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Background: Most surgical training programs have no curriculum to teach palliative care. Programs designed for nonsurgical specialties often do not meet the unique needs of surgeons. With 80-hour workweek limitations on in-hospital teaching, new methods are needed to efficiently teach surgical residents about these problems., Methods: A pilot curriculum in palliative surgical care designed for residents was presented in three 1-hour sessions. Sessions included group discussion, role-playing exercises, and instruction in advanced clinical decision making. Residents completed pretest, posttest, and 3-month follow-up surveys designed to measure the program's success., Results: Forty-seven general surgery residents from Brown University participated. Most residents (94%) had "discussed palliative care with a patient or patient's family" in the past. Initially, 57% of residents felt "comfortable speaking to patients and patients' families about end-of-life issues," whereas at posttest and at 3-month intervals, 80% and 84%, respectively, felt comfortable (P < .01). Few residents at pretest (9%) thought that they had "received adequate training in palliation during residency," but at posttest and at 3-month follow-up, 86% and 84% of residents agreed with this statement (P < .01). All residents believed that "managing end-of-life issues is a valuable skill for surgeons." Ninety-two percent of residents at 3-month follow-up "had been able to use the information learned in clinical practice.", Conclusions: With a reasonable time commitment, surgical residents are capable of learning about palliative and end-of-life care. Surgical residents think that understanding palliative care is a useful part of their training, a sentiment that is still evident 3 months later.

Background: Primary vaginal melanoma is a rare and highly malignant disease. The impact of therapy on outcomes is poorly understood., Methods: Records of all patients treated for primary vaginal melanoma at Memorial Sloan-Kettering Cancer Center from 1977 to 2001 were reviewed. Survival analysis was performed based on appropriate patient, tumor, and treatment variables. Pathologic materials were reviewed to confirm the original diagnosis and examine appropriate clinicopathologic features., Results: Thirty-five women were treated for vaginal melanoma; the primary treatment selected was surgical for 69% (24) and radiotherapy for 31% (11) of the patients. Surgical removal of the tumor was achieved in 92% (22) of the 24 patients selected for surgical therapy. At operation, radical excision with en bloc removal of involved pelvic organs was performed in 50% (12) of the 24 patients, a wide excision was performed in 42% (10), and a total vaginectomy was performed in 8% (2). Elective pelvic lymph node dissection was performed in 74% (26) of the 35 cases. Lymph node metastasis was found in only 8% (2) of these 26 patients. The overall median survival was 20 months. Primary surgical therapy was associated with longer overall survival (25 vs. 13 months; P =.039). Recurrence-free survival was not associated with the extent of surgery. None of the examined clinicopathologic features were associated with survival differences., Conclusions: The prognosis is poor for patients with primary vaginal melanoma. Improved clinical outcomes were associated with surgical removal of gross disease whenever possible. Because of the low rate of lymph node metastasis, elective pelvic lymph node dissection is not obligatory. In cases of surgically unresectable disease, primary radiation therapy is indicated.

Background: Although resection of locally recurrent rectal cancer has been associated with improved survival, clinical outcomes after such repeat surgery have been incompletely characterized., Methods: From 1997 to 1999, 105 consecutive patients requiring repeat surgery for locally recurrent rectal cancer were identified. Patients were observed for a minimum of 2 years or until death., Results: An operation was performed with palliative intent in 23% of patients. Before repeat surgery, 79% of the palliative-intent patients had symptoms: 21% bleeding, 42% obstruction, and 21% pain. After repeat surgery with palliative intent, improvement was noted in 40% with bleeding, 70% with obstruction, and 20% with pain. Additional or recurrent symptoms were noted in 87% during follow-up. Seventy-seven percent of patients had an operation with nonpalliative intent. Before repeat surgery, 57% of nonpalliative patients had symptoms, with 32% experiencing bleeding, 11% obstruction, and 19% pain. After repeat surgery with nonpalliative intent, initial improvement was noted in 88% with bleeding, 78% with obstruction, and 40% with pain. During follow-up, symptoms arose in 37% of the initially asymptomatic patients, and additional or recurrent symptoms were seen in 63% of those previously symptomatic., Conclusions: Although symptomatic relief is associated with repeat surgery, the recurrence or development of alternate symptoms makes a completely asymptomatic clinical course uncommon.

