Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue

INTRODUCTION

Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences.

METHODS

TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment.

RESULTS

FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4).

CONCLUSION

Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.

Trends in Distal Esophageal and Gastroesophageal Junction Cancer Care: The Dutch Nationwide Ivory Study

OBJECTIVE

This study evaluated the nationwide trends in care and accompanied postoperative outcomes for patients with distal esophageal and gastro-esophageal junction cancer.

SUMMARY OF BACKGROUND DATA

The introduction of transthoracic esophagectomy, minimally invasive surgery, and neo-adjuvant chemo(radio)therapy changed care for patients with esophageal cancer.

METHODS

Patients after elective transthoracic and transhiatal esophagectomy for distal esophageal or gastroesophageal junction carcinoma in the Netherlands between 2007-2016 were included. The primary aim was to evaluate trends in both care and postoperative outcomes for the included patients. Additionally, postoperative outcomes after transthoracic and tran-shiatal esophagectomy were compared, stratified by time periods.

RESULTS

Among 4712 patients included, 74% had distal esophageal tumors and 87% had adenocarcinomas. Between 2007 and 2016, the proportion of transthoracic esophagectomy increased from 41% to 81%, and neo-adjuvant treatment and minimally invasive esophagectomy increased from 31% to 96%, and from 7% to 80%, respectively. Over this 10-year period, postoperative outcomes improved: postoperative morbidity decreased from 66.6% to 61.8% ( P = 0.001), R0 resection rate increased from 90.0% to 96.5% (P <0.001), median lymph node harvest increased from 15 to 19 ( P <0.001), and median survival increased from 35 to 41 months ( P = 0.027).

CONCLUSION

In this nationwide cohort, a transition towards more neo-adju-vant treatment, transthoracic esophagectomy and minimally invasive surgery was observed over a 10-year period, accompanied by decreased postoperative morbidity, improved surgical radicality and lymph node harvest, and improved survival.

Reasons for low uptake of a psychological intervention offered to cancer survivors with elevated depressive symptoms

Objective

In line with screening guidelines, cancer survivors were consecutively screened on depressive symptoms (as part of standard care), with those reporting elevated levels of symptoms offered psychological care as part of a trial. Because of the low uptake, no conclusions could be drawn about the interventions' efficacy. Given the trial set‐up (following screening guidelines and strict methodological quality criteria), we believe that this observational study reporting the flow of participation, reasons for and characteristics associated with nonparticipation, adds to the debate about the feasibility and efficiency of screening guidelines.

Methods

Two thousand six hundred eight medium‐ to long‐term cancer survivors were consecutively screened on depressive symptoms using the Patient Health Questionnaire‐9 (PHQ‐9). Those with moderate depressive symptoms (PHQ‐9 ≥ 10) were contacted and informed about the trial. Patient flow and reasons for nonparticipation were carefully monitored.

Results

One thousand thirty seven survivors (74.3%) returned the questionnaire, with 147 (7.6%) reporting moderate depressive symptoms. Of this group, 49 survivors (33.3%) were ineligible, including 26 survivors (17.7%) already receiving treatment and another 44 survivors (30.0%) reporting no need for treatment. Only 25 survivors (1.0%) participated in the trial.

Conclusion

Of the approached survivors for screening, only 1% was eligible and interested in receiving psychological care as part of our trial. Four reasons for nonparticipation were: nonresponse to screening, low levels of depressive symptoms, no need, or already receiving care. Our findings question whether to spend the limited resources in psycho‐oncological care on following screening guidelines and the efficiency of using consecutive screening for trial recruitment in cancer survivors.

Palliative resection of the primary tumour in stage IV rectal cancer

AIM

The aim of this study was to investigate the use of resection in a cohort of palliatively treated patients with stage IV rectal cancer. To avoid selection bias, particular attention was paid to correction for comorbidity and extent of disease.

