Small but significant excess mortality compared with the general population for long-term survivors of breast cancer in the Netherlands.

BACKGROUND: Coinciding with the relatively good and improving prognosis for patients with stage I-III breast cancer, late recurrences, new primary tumours and late side-effects of treatment may occur. We gained insight into prognosis for long-term breast cancer survivors. PATIENTS AND METHODS: Data on all 205 827 females aged 15-89 diagnosed with stage I-III breast cancer during 1989-2008 were derived from the Netherlands Cancer Registry. Conditional 5-year relative survival was calculated for every subsequent year from diagnosis up to 15 years. RESULTS: For stage I, conditional 5-year relative survival remained ~95% up to 15 years after diagnosis (a stable 5-year excess mortality rate of 5%). For stage II, excess mortality remained 10% for those aged 15-44 or 45-59 and 15% for those aged 60-74. For stage III, excess mortality decreased from 35% at diagnosis to 10% at 15 years for those aged 15-44 or 45-59, and from ~40% to 30% for those aged ≥60. CONCLUSIONS: Patients with stage I or II breast cancer had a (very) good long-term prognosis, albeit exhibiting a small but significant excess mortality at least up to 15 years after diagnosis. Improvements albeit from a lower level were mainly seen for patients who had been diagnosed with stage III disease. Caregivers can use this information to better inform (especially disease-free) cancer survivors about their actual prognosis.

Benefits and drawbacks of short-course preoperative radiotherapy in rectal cancer patients aged 75 years and older.

PURPOSE: To study incidence of local recurrences, postoperative complications and survival, in patients with rectal carcinoma aged 75 years and older, treated with either surgery and pre-operative 5 × 5 Gy radiotherapy or surgery alone. PATIENTS AND METHODS: A random sample of patients aged over 75 years with pT2-T3, N0-2, M0 rectal carcinoma diagnosed between 2002 and 2004 in the Netherlands was included, treated with surgery alone (N = 296) or surgery in combination with pre-operative radiotherapy (N = 346). Information on local recurrent disease, postoperative complications, ECOG-performance score and comorbidity was gathered from the medical files. RESULTS: Local recurrences developed less frequently in patients treated with pre-operative radiotherapy compared to surgery alone (2% vs 6%, p = 0.002). Postoperative complications developed more frequently in irradiated patients (58% vs 42%, p < 0.0001). Especially deep infections (anastomotic leakage, pelvic abscess) were significantly increased in this group (16% vs 10%, p = 0.02). 30-day mortality was equal in both groups (8%). A significant increase in postoperative complication rate and 30-day mortality was only seen in those with "severe comorbidity" compared to patients without comorbidity (respectively 58% and 10% vs 43% and 3%), COPD (59% and 12%), diabetes (60% and 11%) and cerebrovascular disease (62% and 14%). In multivariable analysis, postoperative complications predicted 5-year survival. CONCLUSION: Elderly patients receiving pre-operative radiotherapy show a lower local recurrence rate. However, as incidence rates of local recurrent disease are low and incidence of postoperative complications is increased in irradiated patients, omitting preoperative RT may be suitable in elderly patients with additional risks for complications or early death.

Axillary recurrences after negative sentinel lymph node biopsy under local anaesthesia for breast cancer: a follow-up study after 5 years.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) is accepted as a standard surgical staging procedure for determining the tumour status of the regional lymph nodes. Until September 2000 we performed SLNB in general anaesthesia. Since 1999, after validation of the SLNB concept, axillary dissection was omitted in SLN-negative patients. This study presents our data after SLNB under local anaesthesia after a follow-up of at least 5 years. MATERIALS AND METHODS: Between September 2000 and May 2003, 356 SLNBs were performed under local anaesthesia without sedation in patients with proven breast cancer (T4-tumours and small in situ carcinomas excluded) and without clinically or ultrasound guided cytological evidence of axillary node involvement. Lymphatic mapping and SLN identification were performed through the combination of blue dye and 99m Tc-nanocolloid. All positive SLNs were followed by an axillary dissection up to level three. SLN-negative patients were followed without axillary clearance. RESULTS: In 353/356 SLNBs at least one sentinel node was found. 254/353 SLNs were tumour free. After a median follow-up of 73 months loco-regional and distant events were encountered in 10/353 SLNBs. Four patients (SLN-negative) showed tumour localization in the residual breast or chest wall (1.1%). Three patients (SLN-negative) presented with supraclavicular metastases (0.8%). In three patients (one SLN-negative and two SLN-positive followed by ALND) an axillary recurrence was encountered (0.8%). CONCLUSION: This survey confirms the safety of the SLNB under local anaesthesia in selecting patients for axillary lymph node dissection in breast cancer.

