Amber A. Guth, M.D.

Surgical outcomes of 63 patients from an international trial of preoperative concurrent paclitaxel- Radiation in locally advanced breast cancer
Dhage S.; Axelrod D.; Guth A.; Vijaykumar D.K.; Apffelstaedt J.; Formenti S.
2011 ;18:S166-S166, Annals of surgical oncology
Objective: Locally advanced breast cancer (LABC) is the most common presentation of breast cancer worldwide. In the United States, neoadjuvant therapy has become the standard of care for LABC. Recently, Adams et al reported a 34% pathologic response rate among 105 patients with LABC treated with taxanebased, preoperative chemo-radiation: 5-year DFS and OS results were comparable to those of much more aggressive chemotherapy regimens in the neoadjuvant setting. As is reported for patients treated by neoadjuvant chemotherapy, the achievement of a pathological response to chemo-radiation reflected better DFS and OS. Importantly, a pathological response occurred in 54% of patients with hormone-negative tumors. Since this approach is simple and cost-effective, it has attracted interest from several international centers. We report the surgical outcomes after taxane-radiation in 63 LABC patients treated in a multiinstitutional clinical trial in India, South Africa, and the United States. Methods: Women with LABC (stages IIB-IIIC), ECOG performance status of 0 to 1, were eligible. Patients were treated with paclitaxel (30 mg/m(2) intravenously twice a week) for 6-12 weeks. Daily radiotherapy was delivered to breast, axillary, and supraclavicular lymph nodes during weeks 2-7 of paclitaxel treatment, at 1.8 Gy per fraction to a total dose of 45 Gy with a tumor boost of 14 Gy at 2 Gy/fraction. Seventeen of 63 patients received four cycles of doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 prior to the paclitaxel -RT regimen. Mastectomy or lumpectomy, as decided by each surgeon, was performed 4 weeks after completion of preoperative therapy or upon recovery of chemoradiationinduced dermatitis. All patients had a level I/II axillary lymph node dissection. Postoperatively, patients who responded to paclitaxel and RT received four cycles of doxorubicin/paclitaxel, whereas patients who did not respond received doxorubicin/cytoxan. Surgical complications were recorded. Results: Forty-three patients underwent modified radical mastectomyand 20 underwent lumpectomy. Of mastectomy patients, 17 (39.5%) underwent immediate breast reconstruction: free flap reconstruction (8), pedicle flaps (3), advancement flaps(2), tissue expander placement (2), and major chest wall and sternum reconstruction (1). Of lumpectomy patients, five (25%) had further surgery for positive margins; a second lumpectomy (3), and a mastectomy (2). All revealed residual disease and negative margins were achieved. Twenty-one patients had at least 1 complication of whom 17 were treated as outpatients. Eleven (17.4%) had a recurrent seroma, 8 (12.7%) had delayed healing, and 7 (11.1%) developed a postoperative infection. Of the 17 who underwent reconstruction, 3 (17.6%) developed flap necrosis, requiring surgical debridement. The degree of acute chemo-radiation dermatitis was analyzed to explore correlation with the surgical complications. Dermatitis was grade 1 in 21 patients, grade 2 in 29 patients, grade 3 in 11 patients, and 2 had none. The grade of dermatitis did not correlate with risk of complications. Conclusions: Preoperative paclitaxel with radiotherapy is relatively well tolerated. Risk of complication is similar to that reported in the literature for patients treated with neoadjuvant therapy. The highest morbidity was associated with immediate free flap reconstruction. Delayed reconstruction may be advisable for patients treated with neoadjuvant chemo-radiation. (Table presented)
— id: 137914, year: 2011, vol: 18, page: S166, stat: Journal Article,

Patient perception of choice in decision-making for early stage breast cancer: does race and socioeconomic status matter?
Dhage, Shubha; Guth, Amber A; Fei, Kezhen; Weidman, Jessica; Bickell, Nina A
2011 Sep;17(5):542-544, Breast journal
— id: 137071, year: 2011, vol: 17, page: 542, stat: Journal Article,

The effects of symptomatic seroma on lymphedema symptoms following breast cancer treatment
Fu, M R; Guth, A A; Cleland, C M; Lima, E D R P; Kayal, M; Haber, J; Gallup, L; Axelrod, D
2011 Sep;44(3):134-143, Lymphology
It has been speculated that symptomatic seroma, or seroma requiring needle aspiration, is one of the risk factors for lymphedema symptoms following breast cancer treatment. These symptoms exert tremendous impact on patients' quality of life and include arm swelling, chest/breast swelling, heaviness, tightness, firmness, pain, numbness, stiffness, or impaired limb mobility. Our aim was to explore if symptomatic seroma affects lymphedema symptoms following breast cancer treatment. Data were collected from 130 patients using a Demographic and Medical Information interview tool, Lymphedema and Breast Cancer Questionnaire, and review of medical record. Arm swelling was verified by Sequential Circumferential Arm Measurements and Bioelectrical Impedance Spectroscopy. Data analysis included descriptive statistics, Chi-squared tests, regression, exploratory factor analysis and exploratory structural equation modeling. Thirty-five patients (27%) developed symptomatic seroma. Locations of seroma included axilla, breast, and upper chest. Significantly, more women with seroma experienced more lymphedema symptoms. A well-fit exploratory structural equation model [X2(79) = 92.15, p = 0.148; CFI = 0.97; TLI = 0.96] revealed a significant unique effect of seroma on lymphedema symptoms of arm swelling, chest/breast swelling, tenderness, and blistering (beta = 0.48, p < 0.01). Patients who developed symptomatic seroma had 7.78 and 10.64 times the odds of developing arm swelling and chest/breast swelling versus those who did not, respectively (p < 0.001). Symptomatic seroma is associated with increased risk of developing lymphedema symptoms following breast cancer treatment. Patients who develop symptomatic seroma should be considered at higher risk for lymphedema symptoms and receive lymphedema risk reduction interventions
— id: 146268, year: 2011, vol: 44, page: 134, stat: Journal Article,

Loss of p27KIP1 Expression in Fully-staged Node-negative Breast Cancer: Association with Lack of Hormone Receptors in T1a/b, but not T1c Infiltrative Ductal Carcinoma
Mirchandani, Deepu; Roses, Daniel F; Inghirami, Giorgio; Zeleniuch-Jacquotte, Anne; Cangiarella, Joan; Guth, Amber; Safyan, Rachael Ann; Formenti, Silvia C; Pagano, Michele; Muggia, Franco
2011 Dec;31(12):4401-4405, Anticancer research
Nuclear expression of the cell cycle inhibitor p27(KIP1) is reduced in a variety of human malignancies, including breast cancer. Loss of nuclear p27(KIP1) during tumor progression, documented by immunohistochemistry (IHC), has been studied for its potential prognostic implication. We examined by IHC the association between nuclear p27(KIP1) expression and hormone receptor status in T1N0M0 breast cancer. PATIENTS AND METHODS: The correlation between nuclear p27(KIP1) expression and estrogen (ER) and progesterone (PR) hormone receptor status was analyzed in 122 human T1N0M0 (68 T1a/b, 54 T1c) breast cancer specimens. All patients were staged as N0 by axillary node dissection. RESULTS: A statistically significant reduction in p27(KIP1) expression was observed as tumor size increased from T1a/b (7%) to T1c (22%). The proportion of tumors with low nuclear p27(KIP1) expression was higher in the ER-negative/PR-negative group compared to the ER-positive/PR-positive group, but this difference was only statistically significant in the T1a/b subgroup (p=0.0007). CONCLUSION: Further investigations into causes of p27(KIP1) deregulation and their relationship to hormone receptor expression in T1N0M0 breast ductal carcinomas are warranted. Such studies may help identify prognostic, as well as predictive, markers of therapy resistance
— id: 149934, year: 2011, vol: 31, page: 4401, stat: Journal Article,

