posther,
Linda M McCall,
Peter W Blumencranz, William E Burak,
Peter D Beitsch,
Nora M Hansen,
Monica Morrow,
Lee G Wilke,
James E Herndon,
Kelly K Hunt,
Armando E Giuliano
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ABSTRACT: Marked variations in sentinel lymph node dissection (SLND) technique have been identified, and definitive qualifications for SLND performance remain controversial. Based on previous reports and expert opinion, we predicted that 20 to 30 cases of SLND with axillary lymph node dissection (ALND) would enable surgeons to identify sentinel lymph nodes (SLN).
In 1999, the American College of Surgeons Oncology Group initiated a prospective trial, Z0010, to evaluate micrometastatic disease in the SLN and bone marrow of women with early-stage breast cancer. Eligible patients included women with biopsy-proven T1/T2 breast cancer and clinically negative lymph nodes who were candidates for lumpectomy and SLND.
Participating surgeons were required to document 20 to 30 SLNDs followed by immediate ALND with failure rates less than 15%. Prior fellowship or residency training in SLND provided exemption from skill requirements. Data for 5237 subjects and 198 surgeons were available for analysis.
Surgeons from academic (48.4%), community (28.6%), or teaching-affiliated (19.8%) institutions qualified with 30 SLND + ALND cases (64.6%), 20 cases (22.2%), or exemption (13.1%). Participants used blue dye + radiocolloid in 79.4%, blue dye alone in 14.8%, and radiocolloid alone in 5.7% of cases, achieving a 98.7% SLN identification rate. Patient factors associated with increased SLND failure included increased body mass index and age, whereas tumor location, stage, and histology, presence of nodal metastases, and number of positive nodes were not. Surgeon accrual of fewer than 50 patients was associated with increased SLND failure; however, SLND technique, specific skill qualification, and institution type were not.
Using a standard skill requirement, surgeons from a variety of institutions achieved an acceptably low SLND failure rate in the setting of a large multicenter trial, validating the incorporation of SLND into clinical practice.
Annals of Surgery 11/2005; 242(4):593-9; discussion 599-602. · 7.49 Impact Factor
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Current Problems in Surgery 12/2004; 41(11):882-935. · 2.33 Impact Factor
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ABSTRACT: This study sought to determine the differences in presentation and treatment of young women (< or =40 years of age) with breast cancer.
A prospective database was analyzed for differences in presentation and care in breast cancer patients < or =40 and >40 years of age.
The study group consisted of 1685 women. Younger women were more likely to present with a palpable mass, have estrogen receptor/progesterone receptor (ER/PR)-negative tumors, and have more advanced disease at presentation. Although there was no difference in breast conservation rates, younger women were more likely to have postmastectomy reconstruction. Younger women were more likely to receive chemotherapy, even with node-negative tumors less than 1 cm in diameter (37% vs. 13%, P = 0.01).
The presentation of younger women with breast cancer differs from that of older women. Although the surgical management is similar, adjuvant therapy differs, with younger women more likely to be treated with chemotherapy.
The American Journal of Surgery 10/2004; 188(4):437-9. · 2.78 Impact Factor
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ABSTRACT: CC49 is a monoclonal antibody directed against a pancarcinoma antigen (TAG-72) expressed by colorectal cancers. The use of murine CC49 in radioimmunoguided surgery (RIGS) was problematic because of the human anti-mouse antibodies (HAMA) generated. This study was designed to assess the clearance, safety, and effectiveness of localization of a complimentarity determining region (CDR)-grafted humanized domain-deleted antitumor CC49 antibody (HuCC49DeltaCH2).
After thyroid blockade, 1 mg of HuCC49DeltaCH2 radiolabeled with 2 mCi of iodine-125 was administered. All patients subsequently underwent traditional exploration followed by a survey with the gamma-detecting probe. In five patients, exploration was performed 10 to 24 days after injection, when precordial counts were sufficiently low (<30 counts per 2 seconds [cp2s]). Traditionally suggestive and probe-positive tissue was biopsied or excised and examined for the presence of carcinoma, when considered appropriate by the operating surgeon. Serum was assessed for HAMA.
