Epidemiology, management and survival outcomes of primary cutaneous melanoma: a ten-year overview.

BACKGROUND: Malignant melanoma (MM) is the most aggressive type of skin cancer, accounting for 90% of all the skin cancer mortality. The objective of this study was providing an overview of current patient- and tumour characteristics, treatment strategies, complications and survival in patients with MM over the past ten years. Hereby, an up-to-date view of every day clinical practice is obtained. METHODS: Files of patients treated for primary cutaneous melanoma (n = 686) in the VieCuri Medical Centre in the Netherlands between January 2002 and December 2013 were retrospectively reviewed. Relevant patient features, tumour characteristics, and (surgical) outcomes were evaluated. RESULTS: The majority of all the patients presented thin tumours (59.1% stage 1A/in situ melanoma). Men showed more ulceration (17.7% vs. 8.4%, p < .01) and a significantly higher Breslow thickness than women (1.2 mm vs. 0.9 mm, p < .01). 14.6% (40/273) underwent sentinel lymph node biopsy (SLNB); 10/40 (25%) showed nodal metastasis, 50 patients (7.3%) developed distant metastases (M: 10.6%, F: 5%, p < .01). One-, 5- and 10- year disease specific survival rates were 96%, 86% and 84%, respectively. Median survival for stage 4 MM was 3 months. Extensive surgery was uncommon (n = 3). CONCLUSIONS: Patients generally presented with thin melanomas. Lymph node disease and distant metastases remained infrequently observed during following years, and general 1- and 5-year overall disease-specific survival rates exceeded 85%. Small numbers of rescue surgery and palliative medical treatment warrant further centralisation and investigation.

Evaluation of nutritional status as an independent predictor of post-operative complications and morbidity after gastro-intestinal surgery.

BACKGROUND: Nutritional Risk Screening-2002 (NRS-2002) and the Malnutrition Universal Screening Tool (MUST) are screening tools for nutritional risk that have also been used to predict post-operative complications and morbidity, though not all studies confirm the reliability of nutritional screening. Our study aims to evaluate the independent predictive value of nutritional risk screening in addition to currently documented medical, surgical and anesthesiological risk factors for post-operative complications, as well as length of hospital stay. METHODS: This study is a prospective observational cohort study of 129 patients undergoing elective gastro-intestinal-surgery. Patients were screened for nutritional risk upon admission using both MUST and NRS-2002 screening tools. Univariate and multivariate analyses were performed to investigate the independent predictive value of nutritional risk for post-operative complications and length of hospital stay. RESULTS: MUST ≥2 (OR 2.87; 95% CI 1.05-7.87) and peri-operative transfusion (OR 2.78; 95% CI 1.05-7.40) were significant independent predictors for the occurrence of post-operative complications. Peri-operative transfusion (HR 2.40; 95% CI 1.45-4.00), age ≥70 (HR 1.50; 95% CI 1.05-2.16) and open surgery versus laparoscopic surgery (HR 1.39; 95% CI 0.94-2.05) were independent predictors for increased length of hospital stay, whereas American Society of Anesthesiology Score (ASA) and MUST were not. CONCLUSION: Nutritional risk screening (MUST ≥2) is an independent predictor for post-operative complications, but not for increased length of hospital stay.

Sentinel node biopsy for patients with early breast cancer under local anaesthesia: time to say goodbye?

From 2000 onwards many papers were published regarding the technique of sentinel lymph node biopsy in early breast cancer under local anaesthesia. This technique enabled a solid base for definitive breast surgery in one session under general anaesthesia, contributing to a better preparation of the patient undergoing definite breast cancer treatment and saving operating time. All papers agreed in safety of the concept, quality and patient satisfaction. As we will more and more waive a complete axillary dissection even after positive sentinel nodes, because there is no proof of gain in survival and local control, there is nowadays less place for the knowledge of the sentinel node status prior to definite breast surgery.

Prognosis following local recurrence after breast conserving treatment in young women with early breast cancer.

