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Zoutendijk R, van Santvoort HC, Raicu MG, Bollen TL, Verdonk RC. [A young woman with auto-immune pancreatitis]. Ned Tijdschr Geneeskd 2023; 167. [PMID: 36928874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Acute pancreatitis is a frequently diagnosed disease. The majority is caused by cholelithiasis or alcohol. There are also two forms of auto-immune pancreatitis (AIP). Type 2 AIP presents on a younger age compared with IgG4 related pancreatitis. Clinical presentation as an acute pancreatitis, a mass in the pancreas or with jaundice. There is an association with inflammatory bowel disease. CASE DESCRIPTION A young patient with Crohn's disease developed abdominal pain compatible with acute pancreatitis. After exclusion of other etiologies a diagnosis of type 2 auto-immune pancreatitis was made with MRI/MRCP and typical histology. She was clinically successfully treated with steroids and follow up scan clearly showed improvement. Steroids were slowly withdrawn. CONCLUSION Also young patients and patients with a normal IgG4 can have an AIP. Diagnosis is based on clinical, radiological and histological criteria. Type 2 AIP is treated with steroids without the need for maintenance therapy.
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Affiliation(s)
- Roeland Zoutendijk
- St. Antonius Ziekenhuis, Nieuwegein, Utrecht en Woerden. Afd. Maag-, Darm- en Leverziekten
- Contact: Roeland Zoutendijk
| | | | - Mihaela G Raicu
- St. Antonius Ziekenhuis, Nieuwegein, Utrecht en Woerden. Afd. Pathologie
| | - Thomas L Bollen
- St. Antonius Ziekenhuis, Nieuwegein, Utrecht en Woerden. Afd. Radiologie
| | - Robert C Verdonk
- St. Antonius Ziekenhuis, Nieuwegein, Utrecht en Woerden. Afd. Maag-, Darm- en Leverziekten
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Daamen LA, Groot VP, Besselink MG, Bosscha K, Busch OR, Cirkel GA, van Dam RM, Festen S, Groot Koerkamp B, Haj Mohammad N, van der Harst E, de Hingh IHJT, Intven MPW, Kazemier G, Los M, Meijer GJ, de Meijer VE, Nieuwenhuijs VB, Pranger BK, Raicu MG, Schreinemakers JMJ, Stommel MWJ, Verdonk RC, Verkooijen HM, Molenaar IQ, van Santvoort HC. Detection, Treatment, and Survival of Pancreatic Cancer Recurrence in the Netherlands: A Nationwide Analysis. Ann Surg 2022; 275:769-775. [PMID: 32773631 DOI: 10.1097/sla.0000000000004093] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether detection of recurrent pancreatic ductal adenocarcinoma (PDAC) in an early, asymptomatic stage increases the number of patients receiving additional treatment, subsequently improving survival. SUMMARY OF BACKGROUND DATA International guidelines disagree on the value of standardized postoperative surveillance for early detection and treatment of PDAC recurrence. METHODS A nationwide, observational cohort study was performed including all patients who underwent PDAC resection (2014-2016). Prospective baseline and perioperative data were retrieved from the Dutch Pancreatic Cancer Audit. Data on follow-up, treatment, and survival were collected retrospectively. Overall survival (OS) was evaluated using multivariable Cox regression analysis, before and after propensity-score matching, stratified for patients with symptomatic and asymptomatic recurrence. RESULTS Eight hundred thirty-six patients with a median follow-up of 37 months (interquartile range 30-48) were analyzed. Of those, 670 patients (80%) developed PDAC recurrence after a median follow-up of 10 months (interquartile range 5-17). Additional treatment was performed in 159/511 patients (31%) with symptomatic recurrence versus 77/159 (48%) asymptomatic patients (P < 0.001). After propensity-score matching on lymph node ratio, adjuvant therapy, disease-free survival, and recurrence site, additional treatment was independently associated with improved OS for both symptomatic patients [hazard ratio 0.53 (95% confidence interval 0.42-0.67); P < 0.001] and asymptomatic patients [hazard ratio 0.45 (95% confidence interval 0.29-0.70); P < 0.001]. CONCLUSIONS Additional treatment of PDAC recurrence was independently associated with improved OS, with asymptomatic patients having a higher probability to receive recurrence treatment. Therefore, standardized postoperative surveillance aiming to detect PDAC recurrence before the onset of symptoms has the potential to improve survival. This provides a rationale for prospective studies on standardized surveillance after PDAC resection.