The effect of providing information about lymphedema on the cognitive and symptom outcomes of breast cancer survivors
Fu, Mei R; Chen, Constance M; Haber, Judith; Guth, Amber A; Axelrod, Deborah
2010 Jul;17(7):1847-1853, Annals of surgical oncology
BACKGROUND: Despite recent advances in breast cancer treatment, breast cancer related lymphedema (BCRL) continues to be a significant problem for many survivors. Some BCRL risk factors may be largely unavoidable, such as mastectomy, axillary lymph node dissection (ALND), or radiation therapy. Potentially avoidable risk factors unrelated to breast cancer treatment include minor upper extremity infections, injury or trauma to the arm, overuse of the limb, and air travel. This study investigates how providing information about BCRL affects the cognitive and symptomatic outcome of breast cancer survivors. METHODS: Data were collected from 136 breast cancer survivors using a Demographic and Medical Information interview instrument, a Lymphedema Education Status interview instrument, a Knowledge Test for cognitive outcome, and the Lymphedema and Breast Cancer Questionnaire for symptom outcome. Data analysis included descriptive statistics, t tests, chi-square (chi(2)) tests, and regression. RESULTS: BCRL information was given to 57% of subjects during treatment. The mean number of lymphedema-related symptoms was 3 symptoms. Patients who received information reported significantly fewer symptoms and scored significantly higher in the knowledge test. After controlling for confounding factors, patient education remains an additional predictor of BCRL outcome. Significantly fewer women who received information about BCRL reported swelling, heaviness, impaired shoulder mobility, seroma formation, and breast swelling. CONCLUSIONS: Breast cancer survivors who received information about BCRL had significantly reduced symptoms and increased knowledge about BCRL. In clinical practice, breast cancer survivors should be engaged in supportive dialogues so they can be educated about ways to reduce their risk of developing BCRL
— id: 149786, year: 2010, vol: 17, page: 1847, stat: Journal Article,

Is surgical excision necessary for radial scars diagnosed on percutaneous biopsy?
Mercado, C; Guth, A; Cangiarella, J
2010 FEB ;17(6):S56-S56, Annals of surgical oncology
— id: 110003, year: 2010, vol: 17, page: S56, stat: Journal Article,

Invasive Micropapillary Carcinoma: Radiographic Features in 18 Patients With This Unusual Variant
Mercado, C; Guth, A; Mercado, C; Moy, L; Lee, J; Toth, H; Cangiarella, J
2010 MAY ;194(5):-, American journal of roentgenology
— id: 111948, year: 2010, vol: 194, page: , stat: Journal Article,

Microinvasive ductal carcinoma in situ: Clinical presentation, imaging features, pathologic findings, and outcome
Vieira, Cristina C; Mercado, Cecilia L; Cangiarella, Joan F; Moy, Linda; Toth, Hildegard K; Guth, Amber A
2010 Jan;73(1):102-107, European journal of radiology
OBJECTIVE: The purpose of our study was to describe the clinical features, imaging characteristics, pathologic findings and outcome of microinvasive ductal carcinoma in situ (DCISM). MATERIALS AND METHODS: The records of 21 women diagnosed with microinvasive ductal carcinoma in situ (DCISM) from November 1993 to September 2006 were retrospectively reviewed. The clinical presentation, imaging and histopathologic features, and clinical follow-up were reviewed. RESULTS: The 21 lesions all occurred in women with a mean age of 56 years (range, 27-79 years). Clinical findings were present in ten (48%): 10 with palpable masses, four with associated nipple discharge. Mean lesion size was 21mm (range, 9-65mm). The lesion size in 62% was 15mm or smaller. Mammographic findings were calcifications only in nine (43%) and an associated or other finding in nine (43%) [mass (n=7), asymmetry (n=1), architectural distortion (n=1)]. Three lesions were mammographically occult. Sonographic findings available in 11 lesions showed a solid hypoechoic mass in 10 cases (eight irregular in shape, one round, one oval). One lesion was not seen on sonography. On histopathologic examination, all lesions were diagnosed as DCISM, with a focus of invasive carcinoma less than or equal to 1mm in diameter within an area of DCIS. Sixteen (76%) lesions were high nuclear grade, four (19%) were intermediate and one was low grade (5%). Sixteen (76%) had the presence of necrosis. Positivity for ER and PR was noted in 75% and 38%. Nodal metastasis was present in one case with axillary lymph node dissection. Mean follow-up time for 16 women was 36 months without evidence of local or systemic recurrence. One patient developed a second primary in the contralateral breast 3 years later. CONCLUSION: The clinical presentation and radiologic appearance of a mass are commonly encountered in DCISM lesions (48% and 57%, respectively), irrespective of lesion size, mimicking findings seen in invasive carcinoma. Despite its potential for nodal metastasis (5% in our series), mean follow-up at 36 months was good with no evidence of local or systemic recurrence at follow-up. Knowledge of these clinical and imaging findings in DCISM lesions may alert the clinician to the possibility of microinvasion and guide appropriate management
— id: 95528, year: 2010, vol: 73, page: 102, stat: Journal Article,

Cultural Preferences for Chaperone Use during Breast Examinations: A Preliminary Study
Checka, CM; Bright, KL; Toth, HB; Chun, J; Guth, AA
2009 DEC 15 ;69(24):849S-849S, Cancer research
— id: 106459, year: 2009, vol: 69, page: 849S, stat: Journal Article,

Triple negative breast cancer: A review
Mercado C.; Cangiarella J.; Guth A.A.
2009 ;5(3):149-156, Current Women's Health Reviews
Triple negative breast cancer has recently been recognized as a distinct subtype of breast cancer. While TNBC and basal-type breast cancers are not identical, the terms are often used synonomously. TNBC have a poorer prognosis than other molecular subtypes of breast cancer. There are no known targeted agents, leaving chemotherapy as the primary adjuvant therapy. TNBC are associated with BRCA1 mutations, are more common in African-American women, and have a more aggressive clinical course, with high early rates of metastatic disease and early relapse. Current research is examining epidemiologic features associated with TNBC, and searching for effective targeted therapy. copyright 2009 Bentham Science Publishers Ltd
— id: 107402, year: 2009, vol: 5, page: 149, stat: Journal Article,

Sucess of Brochure/One Page Universal Consent for Biospecimen Donation
Singh, B; Roses, DF; Guth, AA; Schnabel, FR; Shapiro, RL; Axelrod, DM; Ginsberg, A; Ziguridis, N
2009 DEC 15 ;69(24):849S-850S, Cancer research
— id: 106460, year: 2009, vol: 69, page: 849S, stat: Journal Article,

Breast cancer in young women
Axelrod, Deborah; Smith, Julia; Kornreich, Davida; Grinstead, Eve; Singh, Baljit; Cangiarella, Joan; Guth, Amber A
2008 Jun;206(3):1193-1203, Journal of the American College of Surgeons
— id: 79248, year: 2008, vol: 206, page: 1193, stat: Journal Article,

A tracking and feedback registry to reduce racial disparities in breast cancer care
Bickell, Nina A; Shastri, Kruti; Fei, Kezhen; Oluwole, Soji; Godfrey, Henry; Hiotis, Karen; Srinivasan, Anitha; Guth, Amber A
2008 Dec 3;100(23):1717-1723, Journal of the National Cancer Institute
BACKGROUND: Black and Hispanic women with early-stage breast cancer are more likely than white women to experience fragmented care and less likely to see medical oncologists to get effective adjuvant treatment. We implemented a tracking and feedback registry to close the referral loop between surgeons and oncologists. METHODS: We compared completed oncology consultations and use of adjuvant treatment among a group of 639 women with newly diagnosed stage I or II breast cancer who had undergone surgery at one of six New York City hospitals from 1999 to 2000 with the same outcomes for a different group of 300 women with breast cancer whose surgeries occurred in 2004-2006, after the implementation of the tracking registry. Underuse of adjuvant treatment was defined as no radiotherapy after breast-conserving surgery, no chemotherapy for estrogen receptor (ER)-negative tumors, or no hormonal therapy for ER-positive tumors 1 cm or larger. We used hierarchical modeling to adjust for clustering within hospital and surgeon practice. Odds ratios were converted to adjusted relative risks (aRRs). All statistical tests were two-sided. RESULTS: Implementation of the tracking and feedback registry was accompanied by a statistically significant increase in oncology consultations (83% before vs 97% after the intervention; difference = 14%; 95% confidence interval [CI] = 11% to 18%; P < .001) and decrease in underuse of adjuvant treatment (23% before vs 14% after the intervention; difference = -9%, 95% CI = -12% to -6%; P < .001). Underuse declined from 34% to 14% among black women, from 23% to 13% among Hispanic women, and from 17% to 14% among white women (chi-square of change in underuse from before to after among the three racial groups; P = .001). In multivariable models adjusting for clustering by hospital and surgeon, the intervention was associated with increased rates of oncology consultation (aRR = 1.6, 95% CI = 1.3 to 1.8), and reduced underuse of adjuvant treatment (aRR = 0.75, 95% CI = 0.6 to 0.9). Compared with the preintervention findings, minority race was no longer a risk factor for low rates of oncology consultation (aRR = 1.0, 95% CI = 0.7 to 1.3) or for underuse of adjuvant therapy (aRR = 1.0, 95% CI = 0.8 to 1.3). CONCLUSIONS: A tracking and feedback registry that enhances completed oncology consultations between surgeons and oncologists also appears to reduce rates of adjuvant treatment underuse and to eliminate the racial disparity in treatment
— id: 96570, year: 2008, vol: 100, page: 1717, stat: Journal Article,

