Analysis of metastases rates during follow-up after endoscopic resection of early "high-risk" esophageal adenocarcinoma

BACKGROUND AND AIMS

After endoscopic resection (ER) of early esophageal adenocarcinoma (EAC), the optimal management of patients with high-risk histologic features for lymph node metastases (ie, submucosal invasion, poor differentiation grade, or lymphovascular invasion) remains unclear. We aimed to evaluate outcomes of endoscopic follow-up after ER for high-risk EAC.

METHODS

For this retrospective cohort study, data were collected from all Dutch patients managed with endoscopic follow-up (endoscopy, EUS) after ER for high-risk EAC between 2008 and 2019. We distinguished 3 groups: intramucosal cancers with high-risk features, submucosal cancers with low-risk features, and submucosal cancers with high-risk features. The primary outcome was the annual risk for metastases during follow-up, stratified for baseline histology.

RESULTS

One hundred twenty patients met the selection criteria. Median follow-up was 29 months (interquartile range, 15-48). Metastases were observed in 5 of 25 (annual risk, 6.9%; 95% confidence interval [CI], 3.0-15) high-risk intramucosal cancers, 1 of 55 (annual risk, .7%; 95% CI, 0-4.0) low-risk submucosal cancers, and 3 of 40 (annual risk, 3.0%; 95% CI, 0-7.0) high-risk submucosal cancers.

CONCLUSIONS

Whereas the annual metastasis rate for high-risk submucosal EAC (3.0%) was somewhat lower than expected in comparison with previous reported percentages, the annual metastasis rate of 6.9% for high-risk intramucosal EAC is new and worrisome. This calls for further prospective studies and suggests that strict follow-up of this small subgroup is warranted until prospective data are available.

Placing sexually transmitted infection surveillance data in perspective by using national probability sample surveys

BACKGROUND

Many European countries do not have comprehensive sexually transmitted infection (STI) surveillance in place. The objective was to investigate whether national probability sample surveys are useful in placing STI surveillance into perspective.

METHODS

We used data from the Dutch national cross-sectional probability sample survey on sexual health 2016 (18-34-year-old sexually active individuals). Descriptive analyses were performed regarding STI testing (last year). Test numbers were extrapolated from the survey and compared with surveillance data from sexual health centres (SHCs) (complete) and general practitioners (GPs) (representative estimates from 7% of all GPs). Statistical differences in characteristics between SHC attendees and general population (according to weighted survey participants) were determined using χ2 statistic. Predictors of recent testing at GPs or SHCs were determined using multinomial multivariable logistic regression.

RESULTS

Of the 17 222 survey invitees, 3217 (19%) were eligible for analyses. Testing uptake was higher in women (17.2%, 14.8-20.0%) than men (11.5%, 9.1-14.3%). The majority of tests were conducted by GPs followed by SHCs and hospitals. Number of tests extrapolated from the survey was similar to SHC surveillance data, but higher than GP surveillance data (women only). Testing at SHCs was associated with high-risk behaviour and with living in highly urbanized areas. Low education level and older age were, next to high-risk behaviour factors, determinants of testing at GPs.

CONCLUSIONS

National probability sample surveys are useful for placing STI surveillance data into perspective by providing insights in testing patterns in the general population and identifying strengths and weaknesses of national surveillance systems.

Changes in young women’s contraceptive use in the Netherlands: findings from three sex under the age of 25 surveys

Prevention of unintended pregnancy among adolescents and young adults under 25 years is pivotal from an individual as well as societal perspective. In the USA, the use of long-acting reversible contraceptive (LARC) has been shown to increase, with no or little change in the use of short-acting reversible contraceptive (SARC). We assessed trends in no contraceptive, SARC, and LARC use by young women, aged between 12 and 25 years, and differences in trends within demographic groups (age, religion, ethnic background, and educational level) among these young women in the Netherlands. Data of sexually active young women aged 12–25 years from three cross-sectional representative surveys, 2005, 2012, and 2017, were used for this study. In total, 11,229 Dutch young women were included with a median age of 20 years (interquartile range 18–23 years). Overall, the proportion of young women using SARC decreased significantly between 2005 and 2017 from 88 to 76%. LARC use increased significantly between 2005 and 2017 from 3 to 16%. These trends varied by religious groups and educational level, emphasizing potential for tailored preventative measures for these groups. A shift towards LARC use might eventually lead to a further decrease in unwanted pregnancy and potentially abortion because of the lower risk of user errors.

Effect Evaluation of a Web-Based Coaching Intervention to Support Implementation of Sex Education Among Secondary School Teachers: Randomized Controlled Trial

BACKGROUND

The quality of implementation is important to ensure the effectiveness of behavioral change interventions in practice. Implementing such programs with completeness and adherence is not an automatic process and may require additional support. In school settings, the support teachers receive during implementation is often limited and appears to fall short when attempting to preserve completeness and adherence in program delivery. With the aim to improve completeness and adherence of teachers' delivery of a sexual health promoting intervention ("Long Live Love" [LLL]) in secondary education, a Web-based e-coach was developed ("lesgevenindeliefde.nl"or"teachinglove.nl"). The effectiveness of the e-coach, as part of a broader implementation strategy, in influencing teachers' implementation was evaluated.

OBJECTIVE

This study aimed to report on the effect evaluation to determine the effect of the Web-based e-coach on teacher implementation of a school-based sex education program called LLL and on its determinants.

METHODS

A cluster randomized controlled trial (e-coaching vs waiting list control) was conducted with a baseline assessment (T0) and follow-up (T1) 2 weeks after completing the LLL program. A total of 43 schools with 83 teachers participated in the study. In the follow-up, 38 schools participated, 23 in the e-coaching condition with 41 teachers and 15 in the control condition with 26 teachers. Multilevel regression analysis was used to evaluate the effect of the e-coaching website on implementation behavior, namely, completeness and adherence to LLL implementation, and on its determinants.

