Guideline adherence of mediastinal staging of non-small cell lung cancer: A multicentre retrospective analysis.

OBJECTIVES: Mediastinal lymph node staging of NSCLC by initial endosonography and confirmatory mediastinoscopy is recommended by the European guideline. We assessed guideline adherence on mediastinal staging, whether staging procedures were performed systematically and unforeseen N2 rates following staging by endosonography with or without confirmatory mediastinoscopy. MATERIAL AND METHODS: We performed a multicentre (n = 6) retrospective analysis of NSCLC patients without distant metastases, who were surgical candidates and had an indication for mediastinal staging in the year 2015. All patients who underwent EBUS, EUS and/or mediastinoscopy were included. Surgical lymph node dissection was the reference standard. Guideline adherence was based on the 2014 ESTS guideline. RESULTS: 330 consecutive patients (mean age 69 years; 61% male) were included. The overall prevalence of N2/N3 disease was 42%. Initial mediastinal staging by endosonography was done in 84% (277/330; range among centres 71-100%; p < .01). Confirmatory mediastinoscopy was performed in 40% of patients with tumour negative endosonography (61/154; range among centres 10%-73%; p < .01). Endosonography procedures were performed 'systematically' in 21% of patients (57/277) with significant variability among centres (range 0-56%; p < .01). Unforeseen N2 rates after lobe-specific lymph node dissection were 8.6% (3/35; 95%-CI 3.0-22.4) after negative endosonography versus 7.5% (3/40; 95% CI 2.6-19.9) after negative endosonography and confirmatory mediastinoscopy. CONCLUSION: Although adherence to the European NSCLC mediastinal staging guideline on initial use of endosonography was good, 30% of endosonography procedures were performed insufficiently. Confirmatory mediastinoscopy following negative endosonography was frequently omitted. Significant variability was found among participating centres regarding staging strategy and systematic performance of procedures. However, unforeseen N2 rates after mediastinal staging by endosonography with and without confirmatory mediastinoscopy were comparable.

The PINCH-Phone: a new screenings method for recurrent incisional hernias.

BACKGROUND: Debate persists on the optimal management of incisional hernias due to paucity of accurate recurrence rates. Reoperation rates implicate a severe underestimation of the risk of a recurrence. Therefore, long-term postoperative clinic visits allowing physical examination of the abdomen are deemed necessary. However, these are time and costs consuming. Aim of this study was to develop and evaluate a new screenings method for recurrent hernias, the 'PINCH-Phone' (Post-INCisional-Hernia repair-Phone). METHODS: The PINCH-Phone is a telephone questionnaire. In this multicenter prospective study, the PINCH-Phone was answered by patients after incisional hernia repair. Afterwards the patients were seen at the clinic and physical examination was done to detect any recurrences. RESULTS: The PINCH-Phone questions were answered by 210 patients with a median postoperative follow-up of 36 months. Fifty-six patients were seen after multiple incisional hernia repairs. In 137 patients who had replied positively to one or more questions, 28 recurrent incisional hernias were detected at physical examination. Six recurrences were noted in 73 patients who had replied negatively to all questions. The overall sensitivity and specificity of the PINCH-Phone were 82% and 38%, respectively. CONCLUSION: The PINCH-Phone appears a simple and valuable screenings method for recurrences after incisional hernia repair and, hence, is recommended for implementation.

Accuracy of MRI in Restaging Locally Advanced Rectal Cancer After Preoperative Chemoradiation.

BACKGROUND: Patients with a locally advanced rectal carcinoma benefit from preoperative chemoradiotherapy. MRI is considered the first choice imaging modality after preoperative chemoradiation, although its reliability for restaging is debatable. OBJECTIVE: The purpose of this study was to determine the accuracy of MRI in restaging locally advanced rectal cancer after preoperative chemoradiation. DESIGN: This was a retrospective study. SETTINGS: The study was conducted in a Dutch high-volume rectal cancer center. PATIENTS: A consecutive cohort of 48 patients with locally advanced rectal cancer treated with a curative intent was identified. MAIN OUTCOME MEASURES: Three readers independently evaluated the MRI both for primary staging and for restaging after preoperative chemoradiation and were blinded to results from the other readers as well as histological results. Interobserver variability was determined. Accuracy of the restaging MRI was assessed through the comparison of tumor characteristics on MRI with histopathologic outcomes. RESULTS: T stage was correctly predicted by the 3 readers in 47% to 68% and N stage in 68% to 70%. Overstaging was more common than understaging. Positive predictive values (PPV) among the 3 readers for T0 were 0%, and negative predictive values (NPVs) varied from 84% to 85%. For T1/2, PPVs and NPVs were 50% to 67% and 72% to 90%, and for T3/4 they were 54% to 62% and 33% to 78%. PPVs and NPVs for N0 stage were 81% to 95% and 58% to 73%. Tumor regression grade on MRI did not correspond with histopathologic tumor regression grade; PPVs for good response (tumor regression grade on MRI 1-2) were 48% to 61%, and NPVs were 42% to 58%. Interobserver agreement was fair to moderate for T stage, N stage, and tumor response (κ = 0.20-0.41) and fair to substantial for the relation with the mesorectal fascia (κ = 0.33-0.77). In none of the patients was the surgical plan changed after the restaging MRI. LIMITATIONS: This study was limited by its small sample size and retrospective nature. CONCLUSIONS: MRI has low accuracy for restaging locally advanced rectal cancer after preoperative chemoradiation, and the interobserver variability is significant.

