Biomedical subjects
Publications and source records attributed to A Sardi.
Explore the source record for details and available documents.
Computed tomography (CT) has been compared to plain radiographs and bronchial washings as a screening tool for lung cancer. In comparison with other screening modalities, CT allows detection of lung lesions at an earlier cancer stage. Technologic improvements have decreased imaging costs, thus making chest CT a more feasible option as a screening tool in the community hospital. In this study, smokers over the age of 45 years with a greater than 20 pack-year smoking history were referred for screening chest CT. Noncalcified nodules larger than 10 mm underwent CT-guided biopsy, and smaller nodules underwent follow-up CT in 3 months. Currently, patients have been followed for 4 years. The prevalence, stage, and histology of lung cancer were compared to study results from academic centers. Eighty-seven patients underwent screening chest CT. The study population was 51 per cent male with a mean age of 64 +/- 9 years. Four (3 female and 1 male) patients were biopsied and found to have lung cancer giving a prevalence of 5 per cent. Stage IA disease was found in three patients and stage IIIA disease was found in one patient. Adenocarcinoma was present in two patients, adeno-squamous carcinoma in one patient, and squamous cell carcinoma in one patient. The stage and histology of lung carcinomas in this study were comparable to studies performed at larger institutions. However, the disease prevalence was almost double the highest prevalence found in other studies. This discrepancy could be related to study size, as the patient populations were similar. Clearly, screening chest CT in the community setting is equally efficacious in the diagnosis of lung cancer at earlier stages. Following these patients beyond the 5-year mark will give some insight on the effect of screening chest CT on the mortality of lung cancer.
OBJECTIVE: The purpose of this clinical trial was to determine the efficacy of a dynamic computerized infrared imaging system for distinguishing between benign and malignant lesions in patients undergoing biopsy on the basis of mammographic findings. SUBJECTS AND METHODS: A 4-year clinical trial was conducted at five institutions using infrared imaging of patients for whom breast biopsy had been recommended. The data from a blinded subject set were obtained in 769 subjects with 875 biopsied lesions resulting in 187 malignant and 688 benign findings. The infrared technique records a series of sequential images that provides an assessment of the infrared information in a mammographically identified area. The suspicious area is localized on the infrared image by the radiologist using mammograms, and an index of suspicion is determined, yielding a negative or positive result. RESULTS: In the 875 biopsied lesions, the index of suspicion resulted in a 97% sensitivity, a 14% specificity, a 95% negative predictive value, and a 24% positive predictive value. Lesions that were assessed as false-negative by infrared analysis were microcalcifications, so an additional analysis was performed in a subset excluding lesions described only as microcalcification. In this restricted subset of 448 subjects with 479 lesions and 110 malignancies, the index of suspicion resulted in a 99% sensitivity, an 18% specificity, a 99% negative predictive value, and a 27% positive predictive value. Analysis of infrared imaging performance in all 875 biopsied lesions revealed that specificity was statistically improved in dense breast tissue compared with fatty breast tissue. CONCLUSION: Infrared imaging offers a safe noninvasive procedure that would be valuable as an adjunct to mammography in determining whether a lesion is benign or malignant.
Hepatic adenomas (HAs) are benign but can present as an acute surgical emergency. The relationship between HA and oral contraceptives (OCs) has been well documented and there have been several reports of tumor regression after the withdrawal of hormonal agents. However, not all HAs regress in this manner; have been reported to remain stable, increase in size, hemorrhage, or rarely, undergo malignant transformation. Given the unpredictable nature of these lesions they are generally treated surgically. In July 1995 a patient with a 6-year history of OC use was admitted with a history of sudden-onset right upper quadrant abdominal pain of 2 days' duration. The clinical picture and imaging studies led to the diagnosis of a bleeding hepatic adenoma without rupture. She was treated expectantly for a period of 14 months before surgery. This allowed the tumor to significantly decrease in size and thus limit the extent of resection. If the patient presented in this case had undergone surgery at the time of initial diagnosis a right hepatic lobectomy as opposed to a wedge resection would have been required. Treating this patient expectantly significantly decreased the potential morbidity associated with a larger resection.
