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de Wijkerslooth EM, Boerma EJG, van Rossem CC, Koopmanschap MA, Baeten CI, Beverdam FH, Bosmans JW, Consten EC, Dekker JWT, Emous M, van Geloven AA, Gijsen AF, Heijnen LA, Jairam AP, van der Ploeg AP, Steenvoorde P, Toorenvliet BR, Vermaas M, Wiering B, Wijnhoven BP, van den Boom AL. Two Days Versus Five Days of Postoperative Antibiotics for Complex Appendicitis: Cost Analysis of a Randomized, Noninferiority Trial. Ann Surg 2024; 279:885-890. [PMID: 37698025 PMCID: PMC10997181 DOI: 10.1097/sla.0000000000006089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To compare costs for 2 days versus 5 days of postoperative antibiotics within the antibiotics after an aPPendectomy In Complex appendicitis trial.Background:Recent studies suggest that restrictive antibiotic use leads to a significant reduction in hospital stays without compromising patient safety. Its potential effect on societal costs remains underexplored. METHODS This was a pragmatic, open-label, multicenter clinical trial powered for noninferiority. Patients with complex appendicitis (age ≥ 8 years) were randomly allocated to 2 days or 5 days of intravenous antibiotics after appendectomy. Patient inclusion lasted from June 2017 to June 2021 in 15 Dutch hospitals. The final follow-up was on September 1, 2021. The primary trial endpoint was a composite endpoint of infectious complications and mortality within 90 days. In the present study, the main outcome measures were overall societal costs (comprising direct health care costs and costs related to productivity loss) and cost-effectiveness. Direct health care costs were recorded based on data in the electronic patient files, complemented by a telephone follow-up at 90 days. In addition, data on loss of productivity were acquired through the validated Productivity Cost Questionnaire at 4 weeks after surgery. Cost estimates were based on prices for the year 2019. RESULTS In total, 1005 patients were evaluated in the "intention-to-treat" analysis: 502 patients were allocated to the 2-day group and 503 to the 5-day group. The mean difference in overall societal costs was - €625 (95% CI: -€ 958 to -€ 278) to the advantage of the 2-day group. This difference was largely explained by reduced hospital stay. Productivity losses were similar between the study groups. Restricting postoperative antibiotics to 2 days was cost-effective, with estimated cost savings of €31,117 per additional infectious complication. CONCLUSIONS Two days of postoperative antibiotics for complex appendicitis results in a statistically significant and relevant cost reduction, as compared with 5 days. Findings apply to laparoscopic appendectomy in a well-resourced health care setting.
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Affiliation(s)
| | - Evert-Jan G. Boerma
- Departments of Surgery, Zuyderland Medical Center, Heerlen/Sittard, The Netherlands
| | | | - Marc A. Koopmanschap
- Departments of Surgery, Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Coen I.M. Baeten
- Departments of Surgery, Groene Hart Hospital, Gouda, The Netherlands
| | | | | | - Esther C.J. Consten
- Departments of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Departments of Surgery, University Medical Center Groningen, The Netherlands
| | | | - Marloes Emous
- Departments of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | - Anton F. Gijsen
- Departments of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Luc A. Heijnen
- Departments of Surgery, Northwest Clinics, Alkmaar/Den Helder, The Netherlands
| | - An P. Jairam
- Departments of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Pascal Steenvoorde
- Departments of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | | | - Maarten Vermaas
- Departments of Surgery, IJsselland Hospital, Capelle a/d Ijssel, The Netherlands
| | - Bas Wiering
- Departments of Surgery, Slingeland Hospital, Doetinchem, The Netherlands
| | - Bas P.L. Wijnhoven
- Departments of Surgery, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
| | - Anne Loes van den Boom
- Departments of Surgery, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
