Warm and Neutral Tumescent Anesthetic Solutions Are Essential Factors for a Less Painful Injection

BACKGROUND: Tumescent local anesthesia is widely used in dermatologic surgery. Minimizing pain associated with injections is crucial to successful surgical procedures. OBJECTIVE: This study investigates the pain associated with warm and room temperatures in neutralized or nonneutralized tumescent anesthetic solutions injection. METHODS: Thirty-six patients with axilla osmidrosis who underwent local anesthesia for surgery were randomly assigned to three groups. Group A received warm neutral (40 degrees C) and room-temperature neutral (22 degrees C) tumescent injections to each axillary region. Group B received warm neutral (pH 7.35) and warm nonneutral (pH 4.78) tumescent injections on each side of axilla. Group C received warm nonneutral and room-temperature nonneutral tumescent injections on each side of axilla. Pain associated with infiltration of anesthesia was rated on a visual analog scale (VAS). RESULTS: A statistically significant decrease (p < .001) in pain sensation was reported on the warm, neutral injection side (mean rating, 32.7 mm) compared with the room-temperature, neutral injection side (mean rating, 53.3 mm). Patient-reported pain intensity was significantly lower on the side that received warm, neutral tumescent anesthesia (mean rating, 26.8 mm) than on the side receiving warm, nonneutral tumescent anesthesia (mean rating, 44.9 mm; p < .001). The difference in VAS scores between warm neutral (mean rating, 23.9 mm) and room-temperature nonneutral (mean rating, 61.2 mm) was statistically significant (p < .001). CONCLUSION: The warm, neutral tumescent anesthetic preparation effectively suppressed patient pain during dermatologic surgical procedures.     

Topically Applied Botulinum Toxin Type A for the Treatment of Primary Axillary Hyperhidrosis: Results of a Randomized, Blinded, Vehicle-Controlled Study

OBJECTIVE The objective was to demonstrate that botulinum toxin type A (BTX-A) can be delivered to targeted skin sites with topical application for the treatment of primary axillary hyperhidrosis.
METHODS This randomized, blinded, vehicle-controlled study enrolled 12 patients with primary axillary hyperhidrosis with greater than 50 mg of sweat produced per 5 minutes. BTX-A (200 U), combined with a proprietary transport peptide molecule to bind the toxin in a noncovalent manner, was topically applied to one axilla; vehicle without BTX-A was applied to the other axilla. Rates of sweat production were measured and imaged at baseline and 4 weeks after application.
RESULTS Two patients were excluded from analyses. At 4 weeks, 10 axillae treated topically with BTX-A demonstrated a 65.3±21.5% mean reduction in sweating relative to the same-patient, vehicle-control axillae, which had a 25.3±66.2% mean reduction. The 40% difference in mean sweat reduction between groups was statistically significant ( p< .05). Quantitative image analysis of the results of the Minor's iodine starch test confirmed the reduction of sweat production in the BTX-A–treated versus the vehicle-treated axillae.
CONCLUSION Topically applied BTX-A appears to be safe and may prove to be effective for the treatment of axillary hyperhidrosis.     

Long-Term Morbidity of Sentinel Node Biopsy Versus Complete Axillary Dissection for Unilateral Breast Cancer

Background  Postoperative changes after axillary lymph node surgery may significantly alter breast cancer survivors’ (BCS) quality of life. Although sentinel lymph node biopsy (SLNB) has less immediate morbidity than axillary lymph node dissection (ALND), its long-term impact on shoulder abduction, arm swelling, and neurosensory changes has not been evaluated. The purpose of this study was to compare long-term morbidity after SLNB or ALND and breast-conservation surgery. Methods  Female BCS who remained free of disease at least 3 years after ALND or SLNB for Stage I–III unilateral breast cancer completed a symptom questionnaire and a brief neurosensory physical examination of the upper arm and axilla (range of motion, arm circumference, and sensation to light touch with cotton and needle). Results  The mean age of the 187 participating BCS was 62 years. At a mean follow-up of 6.6 years after ALND and 4.9 years after SLNB, most BCS had full abduction; only 10 cases (8 ALND, 2 SLNB) had a ≥2 cm proximal and/or distal circumference difference on the ipsilateral side compared with the contralateral side. ALND was associated with a significantly greater likelihood of subjective arm numbness (P < .001), chest or axillary numbness (P < .001), arm or hand swelling (P < .001), and objective neurosensory changes in the posterior axilla, medial and distal upper arm (P < .001). Operative procedure was the only significant predictor of neurosensory changes (P < .001). Conclusion  SLNB is associated with significantly less subjective and objective long-term morbidity than ALND.     