INTRODUCTION: Multiple radioactive lymph nodes are often removed during the course of sentinel lymph node (SLN) biopsy for breast cancer when both blue dye and radioactive colloid injection are used. Some of the less radioactive lymph nodes are second echelon nodes, not true SLNs. The purpose of this analysis was to determine whether harvesting these less radioactive nodes, in addition to the "hottest" SLNs, reduces the false-negative rate. METHODS: Patients were enrolled in this multicenter (121 surgeons) prospective, institutional review board-approved study after informed consent was obtained. Patients with clinical stage T1-2, N0, M0 invasive breast cancer were eligible. This analysis includes all patients who underwent axillary SLN biopsy with the use of an injection of both isosulfan blue dye and radioactive colloid. The protocol specified that all blue nodes and all nodes with 10% or more of the ex vivo count of the hottest node should be removed and designated SLNs. All patients underwent completion level I/II axillary dissection. RESULTS: SLNs were identified in 672 of 758 patients (89%). Of the patients with SLNs identified, 403 patients (60%) had more than 1 SLN removed (mean, 1.96 SLN/patient) and 207 patients (31%) had nodal metastases. The use of filtered or unfiltered technetium sulfur colloid had no impact on the number of SLNs identified. Overall, 33% of histologically positive SLNs had no evidence of blue dye staining. Of those patients with multiple SLNs removed, histologically positive SLNs were found in 130 patients. In 15 of these 130 patients (11.5%), the hottest SLN was negative when a less radioactive node was positive for tumor. If only the hottest node had been removed, the false-negative rate would have been 13.0% versus 5.8% when all nodes with 10% or more of the ex vivo count of the hottest node were removed (P =.01). CONCLUSIONS: These data support the policy that all blue nodes and all nodes with 10% or more of the ex vivo count of the hottest SLN should be harvested for optimal nodal staging.
OBJECTIVE: To evaluate the role of preoperative lymphoscintigraphy in sentinel lymph node (SLN) biopsy for breast cancer. SUMMARY BACKGROUND DATA: Numerous studies have demonstrated that SLN biopsy can be used to stage axillary lymph nodes for breast cancer. SLN biopsy is performed using injection of radioactive colloid, blue dye, or both. When radioactive colloid is used, a preoperative lymphoscintigram (nuclear medicine scan) is often obtained to ease SLN identification. Whether a preoperative lymphoscintigram adds diagnostic accuracy to offset the additional time and cost required is not clear. METHODS: After informed consent was obtained, 805 patients were enrolled in the University of Louisville Breast Cancer Sentinel Lymph Node Study, a multiinstitutional study involving 99 surgeons. Patients with clinical stage T1-2, N0 breast cancer were eligible for the study. All patients underwent SLN biopsy, followed by level I/II axillary dissection. Preoperative lymphoscintigraphy was performed at the discretion of the individual surgeon. Biopsy of nonaxillary SLNs was not required in the protocol. Chi-square analysis and analysis of variance were used for statistical comparison. RESULTS: Radioactive colloid injection was performed in 588 patients. In 560, peritumoral injection of isosulfan blue dye was also performed. A preoperative lymphoscintigram was obtained in 348 of the 588 patients (59%). The SLN was identified in 221 of 240 patients (92.1%) who did not undergo a preoperative lymphoscintigram, with a false-negative rate of 1.6%. In the 348 patients who underwent a preoperative lymphoscintigram, the SLN was identified in 310 (89.1%), with a false-negative rate of 8.7%. A mean of 2.2 and 2. 0 SLNs per patient were removed in the groups without and with a preoperative lymphoscintigram, respectively. There was no statistically significant difference in the SLN identification rate, false-negative rate, or number of SLNs removed when a preoperative lymphoscintigram was obtained. CONCLUSIONS: Preoperative lymphoscintigraphy does not improve the ability to identify axillary SLN during surgery, nor does it decrease the false-negative rate. Routine preoperative lymphoscintigraphy is not necessary for the identification of axillary SLNs in breast cancer.
