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Combination chemotherapy versus single-agent therapy as first- and second-line treatment in metastatic breast cancer: a prospective randomized trial prostate cancer 85 year old man purchase generic proscar canada. Comparison of chemotherapy with chemohormonal therapy as first-line therapy for metastatic mens health online store order genuine proscar on-line, hormone-sensitive breast cancer: an Eastern Cooperative Oncology Group study prostate cancer 34 discount proscar 5 mg mastercard. Chemohormonal therapy in advanced carcinoma of the breast: Cancer and Leukemia Group B Protocol 8081 prostate forum order 5 mg proscar amex. Interrupted versus continuous chemotherapy in patients with metastatic breast cancer. A randomized trial of six versus twelve courses of chemotherapy in metastatic carcinoma of the breast. A randomized trial of two dose levels of cyclophosphamide, methotrexate, and fluorouracil chemotherapy for patients with metastatic breast cancer. Dose-response relationship of epirubicin in the treatment of postmenopausal patients with metastatic breast cancer: a randomized study of epirubicin at four different dose levels performed by the Danish Breast Cancer Cooperative Group. Multicenter, randomized comparative study of two doses of paclitaxel in patients with metastatic breast cancer. Randomized trial of 3-hour versus 24-hour infusion of high-dose paclitaxel in patients with metastatic or locally advanced breast cancer: National Surgical Adjuvant Breast and Bowel Project protocol B-26. High-dose combination alkylating agents with bone marrow support as initial treatment for metastatic breast cancer. High-dose chemotherapy with reinfusion of purged autologous bone marrow following dose-intense induction as initial therapy for metastatic breast cancer. Prognostic factors for prolonged progression-free survival with high dose autologous stem cell support for breast cancer in North America. Prognostic and predictive factors for patients with metastatic breast cancer undergoing aggressive induction therapy followed by high-dose chemotherapy with autologous stem-cell support. Factors correlated with progression-free survival after high-dose chemotherapy and hematopoietic stem cell transplantation for metastatic breast cancer. Conventional-dose chemotherapy compared with high dose-chemotherapy plus autologous hematopoietic stem-cell transplantation for metastatic breast cancer. Conventional- vs high-dose therapy for metastatic breast cancer: comparison of Cancer and Leukemia Group B and Blood and Marrow Transplant Registry patients. Editorial: high-dose chemotherapy plus autologous bone marrow transplantation for metastatic breast cancer. Efficacy of pamidronate in reducing skeletal complications in patients with breast cancer and lytic bone metastases. Quality-of-life benefit in chemotherapy patients treated with epoietin alfa is independent of disease response or tumor type: results from a prospective community oncology study. Recommendations for the use of antiemetics: evidence-based, clinical practice guidelines. The era of diagnosis with less extensive cancers has ushered in less extensive total mastectomies, including "skin sparing" with an incision only around the areola. Presently, the typical patient has many choices, not only regarding the cancer management but also regarding multiple surgical options after mastectomy. The patient then faces postmastectomy appearance and the need, in most women, for an external prosthesis to restore appearance and weight balance. Then foam rubber forms were manufactured with holes in the back for metal weights to add stability and gravity. It is very rare, but possible, to require custom manufacturing of the form for irregular mastectomy defects. The external prosthesis is completely concealed in a bra with an adjustable built-in pocket specially constructed to accommodate it. Wearing the weighted prosthesis should help the body maintain its posture and balance and may prevent back and neck strain. With the concern that the prosthesis could become dislodged, even with such a specially fitted bra or swimsuit, adherent forms have now become popular. Using a variety of surgical adhesives, the form adheres to the chest wall or to a backing on the skin of the chest wall, so that the form can be removed every night while the backing can remain for a week or more. In retrospective studies, 1,2 the differences among those opting for breast reconstruction, those wearing external prostheses, and those doing neither were explored.