腋臭除臭剂功效评估方法的探讨

目的 探索腋臭除臭剂的功效评价方法.方法 4名经过培训入选的评判者,用盲法对入选的60名受试者在应用腋臭除臭剂前,以及应用后6 h和24 h进行直接法和间接法腋窝气味评估.间接法是在受试者每次评分后为受试者提供新的体恤衫,用体恤衫转移的腋窝气味进行间接腋窝气味评估.统计分析应用除臭剂前后,受试者腋窝气味变化.结果 在应用3种不同剂型的腋臭除臭剂后,两种评估法所评出的结果,腋窝气味评估均有下降.但3种除臭剂的有效率不同.结论 腋窝气味直接评估法是腋臭除臭剂功效评价的较好方法.     

腋臭除臭剂功效评估方法的探讨

目的 探索腋臭除臭剂的功效评价方法.方法 4名经过培训入选的评判者,用盲法对入选的60名受试者在应用腋臭除臭剂前,以及应用后6 h和24 h进行直接法和间接法腋窝气味评估.间接法是在受试者每次评分后为受试者提供新的体恤衫,用体恤衫转移的腋窝气味进行间接腋窝气味评估.统计分析应用除臭剂前后,受试者腋窝气味变化.结果 在应用3种不同剂型的腋臭除臭剂后,两种评估法所评出的结果,腋窝气味评估均有下降.但3种除臭剂的有效率不同.结论 腋窝气味直接评估法是腋臭除臭剂功效评价的较好方法.     

腋臭除臭剂功效评估方法的探讨

目的 探索腋臭除臭剂的功效评价方法.方法 4名经过培训入选的评判者,用盲法对入选的60名受试者在应用腋臭除臭剂前,以及应用后6 h和24 h进行直接法和间接法腋窝气味评估.间接法是在受试者每次评分后为受试者提供新的体恤衫,用体恤衫转移的腋窝气味进行间接腋窝气味评估.统计分析应用除臭剂前后,受试者腋窝气味变化.结果 在应用3种不同剂型的腋臭除臭剂后,两种评估法所评出的结果,腋窝气味评估均有下降.但3种除臭剂的有效率不同.结论 腋窝气味直接评估法是腋臭除臭剂功效评价的较好方法.     

Fibroadenoma of the Axilla

Background. Ectopic, axillary breast tissue can develop any disease that affects the normal breast, including fibroadenoma.
Objective. To report and discuss a case of fibroadenoma of the axilla in a 23-year-old woman.
Methods. Case report and discussion of the rare entity of fibroadenoma of the axilla.
Results. The histology was identical to the fibroadenomas seen in the breast and those observed along the milk line.
Conclusion. Differential diagnosis of an axillary tumor should include ectopic breast tissue.     

Split-Face Treatment of Facial Dyschromia: Pulsed Dye Laser with a Compression Handpiece versus Intense Pulsed Light

BACKGROUND Many visible light lasers and intense pulsed light (IPL) devices are available to treat photodamaged skin.
OBJECTIVES The objective was to perform a multiple-treatment split-face comparison evaluating a pulsed dye laser (PDL) with a compression handpiece versus IPL for photorejuvenation.
METHODS Ten subjects were treated three times at 3- to 4-week intervals. One side of the face was treated with the PDL with compression handpiece, and the other with IPL. One month after final treatment, blinded evaluation assessed for improvements in dyschromias and texture. Patients provided self-assessment of improvement in dyschromias and texture. Time to complete final treatments and pain during all treatments were recorded for each device.
RESULTS Improvement of the PDL was (mean) 86.5, 65, 85, 38, and 40% for dark lentigines, light lentigines, vessels <0.6 mm, vessels >0.6 mm, and texture, respectively, versus 82, 62.5, 78.5, 32.5, and 32%, respectively, for the IPL side. Patient-evaluated difference in improvement for vascular lesions significantly favored the PDL ( p =.011). Mean third treatment times were 7.7 minutes for PDL versus 4.6 minutes for the IPL ( p =.005). Mean pain ratings were 5.8 for the PDL and 3.1 for the IPL ( p =.007). Purpura-free procedures depended on proper technical use of the compression handpiece when treating lentigines with the PDL.
CONCLUSIONS The PDL with compression handpiece and IPL are highly effective for photorejuvenation.     

