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Biomedical subjects

M J Krasna

Publications and source records attributed to M J Krasna.

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

Search for a primary lung neoplasm in patients with brain metastasis: is the chest radiograph sufficient?

OBJECTIVE: We assessed whether chest CT provided an advantage over chest radiography when diagnosing a primary lung neoplasm in a selected group of patients. MATERIALS AND METHODS: From a retrospective evaluation of 925 patients who had a discharge diagnosis of brain metastasis, we identified 32 patients who presented without a known primary tumor site and who were investigated subsequently with both chest radiography and CT. Reports of chest radiographs were classified as showing a primary lung neoplasm (positive), as abnormal but nonspecific, or as negative. Patients were categorized as having negative chest radiograph, negative CT; positive chest radiograph, positive CT; nonspecific chest radiograph, positive CT; or negative chest radiograph, positive CT. Radiographic technique and clinical and lesion characteristics were compared among these categories. RESULTS: We found negative chest radiograph and negative CT in one patient who ultimately proved to have breast cancer. The remaining 31 patients (97%) had primary lung carcinoma. In 19 (59%) of the 32 patients, chest radiographs and CT were positive. Twelve patients (38%) had a nonspecific or negative chest radiograph and positive CT. In the 31 patients with lung carcinoma, the mean diameter of lesions in patients with positive chest radiographs was 4.2 cm, compared with 2.5 cm in patients with normal or nonspecific radiographs (p < .01). CONCLUSION: Lung cancer is by far the most common cause of a de novo presentation with brain metastasis. Chest CT is valuable to supplement chest radiography in patients with metastatic brain disease in whom a primary lesion is sought. Lesion size appears to be the most important determinant of detectability of a primary tumor on chest radiographs.

Brain Neoplasms↗
PubMed1997

Endoscopic knot.

A new technique for a simplified endoscopic knot with careful attention to knot formation is presented. This knot has been shown to be strong and reliable without the need for intracorporeal knot tying or knot pushers.

Endoscopy↗
PubMed1996

Complications of thoracoscopy.

BACKGROUND: The revolution in video technology has led to the acceptance of thoracoscopy as an important tool in thoracic surgery. METHODS: A review of all patients undergoing thoracoscopy at the University of Maryland between November 1991 and March 1995 was performed to identify the incidence of intraoperative and postoperative complications. In addition, the role of computed tomography for predicting intraoperative complications was analyzed. RESULTS: Three hundred forty-eight procedures were performed in 321 patients. Twenty-seven patients required conversion to thoracotomy for various indications. In 12 patients further resection was required after frozen section diagnosis confirmed lung carcinoma. Six patients were opened due to adhesions. Two patients were opened due to inability to find the lesion (this represents 1.6% of all solitary pulmonary nodules). Three cases were converted to thoracotomy for lesions that were too large to remove (representing 2.5% of all solitary pulmonary nodules resected). Two patients required conversion to thoracotomy because of inability to obtain one-lung ventilation. One case required a limited thoracotomy for a lost needle used for needle localization of a solitary intraparenchymal nodule, and 1 patient had emergent exploration for bleeding. Early postoperative complications developed in 10 patients. There were two explorations in the immediate postoperative period for bleeding. Prolonged air leak occurred in 3 patients, empyema in 2, and recurrent pneumothorax, pulmonary edema, and pneumonia in 1 patient each. Computed tomography failed to diagnose adhesions in the majority of patients requiring conversion to thoracotomy. CONCLUSIONS: Thoracoscopy is a safe and effective procedure with low intraoperative and postoperative complication rates.

Baltimore↗
PubMed1996

Combined thoracoscopic/laparoscopic staging of esophageal cancer.