RESULTS

The e-coaching intervention was not found to have an effect on teachers' implementation behavior; teachers assigned to the experimental e-coaching website did not score higher on completeness (P=.60) or adherence (P=.67) as compared with teachers in the control condition. When comparing the 30 teachers who made actual use of the e-coaching website with the 37 teachers who did not, no significant differences were found either (P≥.54). In addition, there was no effect of e-coaching on the determinants of teacher implementation behavior (t_67-75≤0.69; P≥.22).

CONCLUSIONS

E-coaching was not found to be effective in enhancing completeness of and adherence to LLL by teachers. The lack of effect may be attributed to the intervention content, the limited use, or the study design itself. The e-coaching intervention may not have adequately addressed adherence and completeness of LLL to bring about behavioral change. Furthermore, the e-coaching intervention was not or insufficiently used by teachers. A possible biased sample of motivated, able teachers may have agreed to participate in the study, and a possible "ceiling effect" may have been present because of the high implementation grade. This, however, does not imply that Web-based coaching in itself is an ineffective strategy to promote adherence and completeness of program implementation. A process evaluation is required as follow-up.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN11754581; http://www.isrctn.com/ISRCTN11754581 (Archived by WebCite at http://www.webcitation.org/70C5TUOOh).

[Sex under the age of 25 in 2017: the sexual health of young people in the Netherlands]

OBJECTIVE

To gain insight in the sexual health of young people aged 12 to 25 in the Netherlands. Municipal health services and other stakeholders in the area of the promotion of sexual health were involved in various phases of this study, the results of which can be applied better to maintaining or improving the sexual health of young people.

DESIGN

Large-scale representative study with a cross-sectional design which was previously conducted in 2005 and 2012.

METHOD

We used data from students in secondary education (aged 12-16 years) as well as data from a sample drawn from the municipal population registers (aged 17-24 years). Fifteen municipal health services recruited extra respondents from their own regions, so that they obtained reliable and representative figures on the sexual health of young people at a local level. This investment also led to a total of 20,500 young people filling in a digital questionnaire containing questions on a wide range of sexuality-related topics.

RESULTS

The study shows that young people are having their first sexual experiences at a later age and protect themselves well against pregnancy. New developments were also apparent in the use of online media for 'sexting' and meeting partners. Condom use was low, particularly with casual partners, and despite a reduction in sexual violence it still occurs too frequently.

CONCLUSION

Sexual health among young people is generally good, but there are still concerns. The findings of this study were discussed with professionals working in the field of young people and sexual health. Their recommendations on interventions, care and policy resulting from these discussions will be included in a national action plan.

Offline and Online Sexual Risk Behavior among Youth in the Netherlands: Findings from "Sex under the Age of 25"

Sexually developing adolescents and emerging adults face sexual health risks as well as potentially negative outcomes of online sexual behaviors. The goal of this study was to describe three categories of sexual risk behavior: (1) behavior related to STI/HIV, (2) behavior related to unplanned pregnancy, and (3) online sexual risk behavior. In addition, we investigated whether these behaviors are actually related to negative (health) outcomes. For this purpose, we used data from a Dutch probability survey: "Sex under the age of 25." Adolescents and emerging adults aged 12 through 24 (8,053 boys and 12,447 girls) completed a digital questionnaire, including measures of the risk of STI/HIV and pregnancy, online sexual behavior and non-consensual sex. Chi-square tests and logistic regressions were used to test for gender and age differences and compute associations between risk behavior and negative outcomes. The results showed that the risk of unplanned pregnancy is low in the Netherlands. It seems that adolescents and emerging adults are less aware of the risk of STI/HIV than of the risk of pregnancy. About 11% of the participants had had more than one partner in the last 6 months and had not used condoms consistently with their last partner, and these participants had a 3.56 times higher likelihood of ever being diagnosed with an STI. Although many young people stop using condoms with their partner after a while, most of them did not get tested for STIs. More emerging adults (aged 18-24) engage in sexting (sending personal nude pictures and sex videos to others), but the chance that these images are shared with other people than the intended recipient is higher among adolescents (aged 12-17). The results of this study can guide professionals working in sex education and sexual health services to focus their efforts on the risk behaviors in the Netherlands that deserve most attention.

[Ultrasound-guided surgery for breast cancer]

Recent literature shows that perioperative ultrasound guidance of surgery for palpable and nonpalpable breast carcinoma results in improved surgical effectiveness. Ultrasound-guided surgery can easily lead to significant improvement of the number of radical resections and can decrease the need for additional surgery or extra radiotherapy. Ultrasound-guided surgery also contributes to a reduction in the amount of excessive breast tissue removal, which means the final cosmetic result is better. Ultrasound-guided surgery is cost-effective and easy to learn. Implementation of ultrasound-guided surgery has increased in recent years, albeit slowly. Surgeons as well as radiologists should become more aware of the improvement of primary and secondary outcome measures that can be achieved with ultrasound-guided surgery of breast cancer. In addition to radicality, the quantity of excised tissue - tumour tissue and healthy tissue - can be used as a quality indicator, given the impact on cosmetic outcome and quality of life for patients with breast cancer.

Intraoperative ultrasound guidance in breast-conserving surgery shows superiority in oncological outcome, long-term cosmetic and patient-reported outcomes: Final outcomes of a randomized controlled trial (COBALT)

BACKGROUND

The multicenter randomized controlled COBALT trial demonstrated that ultrasound-guided breast-conserving surgery (USS) results in a significant reduction of margin involvement (3.1% vs. 13%) and excision volumes compared to palpation-guided surgery (PGS). The aim of the present study was to determine long term oncological and patient-reported outcomes including quality of life (QoL), together with their progress over time.

METHODS

134 patients with T1-T2 breast cancer were randomized to USS (N = 65) or PGS (N = 69). Cosmetic outcomes were assessed with the Breast Cancer Conservative Treatment cosmetic results (BCCT.core) software, panel-evaluation and patient self-evaluation on a 4-point Likert-scale. QoL was measured using the EORTC QLQ-C30/-BR23 questionnaire.

