Naturalistic study of course, effectiveness, and predictors of outcome among female adolescents in residential treatment for eating disorders.

Few empirical data address naturalistic outcomes of residential eating disorder (ED) treatment. Study aims were to evaluate course, effectiveness, and predictors of outcome in a residential treatment program. We evaluated 80 consecutively admitted female adolescents with the SCID-IV. Primary outcomes were treatment completion, subsequent readmission, clinical global impressions, and changes in body weight. Mean length of stay was 51 days, and 80% of patients were discharged according to treatment plans. Mean expected body weight (EBW) for AN patients increased from 80% to 91%. Patients reported significant improvements in ED symptoms, depression, and quality of life. Low admission %EBW and previous psychiatric hospitalizations were associated with premature termination. Overall, findings support that residential treatment is largely acceptable to patients, and that residential care may provide an opportunity for substantive therapeutic gains.

Power of Judgment: The Significance of Kant's Philosophy for the Medical System Today.

The ways of thinking in the manufacturing sciences are increasingly determining the rationality within medicine as a practical or action-based science. This "technological paradigm" infiltrates the field of medicine with the promise of increasing efficiency while simultaneously improving quality at various points in the system. Simple linear causal relationships generally need to be taken into account when manufacturing products. Even complex manufacturing processes can be broken down into the smallest units and, therefore, also be automated. The situation in complex systems such as the human body, however, is completely different. In order for doctors to be able to carry out their actions within this complex system, medicine as a science provides the physician with rules on the means that should be used to decide which remedy should be used, when and how. This judgment of which remedy should be used, when and how, what is known as the indication, is a central medical moment. This requires a power of judgment sharpened by experience. The indication, in turn, essentially determines the course of a disease and thus the quality of the treatment or the quality of result so often referred to these days.

[Psychological stressors, resources and well-being of surgeons in Germany : A cross-sectional study]. / Psychische Belastungen, Ressourcen und Wohlbefinden von Chirurgen in Deutschland : Eine Querschnittsstudie.

BACKGROUND: Psychological stress at work is associated with detrimental and health-impairing consequences for employees. OBJECTIVE: In this study major stress factors and the resource job control at the workplace of surgeons and facets of mental health were examined and compared to benchmark results of a large reference sample. METHOD: Data were collected by a representative online survey among surgeons throughout Germany who were contacted via the Professional Association of German Surgeons. In total 643 surgeons from different organizations and different disciplines completed the questionnaire that was developed using well-validated instruments. RESULTS: Time pressure was the most meaningful stress factor for surgeons. Moreover, the results for medical assistants showed adverse stress combinations of high goal uncertainty and low job control as well as high emotional exhaustion and low job satisfaction. In addition, the results indicated that surgeons in single and group practices as well as in outpatient healthcare centers have less stressors and more job resources. CONCLUSION: The survey results suggest high levels of burnout risk for German surgeons, especially among medical assistants and medical specialists from large hospitals. In order to maintain a high quality in the surgical disciplines, a concerted effort by all players in the healthcare system is necessary.

Dose escalated, hypofractionated radiotherapy using helical tomotherapy for inoperable non-small cell lung cancer: preliminary results of a risk-stratified phase I dose escalation study.