Role of circumferential margin involvement in the local recurrence of rectal cancer prostate 3 times normal size order generic proscar on line. An evaluation of postoperative follow-up tests in colon cancer patients treated for cure prostate cancer brachytherapy order online proscar. Primary mucinous adenocarcinomas and signet-ring cell carcinomas of colon and rectum primary androgen hormone buy proscar 5mg low price. Molecular characteristics of poorly differentiated adenocarcinoma and signet-ring-cell carcinoma of colorectum prostate cancer lung metastasis cheap 5mg proscar with mastercard. Clinicopathological and genetic characteristics of mucinous carcinomas in the colorectum. Genetic instability of cancer cells is proportional to their degree of aneuploidy. A multivariate analysis of pathologic prognostic indicators in large bowel cancer. Prognostic significance in patients with rectal carcinomaa long term prospective study. Preoperative carcinoembryonic antigen predicts outcomes in node-negative colon cancer patients: a multivariate analysis of 572 patients. Preoperative carcinoembryonic antigen is related to tumour stage and long-term survival in colorectal cancer. Rectal cancer: factors influencing the development of local recurrence after radical anterior resection. Characterisation of tumour infiltrating lymphocytes and correlations with immunological surface molecules in colorectal cancer. Thymidylate synthase level as the main predictive parameter for sensitivity to 5-fluorouracil, but not for folate-based thymidylate synthase inhibitors, in 13 nonselected colon cancer cell lines. Mutated p53 gene is an independent adverse predictor of survival in colon carcinoma. Blood group-related carbohydrate antigen expression in malignant and premalignant colonic neoplasms. Prognostic value of the histochemical expression of helix pomatia agglutinin in advanced colorectal cancer. Expression of autocrine motility factor receptor in colorectal cancer as a predictor for disease recurrence. Association between high levels of ornithine decarboxylase activity and favorable prognosis in human colorectal carcinoma. Involvement of carbohydrate antigen sialyl Lewis(x) in colorectal cancer metastasis. Transanal excision of large sessile villous adenomas using an endorectal traction flap. For debate: Can we safely delay or avoid prophylctic colectomy in familial adenomatous polyposis Colectomy with ileorectal anastomosis for familial adenomatous polyposis: the risk of rectal cancer. Quality of life after prophylactic colectomy and illeorectal anastomosis in patients with familial adenomatous polyposis. Factors affecting the risk of rectal cancer following rectum-preserving surgery in patients with familial adenomatous polyposis. Long term functional outcome and quality of life after stapled restorative proctocolectomy. Results after restorative proctocolectomy and ileal pouch anal anastomosis in patients with familial adenomatous polyposis and coexisting colorectal cancer. Combined molecular and clinical approaches for the identification of families with familial adenomatous polyposis coli. Choice of prophylactic surgery for the large bowel component of familial adenomatous polyposis. Prophylactic colectomy in patients with hereditary nonpolyposis in colorectal cancer. Intraoperative ultrasonography in detection of hepatic metastases from colorectal cancer.