Seventeen sites were identified as suggestive of carcinoma on traditional exploration and 21 by RIGS. Of these, pathologic correlation was obtained in 15. The sensitivity of RIGS was 92%, and the positive predictive value was 100%. None of the patients expressed significant HAMA.
This initial study indicates that the HuCC49DeltaCH2 monoclonal antibody, when used with RIGS, is safe and sensitive in detecting recurrent intra-abdominal colon cancer.
Annals of Surgical Oncology 02/2004; 11(2):197-202. · 4.17 Impact Factor
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ABSTRACT: Radiofrequency ablation (RFA) is gaining acceptance as a treatment modality for several tumor types. However, its use in patients with breast carcinoma remains investigational. The current study was undertaken to determine the feasibility of treating small breast malignancies with RFA and to evaluate the postablation magnetic resonance imaging scans (MRI) and histologic findings.
Patients with core-needle biopsy-proven invasive carcinoma (< 2 cm in greatest dimension) underwent ultrasound-guided RFA under local anesthesia. Surgical excision was undertaken 1-3 weeks later. All patients had breast MRI scans performed before ablation and repeated within 24 hours of surgery.
Ten patients completed the treatment and experienced minimal or no discomfort. The mean tumor size was 1.2 cm (range, 0.8-1.6 cm). The mean time required for ablation was 13.8 minutes (range, 7-21 minutes). There were no treatment-related complications other than minimal breast ecchymosis. A pre-RFA MRI scan showed enhancing tumors in 9 of 10 (90%) patients. A post-RFA MRI scan revealed no residual lesion enhancement in 8 of these 9 patients (89%), and the zone of ablation was demonstrated in all patients. One patient had residual enhancement anteriorly consistent with residual tumor, which was confirmed histologically. Evaluation of the remaining ablated lesions revealed a spectrum of changes ranging from no residual tumor to coagulation necrosis with recognizable malignant cells. Immunostains for cytokeratin 8/18 were negative in these recognizable malignant cells.
RFA of small breast malignancies can be performed under local anesthesia in an office-based setting. A postablation MRI scan appears to predict histologic findings, although tumor viability needs to be assessed in a long-term study.
Cancer 11/2003; 98(7):1369-76. · 4.77 Impact Factor
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ABSTRACT: Older women with breast carcinoma are less likely than younger women to receive adjuvant chemotherapy. The authors hypothesized that after controlling for confounders (i.e., variables related to both age and chemotherapy use) and effect modifiers (i.e., variables that have a significant interaction with age), age would become a less significant factor for predicting adjuvant chemotherapy use.
Data on 480 women with localized breast carcinoma were entered into the National Comprehensive Cancer Network database at The Ohio State University Medical Center. Women were divided into 3 groups: women age < 50 years (n = 143 [30%]), women ages 50-65 years (n = 216 [45%]), and women age > 65 years (n = 121 [25%]). Chi-square and Wilcoxon rank sum tests were used for univariate analyses of the variables of interest, and logistic regression was used for multivariate analyses.
After adjustment for confounders (stage, tumor size, progesterone receptor status, and lymph node involvement) and effect modifiers (namely, estrogen receptor [ER] status), the odds of not receiving chemotherapy for women ages 50-65 years and women age > 65 years with ER-positive breast carcinoma were approximately 6 (odds ratio [OR], 6.4; 95% confidence interval [CI], 3.1-13.3; P < 0.001) and 62 (OR, 62.4; 95% CI, 21.8-178.7; P < 0.001) times greater, respectively, than the odds for women age < 50 years. Women ages 50-65 years with ER-negative breast carcinoma were not significantly different from women age < 50 years with respect to chemotherapy use (OR, 1.9; 95% CI, 0.5-7.3; P = 0.374). However, the odds of not receiving chemotherapy for women age > 65 years with ER-negative breast carcinoma were 7 times (OR, 6.7; 95% CI, 1.5-30.6; P = 0.013) greater than the odds for women age < 50 years.
