Multicentre study of short-course radiotherapy, systemic therapy and resection/ablation for stage IV rectal cancer.

BACKGROUND: The optimal treatment sequence for patients with rectal cancer and synchronous liver metastases remains unclear. The aim of this study was to evaluate the feasibility and effectiveness of short-course pelvic radiotherapy (5 × 5 Gy) followed by systemic therapy and local treatment of all tumour sites in patients with potentially curable stage IV rectal cancer in daily practice. METHODS: This was a retrospective study performed in eight tertiary referral centres in the Netherlands. Patients aged 18 years or above with rectal cancer and potentially resectable liver ± extrahepatic metastases, treated between 2010 and 2015, were eligible. Main outcomes included full completion of treatment schedule, symptom control and survival. RESULTS: In total, 169 patients were included with a median follow-up of 49·5 (95 pr cent c.i. 43·6 to 55·6) months. The completion rate for the entire treatment schedule was 65·7 per cent. Three-year progression-free survival and overall survival (OS) rates were 24·2 (95 per cent c.i. 16·6 to 31·6) and 48·8 (40·4 to 57·2) per cent respectively. Median OS of patients who responded well and completed the treatment schedule was 51·5 months, compared with 15·1 months for patients who did not complete the treatment (P < 0·001). Adequate symptom control of the primary tumour was achieved in 87·0 per cent of all patients. CONCLUSION: Multimodal treatment leads to relief of symptoms in most patients, and is associated with good survival rates in those able to complete the schedule. [Correction added on 12 February 2020, after first online publication: the Conclusion has been reworded for clarity].

ANTECEDENTES: La secuencia óptima de tratamiento en pacientes con cáncer de recto y metástasis hepáticas sincrónicas sigue sin estar clara. El objetivo de este estudio fue evaluar en la práctica diaria la viabilidad y efectividad de la radioterapia pélvica de ciclo corto (5 x 5 Gy) seguida de tratamiento sistémico y tratamiento local de todas las localizaciones del tumor primario en pacientes con cáncer de recto estadio IV potencialmente curables. MÉTODOS: Estudio retrospectivo realizado en ocho centros terciarios de referencia en Holanda. Se consideró elegibles a los pacientes mayores de 18 años con cáncer de recto y metástasis hepáticas ± extrahepáticas potencialmente resecables, que fueron tratados entre 2010 y 2015. Los criterios de valoración principales incluyeron la finalización completa del programa de tratamiento, el control de los síntomas y la supervivencia. RESULTADOS: En total se incluyeron 169 pacientes con una mediana de seguimiento de 50 meses (rango 2-89 meses). La tasa de finalización del programa de tratamiento completo fue del 65,7%. Las tasas de supervivencia libre de progresión a 3 años y supervivencia global (overall survival, OS) fueron 24,2% (i.c. del 95% 16,6-31,6) y 48,8% (i.c. del 95% 40,4-57,2), respectivamente. La mediana de OS de los pacientes que respondieron bien y completaron el programa de tratamiento fue de 51,5 meses, en comparación con 15,1 meses en pacientes que no completaron el tratamiento (P < 0,001). Se logró un control adecuado de los síntomas del tumor primario en el 87,0% de todos los pacientes. CONCLUSIÓN: El tratamiento multimodal consigue paliar los síntomas en la mayoría de los pacientes y se asocia con buenas tasas de supervivencia en aquellos pacientes que pueden completar el programa.

The value of tumor-stroma ratio as predictor of pathologic response after neoadjuvant chemoradiotherapy in esophageal cancer.

