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PubMed1999

Outcome evaluation of the 1997 American Joint Committee on Cancer staging system for prostate carcinoma treated by radiation therapy.

BACKGROUND: The 1997 American Joint Committee on Cancer (AJCC) staging system condensed unilobular tumors into one entity and continues the use of both imaging and biopsy to alter classification status in T2 and T3 carcinomas. This study analyzes the biochemical freedom from disease recurrence (bNED) outcome in a large database to determine whether these changes reflect outcome differences. METHODS: Five hundred and thirty-seven patients with adenocarcinoma of the prostate were treated with radiation therapy to a median dose of 7180 centigrays (cGy) (range, 6316-8074 cGy) between November 1987 and November 1994. The median age of the patients was 70 years and the median follow-up was 51 months. The median pretreatment prostate specific antigen (PSA) was 11.0 ng/mL. Patients were analyzed using 1992 AJCC stage comparing bNED outcome after radiation therapy for T2a versus T2b versus T2c tumors using Kaplan-Meier estimation and the log rank test. Patients then were analyzed multivariately using Cox regression with the known prognostic variables of dose, pretreatment PSA, palpation stage, and grade in addition to palpation plus imaging stage and palpation plus biopsy stage. The prognostic endpoint was bNED with failure as defined by the 1997 American Society for Therapeutic Radiology and Oncology Consensus Panel. RESULTS: The 1992 AJCC palpation classifications T2a versus T2b versus T2c have a significantly different (P = 0.02) bNED outcome. Prognostic significance is lost by pooling these three classifications in the 1997 AJCC staging system. Adding imaging information to palpation did not improve the ability of palpation alone to assess bNED status (P = 0.33). However, the addition of biopsy information to palpation significantly (P = 0.02) increased the accuracy of palpation stage alone to predict for bNED outcome for T2 and T3 tumors. CONCLUSIONS: The subdivision of T2 tumors in the 1992 AJCC classification (T2a, T2b, and T2c) should be used in the next revision of the 1997 AJCC staging system. The addition of imaging data does not discriminate bNED outcome any better than palpation stage alone in T2 and T3 tumors and should not be used. The addition of biopsy information to palpation stage did significantly improve the predicted outcome compared with palpation alone and should continue to be used.

Adenocarcinoma↗
PubMed1991

The bedside assessment of splenic enlargement.

STUDY OBJECTIVE: To evaluate the clinical assessment of splenic enlargement using specific bedside maneuvers including Traube's space percussion, the splenic percussion sign, Middleton's maneuver, supine palpation, and right lateral decubitus palpation. DESIGN: Quasi-experimental prospective study of cases and controls selected according to the results of abdominal ultrasonographic examinations. SETTING: Selected inpatients of a tertiary care hospital. MAIN RESULTS: Comparing the areas under the receiver operating characteristic curves for each bedside maneuver demonstrated that Traube's space percussion and palpation were significant discriminators (p less than 0.001) of splenic enlargement with respective areas of 0.70 +/- 0.04 and 0.76 +/- 0.04. No one palpation maneuver was superior to another, and right lateral decubitus palpation was not useful when performed after supine palpation. The splenic percussion sign (sensitivity 79%, specificity 46%) was no better than Traube's space percussion (sensitivity 62% and specificity 72%) in assessing splenic enlargement. The palpation maneuvers appeared more sensitive and more specific than Traube's space percussion. Palpation was a significant clinical discriminator when performed on patients who exhibited percussion dullness of Traube's space (area = 0.87 +/- 0.04, p less than 0.0001) but was of little value among those without percussion dullness (area = 0.55 +/- 0.08). Also, palpation was significantly more accurate when performed on lean patients versus obese patients (areas = 0.83 +/- 0.04 versus 0.65 +/- 0.08, p less than 0.05). When a positive bedside examination was defined as positive palpation and positive percussion (concordant-positive), the combined test sensitivity and specificity were 46% and 97% respectively. CONCLUSIONS: The optimal clinical assessment of splenic enlargement includes the percussion of Traube's space. If Traube's space is dull, palpation of the spleen is warranted. This assessment is most accurate in lean patients.

Adult↗
PubMed1996

Prostate carcinoma patients upstaged by imaging and treated with irradiation. An outcome-based analysis.