Regardless of their site of origin prostate 5lx new chapter proscar 5 mg on line, most paragangliomas are extremely vascular and tend to bleed profusely when manipulated prostate cancer therapy purchase proscar 5 mg. The jugulotympanic tumors extend into the skull prostate zoloft best proscar 5mg, the eustachian tubes prostate 5x order discount proscar online, and the normal cracks and furrows of the ear space. If the tumor originates in the hypotympanicum or on the jugular bulb, it often can be seen through the tympanic membrane. A bluish red mass behind the membrane or a polyp in the external ear canal can be but the surface of an extensive paraganglioma, and a casual biopsy or myringotomy can lead to troublesome bleeding. The jugulotympanic paragangliomas often initially create a sense of fullness in the ear, followed by a conductive hearing loss and pulsatile tinnitus. Destruction of the temporal bone can lead to facial nerve weakness, vertigo, deafness, and intracranial complications such as cerebrospinal fluid leak and meningitis. When a tumor occurs in the jugular bulb area, its otologic manifestations often precede vagal nerve signs. Paragangliomas of the vagus nerve, on the other hand, almost always create vocal cord paralysis before otologic symptoms and signs occur. When the tumors are located high on the nerve, they tend to displace the internal carotid artery anteriorly. The arteriographic appearance is, therefore, different from that of carotid body paragangliomas, which generally cause splaying of the external and internal carotid arteries (. When discovered, they present as a discolored, submucosal mass that is atypical in appearance and is often confused with other tumors, especially neuroendocrine carcinoma. Most commonly, carotid body paragangliomas present as painless masses located deep to the anterior border of the sternocleidomastoid muscle in the upper or midneck. These are generally slow growing and often have been obvious for years before diagnosis. These facts are important in determining treatment philosophy, especially in older, asymptomatic patients. They begin in the arterial adventitia, usually at or around the bifurcation of the internal and external carotid arteries. Because these tumors generally develop from the medial aspect of the great vessels, the arteries generally are displaced laterally. This typical appearance of splayed and lateralized vessels distinguishes the carotid body tumors radiographically from vagal nerve paragangliomas. As these neoplasms become larger, they can occupy the parapharyngeal space, actually presenting as a bulge in the tonsil area, and encroachment into this area can produce dysphagia. Imaging should delineate bone destruction and complete tumor, intracranial and extracranial. With proper enhancement techniques, one or both of these images plus clinical evaluation can provide sufficient information to plan treatment of most paragangliomas. This point is relevant to overall management strategy; if radiation therapy is the planned treatment, the radiation oncologist must be comfortable enough with the diagnosis to proceed without a biopsy. Open biopsy becomes necessary when the diagnosis is not achieved by these other means. Invasive arteriography is valuable in preoperative preparation because it provides a picture of contralateral vascular crossover and because it allows tumor embolization to be done before contemplated surgery. Paragangliomas are usually very vascular, and when surgery is planned, intraluminal embolization of the main arterial supply and the tumor bed is helpful for safe and less morbid removal of large tumors. The continued concern for the purity of the commercial blood supply is such that surgeons should avoid transfusion whenever possible, and preoperative embolization can be extremely helpful in pursuing this goal. This technique has its most impressive impact in the removal of larger carotid body and jugular bulb tumors and is probably unnecessary for most small tumors. The techniques of embolization are beyond the scope of this chapter, and the reader is referred to the literature on the subject; it must be emphasized, however, that use of this technology carries significant risks and should be undertaken only by an experienced interventional radiology team. Finally, embolization of paragangliomas is only an adjunct to surgery and should not be considered primary treatment for these highly vascular tumors, no matter how successful the devascularization. If embolization is not followed promptly by tumor removal, undesirable collateral circulation and vascular shunting can develop, ultimately complicating an already challenging surgical process. In fact, the sooner the surgery follows the embolization, the more effective the hemostasis will be during surgery. If surgery is not to be the treatment of choice, then embolization should probably not be done. Traditionally, the mainstay of treatment has been surgical removal, 158,159 but repeated series of cases treated by radiation therapy have demonstrated its effectiveness in achieving local control of these tumors.