Is surgical excision necessary for the management of atypical lobular hyperplasia and lobular carcinoma in situ diagnosed on core needle biopsy?: a report of 38 cases and review of the literature
Cangiarella, Joan; Guth, Amber; Axelrod, Deborah; Darvishian, Farbod; Singh, Baljit; Simsir, Aylin; Roses, Daniel; Mercado, Cecilia
2008 Jun;132(6):979-983, Archives of pathology & laboratory medicine
CONTEXT: Both atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS) have traditionally been considered to be risk factors for the development of invasive carcinoma and are followed by close observation. Recent studies have suggested that these lesions may represent true precursors with progression to invasive carcinoma. Due to the debate over the significance of these lesions and the small number of cases reported in the literature, the treatment for lobular neoplasia diagnosed by percutaneous core biopsy (PCB) remains controversial. OBJECTIVE: To review our experience with pure LCIS or ALH diagnosed by PCB and correlate the radiologic findings and surgical excision diagnoses to develop management guidelines for lobular neoplasia diagnosed by PCB. DESIGN: We searched the pathology database for patients who underwent PCB with a diagnosis of either pure LCIS or ALH and had subsequent surgical excision. We compared the core diagnoses with the surgical excision diagnoses and the radiologic findings. RESULTS: Thirty-eight PCBs with a diagnosis of ALH (18 cases) or LCIS (20 cases) were identified. Carcinoma was present at excision in 1 (6%) of the ALH cases and in 2 (10%) of the LCIS cases. In summary, 8% (3/38) of PCBs diagnosed as lobular neoplasia (ALH or LCIS) were upgraded to carcinoma (invasive carcinoma or ductal carcinoma in situ) at excision. CONCLUSIONS: Surgical excision is indicated for all PCBs diagnosed as ALH or LCIS, as a significant percentage will show carcinoma at excision
— id: 79288, year: 2008, vol: 132, page: 979, stat: Journal Article,

Isolated tumor cells on sentinel lymph node biopsy: Our experience over a decade
Darvishian, F; Guth, A; Dhage, S; Singh, B; Roses, D; Axelrod, D; Mercado, C; Cangiarella, J
2008 JAN ;21(2):27A-28A, Modern pathology
— id: 75903, year: 2008, vol: 21, page: 27A, stat: Journal Article,

Isolated tumor cells on sentinel lymph node biopsy: Our experience over a decade
Darvishion, F; Guth, A; Dhage, S; Singh, B; Roses, D; Axelrod, E; Mercado, C; Cangiarella, J
2008 JAN ;88(2):27A-28A, Laboratory investigation
— id: 75925, year: 2008, vol: 88, page: 27A, stat: Journal Article,

Can axillary dissection be avoided in patients with sentinel node micrometastasis? The role of pathologic assessment of breast tumors in predicting non-sentinel node metastasis
Gupta, R; Cangiarella, J; Singh, B; Guth, A; Axelrod, D; Roses, D; Darvishian, F
2008 JAN ;88(2):35A-35A, Laboratory investigation
— id: 75927, year: 2008, vol: 88, page: 35A, stat: Journal Article,

A decade of change : an institutional experience with breast surgery in 1995 and 2005
Guth AA; Shanker BA; Roses DF; Axelrod D; Singh B; Toth H; Shapiro RL; Hiotis K; Diflo T; Cangiarella JF
2008 ;1:51-55, Breast cancer : basic & clinical research
— id: 93532, year: 2008, vol: 1, page: 51, stat: Journal Article,

Microinvasive breast cancer and the role of sentinel node biopsy: an institutional experience and review of the literature
Guth, Amber A; Mercado, Cecilia; Roses, Daniel F; Darvishian, Farbod; Singh, Baljit; Cangiarella, Joan F
2008 Jul-Aug;14(4):335-339, Breast journal
Ductal carcinoma in situ with microinvasion (DCISM) is a distinct clinicopathologic entity. Its true metastatic potential has been unclear, due in part to historical differences in the definition of microinvasion. The role of routine axillary staging for DCISM is controversial, given the reportedly low incidence of axillary metastases. We describe our institutional experience with DCISM, and define the role of axillary staging. A retrospective analysis was made of patients with DCISM. Forty-four patients underwent axillary staging (24 axillary lymph node dissection [ALND], 22 sentinel node biopsy [SNB]). Macrometastatic disease was present in three patients (7%), and two patients had isolated tumor cells (itc) in the sentinel node. Patients with axillary metastases tended to be younger. Comedonecrosis, nuclear grade, multifocal microinvasion or presentation as a clinical mass was not associated with a higher rate of axillary metastases. In this series, 7% of patients had macrometastatic disease, and two patients (5%) had itc only. Axillary staging is indicated, and SNB is appropriate for the identification of axillary metastatic disease
— id: 81349, year: 2008, vol: 14, page: 335, stat: Journal Article,

A decade of change: an institutional experience with breast surgery in 1995 and 2005
Guth, Amber A; Shanker, Beth Ann; Roses, Daniel F; Axelrod, Deborah; Singh, Baljit; Toth, Hildegard; Shapiro, Richard L; Hiotis, Karen; Diflo, Thomas; Cangiarella, Joan F
2008 ;1:51-55, Breast cancer : basic & clinical research
INTRODUCTION: With the adoption of routine screening mammography, breast cancers are being diagnosed at earlier stages, with DCIS now accouting for 22.5% of all newly diagnosed breast cancers. This has been attributed to both increased breast cancer awareness and improvements in breast imaging techniques. How have these changes, including the increased use of image-guided sampling techniques, influenced the clinical practice of breast surgery? METHODS: The institutional pathology database was queried for all breast surgeries, including breast reconstruction, performed in 1995 and 2005. Cosmetic procedures were excluded. The results were analysed utilizing the Chi-square test. RESULTS: Surgical indications changed during 10-year study period, with an increase in preoperatively diagnosed cancers undergoing definitive surgical management. ADH, and to a lesser extent, ALH, became indications for surgical excision. Fewer surgical biopsies were performed for indeterminate abnormalities on breast imaging, due to the introduction of stereotactic large core biopsy. While the rate of benign breast biopsies remained constant, there was a higher percentage of precancerous and DCIS cases in 2005. The overall rate of mastectomy decreased from 36.8% in 1995 to 14.5% in 2005. With the increase in sentinel node procedures, the rate of ALND dropped from 18.3% to 13.7%. Accompanying the increased recognition of early-stage cancers, the rate of positive ALND also decreased, from 43.3% to 25.0%. CONCLUSIONS: While the rate of benign breast biopsies has remained constant over a recent 10-year period, fewer diagnostic surgical image-guided biopsies were performed in 2005. A greater percentage of patients with breast cancer or preinvasive disease have these diagnoses determined before surgery. More preinvasive and Stage 0 cancers are undergoing surgical management. Earlier stage invasive cancers are being detected, reflected by the lower incidence of axillary nodal metastases
— id: 149787, year: 2008, vol: 1, page: 51, stat: Journal Article,

A cautionary tale: anaphylaxis to isosulfan blue dye after 12 years and 3339 cases of lymphatic mapping
Kaufman, Gabriel; Guth, Amber A; Pachter, H Leon; Roses, Daniel F
2008 Feb;74(2):152-155, American surgeon
Sentinel node biopsy has become the standard method for lymphatic staging in early-stage breast cancer and melanomas. The most commonly used technique uses both a radioactive tracer as well as blue dye, usually isosulfan blue. In this report, we discuss two episodes of anaphylaxis to isosulfan blue during lymphatic mapping, occurring 12 years and 3339 lymphatic mapping cases after adoption of the technique, and discuss management issues raised by these events
— id: 77869, year: 2008, vol: 74, page: 152, stat: Journal Article,

