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Van den Broek WT, Makay O, Berends FJ, Yuan JZ, Houdijk APJ, Meijer S, Cuesta MA. Laparoscopically assisted transhiatal resection for malignancies of the distal esophagus. Surg Endosc 2004; 18:812-7. [PMID: 15216864 DOI: 10.1007/s00464-003-9173-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2003] [Accepted: 11/07/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Resection of the esophagus remains the only curative therapy for esophageal cancer. Conventional resections are right-side thoracotomy in combination with laparotomy, gastric tube creation, and the transhiatal approach according to Orringer. This study evaluated laparoscopically assisted transhiatal esophagus resection, which offers perfect visualization of the esophagus during mediastinal dissection without the necessity of a thoracotomy. METHODS In this study, 25 laparoscopically assisted transhiatal esophagus resections were compared with a historical control group consisting of 20 open transhiatal esophagus resections. RESULTS Nine laparoscopically assisted resections (36%) were converted to open procedures. The operating time was longer in the laparoscopically assisted group (300 vs 257 min; p < 0.05), but laparoscopically assisted esophagus resection was associated with less blood loss (600 vs 900 ml; p < 0.05) and shorter intensive care unit stay (1 vs 2 days; p < 0.05). There were no differences in morbidity, mortality, and hospital stay. During a shorter follow-up time for the laparoscopic group (17 vs 54 months), 11 patients (44%) in the laparoscopically assisted group and 10 (50%) patients in the open group had recurrence of the disease. CONCLUSIONS Laparoscopically assisted transhiatal esophagus resection is a safe procedure with important advantages, as compared with the open procedure, such as less blood loss and shorter intensive care unit stay. At this point, the oncologic consequences are not clear.
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Gietema HA, Vuylsteke RJCLM, van Diest PJ, Meijer S, van Leeuwen PAM. Predicting nonsentinel lymph node involvement in stage I/II melanoma. Ann Surg Oncol 2004; 10:993; author reply 993-4. [PMID: 14527921 DOI: 10.1245/aso.2003.04.910] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nijveldt R, Teerlink T, Siroen M, Van der Hoven B, Prins H, Van der Sijp J, Cuesta M, Meijer S, Van Leeuwen P. Elevation of asymmetric dimethylarginine (ADMA) in patients developing hepatic failure after major hepatectomy. Clin Nutr 2003. [DOI: 10.1016/s0261-5614(03)80172-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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79
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Mijnhout GS, Hoekstra OS, van Lingen A, van Diest PJ, Adèr HJ, Lammertsma AA, Pijpers R, Meijer S, Teule GJJ. How morphometric analysis of metastatic load predicts the (un)usefulness of PET scanning: the case of lymph node staging in melanoma. J Clin Pathol 2003; 56:283-6. [PMID: 12663640 PMCID: PMC1769919 DOI: 10.1136/jcp.56.4.283] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND In primary cutaneous melanoma, the sentinel node (SN) biopsy is an accurate method for the staging of the lymph nodes. Positron emission tomography (PET) has been suggested as a useful alternative. However, the sensitivity of PET may be too low to detect SN metastases, which are often small. AIM To predict the value of PET for initial lymph node staging in melanoma based on morphometric analysis of SN metastatic load, without exposing patients to PET. MATERIALS AND METHODS In 59 SN positive patients with melanoma, the sizes of tumour deposits in the SNs and subsequent dissection specimens were measured by morphometry and correlated with the detection limits of current and future PET scanners. RESULTS The median tumour volume within the basin was 0.15 mm(3) (range, 0.0001-118.86). Seventy per cent of these deposits were smaller than 1 mm(3). State of the art PET scanners that have a resolution of about 5 mm would detect only 15-49% of positive basins. Logistic regression analysis revealed no pretest indicators identifying patients expected to have a positive PET. However, the SN tumour load was a significant and single predictor of the presence of PET detectable residual tumour. CONCLUSION Morphometric analysis of metastatic load predicts that PET scanning is unable to detect most metastatic deposits in sentinel lymph nodes of patients with melanoma because the metastases are often small. Therefore, the SN biopsy remains the preferred method for initial regional staging.