Unlike mediastinoscopy in lung cancer, there exists no standard minimally invasive test to stage esophageal cancer. If it were possible to obtain exact preoperative staging in esophageal cancer, patients could be separated prospectively to receive neoadjuvant therapy appropriately. We studied the feasibility and efficacy of thoracoscopic and laparoscopic lymph node staging in esophageal cancer. Thoracoscopic staging was performed in 45 patients with biopsy-proven carcinoma of the esophagus. Laparoscopic staging was done in the last 19 patients. Thoracoscopic staging was aborted in three patients because of adhesions. Thoracic lymph node stage was N0 in 39 patients and N1 in three; celiac lymph nodes were normal in 13 and diseased in six. Esophageal resection was performed in 30 patients after thoracoscopic staging; 17 of these underwent laparoscopic staging. Thoracoscopic staging showed N0 lymph node status in 28 patients and N1 in two patients. Two of the 28 patients (7%) with N0 disease were found at resection to have paraesophageal lymph node involvement (N1); thus the disease was understaged by thoracoscopic staging. Thoracoscopic staging was accurate in detecting the presence of diseased thoracic lymph nodes in 28 of 30 cases (93%). Laparoscopic staging detected normal celiac nodes in 12 patients and diseased lymph nodes in five patients. After esophagectomy, the final pathology report in the 12 patients with N0 disease was N0 in 11 and diseased lymph nodes in one patient. Thus laparoscopic staging was accurate in detecting lymph node metastases in 16 of 17 patients (94%). Thoracoscopic and laparoscopic staging are more accurate than existing staging methods. Six of 19 patients in whom laparoscopic staging was used had unsuspected celiac axis lymph node involvement that had been missed by standard noninvasive techniques. One of three patients with thoracic lymph nodes and three of six with celiac lymph nodes were downstaged after preoperative chemotherapy/radiotherapy. The role of thoracoscopy and laparoscopy in staging esophageal cancer should be further evaluated in a multiinstitutional trial.

Adenocarcinoma↗
PubMed1996

From the archives of the AFIP. Malignant pleural mesothelioma: radiologic-pathologic correlation.

Malignant pleural mesothelioma (MPM) is a rare malignant neoplasm that typically affects individuals occupationally exposed to asbestos through a variety of industries. The patients experience an insidious onset of symptoms, including dyspnea, chest pain, cough, malaise, and weight loss. The pathologic diagnosis of MPM is difficult, and special stains or immunohistochemical or ultrastructural analysis may be required to differentiate MPM from metastatic adenocarcinoma. The tumor affects both the parietal and visceral pleural surfaces and progresses to encase the lung and invade the lung, mediastinum, and chest wall. Radiologically, MPM manifests as unilateral pleural effusion, pleural nodules, or pleural masses. Imaging studies are useful for diagnosis and staging in patients who are potential surgical candidates. Although a variety of multimodality therapies are available and radical surgical procedures have been developed, the prognosis remains dismal.

Aged↗
PubMed1996

Thoracoscopic versus laparoscopic placement of defibrillator patches.

Nonthoracotomy lead systems have been developed to reduce the morbidity associated with cardioverter/defibrillator implantation. Total endocardial lead systems are effective in only about 50% of patients with standard monophasic waveforms; so patch placement is frequently required. We developed a new patch design and surgical techniques for thoracoscopic patch placement over the left ventricle and laparoscopic placement under the diaphragm. To compare the efficacy of these approaches, patches were placed in both locations in pigs acutely with a right ventricular coil serving as the anode for defibrillation. Defibrillation testing was performed, alternating between patches. The energies associated with 50% (DF50) and 90% (DF90) probability of successful defibrillation with biphasic shocks with determined. Defibrillator thresholds were significantly lower with intrathoracic than with subdiaphragmatic patches. Animal autopsy following more than 30 shocks from each patch revealed no gross damage to the lung or diaphragm in any animal.

Animals↗
PubMed1996

Role of thoracoscopic lymph node staging for lung and esophageal cancer.

Staging is extremely important in determining the proper treatment of patients with thoracic malignancies. Staging groups can be used to predict outcome after cancer treatment and allocate patients to appropriate treatment regimens. Thoracoscopy is an excellent means of staging intrathoracic malignancies. It is a good tool for biopsy of mediastinal lymph nodes and evaluation of the pleural cavity. Routine thoracoscopic and laparoscopic lymph node staging have been used in patients with esophageal carcinoma with excellent results. For patients with lung cancer, thoracoscopy augments other noninvasive and minimally invasive staging procedures. It is used as a complement to standard cervical mediastinoscopy in assessing mediastinal and hilar lymph nodes. It can thus help avoid an unnecessary thoracotomy for attempted resection in a patient who is found to have gross spread of locoregional disease.

