A randomised feasibility trial of an employer-based intervention for enhancing successful return to work of cancer survivors (MiLES intervention).

BACKGROUND: Employers express a need for support during sickness absence and return to work (RTW) of cancer survivors. Therefore, a web-based intervention (MiLES) targeted at employers with the objective of enhancing cancer survivors' successful RTW has been developed. This study aimed to assess feasibility of a future definitive randomised controlled trial (RCT) on the effectiveness of the MiLES intervention. Also preliminary results on the effectiveness of the MiLES intervention were obtained. METHODS: A randomised feasibility trial of 6 months was undertaken with cancer survivors aged 18-63 years, diagnosed with cancer < 2 years earlier, currently in paid employment, and sick-listed < 1 year. Participants were randomised to an intervention group, with their employer receiving the MiLES intervention, or to a waiting-list control group (2:1). Feasibility of a future definitive RCT was determined on the basis of predefined criteria related to method and protocol-related uncertainties (e.g. reach, retention, appropriateness). The primary effect measure (i.e. successful RTW) and secondary effect measures (e.g. quality of working life) were assessed at baseline and 3 and 6 months thereafter. RESULTS: Thirty-five cancer survivors were included via medical specialists (4% of the initially invited group) and open invitations, and thereafter randomised to the intervention (n = 24) or control group (n = 11). Most participants were female (97%) with breast cancer (80%) and a permanent employment contract (94%). All predefined criteria for feasibility of a future definitive RCT were achieved, except that concerning the study's reach (90 participants). After 6 months, 92% of the intervention group and 100% of the control group returned to work (RR: 0.92, 95% CI: 0.81-1.03); no difference were found with regard to secondary effect measures. CONCLUSIONS: With the current design a future definitive RCT on the effectiveness of the MiLES intervention on successful RTW of cancer survivors is not feasible, since recruitment of survivors fell short of the predefined minimum for feasibility. There was selection bias towards survivors at low risk of adverse work outcomes, which reduced generalisability of the outcomes. An alternative study design is needed to study effectiveness of the MiLES intervention. TRIAL REGISTRATION: The study has been registered in the Dutch Trial Register ( NL6758/NTR7627 ).

The Dilemma After an Unforeseen Positive Sentinel Node in Primary Breast Cancer: Is Completion Axillary Dissection Necessary?

BACKGROUND: In the majority of cases, the sentinel node is the only positive node in the axilla and completion ALND (cALND) is a futile procedure. However, refraining from cALND will lead to less accurate staging and, possibly, undertreatment. To help resolve this dilemma, we examined the clinical value of cALND in staging and determining adjuvant treatment. METHODS: In a retrospective cohort, all consecutive patients over a five-year period with primary breast cancer who received ALND were identified and grouped based on timing of ALND. Total nodal yield and positive lymph nodes were defined and factors with possible impact identified. In the case of cALND, N-status upstaging and possible impact on adjuvant treatment were studied in detail. RESULTS: A total of 280 patients were selected of whom 204 underwent primary ALND (pALND) and 76 cALND. pALND resulted in a significantly higher total nodal yield and more positive nodes when compared to cALND (p = 0.003, and p < 0.001, respectively). Neoadjuvant chemotherapy (NAC) had no effect on total nodal yield (p = 0.413), but resulted in fewer positive nodes (p < 0.001). Due to the results of cALND, only 11 patients (14%) had upstaging of N-status. All these patients were advised more extensive adjuvant radiotherapy. CONCLUSION: In the majority of patients, cALND does not lead to upstaging. cALND should be performed only after a careful discussion with the patient about the pros and cons of this procedure, and most probably only in the presence of multiple risk factors for axillary disease in the absence of systemic therapy.

Two-Year Follow-Up of a Multi-centre Randomized Controlled Trial to Study Effectiveness of a Hospital-Based Work Support Intervention for Cancer Patients.