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Vuylsteke RJCLM, van Leeuwen PAM, Statius Muller MG, Gietema HA, Kragt DR, Meijer S. Clinical outcome of stage I/II melanoma patients after selective sentinel lymph node dissection: long-term follow-up results. J Clin Oncol 2003; 21:1057-65. [PMID: 12637471 DOI: 10.1200/jco.2003.07.170] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Although sentinel lymph node (SLN) status is part of the new American Joint Committee on Cancer staging system, there is no final proof that the SLN procedure in melanoma patients influences outcome of disease. This study investigated the accuracy of the SLN procedure and clinical outcome in melanoma patients after at least 60 months of follow-up. PATIENTS AND METHODS Between 1993 and 1996, 209 patients with stage I/II cutaneous melanoma underwent selective SLN dissection by the triple technique. If the SLN contained metastatic disease, a completion lymphadenectomy was performed. Survival analyses were performed using the Kaplan-Meier approach. Factors associated with survival were analyzed using the Cox proportional hazards regression model. RESULTS The success rate was 99.5%. Median follow-up was 72 months. Forty patients (19%) had a positive SLN. The false-negative rate was 9%. Five-year overall survival was 87% for the entire group and 92% and 67% for SLN-negative and SLN-positive patients (P <.0001), respectively. All patients with a positive SLN and a Breslow thickness < or = 1.00 mm survived, and SLN-positive patients with a Breslow thickness less than 2.00 mm tend to have a better prognosis compared with SLN-negative patients with a Breslow thickness greater than 2.00 mm. SLN status (P =.002), Breslow thickness (P =.002), and lymphatic invasion (P =.0009) were all found to be independent prognostic factors for overall survival. CONCLUSION With a success rate of 99.5% and a false-negative rate of 9% after long-term follow-up, the triple-technique SLN procedure is a reliable and accurate method. Survival data seem promising, although a therapeutic effect is still questionable. As shown in this study, not all SLN-positive patients have a poor prognosis.
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Wu FPK, Sietses C, von Blomberg BME, van Leeuwen PAM, Meijer S, Cuesta MA. Systemic and peritoneal inflammatory response after laparoscopic or conventional colon resection in cancer patients: a prospective, randomized trial. Dis Colon Rectum 2003; 46:147-55. [PMID: 12576886 DOI: 10.1007/s10350-004-6516-2] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE This study was designed to evaluate differences in both the peritoneal and systemic immune response after laparoscopic and conventional surgical approaches. METHODS Patients with a primary carcinoma were prospectively randomized to curative laparoscopic (n = 12) or conventional (n = 14) colon resection. The proinflammatory cytokines interleukin-6, interleukin-8, and tumor necrosis factor-alpha were measured in the peritoneal drain fluid and in the serum. C-reactive protein and leukocyte counts and the differences in leukocyte subpopulations and expression of human leukocyte antigen-DR on monocytes were measured perioperatively. RESULTS Significantly higher levels of proinflammatory cytokine were found in the peritoneal drain fluid than in the circulation after both procedures. Serum interleukin-6 and interleukin-8 levels were significantly lower 2 hours after laparoscopic surgery than with the conventional procedure. Postoperative cellular immune counts and human leukocyte antigen-DR expression normalized earlier after the laparoscopic approach. CONCLUSIONS The systemic proinflammatory concentrations after both surgical approaches represent only a small fragment of what is generated in the peritoneal drain fluid. Even if the immediate levels of proinflammatory cytokines in the serum are significantly lower in the laparoscopic group, the same cytokines locally produced showed no differences, which suggests that the two intra-abdominal approaches are equally traumatic. No differences in cellular response were observed between the groups.
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Rahusen FD, Bremers AJA, Fabry HFJ, van Amerongen AHMT, Boom RPA, Meijer S. Ultrasound-guided lumpectomy of nonpalpable breast cancer versus wire-guided resection: a randomized clinical trial. Ann Surg Oncol 2002; 9:994-8. [PMID: 12464592 DOI: 10.1007/bf02574518] [Citation(s) in RCA: 183] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The wire-guided excision of nonpalpable breast cancer often results in tumor resections with inadequate margins. This prospective, randomized trial was undertaken to investigate whether intraoperative ultrasound (US) guidance enables a better margin clearance than the wire-guided technique in the breast-conserving treatment of nonpalpable breast cancers. METHODS Patients with a preoperative histological diagnosis of nonpalpable breast cancer that could be visualized both with US and mammography were included. Patients were randomized to undergo either a wire-guided or a US-guided excision. Adequate margins were defined as >or=1 mm. RESULTS Of 49 included patients, 23 were assigned to undergo wire-guided excision and 26 to undergo US-guided excision. One patient crossed over to US-guided excision after inadvertent wire displacement. Mean tumor diameter, specimen weight, and operating time were similar in both groups. The excision was adequate in 24 (89%) of 27 US-guided excisions and 12 (55%) of 22 wire-guide excisions (P =.007). CONCLUSIONS US-guided excision seems to be superior to wire-guided excision with respect to margin clearance of mammographically detected and US-visible nonpalpable breast cancers. Patients do not have to undergo the unpleasant wire placement before surgery.