To improve local control for inoperable non-small cell lung cancer (NSCLC), a phase I dose escalation study for locally advanced and medically inoperable patients was devised to escalate tumor dose while limiting the dose to organs at risk including the esophagus, spinal cord, and residual lung. Helical tomotherapy provided image-guided IMRT, delivered in a 5-week hypofractionated schedule to minimize the effect of accelerated repopulation. Forty-six patients judged not to be surgical candidates with Stage I-IV NSCLC were treated. Concurrent chemotherapy was not allowed. Radiotherapy was delivered via helical tomotherapy and limited to the primary site and clinically proven or suspicious nodal regions without elective nodal irradiation. Patients were placed in 1 of 5 dose bins, all treated for 25 fractions, with dose per fraction ranging from 2.28 to 3.22 Gy. The bin doses of 57 to 80.5 Gy result in 2 Gy/fraction normalized tissue dose (NTD) equivalents of 60 to 100 Gy. In each bin, the starting dose was determined by the relative normalized tissue mean dose modeled to cause < 20% Grade 2 pneumonitis. Dose constraints included spinal cord maximum NTD of 50 Gy, esophageal maximum NTD < 64 Gy to < or = 0.5 cc volume, and esophageal effective volume of 30%. No grade 3 RTOG acute pneumonitis (NCI-CTC v.3) or esophageal toxicities (CTCAE v.3.0 and RTOG) were observed at median follow-up of 8.1 months. Pneumonitis rates were 70% grade 1 and 13% grade 2. Multivariate analysis identified lung NTD(mean) (p=0.012) and administration of adjuvant chemotherapy following radiotherapy (p=0.015) to be independent risk factors for grade 2 pneumonitis. Only seven patients (15%) required narcotic analgesics (RTOG grade 2 toxicity) for esophagitis, with only 2.3% average weight loss during treatment. Best in-field gross response rates were 17% complete response, 43% partial response, 26% stable disease, and 6.5% in-field thoracic progression. The out-of-field thoracic failure rate was 13%, and distal failure rate was 28%. The median survival was 18 months with 2-year overall survival of 46.8% +/- 9.7% for this cohort, 50% of whom were stage IIIB and 30% stage IIIA. Dose escalation can be safely achieved in NSCLC with lower than expected rates of pneumonitis and esophagitis using hypofractionated image-guided IMRT. The maximum tolerated dose has yet to be reached.

[Trust and reliability in surgery]. / Vertrauen und Verlässlichkeit in der Chirurgie.

Social interactions are hardly possible without trust. Medical and in particular surgical actions can change the lives of people directly and indirectly existentially. Thus, the relationship between doctor and patient is a special form of social interaction, and will be hard to find anywhere else. The nature of the doctor-patient relationship also determines the success of a treatment. The core and the importance of trust, as a central part of this relationship, will be reconstructed in the present paper. The increasing possibilities of information acquisition in modern societies, and the ever-present need for transparency, impact more and more on the doctor-patient relationship. At first glance, concepts of trust seem to be of secondary importance. The current developments regarding the remuneration of services in the medical system likewise bear the risk to increasingly determine the importance of trust in the doctor-patient relationship. However, it is necessary to delineate reliability from trust. Due to the conditions which are constitutive for the operational disciplines, a climate of trust, even in a modern information society, is more necessary than ever.

A multilayered electrospun graft as vascular access for hemodialysis.

Despite medical achievements, the number of patients with end-stage kidney disease keeps steadily raising, thereby entailing a high number of surgical and interventional procedures to establish and maintain arteriovenous vascular access for hemodialysis. Due to vascular disease, aneurysms or infection, the preferred access-an autogenous arteriovenous fistula-is not always available and appropriate. Moreover, when replacing small diameter blood vessels, synthetic vascular grafts possess well-known disadvantages. A continuous multilayered gradient electrospinning was used to produce vascular grafts made of collagen type I nanofibers on luminal and adventitial graft side, and poly-ɛ-caprolactone as medial layer. Therefore, a custom-made electrospinner with robust environmental control was developed. The morphology of electrospun grafts was characterized by scanning electron microscopy and measurement of mechanical properties. Human microvascular endothelial cells were cultured in the graft under static culture conditions and compared to cultures obtained from dynamic continuous flow bioreactors. Immunofluorescent analysis showed that endothelial cells form a continuous luminal layer and functional characteristics were confirmed by uptake of acetylated low-density-lipoprotein. Incorporation of vancomycin and gentamicin to the medial graft layer allowed antimicrobial inhibition without exhibiting an adverse impact on cell viability. Most striking a physiological hemocompatibility was achieved for the multilayered grafts.