Receptor status and ethnicity of indigent patients with breast cancer in New York City
Marti, Jennifer L; Guth, Amber; Naik, Arpana; Hiotis, Karen L
2008 Dec;143(12):1227-1230, Archives of Surgery (Chicago)
Previous studies have suggested racial differences in breast cancer hormonal receptor status, reflecting possible differences in tumor biology. However, racial differences in socioeconomic status and reproductive risk factors may influence receptor status. We investigated this issue, studying a racially diverse but socioeconomically homogeneous cohort of 215 patients with breast cancer at a New York public hospital from January 1, 1999, through December 31, 2003. We analyzed positive findings for estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) (HER2/neu) receptors, considering patients in racial groups by cancer stage and overall. No difference was found in rates of estrogen, progesterone, or HER2/neu positivity among Asian, black, Hispanic, or white patients presenting with ductal carcinoma in situ or with invasive cancer
— id: 91464, year: 2008, vol: 143, page: 1227, stat: Journal Article,

Sonographically guided marker placement for confirmation of removal of mammographically occult lesions after localization
Mercado, Cecilia L; Guth, Amber A; Toth, Hildegard K; Moy, Linda; Axelrod, Deborah; Cangiarella, Joan
2008 Oct;191(4):1216-1219, American journal of roentgenology
OBJECTIVE: We evaluated the benefit of placing a marker under sonographic guidance at the time of localization to aid in identifying mammographically occult lesions within the specimen at the time of surgical excision and to evaluate margin status. MATERIALS AND METHODS: We reviewed 135 sonographically guided needle localizations performed on mammographically occult lesions. Imaging during the localization procedure, marker placement, and specimen radiographs were reviewed, and the findings were correlated with the histopathologic findings. RESULTS: Of the 135 mammographically occult lesions, 77 were localized without marker placement and 58 with marker placement. The 58 localizations with marker placement were for masses with a mean lesion size of 9 mm. Specimen radiography of these lesions showed a marker within the specimen in 56 cases (97%) and visualization of the lesion in only seven cases (12%). Specimen radiography of localizations without marker placement showed visualization of the lesion in 18 cases (23%). Of the 11 malignant lesions (19%) localized with marker placement, none had a positive inked margin, but five (46%) had close margins necessitating reexcision. Of the 26 malignant lesions (34%) localized without marker placement, two (8%) had a positive inked margin, and eight (31%) had close margins necessitating reexcision. CONCLUSION: At needle localization of breast lesions, marker placement under sonographic guidance is beneficial because it enables immediate confirmation of accurate surgical removal of the localized lesion at surgical excision. Use of marker placement, however, does not reduce the percentage of cases with close margins necessitating reexcision
— id: 93371, year: 2008, vol: 191, page: 1216, stat: Journal Article,

A tattoo-pigmented node masquerading as the sentinel node in a case of breast cancer
Schlager, Avi; Laser, Alice; Melamed, Jonathan; Guth, Amber A
2008 May-Jun;14(3):299-300, Breast journal
— id: 78829, year: 2008, vol: 14, page: 299, stat: Journal Article,

Impact of micropapillary type of ductal carcinoma in situ on rate of re-excision after breast conserving therapy
Wen, H; Roses, D; Guth, A; Axelrod, D; Singh, B
2008 OCT ;53(1):72-72, Histopathology
— id: 91388, year: 2008, vol: 53, page: 72, stat: Journal Article,

Rate of re-excision with breast conserving therapy with and without additional margins in patients with ductal carcinoma in situ
Wen, YH; Roses, DF; Axelrod, DM; Guth, AA; Shapiro, RL; Berman, R; Singh, B
2008 FEB ;15(1):75-76, Annals of surgical oncology
— id: 98149, year: 2008, vol: 15, page: 75, stat: Journal Article,

Prospective trial of individual optimal positioning (prone versus supine) for whole breast radiotherapy: results of 194 patients
Formenti, SC; Guth, AA; Axelrod, DM; Goldberg, JD; DeWyngaert, JK
2007 DEC ;106(1):S194-S194, Breast cancer research & treatment
— id: 75805, year: 2007, vol: 106, page: S194, stat: Journal Article,

Phase I-II trial of prone accelerated intensity modulated radiation therapy to the breast to optimally spare normal tissue
Formenti, Silvia C; Gidea-Addeo, Daniela; Goldberg, Judith D; Roses, Daniel F; Guth, Amber; Rosenstein, Barry S; DeWyngaert, Keith J
2007 Jun 1;25(16):2236-2242, Journal of clinical oncology
PURPOSE: To report the clinical feasibility of a trial of accelerated whole-breast intensity modulated radiotherapy, with the patient in prone position, optimally to spare the heart and lung. PATIENTS AND METHODS: Patients with stages I or II breast cancer, excised by breast conserving surgery with negative margins, were eligible for this institutional review board-approved prospective trial. Computed tomography simulation was performed with the patient prone on a dedicated breast board, in the exact position used for treatment. A dose of 40.5 Gy, delivered at 2.7 Gy in 15 fractions, was prescribed to the index breast with an additional concomitant boost of 0.5 Gy delivered to the tumor bed, for a total dose of 48 Gy to the lumpectomy site. Physics constraints consisted of limiting 5% of the heart volume to receive > or = 18 Gy and < or = 10% of the ipsilateral lung volume to receive > or = 20 Gy. RESULTS: Between September 2003 and August 2005, 91 patients were enrolled on the study. Median length of follow-up was 12 months (range, 1 to 28 months). In all patients the technique was feasible and heart and lung sparing was achieved as prescribed by the protocol. Acute toxicities consisting mostly of reversible grades 1-2 skin dermatitis (67%) and fatigue (18%) occurred in 75 patients. One patient sustained a regional recurrence rapidly followed by distant metastases. CONCLUSION: Accelerated whole breast intensity modulated radiotherapy in the prone position is feasible and it permits a drastic reduction in the volume of lung and heart tissue exposed to significant radiation.
— id: 72870, year: 2007, vol: 25, page: 2236, stat: Journal Article,

Microinvasive breast cancer: The role of sentinel node biopsy
Guth, AA; Mercado, C; Roses, DF; Darvishian, F; Singh, B; Cangiarella, JF
2007 FEB ;14(2):43-43, Annals of surgical oncology
— id: 71054, year: 2007, vol: 14, page: 43, stat: Journal Article,

Accuracy of preoperative evaluation of the axilla with MRI in breast cancer
Kaufman, G; Guth, AA; Axelrod, D; May, L
2007 DEC ;106(1):S45-S45, Breast cancer research & treatment
— id: 75801, year: 2007, vol: 106, page: S45, stat: Journal Article,

The utility of MRI in preoperative planning for brest-conserving therapy
Kaufman, G; Guth, AA; Singh, A; Axelrod, D; Moy, L
2007 DEC ;106(1):S43-S43, Breast cancer research & treatment
— id: 75800, year: 2007, vol: 106, page: S43, stat: Journal Article,

Does Sonographically Guided Clip Placement Facilitate Confirmation of Removal of Mammographically Occult Lesions After Localization?
Mercado CL; Guth AA; Axelrod DM; Moy L; Toth HK; Cangiarella J
2007 ;188:A32-A34 #110, American journal of roentgenology
— id: 97098, year: 2007, vol: 188, page: A32, stat: Journal Article,

Accuracy of intraoperative sentinel lymph node evaluation for breast
Richards, V; Roses, DF; Axelrod, DM; Guth, AA; Shapiro, RL; Cangiarella, J; Ziguridis, N; Darvishian, F
2007 ;20(3):195-273, Modern pathology
— id: 93501, year: 2007, vol: 20, page: 195, stat: Journal Article,

Accuracy of intraoperative sentinel lymph node evaluation for breast cancer
Richards, V; Roses, DF; Axelrod, DM; Guth, AA; Shapiro, RL; Cangiarella, J; Ziguridis, N; Darvishian, F; Singh, B
2007 ;87(3):195-273, Laboratory investigation
— id: 93502, year: 2007, vol: 87, page: 195, stat: Journal Article,

Trends in breast cancer surgery: Comparison of an institutional experience between 1995 and 2005
Shanker, BA; Guth, AA; Roses, DF; Axelrod, D; Singh, B; Shapiro, RL; Diflo, T; Cangiarella, JA
2007 FEB ;14(2):88-88, Annals of surgical oncology
— id: 71055, year: 2007, vol: 14, page: 88, stat: Journal Article,

