Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomized controlled trial.

AIM: Individualized, goal-directed fluid therapy (GDFT), based on Doppler measurements of stroke volume, has been proposed as a treatment strategy in terms of reducing complications, mortality and length of hospital stay in major bowel surgery. We studied the effect of Doppler-guided GDFT on intestinal damage as compared with standard postoperative fluid replacement. METHOD: Patients undergoing elective colorectal resection for malignancy were randomized either to standard intra- and postoperative fluid therapy or to standard fluid therapy with additional Doppler-guided GDFT. The primary outcome was intestinal epithelial cell damage measured by plasma levels of intestinal fatty acid-binding protein (I-FABP). Global gastrointestinal perfusion was measured by gastric tonometry, expressed as regional (gastric) minus arterial CO2 -gap (Pr-a CO2 -gap). RESULTS: I-FABP levels were not significantly different between the intervention group and the control group (respectively, 440.8 (251.6) pg/ml and 522.4 (759.9) pg/ml, P = 0.67). Mean areas under the curve (AUCs) of intra-operative Pr-a CO2 -gaps were significantly lower in the intervention group than in the control group (P = 0.01), indicating better global gastrointestinal perfusion in the intervention group. Moreover, the mean intra-operative Pr-a CO2 -gap peak in the intervention group was 0.5 (1.0) kPa, which was significantly lower than the mean peak in the control group, of 1.4 (1.4) kPa (P = 0.03). CONCLUSION: Doppler-guided GDFT during and in the first hours after elective colorectal surgery for malignancy increases global gastrointestinal perfusion, as measured by Pr-a CO2 -gap.

Sustainability of an enhanced recovery after surgery program (ERAS) in colonic surgery.

BACKGROUND: Between 2006 and 2008 the enhanced recovery after surgery (ERAS) program was implemented in colonic surgery in one-third of all hospitals in the Netherlands (n = 33). This resulted in enhanced recovery and a decrease in hospital length of stay (LOS) from a median of 9 days at baseline to 6 days at one-year follow-up. The present study assessed the sustainability of the ERAS program 3-5 years after its implementation. MATERIALS AND METHODS: From the 33 ERAS hospitals, 10 initially successful hospitals were selected, with success defined as a median LOS of 6 days or lower and protocol adherence rates above 70 %. In 2012 a retrospective audit of 30 consecutive patients was performed in each of these hospitals. Sustainability of the ERAS program was assessed on hospital level, using median hospital LOS, protocol adherence rates and time to functional recovery. Data were compared with the implementation phase data. RESULTS: Overall median LOS in the selected hospitals increased from 5.25 days (interquartile range [IQR] 4.75-6.00; min, 4.00-max, 6.00) to 6 days (IQR 5.00-7.00; min, 5.00-max, 8.00), but this change was not significant (p = 0.052). Time to functional recovery was equal in both phases: median 3.00 days (p = 0.26). Protocol adherence decreased from 75 to 67 % (p = 0.32). Especially adherence to postoperative care elements dropped considerably. CONCLUSIONS: Despite a slight decrease in protocol adherence, the ERAS program was sustained reasonably well in the 10 selected hospitals, although there was quite some variation between the hospitals.

The quality of life in long-term breast cancer survivors with breast cancer related lymphedema.

AIM: To compare the health related quality of life (HRQOL) of long-term breast cancer survivors with and without breast cancer related lymphedema (BCRL) treated in the sentinel lymph node biopsy (SLNB) era. METHODS: HRQOL was assessed as subject of a secondary analysis of data gathered for a study evaluating the prevalence of BCRL in long-term breast cancer survivors. The 145 women in this study cohort had undergone SLNB and or axillary lymph node dissection (ALND) according to Dutch Breast cancer treatment guidelines. HRQOL was assessed using two questionnaires : the European Organization for Research and Treatment of Cancer Quality (QLQ-C30) and the Breast Cancer-specific Quality of life questionnaire (QLQ-BR23). RESULTS: Twenty-six women, of whom 5 only underwent SLNB, were identified with objectively measured lymphedema and/or self-perceived arm swelling. Patients with BCRL scored significantly lower on the social (p = 0.000) functioning scale after adjustment for BMI and age compared to women without BCRL. Compared to normative data, women with BCRL scored significantly lower on social- (p < 0.001) and role (p = 0.001) functioning scales. CONCLUSIONS: HRQOL in long-term breast cancer survivors with BCRL is structurally lower than of those without BCRL, even in this small cohort of cancer survivors treated in the SLNB-era.