Treatment of the axilla in early breast cancer: past, present and future

Background: The optimal treatment of the axilla in early breast cancer is controversial. The present study reviews the pattern and predictors of regional recurrence (RR) and prognosis after RR in patients with early breast cancer treated by conservative surgery and radiotherapy (CS + RT). Implications of the results on current practice and future directions are explored. Methods: Between 1979 and 1994, 1158 patients with stage I or II breast cancer were treated with CS + RT at Westmead Hospital. Two groups of patients were compared: 782 patients who underwent axillary dissection (axillary surgery group) and 229 patients who received radiotherapy (axillary RT group) as the only axillary treatment. At least 10 lymph nodes were dissected in 82% of the axillary surgery group. Of the women in the RT group, 90% received RT to the axilla and supraclavicular fossa (SCF) only and 10% also received RT to the internal mammary chain (IMC). Results: With a median follow‐up period of 79 months for the axillary surgery group and 111 months for the axillary RT group, 27 patients developed a RR (2.8% and 2.2%, respectively). Seven patients (0.9%) in the axillary surgery group and three patients (1.3%) in the axillary RT group developed a RR in the axilla (P, not significant). Of the patients with SCF recurrences, 14 (1.8%) were in the axillary surgery group and one (0.4%) in the axillary RT group (P, not significant). One patient in the axillary surgery group developed concurrent axillary and SCF recurrences, while a patient in the axillary RT group developed an IMC recurrence. Twenty (74%) of the 27 patients with a RR developed a concurrent or subsequent distant relapse (30% and 44%, respectively). In the pathologically node‐positive patients, the axillary recurrence rate was higher in those who had less than five nodes removed (17%) than those who had 10 or more nodes removed (0%; P = 0.01). The SCF recurrence rate was higher in patients with four or more positive axillary nodes (9.5%) than in those with 0–3 positive nodes (1.5%; P = 0.003). Conclusion: Adequate treatment of the axilla by surgery or RT alone is associated with a low rate of RR. The incidence of distant relapse was substantial in patients who developed a RR, which gives emphasis to the importance of optimizing local–regional control.     

Subdermal Nd-YAG Laser for Axillary Hyperhidrosis

BACKGROUND Axillary hyperhidrosis is a common but difficult-to-treat condition with major social, labor, and emotional consequences.
OBJECTIVE The aim of this study is to present the Nd-YAG laser as a safe and effective option for the treatment of axillary hyperhidrosis.
MATERIALS AND METHODS From January 2002 to April 2007, 17 patients (15 women and 2 men) with axillary hyperhidrosis were treated using a subdermal 1,064-nm Nd-YAG laser. The results were evaluated by the patients as well as by the physician. The objective evaluation was realized by Minor's iodine starch test combined with planimetry. Histology was performed in axillary skin after the laser treatment.
RESULTS The subdermal laser-assisted axillary hyperhidrosis treatment using a 1,064-nm Nd-YAG laser resulted in significant clinical improvement.
CONCLUSIONS The treatment of axillary hyperhidrosis using the 1,064-nm Nd-YAG laser has the advantage of a minor invasive procedure without leaving large scars and causing temporary impairment. The laser proved to be effective and safe. Although the laser treatment has shown promising results in this pilot trial, further studies are necessary for final conclusions.     

Comparative Evaluation of Long-Pulse Alexandrite and Long-Pulse Nd:YAG Laser Systems Used Individually and in Combination for Axillary Hair Removal

