Indeterminate pulmonary nodules in colorectal-cancer: do radiologists agree?

BACKGROUND: The clinical significance of indeterminate pulmonary nodules (IPN) at staging computed tomography (CT) for colorectal cancer (CRC), and the optimal diagnostic approach, are debated. This study aimed to analyse variability in radiologists' detection of IPN at staging CT for CRC. METHODS: All patients with CRC referred to our center between 2006 and 2011 were included. Primary staging CT scans were re-evaluated by an experienced thoracic radiologist whose findings were entered into a dedicated database and merged with data from the Danish Colorectal Cancer Group database, the National Patient Registry, the Danish Pathology Registry, and the primary CT evaluation. Inter-reader agreement was calculated by Kappa statistics, and associations between variables and malignancy of pulmonary nodules were analyzed with χ (2) and Mann-Whitney-Wilcoxon tests. Multivariable logistic regression analyses were used to adjust for potential confounding variables. RESULTS: In total, 841 patients were included. The primary CT assessment reported IPN in 9.8 % of patients and pulmonary metastases in 5.1 % of patients compared with 5.6 and 7.0 %, respectively, reported by the experienced thoracic radiologist. Kappa for agreement between the primary assessor and the thoracic radiologist on IPN was 0.31 and 0.65 for pulmonary metastases. Synchronous liver metastases were predictive of malignancy of IPN (adjusted odds ratio 20.1; 95 % confidence interval 2.64-437.66; p = 0.012), whereas no other investigated radiological characteristics or clinicopathological factors were significantly associated with malignancy of IPN. CONCLUSION: The characterization of pulmonary findings on staging CT for CRC varied greatly between the radiologists, and double-reading of scans with IPN is recommended prior to further diagnostic work-up.

Occurrence and survival of synchronous pulmonary metastases in colorectal cancer: a nationwide cohort study.

OBJECTIVE: To investigate the occurrence of synchronous colorectal cancer metastases (SCCM) confined to the lungs, risk factors for these metastases and their impact on survival. METHODS: In a nationwide cohort study of 26,200 patients data were prospectively entered into the Danish Colorectal Cancer Group's (DCCG's) database between May 2001 and December 2011. The recorded data were merged with data from the Danish Pathology Registry and the National Patient Registry. Multivariable logistic- and extended Cox regression analyses were used to adjust for confounding variables. RESULTS: In total, 1970 patients (7.5%) had pulmonary SCCM of whom 736 (37%) had metastases exclusively in the lungs. Advanced age, recent years of diagnosis and a rectal index cancer were significantly associated with pulmonary SCCM. Adjustment for excess use of thoracic CT scans in rectal cancer patients did not alter this association (adjusted OR=1.81 (95% CI: 1.46-2.25, P<0.001)). Patients subjected to pulmonary metastasectomy, resection of primary tumour and chemotherapy had a superior overall survival compared with non-treated patients, especially when these therapeutic modalities were combined. CONCLUSIONS: The occurrence of pulmonary SCCM was higher than previously reported and had a severe impact on survival. Our analyses suggest that pulmonary metastasectomy, resection of the primary tumour and chemotherapy may be a sound strategy in patients with confined pulmonary SCCM, but the risk of selection bias and consequent exaggeration of the treatment effect should be kept in mind. This study may serve as a reliable un-biased reference for future evaluation on detection strategies and potential therapeutic interventions.

Indeterminate pulmonary nodules at colorectal cancer staging: a systematic review of predictive parameters for malignancy.

