Laparoscopic mesh removal for chronic postoperative inguinal pain following endoscopic hernia repair: a cohort study on the effect on pain

PURPOSE

Chronic postoperative inguinal pain (CPIP) after pre-peritoneal hernia repair is rare but may be severely invalidating. Mesh may be a contributing factor to the development of CPIP. International guidelines acknowledge mesh removal as a treatment option for CPIP after open repair, but experience in laparoscopic mesh removal is limited. Surgeons are hesitant to remove pre-peritoneal meshes because of fear of operative complications. This observational study describes risks and effectiveness of laparoscopic mesh removal in patients with CPIP after endoscopic inguinal hernia repair.

METHODS

Questionnaires and operative findings of consecutive patients undergoing a laparoscopic mesh removal for CPIP between August 2014 and February 2019 in the center for groin pain were prospectively recorded. Long-term efficacy was determined using pre and postoperative questionnaires on pain and quality of life.

RESULTS

Forty-four patients were included (37 males, median age 51 years). Complete or sufficient pain relief was reported in every two out of three patients (68%) and quality of life improved significantly. Intraoperative findings included wrinkled mesh (n = 19), meshoma (n = 14) and infected mesh (n = 1). Surprisingly, over half of the meshes (n = 23) did not fully cover the groin, with three clear recurrent hernias. Intraoperative complications included two bladder injuries. One patient undergoing removal of 3 meshes on one side developed a necrotic testicle. During follow-up, three patients developed a recurrent hernia requiring open surgery.

CONCLUSION

Laparoscopic mesh removal is safe and effective in selected patients with CPIP after endoscopic hernia repair. We believe that this technique should be adopted by dedicated hernia surgeons.

Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial

Background

This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.

Methods

Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.

Results

Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.

Conclusion

Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

Graphical abstract

Should all gallbladders be examined routinely or selectively by microscopy after cholecystectomy? Population-based Dutch study over a decade

The need for routine histopathological examination of gallbladders after cholecystectomy is debated. This study suggests that selective histopathological examination of the gallbladder may be considered oncologically safe.

While the necessity of a routine histopathologic examination of gallbladders after cholecystectomy is debated. This study suggests that a selective histopathologic examination of the gallbladder may be considered as oncologically safe.

Comparing practice and outcome of laparoscopic liver resection between high-volume expert centres and nationwide low-to-medium volume centres

BACKGROUND

Based on excellent outcomes from high-volume centres, laparoscopic liver resection is increasingly being adopted into nationwide practice which typically includes low-medium volume centres. It is unknown how the use and outcome of laparoscopic liver resection compare between high-volume centres and low-medium volume centres. This study aimed to compare use and outcome of laparoscopic liver resection in three leading European high-volume centres and nationwide practice in the Netherlands.

METHOD

An international, retrospective multicentre cohort study including data from three European high-volume centres (Oslo, Southampton and Milan) and all 20 centres in the Netherlands performing laparoscopic liver resection (low-medium volume practice) from January 2011 to December 2016. A high-volume centre is defined as a centre performing >50 laparoscopic liver resections per year. Patients were retrospectively stratified into low, moderate- and high-risk Southampton difficulty score groups.

RESULTS

A total of 2425 patients were included (1540 high-volume; 885 low-medium volume). The median annual proportion of laparoscopic liver resection was 42.9 per cent in high-volume centres and 7.2 per cent in low-medium volume centres. Patients in the high-volume centres had a lower conversion rate (7.4 versus 13.1 per cent; P < 0.001) with less intraoperative incidents (9.3 versus 14.6 per cent; P = 0.002) as compared to low-medium volume centres. Whereas postoperative morbidity and mortality rates were similar in the two groups, a lower reintervention rate (5.1 versus 7.2 per cent; P = 0.034) and a shorter postoperative hospital stay (3 versus 5 days; P < 0.001) were observed in the high-volume centres as compared to the low-medium volume centres. In each Southampton difficulty score group, the conversion rate was lower and hospital stay shorter in high-volume centres. The rate of intraoperative incidents did not differ in the low-risk group, whilst in the moderate-risk and high-risk groups this rate was lower in high-volume centres (absolute difference 6.7 and 14.2 per cent; all P < 0.004).