BACKGROUND The 755-nm alexandrite and the 1,064-nm Nd:YAG lasers are both utilized for hair removal. Advances in laser technology have led to the development of dual-wavelength treatment for increased efficacy.
OBJECTIVE The objective was to evaluate the safety and efficacy of combining 755- and 1,064-nm wavelengths for axillary hair removal.
METHODS Twenty patients received three treatments at 4- to 6-week intervals in four axillary quadrants. The left upper axilla was treated with the alexandrite laser, the left lower axilla with the Nd:YAG laser, the right upper axilla with combination alexandrite and Nd:YAG laser, and the right lower quadrant with the diode laser. At 1- and 2-month follow-up visits, subjects completed questionnaires and were assessed for percentage of hair reduction.
RESULTS Eighteen subjects completed the study. The greatest reduction was seen with the alexandrite laser at 70.3% and combination of alexandrite and Nd:YAG laser at 67.1%. The diode laser was less efficacious at 59.7% and the Nd:YAG laser had the least improvement with 47.4% reduction. Subjects found the alexandrite and diode lasers to be the most tolerable and the Nd:YAG and combination treatment to be the most painful.
CONCLUSION Combination treatment of alexandrite and Nd:YAG lasers provides no added benefit over the alexandrite laser alone.     

Competing considerations in regional nodal treatment for early breast cancer

The purpose of this article was to review the patterns and morbidity of regional recurrence (RR) in patients with early breast cancer, efficacy of salvage therapy for RR, and complications of regional nodal treatment. A retrospective evaluation of 1,158 patients with stage I or stage II breast cancer treated with conservative surgery and radiotherapy (RT) between 1979 and 1994 was performed. Seven hundred fifty patients underwent axillary surgery, and 229 patients received RT as their only treatment of the regional lymphatics. Regional nodal RT was given to 168 patients who also had axillary surgery. The regional lymphatics of 11 patients were not treated. The patterns and morbidity of RR, relapse management, and complications related to regional nodal treatment were reviewed from the patients' records. With a median follow-up of 88 months, a total of 31 patients (2.7%) developed a RR. Nine of 31 patients (29%) with an RR experienced significant morbidity, including pain, fungating tumor, dysphagia, dyspnoea, and/or sensory motor changes at diagnosis. Nineteen patients (61%) had symptomatic residual or progressive regional disease after salvage therapy at last follow-up or death. Six of nine patients (67%) who developed an isolated axillary recurrence and underwent salvage surgery had no further axillary recurrence. The addition of regional nodal RT to breast irradiation significantly increased the incidence of symptomatic pneumonitis (1% without regional nodal RT and 4% with regional nodal RT, p < 0.001). Combined axillary dissection and nodal irradiation resulted in a significantly higher incidence of arm edema compared with either alone (9.5% with axillary dissection, 6.1% with RT to the axilla and supraclavicular fossa, and 31% with combined modality therapy, p < 0.001). Five of 380 patients (1%) who received RT to the axilla and/or supraclavicular fossa developed a transient brachial plexus neuropathy. Although RR was uncommon in patients treated with axillary surgery and/or regional nodal irradiation, salvage therapy failed to eradicate the recurrence in approximately two thirds of the patients with a RR. Ongoing research is essential to optimize regional control with an acceptable level of risk of treatment complications. Sentinel lymph node biopsy, if validated as an accurate method of staging the axilla in patients with breast cancer, would allow selective avoidance of regional nodal treatment and hence the associated morbidity.     

Skin cooling for botulinum toxin A injection in patients with focal axillary hyperhidrosis: a prospective, randomized, controlled study

BACKGROUND: Botulinum toxin A (BTX-A) injections are a commonly used and effective therapy for patients with focal axillary hyperhidrosis. However, injections are often painful. Therefore, we studied whether skin cooling decreases pain during injection. METHODS: Thirty-one patients (n = 31) with focal axillary hyperhidrosis were enrolled in the present study. Patients were treated with 50 MU BTX-A (Botox; Allergan, Irvine, CA) in each axilla. One group (n = 21) received a skin cooling using a cold-air system (SmartCool; Cynosure, Westford, MA) versus no cooling on the other side. In the second group (n = 10), patients were cooled with the same cold air blower on one axilla and ice cubes on the other. For evaluation of the effect of cooling in both groups, relative pain scores using a visual analog scale (VAS) were recorded. RESULTS: In the first group, the air-cooled-side pain scores ranged from 0 to 4 (average: 2.5) versus 5 to 10 (average: 7.4) on the noncooled side. The air-cooled side showed a 66.2% higher reduction in pain score. In the second group, no significant difference was seen between air and ice cooling (average pain score 2.0 versus 2.4; P > 0.05). CONCLUSION: Skin cooling decreases pain during injection of BTX-A in patients with focal axillary hyperhidrosis, with ice and air cooling showing the same efficacy.     