PURPOSE: Previous studies have demonstrated the feasibility of sentinel lymph node (SLN) biopsy for nodal staging of patients with breast cancer. However, unacceptably high false-negative rates have been reported in several studies, raising doubt about the applicability of this technique in widespread surgical practice. Controversy persists regarding the optimal technique for correctly identifying the SLN. Some investigators advocate SLN biopsy using injection of a vital blue dye, others recommend radioactive colloid, and still others recommend the use of both agents together. PATIENTS AND METHODS: A total of 806 patients were enrolled by 99 surgeons. SLN biopsy was performed by single-agent (blue dye alone or radioactive colloid alone) or dual-agent injection at the discretion of the operating surgeon. All patients underwent attempted SLN biopsy followed by completion level I/II axillary lymph node dissection to determine the false-negative rate. RESULTS: There was no significant difference (86% v 90%) in the SLN identification rate among patients who underwent single- versus dual-agent injection. The false-negative rates were 11.8% and 5.8% for single- versus dual-agent injection, respectively (P <.05). Dual-agent injection resulted in a greater mean number of SLNs identified per patient (2. 1 v 1.5; P <.0001). The SLN identification rate was significantly less for patients older than 50 years as compared with that of younger patients (87.6% v 92.6%; P =.03). Upper-outer quadrant tumor location was associated with an increased likelihood of a false-negative result compared with all other locations (11.2% v 3. 9%; P <.05). CONCLUSION: In multi-institutional practice, SLN biopsy using dual-agent injection provides optimal sensitivity for detection of nodal metastases. The acceptable SLN identification and false-negative rates associated with the dual-agent injection technique indicate that this procedure is a suitable alternative to routine axillary dissection across a wide spectrum of surgical practice and hospital environments.
Metastatic tumors to the liver account for the majority of hepatic neoplasms. Improvement in resection has been shown to be beneficial and has remained the treatment of choice, carrying a 5-year survival rate of approximately 20 to 30 per cent. In evaluating candidates for surgery, intraoperative assessment for resectability is a key factor and dictates surgical approach, as well as patient prognosis. Historically, imaging techniques such as CT scan, magnetic resonance imaging, and CT arterial portography (CTAP) have been used in preoperative evaluation. However, the sensitivities of these diagnostic tools have been found to be less than optimal. Intraoperative ultrasound (IOUS) has emerged as an important tool in accurately staging metastatic liver disease with a sensitivity of 98 per cent. From 1994 to 1996, 23 patients have undergone IOUS for evaluation of suspected liver neoplasms in an ongoing prospective study. All patients had colorectal carcinoma. All patients received preoperative CT scan, and 11 patients with positive CT scans had CTAP. Fifteen patients were found to have colorectal metastasis to the liver. Surgical management in 7 of the 15 patients was modified because of the use of IOUS. Two patients were found to have unresectable disease thus abandoning hepatic resection, two were found to have additional lesions undetected by preoperative evaluation and were resected, and in two patients margins of resection were changed. One patient was found to have benign hepatic cysts, and no resection was performed. The use of IOUS modified the management of 44 per cent of our patients with liver metastases. IOUS should be routinely used in patients undergoing liver resection for metastatic liver disease.
Sarcoidosis is a multisystemic disease that may involve the breast parenchyma and can be confused with benign or malignant tumors. A recent case of sarcoidosis of the breast treated in our institution prompted us to review the world literature on the topic. From 1921 to 1997, 45 cases relating to sarcoidosis of the breast were reported; 10 of these cases were excluded from our review because of the lack of histological proof of sarcoidosis. The data were organized according to clinical presentation, diagnostic studies, treatment plan, and follow-up care. The mean age at presentation was 47 years (range 20-72 years) and all patients were female. Seven patients (20%) had a breast mass as primary presentation of sarcoidosis without any clinical evidence of systemic sarcoidosis. Thirty-one patients (89%) presented with a self-detected mass and three patients (8%) demonstrated skin dimpling and peau d'orange appearance mimicking cancer. The size of the breast lesions ranged from 0.25 to 5 cm in diameter. One patient presented with bilateral breast lesions and one with more than one lesion in the same affected breast. A single breast mass was found in the rest of the patients. Of the seven patients evaluated by mammography, only one revealed changes suspicious for malignancy. Fine-needle aspiration was used only in four cases; the results of two were compatible with sarcoidosis and two required an excisional biopsy as a result of inconclusive results. Seventeen cases reported excisional biopsy as the diagnostic procedure. In 11 patients the type of biopsy was not stated. In two cases of radical mastectomies for breast adenocarcinoma, sarcoidosis was an incidental finding, either in the remaining breast tissue or in the axillary nodes. One patient underwent a partial mastectomy revealing sarcoidosis as the definitive diagnosis. Ultrasound was used in two cases; one revealed a suspicious lesion and one was inconclusive. Although sarcoidosis of the breast constitutes a rare entity it should be considered in the differential diagnosis of breast cancer even in patients without clinical evidence of systemic sarcoidosis. These patients should undergo a biopsy to rule out malignancy because clinical findings, mammography, and ultrasound results can be misleading or inconclusive.