Factors that predict the likelihood of response to subsequent chemotherapy include the interval between completion of induction and relapse mens health life generic proscar 5mg mastercard, the extent of tumor regression achieved with the induction regimen mens health questionnaire purchase proscar online pills, and the composition of the induction program man health wire purchase proscar with mastercard. Activity of Combination Chemotherapy Regimens at Relapse For patients who relapse early prostate cancer 5k run walk discount proscar 5mg amex, both the regimen used for second-line and the induction regimen may be important in determining the likelihood of a secondary response. More dose-intensive therapy with a weekly regimen has been reported to produce a 30% 1-year survival rate in patients with good performance status in sensitive relapse. The likelihood of a secondary response may be better in patients who have not previously been treated with a platinum agent. A resection rate of 82% was possible in this selected group, and ten patients (36%) had mixed elements histologically. We believe it is important to verify these findings in other patients who are prospectively identified by specific selection criteria before recommending such an approach. Patients are at greatest risk of dying during the first 24 months after diagnosis; this risk declines between years 2 and 3 and is further reduced beyond the third year. In the Surveillance, Epidemiology, and End Results database, overall survival at 2, 3, and 5 years was 11. Late relapse occurs in approximately 10% of patients who are free of disease at 5 years. Overall, the relative risk of a second primary tumor in survivors beyond 2 years is increased by 3. The cumulative risk of a second lung cancer was 32% at 12 years and continued to increase beyond that time point. Effect of Treatment on Survival in Small Cell Lung Cancer According to Extent of Disease Long-term survivors are also at increased risk for noncancer-related morbidity. In a French study of patients surviving beyond 30 months, treatment-related sequelae included neurologic impairment in 13% of the patients, pulmonary fibrosis in 18%, and cardiac disorders in 10%. In a Danish analysis of patients surviving 5 years or longer, there was a sixfold increase risk of death from nonneoplastic causes, particularly cardiovascular and pulmonary diseases. At 2 years after diagnosis no more than 5% of these patients remain alive, and the survival rate at 5 years is only 1%. There is significant heterogeneity among patients in their capacity to tolerate aggressive therapy, and optimal management requires therapy that is tailored to the tolerance of the individual patient. It is estimated that approximately 1000 cases are diagnosed in the United States annually. Mixed tumors, which include a variety of cell types, may occur more frequently, and deletions of chromosome 3p may be less common with extrapulmonary tumors. There appears to be a sex predilection based on the primary site: Most of the small cell carcinomas of the head and neck region, esophagus, and bladder are found in male subjects. With the exception of primary tumors arising in the cervix in which a younger age group is affected, the majority of patients are middle-aged or older. A history of tobacco use is common, particularly in tumors that occur in the head and neck region and the esophagus, but there is not as strong an association with smoking as there is with pulmonary small cell carcinoma. Paraneoplastic syndromes due to the ectopic production of adrenocorticotropic and antidiuretic hormones also occur with extrapulmonary small cell cancer, and there is at least one case report in which humorally mediated hypercalcemia was identified. Merkel-cell carcinoma is a distinct entity that is primarily found in the skin and can be distinguished by certain immunocytochemical characteristics. Extrapulmonary small cell carcinomas can disseminate widely, and the recommended staging studies are similar for pulmonary small cell carcinoma. Limited disease is defined as tumor confined to the organ of origin and the local regional nodes that are encompassable within a radiation protal. In a series of 71 patients from the Mayo Clinic, 76% of the tumors were localized at diagnosis. In many respects, natural history and response to treatment for small cell carcinoma are similar for both pulmonary and extrapulmonary sites.

