Predicting postoperative complications and their impact on quality of life and functional status in older patients with breast cancer.

BACKGROUND: The percentage of older patients undergoing surgery for early-stage breast cancer has decreased over the past decade. This study aimed to develop a prediction model for postoperative complications to better inform patients about the benefits and risks of surgery, and to investigate the association between complications and functional status and quality of life (QoL). METHODS: Women aged at least 70 years who underwent surgery for Tis-3 N0 breast cancer were included between 2013 and 2018. The primary outcome was any postoperative complication within 30 days after surgery. Secondary outcomes included functional status and QoL during the first year after surgery, as assessed by the Groningen Activity Restriction Scale and the European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 questionnaires. A prediction model was developed using multivariable logistic regression and validated externally using data from the British Bridging the Age Gap Study. Linear mixed models were used to assess QoL and functional status over time. RESULTS: The development and validation cohorts included 547 and 2727 women respectively. The prediction model consisted of five predictors (age, polypharmacy, BMI, and type of breast and axillary surgery) and performed well in internal (area under curve (AUC) 0.76, 95 per cent c.i. 0.72 to 0.80) and external (AUC 0.70, 0.68 to 0.72) validations. Functional status and QoL were not affected by postoperative complication after adjustment for confounders. CONCLUSION: This validated prediction model can be used to counsel older patients with breast cancer about the postoperative phase. Postoperative complications did not affect functional status nor QoL within the first year after surgery even after adjustment for predefined confounders.

Surgery remains the standard of care for the majority of older patients with breast cancer. The percentage of older patients with breast cancer receiving surgery is decreasing. The reason for this decline is unknown, but it might be due to fear of complications. To better inform patients about the benefits and risks of surgery, the aim of this study was to develop a prediction model for complications after surgery. Another important aspect, especially for older adults with breast cancer, is quality of life, functional capacity, and ability to carry out daily tasks (functional status) after therapy. This study showed that quality of life and functional status did not decline after breast surgery, irrespective of the occurrence of postoperative complications.

Contralateral breast cancer risk in relation to tumor morphology and age-in which patients is preoperative MRI justified?

Identification of patients who are at increased risk for contralateral breast cancer is essential to determine which patients should be routinely screened for contralateral breast cancer using MRI. The aim of this study was to assess the association of age and tumor morphology with contralateral breast cancer incidence in a large, nationwide population-based study in the Netherlands. All patients with breast cancer stage I-III, diagnosed between 1989 and 2009, were selected from the Netherlands Cancer Registry. The association between contralateral breast cancer risk with tumor morphology and age was assessed using competing-risk regression according to Fine & Gray. Overall, 194,898 patients were included. In multivariable analyses, lobular tumors were significantly associated with an increased risk of contralateral breast cancer within 6 months (cumulative incidence 1.9 %, subdistribution hazard ratio (SHR) 1.17, 95 % confidence interval (CI) 1.06-1.30 compared with 1.3 % in ductal tumors, p = 0.002). Age was also associated with an increased risk of contralateral breast cancer within 6 months (SHR 2.34, 95 % CI 2.08-2.62, p < 0.002 for patients over the age of 75 as compared to patients younger than 50 years). The absolute risk of contralateral breast cancer within 6 months is only slightly increased in patients with a lobular tumor and older patients. In our view, this small increased risk does not justify standard use of preoperative MRI based on tumor morphology or age alone. We propose a more personalized strategy in which additional risk factors (family history, prognosis of primary tumor, and others) may play a role.

Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making.

OBJECTIVE: To evaluate the diagnostic accuracy of clinical evaluation and cross-sectional imaging modalities such as ultrasound and computed tomography for patients with suspected colonic diverticulitis and to determine the value of these examinations in clinical decision-making. METHOD: A prospective analysis was conducted of 802 consecutive patients that presented with abdominal pain at the emergency department. Initial clinical diagnoses and management proposals were compared to the final diagnoses and therapeutic strategies for all patients. RESULTS: Fifty-seven patients were identified with colonic diverticulitis as the final diagnosis. The positive and negative predictive values for the clinical diagnosis of colonic diverticulitis were 0.65 and 0.98 respectively. Additional cross-sectional imaging had a positive and negative predictive value of respectively 0.95 and 0.99 or higher. These additional examinations led to a correct change of the initial clinical diagnosis in 37% of the patients, and a change in management in only 7%. CONCLUSION: The accuracy of the clinical diagnosis for colonic diverticulitis is low. Ultrasound and computed tomography have superior diagnostic accuracy but these examinations rarely change the initial management proposal.