BACKGROUND: Few studies have focussed on the prognosis of young women with local recurrence (LR) after breast-conserving therapy and the factors that can be used to predict their prognosis. METHODS: We studied the outcome and related prognostic factors in 124 patients with an isolated local recurrence in the breast following breast-conserving surgery and radiotherapy for early stage breast cancer diagnosed at the age of 40 years or younger. RESULTS: The median follow-up of the patients after diagnosis of LR was 7.0 years. At 10 years from the date of salvage treatment, the overall survival rate was 73% (95% CI, 63-83), the distant recurrence-free survival rate was 61% (95% CI, 53-73), and the local control rate (i.e. survival without subsequent LR or local progression) was 95% (95% CI, 91-99). In the multivariate analysis, the risk of distant metastases also tended to be higher for patients with LR occurring within 5 years after BCT, as compared to patients with LR more than 5 years after BCT (Hazard ratio [HR], 1.89; p = 0.09). A worse distant recurrence-free survival was also observed for patients with a LR measuring more than 2 cm in diameter, compared to those with a LR of 2 cm or smaller (HR, 2.88; p = 0.007), and for patients with a LR causing symptoms or suspicious findings at clinical breast examination, compared to those with a LR detected by breast imaging only (HR 3.70; p = 0.03). CONCLUSIONS: These results suggest that early detection of LR after BCT in young women can improve treatment outcome.

Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge.

AIM: The purpose of this multicenter cohort study was to evaluate whether a differentiated treatment of primary rectal cancer based on magnetic resonance imaging (MRI) can reduce the number of incomplete resections and local recurrences and improve recurrence-free and overall survival. METHODS: From February 2003 until January 2008, 296 patients with rectal cancer underwent preoperative MRI using a lymph node specific contrast agent to predict circumferential resection margin (CRM), T- and N-stage. Based on expert reading of the MRI, patients were stratified in: (a) low risk for local recurrence (CRM>2mm and N0 status), (b) intermediate risk and (c) high risk (close/involved CRM, N2 status or distal tumours). Mainly based on this MRI risk assessment patients were treated with (a) surgery only (TME or local excision), (b) preoperative 5 × 5 Gy+TME and (c) a long course of chemoradiation therapy followed by surgery after a 6-8 week interval. RESULTS: Overall 228 patients underwent treatment with curative intent: 49 with surgery only, 86 with 5 × 5 Gy and surgery and 93 with chemoradiation and surgery. The number of complete resections (margin>1mm) was 218 (95.6%). At a median follow-up of 41 months the three-year local recurrence rate, disease-free survival rate and overall survival rate is 2.2%, 80% and 84.5%, respectively. CONCLUSION: With a differentiated multimodality treatment based on dedicated preoperative MR imaging, local recurrence is no longer the main problem in rectal cancer treatment. The new challenges are early diagnosis and treatment, reducing morbidity of treatment and preferably prevention of metastatic disease.

Is the sentinel lymph node pathology protocol in breast cancer patients associated with the risk of regional recurrence?

BACKGROUND: Internationally, there is no consensus on the pathology protocol to be used to examine the sentinel lymph node (SN) in breast cancer patients. Previously, we reported that ultra-staging led to more axillary lymph node dissections (ALND). The question was, whether ultra-staging is effective in reducing the risk of regional relapse. METHODS: From January 2002 to July 2003, 541 patients from 4 hospitals were prospectively registered when they underwent a SN biopsy. In hospitals A, B, and C, 3 levels of the SN were examined pathologically, whereas in hospital D at least 7 additional levels were examined. Patients with a positive SN, including isolated tumor cells, underwent an ALND. This analysis focuses on the 341 patients with a negative SN. Primary endpoint was 5-year regional recurrence rate. RESULTS: In hospital D 34% of the patients had a negative SN as compared to 71% in hospitals A, B, and C combined (p < 0.001). At 5 years follow-up, 9 (2.6%) patients had developed a regional lymph node relapse. In hospital D none of the patients had a regional recurrence, as compared to 9 (2.9%) cases of recurrence in hospitals A, B, and C. CONCLUSION: The less intensified SN pathology protocol appeared to be associated with a slightly increased risk of regional recurrence. The absolute risk was still less than 3%, and does not seem to justify the intensified SN pathology protocol of hospital D.