[The validity of routine data on quality assurance: A qualitative systematic review]. / Die Validität von Routinedaten zur Qualitätssicherung : Eine qualitative systematische Übersichtsarbeit.

BACKGROUND: The assessment of the quality of medical practice is a legitimate requirement by society. Reliable methods for measurement of the quality of performance are sought worldwide. Quality is often quantified by using administrative data and in Germany this method has been implemented by the health insurance company AOK. OBJECTIVES: (1) How is the AOK quality system rated by senior consultant surgeons? (2) How valid are quality statements derived from administrative data? METHODS: This article was compiled following the PRISMA (i.e. preferred reporting items for systematic reviews and meta-analyses) statement for qualitative systematic reviews. In order to answer the first question the Professional Association of German Surgeons (Berufsverband der Deutschen Chirurgen) initiated two surveys and to answer the second question a structured literature search following the PICO (i.e. patient problem or population, intervention, comparison control or comparator and outcomes) format was initiated. In addition numerous websites were contacted. RESULTS: Of the responding senior consultant surgeons 95% considered that the AOK method of quality measurement by administrative data is not objective. One third was definitely wrongly classified. The literature search revealed that no validation data exist for the AOK indicators, including the Elixhauser comorbidity risk score. Altogether, the sensitivity of indicators is poor when good sensitivity is defined by the Institute for Applied Quality Improvement and Research in Health Care (AQUA Institute) as ≥ 80 < 90%. CONCLUSIONS: Quality statements resulting from administrative data alone are unreliable.

Rapid production of interleukin-2-secreting tumor cells by herpes simplex virus-mediated gene transfer: implications for autologous vaccine production.

Production of autologous tumor vaccines would be facilitated by the development of a rapid and efficient method for the transfer of genes into freshly isolated cells. To evaluate the potential of replication defective herpes simplex viral (HSV) amplicon vectors as gene transfer vehicles for tumor vaccine generation, a vector that expresses the human interleukin-2 (IL-2) gene (HSV-IL2) and one that expresses Escherichia coli beta-galactosidase (HSVlac) were tested in hepatoma cells of both murine and human origin. Gene transfer into murine hepatoma cells (HEPA 1-6) was both rapid and highly efficient: greater than 50% of cells expressed beta-Gal when infected at a multiplicity of infection (m.o.i.) of 1 with an exposure period of 20 min. Moreover, gene transfer was as efficient in tumor cells after irradiation with 10,000 rads as in nonirradiated tumor cells. Irradiated HEPA 1-6 cells infected with HSV-IL2 for 20 min secreted IL-2 at a rate of 1,200 +/- 160 ng/10(6) cells per day. C57B1/6J mice immunized with irradiated, HSV-IL-2-transduced tumor cells produced in this way demonstrated specific tumor immunity by in vitro splenocyte tumoricidal activity and by in vivo protection against tumor challenge. Human hepatobiliary tumor specimens harvested at the time of operation, irradiated, and infected with HSV-IL-2 also produced nanogram quantities of IL-2/10(6) cells per 24 hr. These results indicate that the HSV amplicon vector is a good candidate vehicle for gene transfer in the production of autologous tumor vaccines. By allowing rapid gene transfer to freshly harvested tumor specimens, these vectors bypass the requirement for cell culture and make feasible reinfusion of genetically modified and irradiated autologous cells within hours of tumor harvest.

Occurrence of congenital heart defects in siblings of patients with univentricular heart and tricuspid atresia.