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de Wijkerslooth EML, Boerma EJG, van Rossem CC, van Rosmalen J, Baeten CIM, Beverdam FH, Bosmans JWAM, Consten ECJ, Dekker JWT, Emous M, van Geloven AAW, Gijsen AF, Heijnen LA, Jairam AP, Melles DC, van der Ploeg APT, Steenvoorde P, Toorenvliet BR, Vermaas M, Wiering B, Wijnhoven BPL, van den Boom AL. 2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial. Lancet 2023; 401:366-376. [PMID: 36669519 DOI: 10.1016/s0140-6736(22)02588-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/20/2022] [Accepted: 11/18/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND The appropriate duration of postoperative antibiotics for complex appendicitis is unclear. The increasing global threat of antimicrobial resistance warrants restrictive antibiotic use, which could also reduce side-effects, length of hospital stay, and costs. METHODS In this pragmatic, open-label, non-inferiority trial in 15 hospitals in the Netherlands, patients with complex appendicitis (aged ≥8 years) were randomly assigned (1:1) to receive 2 days or 5 days of intravenous antibiotics after appendicectomy. Randomisation was stratified by centre, and treating physicians and patients were not masked to treatment allocation. The primary endpoint was a composite endpoint of infectious complications and mortality within 90 days. The main outcome was the absolute risk difference (95% CI) in the primary endpoint, adjusted for age and severity of appendicitis, with a non-inferiority margin of 7·5%. Outcome assessment was based on electronic patient records and a telephone consultation 90 days after appendicectomy. Efficacy was analysed in the intention-to-treat and per-protocol populations. Safety outcomes were analysed in the intention-to-treat population. This trial was registered with the Netherlands Trial Register, NL5946. FINDINGS Between April 12, 2017, and June 3, 2021, 13 267 patients were screened and 1066 were randomly assigned, 533 to each group. 31 were excluded from intention-to-treat analysis of the 2-day group and 30 from the 5-day group owing to errors in recruitment or consent. Appendicectomy was done laparoscopically in 955 (95%) of 1005 patients. The telephone follow-up was completed in 664 (66%) of 1005 patients. The primary endpoint occurred in 51 (10%) of 502 patients analysed in the 2-day group and 41 (8%) of 503 patients analysed in the 5-day group (adjusted absolute risk difference 2·0%, 95% CI -1·6 to 5·6). Rates of complications and re-interventions were similar between trial groups. Fewer patients had adverse effects of antibiotics in the 2-day group (45 [9%] of 502 patients) than in the 5-day group (112 [22%] of 503 patients; odds ratio [OR] 0·344, 95% CI 0·237 to 0·498). Re-admission to hospital was more frequent in the 2-day group (58 [12%] of 502 patients) than in the 5-day group (29 [6%] of 503 patients; OR 2·135, 1·342 to 3·396). There were no treatment-related deaths. INTERPRETATION 2 days of postoperative intravenous antibiotics for complex appendicitis is non-inferior to 5 days in terms of infectious complications and mortality within 90 days, based on a non-inferiority margin of 7·5%. These findings apply to laparoscopic appendicectomy conducted in a well resourced health-care setting. Adopting this strategy will reduce adverse effects of antibiotics and length of hospital stay. FUNDING The Netherlands Organization for Health Research and Development.
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Affiliation(s)
| | | | | | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC - University Medical Centre, Rotterdam, Netherlands; Department of Epidemiology, Erasmus MC - University Medical Centre, Rotterdam, Netherlands
| | - Coen I M Baeten
- Department of Surgery, Groene Hart Hospital, Gouda, Netherlands
| | | | | | - Esther C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands; Department of Surgery, University Medical Centre Groningen, Netherlands
| | | | - Marloes Emous
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | | | - Anton F Gijsen
- Department of Surgery, Medical Spectrum Twente, Enschede, Netherlands
| | - Luc A Heijnen
- Department of Surgery, Northwest Clinics, Alkmaar, Netherlands
| | - An P Jairam
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Damian C Melles
- Department of Medical Microbiology and Medical Immunology, Meander Medical Centre, Amersfoort, Netherlands
| | | | | | | | - Maarten Vermaas
- Department of Surgery, IJsselland Hospital, Capelle aan den Ijssel, Netherlands
| | - Bas Wiering
- Department of Surgery, Slingeland Hospital, Doetinchem, Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Centre, Rotterdam, Netherlands.