BACKGROUND AND PURPOSE: With currently available techniques, the prediction of pathologic complete response after neoadjuvant chemoradiotherapy is insufficient. The tumor-stroma ratio (TSR) has proven to be a predictor of survival for several types of cancer, including esophageal. The aim of this study was to investigate the value of TSR in predicting pathologic response after neoadjuvant chemoradiotherapy in esophageal cancer patients. MATERIALS AND METHODS: Patients with esophageal adenocarcinoma or squamous cell carcinoma who received neoadjuvant chemoradiotherapy followed by a resection were selected. Haematoxylin and eosin (H&E) stained sections of diagnostic biopsies were collected and TSR was independently assessed by two investigators. Patients were categorized in stroma-low (≤50% stroma) and stroma-high (>50% stroma) groups for further analyses. The tumor regression grade (TRG) was assessed on H&E stained sections of the resected primary tumor to determine pathologic response. RESULTS: A total of 94 patients were included in this study, of which 76 patients were categorized as stroma-low and 18 as stroma-high. Forty-two (45%) patients had a major pathologic response (TRG 1-2), whereas 52 (55%) were considered non-responders. After adjustment for gender, tumor type, cT-status and differentiation grade, patients with a stroma-high tumor showed a higher chance of no response compared to patients with a stroma-low tumor (OR 3.57, 95%CI 1.03-12.31, P = 0.04). CONCLUSION: TSR showed to have the potential to aid in the prediction of pathologic response in esophageal cancer patients receiving neoadjuvant chemoradiotherapy. Larger validation studies are necessary before implementing this method in daily practice.

[A male with intra-abdominal nodules on a CT scan]. / Een man met intra-abdominale noduli op een CT-scan.

A 38-year-old male with a history of laparoscopic cholecystectomy and successfully treated Hodgkin lymphoma had a follow-up CT-scan which showed four nodular densities behind the bladder. Additional investigations demonstrated spilled gallstones instead of a relapse of Hodgkin lymphoma. Spillage of gallstones is relatively common and may mimic malignant diseases.

Clinical outcomes of definitive chemoradiotherapy using carboplatin and paclitaxel in esophageal cancer.

Patients with nonmetastatic esophageal cancer not suitable for surgery can be treated with definitive chemoradiotherapy with curative intent. The purpose of this retrospective study is to evaluate the clinical outcomes of definitive chemoradiotherapy using carboplatin and paclitaxel. Medical records were reviewed of patients treated for nonmetastatic squamous cell or adenocarcinoma of the esophagus between January 2009 and December 2013 in two collaborating institutes. Treatment consisted of external beam radiotherapy (28 fractions of 1.8 Gy) and 6 weekly courses of carboplatin (AUC = 2) and paclitaxel (50 mg/m2). Data on survival, progression, toxicity, and effect on dysphagia were recorded. Sixty-six patients were included. Median overall survival (OS) was 13.1 months (95% CI 4.7-21.5 months) and a 2-year OS was 30% (95% CI 18%-42%). At 2 years, 26% of patients developed local progression (95% CI 15%-37%) and 49% developed distant metastases (95% CI 36%-64%). Acute toxicity grade ≥3 was observed in 47% of patients. Late adverse events grade ≥3 were seen in 20%, mostly esophageal stenoses. Of patients with available data 3 months after treatment, 70% had relief of dysphagia. Definitive chemoradiotherapy led to a median OS of 13 months. Toxicity was common, mostly due to hematological toxicity. Given the relatively short median survival, an adequate selection of patients for this intensive treatment is required.

Real-world and trial-based cost-effectiveness analysis of bevacizumab in HER2-negative metastatic breast cancer patients: a study of the Southeast Netherlands Breast Cancer Consortium.