Three-dimensional imaging provides valuable clinical data to aid in unilateral tissue expander-implant breast reconstruction
Tepper, OM; Karp, NS; Small, K; Unger, J; Pritchard, A; Roses, D; Shapiro, R; Guth, A; Axelrod, D; Choi, M
2007 DEC ;106(1):S239-S239, Breast cancer research & treatment
— id: 75806, year: 2007, vol: 106, page: S239, stat: Journal Article,

Impact of complete removal of breast carcinoma by aggressive biopsy techniques
Wen, YH; Roses, DF; Axelrod, DM; Guth, AA; Shapiro, RL; Cangiarella, J; Ziguridis, N; Darvishian, F; Mercado, C; Singh, B
2007 ;20(2):226-50, Modern pathology
— id: 93504, year: 2007, vol: 20, page: 226, stat: Journal Article,

Impact of complete removal of breast carcinoma by aggressive biopsy techniques
Wen, YH; Roses, DF; Axelrod, DM; Guth, AA; Shapiro, RL; Cangiarella, J; Ziguridis, N; Darvishian, F; Mercado, C; Singh, B
2007 ;87(2):226-50, Laboratory investigation
— id: 93505, year: 2007, vol: 87, page: 226, stat: Journal Article,

Prophylactic mastectomy - trends in pathology findings
Wen, YH; Roses, DF; Axelrod, DM; Guth, AA; Shapiro, RL; Cangiarella, J; Ziguridis, N; Darvishian, F; Singh, B
2007 DEC ;106(1):S136-S136, Breast cancer research & treatment
— id: 75803, year: 2007, vol: 106, page: S136, stat: Journal Article,

Breast carcinoma in women 30 years and younger
Wen, YH; Roses, DF; Axelrod, DM; Guth, AA; Shapiro, RL; Cangiarella, JF; Ziguridis, N; Darvishian, F; Singh, B
2007 ;14(2):50-50, Annals of surgical oncology
— id: 93503, year: 2007, vol: 14, page: 50, stat: Journal Article,

Missed opportunities: racial disparities in adjuvant breast cancer treatment
Bickell, Nina A; Wang, Jason J; Oluwole, Soji; Schrag, Deborah; Godfrey, Henry; Hiotis, Karen; Mendez, Jane; Guth, Amber A
2006 Mar 20;24(9):1357-1362, Journal of clinical oncology
PURPOSE: Underuse of adjuvant therapy is a potentially important and remediable explanation for the inferior survival of minority women with breast cancer. We sought to measure a racial disparity in the underuse of adjuvant treatments for early-stage breast cancer and to identify associated factors. METHODS: Cross-sectional study with review of all inpatient and outpatient medical records of 677 women treated surgically for a primary American Joint Committee on Cancer stage I or II breast cancer in 1999 to 2000. Underuse was defined as omissions of radiation therapy after breast-conserving surgery, adjuvant chemotherapy after resection of hormone-receptor-negative tumors > or = 1 cm, or hormonal therapy for receptor-positive tumors > or = 1 cm. RESULTS: One hundred forty-five (21%) of 677 women experienced underuse of appropriate adjuvant therapy: 16% in whites, 34% in blacks, and 23% in Hispanics (P < .001). Women referred to medical oncologists were less likely to experience underuse of necessary adjuvant treatments (relative risk [RR] for underuse = 0.2; 95% CI, 0.1 to 0.3). Women who were minorities (RR = 2.0; 95% CI, 1.3 to 3.1), had higher levels of comorbidity (RR = 1.4; 95% CI, 1.1 to 1.8) and lacked insurance (RR = 1.9; 95% CI, 0.9 to 4.0) were at greater risk for underuse. CONCLUSION: Minority women with early-stage breast cancer have double the risk of white women for failing to receive necessary adjuvant treatments despite rates of oncologic consultation similar to those for white women. Oncology referrals are necessary to reduce treatment disparities but are not sufficient to ensure patients' receipt of efficacious adjuvant treatment
— id: 96571, year: 2006, vol: 24, page: 1357, stat: Journal Article,

The management of atypical lobular hyperplasia and lobular carcinoma in-situ diagnosed by core biopsy: is surgical excision necessary?
Cangiarella, J; Axelrod, D; Guth, A; Singh, B; Skinner, K; Roses, D; Simsir, A; Mercado, C
2006 FEB ;100(2):S176-S176, Breast cancer research & treatment
— id: 71008, year: 2006, vol: 100, page: S176, stat: Journal Article,

"You've got mail!": The role of e-mail in clinical breast surgical practice
Guth, Amber A; Diflo, Thomas
2006 Dec;15(6):713-717, Breast
Easy Internet access is changing the practice of medicine in the US. At least 137 million Americans have access to the World Wide Web, and up to one-half would like to communicate with their physicians by e-mail. The membership of the American Society of Breast Surgeons was surveyed to evaluate the current role of e-mail in patient-doctor relationships. Due to the extensive discussions often involved in the evaluation of breast disease, and the elective nature of most surgical procedures, this specialty may be particularly well-suited to using e-mail communication as an extension of discussions during traditional office visits. A questionnaire was e-mailed to all members of the ASBS who had provided an e-mail address. About 1236 questionnaires were sent, and 285 surgeons responded, a 23% response rate. About 130 (46%) responders were female; 209 responders (73%) did not use e-mail to communicate with patients (76% of responding females, 70% of males). The oldest and youngest surgeons were least likely to use e-mail to communicate with patients. There was no gender-related difference in e-mail use. There was no difference in e-mail use between surgeons who limit their practice to breast disease and those who do not. Urban and university-based surgeons were more likely to use e-mail. Medical-legal liability concerns and confidentiality issues were the most common reasons for not using e-mail. Among those surgeons who did use e-mail, ability to answer at one's own discretion, and the ability to provide an organized response were the major reasons for using e-mail. Overall, the membership expressed a preference for personal interaction over electronic communication
— id: 64506, year: 2006, vol: 15, page: 713, stat: Journal Article,

E-mail and the breast surgeon: a survey of the membership of the American Society of Breast Surgeons
Guth, Amber A; Diflo, Thomas
2006 Sep-Oct;12(5):505-506, Breast journal
— id: 69340, year: 2006, vol: 12, page: 505, stat: Journal Article,

Intramammary lymph nodes and breast cancer: a marker for disease severity, or just another lymph node?
Guth, Amber A; Mercado, Cecilia; Roses, Daniel F; Hiotis, Karen; Skinner, Kristin; Diflo, Thomas; Cangiarella, Joan
2006 Oct;192(4):502-505, American journal of surgery
BACKGROUND: Axillary lymph node status is still considered the most significant prognostic factor for breast cancer outcome, and treatment decisions are based on the presence or absence of nodal disease. Intramammary lymph nodes (IMLNs) can be a site of regional spread. Is this a marker for more aggressive disease? METHODS: We reviewed the cancer center pathology database from 1991 to 2005 for all cases of breast cancer with IMLNs. RESULTS: IMLNs were identified in 64 breast cancer patients, with metastatic spread in 20 patients, and benign IMLNs described in 44 patients. Positive IMLNs were associated with more aggressive disease, including higher rates of invasive versus noninvasive cancers (5% ductal carcinoma-in-situ [DCIS] with positive IMLNs vs. 23% with negative IMLNs), lymphovascular invasion (55% vs. 11%), and a higher rate of axillary lymph node involvement (72% vs. 18%). Patients with positive IMLNs were also more likely to undergo mastectomy (75% vs. 54%). CONCLUSIONS: IMLN metastases are a marker for disease severity; recognition of this may influence choice of adjuvant therapy. The presence of metastatic disease in an IMLN is associated with a high rate of axillary nodal involvement, and should mandate axillary dissection. Preoperative lymphoscintigraphy may help identify these extra-axillary metastases
— id: 69076, year: 2006, vol: 192, page: 502, stat: Journal Article,

Public health lessons learned from analysis of New York City subway injuries
Guth, Amber A; O'Neill, Andrea; Pachter, H Leon; Diflo, Thomas
2006 Apr;96(4):631-633, American journal of public health. AJPH
Serious subway injuries are devastating to their young victims and have high rates of mortality and amputation. We identified the urban population at greatest risk for subway injuries and investigated the influence of local economies on injury rates. We propose using changes in social conditions as a 'trigger' for increased vigilance and protective measures at times of higher risk
— id: 64028, year: 2006, vol: 96, page: 631, stat: Journal Article,

