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D N Krag

Publications and source records attributed to D N Krag.

At least 37 records · Page 2Linked to original sources
PubMed1998

Use of touch preps for intraoperative diagnosis of sentinel lymph node metastases in breast cancer.

BACKGROUND: Intraoperative touch prep (TP) is highly accurate for determining positive breast cancer margins and thereby reducing the need for second surgeries. It also may be useful in determining the status of the sentinel lymph node (SLN) during the initial surgical resection. The objective of this study was to test the ability of intraoperative TP to predict metastatic disease and, thus, the necessity for axillary lymph node dissection (ALND) at the time of SLN biopsy. METHODS: Fifty-five patients with invasive breast cancer were entered in the SLN biopsy protocol. The SLN was identified by gamma probe, dissected, and sent to pathology for TP and permanent sections. Level I and II ALND was then performed. Any radiolabeled LN in the lymphadenectomy specimen also was sent for TP and permanent sections. RESULTS: A total of 124 radiolabeled lymph nodes (LNs) were submitted for TP; of these, 93 (75%) were SLNs. Pathologic diagnosis by TP was correct compared with permanent sections for 99.2% of the nodes. There were no false positives. There was one (0.8%) false negative. The positive predictive value was 100% and the negative predictive value was 99%. Sensitivity was 95.7% and specificity was 100%. CONCLUSIONS: TP is a simple, quick, and accurate method for detecting metastatic disease in the SLN and, when used intraoperatively, enables the surgeon to determine whether or not an ALND is necessary at the time of the initial surgery.

Adult↗
PubMed1998

Ultrasonographically guided injection improves localization of the radiolabeled sentinel lymph node in breast cancer.

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

Analysis of Variance↗
PubMed1998

Sentinel lymph node biopsy for melanoma.

BACKGROUND: The most powerful predictor of survival for patients with melanoma is the status of the regional lymph nodes. Sentinel lymph node biopsy may provide improved staging accuracy without the morbidity of elective lymph node dissection (ELND). METHODS: Sixty-eight patients with intermediate thickness melanoma underwent gamma probe guided sentinel node biopsy without ELND and were followed up over a mean of 22 months. RESULTS: A sentinel node was found in all patients. Six patients (9%) had positive sentinel nodes; all underwent complete lymphadenectomy. Two patients (3%) with negative sentinel nodes developed nodal recurrence; 1 of these patients was found to have microscopic disease on reexamination of the sentinel node. Two patients (3%) developed systemic disease. CONCLUSION: Gamma probe guided sentinel node biopsy can be performed with a high rate of technical success. It provides accurate pathological staging with a low incidence of nodal basin failure.

Adult↗
PubMed1998

Sentinel lymph node biopsy for staging breast cancer.

BACKGROUND: Determination of axillary nodal status is essential for the staging of breast cancer since nodal status is one of the most important predictors of survival. The objective of this study was to test the hypothesis that the histology of the first draining lymph node (LN) accurately predicts the histology of the rest of the axillary LNs. METHODS: Fifty-five patients with operable invasive breast carcinoma and clinically negative axillary lymph nodes were studied. Patients were injected with Technetium-99 (99Tc) sulfur colloid around the primary tumor. A hand-held gamma detector probe was used to identify the sentinel LN (SLN). After the SLN was identified and removed, a level I and II lymphadenectomy was performed. RESULTS: The SLN was identified in 53 (96.3%) of the 55 patients entered into the trial. The sensitivity was 88.2% and the specificity was 100%. The positive predictive value was 100% and the negative predictive value was 94.6%. The accuracy of the study was 96.2%. CONCLUSIONS: The SLN biopsy for breast cancer staging is highly accurate in our hands and has the potential to decrease the morbidity and cost of managing patients with breast cancer without compromise of staging.

Adult↗
PubMed1998

Transport and retention of colloidal tracers in regional lymphoscintigraphy in melanoma: influence on lymphatic mapping and sentinel node biopsy.