Primary liver cancers are a significant cause of both morbidity and mortality. Although surgical resection remains the treatment of choice for these tumors, only 10 to 20 per cent of the primary liver tumors are found to be resectable. Presently, the options for these patients include liver transplantation, cryosurgery, or nonsurgical therapy, such as transarterial chemoembolization. Techniques such as alcohol injection, interstitial radiotherapy, laser hypothermia, and radiofrequency electrodissection have all been attempted with limited success. We present a case of a 68-year-old woman with a 10-year history of liver cirrhosis secondary to chronic active hepatitis C. A lateral segmentectomy was recommended but could not be done due to severe underlying cirrhosis. Cryosurgery aided by intraoperative ultrasonography was performed successfully. The patient developed recurrent disease at 58 months and died with disease at 62 months. Advances in instrumentation and intraoperative ultrasonography are making cryosurgery a viable surgical therapeutic alternative in the management of patients with unresectable hepatocellular carcinoma. The procedure can be performed safely with low morbidity.
We report a case in which cryosurgical ablation was used to treat recurrent rectal cancer. Several years after low anterior resection for rectal cancer, the patient was found to have a large pelvic recurrence with involvement of the presacral space. After resection of the pelvic mass, cryosurgery was applied to the presacral space, extending to the lateral pelvic wall and up to the sacral promontory. After a 24-month follow-up, the patient remains disease-free with a Karnofsky performance status of 100 per cent. Cryosurgery can be used as an adjuvant therapy at the time of resection to successfully treat a pelvic recurrence.
Gastric cancer has the second highest mortality rate of all cancers worldwide. More attention is now being paid to the symptoms and risk factors involved. There is also increasing use of esophagastroduodenoscopy and random biopsies in symptomatic patients, especially as a screening mechanism in Japan. As a result, lesions are being diagnosed earlier.
Retrosternal goiter is defined as any goiter in which at least 50 per cent of the thyroid resides below the level of the thoracic inlet. The incidence of retrosternal goiter varies from 3 to 20 per cent with respect to thyroidectomy patients. A retrospective chart review from June 1991 to December 1997 found 232 thyroidectomies performed at our institution. Sixteen patients were found to have retrosternal goiters (6.9%). The mean age was 57.8 years (range, 34-92). All were of benign pathology. Symptoms included shortness of breath (68.8%), hoarseness (37.5%), dysphagia (31.3%), and superior vena cava obstruction (6.25%). Thirteen patients were female (81.3%). Fifteen patients had surgical intervention (93.8%). Total thyroidectomy was performed in nine cases (60%), whereas lobectomy was performed in six cases (40%). All treated patients had complete resolution of symptoms. A cervical incision alone was used in 13 cases (86.7%). Complications consisted of one postoperative pleural effusion and in one case a traumatic C5 nerve root compression occurred. There were no instances of long-term vocal cord paralysis or hypoparathyroidism. There was no perioperative mortality. In the majority of patients with retrosternal goiter, surgery can be done expeditiously through a cervical incision with minimal morbidity and mortality.
Swan-Ganz catheter-induced pulmonary artery (PA) rupture is rare, with an incidence of 0.016 to 0.2 per cent, but it remains the most dreaded complication in the placement of these catheters with a mortality above 50 per cent. We report two cases of PA rupture after catheter placement. Both patients were managed nonoperatively and without any invasive procedure. They both stopped bleeding after the initial episode and were discharged a few days later. We believe that in the absence of high-risk factors, such as pulmonary hypertension and systemic anticoagulation, PA rupture from a Swan-Ganz catheter can be successfully treated by withdrawal of the catheter and supportive care.
