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 20,210 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Acquired TEF is a rare complication that can occur from a variety of causes. The most common etiology of nonmalignant TEF is as a complication of intubation with cuff-related tracheal injury. Most patients present with increased secretions, pneumonia, and evidence of aspiration of gastric contents while the patient is on mechanical ventilation. When diagnosed after extubation, the most frequent sign of TEF is coughing after swallowing. A high index of suspicion is required in patients at risk for developing a TEF. The diagnostic evaluation is by bronchoscopy and esophagoscopy. When the diagnosis has been made, the immediate goal should be to minimize tracheobronchial soilage by placing the cuff of a tracheostomy tube distal to the fistula. Reflux of gastric contents is diminished by placement of a gastrostomy tube, and adequate nutrition is facilitated by inserting a jejunostomy tube. Surgical correction is required because spontaneous closure is rare, but surgery should be postponed until the patient is weaned from mechanical ventilation because positive pressure ventilation after tracheal repair carries an increased risk of anastomotic dehiscence and restenosis. An anterior cervical collar incision can be used for most cases of post-intubation TEFs. The esophagus should be closed in two layers over a nasogastric tube and buttressed with a pedicled strap muscle flap. If the tracheal defect is small, primary repair can be employed. In most cases, however, the best results can be achieved with tracheal resection and reconstruction. The patient should be extubated at the completion of the case, if possible. With this strategy, as first described by Grillo and colleagues [27], single-stage repair can be performed safely and with a high success rate. Malignant TEFs cannot be cured because of the underlying incurable disease process. As with nonmalignant TEFs, the principal complications are tracheo-bronchial contamination and poor nutrition. Without prompt palliation, death occurs rapidly, with a mean survival time of between 1 and 6 weeks in patients who are treated with supportive care alone. The most common primary tumor causing malignant TEF is esophageal carcinoma. The other frequent cause is lung cancer. Patients present with signs and symptoms typical of TEF, including coughing after swallowing. Diagnosis is made by barium esophagography, and the location and size of the fistula is determined by bronchoscopy and esophagoscopy. Treatment must correct the two problems of airway contamination and poor nutrition. The most effective treatments are esophageal bypass and esophageal stenting. Bypass is demonstrated to resolve respiratory soilage and allow fairly normal swallowing, but it should be reserved for patients who can tolerate a major operation. Stenting can be offered to nearly all patients regardless of their physiologic condition. Stenting also limits aspiration and allows swallowing. Esophageal exclusion is rarely indicated in the current era of familiarity with stenting techniques. Direct fistula closure and fistula resection do not yield satisfactory results. Radiation therapy and chemotherapy combined might offer a survival benefit compared with supportive care alone. The complication of TEF secondary to malignancy is a devastating problem that carries a bleak prognosis, but when it is performed promptly after the diagnosis of a malignant TEF, esophageal bypass or stenting improves survival and quality of life for these unfortunate patients.
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PMID:Tracheoesophageal fistula. 1275 13

Recently, we showed by gene-expression profiling that the molecular program established in a human primary breast carcinoma is highly preserved in its distant metastases. According to the predominant model of metastasis, the capacity of a primary tumor to metastasize is acquired only rarely and late in tumorigenesis. Our findings challenge this common theory and imply that the metastatic nature of 'poor prognosis profile' breast carcinomas is an inherent feature, and not reserved to advantageous subpopulations.
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PMID:Hard-wired genotype in metastatic breast cancer. 1515 10

This report reviews the roles of conventional radiography, computerized axial tomography, and nuclear bone scanning in the diagnosis, staging, follow-up, and management of prostatic cancer. Computed tomography (CT) offers great promise for the better definition of the extent of the primary tumor of prostatic cancer. It contributes positively to the planning of radiation therapy portals in the treatment of localized disease. By means of bipedal lymphangiography and CT scanning, pelvic and periaortic lymphadenopathy may be detected more often than was previously possible without staging pelvic lymphadenectomy, which can be reserved for the discovery of microscopic disease. Soft-tissue metastases that are located deep within the body cavities can now be measured accurately by CT scanning, as can their response to therapy. Skeletal metastases, the most common variety in prostatic cancer, can be detected with a high degree of sensitivity by nuclear bone imaging. Serial bone scans are remarkably useful in following the response of osseous deposits to treatment, as well as in detecting relapsing disease. The management of malignant obstruction of the ureters has been greatly facilitated by the application of angiographic techniques to percutaneous nephrostomy performed under fluoroscopic control.
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PMID:The role of radiography, computed tomography and bone scanning in prostatic cancer. 1561 24