Activated macrophages containing tumor marker in colon carcinoma: immunohistochemical proof of a concept.

The presence of carcinoembryonic antigen (CEA)-containing activated macrophages has been demonstrated in peripheral blood from patients with colorectal carcinoma. Macrophages migrate from the circulation into the tissue, phagocytose debris, and return to the bloodstream. Hence it seems likely that activated macrophages containing tumor debris, i.e., tumor marker, are present in the stroma of colorectal carcinoma. After phagocytosis, they could follow a hematogenic or lymphogenic route to the peripheral blood. The aim of this study is to assess the presence of tumor marker-containing activated macrophages in the stroma of colon carcinoma and in regional lymph nodes. From 10 cases of colon carcinoma, samples of tumor tissue and metastasis-free lymph nodes were cut in serial sections and stained for CD68 to identify macrophages and for CEA, cytokeratin, or M30 presence. Slides were digitalised and visually inspected using two monitors, comparing the CD68 stain to the tumor marker stain to evaluate the presence of tumor marker-positive macrophages. Macrophages containing tumor marker could be identified in tumor stroma and in metastasis-free regional lymph nodes. The distribution varied for the different markers, CEA-positive macrophages being most abundant. The presence of macrophages containing tumor marker in the tumor stroma and lymph nodes from patients with colon carcinoma could be confirmed in this series using serial immunohistochemistry. This finding supports the concept of activated macrophages, after phagocytosing cell debris, being transported or migrating through the lymphatic system. These results support the potential of tumor marker-containing macrophages to serve as a marker for diagnosis and follow-up of colon cancer patients.

Implementation of a short-stay programme after breast cancer surgery.

BACKGROUND: : Short-stay breast cancer surgery (24 h or day case) is not common practice in Europe. This before-after comparative study was carried out to test the feasibility of systematically implementing a care programme incorporating short-stay admission using strategies tailored to individual hospital needs, and to assess safety and facilitating factors. METHODS: : Patients with breast cancer from four Dutch hospitals participated. The intervention concerned the programme developed by the Maastricht University Medical Centre. This was implemented through local multidisciplinary meetings and educational outreach visits. RESULTS: : Of 421 eligible patients, 324 (77.0 per cent) gave consent to participate. The proportion of patients who had short-stay treatment increased from 45.3 per cent before to 82.2 per cent after implementation of the programme (P < 0.001). No increase was observed in the rate of complications, readmissions, reoperations or number of visits to the emergency department. Factors associated with an increased chance of short-stay treatment were: breast-conserving surgery, having children and being employed. Being aged over 64 years showed a trend towards a decreased chance. CONCLUSION: : Introducing a care programme incorporating short stay following breast cancer surgery in four hospitals was feasible and safe.

Additional tracer injection to improve the technical success rate of lymphoscintigraphy for sentinel node biopsy in breast cancer.