Simultaneous bilateral breast cancer in a male: a case report and review of the literature.

A 63-year-old male presented with a bilateral breast carcinoma. Both axillae showed metastases. The patient was treated with a bilateral modified breast amputation. Study of the literature shows that synchronous bilateral breast cancer in males is uncommon. Even in a male with changing breast tissue a carcinoma has to be considered. In male breast cancer, adherence to diagnostic and treatment guidelines for female breast cancer is generally advocated. In males, hormonal causes have to be excluded.

[Unexplained vague abdominal complaints in adults: indication for CT in case of suspected intussusception]. / Onbegrepen vage buikklachten bij volwassenen: bij vermoeden van een invaginatie CT verrichten.

In two adult patients, a 74-year-old woman and a 84-year-old man, who suffered from vague abdominal complaints, an intussusception was diagnosed by CT. Surgical resection of the affected bowel parts was successful. Intussusception is usually seen in children; in adults it is a rare condition. Adult patients mostly complain about vague abdominal pain only. Physical examination, laboratory investigations and plain abdominal X-rays often don't give any additional information. In such patients it is advised to perform CT of the abdomen at an early stage. CT may show a so-called 'target sign' which is characteristic of an intussusception. In addition it can provide information about the possible causes of the intussusception, most commonly a malignant tumour in adults. During laparotomy one should not attempt to reduce the intussusception because of the risk of tumour spill. In this clinical review, we present two adult patients with unexplained abdominal complaints due to intussusception, caused by malignancy.

Continuous leakage measurement during hyperthermic isolated limb perfusion.

BACKGROUND: Continuous measurement of perfusate leakage into the systemic circulation is of the utmost importance and can be performed with the help of radioactive tracers. The purpose of this study was to assess changes in the perfusion leakage rate between two periods: 1977-1990 and 1991-2000, and to determine the factors responsible for these changes. METHODS: During the 1991-2000 period, 119 patients underwent HILP mainly for locally recurrent melanoma or locally advanced soft tissue sarcoma. HILP was performed with melphalan (33%) or in combination with TNFalpha (65%). There were 67 iliacal, 12 femoral, 25 popliteal, and 15 axillary perfusions performed. Leakage into the systemic circulation was monitored continuously with the help of 131I-albumin and a stationary scintillation detector placed above the heart. RESULTS: The median maximum leakage was 2.7% (range 0%-21%) which is significantly less than the previous period (1977-1990) where leakage of 8% (range 0%-30%) was reported (P < .05). A statistical difference in leakage was detected among perfusion locations where the iliac and femoral vessels showed more leakage than the axillary and popliteal vessels (P < .05). Furthermore, there appeared to be significantly less leakage when TNFalpha was used than when melphalan was the sole drug (P < .05). CONCLUSIONS: Nowadays leakage from isolated perfusions into the systemic circulation is further minimized compared with the days when melphalan was the sole drug used. Increased awareness about TNFalpha leakage, continuous external monitoring with 131I-albumin as the main isotope, flow rate regulation in the perfusion circuit, and regulation of the patient's systemic blood pressure have all been major contributors to this improvement.

Soft tissue sarcoma--compliance with guidelines.