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Affiliation(s)
- Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Geert A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
- Department of Medical Oncology, Meander Medical Center, Amersfoort, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
| | | | | | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | | | | | - Martijn P W Intven
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Bobby K Pranger
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mihaela G Raicu
- Department of Pathology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Centre Utrecht; Utrecht University, Utrecht, the Netherlands
| | - Izaak Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
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Dang H, van Pelt GW, Haasnoot KJC, Backes Y, Elias SG, Seerden TCJ, Schwartz MP, Spanier BWM, de Vos tot Nederveen Cappel WH, van Bergeijk JD, Kessels K, Geesing JMJ, Groen JN, ter Borg F, Wolfhagen FHJ, Seldenrijk CA, Raicu MG, Milne AN, van Lent AUG, Brosens LAA, Johan A. Offerhaus G, Siersema PD, Tollenaar RAEM, Hardwick JCH, Hawinkels LJAC, Moons LMG, Lacle MM, Mesker WE, Boonstra JJ. Tumour-stroma ratio has poor prognostic value in non-pedunculated T1 colorectal cancer: A multi-centre case-cohort study. United European Gastroenterol J 2020; 9:2050640620975324. [PMID: 33210982 PMCID: PMC8259249 DOI: 10.1177/2050640620975324] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/28/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Current risk stratification models for early invasive (T1) colorectal cancer are not able to discriminate accurately between prognostic favourable and unfavourable tumours, resulting in over-treatment of a large (>80%) proportion of T1 colorectal cancer patients. The tumour-stroma ratio (TSR), which is a measure for the relative amount of desmoplastic tumour stroma, is reported to be a strong independent prognostic factor in advanced-stage colorectal cancer, with a high stromal content being associated with worse prognosis and survival. We aimed to investigate whether the TSR predicts clinical outcome in patients with non-pedunculated T1 colorectal cancer. METHODS Hematoxylin and eosin (H&E)-stained tumour tissue slides from a retrospective multi-centre case cohort of patients with non-pedunculated surgically treated T1 colorectal cancer were assessed for TSR by two independent observers who were blinded for clinical outcomes. The primary end point was adverse outcome, which was defined as the presence of lymph node metastasis in the resection specimen or colorectal cancer recurrence during follow-up. RESULTS All 261 patients in the case cohort had H&E slides available for TSR scoring. Of these, 183 were scored as stroma-low, and 78 were scored as stroma-high. There was moderate inter-observer agreement (κ = 0.42). In total, 41 patients had lymph node metastasis, 17 patients had recurrent cancer and five had both. Stroma-high tumours were not associated with an increased risk for an adverse outcome (adjusted hazard ratio = 0.66, 95% confidence interval 0.37-1.18; p = 0.163). CONCLUSIONS Our study emphasises that existing prognosticators may not be simply extrapolated to T1 colorectal cancers, even though their prognostic value has been widely validated in more advanced-stage tumours.
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Affiliation(s)
- Hao Dang
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
| | - Gabi W. van Pelt
- Department of SurgeryLeiden University Medical CentreLeidenThe Netherlands
| | - Krijn J. C. Haasnoot
- Department of Gastroenterology and HepatologyUniversity Medical Centre UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Yara Backes
- Department of Gastroenterology and HepatologyUniversity Medical Centre UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Sjoerd G. Elias
- Julius Centre for Health Sciences and Primary CareUniversity Medical Centre UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Tom C. J. Seerden
- Department of Gastroenterology and HepatologyAmphia HospitalBredaThe Netherlands
| | - Matthijs P. Schwartz
- Department of Gastroenterology and HepatologyMeander Medical CentreAmersfoortThe Netherlands
| | | | | | | | - Koen Kessels
- Department of Gastroenterology and HepatologySint Antonius HospitalNieuwegeinThe Netherlands
| | - Joost M. J. Geesing
- Department of Gastroenterology and HepatologyDiakonessenhuisUtrechtThe Netherlands
| | - John N. Groen
- Department of Gastroenterology and HepatologySint JansdalHarderwijkThe Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and HepatologyDeventer HospitalDeventerThe Netherlands
| | - Frank H. J. Wolfhagen
- Department of Gastroenterology and HepatologyAlbert Schweitzer HospitalDordrechtThe Netherlands
| | | | | | - Anya N. Milne
- Pathology DNASint Antonius HospitalNieuwegeinThe Netherlands
| | - Anja U. G. van Lent
- Department of Gastroenterology and HepatologyOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands
| | - Lodewijk A. A. Brosens
- Department of PathologyUniversity Medical Centre UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - G. Johan A. Offerhaus
- Department of PathologyUniversity Medical Centre UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Peter D. Siersema
- Department of Gastroenterology and HepatologyRadboud University Medical CentreNijmegenThe Netherlands
| | | | - James C. H. Hardwick
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
| | - Lukas J. A. C. Hawinkels
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
| | - Leon M. G. Moons
- Department of Gastroenterology and HepatologyUniversity Medical Centre UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Miangela M. Lacle