BACKGROUND: Sentinel node (SN) biopsy has become the standard of care in the treatment of breast cancer. The aim of this study is to determine the value of additional tracer injection to increase the technical success rate of the SN procedure and to identify factors that influence the ability to visualize hotspots. METHODS: From February 1997 to August 2007, 1,208 clinically node-negative breast cancer patients underwent lymphatic mapping for SN biopsy. The technique involved the injection of 370 MBq (10 mCi) Tc-99 m-nanocolloid peritumorally. In case of insufficient or absent visualization of hotspots 37 MBq (1 mCi) of additional tracer was given intracutaneously above the tumor. RESULTS: In 93 patients (7.7%) visualization of hotspots on initial lymphoscintigraphy was insufficient (41 patients) or absent (52 patients). The first 14 patients did not receive additional tracer injection. In five patients, additional tracer did not result in successful lymphoscintigraphy, which is correlated with massive nodal tumor infiltration. In 33 patients with negative initial lymphoscintigraphy, additional tracer injection resulted in secondary SN visualization. In 41 patients with faint hotspots on initial lymphoscintigraphy, additional tracer injection, by increasing nodal uptake, simplified accurate SN biopsy. Decreased radiotracer uptake in this group was associated with older age and high body mass index (BMI). CONCLUSIONS: Additional tracer injection following initial scan failure increases the success rate of lymphoscintigraphy during lymphatic mapping in breast cancer, without compromising accuracy. If additional tracer injection does not result in secondary SN visualization, gross nodal tumor involvement is often present and axillary lymph node dissection (ALND) is mandatory.

[Elective colon surgery according to a 'fast-track' programme]. / Electieve colonoperaties volgens een 'sneltraject'-programma.

In fast-track surgical programmes, a variety ofperioperative elements are combined in an intensive multidisciplinary approach for the purpose of preserving the preoperative body composition and organ functions and actively stimulating functional recovery. Such programmes have already been introduced in several surgical procedures. The essence of fast-track colon surgery consists of extensive preoperative counselling, adequate preoperative nutrition with the avoidance of prolonged fasting, a minimum of invasive procedures and anaesthesia, no routine use of drains and nasogastric tubes, adequate perioperative analgesia encompassing high thoracic epidural anaesthesia, rapid mobilisation, rapid resumption of postoperative feeding, and medicinal support with prokinetics and laxatives. A systematic review shows that this programme accelerates recovery and hence shortens the primary and total hospital stay.

Effect of different tumor types on resting energy expenditure.

The purpose of this study was to investigate whether the presence of a malignant tumor influences energy metabolism of the host. Resting energy expenditure (REE) was measured in 104 gastric and colorectal (GCR) cancer patients and in 47 non-small cell lung cancer patients and was compared with REE values in 40 healthy controls. REE expressed per kilogram of fat-free mass (FFM) in lung cancer patients was elevated, in comparison with healthy controls (33.6 +/- 4.6 and 29.6 +/- 2.9 kcal, respectively; P less than 0.001), in contrast to REE/FFM in GCR cancer patients, which showed no difference, compared with these controls (29.8 +/- 4.3 kcal). In 47 patients with GCR cancer and in 14 patients with lung cancer, REE was also determined after tumor resection. REE in GCR cancer patients measured 1.5 years after tumor resection showed a small but significant increase. No differences were observed between GCR cancer patients with or without signs of tumor recurrence. REE in lung cancer patients with no signs of tumor recurrence measured 1 year after tumor resection had a significant decrease in REE (REE/FFM, -6.8%; P less than 0.05), while patients who had evidence of tumor recurrence showed no change in REE or even an increase. After curative surgery REE returned to a normal level in the lung cancer patients. These results suggest that tumor type is a major determinant of an increased energy expenditure in cancer patients.

Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial.

