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D Reintgen

Publications and source records attributed to D Reintgen.

At least 55 records · Page 3Linked to original sources
PubMed1997

Investment in new technology research can save future health care dollars.

OBJECTIVE: To perform a cost analysis of the emerging technology of lymphatic mapping for patients with malignant melanoma. DESIGN: A retrospective, computer-aided chart and financial cost and charge review of consecutive patients with the diagnosis of melanoma registered at a cancer center from December, 1995 to March, 1996. PARTICIPANTS: 73 consecutive patients with the diagnosis of Stage 1 and 2 melanoma (cutaneous disease only) had nodal staging of their disease with either a sentinel node (SLN) biopsy or an elective complete node dissection (ELND). This was determined largely by patient choice and the protocol in operation at the time of the presentation of the patient to the clinic. OUTCOMES MEASURED: There were no deaths in the series. Patient morbidity endpoints included rates of infection, incidence of extremity lymphedema, development of a seroma in the regional nodal basin wound and wound healing. Clinical outcome was measured by the ability to obtain complete nodal staging information with the new lymphatic mapping technology, and recurrence rates in the nodal basin after a negative SLN biopsy. Total charges, direct costs and total costs were calculated from all hospital, OR, pathology and lab charges. Professional fees were included in the analysis. RESULTS: Group 1 patients (50) had melanomas greater than 0.76 mm in thickness treated with a wide local excision (WLE), lymphatic mapping and SLN biopsy under general anesthesia. Five patients (Group 2) had their procedure performed under a straight local anesthesia. Group 3 patients (18) had nodal staging performed with an elective node dissection. In Groups 1 and 2, if the SLN was positive for micrometastases, the patients were taken back to the OR for a complete node dissection. The total charges per patient were $13,835, $6,853 and $19,285, respectively. Significant dollar savings were achieved if the nodal staging could be accomplished with the lymphatic mapping technology (p = 0.001). Morbidity was significantly less in Groups 1 and 2 compared to Group 3. After a mean follow-up of three years, only one patient has recurred in a SLN negative basin. CONCLUSIONS: With 38,300 new cases of melanoma diagnosed each year in the United States, a projected savings of $172 million per year (general anesthesia) and $350 million per year (local anesthesia) could be realized if this new mapping technology could be incorporated into the care of the melanoma patient. Patient morbidity is minimized, nodal staging is complete and patients return to work sooner. Recently approved adjuvant therapy can be applied in a selective fashion, treating only those patients in which a documented benefit has been obtained, saving the health care system more dollars. Initial investment in defining the technology was minimal.

Anesthesia, General↗
PubMed1997

Redefining cutaneous lymphatic flow: the necessity of preoperative lymphoscintigraphy in the management of malignant melanoma.

OBJECTIVE: The purpose of this study is to emphasize the instrumental role of preoperative lymphoscintigraphy in the surgical treatment of patients with malignant melanoma. SUMMARY BACKGROUND DATA: The efficacy of lymphoscintigraphy is reflected in its ability to reveal cutaneous lymphatic drainage to regional nodal basins that are at risk for melanoma metastases but not necessarily discernable to be at risk through standard historical anatomical guidelines or clinical experience. This preoperative lymphatic mapping technique has contributed greatly to the accuracy and efficiency of staging procedures including sentinel node biopsy and elective lymph node dissection. PATIENTS AND METHODS: After informed consent, a selected series of four patients with primary melanomas located in watershed areas of the body (left neck, right mid-abdomen, right scapula, left back) and two patients with extremity melanomas (right distal forearm and left ankle) underwent pre-operative lymphoscintigraphy to identify all basins for metastases. RESULTS: In all of the cases, lymphatic drainage occurred in an unusual and unexpected basin that could not have been predicted clinically and in three of the cases the resected basins contained positive sentinel nodes. If not for the preoperative lymphoscintigraphy, these nodal basins would not have been resected and metastatic disease would have been left behind. In addition, the staging of the melanoma patient would have been inaccurate. CONCLUSION: If the sentinel node biopsy of elective lymph node dissection (ELND) were based on clinical predictions only, nodes equally at risk for metastatic disease would not have been resected and in some cases, nodal basins not at risk for metastases would have been resected unnecessarily. Without lymphoscintigraphy, the validity and efficacy of the ELND or the sentinel node biopsy for nodal staging is greatly compromised. These six case studies illustrate the difficulty of predicating lymphatic drainage from primary sites located on the head and neck, truck and even the extremities and demonstrate the indispensability of preoperative lymphoscintigraphy in the management of malignant melanoma.