Because of the rarity of univentricular heart and tricuspid atresia, no study of a large number of patients has been made to determine the empiric occurrence risks of a congenital heart defect in their siblings. A retrospective chart review was performed of 223 patients with univentricular heart and 113 with classic tricuspid atresia evaluated from 1982 to 1987. Thirty-four patients with univentricular heart and 17 with tricuspid atresia had no siblings and were excluded. Eleven of the total 388 siblings (2.8%) of the 189 patients with univentricular heart had a congenital heart defect. Of the siblings born after the index case of univentricular heart, 7 of 169 (4.1%) had a congenital heart defect. Two of the 210 siblings (1.0%) of the 96 patients with tricuspid atresia had a congenital heart defect. The patients with univentricular heart were subdivided into 4 groups: (1) double-inlet left ventricle; (2) complex univentricular heart with single or common inlet, or with a ventricle of common or right ventricular morphology; (3) complex univentricular heart with asplenia; and (4) complex univentricular heart with polysplenia. One of the 202 siblings (0.5%) of the 102 patients with double-inlet left ventricle had a congenital heart defect, compared with 7 of the 140 siblings (5.0%) of the 69 patients with complex univentricular heart, 1 of the 29 siblings (3.4%) of the 14 patients with complex univentricular heart and asplenia, and 2 of the 7 siblings (28.6%) of the 4 patients with complex univentricular heart and polysplenia.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of ventricular morphology on outcome after the Fontan procedure.

The modified Fontan procedure has gained wide acceptance in the treatment of various congenital heart defects. Determination of risk factors for mortality remains an important issue for optimizing patient selection for the Fontan procedure. Conflicting results have been reported about whether ventricular morphology is a risk factor in these patients. Survival free of Fontan takedown or cardiac transplantation was assessed in the first 500 patients undergoing the Fontan procedure at our institution. This survival was correlated with ventricular morphology as evaluated by angiography. Both multivariate and univariate analyses indicated ventricular morphology was predictive of early survival free of Fontan takedown or cardiac transplantation following the procedure. However, there was no statistical evidence for ventricular morphology being a risk factor for mortality in patients alive 6 months after the procedure. Ventricular morphology is a risk factor for early survival in patients undergoing a Fontan procedure, with left ventricular morphology associated with a better early survival than right ventricular morphology.

Detecting arrhythmia by exercise electrocardiography in pediatric patients: assessment of sensitivity and influence on clinical management.

We studied 49 patients with suspected arrhythmias (group 1) and 92 patients with previously documented arrhythmias (group 2) who underwent exercise electrocardiography (EECG) at our institution between 1979 and 1987. Among group 1 patients, all of whom had sinus rhythm before exercise, 10 (20%) had abnormal findings on EECG, and treatment was modified in 4 of these 10 (8% of group 1). Further testing (24-hour ambulatory or transtelephonic electrocardiographic monitoring or electrophysiologic study) of the 39 patients with normal EECG findings revealed 8 additional patients with arrhythmias. In group 1, the sensitivity of EECG was 56%, and its negative predictive value was 79%. Group 2 consisted of 38 patients with atrial arrhythmias, 31 with ventricular arrhythmias, and 23 with atrioventricular conduction abnormalities before EECG. Of these 92 patients, 68 (74%) had abnormal EECG findings. All but 1 of the 24 patients with normal findings underwent further testing, and rhythm abnormalities were induced in 16. Patients with atrial arrhythmias were more likely to have normal EECG results (42%) than were those with ventricular arrhythmias (23%) or an atrioventricular conduction abnormality (4%). Of the 35 patients who had been referred for suppression of an arrhythmia, 25 (71%) had abnormal rhythm suppressed during exercise. Clinical management was modified in 27% of group 2 patients on the basis of EECG findings.

Anomalous origin of the left coronary artery. A twenty-year review of surgical management.