RESULTS

No locoregional recurrences were reported after mean follow-up of 41 months. Seven patients (5%) developed distant metastatic disease (USS 6.3%, PGS 4.4%, p = 0.466), of whom six died of disease (95.5% overall survival). USS achieved better cosmetic outcomes compared to PGS, with poor outcomes of 11% and 21% respectively, a result mainly attributable to mastectomies due to involved margins following PGS. There was no difference after 1 and 3 years in cosmetic outcome. Dissatisfied patients included those with larger excision volumes, additional local therapies and worse QoL. Patients with poor/fair cosmetic outcomes scored significantly lower on aspects of QoL, including breast-symptoms, body image and sexual enjoyment.

CONCLUSION

By significantly reducing positive margin status and lowering resection volumes, USS improves the rate of good cosmetic outcomes and increases patient-satisfaction. Considering the large impact of cosmetic outcome on QoL, USS has great potential to improve QoL following breast-conserving therapy.

Innovatively Supporting Teachers' Implementation of School-Based Sex Education: Developing A Web-Based Coaching Intervention From Problem to Solution

BACKGROUND

Full program implementation is crucial for effectiveness but is often overlooked or insufficiently considered during development of behavioral change interventions. For school-based health promotion programs, teachers are key players in program implementation, but teacher support in this phase is mostly limited to technical support and information. To ensure optimal implementation of the Dutch school-based sexual health program Long Live Love, a Web-based coaching website was developed to support teachers in completeness and fidelity of program implementation.

OBJECTIVE

The aim of this paper is to provide insight into the process of systematic development of a Web-based coaching intervention to support teachers in their implementation of a school-based sexual health program.

METHODS

The intervention mapping (IM) protocol was applied for the development of a theory- and evidence-based intervention. The IM process begins with (1) a needs assessment, followed by (2) the formulation of change objectives, (3) the selection of theory-based intervention methods and practical applications that take the parameters for effectiveness into consideration, (4) integration of practical applications into an organized program, (5) planning for adoption, implementation, and sustainability of the program, and finally, (6) generating an evaluation plan to measure program effectiveness.

RESULTS

Teacher's implementation behavior was characterized by inconsistently selecting parts of the program and not delivering (all) lessons as intended by program developers. Teachers, however, did not perceive this behavior as problematic, revealing the discrepancy between teacher's actual and perceived need for support in delivering Long Live Love lessons with completeness and fidelity. Teachers did, however, acknowledge different difficulties they encountered which could potentially negatively influence the quality of implementation. With the IM protocol, this Web-based coaching intervention was developed based on a concept of unobtrusive coaching, by and for teachers, to bring about change in teachers' implementation behavior.

CONCLUSIONS

This paper provides an example of a Web-based intervention to bring about behavioral change in a target group of intermediaries who lack intrinsic motivation for coaching and who's perceptions differ from their actual problematic behavior. The IM protocol is a useful tool for guiding the scientific development of interventions and making them compatible with the needs and preferences of the target group.

A nationwide pathology study on surgical margins and excision volumes after breast-conserving surgery: There is still much to be gained

AIM OF THE STUDY

The current study aims to assess margin status in relation to amount of healthy breast tissue resected in breast-conserving surgery (BCS) on a nationwide scale.

METHODS

Using PALGA (a nationwide network and registry of histology and cytopathology in the Netherlands), all patients who underwent BCS for primary invasive carcinoma in 2012-13 were selected (10,058 excerpts). 9276 pathology excerpts were analyzed for a range of criteria including oncological margin status and distance to closest margin, specimen weight/volume, greatest tumor diameter, and with or without localization method. Calculated resection ratios (CRR) were assessed to determine excess healthy breast tissue resection.

RESULTS

Margins for invasive carcinoma and in situ carcinoma combined were tumor-involved in 498 (5.4%) and focally involved in 1021 cases (11.0%) of cases. Unsatisfactory resections including (focally) involved margins and margins ≤ 1 mm were reported in 33.8% of patients. The median lumpectomy volume was 46 cc (range 1-807 cc; SD 49.18) and median CRR 2.32 (range 0.10-104.17; SD 3.23), indicating the excision of 2.3 the optimal resection volume.

CONCLUSION

The unacceptable rate of tumor-involved margins as well as margins ≤ 1 mm in one third of all patients is also achieved at the expense of healthy breast tissue resection, which may carry the drawback of high rates of cosmetic failure. These data clearly suggest the need for improvement in current breast conserving surgical procedures to decrease tumor-involved margin rates while reducing the amount of healthy breast tissue resected.

Prevalence of Non-Volitional Sex Types and Associated Factors: A National Sample of Young People

Background

Non-volitional sex (NVS) in young people continues to be a major public health problem with long-term negative health outcomes. For the first time, the prevalence of different types of NVS and associated factors are compared between young people with same-sex sexual activities and those who have not.

Methods

We obtained data from 10,401 young women and men (aged 12 to 25 years) who participated in a population study on sexual health, the Netherlands. We calculated and compared the prevalence of six types of NVS between women who had sex with men (yWSM) or women (yWSW), and men who had sex with women (yMSW) or men (yMSM). In sexually experienced participants (n = 5986) logistic regression analyses were applied to assess associations with NVS by assault or penetration. Analyses were weighted to represent the Dutch population.

Results

The prevalence of NVS ranged from 1% to 61%, depending on type. Prevalence was higher for young women (any: 40.6%) than men (any: 20.4%), and highest for yMSM and yWSW. Prevalence of NVS by assault or penetration was related to a range of socio-demographic, behavioral and social factors, which were largely similar regardless of sex or same-sex-experiences. The NVS perpetrators were in over 70% of cases known to the victim; 1 in 4 cases of NVS by penetration were accompanied by violence.