Abdomen↗
PubMed1997

Lymphatic mapping and sentinel node biopsy in patients with malignant melanoma.

Intra-operative sentinel lymph node (SLN) mapping and biopsy is a procedure that accurately stages the regional lymph node basin. Defined patterns of lymphatic drainage allow intra-operative determination of the first (sentinel) lymph node in the regional basin, and the absence of metastatic disease in the SLN accurately reflects the absence of melanoma in the remaining regional nodes. The use of a radiocolloid and a handheld gamma probe together with a vital blue dye provides optimal results, and allows for the successful identification of the SLN(s) in over 98 percent of the procedures. Close collaboration between surgeons, nuclear radiologists and pathologists is required to ensure optimal results. Surgical excision of the SLN allows for a more thorough and focused pathological examination of one or two nodes. Examination of serially sectioned SLNs by H&E staining, immunohistochemical staining and perhaps RT-PCR should reduce the number of patients with missed microscopic melanoma in the regional lymph nodes. Recently reported survival data from the Intergroup Melanoma Trial suggest that patients may benefit from identification and removal of regional lymph nodes that contain metastatic melanoma. Furthermore, the survival benefit recently reported in patients with melanoma metastatic to regional nodes prospectively randomized to receive high dose Interferon alfa-2b signals that the surgeons should aggressively examine patients for the presence of occult regional melanoma metastases. Intra-operative SLN mapping and SLN biopsy is a cost-effective procedure that allows accurate identification of regional lymph nodes that contain metastatic melanoma.

Antineoplastic Agents↗
PubMed1996

Evaluation of new putative tumor markers for melanoma.

BACKGROUND: The early diagnosis of recurrent melanoma can contribute to better outcome if the disease can be surgically resected or if the metastases are responsive to systemic therapies. Lipid-associated sialic acid (LASA-P) and the S-100 protein (S-100) were evaluated as tumor markers for melanoma with the goal of early detection of recurrence. METHODS: Sixty-seven patients were identified who had levels of S-100 and LASA-P drawn during their clinical course. A multivariate regression analysis was performed to determine the significance of the serum markers in relation to other prognostic factors for melanoma. RESULTS: After a median follow-up of 30 months, 58 patients had recurrences, and 49 patients died of disease. LASA-P elevation was not associated with the time to recurrence (p = 0.2176) or survival (p = 0.2507). S-100 positivity was a significant predictor of recurrence (p < 0.0001) and survival (p = 0.0059). The median time to recurrence for S-100-positive and S-100-negative patients was 7.6 and 33.8 months, respectively. The median survival time was 59.2 months for S-100-negative patients and 29.6 months for patients positive for S-100. CONCLUSIONS: Serum S-100 shows significant correlations to both time to recurrence and survival and could be useful in the clinical detection of malignant melanoma.

Adult↗
PubMed1996

Computer database for melanoma registry. A clinical management and research tool to monitor outcomes and ensure continuous quality improvement.

The need for an efficient method of handling data is more apparent today in medical practice than at any time in the past. This PC-based database helps with the daily collection, filing, storage, and abstraction of data for clinical management and research. The program also provides a mechanism for continuous quality assessment to monitor clinical standards of care and make interventions to improve the care of the melanoma patient.

Databases, Factual↗
PubMed1996

More rational and conservative surgical strategies for malignant melanoma using lymphatic mapping and sentinel node biopsy techniques.

Stimulated by novel lymphatic mapping techniques, the surgical care of the melanoma patient is becoming more conservative. Preoperative lymphoscintigraphy can identify all regional nodal basins at risk for metastatic disease, areas of "intransit" nodal collections, and the location and number of the primary draining nodes in relation to the rest of the nodes in the basin. Intraoperative mapping techniques, using a combination of a vital blue dye and a radioactive tracer, can then be used to harvest this first draining node, termed the sentinel node, for examination. It is clear that the most powerful prognostic factor for any solid tumor, including melanoma, is the presence or absence of regional lymph node disease. However, routine histologic examination may underestimate the number of patients with nodal disease. Serial sectioning and immunohistochemical staining, techniques that have been available for years, can increase the yield of positive dissections compared with routine histology. The selective approach to the nodal basin would allow the pathologist to be more detailed in examining the harvested sentinel node, providing more accurate staging information for melanoma.