CONCLUSION

High-volume expert centres had a sixfold higher use of laparoscopic liver resection, less conversions, and shorter hospital stay, as compared to a nationwide low-medium volume practice. Stratification into Southampton difficulty score risk groups identified some differences but largely outcomes appeared better for high-volume centres in each risk group.

Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation

Background

Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME.

Methods

Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence.

Results

The implementation cohort of 120 patients had a median follow up of 21·9 months. Short‐term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre).

Conclusion

TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

Cardiac overscreening hip fracture patients

BACKGROUND

The aim of this study was to prospectively investigate the adherence to the American College of Cardiology (ACC) and the American Heart Association guidelines for perioperative assessment of patients with hip fracture in daily clinical practice and how this might affect outcome.

METHODS

This prospective cohort study from Maastricht University Medical Centre included 166 hip fracture patients within a 3-year inclusion period. The preoperative cardiac screening and adherence to the ACC/AHA guideline were analyzed. Cardiac risk was classified as low, intermediate and high risk. Secondary outcome measurements were delay to surgery, perioperative complications and in-hospital, 30-day, 1-year and 2-year mortality.

RESULTS

According to the ACC/AHA guideline, 87% of patients received correct preoperative cardiac screening. The most important reason for incorrect preoperative cardiac screening was overscreening (> 90%). Multivariate analysis showed that a cardiac consultation (p = 0.003) and overscreening (p = 0.02) as significant predictors for increased delay to surgery, while age, sex, previous cardiac history and preoperative mobility were not. High risk patients had in comparison with low risk patients a significantly higher relative risk ratio for in-hospital mortality (RR 6, 95% CI 2-17). Multivariate analysis showed that a previous cardiac history and increased delay to surgery were predictors for early mortality. High age and previous cardiac history were risk factors for late mortality.

CONCLUSION

Preoperative cardiac screening for hip fracture patients in adherence to the ACC/AHA guideline is associated with a diminished use of preoperative resources. Overscreening leads to greater delay to surgery, which poses a risk for perioperative complications and early mortality.

LEVEL OF EVIDENCE

II.

Selective Histological Examination After Cholecystectomy: An Analysis of Current Daily Practice in The Netherlands

BACKGROUND

The 2016 Dutch national guidelines on handling of a removed gallbladder for cholelithiasis proposes a selective histopathologic policy (Sel-HP) rather than routine policy (Rout-HP). The aim of this study was to determine the current implementation of the present guideline and the daily practice of Sel-HP.

METHODS

Surgeons who were engaged in gallbladder surgery in the Netherlands and were involved in local hospitals' gallbladder protocols completed a questionnaire study regarding gallbladder policy, between December 2017 and May 2018. Data were analyzed using standard statistics.

RESULTS

A 100% response rate was obtained (n = 74). Approximately 64% of all gallbladders (n = 22,500) were examined microscopically. Sixty-nine (93.2%) hospitals confirmed they were aware of the new guidelines, and 56 (75.7%) knew the guideline was adjusted in favor of Sel-HP. Half of the hospitals (n = 35, 47.3%) had adopted a Sel-HP, and 39 (52.7%) a Rout-HP. Of the 39 hospitals who had a Rout-HP, 36 were open to a transition to a Sel-HP although some expressed the need for more evidence on safety or novel guidelines.

CONCLUSIONS

The current implementation of the 2016 Dutch guideline advising a selective microscopic analysis of removed gallbladders for gallstone disease is suboptimal. Evidence demonstrating safety and cost-effectiveness of an on demand histopathological examination will aid in the implementation process.

Outcome of Surgical Inspection of the Gallbladder in Relation to Final Pathology

INTRODUCTION

Routine histopathologic gallbladder examination after cholecystectomy has been a point of discussion. The aim of this study was to evaluate the macroscopic examination by the surgeon in relation to the final histology.