Conclusion

A substantial proportion of young people in the Netherlands have experienced NVS. Medical professionals, educators and caregivers should integrate services to continue to address NVS by targeting young people’s multifaceted risk profiles and evidenced based interventions for doing so are needed.

Educational Differences in Adolescents' Sexual Health: A Pervasive Phenomenon in a National Dutch Sample

Educational level is strongly associated with age of first intercourse and risk of unintended pregnancies. This study examined these associations in a large representative sample of Dutch adolescents and also included associations of educational level with other sexual health aspects. Adolescents aged 12 to 25 (3,926 boys and 3,915 girls) completed an online questionnaire that included measures of romantic and sexual experience; the evaluation of their sexual debut; the risk of sexually transmitted infections (STIs) and pregnancy; and sexual attitudes, satisfaction, self-efficacy, knowledge, victimization, and functioning. The results showed that adolescents on a vocational track or who completed fewer years of education were more at risk of several adverse sexual health outcomes than adolescents on an academic track. They had their first sexual experiences at an earlier age; evaluated these experiences less favorably; had less sexual health knowledge and fewer refusal skills; and had a higher risk of unintended pregnancy, STIs, and victimization. Possible explanations for these consistent differences are discussed. Sex education and services should pay specific and targeted attention to less educated young people and tailor their efforts specifically to the needs, characteristics, and realities of this group.

Ultrasound-guided surgery for palpable breast cancer: a historical perspective

SUMMARY 

Breast cancer surgery has changed dramatically from the en bloc removal of the breast to the less invasive breast-conserving surgery. The recent COBALT trial comparing ultrasound-guided surgery with palpation-guided surgery for palpable breast cancer showed less margin involvement and decreased excision volumes with ultrasonography, which resulted in less additional therapy and possibly improved cosmetic outcome. Other surgical techniques pursuing these same aims have been developed over the past two decades and are referred to as oncoplastic surgery. Unfortunately oncoplastic surgery lacks sufficient evidence to corroborate its widespread implementation and should thereby solely be applied to selected cases. This review aims to highlight the position of ultrasound-guided surgery from a perspective of breast-conserving surgery in the search for better oncological and cosmetic outcomes.

Anaesthetic management during open and percutaneous irreversible electroporation

BACKGROUND

Irreversible electroporation (IRE) is a novel tumour ablation technique involving repetitive application of electrical energy around a tumour. The use of pulsed electrical gradients carries a risk of cardiac arrhythmias, severe muscle contractions, and seizures. We aimed to identify IRE-related risks and the appropriate precautions for anaesthetic management.

METHODS

All patients who were treated with IRE were prospectively included. Exclusion criteria were arrhythmias, congestive heart failure, active coronary artery disease, and epilepsy. All procedures were performed under general anaesthesia with complete muscle relaxation during ECG-synchronized pulsing. Adverse events, cardiovascular effects, blood samples, cerebral activity, and post-procedural pain were analysed.

RESULTS

Twenty-eight patients underwent 30 IRE sessions for tumours in the liver, pancreas, kidney, and lesser pelvis. No major adverse events occurred during IRE. Median systolic and diastolic blood pressure increased by 44 mm Hg (range -7 to 108 mm Hg) and 19 mm Hg (range 1-50 mm Hg), respectively. Two transient minor cardiac arrhythmias without haemodynamic consequences were observed. Muscle contractions were mild and IRE caused no reactive brain activity on a simplified EEG. Pain in the first 24 h after percutaneous IRE was generally mild, but higher pain scores were reported after pancreatic treatment (mean VAS score 3; range 0-9).

CONCLUSIONS

Side-effects during IRE on tumours in the liver, pancreas, kidney, and lesser pelvis seem mild and manageable when current recommendations for anaesthesia management, including deep muscle relaxation and ECG synchronized pulsing, are followed. Electrical pulses do not seem to cause reactive cerebral activity and evidence for pre-existing atrial fibrillation as an absolute contra-indication for IRE is questionable.

Long Live Love. The implementation of a school-based sex-education program in The Netherlands

Implementation of health education programs is often inadequately considered or not considered at all in planning, developing and evaluating interventions. With the focus being predominantly on the adoption stage, little is known about the factors influencing the implementation and continuation stages of the diffusion process. This study contributes to the understanding of factors that promote or impede each stage of the diffusion process in the school setting using the sex education program Long Live Love (LLL) as an example. A survey integrating different diffusion-related concepts was completed by 130 teachers. Results showed that teacher curriculum-related beliefs were associated with all stages in the diffusion process. Although adoption of LLL was predominantly related to teacher curriculum-related beliefs, implementation completeness and fidelity and continued use of LLL were also enhanced by contextual factors, namely teacher training and interactive context variables (school policy, governing body support and student response), respectively. The results of this study can be used to optimize the adoption, implementation and continuation of school-based (sexual) health promotion programs.

Ultrasound-guided surgery for palpable breast cancer is cost-saving: results of a cost-benefit analysis

Ultrasound-guided surgery (USS) has recently been proven to result in a significant reduction of tumour-involved surgical margins, for patients with palpable invasive breast cancer. The objective of this economic evaluation alongside a randomised trial was to evaluate the costs and benefits of USS compared to palpation-guided surgery (PGS). The hospital perspective was used. On the cost side of the analysis, resource use related to baseline treatment was taken into account and on the benefit side, resource use related to additional treatments was included. On the cost side, the difference in costs per patient was €193 (95% CI €153-€233) with higher costs in the USS group. On the benefit side, the difference in costs per patient was -€349 (95% CI -€591 to -€103) with higher costs in the PGS group. This resulted in a cost decrease of -€154 (95% CI -€388 to €81) in the USS group compared to the PGS group. Intra-operative use of a US system during BCS reduces the rate of tumour-involved margins and thereby the costs of additional treatments.