Hemangioma is the most common primary tumor of the liver and its diagnosis has become increasingly prevalent. Most of these lesions are asymptomatic and are managed conservatively. Large hemangiomas are often symptomatic and reports of surgical intervention are becoming increasingly frequent. We present our experience, over the last 14 years, with diagnosis and management of 249 liver hemangiomas, with special attention to a conservative strategy. Clinical presentation, diagnosis, treatment, and long-term outcome are analyzed. Of 249 patients, 77 (30.9%) were symptomatic, usually with right abdominal upper quadrant pain. Diagnosis was based on a radiologic algorithm according to the size and characteristics of the tumor; diagnosis by this method was not possible in only one case (0.4 %). Giant hemangiomas (>4 cm) were found in 68 patients (27.3%) and in 16 were larger than 10 cm. Eight patients (3.2%) underwent surgical treatment; indications were incapacitating pain in 6, diagnostic doubt in 1, and stomach compression in 1. No postoperative complications or mortality were observed in this series. Patients who did not undergo surgery (n = 241) did not present any complication related to the hemangioma during long-term follow-up (mean = 78 months). Hemangioma is a benign course disease with easy diagnosis and management. We propose a conservative approach for these lesions. Resection, which can be safely performed, should be reserved for the rare situations such as untreatable pain, diagnostic uncertainty, or compression of adjacent organs.
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PMID:Management of hepatic hemangiomas: a 14-year experience. 1598 44

Breast cancer is presenting earlier, and treatment is becoming less invasive. We review two recent changes in the approach to management. Sentinel lymph node biopsy is a minimally invasive technique to identify the first draining lymph node in direct communication with the primary tumor; it enables "selective lymphadenectomy." Axillary lymph node dissection is reserved as a therapeutic procedure only for proven node positive patients. The concept has been validated, the techniques have been optimized, and randomized controlled trials have confirmed lower morbidity without compromising regional control compared with conventional treatment. The procedure is considered by many as the standard of care for staging the axilla in early breast cancer, although several unanswered questions remain. Adequate training and experience in the technique are vital to ensure high sentinel node identification and low false negative rates. Intraoperative radiotherapy is an attractive concept that enables delivery of single fraction radiotherapy in the operating room immediately after resection of the primary tumor. It is convenient for patients and appears effective in pilot studies. Partial breast irradiation to the index quadrant has been practiced for many years in the form o brachytherapy. Trials are under way comparing intraoperative radiotherapy with conventional external bea irradiation. Intra-operative radiotherapy should not be used outside of clinical trials until the results of the current randomized trials are known.
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PMID:New approaches in breast cancer management: sentinel node biopsy and intraoperative radiotherapy. 1646 72

For many types of cancers, adjuvant chemotherapy showed a moderate but significant benefit in terms of survival improvement. In sarcomas, the situation is contrasted and depends on the histological, molecular sub-types, as well as the topography of the tumor. Soft tissue sarcomas are in general poorly chemosensitive tumors and while adjuvant chemotherapy was found effective to delay relapses or to decrease the local relapses, it failed to yield a significant benefit with regard to overall survival. Sub-groups analysis indicate a significant lengthening of survival for the soft tissues sarcomas of the extremities. Neoadjuvant chemotherapy of the soft tissues sarcomas starts should be reserved to rhabdomyosarcomas and the bone sarcomas like the osteosarcomas and the Ewing's sarcomas of bones are more susceptible to chemotherapy, which is an integral part of the treatment with a preoperative chemotherapy and, following surgery of the primary tumor, an adjuvant chemotherapy adapted to the histological response to the neoadjuvant treatment.
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PMID:[Adjuvant chemotherapy in the treatment of sarcomas]. 1656 12