Purpose Purpose is to: (1) study effectiveness of the hospital-based work support intervention for cancer patients at two years of follow-up compared to usual care and (2) identify which early factors predict time to return-to-work (RTW). Methods In this multi-center randomised controlled trial (RCT), 106 (self-)employed cancer patients were randomized to an intervention group or control group and provided 2 years of follow-up data. The intervention group received patient education and work-related support at the hospital. Primary outcome was RTW (rate and time) and quality of life (SF-36), and secondary outcomes were, work ability (WAI), and work functioning (WLQ). Univariate Cox regression analyses were performed to study which early factors predict time to full RTW. Results Participants were diagnosed with breast (61%), gynaecological cancer (35%), or other type of cancer (4%). RTW rates were 84% and 90% for intervention versus control group. They were high compared to national register-based studies. No differences between groups were found on any of the outcomes. Receiving chemotherapy (HR = 2.43, 95% CI 1.59-3.73 p < 0.001), low level of education (HR = 1.65, 95% CI 1.076-2.52 p = 0.02) and low work ability (HR = 1.09 [95% CI 1.04-1.17] p = 0.02) were associated with longer time to full RTW. Conclusions We found high RTW rates compared to national register-based studies and we found no differences between groups. Future studies should therefore focus on reaching the group at risk, which consist of patients who receive chemotherapy, have a low level of education and have a low work ability at diagnosis. TRIAL REGISTRATION: Netherlands Trial Registry (NTR) (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1658): NTR1658.

Magnetic resonance imaging in patients with unilateral bloody nipple discharge; useful when conventional diagnostics are negative?

BACKGROUND: Unilateral bloody nipple discharge (UBND) is mostly caused by benign conditions such as papilloma or ductal ectasia. However, in 7-33 % of all nipple discharge, it is caused by breast cancer. Conventional diagnostic imaging like mammography (MMG) and ultrasonography (US) is performed to exclude malignancy. Preliminary investigations of breast magnetic resonance imaging (MRI) assume that it has additional value. With an increasing availability of MRI, it is of clinical importance to evaluate this. We evaluated the additional diagnostic value of MRI in patients with UBND in the absence of a palpable mass, with normal conventional imaging. METHODS: All women with UBND in the period November 2007-July 2012 were included. In addition to the standard work-up (patient's history, physical examination, MMG, and US), MRI was performed. Data from these examinations and treatment were collected retrospectively. RESULTS: A total of 111 women (mean age 52 years; range 23-80) were included. In nine (8 %) patients, malignancy was suspected on MRI while conventional imaging was normal. In eight (89 %) of these patients, histology was obtained, two by core biopsy and six by terminal duct excision. Benign conditions were found in six patients (86 %) and a (pre-) malignant lesion in two patients. In both cases, it concerned a ductal carcinoma in situ, which was treated with breast-conserving therapy. Moreover, in two cases of (pre)malignancy, the MRI was interpreted as negative. CONCLUSION: In patients with UBND who show no signs of a malignancy on conventional diagnostic examinations, the added value of a breast MRI is limited, since a malignancy can be demonstrated in <2 %.

Cardiac metastasis of malignant melanoma: a case report.

The heart is regularly involved in metastatic neoplasms with cardiac metastases being found in up to 20 % of autopsies. We present a case about a 42-year-old Caucasian female with a fatal metastatic melanoma to the heart. The five- year survival rate for stage IV melanoma (melanoma with metastases to other organs) is 15 to 20 %. If patients with malignant melanoma present with new onset of cardiac symptoms, clinicians should always be aware of the possibility of cardiac metastases and perform further investigations.

Comparison of extended hemicolectomy versus transverse colectomy in patients with cancer of the transverse colon.