Biopsy↗
PubMed1996

Alterations of transforming growth factor-beta 1 receptor type II occur in ulcerative colitis-associated carcinomas, sporadic colorectal neoplasms, and esophageal carcinomas, but not in gastric neoplasms.

BACKGROUND & AIMS: Gastric cancers, sporadic colorectal cancers, and ulcerative colitis (UC)-associated colorectal carcinomas and dysplasias manifest microsatellite instability (MI); however, esophageal carcinomas rarely exhibit MI. Recently, a transforming growth factor-beta 1 type II receptor (TGF-beta 1RII) mutation in a coding microsatellite was described in primary colorectal carcinomas demonstrating MI. No previous studies of TGF-beta 1RII have addressed mechanisms of inactivation other than MI in human tumors; furthermore, MI-negative tumors have not been examined for TGF-beta 1RII mutation. We evaluated 138 primary human neoplasms for mutation in the poly-A microsatellite tract of TGF-beta 1RII. Additionally, a group of esophageal tumors was evaluated for the expression of TGF-beta 1RII messenger RNA (mRNA). METHODS: First, we determined whether MI was present at other chromosomal loci in these lesions. The poly-deoxyadenine (poly-A) microsatellite tract within the TGF-beta 1RII coding region was then PCR-amplified. In a group of MI-negative esophageal tumors, RT-PCR was performed to determine the expression of TGF-beta 1RII mRNA. RESULTS: Among 17 MI+ UC specimens, 3 (18%) demonstrated TGF-beta 1RII poly-A tract mutation (2 cancers and 1 dysplasia), while 2 (4%) of 44 MI-negative UC specimens (1 dysplasia and 1 tumor), and 13 (81%) of 16 MI+ sporadic colorectal cancers, contained TGF-beta 1RII poly-A mutation. No gastric or esophageal tumors contained TGF-beta 1RII mutation. Among 21 MI-negative esophageal carcinomas. 6 cases (28.5%) had TGF-beta 1RII transcripts that were low or undetectable by RT-PCR. CONCLUSIONS: Mutation within the poly-A microsatellite tract of TGF-beta 1RII occurs early in a subset of UC-neoplasms and commonly in sporadic colorectal cancers, but may be rare in MI+ gastric tumors. Diminished expression of TGF-beta 1RII mRNA in esophageal tumors suggests that mechanisms of inactivation in this gene other than MI play a role in esophageal carcinogenesis.

Colitis, Ulcerative↗
PubMed1995

TP53 and RAS mutations in metachronous tumors from patients with cancer of the upper aerodigestive tract.

Patients who initially develop an upper aerodigestive tract cancer have an increased risk of second primary cancers. We examined TP53 and RAS mutations and p53 protein in 21 tumors from 10 patients with upper aerodigestive tract cancer who developed a metachronous tumor, to assess the genetic changes that occur in multiple primary tumors from the same individual. Thirteen of 21 (62%) tumors were found to have mis-sense mutations of either TP53 or RAS. Six tumors had TP53 mutations in codons 5 to 8 and 10 tumors from 7 patients had mutations of codons 12 or 13 of K-RAS. Only one patient had concordance of a mutation in 2 tumors; this mutation occurred in K-RAS and was accompanied by discordance of TP53 mutation. Three patients had tumors discordant for both TP53 and RAS mutations. Smoking-related tumors had TP53 and RAS mutations which were transversions in 11 (9 G:C to T:A and 2 G:C to C:G) and transitions in 3 (2 G:C to A:T and 1 A:T to G:C). Tumors not associated with smoking contained only transitions (both G:C to A:T). p53 protein was detected by immunohistochemistry in 7 of 13 (54%) tumors and was concordant in the multiple tumors of 3 patients. Three of the 7 tumors staining for p53 also had TP53 mutations. Thus, genetic alterations are discordant in multiple primary cancers and the pattern of mutations is similar to that found in patients with a single primary tumor, supporting the concept that these cancers arise independently.

Adenocarcinoma↗
PubMed1995

The role of thoracoscopy in the diagnosis of interstitial lung disease.