Supracondylar fractures of the humerus in children. Comparison of results in two treatment periods.

Displaced supracondylar fractures of the humerus in children may be managed with or without Kirschner-wire fixation. The results of treatment of displaced supracondylar fractures of the humerus in children were analyzed, comparing the period before and after an audit of our results in 1997. From 1998 onward a more active policy regarding the use of percutaneous Kirschner-wire fixation was adopted. We treated 33 children between 1991 and 1997 (Period 1) and 49 children between 1998 and 2004 (Period 2). In Period 1, closed reduction and plaster immobilisation was performed in 29 patients. Four received initial Kirschner-wire fixation with plaster immobilisation. Secondary dislocation necessitating re-reduction occurred in 14 patients. In Period 2 initial Kirschner-wire fixation was performed in 41 patients, of whom 23 had open reduction. The other eight had conservative treatment consisting of closed reduction and plaster immobilization, two of them needing re-reduction. This evaluation indicates that a more active policy with regard to (open) reduction with Kirschner-wire fixation in displaced supracondylar humeral fractures in children, results in less need for secondary intervention with comparable functional and cosmetic outcome.

Primary retroperitoneal mucinous cystadenoma with sarcoma-like mural nodule : a case report and review of the literature.

Primary retroperitoneal cystadenomas are extremely rare. This is the first report in literature to describe a primary retroperitoneal cystadenoma with a sarcoma-like mural nodule. A 45-year-old woman complained of a left-sided abdominal mass. A computed tomography scan revealed a cystic mass with a mural nodule, which seemed to originate from the tail of the pancreas. At laparotomy the cyst was not adhered to the pancreas but localized retroperitoneally. Histologic examination showed a mucinous cystadenoma with only foci of borderline malignancy with a mural "sarcoma-like" nodule. In view of the surgical and histopathological findings, the mucinous cystadenoma was regarded as primary retroperitoneal. This case demonstrates that in the era of radiological preoperative refinement, pathological diagnosis remains of utmost importance, especially for rare cases.

[Angiosarcoma following breast-conserving therapy]. / Angiosarcoom na borstsparende behandeling.

Two women with breast cancer, 59 and 72 years of age, were treated by means of breast-conserving surgery and radiotherapy. At the age of 66 and 77, respectively, discolouration of the skin was seen in the treated breast. Punch biopsy did not show secondary malignancy. Diagnostic (deeper) excisional biopsy revealed angiosarcoma. Ablation of the breast was performed in both patients. The younger woman, however, had a recurrence four months later that was treated with wide local excision and omentum-plasty. The older woman died two years after the ablation as a result of haematogenous metastases. Knowledge of the symptoms and diagnostic pitfalls of radiotherapy-induced angiosarcoma after breast-conserving treatment is important in the follow-up of breast-cancer patients. Histological diagnosis of a biopsy taken at sufficient depth is indicated when a secondary angiosarcoma is suspected.

False negative sentinel node procedure established through palpation of the biopsy wound.

We describe our first false negative sentinel node biopsy after ceasing confirmatory axillary lymph node dissection in breast cancer. Palpation of the axilla through the biopsy wound prevented understaging.

Changes in venous hemodynamics after renal transplantation.