METHODS

A prospective study was conducted to investigate the practice of macroscopic gallbladder examination by a surgeon compared to routine histopathology by a pathologist. All consecutive cholecystectomies were included between November 2009 and February 2011.

RESULTS

A total of 319 consecutive cholecystectomies were performed. Of all macroscopic examinations, the surgeon identified 62 gallbladders with macroscopic abnormalities, ranging from polyps to wall thickening or ulcers. In 55 (17.2%) cases, the surgeon judged that further examination of the specimen by the pathologist could possibly lead to additional and relevant findings. There was a strong agreement between the surgeon and the pathologist concerning the macroscopic examination (κappa = 0.822). The surgeon and the pathologist had disagreement on the macroscopic examination of 18 gallbladders, without clinical consequences for the patient.

DISCUSSION

The present prospective study shows that the surgeon should be able to select those gallbladders needing a microscopic gallbladder examination. Potentially, about 80% of this kind of routine histology can be reduced.

What you should know about the low anterior resection syndrome - Clinical recommendations from a patient perspective

INTRODUCTION

Functional bowel complaints, referred to as Low Anterior Resection Syndrome (LARS), are common after sphincter-saving surgical procedures and have a severe impact on quality of life (QoL). Care for LARS patients is complex and surgeons underestimate or misinterpret its associated symptoms. This study aimed to explore the impact of LARS from a patient perspective facilitating the construction of a set of recommendations improving current care stratagems.

METHODS

In a non-academic Dutch teaching hospital, three focus group sessions were conducted with 16 patients (males = 50%) who had undergone colorectal surgery between 2012 and 2017. A trained moderator orchestrated patient-discussion regarding illness perception and health-care needs. Transcripts were analysed using inductive content analysis.

RESULTS

Three themes were identified: illness perception, preoperative care and postoperative supportive care. Specific attention and screening for LARS is deemed necessary for breaking the taboo surrounding it. Extension of preoperative counselling on the normal postoperative course, including ways to optimize social support, were identified as crucial. After discharge, patients experienced a lack of supportive care regarding functional complaints and did not know who to counsel. In addition, they felt intrinsically motivated to actively prepare for surgery, i.e. by participating in prehabilitation programs.

CONCLUSION

Exploring perspectives in LARS patients resulted in the identification of potential improvements in current care pathways. Recommendations on ways to improve information provision, screening of LARS and methods to intervene in the gap of supportive care after discharge are presented. We recommend to implement these measures as QoL of patients undergoing colorectal cancer surgery may be improved.

Laparoscopic mesh removal for otherwise intractable inguinal pain following endoscopic hernia repair is feasible, safe and may be effective in selected patients

BACKGROUND

Laparoscopic inguinal hernia repair is preferred over an open technique because of reduced recovery time, favorable cost effectiveness, and less chronic postoperative inguinal pain. Nevertheless, some patients develop a nociceptive inguinal pain syndrome possibly related to the presence of the mesh. This is the first study describing feasibility, safety, and effectiveness of laparoscopic mesh removal in patients with chronic pain after endoscopic hernia repair.

METHODS

Pre- and intraoperative data of chronic pain patients scheduled for endoscopic mesh removal were prospectively collected by a standard evaluation form. Long-term efficacy was determined using pain scores, patient satisfaction, and quality of life questionnaire. A Wilcoxon signed-rank test was used to determine significant differences between pre- and postoperative pain scores.

RESULTS

Fourteen patients were studied (11 males, median 52 years). Median operating time was 103 min. Conversion to open surgery was not required. One intraoperatively recognized bladder laceration was laparoscopically closed. Otherwise, no intraoperative or postoperative complications occurred. Eight months postoperatively (median), pain scores had dropped from eight to four (p < 0.01). Satisfaction was good or excellent in ten patients. A recurrent hernia developed in two patients requiring an open mesh repair in one.

CONCLUSIONS

Laparoscopic mesh removal is a feasible, safe, and effective option in selected patients with chronic groin pain after endoscopic hernia repair in the hands of an experienced surgeon.

