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1.
Dig Surg ; 41(3): 133-140, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-39097966

RESUMO

BACKGROUND: Patients with extensive lymph node metastases have a poor prognosis. Clinical staging of lymph node metastases poses significant challenges given the limited sensitivity and specificity of imaging techniques. The aim of this study was to investigate the overall survival (OS) of patients with N3 disease in a real-world Dutch population and the added value of surgery in these patients. METHODS: Patients with cN3M0 esophageal or gastroesophageal cancer were identified from the Netherlands Cancer Registry (2012-2019). Treatment consisted of neoadjuvant chemo(radio)therapy followed by resection or chemo(radio)therapy, radiotherapy, or esophagectomy alone. OS was calculated using the Kaplan-Meier method. RESULTS: Some 21,566 patients were diagnosed with esophageal cancer of whom 359 (1.7%) had cN3M0 disease. Median OS of these patients was 12.5 months (95% CI: 10.7-14.3). Median OS following chemoradiotherapy alone and neoadjuvant therapy plus surgery was 13.3 months (95% CI: 10.7-15.9) and 23.7 months (95% CI: 18.3-29.2), respectively. Of all patients who underwent esophagectomy, 391 (2.8%) had (y)pN3 disease, and median OS was 16.1 months (95% CI: 14.8-17.4). Twenty-one patients (5.4%) were correctly classified as cN3, and 3-year OS was 21%. CONCLUSION(S): Clinical staging appears to be difficult, apparently in patients with N3 esophageal cancer. Surgery seems to be of benefit to these patients. More research is required to address the ongoing challenges in clinical staging and the best neoadjuvant therapy.


Assuntos
Neoplasias Esofágicas , Esofagectomia , Metástase Linfática , Terapia Neoadjuvante , Estadiamento de Neoplasias , Sistema de Registros , Humanos , Neoplasias Esofágicas/terapia , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/mortalidade , Masculino , Feminino , Países Baixos , Pessoa de Meia-Idade , Idoso , Taxa de Sobrevida , Quimiorradioterapia , Adulto
2.
Ann Surg ; 277(4): 619-628, 2023 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35129488

RESUMO

OBJECTIVE: This study evaluated the nationwide trends in care and accompanied postoperative outcomes for patients with distal esophageal and gastro-esophageal junction cancer. SUMMARY OF BACKGROUND DATA: The introduction of transthoracic esophagectomy, minimally invasive surgery, and neo-adjuvant chemo(radio)therapy changed care for patients with esophageal cancer. METHODS: Patients after elective transthoracic and transhiatal esophagectomy for distal esophageal or gastroesophageal junction carcinoma in the Netherlands between 2007-2016 were included. The primary aim was to evaluate trends in both care and postoperative outcomes for the included patients. Additionally, postoperative outcomes after transthoracic and tran-shiatal esophagectomy were compared, stratified by time periods. RESULTS: Among 4712 patients included, 74% had distal esophageal tumors and 87% had adenocarcinomas. Between 2007 and 2016, the proportion of transthoracic esophagectomy increased from 41% to 81%, and neo-adjuvant treatment and minimally invasive esophagectomy increased from 31% to 96%, and from 7% to 80%, respectively. Over this 10-year period, postoperative outcomes improved: postoperative morbidity decreased from 66.6% to 61.8% ( P = 0.001), R0 resection rate increased from 90.0% to 96.5% (P <0.001), median lymph node harvest increased from 15 to 19 ( P <0.001), and median survival increased from 35 to 41 months ( P = 0.027). CONCLUSION: In this nationwide cohort, a transition towards more neo-adju-vant treatment, transthoracic esophagectomy and minimally invasive surgery was observed over a 10-year period, accompanied by decreased postoperative morbidity, improved surgical radicality and lymph node harvest, and improved survival.


