Screening for distant metastases in patients with ipsilateral breast tumor recurrence: the impact of different imaging modalities on distant recurrence-free interval.

PURPOSE: In patients with ipsilateral breast tumor recurrence (IBTR), the detection of distant disease determines whether the intention of the treatment is curative or palliative. Therefore, adequate preoperative staging is imperative for optimal treatment planning. The aim of this study is to evaluate the impact of conventional imaging techniques, including chest X-ray and/or CT thorax-(abdomen), liver ultrasonography(US), and skeletal scintigraphy, on the distant recurrence-free interval (DRFI) in patients with IBTR, and to compare conventional imaging with 18F-FDG PET-CT or no imaging at all. METHODS: This study was exclusively based on the information available at time of diagnoses of IBTR. To adjust for differences in baseline characteristics between the three imaging groups, a propensity score (PS) weighted method was used. RESULTS: Of the 495 patients included in the study, 229 (46.3%) were staged with conventional imaging, 89 patients (19.8%) were staged with 18F-FDG PET-CT, and in 168 of the patients (33.9%) no imaging was used (N = 168). After a follow-up of approximately 5 years, 14.5% of all patients developed a distant recurrence as first event after IBTR. After adjusting for the PS weights, the Cox regression analyses showed that the different staging methods had no significant impact on the DRFI. CONCLUSIONS: This study showed a wide variation in the use of imaging modalities for staging IBTR patients in the Netherlands. After using PS weighting, no statistically significant impact of the different imaging modalities on DRFI was shown. Based on these results, it is not possible to recommend staging for distant metastases using 18F-FDG PET-CT over conventional imaging techniques.

The Importance of the Microbiome in Bariatric Surgery: a Systematic Review.

Bariatric surgery results in sustained weight loss, improvement of metabolic and hormonal changes, and reduction of comorbidities in obese patients. However, beneficial effects of bariatric surgery are not solely explained by restriction and malabsorption induced by surgery itself. Changes in the microbiome might play a role in this mechanism. A systematic review was performed in which 21 studies were included. The microbiome was affected by surgery and profound changes occurred in the first year of follow-up. An increase in Bacteroides and Proteobacteria and a decrease in Firmicutes were observed postoperatively in most studies. These changes were associated with weight loss. Bariatric surgery induces profound changes in the microbiome. This may be related to the beneficial effect of bariatric surgery on comorbidities associated with obesity.

Low Risk of Development of a Regional Recurrence After an Unsuccessful Repeat Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence.

BACKGROUND: Unlike sentinel lymph node biopsy (SLNB) in the primary setting, the repeat SLNB (rSLNB) in patients with ipsilateral breast tumor recurrence (IBTR) is challenging, because it is difficult to visualize and/or harvest a sentinel lymph node in every patient. Regional treatments options and safety in terms of regional disease control after such an unsuccessful rSLNB remain unclear. This study assesses factors associated with the performance of axillary lymph node dissection (ALND) after unsuccessful rSLNB and evaluates the occurrence of regional recurrences. METHODS: Data were obtained from the Sentinel Node and Recurrent Breast Cancer (SNARB) study. In 239 patients, the rSLNB was unsuccessful, of whom 60 patients underwent ipsilateral ALND. RESULTS: A shorter time interval between primary treatment and IBTR, and a primary negative SLNB were significantly associated with a higher probability to be treated with ALND after unsuccessful rSLNB (P < 0.001). The 5-year regional-recurrence rate was 0.0% in the ALND group compared with 3.7% in the group treated without ALND (P = 0.113). Of the 179 patients treated without ALND, after a median follow-up of 5.1 years (range 0.3-13.2), 7 (3.9%) developed a regional recurrence as first event after unsuccessful rSLNB. None of the seven recurrences occurred in the ipsilateral axilla. Univariable analysis showed no factors associated with regional recurrence as first event after unsuccessful rSLNB (P > 0.05). CONCLUSIONS: The present study demonstrates that the risk of regional recurrence in patients with an IBTR and an unsuccessful rSLNB is negligible, irrespective of the use of ALND. This suggests that there is no need for additional treatment of the axilla after an unsuccessful rSLNB.

The rationale for and long-term outcome of incomplete axillary staging in elderly women with primary breast cancer.