Biopsy↗
PubMed1996

The use of intraoperative radiolymphoscintigraphy for sentinel node biopsy in patients with malignant melanoma.

BACKGROUND: Selective lymphadenectomy or "sentinel node" biopsy has been introduced recently by Morton and colleagues (Arch Surg 1992;127:392-9) to stage patients with intermediate and thick malignant melanomas. It has proven to be an effective way to identify nodal basins at risk for metastasis without the morbidity of a complete lymph node dissection. The majority of biopsies can be performed under local anesthesia with small incisions, but technical difficulties occasionally result in unsuccessful explorations. Identification of the sentinel node can be enhanced by a intraoperative radiolymphoscintigraphy, a technique introduced Alex and Krag (Surg Oncol 1993;137-43) that uses radiolabeled sulfur colloid and a hand-held gamma probe. OBJECTIVE: We used intraoperative radiolymphoscintigraphy in conjunction with 1% lymphazurin blue dye to define the sentinel node(s) in 148 patients with greater than 0.76 mm in thickness or Clark level IV melanomas. Sentinel lymph nodes were isolated, harvested, and examined using conventional histopathology, and immunohistochemistry for S-100 and HMB-45 antibodies. RESULTS: The overall success rate of sentinel lymph node localization was 97% using a combination of the two techniques. Twenty-one (14%) patients had micrometastasis, and 17 of these subsequently underwent complete lymph node dissection. A total of 220 of 275 (80%) sentinel nodes harvested were radioactive or "hot" compared with 165 of 275 (60%) with the blue dye alone. Four of the patients with micrometastasis had sentinel nodes positive by gamma probe, but negative by blue dye mapping techniques. CONCLUSION: Our results suggest that intraoperative radiolymphoscintigraphy using a hand-held gamma detecting probe improves the identification of sentinel lymph nodes during selective lymphadenectomy. This may reduce the number of "unsuccessful explorations" using the vital blue dye technique for lymphatic mapping, and appeal to a greater variety of surgeons, including dermatologic surgeons.

Biopsy↗
PubMed1996

Age and the Risk of Breast Cancer Recurrence.

BACKGROUND: Various parameters assist in the definition of prognosis and in the choice of therapy for breast cancer. This study evaluates the effects of prognostic factors on disease outcome in elderly women. METHODS: A retrospective cohort analysis was performed on 1,267 consecutive patients with locoregional breast cancer, including 374 patients 65 years of age or older, who were referred to a university cancer center over an eight-year period. Information on prognostic factors, disease outcome, and survival was analyzed. RESULTS: Women 65 years of age or older were more likely to have early-stage cancers, lower histologic grade, higher hormone receptor levels, and lower S-phase fractions. They experienced a longer time to disease recurrence and overall longer survival than their younger counterparts. CONCLUSIONS: Advancing age should not be considered an unfavorable risk factor for breast cancer. Prognosis and treatment should be based on disease stage and histologic and biologic parameters rather than patient age.

Journal Article↗
PubMed1996

The tumor biology of melanoma nodal metastases.

Approximately 20 per cent of melanomas greater than 0.76 mm in thickness will metastasize to the regional lymph nodes if treated with wide local excision alone (WLE). Elective lymph node dissection (ELND) is associated with significant morbidity, which includes lymphedema, wound complications, and paresthesias of the extremity. An alternative operative approach uses selective lymphadenectomy with the identification of the sentinel node, defined as the first node in the lymphatic basin that drains the primary cutaneous site. This study consisted of 132 patients with melanomas greater than 0.76 mm. One hundred nine patients (83%) had histologic negative sentinel nodes, and 23 patients (17%) had one or more sentinel nodes positive for disease. In patients with metastatic disease, 30/35 (86%) sentinel nodes were positive, and 25/357 (7%) nonsentinel nodes were positive (P < 0.001). In 18 patients (78%) of the 23 patients with metastatic disease, the sentinel node was the only node positive, strongly suggesting that there is an orderly progression of metastases. Two patients developed metastatic nodal disease after removal of a negative sentinel node (false negative rate = 1.5). The mean follow-up was 1 year. Sentinel node histology reflects the histology of the remainder of the nodes in the lymphatic basin and "skip" metastases, defined as a negative sentinel node but positive nodes higher in the regional chain positive for metastases or an axillary recurrence after a negative sentinel node biopsy, are rare for malignant melanoma. Harvesting the sentinel node in patients with intermediate or greater thickness melanoma will, therefore, identify a subset of patients with metastatic disease who have the most to benefit from a complete node dissection. This surgical approach allows for complete pathological staging and therapeutic management of patients while significantly reducing expense and overall morbidity.

