The double-wire technique as an aid to selective cannulation of the common bile duct during pediatric endoscopic retrograde cholangiopancreatography.

BACKGROUND: Selective cannulation of the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP) can be difficult. Several techniques have been described to assist endoscopists in obtaining access when initial cannulation fails. The objective of this report is to describe our initial experience with the "double-wire technique" in the pediatric population. PATIENTS AND METHODS: Sixty ERCPs were performed in children with ages ranging from 8 months to 18 years and the technique was used in 8 cases. After wire-guided access to the pancreatic duct is obtained, the wire is left in place within the pancreatic duct to aid subsequent selective cannulation of the CBD. RESULTS: In 2 of these cases, transient increase in pancreatic enzymes was observed after ERCP. Nevertheless, in this small series of patients it was found to be an effective and useful tool in cases in which repeated attempts have yielded only pancreatic duct cannulation. CONCLUSIONS: This technique is a useful aid for the endoscopist attempting to selectively cannulate the CBD in difficult cases. Further study will be needed to establish the safety of this technique in the pediatric population.

Lack of prognostic importance of reverse-transcriptase polymerase chain reaction detection of circulating messenger RNA in patients with melanoma.

BACKGROUND: Molecular serologic markers for detecting early melanoma metastases have been described. The objective of this study was to determine whether reverse-transcriptase polymerase chain reaction detection of circulating tyrosinase messenger RNA (mRNA) can identify the presence of subclinical metastases and predict subsequent clinical recurrence in surgically treated melanoma patients who are at significant risk for relapse. METHODS: Preoperative peripheral blood samples of disease-free melanoma patients, disease stage ranging from I to IV, were analyzed for the presence of tyrosinase mRNA by semiquantitative reverse-transcriptase polymerase chain reaction as a putative marker for circulating melanoma cells. Multivariate analysis was performed to evaluate the prognostic value of tyrosinase mRNA in the blood and in the correlating pathologic stage of disease with recurrence and survival. RESULTS: The study group consisted of 96 patients. The mean age was 54 years (range, 24 to 83 years). The mean Breslow thickness was 3 mm (range, 0.9 to 21 mm). Circulating melanoma cells were detected in 66 patients (69 percent). Blood polymerase chain reaction positivity by American Joint Committee on Cancer stage was as follows: stage I, 19 of 28 patients (68 percent); stage II, 17 of 25 patients (68 percent); stage III, 28 of 41 patients (68 percent); and stage IV, two of two patients (100 percent). Tyrosinase detection was not associated with stage of disease (p = 0.77). At a median follow-up of 30 months, disease recurred in 21 patients (22 percent), and 15 patients (16 percent) died. Disease stage of the patients correlated with recurrence (p < 0.0001) and death (p < 0.0001). The finding of mRNA tyrosinase in peripheral blood samples was not associated with recurrence (p = 0.1) or death (p = 0.77). CONCLUSIONS: The use of polymerase chain reaction to detect circulating tyrosinase mRNA in peripheral blood does not correlate with traditional prognostic indicators in patients with cutaneous melanoma and does not appear to be an effective prognostic tool.

Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma.

The policy of routine angiography (ANG) for all penetrating neck wounds results in a high rate of negative studies. The medical records of all patients who presented to Wishard Memorial Hospital and Methodist Hospital of Indiana with penetrating injuries to the neck from January 1992 to April 2001 were reviewed. All patients who were hemodynamically stable underwent four-vessel ANG to evaluate for vascular injury irrespective of findings on physical examination (PE). A total of 216 patients sustained penetrating neck injuries. Patients were divided according to positive or negative PE findings and the results of ANG. Of the 63 patients with a positive PE, 40 (68%) also had a positive ANG finding. Of the 89 patients with negative PE, only 3 had a positive ANG and none of these injuries required operative repair. PE therefore had a 93 per cent sensitivity (SEN) and a 97 per cent negative predictive value (NPV) for predicting the results of ANG. The SEN and NPV of PE for detecting vascular injuries requiring operative repair were both 100 per cent. In this series, no patient with a negative PE had a vascular injury that required operative repair, irrespective of zone of injury. Routine ANG may therefore be unnecessary for patients with penetrating neck injuries and a negative PE.

Prognostic importance of lymph node tumor burden in melanoma patients staged by sentinel node biopsy.

BACKGROUND: The objective of this study was to investigate the relationship between nodal tumor burden and the outcomes of recurrence and survival in sentinel node-positive melanoma patients. METHODS: We reviewed a series of sentinel node-positive patients with primary cutaneous melanoma treated with completion lymph node dissection (CLND). Microscopic nodal tumor deposits were counted and measured with an ocular micrometer. Various measures of tumor burden and traditional melanoma prognostic indicators were studied in multivariate Cox regression models. RESULTS: Sentinel lymph node and CLND specimens were evaluated in 90 node-positive patients. The diameter of the largest lymph node tumor nodule and the total lymph node tumor volume were significant predictors of recurrence (two-sided P <.0001 for both) and survival (two-sided P =.0018 and P =.0002, respectively). A tumor deposit diameter of 3 mm was identified as the most significant cut point predictive of recurrence (P <.0001; hazard ratio, 5.18) and survival (P <.0001; hazard ratio, 5.43). The 3-year survival probability was.86 for patients with largest tumor deposit diameters of 3 mm (P <.0001). CONCLUSIONS: Microstaging of melanoma sentinel lymph node/CLND specimens by using the diameter of the largest tumor deposit is a highly significant predictor of early relapse and survival.