Sentinel node (SN) biopsy is a staging technique used to select patients for regional lymphadenectomy in melanoma. We compared the two most widely used radioactive tracers, 99mTc-colloidal albumin (99mTc-CA) and 99mTc-sulphur colloid (99mTc-SC), with respect to scintigraphy, success rate in gamma probe guided biopsy and absolute uptake in the SN. Scintigraphy was performed in six volunteers after simultaneous injection of the respective tracers in each leg. Comparison of uptake of both tracers showed a higher uptake on the 99mTc-CA side. The scintigraphic count ratio of SNs labelled with 99mTc-SC compared with 99mTc-CA was 1 to 9 28. Next, 20 patients with biopsy-proven melanoma were randomized for injection of 99mTc-CA or 99mTc-SC followed by SN biopsy. Within 20 min after the injection, focal uptake was seen in all cases of the 99mTc-CA group but in only seven of the 10 patients in the 99mTc-SC group (P < 0.05). Focal accumulations were seen in all patients of both groups after 2 h. Spill to non-SNs was seen in five of the 99mTc-CA patients and three of the 99mTc-SC patients. In all patients the SNs could be retrieved under the guidance of a gamma probe and blue dye. The uptake in the SN was significantly higher (P < 0.001) after the injection of 99mTc-CA (0.92+/-0.40%) compared with 99mTc-SC (0.34+/-0.34%). When dynamic scintigraphy is performed, 99mTc-CA is preferable. SN uptake of 99mTc-SC is less than that of 99mTc-CA but this does not adversely affect the surgical procedure.

Adult↗
PubMed1998

Sentinel lymph node localization in early breast cancer.

METHODS: Thirty-two patients with clinical node-negative breast cancer underwent sentinel node localization study as part of a National Cancer Institute-sponsored multicenter trial. Anatomical and histopathologic characteristics of sentinel lymph node (SLN) and a kinetic analysis of nodal uptake were studied. Patients were injected with 1 mCi/4 ml unfiltered 99mTc-sulfur colloid in four divided doses around the palpable lesion or immediately adjacent to the excision cavity if prior biopsy was performed. SLN biopsy was performed 1.5-6 hr (mean = 3 hr) postinjection. Intraoperative localization was performed using a gamma probe. All patients underwent complete axillary dissection. RESULTS: SLN was identified in 30 of 32 (94%) patients. There were no false-negative SLN biopsies. CONCLUSION: This study supports the clinical validity of SLN biopsy in breast cancer and confirms that, unlike the blue dye technique, the learning curve with unfiltered 99mTc-sulfur colloid and the gamma detection probe is short, and SLN localization is achievable in over 90% of cases by surgeons with modest experience. The use of unfiltered 99mTc-sulfur colloid (larger particle size) with larger injected volume permits effective localization of SLNs.

Adult↗
PubMed1997

Gamma probe guided sentinel node biopsy in breast cancer.

Axillary lymph node status is the most important pathological determinant of prognosis in early breast cancer. Determination of axillary status is crucial in clinical decision-making. It is currently accepted that the total axillary lymphadenectomy is the most reliable staging procedure. However, routine axillary dissection does not benefit a majority of early breast cancer patients who are node-negative, and the patients sustain the potential morbidity and the economic cost of this procedure. There is substantial evidence that there is an orderly progression of breast cancer metastases in a lymphatic basin, sentinel node being the first node to receive lymphatic drainage from the tumor site. Sentinel lymph node biopsy may prove to be the optimal sampling technique for staging of breast cancer patients. A large multicenter trial to study the clinical validity of sentinel lymph node biopsy in breast cancer is underway. This paper addresses the rationale for sentinel lymph node biopsy and discusses the technical issues with regard to anatomy and physiology of breast lymphatics.

Axilla↗
PubMed1996

Preoperative technetium Tc 99m sestamibi imaging. Paving the way to minimal-access parathyroid surgery.