PURPOSE: The extent of lymph node dissection appropriate for gastric cancer is still under debate. We have conducted a randomized trial to compare the results of a limited (D1) and extended (D2) lymph node dissection in terms of morbidity, mortality, long-term survival and cumulative risk of relapse. We have reviewed the results of our trial after follow-up of more than 10 years. PATIENTS AND METHODS: Between August 1989 and June 1993, 1,078 patients with gastric adenocarcinoma were randomly assigned to undergo a D1 or D2 lymph node dissection. Data were collected prospectively, and patients were followed for more than 10 years. RESULTS: A total of 711 patients (380 in the D1 group and 331 in the D2 group) were treated with curative intent. Morbidity (25% v 43%; P <.001) and mortality (4% v 10%; P =.004) were significantly higher in the D2 dissection group. After 11 years there is no overall difference in survival (30% v 35%; P =.53). Of all subgroups analyzed, only patients with N2 disease may benefit of a D2 dissection. The relative risk ratio for morbidity and mortality is significantly higher than one for D2 dissections, splenectomy, pancreatectomy, and age older than 70 years. CONCLUSION: Overall, extended lymph node dissection as defined in this study generated no long-term survival benefit. The associated higher postoperative mortality offsets its long-term effect in survival. For patients with N2 disease an extended lymph node dissection may offer cure, but it remains difficult to identify patients who have N2 disease. Morbidity and mortality are greatly influenced by the extent of lymph node dissection, pancreatectomy, splenectomy and age. Extended lymph node dissections may be of benefit if morbidity and mortality can be avoided.

Long-term prognosis of patients with local recurrence after conservative surgery and radiotherapy for early breast cancer.

We have studied the long-term prognosis of 266 patients considered to have isolated local recurrence in the breast following conservative surgery and radiotherapy for early breast cancer. The median follow-up of the patients still alive after diagnosis of local relapse was 11.2 years. At 10 years from the date of salvage treatment, the overall survival rate for the 226 patients with invasive local recurrence was 39% (95% CI, 32-46), the distant recurrence-free survival rate was 36% (95% CI, 29-42), and the local control rate (i.e., survival without subsequent local recurrence or local progression) was 68% (95% CI, 62-75). Among patients with a local recurrence at or near the original tumour site a better distant disease-free survival was observed for patients with recurrences measuring 1cm or less, compared to those with larger recurrences. This suggests, though does not prove, that early detection of local recurrence can improve the treatment outcome but might as well point towards a different biologic behaviour, facilitating early detection.

The changing role of axillary treatment in breast cancer: Who will remain at risk for developing arm morbidity in the future?

Primary aim is to give an overview of changes in axillary staging and treatment of breast cancer patients. Secondly, we aim to identify patients with a high arm/shoulder morbidity risk, and describe a strategy to improve early detection and treatment. Recent and initiated studies on axillary staging and treatment were evaluated and clustered for clinically node negative and clinically node positive breast cancer patients, together with studies on pathology, detection and (surgical) prevention and treatment of lymphedema. For clinically node negative patients, the indication for axillary lymph node dissection in sentinel node positive patients is fading. On the contrary, clinically node positive patients are routinely subjected to an axillary lymph node dissection, in combination with other therapies associated with an increased lymphedema risk, such as mastectomy, adjuvant radiation- and (taxane-based) chemotherapy. Techniques for prevention, early detection and (surgical) treatment of lymphedema are being developed. Axillary staging and treatment in breast cancer patients with a clinically node negative status will become less invasive, thereby reducing the incidence of morbidity. Nevertheless, in patients with a clinically node positive status, aggressive treatment will still be required for oncologic control. For these patients, a surveillance program should be implemented in order to apply (curative) surgical treatment for lymphedema.

Changes in brain amines associated with cancer anorexia.