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Mutsaerts ELAR, Zoetmulder FAN, Meijer S, Baas P, Hart AAM, Rutgers EJT. Long term survival of thoracoscopic metastasectomy vs metastasectomy by thoracotomy in patients with a solitary pulmonary lesion. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:864-8. [PMID: 12477479 DOI: 10.1053/ejso.2002.1284] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS The aim of this study was to compare long term survival after resection of solitary pulmonary metastasis on CT scan performed by either thoracoscopy or through a standard thoracotomy. METHODS Patients with a solitary, CT scan confirmed, peripherally located lesion suspected for metastasis, less than 3cm in diameter were included. End points were: postoperative complication rate, disease free and overall survival and location of recurrence in the lung. RESULTS Thirty-five patients who underwent a thoracoscopic metastasectomy with (n=19) or without (n=16) confirmatory thoracotomy were included in this study. Patients experienced more complications following a thoracotomy (n=5) compared to those who had a thoracoscopy (n=0) (P=0.049). Two patients appeared to have further disease at thoracotomy besides the CT scan identified lesion, and some at thoracoscopy. At definitive histology, seven lesions were benign and eight appeared to be a second primary. Analysis of 20 patients with histological confirmed metastasis demonstrated a 2-year disease free and overall survival rate of 50% and 67% respectively following thoracoscopic metastasectomy (n=8) compared to 42% and 70% respectively following confirmatory thoracotomy (n=12). Recurrence occurred in three of the patients after thoracoscopic metastasectomy and in five patients after thoracotomy. CONCLUSION Our results suggest that thoracoscopic resection of solitary peripherally located metastasis is a safe and potentially curative procedure with a long term outcome that is comparable with that after resection by thoracotomy.
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Peters GJ, Backus HHJ, Freemantle S, van Triest B, Codacci-Pisanelli G, van der Wilt CL, Smid K, Lunec J, Calvert AH, Marsh S, McLeod HL, Bloemena E, Meijer S, Jansen G, van Groeningen CJ, Pinedo HM. Induction of thymidylate synthase as a 5-fluorouracil resistance mechanism. BIOCHIMICA ET BIOPHYSICA ACTA 2002; 1587:194-205. [PMID: 12084461 DOI: 10.1016/s0925-4439(02)00082-0] [Citation(s) in RCA: 273] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Thymidylate synthase (TS) is a key enzyme in the de novo synthesis of 2'-deoxythymidine-5'-monophosphate (dTMP) from 2'-deoxyuridine-5'-monophosphate (dUMP), for which 5,10-methylene-tetrahydrofolate (CH(2)-THF) is the methyl donor. TS is an important target for chemotherapy; it is inhibited by folate and nucleotide analogs, such as by 5-fluoro-dUMP (FdUMP), the active metabolite of 5-fluorouracil (5FU). FdUMP forms a relatively stable ternary complex with TS and CH(2)THF, which is further stabilized by leucovorin (LV). 5FU treatment can induce TS expression, which might bypass dTMP depletion. An improved efficacy of 5FU might be achieved by increasing and prolonging TS inhibition, a prevention of dissociation of the ternary complex, and prevention of TS induction. In a panel of 17 colon cancer cells, including several variants with acquired resistance to 5FU, sensitivity was related to TS levels, but exclusion of the resistant variants abolished this relation. For antifolates, polyglutamylation was more important than the intrinsic TS level. Cells with low p53 levels were more sensitive to 5FU and the antifolate raltitrexed (RTX) than cells with high, mutated p53. Free TS protein down-regulates its own translation, but its transcription is regulated by E2F, a cell cycle checkpoint regulator. Together, this results in low TS levels in stationary phase cells. Although cells with a low TS might theoretically be more sensitive to 5FU, the low proliferation rate prevents induction of DNA damage and 5FU toxicity. TS levels were not related to polymorphisms of the TS promoter. Treatment with 5FU or RTX rapidly induced TS levels two- to five-fold. In animal models, 5FU treatment resulted in TS inhibition followed by a two- to three-fold TS induction. Both LV and a high dose of 5FU not only enhanced TS inhibition, but also prevented TS induction and increased the antitumor effect. In patients, TS levels as determined by enzyme activity assays, immunohistochemistry and mRNA expression, were related to a response to 5FU. 5FU treatment initially decreased TS levels, but this was followed by an induction, as seen with an increased ratio of TS protein over TS-mRNA. The clear retrospective relation between TS levels and response now forms the basis for a prospective study, in which TS levels are measured before treatment in order to determine the treatment protocol.