BACKGROUND: The American Joint Committee on Cancer (AJCC) staging of prostate cancer relies upon digital rectal examination (DRE) findings, but suggests using all available information, including prostate imaging studies, prior to definitive treatment of prostate carcinoma. We have studied whether patients upstaged by imaging have a different outcome after treatment with external beam radiation therapy (RT) from those not upstaged. METHODS: The records of 499 men with clinically localized adenocarcinoma of the prostate treated with only definitive external beam irradiation from January 1986 to December 1993 were reviewed. The 348 patients with any one or a combination of the following pretreatment imaging studies were considered eligible; transrectal ultrasound (TRUS), pelvic MRI, or endorectal MRI. Patients were assigned two clinical stages: one based upon palpation criteria alone (palpation stage) and the other allowing for any upstaging by imaging abnormalities (AJCC or imaging stage). The Kaplan-Meier method was used to estimate biochemical no evidence of disease (bNED) survival where a failure was defined as a prostate specific antigen (PSA) greater than 1.5 and increasing. Differences in outcome were evaluated by the log-rank test. RESULTS: Overall upstaging by TRUS or MRI to any higher stage occurred in 115 of 312 palpation T1c-T2c patients (37%). These upstaged patients had an unexpected improvement in bNED survival (84% vs. 71%, P = 0.05) compared with those who were not upstaged due to the upstaged patients having a significantly greater number with a pretreatment PSA < 10 ng/mL. T1c patients were upstaged by imaging in 81% of the 94 patients. The 36-month bNED survival of palpation T1c and imaging T2 patients was similar (88% vs. 88%, P = NS), but both were significantly improved compared with the 36-month bNED survival for palpation T2 patients (88% vs. 71%, P = 0.04). There was no significant difference in 36-month bNED survival for imaging T2c (bilobar disease) patients compared with their original palpation stage disease. Upstaging to T3 occurred in 10% of palpation T1c-T2c patients. There was no difference in 36-month bNED survival for the imaging T3 patients compared with their original palpation stage (84% vs. 71%, respectively, P = 0.04). There was a significant improvement in the 36-month bNED survival for imaging T3 patients compared with palpation T3 patients (84% vs. 50% respectively, P = 0.01). Multivariate analysis demonstrated palpation stage to be a significant predictor of bNED survival (P = 0.001), while AJCC stage (including imaging) is not predictive. CONCLUSIONS: Using the endpoint of bNED survival, upstaging by TRUS/MRI does not separate prostate cancer patients treated with RT into groups with different prognoses. Upon multivariate analysis, palpation stage alone, not AJCC stage including imaging upstaging, is a significant predictor of bNED survival.

Adenocarcinoma↗
PubMed2001

Screening high-risk populations for thyroid cancer.

BACKGROUND: Children treated with radiotherapy to the neck or exposed to environmental radiation are at risk for developing thyroid cancer later in life. The best method for screening these high-risk patients is unclear. We systematically reviewed evidence on the accuracy of ultrasound and palpation to detect thyroid nodules and of fine needle aspiration (FNA), a confirmatory test, to diagnose thyroid cancer. PROCEDURE: We searched the MEDLINE database for papers published since 1966, using the MeSH term thyroid neoplasms and terms related to diagnostic test performance. To supplement our MEDLINE searches, we searched reference lists from recent reviews and articles recommended by thyroid cancer experts. We recorded the tests used, the gold standard determination of disease, the test performance results, and the presence of biases that could affect the reported results. We also abstracted the number of patients who underwent surgery and the final diagnoses. We created two decision models: one for screening 10,000 medically irradiated patients, and one for screening 10,000 environmentally irradiated patients. RESULTS: Using ultrasound as the gold standard determination of the presence of a nodule, the sensitivity of palpation for all sized nodules was 10-41 percent, indicating that a high proportion of nodules detected by ultrasound are too small to be palpated. Sensitivity of palpation increased with nodule size. The specificity of palpation ranged from 95 to 100%. In studies from referral centers, the reported sensitivity and specificity of FNA were 71-95 and 52-99%, respectively. However, most authors excluded the proportion of patients (6-33%) who had inadequate or nondiagnostic FNA results when calculating sensitivity and specificity, even though 6-100% of these patients went on to have a diagnostic lobectomy. When each study was reanalyzed so that patients with nondiagnostic FNA results who went directly to surgery were reclassified as positive tests, sensitivity increased slightly, but specificity dropped by 4-20 percentage points per study. The decision model for screening 10,000 medically irradiated patients revealed that if ultrasound were used as an initial screen, 2,741 patients would have nodules at least 1 cm in size; assuming no patients with smaller nodules had surgery, 1,964 patients would have surgery; 275 patients would have a diagnosis of thyroid cancer. Screening with ultrasound as an initial test would detect an additional 150 cases of thyroid cancer compared to those screened with palpation. However, an additional 1,689 patients would have surgery for nonmalignant nodules (compared to 480 patients with nonmalignant nodules screened with palpation). The yield for screening 10,000 environmentally irradiated patients was several times smaller than for screening 10,000 medically irradiated patients. If 10,000 environmentally irradiated patients were screened initially with ultrasound, approximately 708 patients would have nodules at least 1 cm in size; 89 patients would have surgery; and 38 patients would be diagnosed with thyroid cancer. CONCLUSIONS: Regardless of type of exposure, testing initially with ultrasound detects several times more cases of thyroid cancer than palpation. However, when ultrasound is the initial test, many more patients also have surgery for nonmalignant nodules. Screening with palpation is not very reassuring, particularly to medically irradiated patients with negative tests, since almost half (46%) of these patients may have undetected nodules.