Children with anomalous origin of the left coronary artery from the pulmonary artery are at risk for myocardial infarction and death. Surgical management of this condition in children has evolved significantly during the past 20 years. Between 1970 and 1990, a total of 20 of these patients underwent surgical intervention at two institutions. Age at operation ranged from 3 weeks to 11 years (mean, 26 months). Twelve patients had congestive heart failure, three were in cardiogenic shock, and two had cardiac murmurs. Operative techniques included ligation (n = 9), subclavian artery anastomosis (n = 5), aortic implantation (n = 3), internal mammary artery anastomosis (n = 1), intrapulmonary tunnel from aortopulmonary window to coronary artery (n = 1), and cardiac transplantation (n = 1). The three deaths in the series occurred at 3 weeks, at 2 months, and at 9 years after ligation. There have been no deaths after establishment of a two coronary artery system or after transplantation. Two of the five patients who had subclavian artery anastomosis to the anomalous coronary artery have severe anastomotic stenosis and collateralization. For patients with anomalous origin of the left coronary artery from the pulmonary artery, we recommend direct aortic implantation of the anomalous coronary artery at the time of diagnosis. Intrapulmonary tunnel from aortopulmonary window to coronary artery, or aorta-coronary bypass with internal mammary artery are recommended for children in whom aortic implantation is not anatomically feasible. Left coronary artery ligation is not indicated for these patients; those who have survived ligation should be considered for elective establishment of a two coronary artery system because of the risk of late death.

Paclitaxel-induced apoptosis in non-small cell lung cancer cell lines is associated with increased caspase-3 activity.

OBJECTIVE: Our objective was to determine whether paclitaxel-induced apoptosis in human lung cancer cells is Fas dependent. METHODS: Human lung cancer cell lines were evaluated for morphologic evidence of apoptosis, DNA fragmentation (TUNEL positivity), and caspase-3 activation after paclitaxel treatment. Human lung adenocarcinoma, squamous cell carcinoma, undifferentiated lung carcinoma, and bronchoalveolar carcinoma cell lines were each cultured in 10 micromol/L paclitaxel. RESULTS: After 24 hours of culture in paclitaxel, a 22% to 69% increase in the number of apoptotic cells was evident by means of methylene blue-azure A-eosin staining with characteristic blebbing and nuclear condensation. TUNEL assay also confirmed an increase of 19.9% to 73.0% of cells with nuclear fragmentation. Caspase-3 activity, assayed by Z-DEVD cleavage, increased from 20% to 215% (P <.05). ZB4, an antagonistic anti-Fas antibody, did not block paclitaxel induction of caspase-3 activity (155.8 vs 165.8 U, not significant). Apoptotic morphologic changes were inhibited in cells cultured in the presence of paclitaxel and Ac-DEVD-CHO, a caspase-3 inhibitor. CONCLUSIONS: Paclitaxel induces apoptosis in lung cancer cell lines, as assessed by a consistent increase in caspase-3 activity, DNA laddering, and characteristic morphologic changes. Paclitaxel-induced apoptosis in human lung cancer cells is associated with caspase-3 activation but is not Fas dependent.

Endoscopic repair of bronchial dehiscence after lung transplantation.

We report a case of bronchial dehiscence after right single lung transplantation and describe a novel means of management: bronchoscopic closure of the defect with alpha-cyanoacrylate glue.

Repair of coarctation with resection and extended end-to-end anastomosis.