BACKGROUND: Because soft tissue sarcomas (STS) are rare, guidelines for the diagnosis and treatment of patients with STS were developed. Because the diagnostic management is essential for definitive treatment, adherence to these guidelines is important. METHODS: Primary STS registered by the Comprehensive Cancer Center North-Netherlands from January 1989 to January 1996 were analyzed retrospectively with regard to adherence to the diagnostic guidelines. Urogenital, gastrointestinal STS, and Kaposi sarcomas were excluded. RESULTS: Three hundred fifty-one STS patients were analyzed. In the specialized center, 69% of patients were age < 60 years, whereas, in district hospitals, 63% of patients were age > 60 years. With increased age, referral to the center declined in a linear fashion. For all guidelines, adherence was significantly better in the center. In district hospitals, patient volume had no significant influence on compliance with the guidelines, except for the management of patients with STS > or = 3 cm. In district hospitals, where fewer than 15 patients were treated in the 7-year period, significantly more often, an inadequate biopsy or even no biopsy procedure was performed prior to resection. CONCLUSIONS: In many aspects of the diagnostic process of STS, existing guidelines were not followed, especially in community hospitals. Adherence to all individual guidelines was significantly better in the specialized center. To improve compliance with future STS guidelines, appropriate guideline development, dissemination, and implementation programs should be developed. Concentration of patients with STS in a limited number of hospitals and intensified collaboration with specialized centers seem advisable. Special attention should be paid to older patients, who significantly more often were not referred to a specialized center.

Clinico-pathological data and prognostic factors in completely resected AJCC stage I-III liposarcomas.

BACKGROUND: In general, although biological behavior and prognosis of liposarcomas (LPS) are more favorable compared with most other soft tissue sarcomas (STS), prognosis can vary widely depending on tumor characteristics, especially histological subtype and tumor grade. PATIENTS AND METHODS: All consecutive, completely resected stage I-III LPS (as determined by the American Joint Committee on Cancer staging guidelines), treated at the Groningen University Hospital from 1977-2000, were analyzed. RESULTS: A total of 69 patients, 35 males and 34 females, median age 51 (range 11-80) years, were reviewed. After a median follow-up of 71 (range 5-231) months, the overall local recurrence and metastasis rate at five years after diagnosis were 27% and 16%, respectively. Retroperitoneal localization was a significant negative prognostic factor regarding local recurrence; dedifferentiation, grade II-III, and deep location regarding distant metastasis; and dedifferentiation, grade II-III, stage II-III, size >20 cm and non-radical resection regarding survival. CONCLUSIONS: LPS have a relatively mild biologic behavior, with the exception of very large, deeply located, dedifferentiated and/or grade II-III LPS. Radical resection is important for disease-specific survival. LPS have a relatively mild biologic behavior, with the exception of very large, deeply located, dedifferentiated and/or grade II-III LPS.

Long-term results of preoperative intra-arterial doxorubicin combined with neoadjuvant radiotherapy, followed by extensive surgical resection for locally advanced soft tissue sarcomas of the extremities.

BACKGROUND AND PURPOSE: In the 1980s a combined modality therapy of intraarterial doxorubicin, neoadjuvant radiotherapy and surgery was initiated at the Groningen University Hospital as a limb-saving treatment for locally advanced, primarily irresectable high-grade soft tissue sarcomas (STS) of the extremities. This study presents the short- and long-term results. PATIENTS AND METHODS: Between 1983 and 1987, 11 patients were treated with intraarterial doxorubicin, preoperative radiotherapy (10 x 3.5 Gy) and surgical resection. Non-radical resections received additional postoperative radiotherapy of 20-30 Gy. RESULTS: The limb-salvage rate was 91%, without local recurrences during a median follow-up of 84 months. Six patients died (55%); five from metastatic disease (45%). There were five long-term survivors with a median follow-up of 10 years. Three patients (60%) suffered serious late complications, resulting in disabilitating limb function. CONCLUSION: Although this approach is feasible as a limb-saving treatment for these unfavorable STS, long-term morbidity is high.

Epidemiological aspects of soft tissue sarcomas (STS)--consequences for the design of clinical STS trials.