BACKGROUND: Cancer of the transverse colon is rare and postoperative mortality tends to be high. Standard surgical treatment involves either extended hemicolectomy or transverse colectomy, depending on the location of the tumour. The aim of the present study was to compare postoperative mortality and five-year survival between these types of surgery. METHODS: For this observational study, data on patients with a tumour of the transverse colon, treated by open resection in the Dordrecht Hospital from 1989 through 2003, were derived from the database of the regional cancer registry. Information on type of resection, tumour stage, complications, postoperative mortality (30-day) and survival was abstracted from the medical files. Patients with multi-organ surgery, (sub)total colectomy or stage IV disease were excluded from the analysis, leaving a total series of 103 patients. RESULTS: Transverse colectomy comprised one third of operations, predominantly involving partial resections. Postoperative mortality was 6% (2/34) after transverse colectomy and 7% (5/69) after extended hemicolectomy. Five-year survival was slightly higher for the hemicolectomy group (61% versus 50%), but this difference did not reach statistical significance (p = 0.34). CONCLUSION: Our results confirm the high postoperative risk after surgery for cancer of the transverse colon and show that this risk does not depend on the type of surgery. Considering the satisfactory results after partial transverse colectomy, segmental resections may be considered as an option for the treatment of localised tumours of the transverse colon.

Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types.

BACKGROUND: Various definitions are used to calculate postoperative mortality. As variation hampers comparability between reports, a study was performed to evaluate the impact of using different definitions for several types of cancer surgery. METHODS: Population-based data for the period 1997-2008 were retrieved from the Rotterdam Cancer Registry for resectional surgery of oesophageal, gastric, colonic, rectal, breast, lung, renal and bladder cancer. Postoperative deaths were tabulated as 30-day, in-hospital or 90-day mortality. Postdischarge deaths were defined as those occurring after discharge from hospital but within 30 days. RESULTS: This study included 40,474 patients. Thirty-day mortality rates were highest after gastric (8·8 per cent) and colonic (6·0 per cent) surgery, and lowest after breast (0·2 per cent) and renal (2·0 per cent) procedures. For most tumour types, the difference between 30-day and in-hospital rates was less than 1 per cent. For bladder and oesophageal cancer, however, the in-hospital mortality rate was considerably higher at 5·1 per cent (+1·3 per cent) and 7·3 per cent (+2·8 per cent) respectively. For gastric, colonic and lung cancer, 1·0 per cent of patients died after discharge. For gastric, lung and bladder cancer, more than 3 per cent of patients died between discharge and 90 days. CONCLUSION: The 30-day definition is recommended as an international standard because it includes the great majority of surgery-related deaths and is not subject to discharge procedures. The 90-day definition, however, captures mortality from multiple causes; although this may be of less interest to surgeons, the data may be valuable when providing information to patients before surgery.

A hospital-based work support intervention to enhance the return to work of cancer patients: a process evaluation.

PURPOSE: To perform a process evaluation of a hospital-based work support intervention for cancer patients aimed at enhancing return to work and quality of life. The intervention involves the delivery of patient education and support at the hospital and involves the improvement of the communication between the treating physician and the occupational physician. In addition, the research team asked patient's occupational physician to organise a meeting with the patient and the supervisor to make a concrete gradual return-to-work plan. METHODS: Eligible were cancer patients treated with curative intent and who have paid work. Data were collected from patients assigned to the intervention group (N = 65) and from nurses who delivered the patient education and support at the hospital (N = 4) by means of questionnaires, nurses' reports, and checklists. Data were quantitatively and qualitatively analysed. RESULTS: A total of 47 % of all eligible patients participated. Nurses delivered the patient education and support in 85 % of the cases according to the protocol. In 100 % of the cases at least one letter was sent to the occupational physician. In 10 % of the cases the meeting with the patient, the occupational physician and the supervisor took place. Patients found the intervention in general very useful and nurses found the intervention feasible to deliver. CONCLUSIONS: We found that a hospital- based work support intervention was easily accepted in usual psycho-oncological care but that it proved difficult to involve the occupational physician. Patients were highly satisfied and nurses found the intervention feasible.

Morbidity and extent of surgical resection of carcinoid tumors after endobronchial treatment.