Primary true cysts of the spleen constitute 10 per cent of all nonparasitic cysts of the spleen. These cysts have been managed with total or partial splenectomy or marsupialization. Previous series reported elevated serum levels of CA 19-9 and carcinoembryonic antigen (CEA). A 16-year-old male presented with left upper quadrant pain and was found to have a mass on palpation. An ultrasound and a CT scan of the abdomen showed a 20-cm cystic lesion in the spleen. The CA 19-9 and CEA serum levels were 1264 units/ml (nl <33 units/ml) and 7.5 ng/ml (nl <3.1 ng/ml), respectively. Laparoscopic resection of the cyst using the harmonic scalpel was performed. The pathology showed a benign true epithelial cyst of the spleen, with strongly immunoperoxidase stains for keratin, CA 19-9, and CEA. Levels of CA 19-9 and CEA in the cystic fluid were 48,275 units/ml and 96.6 ng/ml, respectively. This is the first case reported in the literature of a true benign splenic cyst producing high levels of CEA and CA 19-9 in serum and cystic fluid. The patient was discharged home on the 1st postoperative day without problems and returned to his normal daily activities with the 1st week after surgery. The CA 19-9 and CEA serum levels returned to normal levels.
Merkel cell carcinoma is a rare and aggressive malignant tumor of the skin. We retrospectively reviewed five patients treated from January 1987 to December 1995. The mean age was 75 years (range, 65-85). There were three primary lesions of the head and neck and two of the extremities. Three were stage II and two were stage III. All primary tumors underwent wide excision with clear margins. Four patients recurred, with a mean time to recurrence of 10 months (range, 2-17). All tumors were positive for immunohistochemical stains (cytokeratin and neuron-specific enolase). Only the two patients who did not have radiotherapy to the primary site had a local recurrence. There was regional recurrence in two of the three patients who had adjuvant radiotherapy to regional lymph nodes. One patient who had a wide excision of the primary lesion, prophylactic lymph node dissection (15 of 34 lymph nodes were positive), and adjuvant chemotherapy is alive and disease free at 23 months. Three patients have died with disease, and two are alive and disease free. Merkel cell carcinoma should be treated aggressively with wide excision of the primary lesion (3-cm margins), and prophylactic lymphadenectomy followed by irradiation to the primary site. If lymph node involvement is detected, then irradiation to the lymph node region must be performed. The role of chemotherapy in this disease is not well defined.
Esophageal cancer, although not one of the more common malignancies in the United States, remains a significant problem. Nearly as many patients as are diagnosed die in the same year, regardless of the treatment employed. Surgery is considered the mainstay of therapy. Esophagectomy with the use of the stomach as a substitute is preferred. Radical procedures have not proven more effective in extending survival. Because of the poor five-year survival rate, multimodality therapy with preoperative chemoradiotherapy (neoadjuvant therapy) followed by esophagectomy has shown encouraging results. Two illustrative cases are presented, one with adenocarcinoma and one with a squamous cell carcinoma, that were treated in this manner.
The increased use of laparoscopy in the management of gastrointestinal problems continues to expand. Procedures such as jejunostomies, diagnosis of intestinal obstruction or ischemia, resection of the small bowel, and lysis of adhesions can be managed with this technique. We present our experience with four cases undergoing laparoscopic resection of the small bowel. The mean age of the three males and one female was 55 years. The operative procedure was performed under general anesthesia with complete laparoscopic exploration of the abdominal cavity. The type of pathology and extent of disease was defined: one had leiomyoma, two had unspecific ileitis, and one had metastatic breast cancer. This was followed by exteriorization and resection. Patients were allowed to have a liquid diet the day of surgery. The average hospital stay was 3 to 4 days. The mean intraoperative time was 124 minutes. No postoperative complications were observed. Laparoscopic small bowel resection can be performed expeditiously and with minimal morbidity, allowing accurate diagnosis and treatment of these conditions.