Systematic review of exercise training in colorectal cancer patients during treatment

Colorectal cancer surgery results in considerable postoperative morbidity, mortality and reduced quality of life. As many patients will undergo additional (neo)adjuvant therapy, it is imperative that each individual optimize their physical function. To elucidate the potential of exercise in patient optimization, we investigated the evidence for an exercise program before and after surgical treatment in colorectal cancer patients. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions, the guidelines of the Physical Therapy Journal and the PRISMA guidelines. No literature pertaining to exercise training during preoperative neoadjuvant treatment was found. Seven studies, investigating the effects of regular exercise during adjuvant chemotherapy for patients with colorectal cancer or a mixed population, were identified. A small effect (effect size (ES) 0.4) of endurance/interval training and strength training (ES 0.4) was found in two studies conducted in patients with colorectal and gastrointestinal cancer. In five studies that included a mixed population of cancer patients, interval training resulted in a large improvement (ES 1.5; P≤.05). Endurance training alone was found to increase both lower extremity strength and endurance capacity. The effects of strength training in the lower extremity are moderate, whereas, in the upper extremity, the increase is small. There is limited evidence available on exercise training during treatment in colorectal cancer patients. One study concluded exercise therapy may be beneficial for colorectal cancer patients during adjuvant treatment. The possible advantages of training during neoadjuvant treatment may be explored by prehabilitation trials.

Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study)

BACKGROUND

Laparoscopic left lateral sectionectomy (LLLS) has been associated with shorter hospital stay and reduced overall morbidity compared with open left lateral sectionectomy (OLLS). Strong evidence has not, however, been provided.

METHODS

In this multicentre double-blind RCT, patients (aged 18-80 years with a BMI of 18-35 kg/m2 and ASA fitness grade of III or below) requiring left lateral sectionectomy (LLS) were assigned randomly to OLLS or LLLS within an enhanced recovery after surgery (ERAS) programme. All randomized patients, ward physicians and nurses were blinded to the procedure undertaken. A parallel prospective registry (open non-randomized (ONR) versus laparoscopic non-randomized (LNR)) was used to monitor patients who were not enrolled for randomization because of doctor or patient preference. The primary endpoint was time to functional recovery. Secondary endpoints were length of hospital stay (LOS), readmission rate, overall morbidity, composite endpoint of liver surgery-specific morbidity, mortality, and reasons for delay in discharge after functional recovery.

RESULTS

Between January 2010 and July 2014, patients were recruited at ten centres. Of these, 24 patients were randomized at eight centres, and 67 patients from eight centres were included in the prospective registry. Owing to slow accrual, the trial was stopped on the advice of an independent Data and Safety Monitoring Board in the Netherlands. No significant difference in median (i.q.r.) time to functional recovery was observed between laparoscopic and open surgery in the randomized or non-randomized groups: 3 (3-5) days for OLLS versus 3 (3-3) days for LLLS; and 3 (3-3) days for ONR versus 3 (3-4) days for LNR. There were no significant differences with regard to LOS, morbidity, reoperation, readmission and mortality rates.

CONCLUSION

This RCT comparing open and laparoscopic LLS in an ERAS setting was not able to reach a conclusion on time to functional recovery, because it was stopped prematurely owing to slow accrual. Registration number: NCT00874224 ( https://www.clinicaltrials.gov).

Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together

BACKGROUND

Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation.

METHODS

Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies).

RESULTS

The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL.

CONCLUSION

Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.

TS gene polymorphisms are not good markers of response to 5-FU therapy in stage III colon cancer patients

AIM

Although the predictive and prognostic value of thymidylate synthase (TS) expression and gene polymorphism in colon cancer has been widely studied, the results are inconclusive probably because of methodological differences. With this study, we aimed to elucidate the role of TS gene polymorphisms genotyping in therapy response in stage III colon carcinoma patients treated with 5-FU adjuvant chemotherapy.

PATIENTS AND METHODS

251 patients diagnosed with stage III colon carcinoma treated with surgery followed by 5-FU based adjuvant therapy were selected. The variable number of tandem repeats (VNTR) and the single nucleotide polymorphism (SNP) in the 5'untranslated region of the TS gene were genotyped.