OBJECTIVES: This study assessed whether endobronchial therapy (EBT) for bronchial carcinoid, if not curative, reduces the extent of the surgical resection and whether EBT is associated with increased surgical morbidity. MATERIAL AND METHODS: Analysis was performed in a cohort of patients with bronchial carcinoid who have undergone surgical resection. A group that underwent EBT before the surgery (S + EBT) was compared with a group where no EBT was performed (S-EBT). Postoperative complications were also compared between both groups. RESULTS: A total of 254 patients treated for a bronchial carcinoid tumor between 2003 and 2019 were screened for inclusion. A total of 65 surgically treated patients were included, of whom 41 (63%) underwent EBT prior to surgery. In 5 out of 41 patients (12%) from the S + EBT group, less parenchyma was resected versus 2 out of 24 (8%) from the S-EBT group (OR 1.528, 95% CI 0.273-8.562, p = 1.000). Two patients from the S + EBT group (5%) underwent lobectomy instead of sleeve lobectomy versus 0 from the S-EBT group (OR 1.051, 95% CI 0.981-1.127, p = 0.527). Comparing complications between the S + EBT and S-EBT group did not result in increased postoperative surgical morbidity (15% S + EBT, 24% S-EBT). CONCLUSION: EBT, if not curative, does not reduce the extent of the subsequent surgical resection. Therefore, if curative EBT is not anticipated, patients should directly be referred for surgery. If curative EBT seems feasible, it should be attempted not only because surgical resection can be prevented, but also because failure of EBT is not associated with excess surgical morbidity.

Endobronchial and surgical treatment of pulmonary carcinoid tumors: A systematic literature review.

The treatment of pulmonary carcinoid has changed over the last decades. Although surgical resection is still the gold standard, minimally invasive endobronchial procedures have emerged as a parenchyma sparing alternative for tumors located in the central airways. This review was performed to identify the optimal treatment strategy for pulmonary carcinoid, with a particular focus on the feasibility and outcome of parenchyma sparing techniques versus surgical resection. A systematic review of the literature was carried out using MEDLINE, Embase and the Cochrane databases, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two separate searches of publications in endobronchial and surgical treatment in patients with pulmonary carcinoid, were performed. Outcomes were overall survival, disease free survival, recurrence rate, complications, quality of life, and healthcare costs. Combining the two main searches for endobronchial therapy and surgical therapy yielded 3111 records. Finally, 43 studies concerning surgical treatment and 9 studies related to endobronchial treatment for pulmonary carcinoid were included. Assessment of included studies showed that lymph node involvement, histological grade, tumor location and tumor diameter were identified as poor prognostic factors and seem to be important for patients with pulmonary carcinoid. For patients with a more favorable prognosis, tumor location and tumor diameter are important factors that can help decide on the optimal treatment strategy. Centrally located small intraluminal pulmonary carcinoids, without signs of metastasis can be treated with minimally invasive alternatives such as endobronchial treatment or parenchyma sparing surgical resection. Patients with parenchyma sparing resections should be followed with long term follow up to exclude recurrence of disease. In a multidisciplinary setting, it should be determined whether individual patients are eligible for parenchyma sparing procedures or anatomical resection. Overall evidence is of low quality and future studies should focus on prospective trials in the treatment of pulmonary carcinoid.

Mesh fixation using staples in Lichtenstein's inguinal hernioplasty: fewer complications and fewer recurrences.

BACKGROUND: Fixation of the mesh in Lichtenstein's inguinal hernioplasty is traditionally performed with polypropylene sutures. A modification of this technique uses staples for securing of the mesh. METHOD: A retrospective comparative study of 149 elective repairs of a primary inguinal hernia was performed: a control group of 67 patients undergoing mesh fixation using sutures and a study group of 82 patients undergoing staple fixation. Operating time, recurrence, postoperative pain, complications and costs were studied. RESULTS: Seven recurrences (11%) occurred in the polypropylene group as compared to one recurrence (1%) in the staple group (P < 0.01). There was a trend of fewer complications in the staple group. Operative time and long-term postoperative pain did not differ significantly between the two groups. The costs per surgery for mesh fixation and skin closure were euro 11.13 for the suture group and euro 24.35 for the staple group. CONCLUSION: Staple fixation of the mesh in Lichtenstein's inguinal hernioplasty can be considered equal to traditional fixation with sutures with regard to operating time and postoperative pain. However, staple fixation seems to show fewer recurrences and fewer complications.