Decision Support Techniques↗
PubMed1993

Examiner dependence on physical diagnostic tests for the detection of splenomegaly: a prospective study with multiple observers.

OBJECTIVE: To determine the reliability and validity of various physical diagnostic techniques (including three methods of palpation and three methods of percussion) in detecting ultrasonographically identified splenomegaly. DESIGN: Prospective, double-blind study. SETTING: University hospital. PATIENTS: Twenty-seven hospitalized male patients with suspected human immunodeficiency virus (HIV) infection. INTERVENTIONS: Three methods of palpation (bimanual, ballottement, and palpation from above) and three methods of percussion (as described by Nixon, Castell, and Barkun et al.) were performed on each patient by eight examiners. Splenic ultrasonography was performed within 96 hours of admission. MEASUREMENTS AND MAIN RESULTS: The prevalence of splenomegaly by ultrasonography (defined as a spleen > or = 13 cm on the longitudinal scan) in this population was 33.3%. The sensitivity and specificity of each method of palpation and percussion varied by examiner. The ranges of sensitivity across examiners for the three methods of palpation and the three methods of percussion were 0%-64.3% and 7.7%-75%, respectively. The ranges of specificity across examiners for the three methods of palpation and the three methods of percussion were 50%-100% and 60%-100%, respectively. Likelihood ratios pooled across observers revealed that for palpation, palpation from above, and percussion, Castell's method had the highest likelihood ratios [LR = 2.66 and 1.97, respectively; 95% CI = 1.52-4.64 and 1.22-3.19, respectively]. A combination of tests (either palpation or percussion) increased the diagnostic accuracy. CONCLUSION: Physical diagnostic techniques for the detection of splenomegaly are relatively insensitive but specific. In this study there was high interobserver variability, which did not appear to be associated to the level of experience. Combining tests increases diagnostic accuracy.

Adult↗
PubMed1990

Comparison of three clinical techniques for evaluating joint sounds.

Two-hundred two consecutive adult patients presenting to the University of Kentucky for general dental care screening were examined for temporomandibular joint sounds by three techniques: (1) lateral pole surface palpation, (2) digital palpation in the external auditory canal, (3) auscultation by a stethoscope. Sixty-nine patients reported joint sounds, but only 32 had sounds diagnosed by auscultation resulting in a 54% false-negative reporting rate. Stethoscopic auscultation was used as the standard to which the other two techniques were compared. The false-negative rate for auditory canal digital palpation was 71% and 77% for lateral pole surface palpation. Surface palpation had only a 2% false-positive incidence while auditory canal digital palpation had a 51% false-positive rate. There was poor agreement between the patients' subjective reporting and clinical exam by any technique. Using stethoscopic auscultation as the standard, both auditory canal and surface palpation had a very high false-negative rate, but only the auditory canal palpation had a poor false-positive incidence. Auditory canal palpation often produces TMJ sounds that are not heard with a stethoscope during normal opening and closure.

Adult↗
PubMed1999

The rational clinical examination. Does this patient have abdominal aortic aneurysm? .