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MESH Headings
- Animals
- Antimetabolites, Antineoplastic/metabolism
- Antimetabolites, Antineoplastic/pharmacology
- Drug Resistance, Neoplasm/physiology
- Enzyme Induction/drug effects
- Fluorouracil/metabolism
- Fluorouracil/pharmacology
- Folic Acid Antagonists/pharmacology
- Humans
- In Vitro Techniques
- Neoplasms/drug therapy
- Neoplasms/enzymology
- Neoplasms/genetics
- Polymorphism, Genetic
- Promoter Regions, Genetic
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- RNA, Neoplasm/genetics
- RNA, Neoplasm/metabolism
- Thymidylate Synthase/antagonists & inhibitors
- Thymidylate Synthase/biosynthesis
- Thymidylate Synthase/genetics
- Tumor Cells, Cultured
- Tumor Suppressor Protein p53/metabolism
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de Lange SM, van Groeningen CJ, Meijer OWM, Cuesta MA, Langendijk JA, van Riel JMGH, Pinedo HM, Peters GJ, Meijer S, Slotman BJ, Giaccone G. Gemcitabine-radiotherapy in patients with locally advanced pancreatic cancer. Eur J Cancer 2002; 38:1212-7. [PMID: 12044508 DOI: 10.1016/s0959-8049(02)00076-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A feasibility study was performed to assess the toxicity and efficacy of a combination of gemcitabine-radiotherapy in patients with locally advanced pancreatic cancer (LAPC). 24 patients (15 females and 9 males) with measurable LAPC were included; the median age of the patients was 63 years (range 39-74 years). The performance status ranged from 0 to 2. Gemcitabine was administered at a dose of 300 mg/m(2), concurrent with radiotherapy, three fractions of 8 Gy, on days 1, 8 and 15. When compliance allowed, gemcitabine alone was continued thereafter, at 1000 mg/m(2), weekly times 3, every 4 weeks, depending on the response and toxicity. All patients were evaluable for toxicity and response. The objective response rate was 29.2% (1 complete remission+6 partial remissions); 12 patients had stable disease. However, 2 of the radiological partial remissions were shown to be complete remissions by pathology assessment. Median duration of response was 3 months (range 1-35+months). Median time to progression was 7 months (range 2-37+months). Median survival was 10 months (range 3-37+months). Dose reduction or omission of gemcitabine was necessary in 10 patients. Non-haematological toxicity consisted of 87.5% nausea and vomiting grade I-II, diarrhoea 54%, ulceration in stomach and duodenum 37.5% (20.8% ulceration with bleeding); 1 patient developed a fistula between the duodenum and aorta, 5 months after treatment. Anaemia grade III-IV was observed in 8.3% of the patients. Neutropenia grade III-IV was observed in 8.3%, thrombocytopenia grades III-IV in 16.7%. In 1 patient who underwent resection postchemoradiation, no viable tumour cells were found. In addition, in the patient who suddenly died of a fistula between the duodenum and aorta, no viable tumour cells were detectable at autopsy. Although the toxicity of this treatment was occasionally severe, the response and survival are encouraging and warrant further studies of this combination.
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Meijer S, Torrenga H, van der Sijp JRM. [Negative sentinel node in breast cancer patients a good indicator for continued absence of axillary metastases]. NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE 2002; 146:942-6. [PMID: 12051063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
OBJECTIVE To determine the prevalence of axillary recurrences in sentinel-node-negative patients with breast cancer who had no axillary dissection. DESIGN Follow-up study. METHOD The first one hundred consecutive sentinel-node-negative patients with a minimal follow-up of 36 months (median 47) were included in this study. All patients underwent sentinel-node biopsy using the triple technique. During the first year after the operation patients were seen on a 3-monthly basis and thereafter every 6 months. RESULTS Intensive pathological examination of the harvested sentinel nodes revealed no (micro)metastases in any patient. One patient developed an axillary recurrence after 24 months. Three out of the 100 patients developed distant metastases during follow-up; 2 of them died as a result of these metastases. One patient was treated for a local mammary recurrence. In terms of survival the sentinel-node procedure did not appear to be disadvantageous: the 3-year survival rate in our study was 98% for node-negative patients, compared to 88-94% quoted in the literature for node-negative patients after axillary dissection. This apparent improvement may be due to better staging of breast-cancer patients through the use of the sentinel-node procedure (stage migration). CONCLUSION The triple technique was a reliable method for identifying the sentinel node in breast-cancer patients. Compared to the historical data on node-negative breast cancer, the sentinel-node procedure improved the prognosis of node-negative breast-cancer patients. This effect was probably due to the more accurate staging of breast-cancer patients using the sentinel-node procedure.