Assuntos
Adenocarcinoma , Neoplasias Esofágicas , Neoplasias Gástricas , Humanos , Adenocarcinoma/cirurgia , Linfonodos/patologia , Junção Esofagogástrica/cirurgia , Junção Esofagogástrica/patologia , Excisão de Linfonodo , Neoplasias Esofágicas/cirurgia , Esofagectomia/efeitos adversos , Neoplasias Gástricas/cirurgia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento
3.
Dig Surg ; 40(1-2): 76-83, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37231877

RESUMO

INTRODUCTION: Curative therapy for gastric cancer usually consists of perioperative chemotherapy combined with a radical (R0) gastrectomy. In addition to a modified D2 lymphadenectomy, a complete omentectomy is recommended. However, there is little evidence for a survival benefit of omentectomy. This study presents the follow-up data of the OMEGA study. METHODS: This multicenter prospective cohort study included 100 consecutive patients with gastric cancer undergoing (sub)total gastrectomy with complete en bloc omentectomy and modified D2 lymphadenectomy. Primary outcome of the current study was 5-year overall survival. Patients with or without omental metastases were compared. Pathological factors associated with locoregional recurrence and/or metastases were tested with multivariable regression analysis. RESULTS: Of 100 included patients, five had metastases in the greater omentum. Five-year overall survival was 0.0% in patients with omental metastases and 44.2% in patients without omental metastases (p = 0.001). Median overall survival time for patients with or without omental metastases was 7 months and 53 months. A (y)pT3-4 stage tumor and vasoinvasive growth were associated with locoregional recurrence and/or metastases in patients without omental metastases. CONCLUSION: The presence of omental metastases in gastric cancer patients who underwent potentially curative surgery was associated with impaired overall survival. Omentectomy as part of radical gastrectomy for gastric cancer might not contribute to a survival benefit in case of undetected omental metastases.


Assuntos
Neoplasias Peritoneais , Neoplasias Gástricas , Humanos , Neoplasias Gástricas/cirurgia , Neoplasias Gástricas/patologia , Estudos Prospectivos , Seguimentos , Recidiva Local de Neoplasia/cirurgia , Excisão de Linfonodo , Neoplasias Peritoneais/cirurgia , Neoplasias Peritoneais/secundário , Gastrectomia/métodos , Estudos Retrospectivos
4.
Ann Surg ; 276(5): 806-813, 2022 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-35880759

RESUMO

OBJECTIVE: This study investigated the patterns, predictors, and survival of recurrent disease following esophageal cancer surgery. BACKGROUND: Survival of recurrent esophageal cancer is usually poor, with limited prospects of remission. METHODS: This nationwide cohort study included patients with distal esophageal and gastroesophageal junction adenocarcinoma and squamous cell carcinoma after curatively intended esophagectomy in 2007 to 2016 (follow-up until January 2020). Patients with distant metastases detected during surgery were excluded. Univariable and multivariable logistic regression were used to identify predictors of recurrent disease. Multivariable Cox regression was used to determine the association of recurrence site and treatment intent with postrecurrence survival. RESULTS: Among 4626 patients, 45.1% developed recurrent disease a median of 11 months postoperative, of whom most had solely distant metastases (59.8%). Disease recurrences were most frequently hepatic (26.2%) or pulmonary (25.1%). Factors significantly associated with disease recurrence included young age (≤65 y), male sex, adenocarcinoma, open surgery, transthoracic esophagectomy, nonradical resection, higher T-stage, and tumor positive lymph nodes. Overall, median postrecurrence survival was 4 months [95% confidence interval (95% CI): 3.6-4.4]. After curatively intended recurrence treatment, median survival was 20 months (95% CI: 16.4-23.7). Survival was more favorable after locoregional compared with distant recurrence (hazard ratio: 0.74, 95% CI: 0.65-0.84). CONCLUSIONS: This study provides important prognostic information assisting in the surveillance and counseling of patients after curatively intended esophageal cancer surgery. Nearly half the patients developed recurrent disease, with limited prospects of survival. The risk of recurrence was higher in patients with a higher tumor stage, nonradical resection and positive lymph node harvest.