A study was undertaken to evaluate the safety and efficacy of thoracoscopic lung biopsy for interstitial lung disease. The relation between operative findings, pathologic findings, and preoperative computed tomographic scan findings was examined. Twenty-six patients, 10 male and 16 female, underwent thoracoscopic lung resection to diagnose interstitial lung disease. Sixteen patients were outpatients for an elective procedure; 10 were inpatients including 2 who were ventilator dependent. The mean length of operation was 54 minutes and the mean length of chest tube duration, 1.3 days. There were no deaths. Staphylococcal pneumonia developed in 1 patient postoperatively. One patient with systemic pulmonary hypertension was ventilator dependent for 48 hours. A double-lumen endotracheal tube was used in all but 2 patients. Twelve-millimeter trocar ports were used to allow easy interchange of staplers and endoscopic instruments. Biopsy of at least two lobes was performed in each patient with resection of a piece of grossly abnormal lung. A single chest tube was left routinely. The pathologic diagnosis was usual interstitial pneumonitis in 7 patients. Four patients had interstitial fibrosis and 4, granulomas. Three patients had diffuse alveolar damage and 3, Wegener's granulomatosis. Two patients had bronchiolitis obliterans with organizing pneumonia. One patient each had lymphangioleiomyomatosis, eosinophilic granuloma, and cytomegalovirus. Sixteen patients underwent preoperative computed tomographic scanning. The scans were assessed by 2 radiologists who were blinded to the surgical results. Computed tomography accurately predicted the site of disease in most instances. Four patients had at least one lobe with no evidence of disease on computed tomography but with interstitial lung disease found thoracoscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

Biopsy↗
PubMed1995

Subarachnoid-pleural fistula after resection of a pancoast tumor with hyponatremia.

Resection of superior sulcus neoplasms is associated with a number of complications resulting from the extensive nature of the resection and the necessity to sacrifice certain adjacent structures. One of the complications of resection is the development of subarachnoid-pleural fistula, with the subsequent appearance of air in the cerebrospinal fluid circulation. We report a case in which a subarachnoid-pleural fistula led to persistent pneumocephaly in a patient who exhibited postoperative hyponatremia, confusion, and gait disturbance.

Aged↗
PubMed1995

Paraplegia after thoracotomy: report of five cases and review of the literature.

Paraplegia complicating thoracotomy is rare but catastrophic. This report comprises 40 cases: 5 of our cases and 35 reported cases. Our cases comprised a stab wound of the left chest (1), decortication (1), lobectomy for bronchogenic carcinoma (2), and segmental resection for tuberculosis (1). The reported cases included 25 cases following thoracotomy for thoracic pathology (bronchogenic carcinoma, 12; pulmonary tuberculosis, 7; thoracic trauma, 2; bronchiectasis, 1; peptic esophagitis, 1; neurogenic tumors, 2; and benign lung lesion, 1 and 10 cases following operation for malignant hypertension. The surgical procedures performed on the 25 patients with thoracic pathology were lobectomy (8), bilobectomy (1), pneumonectomy (7), decortication (1), thoracoplasty (1), excision of neurogenic tumors (2), drainage of tuberculous cavity (1), and Nissen procedure (1). The intraoperative factors contributing to the neurologic deficit were bleeding at the costovertebral angle (9), migration of oxidized cellulose into spinal canal (9), thrombosis of anterior spinal artery (4), epidural hematoma (2), epidural narcotic (2), metastatic carcinoma (1), and hypotension (1). This serious complication can be prevented by meticulous operation and careful hemostasis. The immediate use of tomographic scanning or magnetic resonance imaging followed by surgical decompression might avert this serious complication.

Adult↗
PubMed1995

Endobronchial fibrous histiocytoma.

Fibrous histiocytomas are uncommon pulmonary tumors. They generally involve only the lung parenchyma. Endobronchial involvement is extremely rare. Usually, surgical resection of the mass is required for definitive diagnosis and therapy. We report a case of benign atypical fibrous histiocytoma visualized during fiberoptic bronchoscopy and review the clinical findings and pathologic features of this tumor.

Adult↗
PubMed1995

Thoracoscopic staging of esophageal cancer: a prospective, multiinstitutional trial. Cancer and Leukemia Group B Thoracic Surgeons.