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van der Sijp JRM, Meijer S. An unexpected liver secondary (Br J Surg;2001:627-8). Br J Surg 2002; 89:624. [PMID: 12019501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Baars A, Claessen AME, Wagstaff J, Giaccone G, Scheper RJ, Meijer S, Schakel MJAG, Gall HE, Meijer CJLM, Vermorken JB, Pinedo HM, van den Eertwegh AJM. A phase II study of active specific immunotherapy and 5-FU/Leucovorin as adjuvant therapy for stage III colon carcinoma. Br J Cancer 2002; 86:1230-4. [PMID: 11953877 PMCID: PMC2375342 DOI: 10.1038/sj.bjc.6600254] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2001] [Accepted: 02/22/2002] [Indexed: 12/22/2022] Open
Abstract
Active specific immunotherapy, using vaccines with autologous tumour cells and BCG, significantly reduces the rate of tumour recurrence in stage II colon cancer patients, while no clinical benefit has yet been observed in stage III patients. Adjuvant treatment with 5-Fluorouracil/Leucovorin is now considered standard therapy for stage III colon carcinoma and results in an absolute survival benefit of approximately 10%. Yet, the 5-year overall survival rate of stage III colon cancer patients is only 40-50%. Combining chemotherapy and immunotherapy might improve prognosis for stage III patients, especially when considering that active specific immunotherapy and chemotherapy have shown synergistic effects in pre-clinical tumour models. We performed a phase II study with 56 patients, using the combination of active specific immunotherapy and chemotherapy as an adjuvant therapy in stage III colon cancer patients to assess the influence of 5-Fluorouracil/Leucovorin on anti-tumour immunity induced by autologous tumour cell vaccinations. Anti-tumour immunity was measured before and after chemotherapy by means of delayed type hypersensitivity reactions, taken 48 h after the third and the fourth vaccination. We also investigated the toxicity of this combined immuno-chemotherapy treatment. Delayed type hypersensitivity reactions before chemotherapy had a median size of 20.3 mm, while after chemotherapy delayed type hypersensitivity size was 18.4 mm (P=0.01), indicating that chemotherapy hardly affected anti-tumour immunity. The severity of ulcers at the BCG vaccination sites was comparable to previous studies. In 30% of the patients grade III or grade IV chemotherapy related toxicity was seen; this is comparable to what is normally observed after adjuvant chemotherapy alone. This study shows that the active specific immunotherapy-induced anti-tumour immune response is only minimally impaired by consecutive chemotherapy and that the combined treatment of stage III colon cancer patients with active specific immunotherapy and 5-Fluorouracil/Leucovorin does not cause unexpected toxicity.
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Torrenga H, van Diest PJ, Meijer S. Sentinel-node biopsy in breast cancer. Lancet 2001; 358:1814; author reply 1815. [PMID: 11734270 DOI: 10.1016/s0140-6736(01)06819-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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90
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Torrenga H, Licht J, van der Hoeven JJ, Hoekstra OS, Meijer S, van Diest PJ. Re: Axillary lymph node staging in breast cancer by 2-fluoro-2-deoxy-D-glucose-positron emission tomography: clinical evaluation and alternative management. J Natl Cancer Inst 2001; 93:1659-61. [PMID: 11698576 DOI: 10.1093/jnci/93.21.1659] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Boelens PG, Nijveldt RJ, Houdijk AP, Meijer S, van Leeuwen PA. Glutamine alimentation in catabolic state. J Nutr 2001; 131:2569S-77S; discussion 2590S. [PMID: 11533315 DOI: 10.1093/jn/131.9.2569s] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Glutamine should be reclassified as a conditionally essential amino acid in the catabolic state because the body's glutamine expenditures exceed synthesis and low glutamine levels in plasma are associated with poor clinical outcome. After severe stress, several amino acids are mobilized from muscle tissue to supply energy and substrate to the host. Glutamine is one of the most important amino acids that provide this function. Glutamine acts as the preferred respiratory fuel for lymphocytes, hepatocytes and intestinal mucosal cells and is metabolized in the gut to citrulline, ammonium and other amino acids. Low concentrations of glutamine in plasma reflect reduced stores in muscle and this reduced availability of glutamine in the catabolic state seems to correlate with increased morbidity and mortality. Adding glutamine to the nutrition of clinical patients, enterally or parenterally, may reduce morbidity. Several excellent clinical trials have been performed to prove efficacy and feasibility of the use of glutamine supplementation in parenteral and enteral nutrition. The increased intake of glutamine has resulted in lower septic morbidity in certain critically ill patient populations. This review will focus on the efficacy and the importance of glutamine supplementation in diverse catabolic states.
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Rahusen FD, Torrenga H, van Diest PJ, Pijpers R, van der Wall E, Licht J, Meijer S. Predictive factors for metastatic involvement of nonsentinel nodes in patients with breast cancer. ARCHIVES OF SURGERY (CHICAGO, ILL. : 1960) 2001; 136:1059-63. [PMID: 11529831 DOI: 10.1001/archsurg.136.9.1059] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The potential morbidity of an axillary lymph node dissection in patients with breast cancer can be avoided in patients with a negative sentinel node (SN). HYPOTHESIS It may be possible to identify a subset of patients with a positive SN and without metastases in the remaining axillary lymph nodes. DESIGN Case-control study. SETTING Both primary and referral hospital care. PATIENTS Data were studied for 255 consecutive patients with stage T1 or T2 breast cancer who had a successful identification of the SN. INTERVENTIONS In patients with a positive SN, histological examination of all non-SNs that were negative by routine examination was the same as that for SNs (multiple sectioning and immunohistochemical analysis). MAIN OUTCOME MEASURES The incidence of non-SN metastases was correlated with the surface area and number of SN metastases and primary tumor characteristics. A micrometastasis was defined as less than 1 mm(2). RESULTS Of 255 patients, the SN appeared to be positive in 93 (36%). Subsequent axillary lymph node dissection revealed positive non-SNs in 46 patients (49%). Patients with a single positive SN and patients with metastases less than 1 mm(2) in the SN had significantly less non-SN involvement than patients with more than 1 positive SN (40% vs. 78%) and patients with macrometastases (27% vs. 49%). CONCLUSIONS The incidence of non-SN metastases seemed to be related to the number of positive SNs and the size of SN metastases. However, in the group of patients with a positive SN, it was not possible to identify a subset of patients without non-SN metastases.