In the physical examination of abdominal aortic aneurysm (AAA), the only maneuver of demonstrated value is abdominal palpation to detect abnormal widening of the aortic pulsation. Palpation of AAA appears to be safe and has not been reported to precipitate rupture. The best evidence on the accuracy of abdominal palpation comes from 15 studies of patients not previously known to have AAA who were screened with both abdominal palpation and ultrasound. When results from these studies are pooled, the sensitivity of abdominal palpation increases significantly with AAA diameter (P<.001), ranging from 29% for AAAs of 3.0 to 3.9 cm to 50% for AAAs of 4.0 to 4.9 cm and 76% for AAAs of 5.0 cm or greater. Positive and negative likelihood ratios with 95% confidence intervals (CIs) using a cutoff point for AAAs of 3.0 cm or greater are 12.0 (95% CI, 7.4-19.5) and 0.72 (95% CI, 0.65-0.81), respectively, and for AAAs of 4.0 cm or greater are 15.6 (95% CI, 8.6-28.5) and 0.51 (95% CI, 0.38-0.67). The positive predictive value of palpation for AAA of 3.0 cm or greater in these studies was 43%. Limited data suggest that abdominal obesity decreases the sensitivity of palpation. Abdominal palpation specifically directed at measuring aortic width has moderate sensitivity for detecting an AAA that would be large enough to be referred for surgery but cannot be relied on to exclude AAA, especially if rupture is a possibility.

Aneurysm, Ruptured↗
PubMed2000

Clinical anatomy and palpability of the inferior lateral pterygoid muscle.

STATEMENT OF PROBLEM: The intraoral palpation technique of the inferior belly of the inferior lateral pterygoid (ILP) muscle is a standard diagnostic examination method for temporomandibular joint dysfunction syndrome, although different studies have revealed inconsistent results. PURPOSE: This study assessed the feasibility of the ILP muscle palpation by a simulated clinical setting. MATERIAL AND METHODS: Three dentists performed a bilateral palpation of the ILP muscle in 53 fresh and unfixed human cadavers and decided whether the muscle was palpable or unpalpable. In a second step, it was observed through the dissected infratemporal fossa, whether the examiner's finger did or did not touch the ILP muscle by simulating the performed palpation. Palpatory findings were supplemented by 1-dimensional measurements for determination of topographic relations of the ILP muscle within the infratemporal fossa. For statistical analysis, sensitivity, specificity, and negative and positive predictive values of the palpation technique were calculated. Interexaminer agreement was estimated with the kappa value. RESULTS: In 86 of 106 dissected specimens, a superficial fascicle of the medial pterygoid muscle was found in direct proximity to the ILP muscle. In these cases, a residual distance of 7.8 +/- 3.2 mm remained between the ILP muscle and buccinator fascia indented by the tip of the examiner's finger. In 10 of 20 specimens with an absent superficial fascicle, the finger was able to reach the ILP muscle. CONCLUSION: It is recommended that the ILP muscle palpation technique should no longer be considered as a standard clinical procedure because it is nearly impossible to palpate the ILP muscle anatomically and because the risk of false-positive findings (by palpation of the medial pterygoid muscle) is high.

Facial Pain↗
PubMedDate not supplied

Intraoperative epiaortic ultrasound during cardiac surgery.

BACKGROUND AND AIMS: Recent evidence suggests that the incidence of stroke during cardiac surgery may be reduced by using intraoperative epiaortic ultrasound (IEU) to detect ascending aortic atherosclerosis (AAA). To better define the role of this modality, IEU was performed in 89 patients during elective cardiac procedures. METHODS: The ascending aorta and proximal arch were divided into four segments that were graded (0 to 2) on the extent of disease both by palpation and IEU. A patient score (range 0 to 8) was determined for each modality by summing the segmental scores. Operative plan was determined in part by IEU findings. Preoperative variables were evaluated for associated risk of AAA. Palpation and IEU scores were compared for their ability to identify AAA. RESULTS: Operative technique was modified to avoid AAA in ten (11.2%) patients (mean age 68.3 +/- 2.2 years; mean IEU score = 4.40 +/- 0.40). Stroke occurred in two patients (2.2%), one whose operation was modified to avoid severe AAA and another who had minimal AAA. Mean IEU scores were significantly higher for patients > or = 65 years compared with younger patients (1.35 +/- 0.26 vs 0.66 +/- 0.21; p < 0.05) and for smokers compared with nonsmokers (1.15 +/- 0.19 vs 0 +/- 0; p < 0.05). Mean patient IEU score was greater than mean palpation score (1.06 +/- 0.18 vs 0.74 +/- 0.16; p < 0.05). Sensitivity of palpation (based on 356 segments) was 0.46; however, specificity was 0.96, predictive power of a negative palpation exam was 0.88, and overall accuracy of palpation was 0.86. Thirty of the 38 false negatives resulted from failure to detect 1+ disease. None of the 63 (71%) patients with a palpation score of zero required a technical modification or had a stroke. CONCLUSIONS: These data suggest that AAA may be more severe in older patients and smokers. Aortic palpation may not identify mild AAA. IEU can confirm and clearly define both the extent and distribution of suspected AAA and is useful for determining optimal operative strategy in patients with aortic disease.