Adolescent↗
PubMed1996

Medical-legal pitfalls for the breast surgeon: incomplete mammographic localization of suspicious lesions and the correlation between palpable and mammographic abnormalities.

In approximately 5 per cent of mammographically detected lesions, the mammographic abnormality is present in only one view, either craniocaudal or mediolateral. In such a scenario, the physician has been left with the option of closely following the lesion, hoping it will eventually become apparent in two views, or guessing the approximate location of the lesion for subsequent open biopsy. However, with today's advances in technology, CT scan and its production of a three-dimensional image can compensate for mammography's two-dimensional limitation. With diminished need for identification on two mammographic views, localization in these instances falls more within the realm of possibility. This paper highlights Moffitt Cancer Center's experience with CT-directed breast biopsy as an alternative to close follow-up or blind-biopsy. In addition, because palpable breast abnormalities may not be the same as mammographic abnormalities, the report details the accuracy of CT-directed biopsy in allowing the surgeon to perform precise open biopsy, thus avoiding medical-legal exposure.

Biopsy↗
PubMed1995

Immunohistochemical assessment of tumor vascularity in recurrent Clark II melanomas using antibody to type IV collagen.

Thin melanomas, measuring 0.76 mm or less, are generally associated with an excellent prognosis. However, a certain subset of these seemingly innocuous lesions have been reported to develop recurrences. Therefore, the predictive values of currently accepted prognostic indicators have been questioned in thin melanomas. Several studies concerning tumor vascularity in melanoma and certain non-melanocytic malignancies suggest that the degree of vascularization correlates with growth rate and biologic aggressiveness. In the present study, we determined the vascularity of a small group of Clark level II melanomas that resulted in recurrence, and compared these results to an equal number of nonrecurrent lesions with similar prognostic indicators. Blood vessels were labeled by immunoperoxidase staining techniques for Type IV collagen, and quantified by image analysis. No statistical difference was found between the two groups when mean blood vessel counts and percent vascular area were measured. The recurrent tumors had a mean PVA of 4.68 compared to 4.34 for the nonrecurrent group (p = 0.677). The mean blood vessel count beneath the recurrent group was 29.6 per 400 x field, and the corresponding value for the nonrecurrent group was 31.8 (p = 0.681). Our data is preliminary within this limited group of tumors, yet it suggests that tumor vascularity is not a distinctive prognostic indicator by which eventual outcome can be predicted in thin Clark level II malignant melanomas.

Adult↗
PubMed1995

Accurate Nodal Staging of Malignant Melanoma.

The incidence of malignant melanoma is increasing at a faster pace than that of any other cancer in the United States. It is estimated that people born in the year 2000 will have a 1:75 risk of developing melanoma sometime during his or her lifetime. Stimulated by novel lymphatic mapping techniques, the surgical care of the melanoma patient is evolving toward more conservative resections that can provide the same staging information but without the added morbidity of more radical surgeries. This approach promises to yield positive results in the age of health care reform, outcome measurements, and cost:benefit considerations.

Journal Article↗
PubMed1994

The orderly progression of melanoma nodal metastases.