METHOD

Patients with stage IV rectal cancer in two hospitals in Groningen were consecutively included over a 5-year period. Comorbidity was defined as major (dementia, cardiac failure or left ventricle ejection fraction <30%, or severe chronic obstructive pulmonary disease), minor (diabetes, hypertension, mild renal disease or mild pulmonary disease) or none. The effect of patient and disease characteristics on survival was assessed using Kaplan-Meier and Cox regression analyses.

RESULTS

Of 88 patients, 11 (13%) underwent elective surgical resection without chemotherapy, 15 (17%) received both elective resection and chemotherapy, 21 (24%) underwent palliative chemotherapy only and 41 (47%) had supportive care only. The extent of disease (P<0.01), hospital (P=0.02) and comorbidity (P=0.04) were correlated with worse survival. Patients treated surgically survived for longer than patients treated nonsurgically, when the data were corrected for age, comorbidity, extent of disease and hospital [hazard ratio (HR)=0.4 (95% CI=0.2-0.7)]. Perioperative morbidity was seen in 38% of the patients, and 30-day mortality was 0%.

CONCLUSION

In this retrospective cohort, resection was associated with longer survival independently of the extent of distant metastases, age and comorbidity.

Hyperthermic Isolated Limb Perfusion with TNF alpha and Cisplatin in the Treatment of Osteosarcoma of the Extremities: A Feasibility Study in Healthy Dogs

Purpose. The feasibility of hyperthermic isolated limb perfusion (HILP) with tumor necrosis factor-alpha (TNFalpha ) and cisplatin for the management of osteosarcoma was studied in the canine model.Methods. During seven perfusions in six healthy mongrel dogs (weight 32+/-2 kg) technical aspects of HILP under mild hyperthermia (39- 40) were studied. In five experiments HILP was performed with TNFalpha alone (0.5 mg/l extremity volume), and in two experiments TNFalpha was combined with cisplatin (25 mg/l extremity volume). During the perfusions physiological parameters were monitored and TNFalpha and total cisplatin concentrations were determined.Results. Perfusion conditions (pH, PCO(2) , PO(2), flow and pressure) remained within physiological ranges.Three dogs died within 24 h despite a sublethal systemic concentration of TNFalpha that leaked from the perfusion circuit. Three dogs were terminated; one dog after the second experiment in accordance with Dutch ethical rules; one dog showed an invagination of the small bowel resulting in an ileus; one dog because of necrosis of the perfused limb.Conclusions. This feasibility study in healthy dogs demonstrated that HILP with TNFalpha and cisplatin was associated with a high mortality rate and does not allow us to treat dogs with spontaneous osteosarcoma with TNFalpha and cisplatin HILP. Therefore, an alternative model should be used in the search for the ideal combination of perfusion agents for limb sparing treatment in human osteosarcoma.

Underuse of long-term routine hospital follow-up care in patients with a history of breast cancer?

BACKGROUND

After primary treatment for breast cancer, patients are recommended to use hospital follow-up care routinely. Long-term data on the utilization of this follow-up care are relatively rare.

METHODS

Information regarding the utilization of routine hospital follow-up care was retrieved from hospital documents of 662 patients treated for breast cancer. Utilization of hospital follow-up care was defined as the use of follow-up care according to the guidelines in that period of time. Determinants of hospital follow up care were evaluated with multivariate analysis by generalized estimating equations (GEE).

RESULTS

The median follow-up time was 9.0 (0.3-18.1) years. At fifth and tenth year after diagnosis, 16.1% and 33.5% of the patients had less follow-up visits than recommended in the national guideline, and 33.1% and 40.4% had less frequent mammography than recommended. Less frequent mammography was found in older patients (age > 70; OR: 2.10; 95%CI: 1.62-2.74), patients with comorbidity (OR: 1.26; 95%CI: 1.05-1.52) and patients using hormonal therapy (OR: 1.51; 95%CI: 1.01-2.25).

CONCLUSIONS

Most patients with a history of breast cancer use hospital follow-up care according to the guidelines. In older patients, patients with comorbidity and patients receiving hormonal therapy yearly mammography is performed much less than recommended.