RESULTS

There was a positive association between tumor T stage and the VNTR genotypes (p = 0.05). In both univariate and multivariate survival analysis no effects of the studied polymorphisms on survival were found. However, there was an association between both polymorphisms and age. Among patients younger than 60 years, the patients homozygous for 2R seemed to have a better overall survival, whereas among the patients older than 67 this longer survival was seen by the carriers of other genotypes.

CONCLUSION

We conclude that the TS VNTR and SNP do not predict response to 5-FU therapy in patients with stage III colon carcinoma. However, age appears to modify the effects of TS polymorphisms on survival.

TS gene polymorphisms are not good markers of response to 5-FU therapy in stage III colon cancer patients

Aim: Although the predictive and prognostic value of thymidylate synthase (TS) expression and gene polymorphism in colon cancer has been widely studied, the results are inconclusive probably because of methodological differences. With this study, we aimed to elucidate the role of TS gene polymorphisms genotyping in therapy response in stage III colon carcinoma patients treated with 5-FU adjuvant chemotherapy.

Patients and Methods: 251 patients diagnosed with stage III colon carcinoma treated with surgery followed by 5-FU based adjuvant therapy were selected. The variable number of tandem repeats (VNTR) and the single nucleotide polymorphism (SNP) in the 5′-untranslated region of the TS gene were genotyped.

Results: There was a positive association between tumor T stage and the VNTR genotypes (p=0.05). In both univariate and multivariate survival analysis no effects of the studied polymorphisms on survival were found. However, there was an association between both polymorphisms and age. Among patients younger than 60 years, the patients homozygous for 2R seemed to have a better overall survival, whereas among the patients older than 67 this longer survival was seen by the carriers of other genotypes.

Conclusion: We conclude that the TS VNTR and SNP do not predict response to 5-FU therapy in patients with stage III colon carcinoma. However, age appears to modify the effects of TS polymorphisms on survival.

Risk factors for conversion during laparoscopic cholecystectomy - experiences from a general teaching hospital

BACKGROUND AND AIMS

Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic cholelithiasis. Conversion, however, is sometimes necessary. The aim of this study was to determine predictive factors of conversion in patients undergoing LC for various indications in elective and acute settings in a general teaching hospital.

MATERIAL AND METHODS

A retrospective analysis was performed on 972 consecutive patients who underwent a laparoscopic cholecystectomy in Máxima Medical Centre in Veldhoven, the Netherlands, from January 2000 till January 2006. Recorded data were sex, age, indication for LC, conversion to open cholecystectomy, reason for conversion, performing surgeon, co-morbidity, type of complication, length of hospital stay and 30-day mortality.

RESULTS

Conversion to open cholecystectomy was performed in 121 patients (12%). The most frequent reasons for conversion were infiltration/fibrosis of Calot's triangle (30%) and adhesions (27%). In the multivariate analyses male gender (OR 1.67, 95% CI 1.07-2.59), age >65 years (OR 2.10, 95% CI 1.32-3.34), acute cholecystitis (OR 11.8, 95% CI 6.98-20.1), recent acute cholecystitis (OR 4.71, 95% CI 2.42-9.18) and recent obstructive jaundice (OR 20.6, 95% CI 4.52-94.1) were independent predictive factors for conversion.

CONCLUSIONS

Male gender, age >65 years, (recent) acute cholecystitis and recent obstructive jaundice are independent predictive risk factors for conversion. By appreciating these risk factors for conversion, preoperative patient counselling can be improved.

Doppler perfusion index fails to predict the presence of occult hepatic colorectal metastases

AIMS

To assess the predictive value of the Doppler perfusion index (DPI) in a cohort of patients with colorectal cancer with and without initial metastatic disease and present the data of at least 4 years follow-up.

METHODS

We studied 133 patients admitted with stage I-IV colorectal cancer. In all patients hepatic flow measurements were performed in the week before surgery. All patients who underwent curative surgery on intention were followed up for at least 4 years.