[Splenectomy in a large general hospital: often caused by iatrogenic injury, often causing multiple complications; poor adherence to post-operative guidelines for vaccination and prophylaxis]. / Splenectomie in een groot algemeen ziekenhuis: vaak iatrogeen letsel als oorzaak, veel complicaties tot gevolg; naleving postoperatieve richtlijnen voor vaccinatie en profylaxe gebrekkig.

OBJECTIVE: To assess the indications, complications and mortality associated with splenectomy in a large general hospital, and to evaluate adherence to guidelines for postoperative vaccination and prophylactic antibiotics. DESIGN: Retrospective, descriptive. METHOD: Data were collected on 106 patients who underwent splenectomy between 1999 and 2004. Indications for surgery, complications, duration of hospitalisation, and vaccination status were investigated retrospectively. Patients were contacted by telephone for a structured interview regarding vaccination and antibiotic prophylaxis. RESULTS: Of the 95 patients with sufficient data for analysis, 41 underwent elective surgery and 54 underwent non-elective surgery, including 37 who required splenectomy due to iatrogenic injury. Posteroperative complications arose in 45 patients, including 23 who developed serious complications. 10 patients died due to complications, including 7 who died within one month after the procedure. Vaccination coverage for the entire group was 58%. CONCLUSION: In this large general hospital, splenectomy was often performed due to iatrogenic injury and was associated with a relatively high complication rate. Adherence to guidelines on vaccination and prophylactic antibiotics could be improved.

Patent processus vaginalis in the adult as a risk factor for the occurrence of indirect inguinal hernia.

BACKGROUND: Inguinal hernias are a common entity with nearly 31,000 repairs annually in The Netherlands and over 800,000 in the USA. The aim of the present study is to determine whether a laparoscopically diagnosed patent processus vaginalis (PPV) is a risk factor for the development of groin hernia. METHODS: The study population was originally composed of 599 consecutive cases (189 male, 32%) of laparoscopic transperitoneal surgery for different indications performed in 4 teaching hospitals in The Netherlands between November 1998 and February 2002. During laparoscopy, the deep inguinal ring was inspected bilaterally. The PPV group was compared with the obliterative processus vaginalis (OPV) group. RESULTS: After a mean follow-up of 5.5 years, the studied population consisted of 337 cases (94 male, 28%). In this study 12% of the studied population appeared to have PPV in adult life. The percentage PPV of our study group is much higher than the percentage of hernia repairs performed in the Dutch population. A greater proportion (12%) of hernia repairs in the PPV group was found as compared with the OPV group (3%). The chance of developing an inguinal hernia within 5.3 years is four times higher in the group with PPV. No significant correlation between age and the prevalence of PPV was observed. CONCLUSION: This study demonstrates that PPV is an etiologic factor and a risk factor for acquiring an indirect inguinal hernia in adults.

Satisfaction and complications in post-bariatric surgery abdominoplasty patients.

BACKGROUND: Bariatric surgery is an expanding field, with subsequent increases in the number of patients seeking additional corrective procedures including abdominoplasty. Complication rates and body image changes may be different from the general population seeking corrective procedures. METHODS: We performed a retrospective study by questionnaire and chart-based review of the patients who underwent laparoscopic adjustable gastric banding (LAGB) and abdominoplasty at our hospital between 1995 and 2004. Outcome variables included minor and major complications and satisfaction with body image and functional outcome. RESULTS: Patients who returned the completed questionnaire were included in the study (n = 25). The most prevalent complications were seroma formation (25%) and wound infections requiring antibiotics (13%). Hygiene, mobility and general functional capacity improved in 68%, 72%, and 80%, respectively. Body satisfaction and body mass index (BMI) did not markedly change, while self-efficacy improved after abdominoplasty. CONCLUSION: Abdominoplasty is a safe and effective method of body contour correction in patients with massive weight loss after bariatric surgery. However, a BMI as close to the ideal as possible is necessary for the complication rate to approach that of the general population undergoing abdominoplasty. Patients should be made aware of the difference in body image changes after abdominoplasty as compared to post-LAGB, as well as the trend towards an unchanged BMI.