To explain an occasionally observed transient swelling of the ipsilateral leg in renal transplant recipients in the absence of deep vein thrombosis, we took serial measurements of venous outflow resistance and duplex examinations of both legs. Fourteen recipients of a living related donor kidney graft were submitted to strain gauge plethysmography and duplex examination before transplantation and 1 and 6 weeks thereafter. Venous outflow resistance and venous flow were measured and the veins were assessed for thrombosis. Strain gauge plethysmography showed a significant increase in venous outflow resistance in the leg on the side of the renal transplant 1 week after transplantation [0.28 +/- 0.13 vs 0.40 +/- 0.15 mmHg.s (ml/100 ml)-1; P < 0.05]. Six weeks later, the venous outflow resistance had returned to preoperative values [0.30 +/- 0.11 mmHg.s (ml/100 ml)-1; P = NS]. On the contralateral side, no significant differences were found. Duplex examinations showed no signs of thrombosis. Venous flow measurements in the common femoral vein showed no significant differences. We conclude that the additional blood supply to the iliac veins results in an increase in venous outflow resistance in the ipsilateral leg, which can explain the observed swelling of this leg and may have implications for the preferred method of diagnosis of venous thrombosis after renal transplantation.

Doppler spectrum analysis in the differential diagnosis of renal transplant dysfunction.

Cyclosporin A (CyA) nephrotoxicity and rejection of a renal allograft each demands a specific therapy. This study was designed to establish the capability of Doppler spectrum analysis to diagnose either one of these causes during renal dysfunction. Between October 1989 and October 1991 we performed echo-Doppler examinations in 209 renal transplant recipients on a routine basis during the first three months after transplantation. Echo-Doppler examinations during periods of renal dysfunction were analyzed. A total of 93 periods of renal dysfunction, retrospectively due to rejection (n = 40) or CyA toxicity (n = 53), occurred in 70 patients during the study period. A control group consisted of 82 patients with normal functioning grafts. When compared to the control group, the Doppler features (in segmental arteries) of the rejection group showed significant lower frequency shifts [Fmax (Hz) 1637 +/- 423 vs. 1436 +/- 465; p < 0.05; Fdia (Hz) 582 +/- 180 vs. 458 +/- 225; p < 0.05], a shorter deceleration time of the Doppler spectrum [Tdown (ms) 340 +/- 100 vs. 276 +/- 102; p < 0.05], and a higher Resistance Index (RI 0.64 +/- 0.08 vs. 0.68 +/- 0.13; p < 0.05). Doppler spectra during CyA toxicity showed only a significantly longer acceleration time [Tmax (ms) 123 +/- 36 vs. 139 +/- 40; p < 0.05]. The capability of differentiation between the two causes was assessed with ROC analysis of single Doppler features, stepwise regression and canonic discriminant analysis on a set of Doppler features and with manual selection of several features with extreme values. ROC analysis yielded maximum sensitivity and specificity for the diagnosis of rejection using Tdown (sensitivity 65%; specificity 68%). Stepwise regression and canonic discriminant analysis of a set of features rendered a sensitivity and specificity of 73% and 64%, respectively. Explorative selection of extreme Doppler feature values showed that 18 of the 40 grafts with rejection had values that were only seen in 2 cases with CyA toxicity (positive predictive value 90%; sensitivity 45%; specificity 96%). In half of these cases Doppler features preceded the clinical diagnosis of rejection by a median of 4 d. In conclusion, Doppler spectra are influenced by rejection and CyA toxicity in specific ways. The Doppler features, however do not enable definite differentiation between rejection and CyA toxicity in all cases. Some changes in Doppler spectra are only seen in cases of rejection and thus enable positive identification of grafts with rejection, often earlier than clinical signs indicate rejection. A normal Doppler spectrum does not exclude rejection as the cause of renal dysfunction.

Echo-Doppler diagnosis of renal allograft artery stenosis.