BACKGROUND: The proportion of elderly women diagnosed with breast cancer is rising. Standard treatment, including axillary staging, is often not given to these patients. This study aimed to investigate reasons to omit any surgical axillary staging or to refrain from completion axillary lymph node dissection (cALND) after positive-sentinel lymph node biopsy (SLNB); so-called "incomplete staging". Furthermore, the impact of incomplete staging on regional control and survival in patients aged 75 or older was evaluated. METHODS: A retrospective cohort study was conducted including all primary breast cancer patients aged 75 or older, diagnosed between 2001 and 2008, and documented by the Netherlands Cancer Registry (NCR). Patients with incomplete staging were compared to patients with complete axillary staging. Survival analyses were used to determine the risk of local, regional and distant recurrence and overall survival. RESULTS: In total, 1467 of 2116 (69%) patients were considered eligible, of whom 258 (17.2%) had incomplete axillary staging. For 93 patients, diagnosed in 6 of the 10 hospitals in the NCR-area, examination of clinical records revealed that age, comorbidities and patient preferences were the main reason for omitting complete axillary staging. The 10-year axillary recurrence rate in these 93 patients was 5.2% (95% CI, 0.03-10.1). Of the 77 patients who had died, 64 (83%) died of non-breast-cancer-related causes. No significant difference in overall survival was observed between patients with or without complete axillary staging. CONCLUSION: This study demonstrates that the omission of complete axillary staging is common in selected elderly breast cancer patients with ≥2 comorbidities, with no apparent impact on regional control and 10-year overall survival.

Predicting breast and axillary response after neoadjuvant treatment for breast cancer: The role of histology vs receptor status.

PURPOSE: Neoadjuvant systemic treatment (NST) is increasingly administered in breast cancer patients. This study was conducted to identify predictors for tumor response in the breast and axilla. METHODS: All female patients with nonmetastatic, noninflammatory breast cancer receiving NST between 2003-2013 at the Catharina Cancer Institute in Eindhoven, The Netherlands, were included. RESULTS: The majority of 216 of the 337 patients receiving NST (65%) presented with a cT2 tumor. In 159 patients (47%), the axilla was clinically node positive. A pathologic complete response (pCR) in the breast was achieved in 83 patients (24.6%), and a pCR in the axilla in 65 node-positive patients (40.9%). The triple-negative (OR 4.29, 95% CI 2.15-8.55) and hormone receptor (HR)-negative/HER2-positive tumors (OR 3.73, 95% CI 1.59-8.75) were associated with in-breast pCR. Patients with invasive lobular carcinoma (ILC) were less likely to experience in-breast pCR (OR 0.10, 95% CI 0.01-0.73) than those with invasive ductal cancer. Axillary pCR was found in 65 clinically node-positive patients (41%). Axillary pCR was more likely to occur in HR-positive/HER2-positive (OR 6.24, 95% CI 1.86-20.90) and HR-negative/HER2-positive tumors (OR 6.41, 95% CI 1.95-21.06), compared to HER2-negative disease. In-breast pCR was strongly associated with axillary pCR (OR 10.89, 95% CI 4.20-28.22). CONCLUSION: Response to NST in the breast and axilla is largely determined by receptor status, with high pCR rates occurring in HER2-positive and triple-negative tumors. For axillary pCR, in-breast pCR and HER2-positive disease are the most important predictive factors.

Risk of Regional Recurrence After Negative Repeat Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence.

BACKGROUND: Repeat sentinel lymph node biopsy (rSLNB) has increasingly been used in patients with ipsilateral breast tumor recurrence (IBTR). The safety in terms of regional disease control after this procedure remains unclear. This study evaluates occurrence of regional recurrence as first event in patients with IBTR and negative rSLNB, treated without additional lymph node dissection. PATIENTS AND METHODS: Data were obtained from the Sentinel Node and Recurrent Breast Cancer (SNARB) study. In 201 patients, tumor-negative rSLNB was obtained without performing additional lymph node dissections. RESULTS: With median follow-up of 4.7 (range 0.9-12.7) years, regional recurrence occurred after median time of 3.0 (range 0.4-6.7) years in 4.5% (N = 9) of patients as first event after IBTR and rSLNB. In four of these nine patients, the site of recurrence was in concordance with the anatomical location of rSLNB. Two of the nine recurrences were reported in the ipsilateral axilla, resulting in an ipsilateral axillary regional recurrence rate of 1.0%. In the other seven patients, regional recurrence occurred in aberrant basins. Univariable analysis showed that triple-negative IBTR and lower amount of radioactive-labeled tracer (99mtechnetium) used during rSLNB were associated with developing regional recurrence as first event after negative rSLNB (P < 0.05). CONCLUSIONS: The risk of developing regional recurrence after negative rSLNB is low. The low relapse rate supports the safety of rSLNB as primary nodal staging tool in IBTR. The time has come for clinical guidelines to adopt rSLNB as axillary staging tool in patients with IBTR.

The administration of adjuvant chemo(-immuno) therapy in the post ACOSOG-Z0011 era; a population based study.