INTRODUCTION: The aim of our analysis was to assess the real-world cost-effectiveness of bevacizumab in addition to taxane treatment versus taxane monotherapy for HER2-negative metastatic breast cancer compared with the cost-effectiveness based on the efficacy results from a trial. METHODS: A state transition model was built to estimate costs, life years (LYs) and quality-adjusted life years (QALYs) for both treatments. Two scenarios were examined: a real-world scenario and a trial-based scenario in which transition probabilities were primarily based on a real-world cohort study and the E2100 trial, respectively. In both scenarios, costs and utility parameter estimates were extracted from the real-world cohort study. Moreover, the Dutch health care perspective was adopted. RESULTS: In both the real-world and trial scenarios, bevacizumab-taxane is more expensive (incremental costs of €56,213 and €52,750, respectively) and more effective (incremental QALYs of 0.362 and 0.189, respectively) than taxane monotherapy. In the real-world scenario, bevacizumab-taxane compared to taxane monotherapy led to an incremental cost-effectiveness ratio (ICER) of €155,261 per QALY gained. In the trial scenario, the ICER amounted to €278,711 per QALY gained. CONCLUSION: According to the Dutch informal threshold, bevacizumab in addition to taxane treatment was not considered cost-effective for HER2-negative metastatic breast cancer both in a real-world and in a trial scenario.

In real life, one-quarter of patients with hormone receptor-positive metastatic breast cancer receive chemotherapy as initial palliative therapy: a study of the Southeast Netherlands Breast Cancer Consortium.

BACKGROUND: The objective of this study was to present initial systemic treatment choices and the outcome of hormone receptor-positive (HR+) metastatic breast cancer. PATIENTS AND METHODS: All the 815 consecutive patients diagnosed with metastatic breast cancer in 2007-2009 in eight participating hospitals were identified. From the 611 patients with HR+ disease, a total of 520 patients with HER2-negative (HER2-) breast cancer were included. Initial palliative systemic treatment was registered. Progression-free survival (PFS) and overall survival (OS) per initial palliative systemic therapy were obtained using the Kaplan-Meier method and compared using the log-rank test. RESULTS: From the total of 520 patients with HR+/HER2- metastatic breast cancer, 482 patients (93%) received any palliative systemic therapy. Patients that received initial chemotherapy (n = 116) were significantly younger, had less comorbidity, had received more prior adjuvant systemic therapy and were less likely to have bone metastasis only compared with patients that received initial endocrine therapy (n = 366). Median PFS of initial palliative chemotherapy was 5.3 months [95% confidence interval (CI) 4.2-6.2] and of initial endocrine therapy 13.3 months (95% CI 11.3-15.5), with a median OS of 16.1 and 36.9 months, respectively. Initial chemotherapy was also associated with worse outcome in terms of PFS and OS after adjustment for prognostic factors. CONCLUSIONS: A high percentage of patients with HR+ disease received initial palliative chemotherapy, which was associated with worse outcome, even after adjustment of relevant prognostic factors.

Prognosis of metastatic breast cancer: are there differences between patients with de novo and recurrent metastatic breast cancer?

BACKGROUND: We aimed to determine the prognostic impact of time between primary breast cancer and diagnosis of distant metastasis (metastatic-free interval, MFI) on the survival of metastatic breast cancer patients. METHODS: Consecutive patients diagnosed with metastatic breast cancer in 2007-2009 in eight hospitals in the Southeast of the Netherlands were included and categorised based on MFI. Survival curves were estimated using the Kaplan-Meier method. Cox proportional hazards model was used to determine the prognostic impact of de novo metastatic breast cancer vs recurrent metastatic breast cancer (MFI ⩽24 months and >24 months), adjusted for age, hormone receptor and HER2 status, initial site of metastasis and use of prior (neo)adjuvant systemic therapy. RESULTS: Eight hundred and fifteen patients were included and divided in three subgroups based on MFI; 154 patients with de novo metastatic breast cancer, 176 patients with MFI <24 months and 485 patients with MFI >24 months. Patients with de novo metastatic breast cancer had a prolonged survival compared with patients with recurrent metastatic breast cancer with MFI <24 months (median 29.4 vs 9.1 months, P<0.0001), but no difference in survival compared with patients with recurrent metastatic breast cancer with MFI >24 months (median, 29.4 vs 27.9 months, P=0.73). Adjusting for other prognostic factors, patients with MFI <24 months had increased mortality risk (hazard ratio 1.97, 95% CI 1.49-2.60, P<0.0001) compared with patients with de novo metastatic breast cancer. When comparing recurrent metastatic breast cancer with MFI >24 months with de novo metastatic breast cancer no significant difference in mortality risk was found. The association between MFI and survival was seen irrespective of use of (neo)adjuvant systemic therapy. CONCLUSION: Patients with de novo metastatic breast cancer had a significantly better outcome when compared with patients with MFI <24 months, irrespective of the use of prior adjuvant systemic therapy in the latter group. However, compared with patients with MFI >24 months, patients with de novo metastatic breast cancer had similar outcome.