For the diagnosis of allograft artery stenosis in recipients of a renal transplant with hypertension a noninvasive investigation such as echo-Doppler is preferable to invasive methods such as angiography. Therefore we analyzed our experience with echo-Doppler diagnosis of renal allograft artery stenosis. In 131 renal transplant recipients with hypertension echo-Doppler examinations were performed. During the examinations several features indicative of stenosis were measured, and intrarenal Doppler spectra were quantitatively analyzed with a user-written program. Four patients showed signs of iliac artery stenosis. In 12 patients a renal allograft artery stenosis was suspected on echo-Doppler examination. In 8 of these 12 patients angiography was performed. All these showed a stenosis, 6 of which had more than > 75% stenosis. In 8 patients with normal echo-Doppler findings angiography was performed because of highly suggestive clinical signs of stenosis. In 7 of these no stenosis was found and in one a 50% stenosis was found. Comparison of quantitative Doppler spectrum features from patients with (n = 6) and without severe (> 75%) stenosis on angiography (n = 10) showed significant differences in several Doppler parameters. Subsequently an analysis of the best differentiation between these to groups on the basis of quantitative Doppler criteria was performed. In conclusion, echo-Doppler examinations with quantitative analysis of Doppler spectra enables reliable identification of renal allograft artery stenosis.

Doppler spectrum analysis to diagnose rejection during posttransplant acute renal failure.

During posttransplant acute renal failure (ARF), the diagnosis of allograft rejection constitutes a major problem. We evaluated the value of Doppler ultrasonography in identifying grafts at risk of rejection during ARF. In 184 recipients of a renal allograft, Doppler examinations were performed on the first and fifth postoperative day. Doppler spectra were quantitatively analyzed with a user-written computer program. Doppler findings were not used in clinical decision making. ARF was defined as a diuresis < 400 ml/24 hr and/or the necessity for dialysis. Doppler spectra obtained on the first day after transplantation showed a resistance index (RI) of 0.59 +/- 0.09 in recipients with immediately functioning cadaveric grafts (n = 123), while living related donor grafts (n = 20) showed a lower RI (0.55 +/- 0.07; P < 0.05). Grafts with ARF (n = 41) showed a considerably higher RI (0.67 +/- 0.13; P < 0.05). When grafts with a duration of ARF < or = 4 days (n = 17) were compared with ARF > 4 days (n = 24), RI was not significantly different (0.63 +/- 0.07 vs. 0.68 +/- 0.15; NS). However, the acceleration time of the systolic deflection of the spectrum waveform (Tmax) was shorter in grafts with ARF > 4 days (86 +/- 47 msec vs. 128 +/- 39 msec; P < 0.05). On the fifth day after transplantation, Doppler spectra in grafts with ARF > 4 days (n = 24) showed a Tmax < 90 msec in 9 patients, 8 of whom experienced rejection during ARF (positive predictive value, 8/9 = 89%). In the 15 patients with Tmax > or = 90 msec, only 2 rejections occurred (negative predictive value, 13/15 = 87%). For the RI (> 0.85), positive predictive value was 4/5 = 80% and negative predictive value (RI < or = 0.85) was 13/19 = 68%. In conclusion, a short acceleration time of the Doppler waveform on the first day after transplantation is associated with a longer duration of ARF. Quantitative analysis of Doppler spectra can be helpful in the identification of patients at risk for rejection and in the timing of allograft biopsy during ARF. Persistently short Tmax values on the fifth day after transplantation perform better in identifying grafts at risk of rejection than high RI values.

Traumatic pseudoaneurysm of the superficial temporal artery.

This paper describes, by case histories and a literature review, the cause, diagnosis and therapy of pseudoaneurysm of the superficial temporal artery. Two patients with a traumatic pseudoaneurysm of the superficial temporal artery were examined by physical examination and histology of the excised lesions. Blunt injury caused a histologically proved pseudoaneurysm in two reported cases. A total of 12 additional reports of pseudoaneurysm of the superficial temporal artery were found in the literature. Pseudoaneurysm of the superficial temporal artery is an uncommon complication of blunt head injury. Symptoms are limited and diagnosis can be made by noninvasive means. A high suspicion level for arterial injury and sufficient follow-up of patients is necessary for the detection of arterial injury.

Iliac artery stenosis after kidney transplantation.