BACKGROUND: Lymph node metastasis has been shown to be an important prognosticator in esophageal cancer. A prospective, multiinstitutional study of thoracoscopic lymph node staging in patients with biopsy-proven esophageal cancer was undertaken at University of Maryland, Medical University of South Carolina, and Brigham and Women's Hospital. METHODS: Forty-nine patients underwent thoracoscopic staging between September 1991 and August 1993. Five procedures were incomplete due to adhesions. Preoperative computed tomography, magnetic resonance imaging, esophageal ultrasound, and bronchoscopy were performed. After our initial experience with the left side of the chest, thoracoscopic staging was done through the right side of the chest unless specific indications dictated otherwise. Beginning in January 1993 routine laparoscopic/mini-laparotomy lympho node staging of the celiac axis was performed. RESULTS: Satisfactory thoracoscopic lymph node staging was achieved in 44 patients (95%). Of 33 patients undergoing esophageal resection, 29 were correctly staged (88%). Since initiating concomitant laparoscopic lymph node staging, we have correctly staged all of the last 9 patients with regard to celiac lymph nodes as well. Information regarding T status obtained at thoracoscopy was as follows: 3 patients were correctly "downstaged" to T3 despite preoperative noninvasive tests suggesting T4. In 2 patients thoracoscopy correctly predicted T4 invasion, whereas in 2 patients, thoracoscopy missed T4 lesions. CONCLUSIONS: Thoracoscopy is a valuable tool for staging intrathoracic tumors. Preoperative staging of esophageal cancer may allow better allocation of adjuvant therapy. This pilot study suggests that thoracoscopic staging can correctly predict thoracic lymph node status with high accuracy and aid in better defining T status.

Adenocarcinoma↗
PubMed1995

Anastomosis technique for high pharyngogastrostomy.

Pharyngogastric anastomosis, otherwise referred to as the "gastric pull-up" procedure, is the most reliable method of reconstruction after laryngopharyngectomy. We currently use a method of gastric to pharyngeal anastomosis that avoids excess tension, and thus decreases the incidence of fistulas and flap failures. With the stomach fully mobilized, the "pull-up" is brought high into the neck using a plastic bag to facilitate delivery via the posterior mediastinum. A curved, U-shaped incision is then made in the fundus of the tongue anteriorly, allowing the posterior nasopharynx to be reached without tension.

Anastomosis, Surgical↗
PubMed1995

Results of cancer and leukemia group B protocol 8935. A multiinstitutional phase II trimodality trial for stage IIIA (N2) non-small-cell lung cancer. Cancer and Leukemia Group B Thoracic Surgery Group.

From October 1989 to February 1992, 74 patients with mediastinoscopically staged IIIA (N2) non-small-cell lung cancer from 30 CALGB-affiliated hospitals received two cycles of preresectional cisplatin and vinblastine chemotherapy. Patients with responsive or stable disease underwent standardized surgical resection and radical lymphadenectomy. Patients who underwent resection received sequential adjuvant therapy with two cycles of cisplatin and vinblastine, followed by thoracic irradiation (54 Gy after complete resection and 59.4 Gy after incomplete resection or no resection at 1.8 Gy per fraction). There were no radiographic complete responses to the neoadjuvant chemotherapy, although 65 (88%) patients had either a response or no disease progression. During induction chemotherapy, disease progressed in seven patients (9%). Sixty-three patients (86%) had exploratory thoracotomy, and 46 of those (75%) had resectable lesions. A complete surgical resection was accomplished in 23 patients, and 23 patients had an incomplete resection with either a diseased margin or diseased highest node resected. Operative mortality was 3.2% (2/63). In 10 patients (22% of the 46 having resection) the disease was pathologically downstaged. There was no correlation between radiographic response to the induction chemotherapy and downstaging at surgical resection. The full protocol was completed by 33 patients (45% of original cohort). Overall survival at 3 years was 23%. Patients undergoing resection had significantly improved survival at 3 years compared with patients not having resection: 46% for complete resection (median 20.9 months), 25% for incomplete resection (median 17.8 months), and 0% for no resection (median 8.5 months). Five deaths occurred during the treatment period. A total of 18 of the 46 (39%) patients who underwent resection are either alive and disease-free or have died without recurrence.

Aged↗
PubMed1995

Thoracoscopic staging of esophageal carcinoma.

Thoracoscopy is an excellent complement to mediastinoscopy in staging thoracic malignancies. The author describes the technique of thoracoscopic and laparoscopic lymph node staging for patients with esophageal carcinoma.

Biopsy↗