RESULTS

Reliable DPI measurements were not possible in 29 patients. Three groups were defined for comparison: (A) 57 patients who remained disease free, (B) 11 patients who presented with metachronous liver metastases during follow-up and (C) 19 patients with liver metastases at initial presentation. No significant difference was found for DPI data between the three groups. There was a trend for a higher hepatic artery flow in patients with initial liver metastases compared to those who remained disease free (p=0.07). The previously reported cut-off point for maximal normal DPI (0.3) did not have any predictive value in this patient cohort.

CONCLUSION

The present data do not confirm the usefulness of DPI measurements in daily clinical practice for the early identification of patients with colorectal cancer at high risk for recurrent disease.

Somatostatin receptor imaging, therapy and new strategies in patients with neuroendocrine tumours

BACKGROUND

Somatostatin receptors have been found on a variety of neuroendocrine tumours, such as carcinoids and paragangliomas, as well as on most pancreatic endocrine and breast tumours. Somatostatin receptor scintigraphy with a radionuclide-labelled somatostatin analogue, [111Indium- diethylenetriaminopenta-acetic acid]octreotide, is a sensitive and specific technique for visualizing in vivo the presence of somatostatin receptors on various tumours.

METHODS

Material was identified from previous review articles, references cited in original papers and a Medline search of the literature. Additional material was obtained from recently published abstracts of meetings.

RESULTS AND CONCLUSION

Somatostatin receptor imaging of neuroendocrine tumours is essential in the diagnostic evaluation of most of these tumours. The expression of somatostatin receptors in vivo not only predicts the outcome of somatostatin analogue treatment but also opens the possibility of new therapeutic strategies. Because better information about spread of the disease can be obtained, more justifiable options for therapy can be proposed.

Therapy of neuroendocrine tumors with radiolabeled somatostatin-analogues

Peptide receptor scintigraphy with the radioactive somatostatin-analogue [111In-DTPA0]octreotide (DTPA = diethylenetriaminepentaacetic acid) is a sensitive and specific technique to show in vivo the presence and abundance of somatostatin receptors on various tumors. With this technique primary tumors and metastases of neuroendocrine cancers as well as of many other cancer types can be localised. A new application is the use of peptide receptor radionuclide therapy, administrating high doses of 111In- or 90Y-labeled octreotide-analogues. PRECLINICAL: We investigated the radiotherapeutic effect of 90Y- and 111In-labeled [DOTA0,Tyr3]octreotide (DOTA = tetraazacyclododecanetetraacetic acid) or [111In-DTPA0]octreotide in Lewis rats bearing the somatostatin receptor-positive rat pancreatic tumor CA20948 in A) the flank or B) in the liver.

PATIENTS

Thirty end-stage patients with mostly neuroendocrine progressing tumors were treated with [111In-DTPA0]octreotide, up to a maximal cumulative patient dose of about 74 GBq, in a phase 1 trial. PRECLINICAL RESULTS: A) Flank model: at least two 111MBq injections of [111In-DOTA0,Tyr3]octreotide were needed to reach tumor response, in 40% of the animals complete tumor remission was found after a follow-up period of 10 months. One or two injections of [90Y-DOTA0,Tyr3] octreotide yielded transient stable disease. B) Liver model: we found that peptide receptor radionuclide therapy is only effective if somatostatin receptors are present on the tumors, and is therefore receptor-mediated. High radioactive doses of 370 MBq [111In-DTPA0]octreotide or 93 MBq [90Y-DOTA0,Tyr3]octreotide can inhibit the growth of somatostatin receptor-positive metastases.

CLINICAL RESULTS

There were no major clinical side effects after up to 2 years treatment, except that a transient decline in platelet counts and lymphocyte subsets can occur. Promising beneficial effects on clinical symptoms, hormone production and tumor proliferation were found. Of the 21 patients with progressive disease at baseline and who received a cumulative dose of more than 20 GBq [111In-DTPA0]octreotide, 8 patients showed stabilisation of disease and 6 other patients a reduction in size of tumors. There is a tendency towards better results in patients whose tumors have a higher accumulation of the radioligand.

CONCLUSION

Radionuclide therapy with octreotide-derivatives is feasible, both with 111In and 90Y as radionuclides.