In human kidney transplantation hypertension and renal dysfunction are common complications. Diagnosis of vascular involvement may frequently be necessary. Although iliac artery stenosis is a rare complication after renal transplantation, it can be the cause of hypertension and renal dysfunction. Because colour duplex scanning is a repeatable non-invasive technique, it may provide a useful tool in establishing a diagnosis of iliac artery stenosis in patients with hypertension and/or renal dysfunction. We present four cases of iliac artery stenosis in kidney allograft recipients. Colour duplex scanning was used in these patients to detect and localize the stenosis. Quantitative analysis of Doppler spectra was used to compare the Doppler spectrum waveforms obtained from both femoral arteries and from the kidney allograft arteries of these patients with the normal range. This normal range was determined from Doppler spectra obtained in a control group of 21 kidney allograft recipients. Clinical data, arterial DSA, and the outcome of treatment were used to validate colour duplex findings in the patients with iliac artery stenosis. Quantitative analysis of Doppler spectra showed differences between the femoral artery on the affected side and the contralateral side outside the normal range. In three patients the iliac artery stenosis was located proximal from the anastomosis with the kidney allograft artery and in these three patients Doppler parameters obtained from the allograft artery were also outside the normal range. In one patient the stenosis was located distally from the anastomosis with the kidney allograft artery. In this case Doppler spectra from the kidney allograft artery were within the normal range.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer simulations in comparison with in vivo measurements of nifedipine-induced changes in renal allograft hemodynamics.

Analysis of Doppler spectrum waveforms is increasingly used in the differential diagnosis of human renal allograft dysfunction. The physiologic interpretation of changes in Doppler spectra obtained from renal allografts, however, remains a major problem. Computer simulation models of the renal circulation may provide insight into the physiologic mechanisms responsible for changes in Doppler spectrum characteristics. The results of measurements of renal allograft hemodynamics with both determinations of PAH clearance and Doppler spectrum analysis in 11 kidney allograft recipients were explained physiologically using a computer simulation model of kidney allograft hemodynamics. Using PAH clearance and blood pressure measurements a significant decrease in RVR was found (from 0.32 +/- 0.17 to 0.20 +/- 0.07 mm Hg x min/ml, P < 0.05) after administration of the vasodilatory drug nifedipine. The Doppler spectrum waveform obtained from interlobar renal arteries showed a decrease in the RI (from 0.60 +/- 0.04 to 0.56 +/- 0.06; P < 0.05) and Tmax (from 133 +/- 32 to 98 +/- 32 ms; P < 0.05). The user-designed simulation model of renal hemodynamics showed comparable changes of the waveform when, in the model, the analogs of blood pressure, impedance of the artery, and the impedance of the peripheral vascular bed were altered proportionally.

High incidence of arteriovenous fistula after biopsy of kidney allografts.

Arteriovenous fistula (AVF) is a well known but rarely diagnosed complication of percutaneous biopsy of kidney allografts. In the past diagnosis was usually made when clinical signs of an AVF occurred but Doppler ultrasonography has now enabled non-invasive diagnosis. Doppler examination of kidney allografts was performed after 100 biopsies. A total of ten AVFs were diagnosed within 2 weeks of biopsy. On repeated examination 2 months later, no additional fistula was detected. All fistulas were detected by abnormal colour shading of the artery and vein of the fistula caused by high blood velocity. Quantification in the artery supplying the fistula showed a higher systolic velocity compared with that in a normal artery of comparable size and location in the graft (mean (range) 64 (25-150) versus 36 (20-65) cm/s, P < 0.05). Diastolic velocity was also higher in the artery supplying the fistula than in a normal artery (mean (range) 34 (9-72) versus 7 (0-13) cm/s, P < 0.05). In the group with an AVF the proportion with a prolonged bleeding time (> 3 min) was higher (80 versus 47 per cent, P < 0.05), as was the prevalence of a platelet count < 200 x 10(9)/l (60 versus 22 per cent, P < 0.05). After detection of the fistula, four of the grafts were lost because of rejection and two patients died from sepsis during antirejection treatment. During follow-up of the remaining four AVFs, three disappeared spontaneously and one persisted. None of the fistulas has had an impact on renal function requiring intervention. In conclusion, AVF is a complication observed frequently after kidney allograft biopsy that can be detected and monitored by Doppler ultrasonography.