Is self-disclosure in couples coping with cancer associated with improvement in depressive symptoms?

OBJECTIVE

This study examined associations between the degree of self-disclosure and changes in depressive symptoms in couples coping with colorectal cancer.

METHOD

Sixty-four newly diagnosed patients and their partners completed a measure of depressive symptoms (Center of Epidemiologic Studies Depression Scale) 3 and 9 months postdiagnosis. Furthermore, approximately 2 months after the first assessment, they engaged in a cancer-related conversation in which the patient was asked to introduce a concern. Each partner's verbalizations of emotions, thoughts, and wishes (i.e., self-disclosures) were coded by independent observers.

RESULTS

Patients who reported more depressive symptoms at baseline showed more self-disclosures. Mutual self-disclosure was not associated with lower levels of depressive symptoms in patients and partners as compared with one-sided self-disclosure or low disclosure in both patients and partners. It is important to note that decreases in depressive symptoms over time were least prominent in couples in which the partner disclosed a lot whereas the patient disclosed little.

CONCLUSION

These results suggest that mere disclosure of emotions and thoughts to one's intimate partner is not beneficial in reducing distress. Partners' self-disclosure toward patients who disclose few emotions and concerns even appears to be harmful both for patients and partners, given that it reduces the decrease of depressive symptoms over time. If there is a mismatch in the need for self-disclosure within couples, partners with a strong need to talk about their emotions and concerns may be recommended to confide in someone else in their social network or to consult a health care professional.

Spousal support and changes in distress over time in couples coping with cancer: the role of personal control

This longitudinal study has examined the associations between perceived supportive and unsupportive spousal behavior and changes in distress in couples coping with cancer. We tested whether people relatively low in their sense of personal control were more responsive to spousal supportive and unsupportive behavior than were people relatively high in personal control. Patients with colorectal cancer and their partners (n = 70) completed questionnaires at two assessment points: 3 (at baseline) and 9 months (at follow-up) after the diagnosis. We assessed perceived spousal supportive (SSL) and unsupportive (SSL-N) behavior, sense of personal control (Pearlin & Schooler's Mastery), and depressive symptoms (CES-D) in both patients and partners. Multilevel analysis (MLwiN) was used to examine changes in distress over time in a dyadic context. Patients and partners who perceived more spousal support reported less distress over time, but this only applied to those relatively low in personal control. Moreover, partners who perceived more unsupportive spousal behavior reported more distress, again only if they were relatively low in personal control. Patients and partners relatively high in personal control reported relatively low levels of distress, regardless of spousal behavior. In conclusion, people relatively low in personal control may be more adversely affected by unsupportive behavior and benefit more from supportive behavior than people relatively high in personal control.

Intraoperative assessment of microperfusion with visible light spectroscopy for prediction of anastomotic leakage in colorectal anastomoses

PURPOSE

Anastomotic leakage is associated with increased morbidity and mortality. However, there is no accurate tool to predict its occurrence. We evaluated the predictive value of visible light spectroscopy (VLS), a novel method to measure tissue oxygenation [saturated O(2) (StO(2) )], for anastomotic leakage of the colon and the rectum.

METHOD

Oxygen saturation in the bowel was measured in 77 colorectal resections. The anastomosis was between 2 and 30 cm (mean 13 cm) from the anal verge. The oxygen saturation was measured in the colon and rectum before and after anastomosis construction. This was compared with a reference measurement in the caecum. Data on postoperative complications were prospectively collected.

RESULTS

Anastomotic leakage occurred in 14 (18%) patients. When compared with a leaking anastomosis, normal anastomoses showed rising O(2) values during the operation (mean StO(2) 72.1 ± 9.0-76.7 ± 8.0 vs 73.9 ± 7.9-73.1 ± 7.4) (P ≤ 0.05). There were also higher StO(2) values in the caecum compared with those which ultimately leaked (73.6 ± 5.7 normal anastomoses, 69.6 ± 5.6 anastomotic leaks) (P ≤ 0.05). Both StO(2) values were predictive of anastomotic leakage.