OBJECTIVE: To examine the reliability of technetium Tc 99m sestamibi scanning as a new adjunct to the surgical management of hyperparathyroidism. DESIGN: Preoperative localization of parathyroid adenoma by technetium Tc 99m sestamibi delayed washing-out scanning and high-resolution ultrasound was compared with a historical institutional experience of surgical intervention without preliminary localization studies. A 10-year retrospective review from 1985 to 1995 of patients with surgical hyperparathyroidism was performed. SETTING: Academic tertiary referral medical center. PATIENTS: Thirty-three technetium Tc 99m sestamibi scans in patients with primary hyperparathyroidism were correlated with eventual surgical and pathologic findings. The last 10 patients were also studied with 10-MHz linear transducer ultrasound, and the results were compared with those of the radionuclide scan and eventual surgical and pathologic findings. From 1985 to 1995, 142 patients underwent surgical exploration for primary hyperparathyroidism, and 125 records were available for review. RESULTS: The technetium Tc 99m sestamibi parathyroid scan correctly identified the site and presence of 31 adenomas among 34 confirmed tumors, a sensitivity of 91% and positive predictive value of 97%. The scan detected three anterior mediastinal adenomas that could not be removed through cervical exploration. In each instance median sternotomy was included in the primary surgery and allowed efficient, successful management of these ectopic adenomas. High-resolution ultrasound correctly identified nine of 10 cervical parathyroid adenomas and predicted the volume of each tumor to a statistically significant level. CONCLUSIONS: Hyperthyroidism has traditionally been treated surgically without preliminary localization studies. We found both technetium Tc 99m sestamibi scanning and high-resolution ultrasound to be highly sensitive at detecting parathyroid adenomas at the 90% level. Furthermore, preoperative localization allowed efficient surgical intervention for our group of patients who had high frequency of mediastinal adenomas that required transmediastinal surgery.

Adenoma↗
PubMed1996

The gamma-probe-guided resection of radiolabeled primary lymph nodes.

The finding that the presence of micrometastases in the first draining primary (sentinel) lymph node potentially reflects the incidence of regional micrometastases has created a fundamental change in how a node-negative lymphatic basin can be evaluated and managed. In cutaneous melanoma and carcinoma of the breast, the data verify the significance of the primary lymph node and support the importance of primary lymph node biopsy. Gamma-probe localization and biopsy of the primary node is a safe, minimally invasive technique that is accurate and easy to perform. For many patients, this technique permits the surgical staging of the regional lymphatics to be performed under local anesthesia on an outpatient basis. Our experience with squamous cell carcinoma of the head and neck and Merkel cell carcinoma suggests that the assessment of the regional lymphatics using the gamma-probe technology for identification of the primary node may also be applicable to many other solid tumors.

Breast Neoplasms↗
PubMed1995

Minimal-access surgery for staging of malignant melanoma.

OBJECTIVE: To develop a simple, minimally invasive technique of determining whether regional node metastasis has occurred in patients with melanoma. SETTING: Teaching hospital tertiary care and private practice settings. PATIENTS: Between February 1993 and October 1994, 121 patients with invasive malignant melanoma and clinically negative lymph nodes were enrolled in this clinical trial. DESIGN: Consecutive sample clinical trial. Within 24 hours prior to lymph node resection, a radioactive tracer was injected into the dermis around the site of the primary melanoma. Forty-four patients also had blue dye injected immediately prior to surgical resection. Measurement of radioactivity in the lymph nodes and surgical localization were made using a handheld gamma detector. Radiolabeled nodes were selectively removed with the least dissection possible. In patients with pathologically positive radiolabeled nodes, regional lymphadenectomy was performed. OUTCOME MEASURES: Successful identification of radiolabeled sentinel lymph nodes, correlation of radiolabeling with injection of blue dye, and regional node recurrence rate. RESULTS: Surgeons successfully resected the radiolabeled sentinel lymph nodes in 118 (98%) of 121 patients. One hundred percent of blue-stained lymph nodes were successfully radiolabeled. Fifteen patients had pathologically positive sentinel lymph nodes. In 10 patients, the sentinel node was the only node with metastasis. Two systemic and one regional node recurrences occurred during a mean follow-up of 220 days. CONCLUSIONS: Selective gamma probe-guided resection of the radiolabeled sentinel lymph node is possible in over 95% of patients with melanoma. This technique offers a simple and reliable method of staging of regional lymph nodes in these patients without performing a regional lymphadenectomy.