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Berends FJ, Meijer S, Prevoo W, Bonjer HJ, Cuesta MA. Technical considerations in laparoscopic liver surgery. Surg Endosc 2001; 15:794-8. [PMID: 11443467 DOI: 10.1007/s004640090094] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2000] [Accepted: 12/07/2000] [Indexed: 11/29/2022]
Abstract
BACKGROUND Laparoscopic solid organ surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. Laparoscopic liver surgery mainly comprizes diagnostic procedures and treatment of liver cysts. However, we believe there is room for a laparoscopic approach to the liver in selected cases, with the benefits that may be expected from laparoscopic solid organ surgery. METHODS Between 1993 and 2000, 10 patients with various lesions of the liver underwent laparoscopic surgery. Indications consisted of cystic disease (n = 2), hemangioma (n = 2), focal nodular hyperplasia (n = 2), liver abcess (n = 1), and liver metastasis (n = 3). Laparoscopic treatment varied from fenestration (n = 3) to wedge resections (n = 5), and formal left lateral hepatectomy (n = 2). RESULTS The mean patient age was 54 years (range, 34-71 years). The mean operative time, including laparoscopic ultrasonography, measured 180 min (range, 80-240 min). Peroperative blood loss ranged from 200 to 450 ml. There was no mortality. In two patients, conversion to laparotomy was necessary. There were no postoperative complications. The mean hospital stay was 6 days (range, 4-11 days). CONCLUSION Laparoscopic treatment should be considered in selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver.
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Torrenga H, Rahusen FD, Meijer S, Borgstein PJ, van Diest PJ. Sentinel node investigation in breast cancer: detailed analysis of the yield from step sectioning and immunohistochemistry. J Clin Pathol 2001; 54:550-2. [PMID: 11429428 PMCID: PMC1731471 DOI: 10.1136/jcp.54.7.550] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To evaluate in detail the extent to which step sectioning and immunohistochemical examination of sentinel lymph nodes (SNs) in patients with breast cancer reveal additional node positive patients, to arrive at a sensitive yet workable protocol for histopathological SN examination. METHODS This study comprised 86 women with one or more positive SN after a successful SN procedure for clinical stage T1-T2 invasive breast cancer. SNs were lamellated into pieces of approximately 0.5 cm in size. One initial haematoxylin and eosin (H&E) stained central cross section was made for each block. When negative, four step ribbons were cut at intervals of 250 microm. One section from each ribbon was stained with H&E, and one was used for immunohistochemistry (IHC). RESULTS When taking the cumulative total of detected metastases at level 5 as 100%, the percentage of SN positive patients increased from 80%, 83%, 85%, 87% to 88% in the H&E sections through levels 1 to 5, and with IHC these values were 86%, 90%, 94%, 98%, and 100%. Three of nine patients in whom metastases were detected at levels 3-5 only had metastases in the subsequent axillary lymph node dissection. CONCLUSIONS Multiple level sectioning of SNs (five levels at 250 microm intervals) and the use of IHC detects additional metastases up to the last level. Although more levels of sectioning might increase the yield even further, this protocol ensures a reasonable workload for the pathologist with an acceptable sensitivity when compared with the published literature.
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Mutsaerts EL, Zoetmulder FA, Meijer S, Baas P, Hart AA, Rutgers EJ. Outcome of thoracoscopic pulmonary metastasectomy evaluated by confirmatory thoracotomy. Ann Thorac Surg 2001; 72:230-3. [PMID: 11465185 DOI: 10.1016/s0003-4975(01)02629-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to determine the feasibility, accuracy, and outcome of thoracoscopic resection of peripherally located pulmonary metastases. METHODS The 28 patients had three or fewer solitary metastases, located in the periphery of the lung, with a diameter 3 cm or less on computed tomography scan. A thoracoscopic resection was performed to remove all identified lesions evaluated by confirmatory thoracotomy. RESULTS A thoracoscopic resection was technically impossible in 10 patients. In 1 patient a confirmatory thoracotomy was not performed because the lesion was diagnosed as carcinoid. Among the 17 patients who underwent confirmatory thoracotomy, 12 patients had a complete thoracoscopic resection and 5 patients had residual disease. The success rate appeared to be higher (p = 0.01) in patients with one lesion (11 of 12 patients), than in patients with more than one lesion (1 of 5 patients) found by preoperative computed tomography scan. CONCLUSIONS Thoracoscopic resection can be considered a viable treatment option for patients who present with a solitary pulmonary metastasis with a diameter of 3 cm or less, when the lesion is located in the periphery of the lung.
