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De Rooij L, Kimman ML, Spiekerman van Weezelenburg MA, van Kuijk SMJ, Granzier RWY, Hintzen KFH, Heymans C, Theunissen LLB, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. Economic evaluation of flap fixation techniques after mastectomy: Results of a double-blind randomized controlled trial (SAM-trial). Eur J Surg Oncol 2023; 49:107003. [PMID: 37542999 DOI: 10.1016/j.ejso.2023.107003] [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] [Received: 06/07/2023] [Revised: 07/14/2023] [Accepted: 07/31/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND An economic evaluation was performed alongside an RCT investigating flap fixation in reducing seroma formation after mastectomy. The evaluation focused on the first year following mastectomy and assessed cost-effectiveness from a health care and societal perspective. METHODS The economic evaluation was conducted between 2014 and 2018 in four Dutch breast clinics. Patients with an indication for mastectomy or modified radical mastectomy were randomly assigned to: conventional closure (CON), flap fixation with sutures (FFS) or flap fixation with tissue glue (FFG). Health care costs, patient and family costs and costs due to productivity losses were assessed. Outcomes were expressed in incremental cost-effectiveness ratios (ICERs): the incremental cost per quality-adjusted life year (QALY). Bootstrapping techniques, sensitivity and secondary analyses were employed to address uncertainty. RESULTS The FFS-group yielded most QALYs (0.810; 95%-CI 0.755-0.856), but also incurred the highest mean costs at twelve months (€10.416; 95%-CI 8.231-12.930). CON was the next best alternative with 0.794 QALYs (95%-CI 0.733-0.841) and mean annual costs of €10.051 (95%-CI 8.255-12.044). FFG incurred fewer QALYs and higher costs, when compared to the CON group. The ICER of FFS compared to CON was €22.813/QALY. Applying a willingness to pay threshold in the Netherlands of €20.000/QALY, the probability that FFS was cost-effective was 42%, compared to 37% and 21% for CON and FFG, respectively. CONCLUSION The cost-effectiveness of FFS following mastectomy, versus CON and FFG, is uncertain from a societal perspective. Yet, from a health care and hospital perspective FFS is likely to be the most cost-effective intervention.
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Affiliation(s)
- L De Rooij
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - M L Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center, Maastricht, the Netherlands
| | - R W Y Granzier
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - K F H Hintzen
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - C Heymans
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - L L B Theunissen
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - E R M van Haaren
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - A Janssen
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - Y L J Vissers
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - G L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands; GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - J van Bastelaar
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
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Granzier RWY, Ibrahim A, Primakov S, Keek SA, Halilaj I, Zwanenburg A, Engelen SME, Lobbes MBI, Lambin P, Woodruff HC, Smidt ML. Test-Retest Data for the Assessment of Breast MRI Radiomic Feature Repeatability. J Magn Reson Imaging 2021; 56:592-604. [PMID: 34936160 PMCID: PMC9544420 DOI: 10.1002/jmri.28027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 08/27/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 12/14/2022] Open
Abstract
Background Radiomic features extracted from breast MRI have potential for diagnostic, prognostic, and predictive purposes. However, before they can be used as biomarkers in clinical decision support systems, features need to be repeatable and reproducible. Objective Identify repeatable radiomics features within breast tissue on prospectively collected MRI exams through multiple test–retest measurements. Study Type Prospective. Population 11 healthy female volunteers. Field Strength/Sequence 1.5 T; MRI exams, comprising T2‐weighted turbo spin‐echo (T2W) sequence, native T1‐weighted turbo gradient‐echo (T1W) sequence, diffusion‐weighted imaging (DWI) sequence using b‐values 0/150/800, and corresponding derived ADC maps. Assessment 18 MRI exams (three test–retest settings, repeated on 2 days) per healthy volunteer were examined on an identical scanner using a fixed clinical breast protocol. For each scan, 91 features were extracted from the 3D manually segmented right breast using Pyradiomics, before and after image preprocessing. Image preprocessing consisted of 1) bias field correction (BFC); 2) z‐score normalization with and without BFC; 3) grayscale discretization using 32 and 64 bins with and without BFC; and 4) z‐score normalization + grayscale discretization using 32 and 64 bins with and without BFC. Statistical Tests Features' repeatability was assessed using concordance correlation coefficient(CCC) for each pair, i.e. each MRI was compared to each of the remaining 17 MRI with a cut‐off value of CCC > 0.90. Results