Somatostatin receptor imaging and therapy of pancreatic endocrine tumors

Somatostatin receptors (SS-Rs) have been found on a variety of neuroendocrine tumors like carcinoids, paragangliomas, as well as on brain and breast tumors. SS-Rs are also present on most pancreatic endocrine tumors, while previous in vitro studies indicate the absence of these receptors on pancreatic duct cancers. Somatostatin receptor scintigraphy with a radionuclide labeled somatostatin analogue, [111In-DTPA0]-octreotide, is a sensitive and specific technique to visualize in vivo the presence of SS-Rs on various tumors. The purpose of this article is to review the somatostatin receptor imaging of pancreatic endocrine tumors and to illustrate the impact of SS-R expression for therapeutic strategies.

Anti-proliferative effect of radiolabelled octreotide in a metastases model in rat liver

Most neuroendocrine tumours and several other tumours, such as breast carcinoma and malignant lymphoma, express somatostatin receptors (SS-Rs). Lesions expressing these receptors can be visualised by receptor scintigraphy using a low radioactive dose of the radiolabelled SS analogue [111In-DTPA0]octreotide. This radioligand is internalised and transported to the lysosomes with a long residence time of 111In. The aim of this experimental study in rats was to investigate whether the same agent, given in a high radioactive dose, can be used for therapy of hepatic metastases of different tumour cell lines. The development of hepatic metastases was determined 21 days after direct injection of SS-R-positive or -negative tumour cells into the vena porta in rats. On day 1 and/or 8, animals were treated with 370 MBq (0.5 microg) [111In-DTPA0]octreotide. In one experiment, using SS-R-positive tumour cells, animals were pre-treated with a high dose of cold octreotide to block the SS-R by saturation. The number of SS-R-positive liver metastases was significantly decreased after treatment with [111In-DTPA0]octreotide. Blocking the SS-R by octreotide substantially decreased the efficacy of treatment with [111In-DTPA0]octreotide, suggesting that the presence of SS-R is mandatory. This was confirmed by the finding that the number of SS-R-negative liver metastases was not affected by treatment with [111In-DTPA0]octreotide. Therefore, we conclude that (i) high radioactive doses of [111In-DTPA0]octreotide for PRRT (peptide receptor radionuclide therapy) can inhibit the growth of SS-R-positive liver metastases in an animal model, (ii) PRRT is effective only if SS-Rs are present on the tumours, (iii) the effect of PRRT with [111In-DTPA0]octreotide can be reduced by pre-treatment with cold octreotide, which indicates that receptor binding is essential for PRRT. Our data suggest that PRRT with radiolabelled octreotide might be a new promising treatment modality for SS-R-positive tumours.

Anti-proliferative effect of radiolabelled octreotide in a metastases model in rat liver

Most neuroendocrine tumours and several other tumours, such as breast carcinoma and malignant lymphoma, express somatostatin receptors (SS-Rs). Lesions expressing these receptors can be visualised by receptor scintigraphy using a low radioactive dose of the radiolabelled SS analogue [111In-DTPA0]octreotide. This radioligand is internalised and transported to the lysosomes with a long residence time of 111In. The aim of this experimental study in rats was to investigate whether the same agent, given in a high radioactive dose, can be used for therapy of hepatic metastases of different tumour cell lines. The development of hepatic metastases was determined 21 days after direct injection of SS-R-positive or -negative tumour cells into the vena porta in rats. On day 1 and/or 8, animals were treated with 370 MBq (0.5 microg) [111In-DTPA0]octreotide. In one experiment, using SS-R-positive tumour cells, animals were pre-treated with a high dose of cold octreotide to block the SS-R by saturation. The number of SS-R-positive liver metastases was significantly decreased after treatment with [111In-DTPA0]octreotide. Blocking the SS-R by octreotide substantially decreased the efficacy of treatment with [111In-DTPA0]octreotide, suggesting that the presence of SS-R is mandatory. This was confirmed by the finding that the number of SS-R-negative liver metastases was not affected by treatment with [111In-DTPA0]octreotide. Therefore, we conclude that (i) high radioactive doses of [111In-DTPA0]octreotide for PRRT (peptide receptor radionuclide therapy) can inhibit the growth of SS-R-positive liver metastases in an animal model, (ii) PRRT is effective only if SS-Rs are present on the tumours, (iii) the effect of PRRT with [111In-DTPA0]octreotide can be reduced by pre-treatment with cold octreotide, which indicates that receptor binding is essential for PRRT. Our data suggest that PRRT with radiolabelled octreotide might be a new promising treatment modality for SS-R-positive tumours.

