Faculty Bibliography

PURPOSE/OBJECTIVE:Multiple prospective, randomized studies show that breast conservation therapy (BCT) results in survival rates equal to mastectomy (Mx) for patients with early stage breast cancer (ESBC). Nevertheless, BCT remains underused in certain areas of the nation, without clearly definable reasons. Several studies have implicated socioeconomic status as one potential cause for this disparity in BCT usage. We sought to compare BCT rates in the medically indigent versus insured patients, within the same institution. METHODS:Data from 1993 to 2000, collected from the institutional tumor registry and the hospital's claims records, were analyzed for 928 patients with ESBC (Stages 0, I, and II), treated at a single medical center. The same surgeons treated both insured and indigent patients. Patients treated by BCT or Mx were compared for age, race, stage, insurance status, access to a radiation therapy center, surgeon, and year of diagnosis. RESULTS:Patient age, race, surgeon, or insurance status did not significantly affect the rate of mastectomy. Stage I patients (P < 0.001) and those treated after 1995 had higher BCT rates (54.9% in 1993-95 vs. 70.7% in 1996-2000; P < 0.001). Travel distance to a radiation therapy center had no significant impact on BCT rates, except for patients >40 miles distant. CONCLUSIONS:These data refute the hypothesis that socioeconomic status, as reflected by medical insurance, is a determinant of BCT in women with ESBC. Distance of <40 miles to a radiation therapy facility, Stage I disease, and diagnosis after 1995 were factors associated with higher BCT rates.

PURPOSE/OBJECTIVE:The use of partial breast brachytherapy (PBB) after lumpectomy for selected patients with early-stage breast cancer reduces the adjuvant radiotherapy treatment time to <1 week. Despite the advantages of accelerated treatment, maintaining an acceptable cosmetic outcome is important. In a cohort of patients who received low-dose-rate (LDR) or high-dose-rate (HDR) PBB after lumpectomy, the clinical characteristics and treatment parameters were analyzed to identify predictors for an unfavorable cosmetic outcome. METHODS AND MATERIALS/METHODS:Early-stage breast cancer patients with clear resection margins and 0-3 positive lymph nodes were eligible for PBB. Uniform guidelines for target definition and brachytherapy catheter placement were applied. The HDR PBB dose was 34 Gy in 10 fractions within 5 days, and the LDR dose was 45 Gy given at a rate of 50 cGy/h. The end points included incidence of radiation recall reaction, telangiectasias, and cosmetic-altering fibrosis. RESULTS:Between 1995 and 2000, 44 patients with early-stage breast cancer received PBB without adjuvant external beam radiotherapy after lumpectomy (31 HDR PBB, 13 LDR PBB). After a median follow-up of 42 months (range 18-86), all patients remained locally controlled. The overall rate of good/excellent cosmetic outcome was 79.6% overall and 90% with HDR PBB. Radiation recall reactions occurred in 43% of patients (6 of 14) who received adriamycin. LDR PBB and adriamycin were significant predictors for late unfavorable cosmetic changes in univariate analysis (p = 0.003 and p = 0.005, respectively). CONCLUSION/CONCLUSIONS:Although a high rate of local control and good/excellent cosmetic outcome is provided with HDR PBB, the risk of unfavorable cosmetic changes when treated with both LDR PBB and adriamycin is noteworthy. This suggests that HDR PBB is preferred in patients for whom adriamycin is indicated.

BACKGROUND:Virtual reality simulation is effective in training the novice to perform basic laparoscopic skills. METHODS:Using the Minimally Invasive Surgery Training--Virtual Reality (MIST-VR) trainer, 27 honors high school students were tested at the easy level, prospectively randomized to eight training sessions at the easy (group A, n = 14) or medium (group B, n = 13) level, then retested at the easy level. RESULTS:Both groups were statistically similar at baseline. All scores improved significantly (50.1% to 81.3%) over the period of training (p < 0.05). Although the group A scores were significantly better than the group B scores throughout training (p < 0.05), on final testing at the easy level, group B surpassed group A for all the tasks except TransferPlace (p = 0.054). CONCLUSIONS:Virtual simulation is an effective laparoscopic training method for the novice, providing significant improvement in skill levels over a relatively short period. More challenging training seems to predict greater improvement over time and better final skill levels.