Longitudinal changes and seasonal variations in serum 25-hydroxyvitamin D levels in different age groups: results of the Longitudinal Aging Study Amsterdam.

UNLABELLED: Vitamin D levels remained fairly stable during ageing with increasing levels in persons aged 55-65 years old and decreasing levels in persons aged 65-88 years old. The seasonal variation was larger than the longitudinal change. Our findings implicate that vitamin D supplementation becomes more important in older age groups and during wintertime. INTRODUCTION: Longitudinal changes in serum 25-hydroxyvitamin D (25-OHD) levels during aging have not been studied extensively. Two studies showed increasing serum 25-OHD levels. One of these studies suggested that there might be decreasing levels in persons aged 65 years and older. The objectives of the current study are the following: (1) to examine longitudinal changes in serum 25-OHD levels in different age groups and (2) to describe the seasonal variation in different age groups. METHODS: Data of the Longitudinal Aging Study Amsterdam (LASA), an ongoing cohort study, were used. Two different cohorts were included: (1) younger cohort: aged 55-65 years old at baseline, n = 738, follow-up of 6 years and (2) older cohort: aged 65-88 years old at baseline, n = 1,320, follow-up of 13 years. RESULTS: At baseline, average levels were 56.5 nmol/L in the younger cohort and 51.1 nmol/L in the older cohort. In the younger cohort, a longitudinal increase in the mean serum 25-OHD levels of 4 nmol/L in 6 years was observed; in the older cohort, a longitudinal decrease in the mean serum 25-OHD levels of 4 nmol/L in 13 years was observed. The seasonal variation was ±12 nmol/L in the younger cohort and ±7 nmol/L in the older cohort. CONCLUSIONS: Long-term serum 25-OHD levels remained fairly stable during aging with slightly increasing levels in persons aged 55-65 years old and slightly decreasing levels in persons aged 65-88 years old. On average, the seasonal variation was larger than the longitudinal change. Our findings implicate that vitamin D supplementation becomes more important in older age groups and during wintertime.

Learning to perform endoscopic resection of esophageal neoplasia is associated with significant complications even within a structured training program.

BACKGROUND AND STUDY AIMS: Endoscopic resection is the cornerstone of endoscopic treatment of esophageal high grade dysplasia or early cancer. Endoscopic resection is, however, a technically demanding procedure, which requires training and expertise. The aim of the current study was to prospectively evaluate efficacy and safety of the first 120 endoscopic resection procedures of early esophageal neoplasia performed by six endoscopists (20 endoscopic resections each) who were participating in an endoscopic resection training program. PATIENTS AND METHODS: The program consisted of four tri-monthly 1-day courses with lectures, live-demonstrations, hands-on training on anesthetized pigs, and one-on-one hands-on training days. Gastroenterologists from centers with multidisciplinary expertise in upper gastrointestinal oncology participated, together with an endoscopy nurse and a pathologist. Outcome measures were complete endoscopic removal of the target area and acute complications. RESULTS: A total of 120 consecutive esophageal endoscopic resection procedures (85 ER-cap, 35 multiband mucosectomy [MBM]) were performed by six endoscopists: 109 in Barrett's esophagus, 11 for squamous neoplasia; 85 piecemeal endoscopic resections (median 3 specimens, interquartile range 2 - 4 specimens). Complete endoscopic removal was achieved in 111 /120 cases (92.5 %). Six perforations occurred (5.0 %): five were effectively treated endoscopically (clips, covered stent), and one patient underwent esophagectomy. There were 11 acute mild bleedings (9.2 %), which were managed endoscopically. Perforations occurred in ER-cap procedures performed by four participants (7.1 % ER-cap vs. 0 % MBM; P = 0.18), and in 1.7 % of the first 10 endoscopic resections and 8.3 % of the second 10 endoscopic resections per endoscopist (P = 0.26). CONCLUSION: In this intense, structured training program, the first 120 esophageal endoscopic resections performed by six participants were associated with a 5.0 % perforation rate. Although perforations were adequately managed, performing 20 endoscopic resections may not be sufficient to reach the peak of the learning curve in endoscopic resection.