The purpose of the study was to gain insight into epidemiological aspects of soft tissue sarcomas (STS), based on the population-based cancer registry of the Comprehensive Cancer Center North-Netherlands (CCCN), and to provide data for the development of future STS clinical trials. 456 primary STS (Kaposi, urogenital and gastro-intestinal STS excluded), registered from 1989 to 1995 by the cancer registration of the Comprehensive Cancer Center North-Netherlands (CCCN), were analysed. The annual, age-adjusted, STS incidence was 3.6 per 100,000. Incidence increased with age. Half of the patients were over the age of 65 years. Malignant fibrous histiocytomas and liposarcomas were most frequently encountered. At presentation, nodal involvement was rare (3-8%). Distant metastases were more frequently encountered (9-14%), and appeared to be related to tumour size and site. Above 70 years of age, 16% of patients received no treatment at all, especially for metastatic disease.

Perianal injection of polydimethylsiloxane (Bioplastique implants) paste in the treatment of soiling: pilot study in rats to determine migratory tendency and locoregional reaction.

UNLABELLED: Not much is known about the specific pathophysiologic mechanisms of soiling. Although the causes of soiling may vary, it is mostly associated with anorectal disorders that can deform the contour of the anus and anal canal. In most cases, this disorder can be treated successfully by medical or surgical therapy. If this appropriate treatment is not available or fails, reconstruction of the contour deformity of the anus by perianal (submucosal) injection of soft tissue bulking agents may be successful. PURPOSE: The main purpose of this pilot study was to evaluate locoregional reaction and distant migration after local perianal injection of solid polydimethylsiloxane elastomer particles (Bioplastique implants). METHODS: Twelve Lewis rats received a local perianal injection of Bioplastique implants. Six of them received an additional perianal injection of gentamicin. Six weeks after injection, the rats were euthanized. RESULTS: Microscopically, the local tissue reaction was that of a quiescent foreign body reacting with encapsulation. Microscopic examinations could not reveal any migration to locoregional lymph nodes, liver, spleen, lungs, or brain. CONCLUSION: We conclude that, because of minimum local reaction and lack of evidence of distant migration, polydimethylsiloxane elastomer particle paste (Bioplastique implants) seems to be a potentially safe substance for local perianal injection.

Prevention of wound infection in elective colorectal surgery by local application of a gentamicin-containing collagen sponge.

Preoperative antibiotic prophylaxis is known to significantly reduce the incidence of postoperative wound infection in elective colorectal surgery, and is a recognized part of surgical management. Antibiotics are usually given systemically or orally, or by a combination of the two routes. Local antibiotic delivery to the wound site using an implanted, reabsorbable, gentamicin-containing collagen sponge is a novel concept. We compared postoperative wound infection rates in 221 colorectal surgery patients randomized to receive systemic gentamicin/metronidazole with (Group I, n = 107) or without (Group II, n = 114) the gentamicin-collagen sponge. The two patient groups were identical on the basis of demographics and operations undergone. The postoperative wound infection rate was significantly lower in Group I patients than Group II 5.6% (6/107) and 18.4% (21/ 114), respectively (p < 0.01). The mean duration of hospital stay was 13.8 days in Group I and 16.3 days in Group II, which did not represent a statistically significant difference. The gentamicin collagen sponge was well tolerated and no adverse events were reported that were attributable to its use. This new method for delivering gentamicin directly to the operative site may represent a significant method for reducing postoperative wound infection rates to levels lower than those currently achieved with systemic antibiotics alone.

Laparoscopic introduction of a continuous ambulatory peritoneal dialysis (capd) catheter by a two-puncture technique.

We describe a laparoscopic two-puncture technique for the placement of a continuous ambulatory peritoneal dialysis catheter. With a mean follow-up period of 8 months the short-term results of the first 19 laparoscopic catheter insertions are evaluated and discussed. It appears to be a simple, safe, and viable procedure with a low morbidity and very good results in the short term. The same technique can also be used in catheter salvage in case of outflow obstruction or catheter migration, thus increasing catheter longevity.