Analysis of indole amine metabolism within acute (Walker 256 carcinosarcoma) and chronic (methycholanthrene-induced sarcoma) animal models of cancer anorexia demonstrated elevated levels of plasma free tryptophan, whole brain tryptophan, serotonin and 5-hydroxyindoleacetic acid in anorectic tumor-bearing rats. Whole brain levels of catecholamines were not changed within either tumor line. Regional central nervous system determination of tryptophan metabolism in rats bearing Walker 256 tumors revealed elevated tryptophan in the hypothalamus, corpus striatum, mesencephalon, diencephalon, cerebellum and cortex, increased serotonin in the diencephalon and cerebellum and elevated 5-hydroxyindoleacetic acid in the diencephalon, hippocampus, pons-medulla, cerebellum and cortex. Although tryptophan was significantly increased only in the corpus striatum and diencephalon of the more chronic methycholanthrene tumor model, serotonin concentration was elevated in the corpus striatum, diencephalon, hippocampus, pons-medulla, cerebellum and cortex, while levels of 5-hydroxyindoleacetic acid were significantly increased in all these areas as well as in the mesencephalon. Since similar changes in indole activity were not observed in pair-fed control rats, it is concluded that the elevated serotonin and 5-hydroxyindoleacetic acid levels in tumor-bearing rats did not result from undernutrition alone. Assay of regional catecholamines revealed few food-relevant changes, with norepinephrine being elevated in the corpus striatum and decreased in the pons-medulla of tumor-bearing rats. Therefore, these experiments suggest that the increased serotonin metabolism observed in tumor-bearing rats may be involved in the etiology of the anorexia of cancer.

Resting energy expenditure in patients with newly detected gastric and colorectal cancers.

Resting energy expenditure (REE) was measured in 104 patients with newly detected gastric or colorectal (GCR) cancer and was compared with two groups of control subjects without cancer: healthy subjects (H control subjects) and patients with nonmalignant diseases of the gastrointestinal tract (GI patients). REE in GCR-cancer patients was not significantly different from REE in GI patients or H control subjects. Comparison of measured REE with predicted REE obtained from prediction equations may erroneously suggest that increased REE is a contributing factor in the development of cancer cachexia. No significant differences in REE were found when patients with liver metastases were compared with patients without metastases. There were no differences in REE between gastric and colorectal cancer patients. The decrease in energy expenditure, which normally occurs during starvation and weight loss in healthy men and women, could not be demonstrated in weight-losing, GCR-cancer patients. In conclusion, elevation of REE contributes little to the pathogenesis of cancer cachexia in GCR-cancer patients.

Response of glutamine metabolism to glutamine-supplemented parenteral nutrition.

BACKGROUND: Increasing evidence suggests that glutamine is important for the function of many organ systems and supports the use of glutamine-enriched total parenteral nutrition (TPN) during severe illness. However, the effect of prolonged glutamine supplementation on glutamine kinetics has not been studied. OBJECTIVE: We investigated the effect of 8-10 d of TPN enriched with glutamine dipeptides on glutamine kinetics. DESIGN: Twenty-three preoperative patients were randomly allocated to receive either TPN enriched with glutamine dipeptides (60 micromol glutamine*kg body wt(-1)*h(-1)) or isonitrogenous, isoenergetic, glutamine-free TPN. A primed, continuous, 6-h intravenous infusion of L-[5-(15)N]glutamine and L-[1-(13)C]leucine was given before (baseline) and 8-10 d after the TPN solutions were administered. Baseline measurements were performed after a 40-h administration of a standard solution of glucose and amino acids (no glutamine). RESULTS: Glutamine-enriched TPN increased the total appearance rate of glutamine (P: < 0.05) but did not inhibit or increase the endogenous appearance rate. The standard TPN solution also increased the glutamine appearance rate (P: < 0.05), but the change was much smaller than in the glutamine-supplemented group (P: < 0.01). The plasma glutamine concentration did not rise significantly during either treatment, suggesting increased tissue glutamine utilization, especially in the glutamine-supplemented group. CONCLUSION: In view of the enhanced glutamine requirements in response to trauma and disease by tissues such as those of the gut, the immune system, and the liver, increased glutamine availability during glutamine-enriched TPN may be beneficial preoperatively in patients with gastrointestinal disease.

The role of ultrasonography as an adjunct to mammography in the detection of breast cancer. a systematic review.