CONCLUSION

Tissue oxygenation O(2) appears to be a potentially useful means of predicting anastomotic leakage after colorectal anastomosis.

A longitudinal comparison of arm morbidity in stage I-II breast cancer patients treated with sentinel lymph node biopsy, sentinel lymph node biopsy followed by completion lymph node dissection, or axillary lymph node dissection

Background

Long-term shoulder and arm function following sentinel lymph node biopsy (SLNB) may surpass that following complete axillary lymph node dissection (CLND) or axillary lymph node dissection (ALND). We objectively examined the morbidity and compared outcomes after SLNB, SLNB + CLND, and ALND in stage I/II breast cancer patients.

Materials and Methods

Breast cancer patients who had SLNB (n = 51), SLNB + CLND (n = 55), and ALND (n = 65) were physically examined 1 day before surgery (T0), and after 6 (T1), 26 (T2), 52 (T3), and 104 (T4) weeks. Differences in 8 parameters between the affected and unaffected arms were calculated. General linear models were computed to examine time, group, and interaction effects.

Results

All outcomes changed significantly, mostly nonlinearly, over time (T0–T4). Between T1 and T4, limitations decreased in abduction (all groups); anteflexion, abduction-exorotation, abduction strength (SLNB + CLND, ALND); flexion strength (SLNB + CLND); and arm volume (SLNB, SLNB + CLND). At T4, limitations in anteflexion (SLNB, ALND), abduction (SLNB + CLND, ALND), exorotation (ALND), abduction-exorotation (all groups), and volume (SLNB + CLND, ALND) increased significantly compared with T0. The SLNB group showed an advantage in anteflexion, abduction, abduction-exorotation, and volume. Groups changed significantly but differently over time in anteflexion, abduction, abduction/exorotation, abduction strength, flexion strength, and volume. Effect sizes varied from 0.19 to 0.00.

Conclusion

Initial declines in range of motion and strength were followed by recovery, although not always to presurgery levels. Range of motion and volume outcomes were better for SLNB than ALND, but not strength. SLNB surpassed SLNB + CLND in 2 of the range of motion variables. The clinical relevance of these results is negligible.

The value of surveillance mammography of the contralateral breast in patients with a history of breast cancer

PURPOSE

To determine the contribution of surveillance mammography to the early detection of metachronous contralateral breast cancer (MCBC) and to assess its impact on the survival of breast cancer patients with relation to compliance.

METHOD

Breast cancer patients (5589) were identified using files from the regional cancer registry of the Comprehensive Cancer Centre North Netherlands (CCCN Groningen, The Netherlands). The programme sensitivity and the impact on prognosis of follow-up mammography with relation to compliance were evaluated in 114 patients who developed MCBC during hospital follow-up.

RESULTS

The cumulative MCBC incidence rate at year 10 was 3.4% (95% CI: 2.8-4.0%). The programme sensitivity of surveillance mammography was 59.6% (95% CI: 50.6-68.7). In patients who complied with annual mammography, sensitivity was increased to 70.8% (95% CI: 61.7-80.0). Patients with MCBCs detected by routine mammography have better survival rates than patients with MCBCs detected by other means (HR: 3.18; 95% CI: 1.59-6.34). Though there was a trend towards improved survival in patients being compliant with regular clinical follow-up (HR: 1.69; 95% CI: 0.72-3.96), this was not the case for patients being compliant with annual mammography (HR:1.02; 95% CI:0.50-2.09).

CONCLUSION

Mammography is a valuable tool for the early detection of MCBC during hospital follow-up of breast cancer patients and is probably beneficial to survival. The utilisation of follow-up surveillance in breast cancer patients and its potential impact on survival deserve further investigation.

Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery

BACKGROUND

The dramatic clinical consequences of anastomotic leakage in gastrointestinal surgery can be reduced by a diverting stoma or drainage of the peri-anastomotic area. Currently, the surgeons' clinical judgement is of major importance in decision making, but reliable data of the diagnostic accuracy are lacking. In this prospective clinical study, the surgeons' predictive accuracy for anastomotic leakage was evaluated.

MATERIALS AND METHODS

In 191 patients undergoing colorectal resection with anastomosis, the risk for anastomotic leakage was determined by the surgeon on the basis of a visual analogue scale (VAS). This risk assessment was compared to the actual occurrence of anastomotic leakage post-operatively.

RESULTS

A total of 26 (13.6%) patients showed anastomotic leakage. The surgeons' median predicted leakage rate was 7.1% in anastomoses >15 cm from the anal verge and 9.5% <or=15 cm (sensitivity 38/62%, specificity 46/52%). Diagnostic accuracy was not influenced by the surgeons' training level (VAS score, surgeons 7.8% vs assistant surgeons 8.5%, p = 0.96, sensitivity 41% vs 44%, specificity 59% vs 48%, p = 0.20).

CONCLUSION

The surgeons' clinical risk assessment appeared to have a low predictive value for anastomotic leakage in gastrointestinal surgery. The low a priori risk of anastomotic leakage of 14% resulted in a low post-test odds (11%) of correct prediction of anastomotic leakage. This warrants the ongoing search for a better diagnostic test of anastomotic leakage to prevent morbidity and mortality.

Intraoperative assessment of microperfusion with visible light spectroscopy in esophageal and colorectal anastomoses

BACKGROUND

We evaluated the technical feasibility and stability of measurements using visible light spectroscopy to measure microvascular oxygen saturation (StO(2)) in gastrointestinal anastomoses.

METHODS

In consecutive esophageal (n = 14) or colorectal (n = 30) resections, during which an uncomplicated anastomosis was performed, measurements of serosal StO(2) were performed during the procedure.

RESULTS

In esophageal resections, median (+/- standard error) StO(2) was stable before and after anastomosis in the proximal esophagus (before: 66.0 +/- 4.6, after: 68.3 +/- 6.0%) and the gastric conduit (before: 70.6 +/- 8.6, after: 69.8 +/- 8.0%). Mean colorectal StO(2) before and after anastomosis increased in the proximal part (71.3 +/- 8.4 to 76.6 +/- 8.2%; p < 0.005). Mean StO(2) in the distal part remained stable (72.4 +/- 6.6 to 74.8 +/- 6.7%).

CONCLUSIONS

Visible light spectroscopy is a feasible and fast method for intraoperative assessment of microperfusion of the serosa in esophageal and colorectal anastomosis. Future clinical studies will define its role in the prediction of anastomotic leakage.

Effect of modified Davidson's fixative on examined number of lymph nodes and TNM-stage in colon carcinoma

AIMS

We evaluated the effect of modified Davidson's fixative (mDF) on the number of lymph nodes examined and staging in patients with colon carcinoma.

METHODS

The results of two different fixation methods used in the pathological preparation of the resection specimens were analyzed. A traditional formalin preparation with manual dissection of all nodes was performed in 117 colon specimens between January 2003 and July 2004. After July 2004, the resected specimens of 125 patients was fixated in mDF. Differences in the retrieval and number of nodes and size of suspected nodal metastases were measured. All lymph nodes were stained with conventional H&E methods.

RESULTS

The median number of examined nodes increased from 5 (0-17) to 13 (0-35) nodes after the introduction of mDF (p<0.001). The type of resection and the T-stage influenced the number of retrieved nodes significantly. The percentage of node-positive cases increased from 30% to 41% (p=0.077) with mDF, the median size of the retrieved lymph nodes decreased from 9 mm before to 6 mm after mDF (p<0.001) and more micrometastases were found (6% vs. 16%, p=0.03).

CONCLUSIONS

With mDF technique more lymph nodes were retrieved in the resected colon specimens. Smaller nodes and more micrometastases were found, leading to more node positive patients.