Value of Preoperative Ultrasound-Guided Axillary Lymph Node Biopsy for Preventing Completion Axillary Lymph Node Dissection in Breast Cancer: A Systematic Review and Meta-Analysis

Purpose

This meta-analysis was designed to evaluate the utility of preoperative axillary ultrasound combined with US-guided lymph node biopsy if indicated (AUS ± biopsy), in terms of staging the axilla and preventing two-step axillary surgery in the form of sentinel node biopsy (SNB) followed by completion axillary lymph node (ALN) dissection.

Methods

We systematically searched electronic databases for studies that addressed preoperative assessment of ALN status by AUS ± biopsy. A pooled estimate was calculated for the false-negative rate (FNR) of AUS ± biopsy (defined as the proportion of women with a negative AUS ± biopsy result subsequently proven to have a positive axilla) and sensitivity (defined as the proportion of women with a positive AUS ± biopsy result among all women with a tumor positive axilla).

Results

The pooled FNR was 25 % (95 % confidence interval [CI] = 24–27) and the pooled sensitivity was 50 % (95 % CI = 43–57). There was substantial heterogeneity across studies for both FNR (I ² = 69.42) and sensitivity (I ² = 93.25), which was not explained by between-study differences in biopsy technique, mean/median tumor size, biopsy indication, or study design. Sensitivity was increased in studies with a high prevalence of ALN metastases.

Conclusions

Preoperative axillary ultrasound-guided biopsy is a useful step in the process of axillary staging. Approximately 50 % of women with axillary involvement can be identified preoperatively. Still, one in four women with an ultrasound-guided biopsy-“proven” negative axilla has a positive SNB.     

Therapeutic Lymph Node Dissection in Melanoma: Different Prognosis for Different Macrometastasis Sites?

Background

The prognostic significance of primary tumor location, especially the poor prognosis for melanomas in the scalp and neck region, is well established. However, the prognosis for different sites of nodal macrometastasis has never been studied. This study investigated the prognostic value of the location of macrometastasis in terms of recurrence and survival rates after therapeutic lymph node dissection (TLND).

Methods

All consecutive FDG-PET-staged melanoma patients with palpable and cytologically proven lymph node metastases operated at our clinic between 2003 and 2011 were included. Disease-free survival and disease-specific survival (DSS) were compared for nodal metastases in the groin, axilla, and neck regions by multivariable analysis.

Results

A total of 149 patients underwent TLND; there were 70 groin (47?%), 57 axillary (38?%), and 22 neck (15?%) dissections. During a median follow-up of 18 (range 1?C98) months, 102 patients (68?%) developed recurrent disease. Distant recurrence was the first sign of progressive disease in 78, 76, and 55?% of the groin, axilla, and neck groups, respectively (p?=?0.26). Low involved/total lymph nodes (L/N) ratio (p?<?0.001) and absence of extranodal growth pattern (p?=?0.05) were independent predictors of a longer disease-free survival. For DSS, neck site of nodal metastasis (p?=?0.02) and low L/N ratio (p?<?0.001) were independent predictors of long survival. The estimated 5-year DSS for the groin, axilla, and neck sites was 28, 34, and 66?%, respectively.

Conclusions

There seems significantly longer DSS after TLND for nodal macrometastases in the neck compared to axillary and groin sites, although larger series should confirm this finding.     

半岛黄金微针射频联合欧美娜红光治疗腋臭疗效观察研究

目的 探讨半岛黄金微针射频联合欧美娜红光治疗腋臭的效果。方法 选取2021年4月-2023年3月 江门市新会区皮肤医院接受治疗的60例腋臭患者作为研究对象,随机将患者分为对照组与观察组,每组 30例。对照组采用小切口大汗腺腺体剥离术治疗,观察组采用半岛黄金微针射频联合欧美娜红光治疗,比 较两组腋部气味、腋下汗液分泌范围、临床疗效及并发症发生情况。结果 观察组治疗后腋部气味VAS评 分、腋下汗液分泌范围、治疗总有效率与对照组比较,差异无统计学意义（P＞0.05）;观察组并发症发生 率为3.33%,低于对照组的20.00%（P＜0.05）。结论 针对腋臭患者,采用半岛黄金微针射频联合欧美娜红 光治疗可取得与手术相似的效果,可去除腋部气味,缩小腋下汗液分泌范围,降低并发症发生几率。     

Surgical management of the axilla: do intramammary nodes matter?