The aim of this review was to summarise the diagnostic performance of ultrasonography as an adjunct to mammography in the detection of breast cancer and to identify clinical indications. A systematic review was performed of all publications in MEDLINE and EMBASE between 1990 and 2000 on the role of ultrasonography as an adjunct to mammography. 22 studies were included, showing a large variety of indications for ultrasonography and variations in the diagnostic performance of mammography and ultrasonography. There were six studies comparing a combined diagnosis of mammography and ultrasonography together with mammography alone, of which three studies had an increased sensitivity at the cost of a lower specificity. The methods of selecting the study population and interpretation of ultrasonography significantly influenced the diagnostic performance of mammography and ultrasonography relative to each other (P=0.003, P=0.03, respectively). Based on the studies reviewed, little evidence-based support was found to confirm the well recognised value of ultrasonography as an adjunct to mammography in the detection of breast cancer in clinical practice. Furthermore, no clinical indications for additional ultrasonography could be defined. The heterogeneity in the diagnostic performance in these studies may be explained by the methods of patient selection and ultrasonography interpretation, as well as by their poor quality.

Loco-regional recurrences after mastectomy in breast cancer: prognostic factors and implications for postoperative irradiation.

PURPOSE: Potential risk factors including DNA flow cytometric-derived parameters predicting loco-regional recurrence (LRR) in early breast cancer were investigated. MATERIALS AND METHODS: This study included 608 patients treated by modified radical mastectomy between 1982 and 1987. Recommendations regarding local treatment as well as adjuvant systemic therapy did not change during this period. Patients treated by adjuvant chemotherapy were randomized to receive additional medroxyprogesterone acetate (MPA) treatment. Only 59 (10%) patients received postoperative irradiation (XRT) to the chest wall and/or axillary lymph nodes; another 121 (20%) patients received XRT to the internal mammary nodes because of centromedially located tumours. RESULTS: Patients were followed for a median period of 7.5 years. The event-free survival at 10 years was 50%. The cumulative incidence rate of LRR at 10 years was 18% (n = 93), either with (n = 30) or without (n = 63) concurrent distant metastases. The chest wall, regional lymph nodes or both were involved in 41 (44%), 38 (41%) and 12 (13%) patients, respectively. Multivariate analysis according to the Cox model revealed two factors associated with LRR, i.e. pT (P < 0.05) and nodal status (P < 0.05). In node-positive patients extracapsular tumour extension (ECE) and pT were independent risk factors. DNA ploidy and S-phase fraction did not yield additional information. Based on pT, nodal status and extracapsular extension of tumour growth a high risk (> 10%) and low risk (< 10%) group for LRR could be identified. CONCLUSIONS: Results indicate that T-stage and nodal status, combined with ECE, may help to identify patients at risk for loco-regional recurrence, whereas DNA flow cytometry does not.

Preoperative total parenteral nutrition (TPN) in severe Crohn's disease.

This study was performed to evaluate the effect of preoperative total parenteral nutrition (TPN) on the results after surgical treatment of patients with severe Crohn's disease. Of 67 patients admitted with complications of Crohn's disease, 51 had severe active disease and abdominal masses, fistulas and/or obstruction (mean Crohn's disease activity index score, 301). Forty-four patients received preoperative TPN for a mean period of 33 days. Complications of TPN were limited. Spontaneous closure of fistulas was achieved in 75% of the cases. Serum albumin levels improved significantly, from 29.1 +/- 1.1 gm/L to 35.4 +/- 0.7 gm/L (p less than 0.001). Mean body weights improved from 81% to 89% ideal body weights or 52.6 kg to 57.2 kg, respectively (p less than 0.05). Surgical procedures were facilitated by remission of the active inflammatory process and associated with a major complications rate of only 6%. No deaths occurred. the mean hospital stay for the TPN-treated group of patients was 63 days. TPN is an effective preoperative treatment for patients with severe complicated Crohn's disease. The prolonged hospital stay and high costs, however, are disadvantages of this approach. Preoperative TPN treatment should therefore be limited to patients with severe active disease.