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Statius Muller MG, van Leeuwen PA, de Lange-De Klerk ES, van Diest PJ, Pijpers R, Ferwerda CC, Vuylsteke RJ, Meijer S. The sentinel lymph node status is an important factor for predicting clinical outcome in patients with Stage I or II cutaneous melanoma. Cancer 2001; 91:2401-8. [PMID: 11413531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
BACKGROUND In a cohort of patients, the authors investigated whether and to what extent the sentinel lymph node (SLN) status contributes to predicting the probability of remaining disease free for at least 3 years. In addition, several traditional prognostic factors were analyzed: Breslow thickness, Clark invasion level, ulceration, lymphatic invasion, location, type of the melanoma, and age and gender of the patient. METHODS In 263 consecutive patients with proven American Joint Committee on Cancer Stages I and II cutaneous melanoma, the triple technique SLN procedure was used, i.e., preoperative visualization of the lymph channels from the initial site of the melanoma toward the SLN by (dynamic) lymphoscintigraphy, intraoperative visualization of those particular lymph channels and lymph nodes with blue dye, and a gamma probe to measure accumulated radioactivity in radiolabeled lymph nodes. Median follow-up time was 48 months (range, 36-84 months). Multivariate logistic regression analysis was performed to examine the influence of the SLN status and several other prognostic factors on a minimum 3-year disease free survival. RESULTS In 20% of patients, the SLN proved to be tumor positive. For SLN negative patients, the 5-year disease free survival rate was 91% (+/- 2.4%), and for SLN positive patients it was 49% (+/- 9%). Five variables showed a strong and statistically significant independent prognostic association with outcome, i.e., SLN status (P = 0.0007), thickness of primary melanoma (1.01-2.0 mm; P = 0.04), ulceration (P = 0.05), and lymphatic invasion (P = 0.01) of primary melanoma, and age (40-50 years; P = 0.01). CONCLUSIONS The SLN status-along with Breslow thickness, ulceration, lymphatic invasion, and age--seems to have strong additional value in predicting a minimum 3-year disease free period after the SLN procedure. Patients with a positive SLN have a poorer prognosis than those with a negative SLN.
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Statius Muller MG, van Leeuwen PA, van Diest PJ, Vuylsteke RJ, Pijpers R, Meijer S. No indication for performing sentinel node biopsy in melanoma patients with a Breslow thickness of less than 0.9 mm. Melanoma Res 2001; 11:303-7. [PMID: 11468520 DOI: 10.1097/00008390-200106000-00013] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In thin melanomas, the involvement of regional nodes is very uncommon. Recent sentinel node (SN) studies have confirmed the absence of positive regional lymph nodes in melanomas < 0.76 mm and a 5% positivity in melanomas between 1.0 and 1.99 mm. The chance of regional lymph node involvement - and therefore whether it is relevant to perform the SN procedure - seems to depend on the Breslow thickness of the primary tumour. However, a Breslow thickness cut-off point has not yet been established. We evaluated a melanoma population that had undergone an SN procedure to determine this point, so that the procedure can be restricted to a smaller group of patients in future. In a total of 348 patients with proven American Joint Committee on Cancer (AJCC) stages I or II cutaneous melanoma with a Breslow thickness > or = 0.5 mm the triple technique was used, consisting of preoperative visualization of the lymph channels from the initial site of the melanoma towards the SN by (dynamic) lymphoscintigraphy, intraoperative visualization of those particular lymph channels and nodes with blue dye, and a gamma probe to measure accumulated radioactivity in radiolabelled lymph nodes. In melanomas thinner than 0.90 mm, no positive SN was found (95% confidence interval 0-5%). This group consisted of 75 patients (22%), with a median follow-up of 31 months. Our data suggest that this procedure need no longer be indicated for almost a quarter of the patient population, because the cut-off point for nodal involvement appears to be a Breslow thickness of 0.90 mm.