Advances in laparoscopic surgery have led to recommendations for laparoscopy as an alternative to laparotomy man health doctor purchase cheapest proscar. However mens health 30 day challenge purchase proscar 5 mg line, if the patient has focal disease prostate cancer urination order proscar on line amex, it may be missed at second-look laparoscopy because of technical reasons prostate cancer medications buy 5mg proscar mastercard, or it may not be resectable through a laparoscope and a second-look laparotomy must be performed. Gynecologic oncologists skilled with advanced laparoscopic techniques are now providing data suggesting that, in their hands, laparoscopic second-look operations are comparable to laparotomies. Patients at highest risk for recurrent disease after achieving a complete remission are those who had large-volume disease before initiation of chemotherapy and those with more poorly differentiated tumors. However, the vast majority of patients with recurrent ovarian cancer ultimately succumb to their disease. Consequently, numerous clinical strategies are being studied in an effort to prevent or delay recurrences in patients who achieve a clinical complete remission. Some authors have reported 3-year progression-free survival rates as high as 25% to 35% and occasional 10- to 15-year disease-free survivors among patients treated with abdominal irradiation after an incomplete response to chemotherapy. Two randomized trials have compared whole abdominal irradiation with additional consolidative chemotherapy for patients with minimal disease after surgical cytoreduction and platinum-containing chemotherapy. Bruzzone and associates 154 randomized patients who had minimal or no residual disease after chemotherapy [doxorubicin, cyclophosphamide (Cytoxan), and cisplatin or carboplatin] to receive whole abdominal irradiation or three more cycles of chemotherapy. The study was closed after accruing only 41 patients because disease progression had been observed in 55% of patients treated with radiation versus 29% of those treated with additional chemotherapy (P =. The authors recommended treatment with chemotherapy, but the small number of patients and short median follow-up weaken the conclusions of their study. The 117 patients who had residual disease of 2 cm or less after secondary cytoreduction were then randomized to receive either five additional courses of carboplatin or whole abdominal irradiation (24 Gy in 5 weeks). The authors reported no statistical difference in survival or disease-free survival rates between the two treatment arms. Although a small proportion of patients treated with whole abdominal irradiation for microscopic residual disease after chemotherapy enjoy long disease-free intervals, the control rates appear to be much poorer than those reported for patients treated with initial radiation for a similar volume of residual disease. Patients who have not responded completely to chemotherapy may have disease that is inherently more aggressive than that of patients chosen for primary treatment with whole abdominal irradiation. Radiotherapy is often compromised because of poor hematologic tolerance after aggressive chemotherapy, which further decreases the probability of the tumor being sterilized. It also has been suggested that cytoreductive treatments (surgery, irradiation, or chemotherapy) may stimulate the proliferation of clonogenic tumor cells. Consequently, to overcome rapid repopulation, higher doses of radiation may be required to sterilize tumor cells that remain after a course of chemotherapy. Hoskins and colleagues 156 have reported encouraging results for a regimen that integrated whole abdominal irradiation in the initial treatment of patients with minimal residual disease after cytoreduction. In their study, radiation was given after the first three of six cycles of cisplatin and cyclophosphamide. Comparison with the results of similar patients treated during a later time with six cycles of chemotherapy alone favored the alternating regimen, particularly for patients with stage I disease (P =. Clinical trials of other modalities focused on preventing or delaying recurrence after initial chemotherapy are in progress: consolidation with high-dose chemotherapy, whole abdominal irradiation, intraperitoneal 32P, intraperitoneal chemotherapy with cisplatin, intraperitoneal immunotherapy, and additional cycles of systemic chemotherapy and hormonal therapy with agents such as tamoxifen. Randomized trials addressing these modalities have been limited by slow accrual, and currently there is no evidence that consolidation treatment is able to improve survival after six cycles of initial treatment with paclitaxel plus a platinum compound. Patients with recurrent ovarian cancer can be broadly divided into two subsets with a markedly different prognosis. Patients whose disease recurs with a disease-free interval of less than 6 months have a worse prognosis that approaches that of patients who progress while receiving their initial chemotherapeutic regimen. In contrast, patients who have a disease-free interval of more than 6 months or 1 year have a markedly improved prognosis, primarily because of the increased efficacy of salvage chemotherapy. In patients with a long disease-free interval, secondary cytoreductive surgery can be considered in select subsets of patients. Secondary Cytoreductive Surgery Primary cytoreductive surgery has well-documented benefits in the management of women with advanced ovarian cancer. The median survival for that group was 20 months, compared with 5 months for the 20 patients whose disease could not be optimally cytoreduced. The patients most likely to undergo optimal cytoreductive surgery were those who previously had optimal primary cytoreduction, less than 1000 mL of ascites, and a tumor size of less than 5 cm at the second operation. The interval from the primary to secondary surgery should be longer than 12 months.

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