The results of the current study indicate that based on older age alone, women are less likely to receive adjuvant chemotherapy. In addition, the results suggest that age bias may contribute to undertreatment and lack of accrual of older women into clinical trials.
Cancer 10/2003; 98(6):1141-9. · 4.77 Impact Factor
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ABSTRACT: Consideration of sentinel lymph node biopsy (SLNB) is recommended for thin melanomas with poor prognostic features; however, few metastases are identified. The purpose of this study was to assess the cost effectiveness of SLNB in this population.
The prospective melanoma database was reviewed to identify patients with melanomas <1.2 mm thick who had undergone SLNB. Physician and hospital charges were collected from the appropriate billing department.
A total of 138 patients were identified over an 8-year period (1994-2002). Two patients with positive SLNs were identified (1.4%), one with a melanoma <1 mm thick. Patient charges for SLNB ranged from $10,096 to $15,223 US dollars, compared with $1000 to $1740 US dollars for wide excision as an outpatient. Using these charges, the cost to identify a single positive SLN would be between $696,600 and $1,051,100 US dollars. The cost for wide excision would be between $69,000 and $120,100 US dollars. Assuming that all patients with a positive SLN would die of melanoma, the cost per life saved would be $627,000 to $931,000 US dollars.
The cost of performing SLNB in this population is great and only a small number will have disease identified that will alter treatment. These data call into question the appropriateness of SLNB for thin melanomas.
Surgery 10/2003; 134(4):542-7; discussion 547-8. · 3.10 Impact Factor
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ABSTRACT: This study evaluates the safety, efficacy, and patient acceptance of a vacuum-assisted, hand-held biopsy device (Mammatome) in the percutaneous removal of breast masses using ultrasound guidance.
A multicenter, nonrandomized study evaluated 216 women with low-risk palpable lesions. Lesions 1.5 to 3.0 cm in size were removed using an 8-gauge probe. Those lesions <1.5 cm were removed with the 11-gauge probe. Follow-up evaluation was performed at 10 days and 6 months after biopsy.
A total of 127 patients had biopsies using the 8-gauge probe, and 89 patients had biopsies using the 11-gauge probe. At 6-month follow-up, 98% of the lesions remained nonpalpable, 73% with no ultrasonographically visible evidence of the original lesion. Most complications were mild and anticipated. Most patients (98%) were satisfied with incision appearance, and 92% of patients would recommend the procedure to others.
Percutaneous removal of palpable benign breast masses using the Mammotome system is feasible and safe, and yields high patient satisfaction. The results at 6 months after biopsy demonstrated the effectiveness of benign lesion removal, with correlative clinical data demonstrating lack of palpability and no need for additional procedures. Continuing evaluation of long-term efficacy is ongoing.
The American Journal of Surgery 10/2003; 186(4):362-7. · 2.78 Impact Factor
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William E Burak
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ABSTRACT: The conflicting results of randomized studies have led to confusion over the proper management of patients with esophageal adenocarcinoma. Although there is no firm evidence that neoadjuvant chemoradiation improves survival, because of the shortcomings of these trials, this method of treatment is practiced at many centers. Without the results of another multiinstitutional randomized trial, the true answer may never be known.
The American Journal of Surgery 10/2003; 186(3):296-300. · 2.78 Impact Factor
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ABSTRACT: Sentinel lymph node biopsy (SLNB) is gaining acceptance as an alternative to axillary lymph node dissection. The purpose of this study was to determine the frequency and pattern of disease recurrence after SLNB.
Two-hundred twenty-two consecutive patients undergoing SLNB from April 6, 1998, to October 27, 1999, and who were >or=24 months out from their procedure were identified from a prospectively maintained database. Retrospective chart review and data analysis were performed to identify variables predictive of recurrence.
The median patient follow-up was 32 months (range, 24-43 months). A total of 159 patients (72%) were sentinel lymph node (SLN) negative and had no further axillary treatment. Five of these patients (3.1%) developed a recurrence (one local and four distant), with no isolated regional (axillary) recurrences. Sixty-three patients (28%) were SLN positive and underwent a subsequent axillary lymph node dissection. Six of these patients (9.5%) developed a recurrence (three local, one regional, and two distant). Pathologic tumor size (P <.001), lymphovascular invasion (P =.018), and a positive SLN (P =.048) were all statistically significantly associated with disease recurrence.