Tumour growth stimulation after partial hepatectomy can be reduced by treatment with tumour necrosis factor alpha

This study investigated whether partial hepatectomy enhances the growth of experimental liver metastases of colonic carcinoma in rats and whether treatment with recombinant human tumour necrosis factor (TNF) alpha can reduce this increased growth. Resection of 35 or 70 per cent of the liver was performed in inbred WAG rats, with sham-operated controls (five to eight animals per group). Immediately after surgery 5 x 10(5) CC531 colonic tumour cells were injected into the portal vein. After 28 days the animals were killed and the number of liver metastases counted. A 35 per cent hepatectomy induced a significant increase in the median number of liver metastases (28 versus 3 in controls), whereas a 70 per cent resection provoked excessive growth, consistently leading to more than 100 liver metastases and a significantly increased wet liver weight in all animals. TNF-alpha was given intravenously to rats following 70 per cent hepatectomy or sham operation in a dose of 160 micrograms/kg three times per week. This had only a marginal effect on tumour development in sham-operated rats but was very effective following partial hepatectomy (median 45 liver metastases). These observations confirm previous findings that surgical metastasectomy may act as a 'double-edged sword' by provoking outgrowth of dormant tumour cells and suggest that adjuvant treatment with TNF-alpha may be of benefit in patients undergoing resection of metastases.

Somatostatin receptor-dependent growth inhibition of liver metastases by octreotide

Rats were administered the somatostatin analogue octreotide 15 micrograms intraperitoneally twice daily for 4 weeks after intraportal injection of somatostatin receptor-positive pancreatic tumour cells (CA-20948) and somatostatin receptor-negative colonic tumour cells (CC531). Octreotide significantly inhibited the growth and development of somatostatin receptor-positive tumour cells in the liver. The median number of liver tumours was 286 (range 146 to greater than 500) in the treated animals and more than 500 (range 250 to in excess of 500) in the controls (P < 0.05). This significant difference in tumour load was also represented in the mean(s.e.m.) liver weight (14.5(3.7) g in animals given octreotide versus 17.9(3.0) g in the controls). No effect of octreotide treatment was found on the growth and development of somatostatin receptor-negative tumour cells in the liver. The median (range) number of tumours was 6.5 (0-425) in the treated animals and 11.0 (0-475) in the controls. Mean(s.e.m.) liver weights were 14.0(5.7) g and 11.8(4.5) g respectively. There was no difference in serum levels of growth hormone, prolactin and insulin-like growth factor between control and octreotide-treated rats. The growth inhibition of somatostatin receptor-positive tumour cells was unlikely to be the result of suppressed secretion of one of these tumour growth factors. Octreotide may be useful for the treatment of patients with somatostatin receptor-positive hepatic metastases, which can be demonstrated by somatostatin receptor scintigraphy.

Cross-sectional and longitudinal study of age-related phalangeal bone loss in adult females

To establish a comprehensive model for peripheral phalangeal bone loss, bone mass was studied in 1984 and 1989 using quantitative microdensitometry (QMD) in a total of 330 healthy women (age range 43-78.7 years). Bone mass and changes in bone mass were analyzed in relation to age and menopausal status. Ideal and nonideal populations were distinguished to assess the effect of diseases and medication. Both groups showed a decrease in bone mass, which proved to be more dependent on menopausal status than on age. A substantial loss started in the ideal group in the early postmenopausal period and in the nonideal group in the premenopausal period. Because the nonideal group started to lose bone at an earlier stage, the lifetime risk for osteoporosis is higher than in the ideal group.