Assuntos
Adenocarcinoma , Neoplasias Esofágicas , Adenocarcinoma/patologia , Estudos de Coortes , Esofagectomia , Humanos , Metástase Linfática , Masculino , Recidiva Local de Neoplasia/patologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
5.
JAMA Netw Open ; 7(4): e246556, 2024 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-38639938

RESUMO

Importance: Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association may lead to programs that promote better surgical performance of MIE and improve patient outcomes. Objective: To investigate associations between surgical performance and postoperative outcomes after MIE. Design, Setting, and Participants: In this nationwide cohort study of 15 Dutch hospitals that perform more than 20 MIEs per year, 7 masked expert MIE surgeons assessed surgical performance using videos and a previously developed and validated competency assessment tool (CAT). Each hospital submitted 2 representative videos of MIEs performed between November 4, 2021, and September 13, 2022. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit between January 1, 2020, and December 31, 2021, were included to examine patient outcomes. Exposure: Hospitals were divided into quartiles based on their MIE-CAT performance score. Outcomes were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Transthoracic MIE with gastric tube reconstruction. Main Outcome and Measure: The primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Multilevel logistic regression, with clustering of patients within hospitals, was used to analyze associations between performance and outcomes. Results: In total, 30 videos and 970 patients (mean [SD] age, 66.6 [9.1] years; 719 men [74.1%]) were included. The mean (SD) MIE-CAT score was 113.6 (5.5) in the highest performance quartile vs 94.1 (5.9) in the lowest. Severe postoperative complications occurred in 18.7% (41 of 219) of patients in the highest performance quartile vs 39.2% (40 of 102) in the lowest (risk ratio [RR], 0.50; 95% CI, 0.24-0.99). The highest vs the lowest performance quartile showed lower rates of conversions (1.8% vs 8.9%; RR, 0.21; 95% CI, 0.21-0.21), intraoperative complications (2.7% vs 7.8%; RR, 0.21; 95% CI, 0.04-0.94), and overall postoperative complications (46.1% vs 65.7%; RR, 0.54; 95% CI, 0.24-0.96). The R0 resection rate (96.8% vs 94.2%; RR, 1.03; 95% CI, 0.97-1.05) and lymph node yield (mean [SD], 38.9 [14.7] vs 26.2 [9.0]; RR, 3.20; 95% CI, 0.27-3.21) increased with oncologic-specific performance (eg, hiatus dissection, lymph node dissection). In addition, a high anastomotic phase score was associated with a lower anastomotic leakage rate (4.6% vs 17.7%; RR, 0.14; 95% CI, 0.06-0.31). Conclusions and Relevance: These findings suggest that better surgical performance is associated with fewer perioperative complications for patients with esophageal cancer on a national level. If surgical performance of MIE can be improved with MIE-CAT implementation, substantially better patient outcomes may be achievable.


Assuntos
Neoplasias Esofágicas , Esofagectomia , Masculino , Humanos , Idoso , Estudos de Coortes , Resultado do Tratamento , Esofagectomia/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos , Complicações Pós-Operatórias/etiologia , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/complicações
6.
Eur J Surg Oncol ; 49(5): 974-982, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-36732207

RESUMO

INTRODUCTION: Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences. METHODS: TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment. RESULTS: FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4). CONCLUSION: Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.


Assuntos
Fístula Anastomótica , Esofagectomia , Humanos , Fístula Anastomótica/epidemiologia , Esofagectomia/efeitos adversos , Mortalidade Hospitalar , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
7.
World J Surg ; 35(1): 159-64, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20936283

RESUMO

BACKGROUND: The aim of this study was to evaluate the need of axillary staging in breast cancer patients showing exclusive lymphatic drainage to the internal mammary chain (IMC). METHODS: A total of 2203 patients treated for breast carcinoma in three participating hospitals between July 2001 and July 2008 were analyzed. Only patients showing drainage to the IMC on preoperative lymphoscintigraphy were included. The number of harvested IMC sentinel lymph nodes (SLNs), axillary SLNs, and metastases were recorded. Finally, the follow-up of this group of patients was analyzed. RESULTS: In 25/426 patients, drainage was exclusively to the IMC. Exploration of the axilla resulted in the harvesting of blue SLNs in 9 patients (36%) and the retrieval of an enlarged lymph node in 1 patient. In 4 of the remaining 15 patients, an axillary lymph node dissection (ALND) was done. Lymph node metastases were found in 3 patients who had blue axillary SLNs and in 1 patient who underwent ALND. In the 11 patients who had no blue SLNs and no ALND, no axillary recurrences were observed during follow-up (median = 26 months). CONCLUSIONS: Proper staging of the axilla remains crucial in patients showing exclusive drainage to the IMC. When no axillary node can be retrieved, ALND remains subject to discussion.