The sentinel node procedure in colon carcinoma: a multi-centre study in The Netherlands

BACKGROUND

Lymph node status is the most important predictive factor in colorectal carcinoma. Recurrences occur in 20% of the patients without lymph node metastases. The sentinel lymph node (SLN) biopsy is a tool to facilitate identification of micrometastatic disease and aberrant lymphatic drainage. We studied the feasibility of in vivo SLN detection in a multi-centre setting and evaluated nodal micro-staging using immunohistochemistry (IHC).

MATERIALS AND METHODS

Sub-serosal injection with Patent Blue dye was used in the SLN procedure in 69 patients operated for localized colon cancer in six Dutch hospitals. Each SLN was examined with routine haematoxylin-eosin staining. In tumour-negative SLNs, we performed CK7/8 or 18 IHC.

RESULTS

The procedure was successful in 67 of 69 patients (97%). The SLN was negative in 43 patients. In three cases, it was false negative, resulting in a negative predictive value of 93% and an accuracy of 96%. In 24 of 27 patients with lymph node metastases in a successful SLN procedure, the SLN was positive (sensitivity 89%). In 15 patients, the SLN was the only positive node (21%). In nine patients, we only found micrometastases or isolated tumour cells, resulting in 18% upstaging. Aberrant lymphatic drainage was seen in three patients (4%).

CONCLUSION

The SLN procedure in localized colon carcinoma is reliable in a multi-centre setting. It is helpful to identify patients who would be classified as stage II with conventional staging (18%) and who might benefit from adjuvant treatment.

RT-PCR and immunohistochemical evaluation of sentinel lymph nodes after in vivo mapping with Patent Blue V in colon cancer patients

OBJECTIVE

Lymph node status is the most important predictive factor in the treatment of colorectal cancer. As sentinel lymph node (SLN) biopsy might upstage stage II colon cancer, it could have therapeutic consequences in the future. We investigated the feasibility of in vivo SLN detection with Patent Blue V dye and evaluated nodal microstaging and ultrastaging using cytokeratin immunohistochemistry and reverse transcriptase-polymerase chain reaction (RT-PCR).

MATERIAL AND METHODS

In 30 consecutive patients operated on for colon cancer, subserosal injection with Patent Blue dye was used for SLN detection in four different hospitals under the supervision of one regional coordinator. In searching for occult micrometastases, each SLN was examined at three levels. In tumor-negative SLNs at routine hematoxylin-eosin (H&E) examination (pN0) we performed CK8/CK18 immunohistochemistry (IHC) and RT-PCR for carcinoembryonic antigen (CEA).

RESULTS

The procedure was successful in 29 out of 30 patients (97%). The SLN was negative in 18 patients detected by H&E and IHC. In 16 patients the non-SLN was also negative, leading to a negative predictive value of 89% and an accuracy of 93%. Upstaging occurred in 10 patients (33%) - 7 by IHC and 3 by RT-PCR. Aberrant lymphatic drainage was seen in 3 patients (10%).

CONCLUSIONS

The SLN concept in colon carcinoma using Patent Blue V is feasible and accurate. It leads to upstaging of nodal status in 33% of patients when IHC and PCR techniques are combined. Therefore, the clinical value of SLN should be the subject of further studies.

Small size ductal carcinoma in situ of the breast: predictors of positive margins after local excision

One of the most important predictors of local recurrence after local excision of ductal carcinoma in situ (DCIS) is margin status. The aim was to study the association between margin status and clinical, radiological, and pathological characteristics and to determine predictors of positive margins after local excision of small size (< or = 4 cm) DCIS. Data were tested for differences regarding margin status, and logistic regression was used to determine predictors of margin status. The population consisted of 105 cases. Overall, 51 cases (49%) had free margins and 54 cases (51%) had positive margins. Positive margins were more often associated with a mean mammographic tumor size of 2.1 cm (P = 0.044) and absence of fine granular calcifications (P = 0.004). Also, high-grade (P = 0.013) and a mean pathological size of 3.2 cm (P < 0.001) were associated with positive margins. The only independent predictor of margin status was pathological grade (P = 0.010).