With a minimum follow-up of 24 months, patients with a negative SLN and no subsequent axillary treatment demonstrate a low frequency of disease recurrence. This supports the use of SLNB as the sole axillary staging procedure in SLN-negative patients.
Annals of Surgical Oncology 05/2003; 10(4):376-80. · 4.17 Impact Factor
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ABSTRACT: This study evaluates the safety, efficacy, and patient acceptance of a vacuum-assisted, hand-held biopsy device (Mammotome) in percutaneous removal of breast masses using ultrasound guidance.
A multicenter, nonrandomized study evaluated 124 women with low-risk palpable lesions. Lesions <or=1.5 cm and those >1.5 cm but <or=3.0 cm were removed using 1-gauge or 8-gauge probes, respectively. Follow-up evaluation was performed at 10 days postbiopsy.
The 8-guage probe was used to obtain biopsies from 75 patients, and the 11-gauge was used for 49 patients. Complete removal of the imaged lesion was similar between groups (99% 8-gauge versus 96% 11-gauge). Most complications were mild and anticipated. Most patients (97%) were satisfied with incision appearance, and 98% of patients would recommend the procedure to others.
Percutaneous removal of palpable benign breast masses using the Mammotome system is feasible, safe, and yields high patient satisfaction. Long-term efficacy is being evaluated in the ongoing study.
The American Journal of Surgery 10/2002; 184(4):332-6. · 2.78 Impact Factor
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ABSTRACT: This study was designed to compare the postoperative morbidity and socioeconomic impact of sentinel lymph node biopsy (SLNB) with axillary lymph node dissection (ALND) in patients with early stage breast cancer.
A prospective, nonrandomized, controlled study was designed to include patients who underwent breast conservation surgery and SLNB +/- ALND. Group A consisted of patients who had a negative SLNB and did not go on to completion ALND. Group B consisted of patients who underwent a SLNB followed by a completion ALND because either (1) their sentinel node contained cancer or (2) they were within the validation phase of our institution's sentinel lymph node protocol. Patients were evaluated with a questionnaire and underwent a standardized physical examination to determine arm circumference.
Data were obtained from 96 patients with a mean follow-up period of 15 months (range 8 to 29). Significant differences were seen in subjective measurements of arm complaints and arm numbness (P <0.001), with fewer complaints reported in group A. The difference in mid-bicep and antecubital fossa circumferences was significant when comparing the ratio of the procedure arm with the nonprocedure arm and when subtracting the nonprocedure arm from the procedure arm (P <0.003 and P <0.016, respectively) in favor of group A. Axillary surgery was performed as an outpatient procedure in 88% of group A patients, compared with 15% in group B (P <0.001). Furthermore, 71% of group A patients returned to "normal activity" in less than 4 days, in comparison with 7% of group B (P <0.001).
SLNB results in less postoperative morbidity in terms of subjective arm complaints and mid-arm swelling. Expeditious return to work or normal activity after SLNB has potentially significant socioeconomic consequences.