Fewer than 5% of all adults will have a palpable thyroid nodule, but this is still a large number of individuals who require evaluation. Although most thyroid nodules are a result of a benign disease process (more than 95%), the possibility of thyroid cancer is always a consideration. Important aspects of history taking with a patient in whom a thyroid nodule has been noted include age, gender, family history of thyroid or endocrine disease, prior low dosage head and neck radiation, recent hoarseness, dysphagia, and symptoms of hypermetabolism. Key features of evaluation by physical examination are the size and location of the thyroid abnormality, the degree of firmness of the nodule, the presence of other nodules in the thyroid, palpable cervical lymph nodes, vocal cord paresis or paralysis, and tachycardia and/or tremor. The major categories of thyroid abnormality in such patients include cysts, adenomas, thyroiditis, and cancer. Although radionuclide scans, ultrasound examination and computer tomography have all been employed in the assessment of thyroid nodules, and thyroid stimulating hormone assay is useful for confirming a euthyroid state, fine needle aspiration biopsy (FNAB) has proved to be the most efficient diagnostic tool. The findings from FNAB allow avoidance of operative treatment for a large portion of these patients with palpable thyroid nodules, but a diagnosis of "follicular neoplasm" on FNAB usually requires operation, despite the fact that many such patients do ultimately prove to have a benign lesion. The extent of operation in patients undergoing surgery will depend on the diagnostic findings before operation, but unilateral thyroid lobectomy is the minimum procedure when surgery is required.

BACKGROUND:We hypothesized that the Minimally Invasive Surgery Trainer (MIST-VR; VP Medical R, London, U.K.) would be as effective as the Yale Laparoscopic Skills Course in improving laparoscopic intracorporeal suturing skills. MATERIALS AND METHODS/METHODS:Each student made six attempts to tie a knot laparoscopically. Students were then randomized to train on the MIST-VR for five sessions (six skills/session) or the Yale Skills for five sessions (three skills/session) over 5 days. On completion of training, all students were evaluated by a test consisting of six attempts to tie a laparoscopic knot. RESULTS:The percentage improvement in knot tying time did not differ significantly in the pelvic trainer group (30 +/- 21%) (from 443 +/- 135 to 311 +/- 137 seconds) and the MIST-VR group (39 +/- 21%) (from 409 +/- 109 to 256 +/- 140 seconds) (P = 0.308). CONCLUSIONS:The MIST-VR is equivalent to the Yale Skills Course for training in the advanced laparoscopic skill of intracorporeal suturing.

Although the expression of heat shock proteins (hsps) can be induced by a variety of stressful stimuli, certain neoplasms, including human intestinal T84, HT-29, and Caco2 adenocarcinoma cell lines, express constitutively high levels even under nonstress conditions. In this study, we examine the functional significance of increased hsp72 in spontaneously differentiating Caco2bbe (C2) cells. The expression of hsp72 in these cells was specifically inhibited by hsp72 antisense transfection. The loss of hsp72 expression did not affect growth rate, contact inhibition, morphological development, or functional differentiation. In contrast, these cells were significantly more sensitive to the injurious effects of oxidants and tumor necrosis factor (TNF) but not doxorubicin. To investigate potential mechanisms of action, a number of steps in the TNF-mediated cell death was measured. Antisense reduction of hsp72 did not alter activation of IkappaB. In contrast, mitochondrial cytochrome c release and activation of caspase 9 were significantly delayed in hsp72 antisense cells stimulated either with TNF or monochloramine. In conclusion, high endogenous expression of hsp72 by intestinal adenocarcinoma cells appears to confer selective survival advantage but does not affect their growth and differentiation.

Polyps and polypoid lesion of the small intestine present a major challenge to the surgeon. In contrast to similar lesions in the large intestine, small bowel polyps present late in their course and are difficult to diagnose. Small bowel tumors produce vague symptoms and screening tests are poor. Most of these polyps are found at autopsy or during exploration for another cause. In this article, the authors outline the problem as well as discuss the diagnosis and treatment options.