Compliance with guidelines is related to better local recurrence-free survival in ductal carcinoma in situ

The aim was to study the effect of compliance with guidelines on local recurrence (LR)-free survival in patients treated for ductal carcinoma in situ (DCIS). From January 1992 to December 2003, 251 consecutive patients had been treated for DCIS in two hospitals in the North Netherlands. Every case in this two-hospital sample was reviewed in retrospect for its clinical and pathological parameters. It was determined whether treatment had been carried out according to clinical guidelines, and outcomes in follow-up were assessed. In addition, all patients treated for DCIS in this region (n=1389) were studied regarding clinical parameters, in order to determine whether the two-hospital sample was representative of the entire region. In the two-hospital sample, 31.4% (n=79) of the patients had not been treated according to the guidelines. Positive margins were associated with LR (hazard ratio (HR)=4.790, 95% confidence interval (CI) 1.696–13.531). Breast-conserving surgery and deviation from the guidelines were independent predictors of LR (HR=7.842, 95% CI 2.126–28.926; HR=2.778, 95% CI 0.982–6.781, respectively). Although the guidelines changed over time, time was not a significant factor in predicting LRs (HR=1.254, 95% CI 0.272–5.776 for time period 1992–1995 and HR=1.976, 95% CI 0.526–7.421 for time period 1996–1999). Clinical guidelines for the treatment of patients with DCIS have been developed and updated from existing literature and best evidence. Compliance with the guidelines was an independent predictor of disease-free survival. These findings support the application of guidelines in the treatment of DCIS.

Ductal carcinoma in situ presenting as microcalcifications: the effect of stereotactic large-core needle biopsy on surgical therapy

The aim of this investigation was to study the efficacy of surgical therapy in patients with non-palpable ductal carcinoma in situ (DCIS) presenting as microcalcifications diagnosed by means of stereotactic large-core needle biopsy (SCNB). This is a retrospective study with a historical control group within a 12-year period. Two groups of consecutive patients diagnosed with DCIS (1991-2002) by means of needle-localised open breast biopsy (NLBB, n=49) and SCNB (n=51) were studied. Both groups were comparable for clinical, radiological and pathological characteristics. The therapeutic interval (time from presentation to definitive of therapy) was 62-days in the SCNB group versus 32-days in the NLBB group (p<0.001). In the SCNB group fewer surgical procedures were required for completion of surgical therapy (p=0.006) and after local excision the surgical margins were more often tumour free (p=0.002). It is postulated that the need for fewer surgical procedures and the greater frequency of tumour-free margins after local excision may be attributable to SCNB.

Correlation between imaging and pathology in ductal carcinoma in situ of the breast

BACKGROUND

It is helpful in planning treatment for patients with ductal carcinoma in situ (DCIS) if the size and grade could be reliably predicted from the mammography. The aims of this study were to determine if the type of calcification can be best used to predict histopathological grade from the mammograms, to examine the association of mammographic appearance of DCIS with grade and to assess the correlation between mammographic size and pathological size.

METHODS

Mammographic films and pathological slides of 115 patients treated for DCIS between 1986 and 2000 were reviewed and reclassified by a single radiologist and a single pathologist respectively. Prediction models for the European Pathologist Working Group (EPWG) and Van Nuys classifications were generated by ordinal regression. The association between mammographic appearance and grade was tested with the chi2-test. Relation of mammographic size with pathological size was established using linear regression. The relation was expressed by the correlation coefficient (r).

RESULTS

The EPWG classification was correctly predicted in 68%, and the Van Nuys classification in 70% if DCIS was presented as microcalcifications. High grade was associated with presence of linear calcifications (p < 0.001). Association between mammograhic- and pathological size was better for DCIS presented as microcalcifications (r = 0.89, p < 0.001) than for DCIS presented as a density (r = 0.77, p < 0.001).