The American Journal of Surgery 02/2002; 183(1):23-7. · 2.78 Impact Factor
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ABSTRACT: Background. CC83, a second-generation monoclonal antibody (MAb) against tumor-associated glycoprotein TAG-72 has been shown to have a higher affinity constant than the anti-TAG MAbs CC49 and B72.3. Clinical studies have shown the effectiveness of both CC49 and B72.3 radiolabeled MAbs in localizing colorectal carcinoma with a hand-held gamma-detecting probe during operation. This current study was designed to assess the safety and tumor-binding ability of radiolabeled CC83 MAb in this setting.Methods. Seventeen patients with recurrent colorectal cancer underwent intravenous injection with CC83 Mab radiolabeled with iodine 125 (2.0 mCi 125I/0.2 mg CC83 MAb). Exploratory laparotomy was carried out 21 to 28 days after injection, consisting of a thorough traditional exploration followed by a survey with a hand-held gamma-detecting probe. All traditionally suspicious and probe-positive tissue was either biopsied or resected and subsequently examined for the presence of carcinoma by using routine histochemical staining techniques.Results. Thirty-two sites were identified as suspicious for cancer by traditional surgical exploration and 39 through intraoperative survey with a hand-held gamma-detecting probe in the seventeen patients completing the study. Biopsy or resection yielded 27 tumor sites when tissue was evaluated by using routine hematoxylin-eosin staining. All 27 tumor sites were localized by the radiolabeled CC83 MAb, whereas 12 additional sites were RIGS positive but hematoxylin-eosin negative, resulting in a sensitivity and positive predictive value of 100% and 69%, respectively. Traditional methods of exploration detected 23 of 27 tumor sites (85% sensitivity), and nine false-positive sites were recorded (72% positive predictive value). Occult tumor was found by using CC83 MAb in four (15%) of 27 sites, altering the surgical plan in three patients.Conclusions. This initial study indicates that CC83 MAb, when used with RIGS, is safe and sensitive in detecting recurrent intraabdominal colorectal cancer.
Surgery 08/1995; · 3.10 Impact Factor
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ABSTRACT: Lymphatic mapping and sentinel lymph node biopsy is an established technique for the staging and treatment of melanoma. The success of lymphatic mapping in this realm has broadened its application to other solid neoplasms. This update reviews the status of sentinel lymph node biopsy in its most widely cited applications.
Seminal manuscripts on lymphatic mapping in melanoma, breast, colon, vulvar, cervical, lung, gastric, and head and neck cancers are reviewed.
Studies suggest that the application of lymphatic mapping as a staging tool in breast cancer and melanoma is justified when applied by trained surgeons. Additional validation is necessary before sentinel node biopsy is advocated in gynecologic, colon, lung, and head and neck cancer.
As in breast cancer and melanoma, validation of the sentinel node concept in other solid tumors must occur in institutions other than those in which the technique is being developed before it is generally applied to other neoplasms.
Cancer control: journal of the Moffitt Cancer Center 9(3):189-202.
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The Breast Journal 9(6):501-2. · 1.64 Impact Factor
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ABSTRACT: We determined the effect of positron emission tomography (PET) on surgical decision-making in patients with metastatic or recurrent colorectal cancer.
A total of 114 patients with advanced colorectal cancer were imaged with computed tomography (CT) and PET scans. The PET and CT scans were independently interpreted before surgery and recorded.
Forty-two of the 114 patients had resectable disease on the basis of CT. PET altered therapy in 17 (40%) of these 42 patients on the basis of the following results: extrahepatic disease (n = 9), bilobar involvement (n = 3), thoracic involvement (n = 5), retroperitoneal lymphadenopathy (n = 2), bone involvement (n = 1), and supraclavicular disease (n = 1). In 25 patients with liver metastases only, PET found additional disease in 18 (72%), extrahepatic disease in 11, chest disease in 13, retroperitoneal lymphadenopathy in 4, and bone disease in 3. In five patients, both scans underestimated small-volume peritoneal metastases discovered at laparotomy.
PET altered therapy in 40% of patients. In patients with isolated liver involvement, 72% had more extensive disease that precluded surgical resection. PET scans should be used in the management of patients with recurrent colorectal cancer who are being considered for potentially curative surgery.
Annals of Surgical Oncology 10(1):59-64. · 4.17 Impact Factor
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ABSTRACT: With the improvements in imaging techniques that have allowed the earlier detection of smaller breast cancers and the desire for improvements in cosmetic outcome, a number of minimally invasive techniques for the treatment of early stage breast cancers are being investigated. Ablative therapies, including laser ablation, focused ultrasound, microwave ablation, radiofrequency ablation, and cryoablation, have been described. All of these techniques have shown promise in the treatment of small cancers of the breast; however, additional research is needed to determine the efficacy of these techniques when they are used as the sole therapy and to determine the long-term local recurrence rates and survival associated with these treatment strategies.
The Cancer Journal 11(1):77-82. · 3.26 Impact Factor