Stepwise radical endoscopic resection for Barrett's esophagus with early neoplasia: report on a Brussels' cohort.

BACKGROUND AND STUDY AIMS: The aim of this retrospective study was to assess safety and efficacy of stepwise radical endoscopic resection (SRER) in patients with Barrett's esophagus with high-grade intraepithelial neoplasia (HGIN) or early cancer. PATIENTS AND METHODS: Patients undergoing SRER between 2000 and 2006 were retrospectively evaluated. Patients with Barrett's esophagus who also had HGIN or early cancer were included if they had no signs of submucosal infiltration or metastases. SRER was performed using the cap-technique, at 8-week intervals until all Barrett's esophagus was removed. Follow-up endoscopy was scheduled every 6 months. RESULTS: A total of 34 patients were included (31 male, mean 67 years, median Barrett's dimensions C1M4). HGIN / early cancer was eradicated in all patients in a median of two endoscopic resection sessions (IQR 1-2 sessions). Twelve patients underwent additional argon plasma coagulation for small islets or an irregular Z-line. Barrett's esophagus was eradicated in 28 patients (82 %). Complications occurred in 3/34 patients (9 %): two perforations, one delayed bleeding. In all, 19 patients (56 %) developed dysphagia, which was resolved with dilatation or stent placement. During a median follow-up period of 23 months (IQR 15 - 41 months), HGIN / early cancer recurred in three patients (9 %): two were retreated with endoscopic resection and one patient was referred for curative surgery. Five patients (15 %) had recurrence of nondysplastic Barrett's esophagus. At the end of the follow-up period all patients were free of HGIN / early cancer (one patient after surgery), and 23 patients (68 %) had complete endoscopic and histological eradication of Barrett's esophagus. CONCLUSIONS: SRER resulted in complete eradication of HGIN/early cancer in all patients, and eradication of Barrett's esophagus in a majority of cases. A significant number of patients develop dysphagia, which can be successfully treated endoscopically.

Stepwise circumferential and focal ablation of Barrett's esophagus with high-grade dysplasia: results of the first prospective series of 11 patients.

BACKGROUND AND STUDY AIMS: Stepwise circumferential and focal ablation of nondysplastic Barrett's esophagus has proven safe and effective. This study assessed the efficacy and safety of ablation for Barrett's esophagus with high-grade dysplasia (HGD), and residual Barrett's esophagus with dysplasia after prior endoscopic resection for visible lesions. PATIENTS AND METHODS: This was a prospective cohort study. All visible abnormalities were resected prior to ablation. Persistence of dysplasia and absence of invasive cancer was confirmed with biopsies after endoscopic resection. A balloon-based electrode was used for primary circumferential ablation and an endoscope-mounted electrode was used for secondary focal ablation. Eradication of dysplasia and Barrett's esophagus was the main outcome measure. RESULTS: Eleven patients (eight men; median age 60 years) were treated (median Barrett's length 5 cm). Visible abnormalities were removed with endoscopic resection in six patients. The worst pathological grade of residual Barrett's esophagus after endoscopic resection and prior to ablation was LGD (n = 2) and HGD (n = 9). Patients underwent a median of two circumferential and two focal ablation sessions. Complete remission of dysplasia and complete endoscopic and histological removal of Barrett's esophagus was achieved in 11/11 patients (100%). There were no adverse events or strictures, and in none of the 473 biopsies of neo-squamous mucosa was subsquamous Barrett's esophagus ("buried Barrett's") observed. During a median follow-up period of 14 months after the last treatment session and a median number of two follow-up endoscopies, none of the patients showed recurrence of dysplasia or endoscopic signs of recurrent Barrett's mucosa. CONCLUSIONS: Stepwise circumferential and focal ablation appears to be a safe and effective treatment for complete removal of Barrett's esophagus containing HGD, and can be safely performed after prior endoscopic resection for endoscopically visible abnormalities.