Images without preprocessing produced the highest number of repeatable features for both T1W sequence and ADC maps with 15 of 91 (16.5%) and 8 of 91 (8.8%) repeatable features, respectively. Preprocessed images produced between 4 of 91 (4.4%) and 14 of 91 (15.4%), and 6 of 91 (6.6%) and 7 of 91 (7.7%) repeatable features, respectively for T1W and ADC maps. Z‐score normalization produced highest number of repeatable features, 26 of 91 (28.6%) in T2W sequences, in these images, no preprocessing produced 11 of 91 (12.1%) repeatable features. Data Conclusion Radiomic features extracted from T1W, T2W sequences and ADC maps from breast MRI exams showed a varying number of repeatable features, depending on the sequence. Effects of different preprocessing procedures on repeatability of features were different for each sequence. Level of Evidence 2 Technical Efficacy Stage 1
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Affiliation(s)
- R W Y Granzier
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - A Ibrahim
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,The D-Lab, Department of Precision Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Division of Nuclear Medicine and Oncological Imaging, Department of Medical Physics, Hospital Center Universitaire De Liege, Liege, Belgium.,Department of Nuclear Medicine and Comprehensive diagnostic center Aachen (CDCA), University Hospital RWTH Aachen University, Aachen, Germany
| | - S Primakov
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,The D-Lab, Department of Precision Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - S A Keek
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,The D-Lab, Department of Precision Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - I Halilaj
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,The D-Lab, Department of Precision Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Health Innovation Ventures, Maastricht, The Netherlands
| | - A Zwanenburg
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden, Rossendorf, Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - S M E Engelen
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M B I Lobbes
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - P Lambin
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,The D-Lab, Department of Precision Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - H C Woodruff
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,The D-Lab, Department of Precision Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M L Smidt
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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de Rooij L, van Kuijk SMJ, Granzier RWY, Hintzen KFH, Heymans C, Theunissen LLB, von Meyenfeldt EM, van Essen JA, van Haaren ERM, Janssen A, Vissers YLJ, Beets GL, van Bastelaar J. Reducing Seroma Formation and Its Sequelae After Mastectomy by Closure of the Dead Space: A Multi-center, Double-Blind Randomized Controlled Trial (SAM-Trial). Ann Surg Oncol 2020; 28:2599-2608. [PMID: 33078318 DOI: 10.1245/s10434-020-09225-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Seroma is a common complication after mastectomy, with an incidence of 3% to 85%. Seroma is associated with pain, delayed wound healing, and additional outpatient clinic visits, leading potentially to repeated seroma aspiration or even surgical interventions. This study aimed to assess the effect of flap fixation using sutures or tissue glue in preventing seroma formation and its sequelae. METHODS Between June 2014 and July 2018, 339 patients with an indication for mastectomy or modified radical mastectomy were enrolled in this randomized controlled trial in the Netherlands. Patients were randomly allocated to one of the three following arms: conventional wound closure (CON, n = 115), flap fixation using sutures (FFS, n = 111) or flap fixation using tissue glue (FFG, n = 113). The primary outcome was the need for seroma aspiration. The secondary outcomes were additional outpatient department visits, surgical-site infection, shoulder function and mobility, cosmesis, skin-dimpling, and postoperative pain scores. RESULTS Flap fixation after mastectomy leads to fewer seroma aspirations than conventional wound closure (CON 17.5% vs FFS 7.3% vs FFG 10.8%; p = 0.057), with a significant difference between flap fixation with sutures and conventional wound closure (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.16-0.89; p = 0.025). Flap fixation has no significant negative effect on surgical-site infections, shoulder function and mobility, cosmesis, skin-dimpling, or postoperative pain. CONCLUSION Flap fixation using sutures leads to a significant reduction in aspirations of post-mastectomy seromas. The authors strongly advise surgeons to use sutures for flap fixation in patients undergoing mastectomy. (ClinicalTrials.gov no. NCT03305757). PREREGISTRATION The trial was registered after enrollment of the first participant. However, no specific explanation exists for this except that through the years more importance has been given to central trial registration. Our research team can ensure that after enrollment of the first participant, no changes were made to the trial, analysis plan, and/or study design.