Background: Decisions regarding the use of surgical procedures for the palliation of symptoms caused by advanced malignancies require the highest level of surgical judgment. Prospective analysis of palliative surgical care may facilitate a more effective and representative evaluation of these patients., Methods: Patients requiring surgery planned solely for the palliation of an advanced malignancy were offered entry onto this study. Outcome measurements were made before surgery and monthly thereafter until the patient's death. Accepted techniques of pain assessment, quality of life, and functional status were used., Results: Between May 1997 and December 1999, 26 patients were enrolled. Although 46% (12 of 26) of patients demonstrated improvement in pain control or quality of life after palliative surgery, these benefits lasted a median of only 3.4 months. Palliative surgery was associated with significant postoperative complications in 35% (9 of 26) patients., Conclusions: Although many patients had no apparent demonstrable benefit from surgery, surgeons were able to identify a group of patients who experienced significant benefits after a palliative procedure. The relationships between the patient and family members and the surgeon play an important role in decision-making throughout the palliative phase of cancer treatment.

Background: Several reports have demonstrated accurate prediction of nodal metastasis with radiolocalization and selective resection of the radiolocalized sentinel lymph node (SLN) in patients with breast cancer and melanoma. As reliance on this technique grows, its use by those without experience in radiation safety will increase., Methods: Tissue obtained during radioguided SLN biopsies was examined for residual radioactivity. Specimens with a specific activity greater than the radiologic control level (RCL) of 0.002 microCi/g were considered radioactive. Radiation exposure to the surgical team was measured., Results: A total of 24 primary tissue specimens and 318 lymph nodes were obtained during 57 operations (37 for breast cancer, 20 for melanoma). All 24 (100%) of the specimens injected with radiopharmaceutical and 89 of 98 (91%) of the localized nodes were radioactive after surgery. Activity fell below the RCL 71+/-3.6 hours in primary tissue specimens, 46+/-1.7 hours in nodes from melanoma patients, and 33+/-3.5 hours in nodes from breast cancer patients (P = .037). The hands of the surgical team (n = 22 cases) were exposed to 9.4+/-3.6 mrem/case., Conclusion: Although low levels of radiation exposure are associated with radiolocalization and resection of the SLN, the presented guidelines ensure conformity to existing regulations and allow timely pathologic analysis.

Background: Several reports have demonstrated the accurate prediction of axillary nodal status (ANS) with radiolocalization and selective resection of sentinel lymph nodes (SLN) in breast cancer. To date, no technique has proven to be superior in localizing the SLN., Methods: 1.0 mCi of clear unfiltered 99mtechnetium sulfur colloid was injected under ultrasonographic (US) guidance around the perimeter of the breast lesion (palpable and nonpalpable) or previous biopsy site. Resection of the radiolocalized nodes was performed, followed by complete axillary lymph node dissection (AXLND)., Results: Forty-two breast cancer patients underwent SLN biopsy after US-guided radiopharmaceutical injection. The SLN was localized in 41 patients (98%). The type of previously performed diagnostic biopsy did not influence the ability to localize the sentinel lymph node. Pathology revealed nodal metastasis in 7 of the 41 evaluable patients (17%). ANS was accurately predicted in 40 of 41 patients (98%)., Conclusions: Early experience with radiolocalization and selective resection of SLN in breast cancer remains promising. Use of US-guided injection facilitates localization of the SLN, perhaps as a result of more accurate placement of the radionuclide marker. Use of this technique allowed for effective management of patients regardless of tumor size or the extent of prior biopsy, thereby expanding the potential number of eligible patients for SLN biopsy.