Effective treatment of early Barrett's neoplasia with stepwise circumferential and focal ablation using the HALO system.

STUDY AIMS: The aim of the current study was to evaluate the efficacy and safety of stepwise circumferential and focal ablation using the HALO system for Barrett's esophagus containing flat, high-grade dysplasia (HGD) or residual dysplasia after endoscopic resection for HGD or intramucosal cancer (IMC). METHODS: Visible abnormalities were removed with endoscopic resection prior to ablation. Persistence of dysplasia and absence of IMC were confirmed with biopsy after endoscopic resection. A balloon-based electrode was used for primary circumferential ablation and an endoscope-mounted electrode was used for secondary focal ablation. RESULTS: Twelve patients (nine men; median age 70 years) were treated (median Barrett's length 7 cm). Visible abnormalities were removed by endoscopic resection in seven patients. The worst pathological grade of residual Barrett's esophagus after resection and prior to ablation was low-grade dysplasia (LGD) (n = 1) and HGD (n = 11). Patients underwent a median of one circumferential and two focal ablation sessions. Complete remission of dysplasia was achieved in 12/12 patients (100%). Complete endoscopic and histological removal of Barrett's esophagus was achieved in 12/12 patients (100%). There were no ablation-related stenoses, and no subsquamous Barrett's esophagus was observed in 363 biopsies obtained from post-ablation neo-squamous mucosa. Protocolized cleaning of the ablation zone and electrode in between ablations resulted in superior regression of Barrett's esophagus compared with previous studies. During a median follow-up of 14 months no recurrence of dysplasia or Barrett's esophagus was observed. CONCLUSIONS: Stepwise circumferential and focal ablation for Barrett's esophagus with flat HGD or for Barrett's with residual dysplasia after endoscopic resection for HGD/IMC is a safe and effective treatment modality. Its success rate and safety profile compare favorably with alternatives such as esophagectomy, widespread endoscopic resection or photodynamic therapy.

Surveillance history of endoscopically treated patients with early Barrett's neoplasia: nonadherence to the Seattle biopsy protocol leads to sampling error.

SUMMARY: The study's aim was to retrospectively evaluate the surveillance history of Barrett's esophagus (BE) patients with endoscopically treated early neoplasia. All BE patients endoscopically treated for early cancer (EC) or high-grade intraepithelial neoplasia (HGIN) in a lesion or mass between 1998 and 2005 were included. Endoscopy and histology records were reviewed. Ninety-four patients (78 males, mean age 67 years, 24 HGIN, 70 EC) were included. In 36 (38%) patients, HGIN/EC was diagnosed at (or within 6 months after) initial endoscopy. The remaining 58 (62%) patients had a surveillance history (median duration 7 years, mean 6.7 endoscopies). Seventy-nine percent of these had low-grade intraepithelial neoplasia (LGIN) diagnosed at least once during their surveillance period with a median of seven endoscopies and a median number of biopsies that was 50% of what should have been taken according to the Seattle protocol. Patients without any dysplasia during earlier surveillance (n = 12, 21%) had undergone significantly less endoscopies (median four endoscopies, P = 0.02) and had a median biopsy percentage that was 23% of the Seattle protocol (P < 0.001 versus 50% in LGIN). In this selected cohort of patients with early Barrett's neoplasia, 38% of patients were diagnosed at initial endoscopy. Of the patients with a surveillance history, 79% had shown LGIN prior to HGIN/EC diagnosis. Only 21% of patients had a surveillance history without any dysplasia, which in general encompassed endoscopies with an insufficient number of biopsies, suggesting sampling error. This underlines the importance of obtaining an adequate number of biopsies during surveillance endoscopies.