Adult↗
PubMed2001

The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis.

OBJECTIVE: To compare ultrasonography with bone scintigraphy in the diagnosis of plantar fasciitis and to compare ultrasound-guided injection with palpation-guided injection in the management of idiopathic plantar fasciitis. METHODS: Twenty-three patients with a clinical diagnosis of idiopathic plantar fasciitis in 28 heels underwent ultrasonography and bone scintigraphy of both heels at baseline. The patients were randomized to ultrasound- or palpation-guided injection of triamcinolone hexacetonide and xylocaine into the plantar fascia. The 100 mm visual analogue scale (VAS) of pain, the heel tenderness index (HTI), and ultrasonography were performed at baseline and follow-up (mean=13.4 weeks). RESULTS: The mean thickness (+/-standard error of the mean) of the plantar fascia, measured by ultrasonography, was 5.7+/-0.3 mm in symptomatic heels as compared with 3.8+/-0.2 mm in asymptomatic heels (P<0.001). Ultrasonography findings correlated with bone scintigraphic findings in the diagnosis of plantar fasciitis (P<0.001). Fourteen heels were randomized to ultrasound-guided injection, 10 heels were randomized to palpation-guided injection and four heels were not injected. Ultrasound- and palpation-guided injection resulted in significant mean improvements in VAS [39.6+/-9.2 (ultrasound) vs 41.5+/-8 (palpation)] and HTI [1.35+/-0.2 (ultrasound) vs 1.3+/-0.4 (palpation)]. There was no significant difference in the response rate following corticosteroid injection by either modality (ultrasound=13/14, palpation=8/10). Following injection, the mean thickness of the plantar fascia decreased from 5.7+/-0.3 mm to 4.65+/-0.4 mm (P<0.01). CONCLUSION: Ultrasonography and bone scintigraphy are equally effective in the diagnosis of plantar fasciitis. Ultrasound-guided injection is effective in the management of plantar fasciitis but is not more effective than palpation-guided injection. Ultrasonography may be used as an objective measure of response to treatment in plantar fasciitis.

Fasciitis↗
PubMed2006

[Clinical evaluation of the styloid process by plain radiographs and three-dimensional computed tomography].

OBJECTIVE: To investigate the relation between radiological and clinical diagnosis for Eagle's syndrome and to evaluate the value of plain radiograph (PR) and three-dimensional CT reconstructional image (3-DCT) of styloid process (SP). METHOD: The length of the 144 SPs from the PR was recorded and the palpation of the SP in tonsillar fossa was carried out in 113 patients with suspective Eagles syndrome. Twenty-three of 113 patients also underwent 3-DCT, so that the length and angulation of the 30 SPs were measured. RESULT: Seventy-eight of 113 patients (31 men and 47 women) were diagnosed as having Eagles syndrome. The age ranged from 32 to 68 years (average age: Forty-two years). A good agreement between the PR and the palpation was determinated, Kappa coefficient was 0.58. The difference value of the length of 30 SPs between the PR and the 3-DCT was (1.59 +/- 1.32) mm, and there were statistically significant difference of the length (t = 6.64, P < 0.01) on the length of SP between the PR and the 3-DCT. Positive correlation between the PR and the 3-DCT was found to be statistically significant (r = 0.982 4 +/- 95% confidence interval: 0.9631, 0.9917). The mean of medial angle of SPs was (25.60 +/- 2.56) degrees in patients with positive palpation and (15.42 +/- 2.79) degrees in those with negative palpation, respectively (P < 0.01) and the mean of anterior angle of SPs was (16.86 +/- 4.83) degrees in patients with positive palpation and (12.71 +/- 3.39) degrees in those with negative palpation, respectively (P < 0.01). The abnormal medial and anterior angles of unilateral SP without more than 30mm long was also objectively diagnostic of SPS in 8 patients with positive palpation. Four patients, whose elongated SP is too tenuous to be palpated preoperatively, underwent intraoral styloidectomy because of the fact that 3-DCT showed the tip of SPs medial and anterior deflexion. CONCLUSION: Despite magnifying image, the PR of SP is enough to diagnose Eagle's syndrome for the majority of cases. 3-DCT allows precise measurement of the length and the angulation of SPs, it is the best for the complementary purpose to the PR and to the selection of surgical approach in some cases.

Adult↗