Poor results after surgery for bronchioloalveolar carcinoma.

BACKGROUND: Bronchioloalveolar carcinoma (BAC) is suggested to be less aggressive than other types of lung cancer. To assess the option of treatment modification, actual outcome data were studied and compared with results for other types of lung cancer. METHOD: Retrospective analysis of all consecutive patients who underwent resection for stage I lung cancer in our hospital. For 18 BAC cases, histological specimens were re-evaluated and in three cases diagnosis was revised. RESULTS: In the period 1989 through 2000, 15 patients with BAC and 260 patients with other tumour types underwent surgery in our hospital. Five-year survival rates were 24 and 53%, respectively, (p = 0.01). CONCLUSIONS: Given the poor results after standard surgery, parenchyma-sparing operations do not seem justified in patients with invasive BAC.

Carcinoma of the sigmoid presenting as a right inguinal hernia.

We present the case of a 44-year-old man who presented with nausea, vomiting and acute pain in the right groin. On physical examination an irreducible mass was palpated in the right inguinal region. Ultrasound suggested an inguinal hernia sac with bowel contents. Subsequent right inguinal exploration revealed only unspecified necrotizing tissue, but no hernia sac or bowel contents were identified. Two days later laparotomy was required since the inguinal wound produced faecal discharge. The sigmoid appeared to be necrotic and perforated, and was subsequently resected. Histology revealed a perforated adenocarcinoma without lymph node involvement. Incarcerated inguinal hernias containing an adenocarcinoma of the colon are rare, but should be considered in patients presenting with an irreducible palpable mass in the inguinal region. Moreover, a carcinoma of the sigmoid may invade the right inguinal region. An intestinal perforation to skin-level in this population is even rarer and is associated with high morbidity and mortality rates.

Bilateral axillary metastases of occult breast carcinoma: report of a case with a review of the literature.

The case of a 47-year-old premenopausal woman is presented in whom axillary lymph node metastases occurred on both sides 3 years apart although no primary tumor was detectable in either breast is presented. An overview of the literature on this rare entity is given. Patients with occult breast carcinoma with axillary lymph node metastases should have a complete physical examination, radiologic analysis (mammography, ultrasonography, and MRI of both breasts) and screening for disseminated disease. If there is no evidence of a primary tumor and metastases other than in the axilla, an axillary dissection should be carried out. In addition, the patient should be offered the choice of irradiation of the breast or mastectomy. Postoperatively, patients should receive appropriate systemic therapy tailored to their age, menopausal status, and receptor status.

Prolonged skin staining after intradermal use of patent blue in sentinel lymph node biopsy for breast cancer.

AIMS: To investigate the duration of staining of the skin after intradermal injection of patent blue during sentinel lymph node biopsy (SLNB) for breast cancer. METHODS: The clinical data of 33 consecutive patients who underwent a SLNB in combination with breast conserving therapy (BCT) in our hospital were retrospectively reviewed. Also, patients were interviewed at intervals of 3 months until the blue staining of their skin had disappeared. RESULTS: At mean follow-up of 18 months (range: 12-28) patent blue was visible at the site of injection after 3, 6, 9 and 12 months in 70, 64, 44 and 41% of the patients, respectively. CONCLUSIONS: Use of the intradermal injection technique of patent blue during sentinel lymph node biopsy in BCT may result in remarkably long discolouring of the skin at the site of injection.

[Diagnostic image (237). A man with a swelling on his left buttock. Bednar tumor]. / Diagnose in beeld (237). Een man met een gezwel op zijn linker bil.

A 42-year-old man was referred because of a pigmented dermatofibrosarcoma protuberans, a so-called Bednar tumour, on his left buttock. It was radically excised.