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Vos JAM, Sert E, Busschers WB, Duineveld LAM, Wieldraaijer T, Wind J, Donkervoort SC, Govaert MJPM, Beverdam FH, Smits AB, Bemelman WA, Heuff G, van Weert HCPM, van Asselt KM. Detection of colon cancer recurrences during follow-up care by general practitioners versus surgeons. J Natl Cancer Inst 2023; 115:523-529. [PMID: 36715623 PMCID: PMC10165489 DOI: 10.1093/jnci/djad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/02/2023] [Accepted: 01/09/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND In the I CARE study, colon cancer patients were randomized to receive follow-up care from either general practitioner (GP) or surgeon. Here, we address a secondary outcome, namely detection of recurrences, and effect on time to detection of transferring care from surgeon to GP. METHODS Pattern, stage and treatment of recurrences were described after 3 years. Time to event was defined as date of surgery, until date of recurrence or last follow-up, with death as competing event. Effects on time to recurrence and death were estimated as hazard ratios (HRs) using Cox regression. Restricted mean survival times were estimated. RESULTS Of 303 patients, 141 were randomized to the GP and 162 to the surgeon. Patients were male (67%) with a mean age of 68.0 years (SD 8.4). During follow-up, 46 recurrences were detected; 18 in the GP (13%) versus 28 in the surgeon group (17%). Most recurrences were detected via abnormal follow-up tests (74%) and treated with curative intent (59%). HR for recurrence was 0.75 [95% CI 0.41-1.36] in GP versus surgeon group. Patients in the GP group remained in the disease-free state slightly longer (2.76 versus 2.71 years). 38 patients died during follow-up; 15 in the GP (11%) versus 23 in the surgeon group (14%). 21 deaths (55%) were related to colon cancer. There were no differences in overall deaths between the groups (HR 0.76 [95% CI 0.39-1.46]). CONCLUSION Follow-up provided by GPs versus surgeons leads to similar detection of recurrences. Also, no differences in mortality were found.
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Affiliation(s)
- Julien A M Vos
- Amsterdam UMC, location University of Amsterdam, Department of General Practice, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Public Health, research programme Quality of Care, and Personalized Medicine, Amsterdam, the Netherlands
| | - Edanur Sert
- Amsterdam UMC, location University of Amsterdam, Department of General Practice, Meibergdreef 9, Amsterdam, the Netherlands
| | - Wim B Busschers
- Amsterdam UMC, location University of Amsterdam, Department of General Practice, Meibergdreef 9, Amsterdam, the Netherlands
| | - Laura A M Duineveld
- Amsterdam UMC, location University of Amsterdam, Department of General Practice, Meibergdreef 9, Amsterdam, the Netherlands
| | - Thijs Wieldraaijer
- Amsterdam UMC, location University of Amsterdam, Department of General Practice, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jan Wind
- Amsterdam UMC, location University of Amsterdam, Department of General Practice, Meibergdreef 9, Amsterdam, the Netherlands
| | - Sandra C Donkervoort
- Onze Lieve Vrouwe Gasthuis, Department of Surgery, Oosterpark 9, Amsterdam, the Netherlands
| | - Marc J P M Govaert
- Dijklander Hospital, Department of Surgery, Maelsonstraat 3, Hoorn, the Netherlands
| | - Frédérique H Beverdam
- Franciscus Gasthuis & Vlietland Hospital, Department of Surgery, Vlietlandplein 2, Schiedam, the Netherlands
| | - Anke B Smits
- St. Antonius Hospital, Department of Surgery, Koekoekslaan 1, Nieuwegein, the Netherlands
| | - Willem A Bemelman
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands
| | - Gijsbert Heuff
- Spaarne Gasthuis, Department of Surgery, Spaarnepoort 1, Hoofddorp, the Netherlands
| | - Henk C P M van Weert
- Amsterdam UMC, location University of Amsterdam, Department of General Practice, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Public Health, research programme Quality of Care, and Personalized Medicine, Amsterdam, the Netherlands
| | - Kristel M van Asselt
- Amsterdam UMC, location University of Amsterdam, Department of General Practice, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Public Health, research programme Quality of Care, and Personalized Medicine, Amsterdam, the Netherlands