Breast cancer detection in a minority population: Can we succeed in early diagnosis?
Hiotis, KL; Marti, JL; Harris, MA; Naik, A; Shapiro, RL; Guth, AA
2006 MAY ;15(4):471-471, Journal of women's health (Larchmont, N.Y. : 2002)
— id: 64631, year: 2006, vol: 15, page: 471, stat: Journal Article,

Evaluation of aromatherapy in treating postoperative pain: pilot study
Kim, Jung T; Wajda, Michael; Cuff, Germaine; Serota, David; Schlame, Michael; Axelrod, Deborah M; Guth, Amber A; Bekker, Alex Y
2006 Dec;6(4):273-277, Pain practice
This study compared the analgesic efficacy of postoperative lavender oil aromatherapy in 50 patients undergoing breast biopsy surgery. Twenty-five patients received supplemental oxygen through a face mask with two drops of 2% lavender oil postoperatively. The remainder of the patients received supplemental oxygen through a face mask with no lavender oil. Outcome variables included pain scores (a numeric rating scale from 0 to 10) at 5, 30, and 60 minutes postoperatively, narcotic requirements in the postanesthesia care unit (PACU), patient satisfaction with pain control, as well as time to discharge from the PACU. There were no significant differences in narcotic requirements and recovery room discharge times between the two groups. Postoperative lavender oil aromatherapy did not significantly affect pain scores. However, patients in the lavender group reported a higher satisfaction rate with pain control than patients in the control group (P = 0.0001)
— id: 69409, year: 2006, vol: 6, page: 273, stat: Journal Article,

Qualitative criteria to evaluate sentinel lymph node frozen sections for breast cancer
Singh, B; Ziguridis, N; Guzman, SA; Axelrod, DM; Shapiro, RL; Guth, AA; Skinner, KA; Cangiarella, J; Roses, DF
2006 ;100(2):S173-S173, Breast cancer research & treatment
— id: 93506, year: 2006, vol: 100, page: S173, stat: Journal Article,

Three-dimensional imaging in breast reconstruction: a useful adjunct to surgical planning and assessment
Tepper, OM; Karp, NS; Small, K; Rudolph, L; Roses, D; Shapiro, R; Guth, A; Axelrod, D; Choi, M
2006 FEB ;100(2):S119-S119, Breast cancer research & treatment
— id: 71006, year: 2006, vol: 100, page: S119, stat: Journal Article,

The quality of early-stage breast cancer treatment: what can we do to improve?
Bickell, Nina A; Mendez, Jane; Guth, Amber A
2005 Jan;14(1):103-17, vi, Surgical oncology clinics of North America
Early-stage breast cancer is a highly curable disease with well-established protocols, including surgery, and the adjuvant modalities of regional radiation therapy, chemotherapy, and hormonal therapy. Yet, there is clear evidence that these adjuvant modalities are underused significantly. This article reviews the evidence that supports the use of efficacious local and systemic therapies in early-stage breast cancer, reasons for underuse, and interventions that have proven to be effective in ensuring the delivery of appropriate breast cancer care and suggests strategies to improve the quality of breast cancer care
— id: 96572, year: 2005, vol: 14, page: 103, stat: Journal Article,

Influence of gender on surgical outcomes: does gender really matter?
Guth, Amber A; Hiotis, Karen; Rockman, Caron
2005 Mar;200(3):440-455, Journal of the American College of Surgeons
— id: 50294, year: 2005, vol: 200, page: 440, stat: Journal Article,

Aspiration biopsy of nodular pseudoangiomatous stromal hyperplasia of the breast: Clinicopathologic correlates in 10 cases
Levine, Pascale Hummel; Nimeh, Diana; Guth, Amber A; Cangiarella, Joan F
2005 May 6;32(6):345-350, Diagnostic cytopathology
Nodular pseudoangiomatous stromal hyperplasia (PASH) of the breast is rare and often indistinguishable from fibroadenoma, clinically and on aspiration biopsy smears. We report our observations in 10 patients with PASH, evaluated by fine-needle aspiration (FNA) biopsy and core biopsy.We retrospectively reviewed the clinical, radiographic, cytologic, and histologic findings in 10 cases of pure nodular PASH.Ten patients with a presumed clinical and radiologic diagnosis of fibroadenoma underwent aspiration biopsy. The aspiration smears were diagnosed as fibroadenoma (4 cases), cellular fibroadenoma (1 case), schwannoma versus neurofibroma (1 case), fibrocystic change (3 cases; 2 with atypia), and 'not specific for a lesion' (1 case). A diagnosis of PASH was not suspected in any case. A discrepant or imprecise cytologic diagnosis and /or the presence of dissociated spindle or epithelial cells, or cellular stromal fragments prompted a surgical excision in 7 of 10 patients (70%). The remaining 3 patients exhibited cytologic features of fibroadenoma and were diagnosed as such; however, surgical excision was recommended. Three patients underwent a subsequent core biopsy, with a diagnosis of PASH being made in 1 patient.FNA biopsy could not discriminate PASH from fibroadenoma in 4 of 10 patients (40%) or suggest a diagnosis of PASH in any case. On retrospective review, the finding of plump, spindle-shaped mesenchymal cells may be a cytologic clue to suggest a diagnosis of PASH. Diagn. Cytopathol. 2005;32:345-350. (c) 2005 Wiley-Liss, Inc
— id: 52547, year: 2005, vol: 32, page: 345, stat: Journal Article,

Prone accelerated partial breast irradiation after breast-conserving surgery: Preliminary clinical results and dose-volume histogram analysis
Formenti, Silvia C; Truong, Minh Tam; Goldberg, Judith D; Mukhi, Vandana; Rosenstein, Barry; Roses, Daniel; Shapiro, Richard; Guth, Amber; Dewyngaert, J Keith
2004 Oct 1;60(2):493-504, International journal of radiation oncology biology physics
PURPOSE: To report the clinical and dose-volume histogram results of the first 47 patients accrued to a protocol of accelerated partial breast irradiation. Patients were treated in the prone position with three-dimensional conformal radiotherapy after breast-conserving surgery. METHODS AND MATERIALS: Postmenopausal women with Stage T1N0 breast cancer were eligible only after they had first refused to undergo 6 weeks of standard radiotherapy. Planning CT in the prone position was performed on a dedicated table. The postoperative cavity was defined as the clinical target volume, with a 1.5-cm margin added to determine the planning target volume. A total dose of 30 Gy at 6 Gy/fraction was delivered in five fractions within 10 days. RESULTS: The median age of the patients was 67.5 years (range, 51-88 years). The median tumor diameter was 9 mm (range, 1.3-19 mm). In all patients, the prescribed dose encompassed the planning target volume. The mean volume of the ipsilateral breast receiving 100% of the prescription dose was 26% (range, 10-45%), and the mean volume contained within the 50% isodose surface was 47% (range, 23-75%). The lung and heart were spared by treating in the prone position. Acute toxicity was modest, limited mainly to Grade 1-2 erythema. With a median follow-up of 18 months, only Grade 1 late toxicity occurred, and no patient developed local recurrence. CONCLUSION: These data suggest that this approach is well tolerated, with only mild acute side effects and sparing of the heart and lung
— id: 45301, year: 2004, vol: 60, page: 493, stat: Journal Article,

Hypo-Fractionated Conformal Radiation Therapy to the Tumor Bed After Segmental Mastectomy
Formenti, Silvia C; Roses, Daniel; Harris, Matthew; Shapiro, Richard; Guth, Amber
[Ft. Belvoir, VA] : Ft. Belvoir Defense Technical Information Center, 2003,
The current trial tests a regimen of conformal hypo-fractionated radiotherapy (5 fractions) directed to the original tumor bed with margins in a selected subset of post- menopausal women with breast cancer with a very low risk for local recurrence elsewhere in the breast. We are currently reporting the feasibility results and DVH analysis of the first 4% patients accrued. After planning CT is conducted in the prone position the breast tissue and tumor bed are contoured on a 3D planning system and a 2 cm margin added to determine the PTV. A plan is generated to treat the PTV to 90% of the prescription dose. Six Gy per fraction are delivered to the 95% isodose surface in 5 fractions over ten days weeks to a total dose of 30 Gy. All patients appeared to tolerate treatment very well. DVH varied based on the position of the original tumor bed and the size of the breast. In most cases it was possible to successfully plan and treat a quadrant of the breast with parallel opposed tangent fields without exceeding 50% of the dose to 50% of the breast volume. We continue accrual as planned, to a total of 99 patients
— id: 2130, year: 2003, vol: , page: , stat: ,