BACKGROUND: Our surgical strategy for infant coarctation changed from subclavian flap aortoplasty to resection with extended end-to-end anastomosis in 1991. The purpose of this review was to evaluate the results of that strategy. METHODS: From 1991 through 1997, 55 infants underwent repair of coarctation of the aorta using resection with extended end-to-end anastomosis. Isolated coarctation of the aorta was present in 26 patients, 20 patients had a ventricular septal defect, and 9 patients had other associated intracardiac lesions. Mean age at surgery was 0.20+/-0.24 years (median, 21 days). In 34 patients (62%), arch reconstruction was performed through a left thoracotomy. Twenty patients (36%) had median sternotomy with simultaneous repair of coarctation of the aorta and intracardiac repair of associated lesions. One patient had recoarctation repair through a median sternotomy. All coarctation and ductal tissue was resected and the anastomosis was constructed starting opposite the left carotid artery with running polypropylene suture. RESULTS: There was one early death 26 days after coarctation of the aorta and ventricular septal defect repair in a child on extracorporeal membrane oxygenation for meconium aspiration and 2 late deaths owing to pneumonia and pulmonary hypertension (1) and interventricular hemorrhage (1). There were no instances of paraplegia. Follow-up in survivors ranges from 10 to 76 months (mean, 39.8+/-17.2 months). Recoarctation has developed in 2 patients, who have had successful balloon dilation 6 and 14 months after the operation. This yields a low recoarctation rate of 3.6%. CONCLUSIONS: Resection with extended end-to-end anastomosis yields a low mortality and particularly a low recoarctation rate and is our procedure of choice for infants with coarctation of the aorta.

Postoperative fluorescence bronchoscopic surveillance in non-small cell lung cancer patients.

BACKGROUND: Second lung primaries occur at a rate of 1% to 3% per patient-year after complete resections for non-small cell lung carcinoma (NSCLC). Fluorescence bronchoscopy appears to be a sensitive tool for surveillance of the tracheobronchial tree for early neoplasias. METHODS: Patients who were disease-free after complete resection of a NSCLC were entered into a fluorescence bronchoscopy surveillance program. All suspicious lesions were biopsied along with two areas of normal mucosa to serve as negative controls. RESULTS: A total of 73 fluorescence bronchoscopies were performed after conventional bronchoscopy in 51 patients at a median of 13 months postresection. The majority (46 of 51) of patients had stage I or II NSCLC, whereas 10% (5 of 51) had stage IIIA. Three intraepithelial neoplasias and one invasive carcinoma were identified in 3 of 51 patients (6%), all current or former smokers. Of the four lesions identified, three were in the 20 patients with prior squamous cell carcinomas. No intraepithelial neoplasias were identified by white-light bronchoscopy, whereas two of three were detected by fluorescence examination. The one invasive cancer detected was apparent on both white-light and fluorescence bronchoscopic examinations. CONCLUSIONS: Surveillance with fluorescence bronchoscopy identified lesions in 6% of postoperative NSCLC patients thought to be disease-free. Patients with prior squamous cell carcinomas appear to be a population that may warrant future prospective study of postoperative fluorescence bronchoscopic surveillance.

Minimally invasive esophagectomy.

BACKGROUND: Open esophagectomy can be associated with significant morbidity and delay return to routine activities. Minimally invasive surgery may lower the morbidity of esophagectomy but only a few small series have been published. METHODS: From August 1996 to September 1999, 77 patients underwent minimally invasive esophagectomy. Initially, esophagectomy was approached totally laparoscopically or with mini-thoracotomy; thoracoscopy subsequently replaced thoracotomy. RESULTS: Indications included esophageal carcinoma (n = 54), Barrett's high-grade dysplasia or carcinoma in situ (n = 17), and benign miscellaneous (n = 6). There were 50 men and 27 women with an average age of 66 years (range 30 to 94 years). Median operative time was 7.5 hours (4.5 hours with > 20 case experience). Median intensive care unit stay was 1 day (range 0 to 60 days); median length of stay was 7 days (range 4 to 73 days) with no operative or hospital mortalities. There were four nonemergent conversions to open esophagectomy; major and minor complication rates were 27% and 55%, respectively. CONCLUSIONS: Minimally invasive esophagectomy is technically feasible and safe in our center, which has extensive minimally invasive and open esophageal experience. Open surgery should remain the standard until future studies conclusively demonstrate advantages of minimally invasive approaches.

Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up.