- Department of PathologyUniversity Medical Centre UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Wilma E. Mesker
- Department of SurgeryLeiden University Medical CentreLeidenThe Netherlands
| | - Jurjen J. Boonstra
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
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Backes Y, Elias SG, Groen JN, Schwartz MP, Wolfhagen FHJ, Geesing JMJ, Ter Borg F, van Bergeijk J, Spanier BWM, de Vos Tot Nederveen Cappel WH, Kessels K, Seldenrijk CA, Raicu MG, Drillenburg P, Milne AN, Kerkhof M, Seerden TCJ, Siersema PD, Vleggaar FP, Offerhaus GJA, Lacle MM, Moons LMG. Histologic Factors Associated With Need for Surgery in Patients With Pedunculated T1 Colorectal Carcinomas. Gastroenterology 2018; 154:1647-1659. [PMID: 29366842 DOI: 10.1053/j.gastro.2018.01.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 01/06/2018] [Accepted: 01/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Most patients with pedunculated T1 colorectal tumors referred for surgery are not found to have lymph node metastases, and were therefore unnecessarily placed at risk for surgery-associated complications. We aimed to identify histologic factors associated with need for surgery in patients with pedunculated T1 colorectal tumors. METHODS We performed a cohort-nested matched case-control study of 708 patients diagnosed with pedunculated T1 colorectal tumors at 13 hospitals in The Netherlands, from January 1, 2000 through December 31, 2014, followed for a median of 44 months (interquartile range, 20-80 months). We identified 37 patients (5.2%) who required surgery (due to lymph node, intramural, or distant metastases). These patients were matched with patients with pedunculated T1 colorectal tumors without a need for surgery (no metastases, controls, n = 111). Blinded pathologists analyzed specimens from each tumor, stained with H&E. We evaluated associations between histologic factors and patient need for surgery using univariable conditional logistic regression analysis. We used multivariable least absolute shrinkage and selection operator (LASSO; an online version of the LASSO model is available at: http://t1crc.com/calculator/) regression to develop models for identification of patients with tumors requiring surgery, and tested the accuracy of our model by projecting our case-control data toward the entire cohort (708 patients). We compared our model with previously developed strategies to identify high-risk tumors: conventional model 1 (based on poor differentiation, lymphovascular invasion, or Haggitt level 4) and conventional model 2 (based on poor differentiation, lymphovascular invasion, Haggitt level 4, or tumor budding). RESULTS We identified 5 histologic factors that differentiated cases from controls: lymphovascular invasion, Haggitt level 4 invasion, muscularis mucosae type B (incompletely or completely disrupted), poorly differentiated clusters and tumor budding, which identified patients who required surgery with an area under the curve (AUC) value of 0.83 (95% confidence interval, 0.76-0.90). When we used a clinically plausible predicted probability threshold of ≥4.0%, 67.5% (478 of 708) of patients were predicted to not need surgery. This threshold identified patients who required surgery with 83.8% sensitivity (95% confidence interval, 68.0%-93.8%) and 70.3% specificity (95% confidence interval, 60.9%-78.6%). Conventional models 1 and 2 identified patients who required surgery with lower AUC values (AUC, 0.67; 95% CI, 0.60-0.74; P = .002 and AUC, 0.64; 95% CI, 0.58-0.70; P < .001, respectively) than our LASSO model. When we applied our LASSO model with a predicted probability threshold of ≥4.0%, the percentage of missed cases (tumors mistakenly assigned as low risk) was comparable (6 of 478 [1.3%]) to that of conventional model 1 (4 of 307 [1.3%]) and conventional model 2 (3 of 244 [1.2%]). However, the percentage of patients referred for surgery based on our LASSO model was much lower (32.5%, n = 230) than that for conventional model 1 (56.6%, n = 401) or conventional model 2 (65.5%, n = 464). CONCLUSIONS In a cohort-nested matched case-control study of 708 patients with pedunculated T1 colorectal carcinomas, we developed a model based on histologic features of tumors that identifies patients who require surgery (due to high risk of metastasis) with greater accuracy than previous models. Our model might be used to identify patients most likely to benefit from adjuvant surgery.
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Affiliation(s)
- Yara Backes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Sjoerd G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - John N Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal, Harderwijk, the Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Joost M J Geesing
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, the Netherlands
| | - Frank Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, the Netherlands
| | - Jeroen van Bergeijk
- Department of Gastroenterology and Hepatology, Gelderse Vallei, Ede, the Netherlands
| | - Bernhard W M Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | - Koen Kessels
- Department of Gastroenterology and Hepatology, Flevo Hospital, Almere, the Netherlands
| | | | - Mihaela G Raicu
- Pathology DNA, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Anya N Milne
- Department of Pathology, Diakonessenhuis, Utrecht, the Netherlands
| | - Marjon Kerkhof
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, the Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands.
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