Blood-brain barrier derangement in uremic encephalopathy.

A disturbance of cerebral neurotransmitters and an accumulation of octopamine, a putative false neurotransmitter, have been found in patients with uremic encephalopathy who manifest disorientation, somnolence, asterixis, and coma--symptoms also seen in portal systemic encephalopathy (PSE). Altered plasma concentrations of the neutral amino acids (NAAs) and increased blood-brain NAA transport may play a role in PSE, and in the present study plasma amino acid concentrations and blood-brain barrier NAA transport were investigated in rats with acute and chronic uremia. Acute uremia was produced by unilateral nephrectomy and occlusion of the renal artery of the remaining kidney for 70 minutes; the animals were studied 24 hours later. Chronic uremia was produced by unilateral nephrectomy and 70% to 80% devascularization of the remaining kidney; these animals were studied 2 weeks later. Brain uptake was studied with the technique of Oldendorf, and blood and brain amino acids (AAs) were measured. The blood urea nitrogen (BUN) level in rats with acute uremia increased to 108 mg/dl, in rats with chronic uremic 54 mg/dl, and in sham-operated rats 22 mg/dl. In both uremic groups there was a decrease in plasma branched-chain AAs. In the brain these AA levels were normal, while levels of phenylalanine, tyrosine, and histidine were increased in uremic rats.

Peritoneal carcinomatosis from adenocarcinoma of the colon.

Peritoneal carcinomatosis is a major cause of surgical treatment failure in patients with colorectal cancer. Patients with this condition have in the past always had a lethal outcome. We reviewed the results of 56 consecutive patients treated by the cytoreductive approach. This involved surgery to maximally resect all cancer in the abdomen and pelvis in combination with early postoperative intraperitoneal chemotherapy with 5-fluorouracil (5-FU) and mitomycin C. All patients also had three cycles of adjuvant intraperitoneal 5-FU with systemic mitomycin C. An assessment of the clinical features that may affect prognosis was performed and critically analyzed statistically. A significant clinical feature was defined as one with a p value > or = 0.05. Small lesion size of implants present in the abdomen and pelvis at the time of exploration correlated with a good prognosis (p = 0.0025). A complete cytoreduction with tumor removed to < 0.25 cm correlated with a good prognosis (p = 0.0001). A limited involvement of the five abdominal regions was an important determinant of prognosis, with a p value of 0.0739. Finally, a mucinous histologic type correlated adversely with prognosis when compared with adenocarcinomas (p = 0.0434). These data taken together may suggest that patients with small-volume peritoneal seeding should routinely be treated with cytoreductive surgery and aggressive regional and systemic chemotherapy in an attempt to achieve long-term disease-free survival in this group of poor prognosis patients.

A needle-localised open-breast biopsy for nonpalpable breast lesions should not be performed for diagnosis.

BACKGROUND: The achievement of tumour-free margins on excision of nonpalpable breast lesions that have aroused only an intermediate or low level of suspicion before surgery and do turn out to be malignant is a challenge for the surgeon. The purpose of this study was to determine factors that influence the probability of obtaining tumour-free margins after needle-localised excision of a nonpalpable breast carcinoma. METHOD: During a 10-year period all needle-localised breast biopsies (NLBB) carried out in the Department of Surgery were retrospectively analysed. Possible influential factors considered included: age of the patient, year of NLBB, appearance of the lesion on imaging, preoperative diagnostic index, method of localisation, surgeon's level of experience, specimen size and radiology of the specimen, and all these were analysed in a multivariate logistic regression analysis. RESULTS: In all, 400 needle-localised breast biopsies had been performed. Excision with tumour-free margins was more often achieved, and the final intervention less often took the form of a mastectomy, when the lesion was classified preoperatively as malignant (P = 0.02). CONCLUSION: The outcome of treatment of a needle-localised breast cancer excision is better when the breast lesion is known to be malignant before surgery.