Abstract PD04-01: Intra-operative ultrasound in breast-conserving surgery for palpable breast cancer significantly improves both surgical accuracy and cosmetic outcome while saving costs

Background: Breast-conserving surgery for palpable breast cancer is worldwide associated with a high rate of tumour-involved margins and excessive healthy tissue resection. This results in additional treatment and poor cosmetic outcome. Ultrasound-guided surgery (USS) may resolve both problems by improving surgical accuracy. A randomised controlled trial was initiated to compare USS with the standard palpation-guided surgery (PGS) for palpable breast cancer.

Methods: A total of 134 eligible patients with palpable T1-T2 invasive breast cancer were randomised to either USS (n = 65) or PGS (n = 69). Outcome measures included resection margin status, re-excision rates, mastectomy rates and additional radiotherapy. A calculated resection ratio (CRR) was derived from specimen volumes and tumour diameters, indicating healthy tissue resection. Secondary outcome measures were operative time, complications cosmetic outcome and cost-effectiveness. The costs of purchasing the US-system were included in the USS-group. The mean total costs per patient were calculated and compared between both study groups.

Results: In the USS-group, 3.1% of margins were involved, compared with 17.4% in the PGS-group (p = 0.009). The use of intra-operative US resulted in a significant reduction in additional therapies (p = 0.015); in the PGS-group re-excisions were necessary in 3 patients (4.3%) and in 1 patient (1.5%) in the USS-group, mastectomies were performed in 5 patients (7.2%) of the PGS-group and in none of the patients of the USS-group, and additional radiotherapy boosts in 11 patients (15.9%) of the PGS-group and 6 patients in the USS-group (9.2%). Excision volumes and CRR were both reduced with USS (38cc vs. 58cc and 1.0 vs. 1.7, respectively; both P < 0.002). Analysis of cosmetic self-evaluation after 3 months showed better nipple position in the USS-group compared to the PGS-group (p = 0.016). Furthermore, 3 months after surgery, patients in the USS were more satisfied with the appearance of their breasts than in the PGS group (p = 0.015). Panel evaluation of cosmetic outcome will be conducted in the future. Mean extra costs per patient due to margin involvement in the PGS-group were 446€ compared with 169€ in the USS-group. Yearly costs of a US-system are 8,286€. Therefore, USS for palpable breast cancer can save a breast unit 277€ per patient after the first 30 operated patients (on a yearly basis). A breast unit operating 200 patients per year can achieve 47.090€ of cost savings.

Conclusion: USS can prevent the unacceptably high rate of tumour-involved resection margins in palpable breast cancer excision, thus not only improving oncological and cosmetic outcomes by avoiding subsequent surgery or radiotherapy, but also considerably reducing treatment costs. In addition to palpable breast cancer surgery, USS might be used for non-papable breast cancer surgery, mastectomies and oncoplastic procedures. Therefore even greater cost-savings might be achieved by using a US-system for breast cancer surgery. Long term results of cosmetic outcome and quality of life of this trial are expected in 2013.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD04-01.

Clinical applications of FDG-probe guided surgery

BACKGROUND

For a definitive diagnosis in many oncological, inflammatory and infectious diseases histological examination is required. Non-palpable lesions detected with PET/CT scanning that cannot be localized with conventional imaging methods can be localized and excised using FDG-probe guided surgery. We describe the application of FDG-probe guided surgery in 9 patients.

METHODS

The application of FDG-probe guided surgery used in 9 consecutive patients with oncological and infectious diseases is described. Four hours before surgery, 3.5 MBq/Kg body weight FDG was intravenously administered after which a FDG-PET-scan was performed to confirm the FDG-avid lesion(s). The lesions with highest activity were detected with the FDG-probe and the lesions were subsequently excised and sent for histopathological examination.

RESULTS

In all of the 9 cases the target lesion was successfully identified and subsequently removed. When multiple and/or macroscopically normal lymph nodes were found, the use of the FDG-probe allowed selection of the PET-avid lymph nodes for resection.

CONCLUSION

FDG-probe guided surgery is a relatively simple surgical technique to identify and excise FDG-accumulating suspicious lesions in oncological, inflammatory and infectious diseases.

Ultrasound and fine needle aspiration cytology of axillary lymph nodes in breast cancer. To do or not to do?

AIM

The purpose of our study was to evaluate the accuracy of axillary ultrasound and ultrasound-guided fine needle aspiration cytology (FNAC) in the preoperative diagnosis of axillary metastases.

METHODS

Between 2004 and 2009, 1132 female patients were evaluated and treated in our clinic for histologically proven breast carcinoma. Preoperative axillary ultrasound with subsequent FNAC in case of suspicious lymph nodes was performed in 1150 axillae (18 bilateral breast carcinomas). We analyzed the results of axillary ultrasound and FNAC retrospectively. Pathological node status was used as the reference standard (based on axillary dissection or sentinel node biopsy).

RESULTS

Axillary ultrasound showed suspicious lymph nodes in 327 axillae (28.4%). FNAC showed axillary metastases in 107 of these 327 axillae. Final histological analysis confirmed 106 metastases (one false positive). Histological analysis showed metastatic disease in 429 of 1150 axillae (37.3%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of axillary ultrasound alone were 43.8% (188/429), 80.7% (582/721), 57.5% (188/327) and 70.7% (582/823), respectively. When combining axillary ultrasound with FNAC of suspicious lymph nodes, sensitivity was 24.7% (106/429), specificity was 99.9% (720/721), PPV was 99.1% (106/107) and NPV was 69.0% (720/1043).

CONCLUSIONS

106/429 (24.7%) Node-positive axillae were identified by ultrasound-guided FNAC and spared unnecessary sentinel node biopsy. Unfortunately, the percentage of false negative results of ultrasound-guided FNAC (28.1%, 323/1150) was very high.