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Affiliation(s)
- L de Rooij
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands.
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R W Y Granzier
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - K F H Hintzen
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - C Heymans
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - L L B Theunissen
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - E M von Meyenfeldt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - J A van Essen
- Department of Surgery, St. Jans Gasthuis Hospital, Weert, The Netherlands
| | - E R M van Haaren
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - A Janssen
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - Y L J Vissers
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | - G L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - J van Bastelaar
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
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4
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Samiei S, van Kaathoven BN, Boersma L, Granzier RWY, Siesling S, Engelen SME, de Munck L, van Kuijk SMJ, van der Hulst RRJW, Lobbes MBI, Smidt ML, van Nijnatten TJA. Risk of Positive Sentinel Lymph Node After Neoadjuvant Systemic Therapy in Clinically Node-Negative Breast Cancer: Implications for Postmastectomy Radiation Therapy and Immediate Breast Reconstruction. Ann Surg Oncol 2019; 26:3902-3909. [PMID: 31359276 PMCID: PMC6787110 DOI: 10.1245/s10434-019-07643-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Indexed: 12/27/2022]
Abstract
Background Residual axillary lymph node involvement after neoadjuvant systemic therapy (NST) is the determining factor for postmastectomy radiation therapy (PMRT). Preoperative identification of patients needing PMRT is essential to enable shared decision-making when choosing the optimal timing of breast reconstruction. We determined the risk of positive sentinel lymph node (SLN) after NST in clinically node-negative (cN0) breast cancer. Methods All cT1-3N0 patients treated with NST followed by mastectomy and SLNB between 2010 and 2016 were identified from the Netherlands Cancer Registry. Rate of positive SLN for different breast cancer subtypes was determined. Logistic regression analysis was performed to determine correlated clinicopathological variables with positive SLN. Results In total 788 patients were included, of whom 25.0% (197/788) had positive SLN. cT1-3N0 ER+HER2+, cT1-3N0 ER−HER2+ , and cT1-2N0 triple-negative patients had the lowest rate of positive SLN: 7.2–11.5%, 0–6.3%, and 2.9–6.2%, respectively. cT1-3N0 ER+HER2− and cT3N0 triple-negative patients had the highest rate of positive SLN: 23.8–41.7% and 30.4%, respectively. Multivariable regression analysis showed that cT2 (odds ratio [OR] 1.93; 95% confidence interval [CI] 1.01–3.96), cT3 (OR 2.56; 95% CI 1.30–5.38), grade 3 (OR 0.44; 95% CI 0.21–0.91), and ER+HER2− subtype (OR 3.94; 95% CI 1.77–8.74) were correlated with positive SLN. Conclusions In cT1-3N0 ER+HER2+, cT1-3N0 ER−HER2+, and cT1-2N0 triple-negative patients treated with NST, immediate reconstruction can be considered an acceptable option due to low risk of positive SLN. In cT1-3N0 ER+HER2− and cT3N0 triple-negative patients treated with NST, risks and benefits of immediate reconstruction should be discussed with patients due to the relatively high risk of positive SLN.
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Affiliation(s)
- S Samiei
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands. .,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands. .,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - B N van Kaathoven
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - L Boersma
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Radiation Oncology, Maastricht University Medical Center+ (MAASTRO Clinic), Maastricht, The Netherlands
| | - R W Y Granzier
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - S Siesling
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Center, University of Twente, Enschede, The Netherlands
| | - S M E Engelen
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - L de Munck
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - R R J W van der Hulst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
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