CONCLUSIONS

Prediction of histopathological grade of DCIS presenting as microcalcifications is comparable using the Van Nuys and EPWG classification. There is no strict association of mammographic appearance with histopathological grade. There is a better linear relation between mammographic- and pathological size of DCIS presented as microcalcifications than as a density, although both relations are statistically significant.

Significance of aneuploidy in melanoma of the extremity

Tumor nuclear DNA content was determined by flow cytometry in routinely prepared paraffin blocks from 25 primary malignant melanomas of the extremities. Twelve of the tumors were aneuploid, and 13 were euploid. In this series the presence of aneuploidy appeared to have no prognostic value.

Groin dissection in the treatment of lower-extremity melanoma. Short-term and long-term morbidity

Groin dissection was performed in 151 consecutive patients from 1970 to 1984. Groin dissections were therapeutic in 138 cases (91%) and elective in 13 (9%). One hundred forty-three patients (95%) underwent an ilioinguinal node dissection, while eight (5%) were treated with an inguinal node dissection. In 88 patients, the groin dissection was combined with isolated regional perfusion. Primary wound closure was performed in 140 patients (93%). There was no 30-day postoperative mortality. Complications included temporary seroma (26 [17%] of 151 patients), wound infection (14 patients [9%]), wound necrosis (five patients [3%]), and edema (30 patients [20%]). Residual inguinal node metastases after groin dissection did not occur. Morbidity of groin dissection did not increase when the groin dissection was combined with isolated regional perfusion. Quantification of the degree of edema in 66 patients revealed functional limitation due to edema in three patients (4.5%). This technique of groin dissection gives good results with minimal functional morbidity of the affected leg.

Isolated regional perfusion in the treatment of subungual melanoma

Subungual melanoma is rare and represents only 1% to 3% of all diagnosed melanomas in Western countries. The tumor is frequently mistaken for a benign lesion and the delay in diagnosis and final treatment may be responsible for the high local recurrence rate and the low disease-free survival rate. From 1965 to 1982 the combined-modality therapy of amputation and adjuvant isolated regional perfusion with melphalan with or without dactinomycin was used in the treatment of 22 patients with subungual melanoma. Disease was staged according to the M. D. Anderson classification, as follows: stage I (primary melanoma), 11 patients; stage IIIA (in-transit metastases and/or satellitosis), three patients; stage IIIB (regional lymph nodes), seven patients; and stage IIIAB (in-transit metastases and/or satellitosis and regional lymph nodes), one patient. There were no cardiovascular complications and no treatment mortality. During a follow-up of at least 4.5 years, 12 patients (55%) developed distant metastases, including four patients with stage I disease (36%) and eight patients with stage III disease (73%). There were no locoregional recurrences. The median survival was three years (range, 0.5 to 12.5 years) and the overall five-year survival was 40%, with 56% of patients having stage I disease and 27% having stage III disease. The prognosis of subungual melanoma is determined by the stage of the disease. Isolated regional perfusion may prolong disease-free survival in patients with subungual melanoma compared with previously published data.

Hyperthermic isolated regional perfusion in the treatment of extremity melanoma in children and adolescents

From 1973 to 1982 six children and eight adolescents with extremity melanomas were treated by local excision and adjuvant hyperthermic isolated regional perfusion with Melphalan (L-phenylalanine mustard, manufactured by Burroughs Wellcome Company, Research Triangle Park, NC). The median Breslow thickness of the melanomas was 2.7 mm (range, 1 to 15 mm). According to the M.D. Anderson classification, nine patients were in Stage IA and five were in Stage IIIB. The median follow-up period was approximately 10 years. Distant metastases developed in three patients (21%) (one patient was in Stage IA [11%] and two patients were in Stage IIIB [40%]). In two cases the development of distant metastases was preceded by local recurrence (14%). The 5-year survival rate was 93%. The 10-year survival rate was 81%. The high survival rate, even for patients with unfavorably thick melanomas, seems to be attributable to isolated regional perfusion.