Optimising surgical accuracy in palpable breast cancer with intra-operative breast ultrasound--feasibility and surgeons' learning curve

AIMS

To evaluate if intra-operative guidance with ultrasonography (US) could improve surgical accuracy of palpable breast cancer excision, and to evaluate the performance of surgeons during training for US-guided excision.

MATERIALS AND METHODS

Thirty female patients undergoing breast-conserving surgery for palpable T1-T2 invasive breast cancer were recruited. Three individual breast surgeons, assisted by US, targeted and excised the tumours. The main objective was to obtain adequate resection margins with optimal resection volumes. The specimen volume, tumour diameter and histological margin status were recorded. The specimen volume was divided by the optimal resection volume, defined as the spherical tumour volume plus a 1.0-cm margin. The resulting calculated resection ratio (CRR) indicated the amount of excess tissue resected.

RESULTS

All tumours were correctly identified during surgery, 29 of 30 tumours (96.7%) were removed with adequately negative margins, and one tumour was removed with focally positive margins. The median CRR was 1.0 (range, 0.4-2.8), implying optimal excision volume. For all breast surgeons, CRR improved during the training period. By the 8th procedure, all surgeons showed proficiency in performing intra-operative breast US.

CONCLUSION

Surgeons can easily learn the skills needed to perform intra-operative US for palpable breast tumour excision. The technique is non-invasive, simple, safe and effective for obtaining adequate resection margins. Within the first two cases, resections reached optimal volumes, thereby, presumably resulting in improved cosmetic outcomes. In a multicentre, randomised, clinical trial, intra-operative US guidance for palpable breast tumours will be evaluated for oncological and cosmetic outcomes.

Loss of lamin A/C expression in stage II and III colon cancer is associated with disease recurrence

AIM OF THE STUDY

Loss of the nuclear lamina protein lamin A/C (LMNA) has been observed in several human malignancies. The present study aimed to investigate associations between LMNA expression and clinical outcome in colon cancer patients.

PATIENTS AND METHODS

Clinicopathological data and formalin-fixed paraffin embedded tissues were collected from 370 stage II and III colon cancer patients. Tissue microarrays were constructed, stained for lamin A/C and evaluated microscopically. Microsatellite instability status was determined for 318 tumours.

RESULTS

Low levels of LMNA expression were observed in 17.8% of colon tumours, with disease recurrence occurring in 45.5% of stage II and III colon cancer patients with LMNA-low expressing tumours compared to 29.6% of patients with LMNA-high expressing tumours (p=0.01). For stage II patients, disease recurrence was observed for 35.7% of LMNA-low compared to 20.3% of LMNA-high expressing tumours (p=0.03). Microsatellite stable (MSS) tumours exhibited more frequently low LMNA expression than microsatellite instable (MSI) tumours (21% versus 9.8%; p=0.05). Interestingly, disease recurrence among LMNA-low and LMNA-high expressing MSS tumours varied significantly for stage III patients who had not received adjuvant chemotherapy (100% versus 37.8%; p<0.01) while no such difference was observed for patients who received adjuvant chemotherapy (46.7% versus 46.0%; p=0.96).

CONCLUSION

These data indicate that low expression of LMNA is associated with an increased disease recurrence in stage II and III colon cancer patients, and suggest that these patients in particular may benefit from adjuvant chemotherapy.

A comparison of three methods for nonpalpable breast cancer excision

AIMS

To evaluate the efficacy of three methods of breast-conserving surgery (BCS) for nonpalpable invasive breast cancer in obtaining adequate resection margins and volumes of resection.

MATERIALS AND METHODS

A total of 201 consecutive patients undergoing BCS for nonpalpable invasive breast cancer between January 2006 and 2009 in four affiliated institutions was retrospectively analysed. Patients with pre-operatively diagnosed primary or associated ductal carcinoma in situ (DCIS), multifocal disease, or a history of breast surgery or neo-adjuvant treatment were excluded from the study. The resections were guided by wire localisation (WL), ultrasound (US), or radio-guided occult lesion localisation (ROLL). The pathology reports were reviewed to determine oncological margin status, as well as tumour and surgical specimen sizes. The optimal resection volume (ORV), defined as the spherical tumour volume with an added 1.0-cm margin, and the total resection volume (TRV), defined as the corresponding ellipsoid, were calculated. By dividing the TRV by the ORV, a calculated resection ratio (CRR) was determined to indicate the excess tissue resection.

RESULTS

Of all 201 excisions, 117 (58%) were guided by WL, 52 (26%) by US, and 32 (16%) by ROLL. The rate of focally positive and positive margins for invasive carcinoma was significantly lower in the US group (N = 2 (3.7%)) compared to the WL (N = 25 (21.3%)) and ROLL (N = 8 (25%)) groups (p = 0.023). The median CRRs were 3.2 (US), 2.8 (WL) and 3.8 (ROLL) (WL versus ROLL, p < 0.05), representing a median excess tissue resection of 3.1 times the optimal resection volume.

CONCLUSION

US-guided BCS for nonpalpable invasive breast cancer was more accurate than WL- and ROLL-guided surgery because it optimised the surgeon's ability to obtain adequate margins. The excision volumes were large in all excision groups, especially in the ROLL group.

Long-term results of radiofrequency ablation for unresectable colorectal liver metastases: a potentially curative intervention

OBJECTIVE

The long-term results and prognostic factors of radiofrequency ablation (RFA) for unresectable colorectal liver metastases (CRLM) in a single centre with >10 years of experience were retrospectively analysed.

METHODS

A total of 100 patients with unresectable colorectal liver metastases (CRLM) (size 0.2-8.3 cm; mean 2.4 cm) underwent a total of 126 RFA sessions (237 lesions). The mean follow-up time was 29 months (range 6-93 months). Lesion characteristics (size, number and location), procedure characteristics (percutaneous or intra-operative approach) and major and minor complications were carefully noted. Local control, mean survival time and recurrence-free and overall survival were statistically analysed.