Background

The therapeutic significance of intramammary lymph nodes is uncertain. The purpose of this study was to identify the appropriate surgical management of the axilla in intramammary node-positive patients undergoing sentinel lymph node (SLN) biopsy.

Methods

A retrospective review of consecutive patients staged between September 1996 and December 2004 was performed. Intramammary node identification and pathologic findings were compared with the status of axilla.

Results

Among 7,140 patients, intramammary nodes were identified in 151 (2%). Positive intramammary nodes were identified in 36 patients (24%). Axillary disease was identified in 61% of intramammary node-positive patients. No additional axillary disease was identified when axillary lymph node dissection was performed in intramammary node-positive patients with negative axillary SLN biopsy results.

Conclusions

The results suggest that completion axillary lymph node dissection may be based on the status of axillary SLN biopsies in clinically node negative patients when intramammary lymph node metastases are identified in the breast specimens.     

乳腺癌腔镜腋窝淋巴结清扫策略及价值

乳腺癌腔镜腋窝淋巴结清扫（MALND）特殊的手术视野可清晰暴露腋窝解剖结构,最大限度地避免对腋窝血管、淋巴管和神经的损伤,最大程度减少了常规腋窝淋巴结清扫手术后并发症的发生,达到了微创、保留功能和美观的效果。MALND不同于常规腔镜手术,完成该手术的前提条件是术者应较熟练掌握腔镜技术,同时也须熟悉腋窝区的解剖结构。手术流程遵循“自下而上、从低到高”的“时间顺序”和“空间顺序”,即先从腋窝底部往上,至腋窝中部,最后再到腋窝顶部。MALND改变了传统乳腺癌手术程序和路径、手术方法和技术、以及手术视野角度,并且放大了腋窝内局部视野,降低了手术难度。     

Role of axillary lymph node dissection after tumor downstaging with induction chemotherapy for locally advanced breast cancer

Background: Induction chemotherapy has become the standard of care for patients with locally advanced breast cancer (LABC) and currently is being evaluated in prospective clinical trials in patients with earlier-stage disease. To better gauge the role of axillary lymph node dissection in patients with LABC this study was performed to assess initial axillary status on physical and ultrasound examination, axillary tumor downstaging following induction chemotherapy, and the accuracy of physical examination compared with axillary sonography in predicting which patients will have axillary lymph node metastases found on pathologic examination. Methods: Between 1992 and 1996, 147 consecutive patients with LABC were registered in a prospective trial of induction chemotherapy using 5-fluorouracil, doxorubicin, and cyclophosphamide. Physical and ultrasound examinations of the axilla were performed at diagnosis and after induction chemotherapy. Segmental resection with axillary lymph node dissection or modified radical mastectomy was performed, followed by postoperative chemotherapy and irradiation of the breast or chest wall and regional lymphatics. Results: Following induction chemotherapy, 43 (32%) of the 133 patients with clinically positive lymph nodes on initial examination had axillary tumor downstaging as assessed by physical and ultrasound examination. The sensitivity of axillary sonography in identifying axillary metastases was significantly higher than that of physical examination (62% vs. 45%,P=.012). The specificity of physical examination (84%) was higher than that of sonography (70%), but the difference did not reach statistical significance. Among the 55 patients in whom the findings of both physical and ultrasound examination of the axilla were negative following induction chemotherapy, 29 patients (53%) were found to have axillary lymph node metastases on pathologic examination of the axillary contents. However, 28 (97%) of these patients had either 1 to 3 positive lymph nodes or only micrometastases 2 to 5 mm in diameter. Conclusions: Preoperative clinical assessment of the axilla by physical examination combined with ultrasound examination is not completely accurate in predicting metastases in patients with LABC following tumor downstaging. However, patients with negative findings on both physical and ultrasound examinations of the axilla may be potential candidates for omission of axillary dissection if the axilla will be irradiated because minimal axillary disease remains. Patients who have positive findings on preoperative physical or ultrasound examinations should receive axillary dissection to ensure local control. A prospective randomized trial of axillary dissection versus axillary radiotherapy in patients with a clinically negative axilla following induction chemotherapy is currently underway.Presented at the 51st Annual Cancer Symposium of The Society of Surgical Oncology, San Diego, California, March 28, 1998.