Trauma outcome in the SICU: Does gender really matter?
Guth, AA; Petrulio, C; Hopkins, MA; Pachter, HL
2003 FEB ;31(2):A58-A58, Critical care medicine
— id: 37180, year: 2003, vol: 31, page: A58, stat: Journal Article,

Breast cancer and human immunodeficiency virus infection: issues for the 21st century
Guth, Amber A
2003 Apr;12(3):227-232, Journal of women's health (Larchmont, N.Y. : 2002)
BACKGROUND: As we enter the 21st century, AIDS and breast cancer are two pressing issues in women's health. The spread of AIDS continues unabated. More than 21.8 million people have died of AIDS, and it is estimated that as of December 2000 an additional 36.1 million people, mostly in sub-Saharan Africa, were infected with the human immunodeficiency virus. In addition, women now constitute almost one half of all AIDS cases. With the widespread use of highly active antiretroviral therapy in the United States, the overall health and survival of HIV(+) individuals has improved dramatically. Thus, as the HIV(+) population matures, we will be called on to diagnose and treat more cases of breast cancer in seropositive women. What can we expect as the incidence of these two diseases begins to overlap? METHODS: Medline search, and review of the relevant literature. RESULTS: Forty-six published cases of breast cancer in HIV(+) individuals identified. CONCLUSIONS: Based on epidemiologic data from Western countries and Africa, HIV infection is not permissive for breast cancer. This is reflected in the paucity of available data. Early reports consisted of case reports, describing advanced cancers with unusual presentations and uniformly poor prognoses. Recent series describe more favorable prognoses and long-term survivors. It appears that hormonal therapy is well tolerated and effective, even in cases of locally advanced disease, and the toxicity from standard chemotherapy regimens is unacceptably high
— id: 39197, year: 2003, vol: 12, page: 227, stat: Journal Article,

Hypo-Fractionated Conformal Radiation Therapy to the Tumor Bed After Segmental Mastectomy
Formenti, Silvia C; Roses, Daniel; Harris, Matthew; Shapiro, Richard; Guth, Amber
[Ft. Belvoir, VA] : Ft. Belvoir Defense Technical Information Center, 2002,
The current trial tests a regimen of conformal hypo-fractionated radiotherapy (5 fractions) directed to the original tumor bed with margins in a selected subset of post- menopausal women with breast cancer with a very low risk for local recurrence elsewhere in the breast. We are currently reporting the feasibility results and DVN analysis of the first 29 patients accrued. After planning CT is conducted in the prone position the breast tissue and tumor bed are contoured on a 3D planning system and a 2 cm margin added to determine the PTV. A plan is generated to treat the PTV to 90% of the prescription dose. Six Gy per fraction are delivered to the 95 isodose surface in 5 fractions over ten days weeks to a total dose of 30 Gy. All patients appeared to tolerate treatment very well. DVH varied based on the position of the original tumor bed and the size of the breast. In most cases it was possible to successfully plan and treat a quadrant of the breast with parallel opposed tangent fields without exceeding 50% of the dose to 50% of the breast volume. We continue accrual as planned, to a total of 99 patients
— id: 2129, year: 2002, vol: , page: , stat: ,

Routine chest X-rays after insertion of implantable long-term venous catheters: necessary or not?
Guth AA
2001 Jan;67(1):26-29, American surgeon
Can long-term subcutaneous venous (Mediport) catheters be safely inserted without routine chest X-ray (CXR) verification? An estimated 500,000 Mediport catheters are inserted yearly in the United States, and elimination of unnecessary radiographs would result in substantial savings of increasingly limited health care resources. A total of 513 consecutive Mediport catheters were inserted by a single surgeon over a 5-year period using a standardized protocol and selective indications for follow-up CXR that included unilateral chest pain, aspiration of air, decreased breath sounds, and difficult catheter insertion. The 513 catheters were inserted in 498 patients with 271 patients (53%) undergoing postprocedure CXR. Of the 513 catheters 461 (90%) were placed by percutaneous approach to the subclavian vein. Six pneumothoraces (1.2% incidence) occurred, all in patients who met criteria for immediate CXR. The overall complication rate was 3.1 per cent and included eight instances of catheter-tip malposition (seven of the eight were successfully repositioned by vascular radiology), one mediastinal hematoma, and one chest-wall hematoma. This largest single-surgeon-reported series demonstrates that Mediport insertion can be safely accomplished with minimal complications following a standardized protocol using selective radiologic evaluation
— id: 26810, year: 2001, vol: 67, page: 26, stat: Journal Article,

Domestic violence and the trauma surgeon
Guth AA; Pachter L
2000 Feb;179(2):134-140, American journal of surgery
BACKGROUND: Domestic violence has become increasingly recognized as a public health problem, and was declared a national epidemic by C. Everett Koop in 1992. In the United States, 1 to million women yearly suffer injuries due to domestic violence, and 30% to 50% of female homicides are committed by a present or former partner. The majority of these murder victims had either been seen in emergency rooms for prior domestic violence-related injuries, or had reported these injuries to the police. It is estimated that 50% of all acute injuries and 21% of all injuries in women requiring urgent surgery ar the result of partner abuse. DATA SOURCE: Medline and current literature review. CONCLUSIONS: Health care professionals in the emergency room are an important contact with the victims of domestic violence, and timely identification and intervention can save lives. Overall, upwards of 35% of all emergency room visits by women are the result of domestic violence, whether due to acute injury, problems during pregnancy, or stress-related complaints. Unfortunately, domestic abuse is infrequently disclosed voluntarily by the patient, and often overlooked by the treating physician. Thus, the purpose of this review is to familiarize surgeons with the presentation and management of victims of this hidden epidemic
— id: 11516, year: 2000, vol: 179, page: 134, stat: Journal Article,

Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis
Ochsner MG; Knudson MM; Pachter HL; Hoyt DB; Cogbill TH; McAuley CE; Davis FE; Rogers S; Guth A; Garcia J; Lambert P; Thomson N; Evans S; Balthazar EJ; Casola G; Nigogosyan MA; Barr R
2000 Sep;49(3):505-510, Journal of trauma
BACKGROUND: The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers. OBJECTIVE: The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance. METHODS: Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (<250 mL) or no free fluid detected by an attending radiologist. Data were collected from six major trauma centers during a 4-year period before the introduction of U/S and included demographics, grade of injury (American Association for the Surgery of Trauma scale), need for operative intervention, and outcome. RESULTS: A total of 938 patients with liver and splenic injuries were identified. In this group, 11% of liver injuries and 12% of splenic injuries had no free fluid visible on CT scan and could be missed by diagnostic peritoneal lavage or U/S. Of the 938 patients, 267 (28%) met the inclusion criteria; 161 had injury to the spleen and 125 had injury to the liver. In the 267 patients studied, 97% of the injuries were managed nonoperatively. However, 8 patients (3%) required operative intervention for bleeding. Compared with the liver, the spleen was significantly more likely to bleed (p = 0.01), but the grade of splenic injury was not related to the risk for hemorrhage (p = 0.051). CONCLUSION: Data from this study suggest that injuries to the liver or spleen with minimal or no intraperitoneal fluid visible on CT scan occur more frequently than predicted but usually are of minimal clinical significance. However, patients with splenic injuries may be missed by abdominal U/S. We found a 5% associated risk of bleeding. Therefore, abdominal U/S should not be used as the sole diagnostic modality in all stable patients at risk for blunt abdominal injury
— id: 20061, year: 2000, vol: 49, page: 505, stat: Journal Article,

Breast cancer and HIV: what do we know?
Guth AA
1999 Mar;65(3):209-211, American surgeon
The present acquired human immunodeficiency syndrome-defining neoplasms are Kaposi's sarcoma, non-Hodgkins lymphoma, and cervical cancer. However, other malignancies have recently been associated with human immunodeficiency virus (HIV) infection. Is there also a link between breast cancer and HIV infection? Breast cancer seems to be more aggressive in the setting of immunocompromise by HIV infection, as demonstrated by the clinical course of two patients recently treated at this institution and review of the available literature. As the acquired human immunodeficiency syndrome epidemic affects increasing numbers of women and survival improves, surgeons will be frequently called on to diagnose and treat breast cancer in the HIV+ patient
— id: 57037, year: 1999, vol: 65, page: 209, stat: Journal Article,