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Lopes Cardozo AM, Gupta A, Koppe MJ, Meijer S, van Leeuwen PA, Beelen RJ, Bleichrodt RP. Metastatic pattern of CC531 colon carcinoma cells in the abdominal cavity: an experimental model of peritoneal carcinomatosis in rats. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2001; 27:359-63. [PMID: 11417980 DOI: 10.1053/ejso.2001.1117] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Peritoneal spread of tumour cells is a major source of morbidity and mortality in patients with colorectal cancer. In order to develop strategies to prevent intraperitoneal dissemination and to treat peritoneal carcinomatosis, the spread of tumour cells in the peritoneal cavity was studied. METHODS Two million CC531 colon carcinoma cells were administered intraperitoneally in five groups of eight rats. The rats were killed after 1, 2, 4 and 8 hours and 3, 7, 14 and 21 days. After inspection of the abdominal cavity, samples of blood and ascites were taken. Liver, spleen, omentum, mesentery, diaphragm, parathymic lymph nodes and lungs were removed for histology and immunohistochemistry. RESULTS No abnormalities were seen in the abdominal cavity until day 3. Subsequently the peritoneum and omentum became thickened and after 21 days all rats had haemorrhagic ascites and peritoneal carcinomatosis. The abdominal fluid contained tumour cells at all stages. The number of tumour cells decreased in the first 8 hours, and increased thereafter. At microscopy the peritoneum was completely covered by tumour cells after 3 days. Tumour cells concentrated in the milky spots (MS) of the omentum within 4 hours. The size of the MS increased as a result of an increase in number of tumour cells and macrophages. After 7--21 days the MS were completely replaced by tumour cells and new MS were formed. In the diaphragm tumour cells invaded the lymphatic lacunae after 8 h, and obliterated these after 3--7 days. Also invasion of the muscle fibres was seen after 3 days. Microscopically no tumour cells were found in blood, liver, spleen, parathymic nodes and lung. CONCLUSION After intraperitoneal administration of CC531 colon carcinoma cells, tumour cells spread throughout the abdominal cavity, and concentrate in the milky spots of the greater omentum, the paracolic gutters, the subhepatic and subphrenic spaces and in the lymphatic lacunae of the diaphragm.
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Wiezer MJ, Boelens PG, Vuylsteke RJ, Nijveldt RJ, Meijer C, Cuesta MA, Meijer S, van Leeuwen PA. Perioperative treatment with bactericidal/permeability-increasing protein (rBPI21) in major liver surgery: a concise summary. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2001; 30:226-33. [PMID: 11455733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
INTRODUCTION Major hepatic resections are still associated with considerable morbidity. Gut-derived bacteria and bacterial endotoxin are considered to play a central role in the pathophysiology of complications. Experimental studies suggest that bactericidal/permeability-increasing protein (BPI), which has both antibacterial and endotoxin-neutralising properties, can reduce postoperative complications. MATERIAL AND METHODS A phase II, double-blind, placebo-controlled, multicentre, dose escalation trial was conducted in patients undergoing major liver resection, and clinical outcome, infectious complications, plasma amino acid patterns, coagulation and fibrinolytic cascade systems and neutrophil functions were compared between the two treatment groups and an extra group of patients undergoing major abdominal non-hepatic surgery. RESULTS Drug administration in this patient group was safe, and resulted in a significant reduction of infectious complications. Furthermore, beneficial effects were found in the postoperative amino acid ratio and fibrinolytic cascades, and rBPI21 preserved leukocyte functions. CONCLUSION Administration of rBPI21 in patients undergoing major liver resection is well tolerated and results in improvement of both clinical and biochemical parameters.
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van Riel JM, van Groeningen CJ, Albers SH, Cazemier M, Meijer S, Bleichrodt R, van den Berg FG, Pinedo HM, Giaccone G. Hepatic arterial 5-fluorouracil in patients with liver metastases of colorectal cancer: single-centre experience in 145 patients. Ann Oncol 2001. [PMID: 11205464 DOI: 10.1023/a: 1008369520179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hepatic arterial chemotherapy for liver metastases of colorectal cancer is still under discussion. Mainly because of the technical complications of this mode of treatment and the lack of a survival benefit in randomized studies. We performed an analysis of hepatic arterial 5-fluorouracil (5-FU) chemotherapy in 145 consecutive patients treated at a single institution. PATIENTS AND METHODS One hundred forty-five patients with inoperable liver metastases from colorectal cancer were included. 5-FU, 1000 mg/m2/day continuous infusion for five days every three weeks, was delivered in the hepatic artery by percutaneous catheter or arterial access device. RESULTS The response rate was 34% for all patients, 40% in patients with extrahepatic disease, and 15% in patients with i.v. 5-FU-based pretreatment. TTP and OS for all patients were 7.5 and 14.3 months, respectively. In patients with extrahepatic disease or i.v. 5-FU-based pretreatment, OS was significantly shorter compared to patients without extrahepatic disease or 5-FU-based pretreatment (9.7 vs. 19.3 months and 10.1 vs. 17.4 months, respectively), forty-seven percent of patients stopped treatment because of a complication. Complications most often seen in patients with arterial ports were hepatic artery thrombosis (48%) and dislocation of the catheter (22%). CONCLUSIONS The results of our analysis are in line with previous phase III studies. Extrahepatic disease and i.v. 5-FU-based pretreatment were prognostic for reduced OS. The complication rate of hepatic arterial delivery was worrisome. although, no negative impact on survival could be established. There is a strong need for improvement of hepatic arterial delivery methods before further evaluation of hepatic arterial
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