BACKGROUND: Expandable metal stents palliate malignant dysphagia in most cases, but early complications and outcomes in long-term survivors have not been well described. This report summarizes our experience with expandable metal stents for malignant dysphagia. METHODS: Over a 48-month period, 127 stents were placed in 100 patients with dysphagia from esophageal cancer (93%) or lung cancer. Most had undergone prior treatment. Dysphagia scores, duration of palliation, complications, and reintervention were evaluated. RESULTS: Immediate improvement in dysphagia was observed in 85% of patients with no procedure-related deaths. Dysphagia score decreased from 3.3 before stent to 2.3 (p < 0.005). Average interval to reintervention was 80 days. In 40 patients surviving more than 120 days, 31 (78%) required reintervention. Major complications occurred in 3 patients receiving poststent chemoradiation (tracheoesophageal fistula, T1 vertebral body abscess, mediastinal abscess). Other complications included unsatisfactory deployment requiring immediate removal (3 patients), migration (11 patients), pain requiring removal (2 patients), food impaction (10 patients), and tumor ingrowth (37 patients). CONCLUSIONS: Expandable metal stents offer excellent short-term palliation of malignant dysphagia. In long-term survivors, recurrent dysphagia requiring reintervention is common. In a small subset of patients receiving chemoradiation after stent placement, major complications were observed.

Evaluation of distant metastases in esophageal cancer: 100 consecutive positron emission tomography scans.

BACKGROUND: Pilot studies suggest positron emission tomography (PET) scanning may be superior to conventional imaging in staging esophageal cancer, especially in the detection of radiographically occult distant metastases. This report summarizes our experience with PET in staging esophageal cancer. METHODS: One hundred consecutive PET scans in 91 patients with esophageal cancer referred for surgery were prospectively collected (1995 to 1998) and compared with computerized tomography (CT) and bone scan. PET images were acquired after injection of 18F-fluorodeoxyglucose and evaluated for abnormal uptake. Minimally invasive surgical staging (MIS) and/or clinical correlation were used to confirm or refute imaging results. RESULTS: MIS or clinical correlation confirmed 70 distant metastases in 39 cases. PET detected 51 metastases in 27 of 39 cases (69% sensitivity, 93.4% specificity, 84% accuracy) compared with CT, which detected 26 metastases in 18 of 39 cases (46.1% sensitivity, 73.8% specificity, 63% accuracy) (p < 0.01). CONCLUSIONS: PET was more accurate than CT in detecting distant metastases, but was only 69% sensitive compared with minimally invasive staging.

Detection of micrometastases in histologically negative lymph nodes in esophageal cancer.

BACKGROUND: New molecular techniques may identify micrometastases in histologically negative lymph nodes and have an impact on the staging of esophageal cancer. We investigated the role of the reverse transcriptase-polymerase chain reaction (RT-PCR) assay to identify micrometastases in esophageal cancer. METHODS: The RT-PCR assay to detect carcinoembryonic antigen (CEA) messenger ribonucleic acid (mRNA) was performed on lymph nodes from patients with esophageal cancer and benign esophageal disorders. The presence of CEA mRNA in lymph nodes was considered evidence of metastases. RESULTS: Histopathologic study revealed metastases in 50 (41%) of 123 lymph nodes from 30 patients with esophageal cancer. All histologically positive lymph nodes contained CEA mRNA by RT-PCR. Of 73 histologically negative lymph nodes, 36 (49%) contained CEA mRNA, a significant increase compared with the histopathologic diagnosis (p < 0.001). Lymph nodes in patients with benign disease contained no CEA mRNA. In 10 patients, histologic stage was NO. Five of them were also negative by RT-PCR, and all are alive with only one recurrence. In the remaining 5 patients, RT-PCR was positive for occult lymph node metastases; 2 have died of disease, and 1 is alive with recurrent disease. CONCLUSIONS: In patients with esophageal cancer, RT-PCR detects more lymph node metastases than does histopathology. Initial follow-up suggests a positive RT-PCR with negative histologic findings may have poor prognostic implications. Further studies will be needed to confirm any clinical implications.