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Huijgen D, de Wijkerslooth EML, Janssen JC, Beverdam FH, Boerma EJG, Dekker JWT, Kitonga S, van Rossem CC, Schreurs WH, Toorenvliet BR, Vermaas M, Wijnhoven BPL, van den Boom AL. Multicenter cohort study on the presentation and treatment of acute appendicitis during the COVID-19 pandemic. Int J Colorectal Dis 2022; 37:1087-1095. [PMID: 35415811 PMCID: PMC9005243 DOI: 10.1007/s00384-022-04137-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Current studies have demonstrated conflicting results regarding surgical care for acute appendicitis during the COVID-19 pandemic. This study aimed to assess trends in diagnosis as well as treatment of acute appendicitis in the Netherlands during the first and second COVID-19 infection wave. METHODS All consecutive patients that had an appendectomy for acute appendicitis in nine hospitals from January 2019 to December 2020 were included. The primary outcome was the number of appendectomies for acute appendicitis. Secondary outcomes included time between onset of symptoms and hospital admission, proportion of complex appendicitis, postoperative length of stay and postoperative infectious complications. Outcomes were compared between the pre-COVID group and COVID group. RESULTS A total of 4401 patients were included. The mean weekly rate of appendectomies during the COVID period was 44.0, compared to 40.9 in the pre-COVID period. The proportion of patients with complex appendicitis and mean postoperative length of stay in days were similar in the pre-COVID and COVID group (respectively 35.5% vs 36.8%, p = 0.36 and 2.0 ± 2.2 vs 2.0 ± 2.6, p = 0.93). There were no differences in postoperative infectious complications. A computed tomography scan was used more frequently as a diagnostic tool after the onset of COVID-19 compared to pre-COVID (13.8% vs 9.8%, p < 0.001, respectively). CONCLUSION No differences were observed in number of appendectomies, proportion of complex appendicitis, postoperative length of stay or postoperative infectious complications before and during the COVID-19 pandemic. A CT scan was used more frequently during the COVID-19 pandemic.
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Affiliation(s)
- Demi Huijgen
- Department of Surgery, Erasmus MC – University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | | | - Josephine C. Janssen
- Department of Surgery, Erasmus MC – University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | | | | | | | - Sophia Kitonga
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | | | | | - Maarten Vermaas
- Department of Surgery, IJsselland Hospital, Capelle Aan Den IJssel, The Netherlands
| | - Bas P. L. Wijnhoven
- Department of Surgery, Erasmus MC – University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Anne Loes van den Boom
- Department of Surgery, Erasmus MC – University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
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van den Boom AL, de Wijkerslooth EML, van Rosmalen J, Beverdam FH, Boerma EJG, Boermeester MA, Bosmans JWAM, Burghgraef TA, Consten ECJ, Dawson I, Dekker JWT, Emous M, van Geloven AAW, Go PMNYH, Heijnen LA, Huisman SA, Jean Pierre D, de Jonge J, Kloeze JH, Koopmanschap MA, Langeveld HR, Luyer MDP, Melles DC, Mouton JW, van der Ploeg APT, Poelmann FB, Ponten JEH, van Rossem CC, Schreurs WH, Shapiro J, Steenvoorde P, Toorenvliet BR, Verhelst J, Versteegh HP, Wijnen RMH, Wijnhoven BPL. Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial. Trials 2018; 19:263. [PMID: 29720238 PMCID: PMC5932884 DOI: 10.1186/s13063-018-2629-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022] Open
Abstract
Background Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. Methods Patients of 8 years and older undergoing appendectomy for acute complex appendicitis – defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess – are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at ɑ 0.025). Both per-protocol and intention-to-treat analyses will be performed. Discussion This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly. Trial registration Dutch Trial Register, NTR6128. Registered on 20 December 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2629-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne Loes van den Boom
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Elisabeth M L de Wijkerslooth
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Marja A Boermeester
- Department of Surgery, Academisch Medisch Centrum, Amsterdam, The Netherlands
| | | | | | | | - Imro Dawson
- Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | | | - Marloes Emous
- Department of Surgery, MC Leeuwarden, Leeuwarden, The Netherlands
| | | | - Peter M N Y H Go
- Department of Surgery, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Luc A Heijnen
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Sander A Huisman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Joske de Jonge
- Department of Surgery, Tergooi, Hilversum/Blaricum, The Netherlands
| | - Jurian H Kloeze
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marc A Koopmanschap
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Hester R Langeveld
- Department of Pediatric Surgery, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Damian C Melles
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Jeroen E H Ponten
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | | | | | - Joël Shapiro
- Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | - Pascal Steenvoorde