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.

Life and death of the nasogastric tube in elective colonic surgery in the Netherlands.

BACKGROUND & AIMS: There is abundant evidence that the routine use of nasogastric decompression following elective abdominal surgery is ineffective in achieving any goals it is intended for. Nevertheless its use is still standard of care. The aim of the present study was to investigate whether it is possible to ban nasogastric decompression after elective colonic surgery. METHODS: At first baseline measurements concerning elements of perioperative care, including nasogastric tubes, were recorded retrospectively over the year 2004. In 2006-2007 the implementation of a fast-track colonic surgery project was guided by the Dutch Institute for Quality of Healthcare CBO, using Berwick's Breakthrough approach. RESULTS: A total of 2007 patients were enrolled. The baseline measurement showed that the use of nasogastric drainage is still common practice in the Netherlands. 953 patients (88.3%) had a nasogastric tube postoperatively. That tube was removed after a median of 2.5 days (range 1-3 days). After the implementation of the Perioperative Care Breakthrough project the percentage of patients having a nasogastric tube postoperatively dropped to 9.6% (p<0.0001). CONCLUSIONS: Our results show using the Breakthrough Methodology it is possible to eradicate the inappropriate routine use of NG tubes.

A comparison of quality of life, disease impact and risk perception in women with invasive breast cancer and ductal carcinoma in situ.

We compared the health-related quality of life, impact of the disease, risk perception of recurrence and dying of breast cancer, and understanding of diagnosis of patients with ductal carcinoma in situ (DCIS) and invasive breast cancer 2-3 years after treatment. We included all women (N=211) diagnosed with DCIS or invasive breast cancer TNM stage I (T1, N0, and M0) in three community hospitals in the southern part of The Netherlands in the period 2002-2003. After verifying the medical files, 180 disease free patients proved eligible for study entry, 47 of whom had DCIS and 133 stage I invasive breast cancer. One-hundred and thirty-five patients returned a completed questionnaire (75% response). No significant differences were found between women with DCIS and invasive breast cancer on the physical and mental component scale of the RAND SF-36, nor on the WHO-5, which assesses well-being. In contrast, women with DCIS reportedly had a better physical health, better sex life and better relationships with friends/acquaintances than women with invasive breast cancer. Despite their better prognosis, the DCIS-group had comparable perceptions of the risk of recurrence and dying of breast cancer as women with invasive breast cancer. However, this did not appear to affect their well-being significantly.

[Recurrent abdominal pain caused by left mesocolic hernia]. / Linkszijdige mesocolische hernia als oorzaak van recidiverende buikpijn.

A 37-year-old man presented with symptoms of intestinal obstruction. Laparotomy revealed a congenital left mesocolic hernia. Partial removal ofthe hernial sac that largely enclosed the small intestine resulted in a speedy recovery. Thereafter the patient was able to eat without abdominal symptoms. Congenital mesocolic hernias are an infrequent cause of intestinal obstruction. In order to conduct the operation properly, surgeons must have a good understanding of the origin of the hernia and its anatomic relationships.

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.

Ambulatory sentinel node biopsy under local anaesthesia for patients with early breast cancer.

AIMS: Sentinel lymph node biopsy (SLNB) may permit reliable identification of patients with axillary node involvement. The aim of this study was to report our experience with this procedure under local anaesthesia. METHODS: One hundred and sixty-two patients underwent a sentinel node procedure under local anaesthesia without sedation. The SLN was identified by (99m)Tc-nano-colloid and patent blue. Immediate histopathologic examination and immunohistochemistry was performed. Patients with positive SLNs proceded to axillary dissection under general anaesthesia. RESULTS: In all 162 patients the SLN ('s) were found using blue dye and gamma-probe. The SLN was positive in 55/162 patients (34%). Five of these were detected using immunohistochemistry only. CONCLUSIONS: A 100% detection rate of sentinel nodes in early breast cancer harvested under local anaesthesia was achieved without serious morbidity. This allows the surgeon to select preoperatively the treatment given to the patient.