Laparoscopy for penetrating thoracoabdominal trauma: pitfalls and promises
Guth AA; Pachter HL
1998 Apr-Jun;2(2):123-127, Journal of the Society of Laparoendoscopic Surgeons
BACKGROUND: How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention. DESIGN: Prospective case series. MATERIALS AND METHODS: Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken. RESULTS: Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma victims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy. CONCLUSIONS: Laparoscopy has become a useful and accurate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontherapeutic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the primary technique to evaluate penetrating lower thoracic trauma
— id: 7338, year: 1998, vol: 2, page: 123, stat: Journal Article,

Changing patterns in the management of splenic trauma: the impact of nonoperative management
Pachter HL; Guth AA; Hofstetter SR; Spencer FC
1998 May;227(5):708-717, Annals of surgery
OBJECTIVE: The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed. METHODS: Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy. RESULTS: Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management. CONCLUSIONS: Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate
— id: 7728, year: 1998, vol: 227, page: 708, stat: Journal Article,

Human immunodeficiency virus and the trauma patient: factors influencing postoperative infectious complications
Guth AA; Hofstetter SR; Pachter HL
1996 Aug;41(2):251-255, Journal of trauma
OBJECTIVE: While immunosuppression 2 degrees to human immunodeficiency virus (HIV) infection should logically render HIV+ trauma victims more prone to infection after injury, little data is available regarding trauma outcome in this group of patients. Since the helper CD4+ lymphocyte count is a marker for progression of HIV-associated diseases, we examined the relationship between CD4+ counts, Injury Severity Score (ISS), and bacterial infectious complications in HIV+ trauma patients. METHOD: Retrospective review of 56 consecutive HIV+ trauma patients treated at a Level I trauma center. RESULTS: Nine patients (15%) developed significant infectious complications (four pneumonias, three soft-tissue infections, one urinary tract infection, one wound infection) with no pattern to the causative agents. Evaluation of CD4+ counts, white blood cell counts, serum albumin levels, blood transfusion requirements, and ISS revealed that only the ISS was associated with infectious complications. CONCLUSION: Despite the profound immunosuppression in this group of patients, the incidence of bacterial infectious complications was independent of the CD4+ count (p = 0.958), but was associated with increases in the ISS (p = 0.003)
— id: 56875, year: 1996, vol: 41, page: 251, stat: Journal Article,

Rupture of the pathologic spleen: is there a role for nonoperative therapy?
Guth AA; Pachter HL; Jacobowitz GR
1996 Aug;41(2):214-218, Journal of trauma
INTRODUCTION: While nonoperative management of blunt splenic injury in the stable patient has become the standard of care, splenectomy is still advocated as the safest management for rupture of the diseased spleen. The combination of splenectomy and underlying immunosuppression may render these patients particularly susceptible to postsplenectomy infection, and thus we undertook a prospective trial of nonoperative management of the ruptured pathologic spleen. METHODS: Hemodynamically stable patients with preexisting pathologic splenomegaly and isolated splenic disruptions diagnosed by computed tomographic (CT) scan (American Association for the Surgery of Trauma (AAST) grades 1-4) requiring 2 or less units blood transfusion were prospectively studied. Patients were monitored in a critical care setting, and resolution of splenic disruption was followed by serial CT examinations. RESULTS: Nonoperative management was successful in all 11 patients (eight, HIV/AIDS; one each, acute leukemia, infectious mononucleosis, sickle cell anemia). The mean transfusion requirement was 0.7 units; the mean length of stay was 16 days. CONCLUSIONS: The pathologic spleen can heal after parenchymal disruption. While not appropriate for all patients, a subset of hemodynamically stable patients can be successfully managed nonoperatively using CT diagnosis, close clinical monitoring, and minimal transfusions
— id: 12573, year: 1996, vol: 41, page: 214, stat: Journal Article,

Pitfalls in the diagnosis of blunt diaphragmatic injury
Guth AA; Pachter HL; Kim U
1995 Jul;170(1):5-9, American journal of surgery
BACKGROUND: Severe blunt trauma to the torso can result in diaphragmatic disruption. Prompt recognition of this potentially life-threatening injury is difficult when the initial chest roentgenogram is unrevealing and immediate thoracotomy or celiotomy is not performed. This retrospective study was undertaken to: (1) determine the incidence of missed diaphragmatic injuries on initial evaluation; (2) identify factors contributing to diagnostic delays; and (3) formulate a diagnostic approach that reliably detects diaphragmatic rupture following blunt trauma. METHODS: Retrospective review of hospital records and radiographs from our 18-year experience with blunt diaphragmatic injuries. RESULTS: Seven of 57 (12%) blunt diaphragmatic injuries were missed on initial evaluation. Recognition followed 2 days to 3 months later. Two (4%) isolated left-sided injuries initially presented with normal chest roentgenograms. Five patients (9%) (4 with right-sided ruptures) had abnormalities on chest roentgenogram or computed tomography (CT) initially attributed to chest trauma. They were diagnosed by radionuclide, ultrasound, or CT investigations of hemothorax, pulmonary sepsis, and right upper quadrant pain; and, in 1 case, at thoracotomy for a persistent right hemothorax. In the remaining 50 patients (88%), the diagnosis was established within 24 hours. In 21 (42%) of these, the problem was initially recognized at the time of celiotomy for accompanying injuries. CONCLUSIONS: Blunt diaphragmatic injuries are easily missed in the absence of other indications for immediate surgery, since radiologic abnormalities of the diaphragm--particularly those involving the right hemidiaphragm--are often interpreted as thoracic trauma. In this setting, a high index of suspicion coupled with selective use of radionuclide scanning, ultrasound, and CT or magnetic resonance imaging is necessary for early detection of this uncommon injury
— id: 12750, year: 1995, vol: 170, page: 5, stat: Journal Article,

Combined duodenal and colonic necrosis. An unusual sequela of caustic ingestion [see comments]
Guth AA; Pachter HL; Albanese C; Kim U
1994 Dec;19(4):303-305, Journal of clinical gastroenterology
Two unusual cases of liquid caustic ingestion that resulted in gangrene of the duodenum and adjacent colon, and burns of the esophagus, stomach, and pancreas are presented. The routine evaluation of the oropharynx, esophagus, and stomach after liquid caustic ingestion can seriously underestimate the extent of injury to distal portions of the gastrointestinal (GI) tract, such as the colon and pancreas, that are not usually included in the initial evaluation of ingestion injuries. In stable patients managed nonoperatively, the entire upper GI tract, including the duodenum, must be visualized either by endoscopy or, less preferably, by barium series. Double-contrast computed tomography should be performed when significant duodenal injuries are present in order to inspect the colon, pancreas, and small bowel. With this approach, life-threatening, multi-organ, subdiaphragmatic ingestion injuries can be identified and treated early
— id: 6640, year: 1994, vol: 19, page: 303, stat: Journal Article,

Blast injury to the thoracic esophagus
Guth AA; Gouge TH; Depan HJ
1991 May;51(5):837-839, Annals of thoracic surgery
Blast injury causing pneumatic disruption of the esophagus is a rare and potentially lethal injury. The mortality and morbidity rate are high unless the injury is promptly recognized and treated. Our experience with a midesophageal perforation resulting from a blast injury emphasizes the importance of awareness of this condition and of the chest radiograph in making an early diagnosis
— id: 14027, year: 1991, vol: 51, page: 837, stat: Journal Article,

The reappearance of abdominal tuberculosis
Guth AA; Kim U
1991 Jun;172(6):432-436, Surgery, gynecology & obstetrics
Seventeen patients with abdominal tuberculosis were recently treated at our institution. Two distinct patient populations were identified--immigrants and individuals infected with the human immunodeficiency virus. Abdominal pain, weight loss and fever were the most common complaints, with abdominal tenderness and pyrexia the most frequent physical findings. Only five of 17 patients had concomitant pulmonary tuberculosis. A typical computed tomographic scan was helpful in the diagnosis. Diagnosis was made at emergency (five patients) or elective (six patients) laparotomy, by endoscopic (two patients) or percutaneous (three patients) biopsy or on the basis of roentgenologic and clinical evidence (one patient). All responded to antituberculous chemotherapy. With the spread of acquired immunodeficiency syndrome (AIDS), tuberculosis has become increasingly frequent in urban areas and it must be suspected in all immigrants and patients with AIDS presenting with abdominal complaints
— id: 60906, year: 1991, vol: 172, page: 432, stat: Journal Article,