Renal allograft artery stenosis: results of medical treatment and intervention. A retrospective analysis.

In a retrospective analysis of 1165 renal transplantations in our center, 65 cases of renal allograft artery stenosis were diagnosed angiographically (prevalence 5.5%). Hypertension was present in all cases; a bruit over the allograft and an increase in serum creatinine level were additional reasons for angiography. Shortly after diagnosis of the stenosis, two patients died and two others lost their grafts due to thrombosis. In 24 patients the decision was made not to correct the stenosis. One of these grafts was lost because the stenosis could not be corrected. Medical management of hypertension in these patients resulted in a decrease in diastolic blood pressure from 109 +/- 22 to 96 +/- 12 mm Hg (P < 0.01) 3 months after diagnosis with the use of almost twice as many antihypertensive drugs as at the time of diagnosis (P < 0.01). The stenosis was corrected if the angiography showed it to be so severe that it jeopardized renal allograft function or caused uncontrollable hypertension. Only three of nine percutaneous transluminal angioplasty (PTA) procedures resulted in a definitive correction of the stenosis. Surgical intervention was performed in 30 patients, including two patients whose PTAs had proved unsuccessful. Surgery led to graft loss due to thrombosis in 6 of 30 operations (20%), whereas restenosis occurred twice (7%). In three other cases (10%), the correction was not successful due to local anatomical variations or concomitant rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

Haemodynamic changes in human kidney allografts following administration of nifedipine: assessment with Doppler spectrum analysis.

Cyclosporin (CyA) has been demonstrated to increase the vascular resistance of renal allografts (RVR), whereas calcium channel blocking agents like nifedipine may counteract this effect. In this study RVR was calculated from renal blood flow (RBF), measured by the clearance of para-aminohippurate (PAH), and mean arterial pressure (MAP). Analysis of Doppler spectra obtained under ultrasonographic guidance was used as a non-invasive method of assessing renal haemodynamics. A comparison was made between these two methods to detect changes in renal haemodynamics which were caused by the administration of 10 mg nifedipine orally to 11 renal transplant recipients treated with CyA. RBF increased significantly (444 +/- 176 vs 559 +/- 192 ml/min per 1.73 m2; P < 0.05) despite a decrease in MAP (116 +/- 10 vs 101 +/- 11 mmHg; P < 0.05) after administration of nifedipine. Calculated RVR decreased from 0.31 +/- 0.17 to 0.20 +/- 0.07 mmHg x min/ml (P < 0.05). Results of Doppler spectrum analysis were in concordance with these observations. Resistance index (RI) in interlobar arteries decreased from 0.60 +/- 0.04 to 0.56 +/- 0.06 (P < 0.05) and acceleration time (Tmax) of the Doppler spectrum decreased from 133 +/- 32 to 98 +/- 32 ms (P < 0.05). Theoretically, a lower RI and decreased Tmax indicate a reduced vascular resistance and changes in vascular wall compliance, respectively. Analysis of Doppler spectra may thus become a useful device for non-invasive assessment of acute changes in RVR.

Assessment of hemodynamic changes in human kidney grafts induced by cyclosporin infusion.

Cyclosporin A (CyA) nephrotoxicity is at least partly caused by the vasoconstrictive action of the drug. In this study we set out to assess this hemodynamic effect of CyA on Doppler spectra obtained in arteries of human renal allografts. Doppler spectra of renal arteries were obtained shortly before and after the start of CyA infusion in renal transplant recipients. Doppler spectrum analysis revealed a significant change in several spectrum-derived parameters. Tmax (acceleration time of the systolic frequency peak), in particular, showed a decrease after 4 h of CyA administration (106 +/- 58 ms vs 76 +/- 36 ms in segmental arteries; P less than 0.05). On day 2 the Tmax returned to its original value (117 +/- 57 ms). Thus, Doppler spectrum analysis enables one to detect temporary hemodynamic changes in the transplanted kidney following CyA administration. These observations may be useful in differentiating causes of renal dysfunction by Doppler spectrum analysis in clinical transplantation.