Recurrent pleomorphic adenoma of the parotid gland is a challenging surgical experience. Resection of such recurrences is associated with an increased risk of facial nerve injury and a higher incidence of recurrent disease. Resection of the primary tumor with a cuff of normal tissue around it during the primary surgical resection lowers the incidence of such metastases, but even with them, metastases still occur. Surgery of such metastases requires high surgical expertise as well as intra-operative decision-making. Intraoperative monitoring of the facial nerve may be of help during these surgical interventions, but the surgeon need not rely on the monitor only, but identify the nerve based on its well known anatomy and use the monitor as another surgical tool for safe removal of the tumor. Resection of the facial nerve or some of its branches is usually not necessary, but if the nerve is the only site making the resection an incomplete one - then the nerve should sometimes be resected, after sufficient effort has been made to preserve it. In these cases, the nerve should be reconstructed with a cable graft (mainly greater auricular or sural) when possible. Radiotherapy is reserved for patients that had multiple recurrences or had massive tumor spillage during their surgical procedure of the recurrent tumor.
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PMID:[Recurrent pleomorphic adenoma of the parotid gland]. 1735 79

The presence of distant metastases usually implies disease not amenable to cure through surgical resection. In such cases, chemotherapy is the mainstay of treatment, with surgery or radiation reserved for palliative measures. However, metastases limited to the lung may be resected with resultant prolonged patient survival compared to unresectable, widely disseminated metastases. Isolated pulmonary metastases should therefore not be considered untreatable. In this review, we discuss the pathophysiology of pulmonary metastases. We outline prognostic factors associated with metastases, and propose criteria to help select patients for metastasectomy. Surgical approaches, including various open techniques and video-assisted thoracoscopy, are covered. Surgical issues, including the need for unilateral versus bilateral exploration, the extent of resection to achieve cure, the need for lymph node dissection, and the benefit of repeat operations, are discussed. Finally, we review some of the more common tumors that metastasize to the lungs, and the role of metastasectomy in their treatment. Resection of pulmonary metastases confers a survival benefit to a select group of patients so long as the primary tumor is controlled, metastases are limited to the lungs, the patient can tolerate the operation from a cardiopulmonary standpoint, and the metastases are completely resected.
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PMID:Surgical treatment of metastatic disease to the lung. 1839 99

Surgery is the cornerstone of treatment for women with nonmetastatic breast cancer. In contrast, standard treatment for patients with Stage IV disease includes chemotherapy and radiation, with surgery usually reserved for local tumor-related complications. Little is known about the predictive factors associated with primary tumor resection for Stage IV breast cancer. We conducted a retrospective, population-based, case-control study using the 1988-2003 Surveillance Epidemiology and End Results (SEER) data. Using multiple logistic regression, we identified patient and tumor characteristics from among SEER region, age at diagnosis, year of diagnosis, marital status, race, Hispanic ethnicity, tumor grade, and size that were associated with surgical resection of the primary breast tumor (compared with no surgical resection) among women with stage IV breast cancer. Adjusted odds ratios and 95% confidence intervals are reported. Of 10,017 patients, 4,836 (48%) underwent surgical resection of the primary breast tumor. Patients in the Northeast and Midwest and patients presenting with two or more primary breast tumors were more likely to have surgical resection. Patients who were older, diagnosed after 1992, unmarried, black, and whose tumors were >5 cm, inflammatory, of unknown size, indeterminate grade, or unknown progesterone status were less likely to have had surgical resection of the primary tumor. Several patient and tumor characteristics were significantly associated with surgical resection of the primary breast tumor in Stage IV disease. Further study of the surgery decision-making process is recommended.
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PMID:Patient and tumor characteristics associated with primary tumor resection in women with Stage IV breast cancer: analysis of 1988-2003 SEER data. 1900 55

The widespread availability of novel primary treatment approaches against oropharyngeal cancers has provided several potentially curative surgical and nonsurgical treatment options for patients, generating both hope and controversy. As treatment is usually curative in intent, management considerations must include consideration of primary tumor and nodal disease control as well as long-term toxicities and functional outcomes. Anatomical and functional organ preservation (speech and deglutition) remains of paramount importance to patients with oropharyngeal cancer and the physicians involved in their care, accounting for the growing popularity of chemoradiotherapy and transoral surgical techniques for this indication. These novel approaches have greatly diminished the role of open surgery as initial therapy for oropharyngeal cancers. Open surgery which is often reserved for salvage on relapse, may still be an appropriate therapy for certain early stage primary lesions. The growing treatment armamentarium requires careful consideration for optimal individualized care. The identification of oncogenic human papillomavirus as a predictive and prognostic marker in patients with oropharyngeal cancer has great potential to further optimize the choice of treatment. In this review, novel primary therapies against oropharyngeal squamous cell carcinoma are presented in the context of anatomical, quality of life, and emerging biological considerations.
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PMID:Current trends in initial management of oropharyngeal cancer: the declining use of open surgery. 1986 22


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