BACKGROUND: This study aimed to estimate the prevalence of indeterminate pulmonary nodules and specific radiological and clinical characteristics that predict malignancy of these at initial staging chest computed tomography (CT) in patients with colorectal cancer. A considerable number of indeterminate pulmonary nodules, which cannot readily be classified as either benign or malignant, are detected at initial staging chest CT in colorectal cancer patients. METHODS: A systematic review based on a search in EMBASE, Medline, the Cochrane library and science citation index, PubMed databases, Google scholar, and relevant conference proceedings was performed in cooperation with the Cochrane Colorectal Cancer Group. RESULTS: A total of 2,799 studies were identified, of which 12 studies met the inclusion criteria. The studies primarily consisted of case series and included a total of 5,873 patients. Of these patients, 9% (95% confidence interval [95% CI] 8.9-9.2%) had indeterminate pulmonary nodules at chest CT, of which 10.8% (95% CI 10.3-11.2%) turned out to be colorectal cancer metastases at follow-up. Generally, regional lymph node metastasis, and multiple numbers of indeterminate pulmonary nodules were reported to predict malignancy, whereas calcification of the nodules indicated benign lesions. CONCLUSION: It was found that 1 in 100 colorectal cancer patients subjected to preoperative staging chest CT will have an indeterminate pulmonary nodule that proves to be metastatic disease. Such a low risk suggests that indeterminate pulmonary nodules should not cause further preoperative diagnostic workup or follow-up besides routine regimens.

[Treating high anal fistulae with slow cutting seton]. / Høje analfistler behandlet med langsomt skaerende seton.

INTRODUCTION: The aim was to determine the incidence of anal incontinence, recurrence rate and patient satisfaction after using slow-cutting setons for transsphincteric anal fistula repair. MATERIAL AND METHODS: A retrospective study with prospective follow up in 58 patients who had undergone surgery for transsphincteric perianal fistulas with a slow-cutting seton. A total of 17 patients were excluded or lost in the follow up period. A questionnaire was send to 41 cases to the severity of incontinence for gas, liquid and stool according to the Wexner-score. Recurrence rate, sick leave and satisfaction with the treatment were estimated. RESULTS: The questionnaire was returned from 34 patients. In all 23 men and 11 women had the seton tightened for the first time after a mean period of 32 days. The mean number of tightenings was five (range: 2-9). The mean duration of treatment was 256 days (range: 61-634). A total of four patients (12%) experienced recurrence. Twenty-one patients (61,7%) had a Wexner score of one or more. Eight patients (23,5%) scored more than four. A total of 28 patients (82%) were 75-100% satisfied with the treatment. Two patients (6%) were absolutely dissatisfied, and were considered failures. We found no association between the reported satisfaction with the treatment and the degree of incontinence. CONCLUSION: Despite a very high level of satisfaction among the patients, the high rate of incontinence suggests that other non-invasive techniques should be used as first-line treatment of anal fistulas. In cases where multiple attempts at repair have failed, the slow-cutting seton may be the best option.

[Thrombo-prophylaxis in Danish surgical departments. Status 2005 and 25 years' development]. / Tromboseprofylakse på kirurgiske afdelinger i Danmark. Status 2005 og 25 ars udvikling.

OBJECTIVES: To assess Danish surgical departments' attitudes to and clinical guidelines on the use of perioperative thrombo-prophylaxis (TP). MATERIALS AND METHODS: Questionnaires regarding TP were sent to Danish departments which performed major surgery in 2005. The questionnaires contained questions regarding the use of TP routinely after clinical guidelines for both elective and acute surgery, indications for the use of TP, the type of TP and the duration of the TP treatment. The results are registered descriptively. The results are compared with five previously performed surveys from 1981-2000. RESULTS: In the five surveys from 1981 to 2000, 85%, 90%, 92%, 95%, 93% answered the questionnaire, in the present survey 88% answered. Since the beginning of these surveys, there has been a significant increase in the use of TP following clinical guidelines from approximately 50% in 1981 to 96% of the departments performing major surgery in 2005. In acute surgery we found a significant increase in the number of departments using TP following clinical guidelines from 43% in 2000 to 81% in 2005 (p<0.01 Fishers exact test). All departments that used TP employed low molecular weight heparin. The use of prolonged TP was sporadic. CONCLUSION: 30 years after the first evidence in favour of TP was published, 96% of surgical departments which perform major surgery use TP routinely based on international clinical recommendations. A large number of departments use TP in connection with acute surgery in comparison with previous surveys. A future task is more focus on the use of prolonged TP after major surgical procedures.