Adolescent↗
PubMed1993

Intratumoral chemotherapy with cisplatin in oily emulsion in horses.

Twenty horses with 30 lesions were studied to evaluate the effects of intratumoral chemotherapy with cisplatin in sesame oil on equine sarcoids (n = 19), squamous cell carcinomas (n = 7), and squamous cell papillomas (n = 4). Treatment consisted of 4 sessions of intratumoral cisplatin chemotherapy at 2-week intervals. A controlled-release formulation of cisplatin in sesame oil was used to limit drug egress from the injection site. Mean dosage per session was 0.97 (+/- 0.17, SEM) mg of cisplatin/cm3 of tumor tissue treated for tumor volumes ranging from 10 to 20 cm3. Dosage tended to be slightly higher for smaller tumors and slightly lower for larger tumors. Tumor regression was observed in all horses. Complete response was observed in 18 of the sarcoids, 5 of the squamous cell carcinomas, and 4 of the squamous cell papillomas. The mean relapse-free interval was 21.6 and 14 months in horses with sarcoid and carcinoma/papilloma, respectively. The 1-year relapse-free rates were 87 and 65% for equine sarcoid and carcinoma/papilloma, respectively. In horses with relapse, 70% had tumor recurrence outside the treated field. Cisplatin-related local toxicosis was minimal. Intratumoral cisplatin chemotherapy was found to be a practical and effective treatment of sarcoid and squamous cell carcinoma/papilloma in horses.

Animals↗
PubMed1993

Intraoperative autotransfusion in hepatic resection for malignancy. Is it safe?

To evaluate whether intraoperative autologous transfusion increases the risk of hematogenous dissemination of tumor we reviewed the risk of lung metastasis as well as disease-free and long-term survival of patients who underwent resection of malignant hepatic neoplasms with this technique. A retrospective review of patients undergoing liver resection for malignant disease revealed 39 patients in whom intraoperative autologous transfusion was used. The 2-year actuarial survival in the patients in this series, as calculated with the Kaplan-Meier method, was predicted to be 75%. Two-year actuarial disease-free survival was predicted to be 28%, and the risk of developing lung metastasis at 3 years was estimated to be 40%. The predicted overall survival and risk of recurrence in this series compare favorably with published data for patients in whom intraoperative autologous transfusion was not used.

Actuarial Analysis↗
PubMed1993

Clinical immunoscintigraphy of recurrent ovarian cancer with indium 111-labeled B72.3 monoclonal antibody.

OBJECTIVE: To prospectively evaluate the ability for immunoscintigraphy with monoclonal antibody CYT-103 labeled with indium 111 to detect tumor presence in 15 patients with ovarian cancer undergoing second-look surgery. DESIGN: Prospective, open-label, nonrandomized trial. SETTING: Hospital-based nuclear medicine facility and operating room. STUDY PARTICIPANTS: Patients with previous ovarian cancer scheduled for second-look surgery. MAIN OUTCOME MEASURE: Correctness of prediction of immunoscintigraphy for presence or absence of ovarian cancer compared with serum CA 125 titer and computed tomography. RESULTS: Immunoscintigraphy, computed tomography, and serum CA 125 titer had respective sensitivities of 92%, 42%, and 42%; specificities of 67%, 100%, and 100%; accuracies of 87%, 53%, and 53%; and diagnostic values of 59%, 42%, and 42%. The full regional extent of recurrent tumor was correctly detected in 45% of patients by immunoscintigraphy and in none of the patients by computed tomography. Immunoscintigraphy detected miliary tumor in two of four patients and computed tomography, as expected, was unable to detect miliary disease. CONCLUSIONS: Recurrent ovarian cancer often presents as multiple small lesions throughout the abdominal cavity. In this subset of patients, immunoscintigraphy may be particularly well suited for detection of the presence of recurrent tumor.