OBJECTIVE: The aim of this study was to determine the order of melanoma nodal metastases. SUMMARY BACKGROUND DATA: Most solid tumors are thought to demonstrate a random nodal metastatic pattern. The incidence of skip nodal metastases precluded the use of sampling procedures of first station nodal basins to achieve adequate pathological staging. Malignant melanoma may be different from other malignancies in that the cutaneous lymphatic flow is better defined and can be mapped accurately. The concept of an orderly progression of nodal metastases is radically different than what is thought to occur in the natural history of metastases from most other solid malignancies. METHODS: The investigators performed preoperative and intraoperative mapping of the cutaneous lymphatics from the primary melanoma in an attempt to identify the "sentinel" lymph node in the regional basin. All patients had primary melanomas with tumor thicknesses > 0.76 mm and were considered candidates for elective lymph node dissection. The sentinel lymph node was harvested and submitted separately to pathology, followed by a complete node dissection. The null hypothesis tested was whether nodal metastases from malignant melanoma occurred in equal proportions among sentinel and nonsentinel nodes. RESULTS: Forty-two patients met the criteria of the protocol based on prognostic factors of their primary melanoma. Thirty-four patients had histologically negative sentinel nodes, with the rest of the nodes in the basin also being negative. Thus, there were no skip metastases documented. Eight patients had positive sentinel nodes, with seven of the eight having the sentinel node as the only site of disease. In these seven patients, the frequency of sentinel nodal metastases was 92%, whereas none of the higher nodes had documented metastatic disease. Nodal involvement was compared between the sentinel and nonsentinel nodal groups, based on the binomial distribution. Under the null hypothesis of equality in distribution of nodal metastases, the probability that all seven unpaired observations would demonstrate that involvement of the sentinel node is 0.008. CONCLUSIONS: The data presented demonstrate that nodal metastases from cutaneous melanoma are not random events. The sentinel lymph nodes in the lymphatic basins can be mapped and identified individually, and they have been shown to contain the first evidence of melanoma metastases. This information can be used to revolutionize melanoma care so that only those patients with evidence of nodal metastatic disease are subjected to the morbidity and expense of a complete node dissection. Because sentinel node histology accurately reflects the histology of the remainder of the lymphatic basin, information gained from the sentinel node biopsy can be used as a prognostic factor for melanoma. These findings demonstrate effective pathologic staging, no decrease in standards of care, and a reduction of morbidity with a less aggressive, rational surgical approach.

Adolescent↗
PubMed1993

The anatomy of missed breast cancers.

Missed breast cancer continues to account for the highest percentage of medical malpractice cases in the United States. A retrospective, computer-aided study was performed to investigate the mechanisms of missed breast carcinomas, missed either by mammography or by clinical exam. In a consecutive series of 509 breast cancers found in patients registered at a University Comprehensive Breast Cancer Clinic, no tumour that was 5 mm or less in maximal diameter was clinically palpable. This subgroup consisted of seven in situ and 32 invasive carcinomas. The incidence of palpable tumours in 5 mm increments increased so that when a tumour was between 11 and 15 mm in size, 48% of the lesions were palpable, and with tumours greater than 20 mm in size, 84% were palpable. There was a good correlation between size of the tumour as judged by mammography and the eventual size determined by histologic examination. Smaller breast cancers were detected by mammography than by physical examination. In a separate analysis of 553 consecutive cases of breast cancer examined by mammography, there were 50 (9%) cases in which the cancer was not read from the mammogram. In retrospect, 10 of these mammograms were abnormal for a misinterpretation rate of 1.8%. Cancers associated with false negative mammograms occurred more often in younger women and in dense breast parenchyma than cancers detected by mammography. Cancers missed by mammography were smaller than palpable cancers detected by mammography, more often had negative nodes and presented with a lower stage of disease. Breast augmentation implants were associated more frequently with missed breast cancers, with 5/8 clinically detected breast carcinomas being undetected by mammography. An asymmetric mass was more often associated with cancers missed by mammography, accounting for the sole sign of malignancy in 3% of all cancers, but was the source of 14% of false negative exams. Architectural distortion, ill-defined or well circumscribed masses or calcifications as mammographic signs of malignancy were not associated with an increased frequency of missed cancers. Three 'interval' breast cancers occurred in this series and are included in the false negative mammograms. It is concluded that the threshold of clinically detected breast cancers is 6 mm and experienced clinicians do not detect the majority of breast cancers until the lesions are greater than 16 mm. Mammography has a defined misinterpretation and false negative rate. Likewise, asymmetric mammographic densities that are greater than 16 mm and are not palpable may be followed, since most breast cancers are palpable in this range.

Adult↗