Diagnostic accuracy and patient acceptance of MRI in children with suspected appendicitis.

OBJECTIVE: To compare magnetic resonance imaging (MRI) and ultrasound in children with suspected appendicitis. METHODS: In a single-centre diagnostic accuracy study, children with suspected appendicitis were prospectively identified at the emergency department. All underwent abdominal ultrasound and MRI within 2 h, with the reader blinded to other imaging findings. An expert panel established the final diagnosis after 3 months. We evaluated the diagnostic accuracy of three imaging strategies: ultrasound only, conditional MRI after negative or inconclusive ultrasound, and MRI only. Significance between sensitivity and specificity was calculated using McNemar's test statistic. RESULTS: Between April and December 2009 we included 104 consecutive children (47 male, mean age 12). According to the expert panel, 58 patients had appendicitis. The sensitivity of MRI only and conditional MRI was 100% (95% confidence interval 92-100), that of ultrasound was significantly lower (76%; 63-85, P < 0.001). Specificity was comparable among the three investigated strategies; ultrasound only 89% (77-95), conditional MRI 80% (67-89), MRI only 89% (77-95) (P values 0.13, 0.13 and 1.00). CONCLUSION: In children with suspected appendicitis, strategies with MRI (MRI only, conditional MRI) had a higher sensitivity for appendicitis compared with a strategy with ultrasound only, while specificity was comparable. KEY POINTS: • In children, MRI has a higher sensitivity for appendicitis than ultrasound. • Ultrasound followed by MRI in negative or inconclusive findings is accurate. • The tolerance for ultrasound and MRI in children is comparable. • MRI can be performed in children in an emergency setting.

[A woman with a growing mass near the anus]. / Een vrouw met een groeiende massa tussen de billen.

A 58-year-old woman visited the surgical outpatient clinic because of a mass near the anus that had existed for years and had now grown to a size that made sitting impossible. With histological examination of the 6 x 10 cm exofytic, condylomatic mass, the diagnosis 'giant condyloma acuminatum' was made. Radical excision was performed, the patient recovered well.

[Trends in breast cancer treatment in the elderly at a breast cancer outpatient clinic: guidelines followed better]. / Trends in behandeling borstkanker bij ouderen op een mammapolikliniek: minder vaak operatieve behandeling.

OBJECTIVE: To investigate the treatment of resectable breast cancer in elderly patients at Alkmaar Medical Centre, Alkmaar, the Netherlands, before and after the introduction of a multidisciplinary breast cancer consultation (MDC) with the breast cancer team in February 2006. DESIGN: Retrospective. METHOD: The treatment of patients aged 70 and over with newly diagnosed stage I and II resectable breast cancer was monitored during the period 2002-2007. RESULTS: A total of 84% of the 232 studied patients were treated surgically. Adjuvant treatment with radiotherapy, hormone therapy and chemotherapy was given to 88, 91 and 5 patients, respectively. The percentage of patients who underwent first-line surgery decreased significantly, mainly because fewer patients aged 80 or over received surgery. The number of patients given radiotherapy in accordance with guidelines increased, while for hormonal therapy the number remained more or less the same. Recording of decisions that involved deviation from treatment guidelines improved in the study period. CONCLUSION: In 2002-2007, the breast cancer team became more aware of treatment guidelines and deviations from guidelines were better accounted for. In the elderly, the guidelines for adjuvant radiotherapy were followed better, but there was a remarkable decrease in primary surgical treatment of patients, particularly in patients aged 80 and over. Comorbidity and patients' preferences played an important role in this.