RESULTS

No direct procedure-related deaths were observed. Major complications were present in eight patients. Local RFA site recurrence was 12.7% (n = 30/237); for tumour diameters of <3 cm, 3-5 cm and >5 cm, recurrence was 5.6% (n = 8/143), 19.5% (n = 15/77) and 41.2% (n = 7/17), respectively. Centrally located lesions recurred more often than peripheral ones, at 21.4% (n = 21/98) vs 6.5% (n = 9/139), respectively, p = 0.009. Including additional treatments for recurring lesions when feasible, lesion-based local control reached 93%. The mean survival time from RFA was 56 (95% confidence interval (CI) 45-67) months. Overall 1-, 3-, 5- and 8-year survival from RFA was 93%, 77%, 36% and 24%, respectively.

CONCLUSIONS

RFA for unresectable CRLM is a safe, effective and potentially curative treatment option; the long-term results are comparable with those of previous investigations employing surgical resection. Factors determining success are lesion size, the number of lesions and location.

An exploratory study of Muslim adolescents' views on sexuality: Implications for sex education and prevention

BACKGROUND

This paper describes the results of an exploratory qualitative study on Muslim adolescents' views on sexuality in the Netherlands.

METHODS

Data were gathered from an Internet forum on which 44 Muslim and 33 non-Muslim adolescents discussed sexuality as it relates to Islam. These discussions were subsequently analyzed for content using Nvivo 2.0.

RESULTS

Our analysis revealed several issues that are relevant for the design of future sex education programs targeting Muslim youth. Apart from some expected outcomes regarding, for example, taboos on sexuality, sex outside marriage, abortion, homosexuality and conservative gender roles, our analyses showed that in cases of disputes 1) discussions were polarized, 2) opponents used the same Qur'anic passages to support their views, and 3) the authority of an Imam was questioned when his interpretation of Qur'anic passages was not in line with the views of participants.

CONCLUSIONS

Our findings show that current approaches to sex education among Muslim youth are likely to be unsuccessful given the rigidity of sexual norms in Muslim society. In addition, we also identified new barriers to sex education among Muslim youth (e.g. lack of respect for an Imam who opposes a youth's views on sexuality).

4-1BB-mediated expansion affords superior detection of in vivo primed effector memory CD8+ T cells from melanoma sentinel lymph nodes

We have been studying the re-activation of tumor-associated antigen (TAA)-specific CD8(+) T cells in sentinel lymph nodes (SLN) of melanoma patients upon intradermal administration of the CpG-B oligodeoxynucleotide PF-3512676. To facilitate functional testing of T cells from small SLN samples, high-efficiency polyclonal T cell expansion is required. In this study, SLN cells were expanded via classic methodologies with plate- or bead-bound anti-CD3/CD28 antibodies and with the K562/CD32/4-1BBL artificial APC system (K32/4-1BBL aAPC) and analyzed for responsiveness to common recall or TAA-derived peptides. K32/4-1BBL-expanded T cell populations contained significantly more effector/memory CD8(+) T cells. Moreover, recall and melanoma antigen-specific CD8(+) T cells were more frequently detected in K32/4-1BBL-expanded samples as compared with anti-CD3/CD28-expanded samples. We conclude that K32/4-1BBL aAPC are superior to anti-CD3/CD28 antibodies for the expansion of in vivo-primed specific CD8(+) T cells and that their use facilitates the sensitive monitoring of functional anti-tumor T cell immunity in SLN.

Lymph node negative colorectal cancers with isolated tumor deposits should be classified and treated as stage III

Background

The prognostic role of pericolic or perirectal isolated tumor deposits (ITDs) in node-negative colorectal cancer (CRC) patients is unclear. Rules to define ITDs as regional lymph node metastases changed in subsequent editions of the TNM staging without substantial evidence. Aim of this study was to investigate the correlation between ITDs and disease recurrence in stage II and III CRC patients.

Materials and Methods

The medical files of 870 CRC patients were reviewed. Number, size, shape, and location pattern of all ITDs in node-negative patients were examined in relation to involvement of vascular structures and nerves. The correlation between ITDs and the development of recurrent disease was investigated.

Results

Disease recurrence was observed in 50.0% of stage II patients with ITDs (13 of 26), compared with 24.4% of stage II patients without ITDs (66 of 270) (P < .01). Disease-free survival of ITD-positive stage II patients was comparable with that of stage III patients. Also within stage III, more recurrences were observed in ITD-positive patients compared with ITD-negative patients (65.1 vs. 39.1%, respectively). No correlation was found between size of ITDs and disease recurrence. More recurrences were seen in patients with irregularly shaped ITDs compared with patients with 1 or more smooth ITDs present.

Conclusions

Because of the high risk of disease recurrence, all node-negative stage II patients with ITDs, regardless of size and shape, should be classified as stage III, for whom adjuvant chemotherapy should be considered.

The impact of intraoperative ultrasonography on the surgical treatment of patients with colorectal liver metastases

Introduction

Intraoperative ultrasonography (IOUS) has been the standard in surgical decision making in oncologic liver surgery. Preoperative imaging techniques have improved substantially in resent years; therefore, the importance of IOUS might change. The current results of IOUS were compared with preoperative high-resolution helical CT scanning and the impact of IOUS on surgical decision making was evaluated.

Methods

A total of 100 consecutive patients who underwent open surgery for colorectal liver metastases within 4 weeks after preoperative imaging, performed with high-speed helical CT scanners, were included for this study. During surgery, IOUS was performed by a liver specialized radiologist. The findings on preoperative and intraoperative imaging and surgical exploration were compared regarding number, site, and size of the hepatic lesions. The preoperative surgical plan was compared with the final surgical treatment.