Endoscopic cap resection for treatment of early Barrett's neoplasia is safe: a prospective analysis of acute and early complications in 216 procedures.

This study aimed to prospectively evaluate the safety of endoscopic resection for early neoplasia in Barrett's esophagus (BE) using the endoscopic cap resection (ER cap) technique. All resections performed between September 2000 and March 2006 with the ER-cap technique in patients with BE were included. Complications were classified 'acute' (during the procedure) or 'early' (< 48 h after the procedure). A total of 216 ER-cap procedures were performed in 121 patients, of which 145 were performed with a standard hard cap and 71 with a large flexible cap. Specimens removed with the standard cap had a mean diameter of 20 mm (SD 5.0) versus 23 mm (SD 5.8) for the large cap (P < 0.001). Acute complications occurred in 51 procedures (24%), 49 bleedings and two perforations. All bleedings were effectively treated with hemostatic techniques and classified as mild complications. No patient experienced a drop in hemoglobin levels or required blood transfusions or repeat interventions. The two perforations were classified as severe complications and treated conservatively. Three (1%) early complications, all bleedings, occurred and were effectively treated with endoscopic hemostatic techniques and classified as moderately severe complications. In manova the indication for the resection (high-grade intraepithelial neoplasia or early cancer versus low-grade intraepithelial neoplasia or no dysplasia) was found to be significantly associated with an increased risk of acute bleeding. Endoscopic cap resection in BE is safe. Most complications become apparent immediately during the procedure and can be managed endoscopically. Bleeding after the endoscopic resection procedure and severe acute complications (i.e., perforations) are rare (2%).

Thorium dioxide-related haemangiosarcoma of the liver.

Rare tumours of the liver are occasionally seen; thorium dioxide-related haemangiosarcoma of the liver, with an estimated frequency of 0.14 to 0.25 per million in the normal population, is one of these. Causes, epidemiology and pathobiology are described related to a clinical case of angiosarcoma. A differentiation of hepatic tumours with imaging techniques is presented. Last, a short review on up-to-date treatment of haemangiosarcoma is discussed. Lessons can always be learned from history: will the contrast agent gadolinium be the Th232 of this era?

Sclerosing peritonitis: an unusual cause of ascites in a patient with systemic lupus erythematosus.

Sclerosing peritonitis is a rare condition characterised by fibrosis and adhesion of the peritoneum to loops of the small intestine. It is generally associated with continuous peritoneal dialysis, peritoneo-venous shunts or &beta-adrenergic blocking agents. In this case we report a female patient with idiopathic sclerosing peritonitis and systemic lupus erythematosus.

[Serious intoxication after inhaling methanol]. / Ernstige intoxicatie met methanol door inhalatie.

A 38-year-old man presented with severe methanol intoxication after inhaling methanol over a period of 36 hours in a poorly-ventilated laboratory. He complained of visual disturbances, mild photophobia, hyperventilation and nausea. Laboratory results showed severe metabolic acidosis with a toxic serum-methanol level. He was treated by acute haemodialysis and ethanol infusions. After 9 hours of haemodialysis the serum-methanol value fell below toxic levels. Therapy resulted in the complete disappearance of symptoms and he was able to leave the intensive-care unit 24 hours after presentation. Often, late presentation is a cause of serious morbidity and even mortality in severe methanol intoxication, so early recognition is essential. This is the first published case of methanol intoxication due to inhalation, which is as serious and requires the same treatment as ingestion of methanol.