Assuntos
Axila/diagnóstico por imagem , Neoplasias da Mama/patologia , Metástase Linfática/diagnóstico por imagem , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Cintilografia , Compostos Radiofarmacêuticos , Estudos Retrospectivos , Biópsia de Linfonodo Sentinela , Agregado de Albumina Marcado com Tecnécio Tc 99m
8.
Clin Nucl Med ; 45(12): 1007-1009, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33031238

RESUMO

We present 2 cases that demonstrate photopenia in peripheral areas on whole-body PET/CT imaging with F-FDG as a sign of absent perfusion with severe short-term complications. The scan of the first patient shows photopenia in the right ankle and foot, resulting from compartment syndrome, caused by hemolytic group A streptococcus bacteremia with endocarditis and septic emboli, necessitating lower leg amputation. The scan of the second patient shows photopenia in the transverse colon, resulting from mesenteric venous thrombosis caused by polycythemia vera, leading to necrosis and perforation of the transverse colon, necessitating transverse and right hemicolectomy.


Assuntos
Síndromes Compartimentais/complicações , Fluordesoxiglucose F18 , Isquemia Mesentérica/complicações , Isquemia Mesentérica/diagnóstico por imagem , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Imagem Corporal Total , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
9.
BMC Surg ; 8: 9, 2008 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-18495027

RESUMO

BACKGROUND: With the increasing number of non palpable breast carcinomas, the need of a good and reliable localization method increases. Currently the wire guided localization (WGL) is the standard of care in most countries. Radio guided occult lesion localization (ROLL) is a new technique that may improve the oncological outcome, cost effectiveness, patient comfort and cosmetic outcome. However, the studies published hitherto are of poor quality providing less than convincing evidence to change the current standard of care. The aim of this study is to compare the ROLL technique with the standard of care (WGL) regarding the percentage of tumour free margins, cost effectiveness, patient comfort and cosmetic outcome. METHODS/DESIGN: The ROLL trial is a multi center randomized clinical trial. Over a period of 2-3 years 316 patients will be randomized between the ROLL and the WGL technique. With this number, the expected 15% difference in tumour free margins can be detected with a power of 80%. Other endpoints include cosmetic outcome, cost effectiveness, patient (dis)comfort, degree of difficulty of the procedures and the success rate of the sentinel node procedure. The rationale, study design and planned analyses are described. TRIAL REGISTRATION: (http://www.clinicaltrials.gov, study protocol number NCT00539474).


Assuntos
Neoplasias da Mama/diagnóstico , Neoplasias da Mama/cirurgia , Mastectomia Segmentar/métodos , Compostos Radiofarmacêuticos , Neoplasias da Mama/patologia , Estudos de Coortes , Feminino , Humanos , Avaliação de Resultados em Cuidados de Saúde , Traçadores Radioativos , Projetos de Pesquisa
11.
World J Surg ; 31(12): 2284-92, 2007 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17957404

RESUMO

BACKGROUND: Minimally invasive treatment may be an alternative to breast-conserving surgery. METHODS: A structured PubMed, Embase, Cochrane, and Web of Science search was performed. Endpoints studied were feasibility, completeness of ablation, timing of the sentinel node biopsy (SNB), imaging modalities, and treatment-related complications. RESULTS: A total of 24 articles were retrieved, and the level of evidence varied (2B-4). Mainly phase II studies with a treat-and-resect protocol were analyzed. Up to 100% completeness of ablation was reported for radiofrequency ablation (RFA), cryosurgery, and focused ultrasound (FUS). The oncologic results need further evaluation. Dynamic contrast enhanced MRI seems to be the best method for monitoring treatment response (77% sensitivity, 100% specificity). Ultrasound is suitable for guiding probes into the tumor. There is no consensus on the timing of the SNB. CONCLUSIONS: All studies on minimally invasive ablative modalities published so far show that these techniques are feasible and safe. At this stage only T1 tumors should be ablated in a clinical trial setting; it is unclear which of the modalities is most suitable.


Assuntos
Neoplasias da Mama/terapia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Neoplasias da Mama/patologia , Ablação por Cateter , Criocirurgia , Humanos , Terapia a Laser , Micro-Ondas/uso terapêutico , Invasividade Neoplásica , Estadiamento de Neoplasias , Biópsia de Linfonodo Sentinela , Terapia por Ultrassom
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