C. David Teates

Lymphoscintigraphy and Sentinel Node Biopsy Accurately Stage Melanoma in Patients Presenting After Wide Local Excision

AbstractBackground: Patients have traditionally been considered candidates for sentinel node biopsy (SNBx) only at the time of wide local excision (WLE). We hypothesized that patients with prior WLE may also be staged accurately with SNBx. Methods: Seventy-six patients, including 18 patients from the University of Virginia and 58 from a multicenter study of SNBx led by investigators at the University of Vermont, who had previous WLE for clinically localized melanoma underwent lymphoscintigraphy with SNBx. Median follow-up time was 38 months. Results: Intraoperative identification of at least 1 sentinel node was accomplished in 75 patients (98.6%). The mean number of sentinel nodes removed per patient was 2.0. Eleven patients (15%) had positive sentinel nodes. Among the 64 patients with negative SNBx, 3 (4%) developed nodal recurrences in a sentinel node–negative basin simultaneous with systemic metastasis, and 1 (1%) developed an isolated first recurrence in a lymph node. Conclusions:This multicenter study more than doubles the published experience with SNBx after WLE and provides much-needed outcome data on recurrence after SNBx in these patients. These outcomes compare favorably with the reported literature for patients with SNBx at the time of WLE, suggesting that accurate staging of the regional lymph node bed is possible in patients after WLE.

Computed tomography as a diagnostic aid in diabetic and other problem feet

Determining whether osteomyelitis is present in patients with foot infections represents a significant diagnostic challenge. As bone uptake with nuclide scans can be affected by soft tissue infection, we performed computed tomography (CT) on seven patients to see if marrow or bone abnormalities could be seen and used to predict the presence or absence of osteomyelitis. The CT scans correctly predicted the presence or absence of osteomyelitis in all seven patients. Four patients had osteomyelitis and three patients did not. Nuclide bone scans had one false-positive and one false-negative result. In this small series, CT proved helpful in evaluating foot problems.

Suspected pulmonary embolism and lung scan interpretation: trial of a Bayesian reporting method.

AbstractObjective:To determine whether a Bayesian method of lung scan (LS) reporting could influence the management of patients with suspected pulmonary embolism (PE). Design:1) A descriptive study of the diagnostic process for suspected PE using the new reporting method; 2) a non-experimental evaluation of the reporting method comparing prospective patients and historical controls; and 3) a survey of physicians’ reactions to the reporting innovation. Setting:University of Virginia Hospital. Patients:Of 148 consecutive patients enrolled at the time of LS, 129 were completely evaluated; 75 patients scanned the previous year served as controls. Intervention:The LS results of patients with suspected PE were reported as posttest probabilities of PE calculated from physician-provided pretest probabilities and the likelihood ratios for PE of LS interpretations. Results:Despite the Bayesian intervention, the confirmation or exclusion of PE was often based on inconclusive evidence. PE was considered by the clinician to be ruled out in 98% of patients with posttest probabilities <25% and ruled in for 95% of patients with posttest probabilities >75%. Prospective patients and historical controls were similar in terms of tests ordered after the LS (e.g., pulmonary angiography). Patients with intermediate or indeterminate lung scan results had the highest proportion of subsequent testing. Most physicians (80%) found the reporting innovation to be helpful, either because it confirmed clinical judgement (94 cases) or because it led to additional testing (7 cases). Conclusions:Despite the probabilistic guidance provided by the study, the diagnosis of PE was often neither clearly established nor excluded. While physicians appreciated the innovation and were not confused by the terminology, their clinical decision making was not clearly enhanced.

Radionuclide brain scan findings in superior sagittal sinus thrombosis.

Superior sagittal sinus thrombosis is a serious condition requiring early diagnosis. This paper presents our experience with two cases and describes the findings. In one case radionuclide brain Imaging was the first study performed. In the other, the diagnosis was made at arteriography with scanning used for follow-up.