PURPOSE: The ACOSOG-Z0011-study has resulted in a trend to a more conservative treatment of the axilla for selected sentinel-node-positive patients. However, axillary nodal involvement has always been an important factor for tumor staging and tailoring adjuvant chemotherapy plans. This study evaluates the impact of omitting completion axillary lymph node dissection (cALND) on the administration of adjuvant chemo (-immuno)therapy in Dutch clinical T1-2N0M0 (cT1-2N0M0) sentinel-node-positive breast cancer patients. METHODS: Data were obtained from the nationwide NABON breast cancer audit. Descriptive analyses were used to demonstrate trends in axillary surgery and adjuvant chemo (-immuno)therapy. Multivariable logistic regression analyses were used to identify factors associated with the prescription of chemo (-immuno)therapy. RESULTS: In this cohort of 4331 patients, the omission of a cALND increased from 34% to 92%, and the administration of chemo (-immuno)therapy decreased from 68% to 55%, between 2011 and 2015 (P < 0.001). Patients treated with cALND had an OR of 2.2 for receiving adjuvant chemo (-immuno)therapy compared with SLNB only patients. Lower age, a hormone receptor (HR) status other than HR-positive, HER2-negative, increasing tumor grade and stage, and a lymph node status ≥ pN2 were independently associated with a higher probability of chemo (-immuno)therapy (P < 0.05). CONCLUSIONS: This study showed that Dutch cT1-2N0M0 sentinel node-positive breast cancer patients treated with cALND had a higher independent probability for receiving adjuvant chemo (-immuno)therapy compared with SLNB only patients, even when corrected for lymph node status and HR-status. Probably, the decisions to administer adjuvant chemo (-immuno)therapy were not only based on guidelines and tumor characteristics, but also on the preferences from physicians and patients.

Repeat Sentinel Lymph Node Biopsy for Ipsilateral Breast Tumor Recurrence: A Systematic Review of the Results and Impact on Prognosis.

BACKGROUND: During recent years, an increasing number of patients with ipsilateral breast tumor recurrence (IBTR) and previous axillary surgery have undergone repeat sentinel lymph node biopsy (rSLNB). The influence of axillary nodal status on prognosis for IBTR patients remains unclear. This study aimed to evaluate the technical success rate, follow-up assessment, and prognostic value of rSLNB for patients with IBTR. METHODS: A systematic search conducted in MEDLINE, Embase, and the Cochrane Library up to July 2017 included all studies on rSLNB in IBTR. RESULTS: A total of 34 articles describing 1761 patients were identified. A repeat sentinel lymph node (rSLN) was successfully harvested from 64.3% of the patients with IBTR, and the rate was significantly higher for the patients who had a previous SLNB than for those who had a previous axillary lymph node dissection (ALND) (75.7% vs. 46.1%; P < 0.0001). The rSLN was tumor-positive for 18.2% of the rSLNs, 40% of which were harvested in basins other than the ipsilateral axilla. The negative predictive value of the rSLNB was 96.5%. Overall survival, reported for 21.5% of the patients, was 95.2% after a mean follow-up period of 29.6 months. CONCLUSION: The prognostic impact of rSLN-positive versus rSLN-negative IBTR remains unclear. Further studies are needed to fill in the gap in the management of lymph nodes for patients with IBTR. However, based on the current evidence, rSLNB is feasible for 64% of patients, especially after previous SLNB. With a negative predictive value of 96.5%, rSLNB appears to be highly specific, with substantial advantages over ipsilateral ALND in IBTR.

Trends on Axillary Surgery in Nondistant Metastatic Breast Cancer Patients Treated Between 2011 and 2015: A Dutch Population-based Study in the ACOSOG-Z0011 and AMAROS Era.

OBJECTIVES: To evaluate patterns of care in axillary surgery for Dutch clinical T1-4N0M0 (cT1-4N0M0) breast cancer patients and to assess the effect of the American College for Surgeons Oncology Group (ACOSOG)-Z0011 and After Mapping of the Axilla: Radiotherapy Or Surgery (AMAROS) trial on axillary surgery patterns in Dutch cT1-2N0M0 sentinel node positive breast cancer patients. BACKGROUND: Since publication of the ACOSOG-Z0011 and AMAROS trial, omitting a completion axillary lymph node dissection (cALND) in sentinel node positive breast cancer patients is proposed in selected patients. METHODS: Data were obtained from the nationwide Nationaal Borstkanker Overleg Nederland breast cancer audit. Descriptive analyses were used to demonstrate trends in axillary surgery. Multivariable logistic regression analyses were used to identify factors associated with the omission of cALND in cT1-2N0M0 sentinel node-positive breast cancer patients. RESULTS: Between 2011 and 2015 in cT1-4N0M0 breast cancer patients, the use of sentinel lymph node biopsy as definitive axillary staging increased from 72% to 93%, and (c)ALND as definitive axillary staging decreased from 24% to 6% (P < 0.001). The use of cALND decreased from 75% to 17% in cT1-2N0 sentinel node-positive patients (P < 0.001). Earlier year of diagnosis, lower age, primary mastectomy, invasive lobular subtype, increasing tumor grade, and treatment in a nonteaching hospital were associated with a lower probability of omitting cALND (P < 0.001). CONCLUSIONS: This study shows a trend towards less extensive axillary surgery in Dutch cT1-T4N0M0 breast cancer patients; illustrated by an overall increase of sentinel lymph node biopsy and decrease in cALND. Despite this trend, particularly noticed in cT1-2N0 sentinel node-positive patients after publication of the ACOSOG-Z0011 and AMAROS trial, variations in patterns of care in axillary surgery are still present.