[Treatment of colorectal obstruction with self-expanding metal stents]. / Behandling af kolorektal obstruktion med selvekspanderende metalstent.

INTRODUCTION: Self-expanding metal stents (SEMS) serve as a bridge to surgery in cases of acute colorectal obstruction and provide palliation without surgery in patients with severe co-morbidity or disseminated disease. We describe our experiences with the use of SEMS in colorectal obstruction. MATERIALS AND METHODS: We analysed a consecutive series of 162 SEMS procedures in 141 patients (72 men (51%)) in the period between May 1997 and September 2004. The median age of the patients was 75 years (range 28-101). In 11 patients the stricture was caused by benign pathology. The indication of the procedure was in 62 (44%) of the cases in patients with cancer acute obstruction. RESULTS: Seventeen patients needed more than one SEMS procedure. Perforation of the colon by the stent was seen in 2% of the cases, and the frequency of stent migration was 10%. The 30-day mortality rate after SEMS procedure and subsequent resection was 17% in cases of malign acute obstruction. Resection without stoma was achieved in 76% of the cases. Fifteen patients with acute obstruction received SEMS as the definitive treatment. In the group of patients who received SEMS as palliation, only 10% needed a stoma in the follow-up period. In 11 cases of benign strictures, only 4 were successful. CONCLUSION: SEMS is a safe, effective procedure in the treatment of colorectal obstruction. It reduces the mortality and morbidity rates, as well as the need for stomas. In our experience, stenting of benign strictures is ineffective and associated with higher rates of complications.

[Acute treatment of colon cancer]. / Akut behandling af coloncancer.

The primary treatment of left-sided colonic ileus due to cancer is after localisation of the tumor with water-soluble contrast enema placement of an intraluminal, self-expanding metal stent. If this treatment is unsuccessful, open resection with primary anastomosis is the treatment of choice. In the case of a perforated tumor, resection and primary anastomis may be performed if the patient s general condition is acceptable.

[Follow-up of patients after curative surgery for colorectal cancer]. / Opfølgning af patienter efter kurativ behandling for kolorektal cancer.

Meta-analyses of randomised controlled studies show that intensive follow-up programmes after radical surgery for colorectal cancer have a more positive effect on total survival than do less intensive programmes, but the ideal programme has not yet been found. It appears that monitoring with carcinoembryonal antigen (CEA) and some kind of visualisation of the liver is a way forward, but we do not know how often it should be done. Colonoscopy should be offered every five years to look for metachronous cancer; patients with HNPCC should have a colonoscopy done even more often.

[Junior physicians' acquisition of theoretical knowledge at a surgical department. Evaluation in the form of multiple-choice tests]. / Uddannelsessøgende laegers tilegnelse af teoretisk viden på en kirurgisk afdeling. Evaluering i form af multiple-choice-test.

INTRODUCTION: Denmark has no tradition of formal assessment of junior doctors' theoretical knowledge. We therefore wanted to investigate whether the knowledge of surgical junior doctors has actually increased. MATERIAL AND METHODS: Twenty-three junior doctors were confronted with the same multiple-choice questionnaires twice during a six months period. Subsequently, they were asked whether they would approve the implementation of multiple-choice questionnaires and formal assessment (exam) in the Danish specialist training in surgery. RESULTS: The participants got a significantly higher score the second time they were confronted with the multiple-choice questionnaires (p = 0.0003). When dividing the participants into two groups, viz. young vs. old junior doctors, it was observed that the latter group had a higher score overall but augmented their scores less in relation to their young colleagues (p = 0.038). Forty percent of the participants replied that the multiple-choice questionnaires had motivated them to do further theoretical studies, and half of them approved the introduction of an exam in surgery in the Danish specialist training. DISCUSSION: The theoretical knowledge of junior doctors does actually increase in a relatively short period of time during their employment at a department of surgery. As expected the old junior doctors got a higher score compared to their young colleagues. However, the latter group augments its knowledge relatively more. Multiple-choice questionnaires are easy, accessible, and inexpensive tools for evaluation as well as stimulation for doing further theroretical studies.