Results

One hundred patients with CRLM underwent 117 surgical treatments. In 38 patients IOUS differed from preoperative data. In 23 cases IOUS identified more metastatic lesions. In five patients, intraoperative findings identified smaller or less hepatic lesions. Additional information on the localization of the hepatic lesions was gathered by IOUS and changed the surgical treatment in ten cases. IOUS alone altered the surgical strategy 35 times during 117 procedures. In nearly all cases, discrepancy between the preoperative CT scan and IOUS resulted in a change of surgical treatment.

Conclusions

Despite improvement in preoperative imaging technology, the intraoperative use of ultrasonography remains of crucial importance. The detection of preoperatively unknown lesions remains high with great consequence on surgical therapy.

Sexual trajectories during adolescence: relation to demographic characteristics and sexual risk

The "sexual trajectory" is an age-graded set of various new sexual experiences, defined by three key dimensions: sequence, duration, and timing. A comprehensive description of sexual trajectories creates the possibility to investigate potential risks of certain trajectory types. The present study attempted to answer three questions: (1) Is it possible to identify a typology in (the early stages of) sexual trajectories? (2) Is sexual trajectory type related to demographic characteristics, such as sex, ethnic background, and educational level? (3) What are the associations between sexual trajectory type and recent sexual risk behavior? A representative Dutch sample of 1,263 males and 1,353 females (M = 20.46 years; range, 12-25) who had engaged in sexual intercourse completed a questionnaire about sexual (health) behavior. About three quarters of participants followed a progressive sexual trajectory from less intimate (e.g., kissing) to more intimate behavior (e.g., sexual intercourse). Immigrant groups and less educated youth were more likely to follow a nonlinear trajectory. A progressive trajectory was associated with a higher likelihood of consistent contraceptive use with the most recent partner and, for girls, with a lower likelihood of having unprotected anal intercourse with the last partner. It was hypothesized that the nonlinear trajectory could be ascribed to a lack of opportunities or skills to plan and steer early sexual experiences and that these limitations were fairly stable over time. Sexual education should aim at providing adolescents with sufficient (self) knowledge and skills to construct their sexual trajectories according to their own wishes or needs.

Parental support and knowledge and adolescents' sexual health: testing two mediational models in a national Dutch sample

This study investigated age- and gender-specific associations between parental support and parental knowledge of the child's whereabouts, on the one hand, and sexual experience and sexual health (the ability to have safe and pleasurable sexual experiences) on the other hand. A representative Dutch sample of 1,263 males and 1,353 females (aged 12-25 years), who had previously engaged in sexual intercourse, completed a questionnaire that included measures of these constructs. Both parental support and knowledge were positively associated with contraceptive use, social skills in sexual interactions, sexual satisfaction, and delay of sexual debut. Findings also revealed that the majority of correlations between parental support and sexual experience and sexual health are attributable to the relationship between a supportive family environment and parental knowledge of the child's whereabouts. Parental knowledge thus appeared to be more important for healthy sexual development than parental support.

[Breast self-examination also valuable in women participating in a screening programme]

OBJECTIVE

To evaluate the different methods of detection of breast cancer in women who at time of diagnosis underwent screening mammographies as participants in the Dutch National Breast Cancer Screening Programme (BOB group), and in women who participated in an intensive screening programme for a familial or genetic predisposition to breast cancer (FAM group).

DESIGN

Partly retrospective, partly prospective, descriptive.

METHOD

All patients who had surgery for invasive breast cancer at the VU University Medical Center, Amsterdam, the Netherlands, from 1 January 1995 to 30 June 2006 and who were participating in one of the abovementioned screening programmes at the time of diagnosis, were included. Data concerning the palpability of the tumour at time of diagnosis and the diagnostic method that first led to breast cancer being diagnosed, were collected.

RESULTS

The BOB group consisted of 397 women with invasive carcinoma of which 57% (227/397) tumours were palpable at the time of diagnosis. The majority (64%; 146/227) of the palpable tumours were discovered by breast self-examination as an interval carcinoma. 31% (71/227) were detected by screening mammography and were also palpable. During the same period, 490 women participated in the high risk screening programme; in this FAM group, 23 invasive tumours were detected. A total of 61% (14/23) of these lesions were found during breast self-examination; 7 lesions (30%) were found by imaging.

CONCLUSION

In women who participated in one of the 2 screening programmes, the majority of invasive breast cancers were palpable and more than half were detected by breast self-examination. Performing breast self-examination on a regular basis may contribute to early detection of breast cancer. Therefore, the teaching of breast self-examination to women should be encouraged, even if they are participating in a breast cancer screening programme.

[Low prognostic importance of non-radical melanoma excision and the presence of melanoma cells in the re-excision specimen to overall and disease-free survival of melanoma patients]

OBJECTIVE

To determine in patients with skin melanoma whether disease-free and overall survival are associated with the tumour excision type and the presence of residual tumour cells in the re-excision specimen.

DESIGN

Prospective and descriptive.

METHOD

In the period August 1993-August 2004, 471 patients were diagnosed with stage I/II skin melanoma after partial or non-partial removal of a pigmented skin lesion, followed by re-excision and a sentinel node biopsy at Amsterdam Free University Medical Centre, the Netherlands. All patients were followed prospectively with a mean follow-up of > 5 years. Patients were divided into two groups according to (a) the type of primary excision (radical excision, narrow/radical excision, non-radical excision biopsy and incisional biopsy) and (b) the presence or absence of residual tumour cells in their re-excision specimen. Survival analysis was done using Cox proportional hazard model adjusted for the 8 known most important determinants of melanoma.

RESULTS

Of the 471 patients, the primary excision was radical in 279 patients and narrow/radical in 109 patients; 52 patients underwent a nonradical excision and 31 patients an incisional biopsy. Re-excision was carried out in 441 patients and in 41 of them residual tumour cells were present in the re-excision specimen. Neither the diagnostic biopsy type nor the presence oftumour cells in the re-excision specimen were connected with disease-free or overall survival in the melanoma patients.

CONCLUSION

Non-radical diagnostic biopsies were not negatively associated with overall and disease-free survival in melanoma patients.