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Joost Verhelst
- Department of Surgery, Ikazia Ziekenhuis, Rotterdam, The Netherlands
| | - Hendt P Versteegh
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Rene M H Wijnen
- Department of Pediatric Surgery, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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den Bakker MA, van Weeszenberg A, de Kanter AY, Beverdam FH, Pritchard C, van der Kwast TH, Menke-Pluymers M. Non-sentinel lymph node involvement in patients with breast cancer and sentinel node micrometastasis; too early to abandon axillary clearance. J Clin Pathol 2002; 55:932-5. [PMID: 12461062 PMCID: PMC1769813 DOI: 10.1136/jcp.55.12.932] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS It has been suggested that patients with T1-2 breast tumours and sentinel node (SLN) micrometastases, defined as foci of tumour cells smaller than 2 mm, may be spared completion axillary lymph node dissection because of the low incidence of further metastatic disease. To gain insight into the extent of non-sentinel lymph node (n-SLN) involvement, SLNs and complementary axillary clearance specimens in patients with SLN micrometastases were examined. METHODS A set of 32 patients with SLN micrometastases was selected on the basis of pathology reports and review of SLNs. Five hundred and thirteen n-SLNs from the axillary clearance specimens were serially sectioned and analysed by means of immunohistochemistry for metastatic disease. Lymph node metastases were grouped as macrometastases (> 2 mm), and micrometastases (< 2 mm), and further subdivided as isolated tumour cells (ITCs) or clusters. RESULTS In 11 of 32 patients, one or more n-SLN was involved. Grade 3 tumours and tumours > 2 cm (T2-3 v T1) were significantly associated with n-SLN micrometastases as clusters (grade: odds ratio (OR), 8.3; 95% confidence interval (CI), 1.4 to 50.0; size: T2-3 tumours v T1: OR, 15; 95% CI, 2.18 to 103.0). However, no subgroup of tumours with regard to size and grade was identified that did not have n-SLN metastases. CONCLUSIONS In patients with breast cancer and SLN micrometastases, n-SLN involvement is relatively common. The incidence of metastatic clusters in n-SLN is greatly increased in patients with T2-3 tumours and grade 3 tumours. Therefore, axillary lymph node dissection is especially warranted in these patients. However, because n-SLN metastases also occur in T1 and low grade tumours, even these should be subjected to routine axillary dissection to achieve local control.
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Affiliation(s)
- M A den Bakker
- Department of Pathology, Erasmus Medical Centre Rotterdam, Daniel den Hoed Location, Groene Hilledijk 301, PO Box 5201, 3008 AE, Rotterdam, Netherlands.
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7
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Abstract
The risk of cardiovascular morbidity and mortality is highly increased in patients with diabetic nephropathy. Postulating that the generalized vasculopathy observed in these patients may enhance transcapillary filtration of lipids and lipoproteins resulting in a more atherogenic interstitial lipid profile, we set out to analyze the composition of their interstitial fluid. We studied healthy control subjects (n = 9), normoalbuminuric insulin-dependent diabetes mellitus (IDDM) patients (n = 16), and IDDM patients with diabetic nephropathy (n = 11) matched for age, body mass index, smoking habits, duration of diabetes, and metabolic control. Interstitial fluid was collected after an overnight fast by applying mild suction (200 mmHg) to the skin. Interstitial apolipoprotein A-I (apoA-I) levels were significantly lower in patients with nephropathy (0.18 +/- 0.10 milligram [mean +/- SD]) compared with normoalbuminuric diabetic patients (0.29 +/- 0.08 milligram) and healthy control subjects (0.30 +/- 0.09 milligram). Interstitial apolipoprotein B:apoA-I ratios tended to be higher in patients with diabetic nephropathy. In these patients, normal interstitial low-density lipoprotein cholesterol concentrations were observed in the presence of lower apoA-I levels. Transcapillary filtration of apoA-I was significantly lower in patients with diabetic nephropathy. Furthermore, an altered multiple regression model explaining interstitial apoA-I levels was observed in diabetic nephropathy. In this model, transcapillary protein (IgG) filtration and serum apoA-I levels no longer explained interstitial apoA-I levels. If we assume that interstitial apoA-I is involved in reverse cholesterol transport, these data suggest a more atherogenic interstitial lipoprotein profile in IDDM patients with nephropathy.
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Affiliation(s)
- J T Tamsma
- Department of Endocrinology, University Hospital, Leiden, The Netherlands
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