Antibodies, Monoclonal↗
PubMed1993

Clinical assessment of 111In-CYT-103 immunoscintigraphy in ovarian cancer.

The ability of 111In-CYT-103 immunoscintigraphy to aid in the diagnosis of patients with primary or recurrent/residual ovarian cancer was evaluated in a multicenter trial. The 111In-labeled immunoconjugate of the monoclonal antibody B72.3 was prepared using a site-specific conjugation method. A total of 103 patients received a 1 mg infusion of 111In-CYT-103 and subsequently underwent surgery or biopsy. The infusion of 111In-CYT-103 was well tolerated; only 1 patient experienced a modest elevation in blood pressure that was likely related to the infusion. 111In-CYT-103 immunoscintigraphy correctly identified surgically confirmed tumor in 68% of patients with ovarian adenocarcinoma. The sensitivity of 111In-CYT-103 immunoscintigraphy was positively influenced both by the size of the tumor lesion and the tumor TAG-72 antigen expression. The overall sensitivity of 111In-CYT-103 immunoscintigraphy was greater than that of CT imaging (44%). Antibody imaging detected occult disease in 20 of 71 patients with surgically documented ovarian adenocarcinoma; 6 patients being evaluated after initial surgery and chemotherapy had an otherwise negative presurgical workup and a normal CA 125 serum level. The results of this trial also indicate that 111In-CYT-103 immunoscintigraphy can contribute to the medical and surgical management of some patients with ovarian cancer. The results of this trial indicate that 111In-CYT-103 immunoscintigraphy should be a valuable addition to the presurgical evaluation of patients with suspected persistent or recurrent ovarian cancer.

Adenocarcinoma↗
PubMed1993

Gamma-probe guided localization of lymph nodes.

The initial draining lymph node (Sentinel node) of a tumour may reflect the status of the tumours spread to the remaining lymphatic bed. The sentinel node, which has been reported to predict metastatic melanoma, has recently been localized by a new invasive technique [1]. The goal of our pre-clinical trial was to test a non-invasive technique to localize the sentinel node. Gamma-probe guided localization was used to identify and then surgically remove the first draining lymph node(s) in 16 inguinal lymphatic basins of eight cats. This method was found to be comparable to an invasive method using a blue dye. Gamma-probe localization has several potential advantages in that it can: (a) precisely locate on the surface of the skin the position of an underlying lymph node, (b) intraoperatively guide the surgeon to the lymph node during dissection, (c) verify that the correct node has been biopsied, (d) determine the possible presence of residual lymph nodes, (e) allow lymph nodes to be harvested through a small incision as opposed to raising a skin flap, and (f) be rapidly and easily performed.

Animals↗
PubMed1993

Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe.

We have recently reported on a technique of gamma probe localization of radiolabelled lymph nodes to identify the sentinel node in malignant melanoma. In order to determine whether this technique is applicable to assist in staging breast cancer, a pilot study was begun to address two questions: (i) can the sentinel lymph node draining a breast cancer be identified for selective resection; and (ii) is the sentinel lymph node predictive of the status of the entire axillary lymph nodes? One to four hours prior to axillary lymph node dissection, 22 consecutive patients had approximately 0.4 mCi of technetium sulfur colloid in 0.5 ml saline injected around the perimeter of the breast lesion. A hand-held gamma counter was used at surgery to locate the lymph node(s) receiving drainage from the breast. A sentinel lymph node was identified in 18 of 22 patients. Of these 18 patients, the sentinel lymph node was positive in seven of seven patients, with pathologically verified metastatic breast cancer to at least one lymph node. In three out of seven patients, the sentinel lymph node was the only lymph node with metastatic cancer. In this pilot study of breast cancer patients, we conclude that: (i) radiolocalization and selective resection of sentinel lymph nodes is possible; and (ii) the sentinel lymph node appears to predict correctly the status of the remaining axilla. These data justify a larger clinical trial to verify the value of this technique.

Adult↗