Patterns of Care in the Administration of Neo-adjuvant Chemotherapy for Breast Cancer. A Population-Based Study.

Neo-adjuvant chemotherapy (NAC) is used to facilitate radical surgery for initially irresectable or locally advanced breast cancer. The indication for NAC has been extended to clinically node negative (cN0) patients in whom adjuvant systemic therapy is foreseen. A population-based study was conducted to evaluate the increasing use of NAC, breast conserving surgery (BCS) after NAC and timing of the sentinel node biopsy (SNB). All female breast cancer patients, treated in 10 hospitals in the Eindhoven Cancer Registry area in the Netherlands between January 2003 and June 2012 were included (N = 18,427). In total, 1,402 patients (7.6%) received NAC. The administration increased from 2.5% in 2003 to 13.0% in 2011 (p < 0.001). Use of NAC increased from 0.5% to 2.3% for cT1 tumors, from 2.8% to 27.0% for cT2, from 30.6% to 70.9% for cT3, and from 40.5% to 58.1% for cT4 tumors (p < 0.001). In cN0 patients, use of NAC increased from 1.0% to 4.4% and in clinically node positive patients from 12.0% to 57.5% (p < 0.001). Downsizing of the tumor and BCS are achieved increasingly. In 2011, in three hospitals NAC was administered in <10% of patients, in five hospitals in 10-15% and in two hospitals the proportion of patients receiving NAC was >20% (p < 0.001). Of the 1,402 patients with NAC, 495 patients underwent SNB, 91.5% of whom prior to NAC. In the Netherlands up to one in eight patients receive NAC. The administration of NAC and the percentage of BCS increased over the past decade, especially in cT2 tumors. Considerable hospital variation in the administration of NAC exists.

[A man with a swelling of his lower leg since 69 years]. / Een man met al 69 jaar een zwelling aan het been.

A 76-year-old man visited the Emergency Room because of pain of a progressive, swelling of his right lower leg that had developed 69 years ago after a posttraumatic compartment syndrome. We performed debridement on the necrotic, infected wound and made the diagnosis 'calcific myonecrosis'.

Late recovery of atrioventricular conduction after postsurgical chronic atrioventricular block is not exceptional.

OBJECTIVE: Postsurgical atrioventricular block may complicate surgery for congenital heart defects and is generally considered permanent when persisting longer than 14 days after surgery. In this study, we evaluate the occurrence of spontaneous late recovery of atrioventricular conduction in postsurgical chronic atrioventricular block and discuss its clinical implications. METHODS: We retrospectively reviewed all cardiac surgical procedures on cardiopulmonary bypass between January 1993 and November 2010 in subjects younger than 18 years. Patients with postsurgical advanced second- or third-degree atrioventricular block persisting longer than 14 days after surgery were included. RESULTS: Of a total of 2850 cardiac surgical procedures on cardiopulmonary bypass, 59 (2.1%) were immediately complicated by chronic postsurgical atrioventricular block of advanced second (n = 4) or third degree (n = 55). In another 6 patients (0.2%), late occurrence of chronic advanced second- (n = 3) or third-degree (n = 3) atrioventricular block, without signs of any etiology other than previous surgery, was seen 0.4 to 10 years after surgery (median, 5.7 years). Late (>2 weeks) regression to either completely normal atrioventricular conduction or asymptomatic first-degree atrioventricular block occurred 3 weeks to 7 years (median, 3.1 years) after surgery in 7 (12%) patients with immediate postsurgical chronic atrioventricular block. CONCLUSIONS: Complete recovery of atrioventricular conduction or regression to asymptomatic first-degree atrioventricular block occurred in 12% of patients with postsurgical chronic second- or third-degree atrioventricular block. To prevent unnecessary adverse side effects of chronic ventricular pacing and to prolong battery longevity, ventricular pacing should be minimized in patients with recovered normal atrioventricular conduction.