Validation of Six Nomograms for Predicting Non-sentinel Lymph Node Metastases in a Dutch Breast Cancer Population.

BACKGROUND: The usefulness of axillary lymph node dissection (ALND) in patients with positive sentinel nodes (SN) is still an ongoing debate. Several nomograms have been developed for predicting non-sentinel lymph node metastases (NSLNM). We validated six nomograms using data from 10 years of breast cancer surgery in our hospital. METHODS: We retrospectively analyzed all patients with a proven breast malignancy and a SN procedure between 2001 and 2011 in our hospital. RESULTS: Data from 1084 patients were reviewed; 260 (24 %) had a positive SN. No patients with isolated tumor cells, 6 patients (8 %) with micrometastases, and 65 patients (41 %) with macrometastases had additional axillary NSLNM. In 2 patients (3 %) with micrometastases, the ALND influenced postoperative treatment. In the group of patients with macrometastases tumor size >2 cm, extranodal growth and having no negative SNs were predictors of NSLNM. The revised MD Anderson Cancer Center and Helsinki nomograms performed the best, with an area under the curve value of 0.78. CONCLUSIONS: ALND could probably be safely omitted in most patients with micrometastases but is still indicated in patients with macrometastases, especially in patients with tumor size >2 cm, extranodal growth, and no negative SNs. The revised MD Anderson Cancer Center and Helsinki nomograms were the most predictive in our patient group.

Prediction of tumor stage and lymph node involvement with dynamic contrast-enhanced MRI after chemoradiotherapy for locally advanced rectal cancer.

PURPOSE: The usefulness of restaging by magnetic resonance imaging (MRI) after chemoradiotherapy (CTx/RTx) in patients with locally advanced rectal cancer has not yet been established, mostly due to the difficult differentiation between viable tumor and fibrosis. MRI with dynamic contrast-enhanced (DCE) sequences may be of additional value in distinguishing malignant from nonmalignant tissue. The aim of this study was to assess the accuracy of tumor, nodal staging, and circumferential resection margin (CRM) involvement by MRI with DCE sequences after CTx/RTx. METHODS: The accuracies were assessed by MRI on T2-weighted magnetic resonance (MR) images with DCE sequences in patients with locally advanced rectal cancer after a long course of CTx/RTx. MR images were assessed by two independent radiologists. RESULTS: For tumor staging and CRM involvement, MRI with DCE sequences had an accuracy of 45 and 60 %, respectively. The accuracy for nodal staging was 93 %. On MRI, malignant lymph nodes had a median diameter of 8 mm (range, 4-18) and benign lymph nodes a median diameter of 4 mm (range, 3-11). A significant indicator for benign nodes was hypointensity on T2-weighted images (p < 0.001) and early complete arterial phase enhancement on DCE-weighted images (p < 0.001). A significant indicator for malignant nodes was heterogeneity on T2-weighted images (χ (2), p < 0.000) and early incomplete arterial phase enhancement on DCE (p < 0.001). CONCLUSIONS: MRI with DCE is a useful tool for nodal staging after CTx/RTx. The addition of DCE sequences did not improve the accuracy of determining the tumor stage, CRM involvement, and in detecting complete response.

Effect of bevacizumab added preoperatively to oxaliplatin on liver injury and complications after resection of colorectal liver metastases.

BACKGROUND: Chemotherapy (CTx) before resection of colorectal liver metastases (CRLM) may cause hepatic injury and postoperative complications. To ascertain whether adding bevacizumab, a monoclonal antibody against VEGF, to oxaliplatin-based CTx has an influence on liver injury and postoperative complications. METHODS: Patients with CRLM who received neoadjuvant CTx and underwent resection between 2003 and 2008 were analyzed whether or not they received bevacizumab added to oxaliplatin-based CTx. RESULTS: The total study group existed of 104 patients: 53 patients received oxaliplatin-based CTx and 51 patients received oxaliplatin-based CTx and bevacizumab. The overall complication rate (29%) was not significantly different between the two groups. The bevacizumab group exhibited less moderate sinusoidal dilatation (8% vs. 28%, P = 0.01). No difference in complication rate was found between patients given fewer than six cycles of oxaliplatin-based CTx and those given six or more cycles, or between patients with a short (<5 weeks) interval between the last dose of oxaliplatin and resection and those in which the interval was longer. CONCLUSION: Bevacizumab added to oxaliplatin-based CTx may protect against moderate sinusoidal dilatation without significantly influencing morbidity. Neither duration of oxaliplatin-based CTx nor the time interval between cessation of oxaliplatin-based CTx and surgery were associated with postoperative complications.

Predicting the outcome of closed-loop small bowel obstruction by preoperative characteristics.

BACKGROUND: Closed-loop small bowel obstruction (CL-SBO) can threaten the viability of the intestine by obstructing a bowel segment at two adjacent points. Prompt recognition and surgery are crucial. AIM: To analyze the outcomes of patients who underwent surgery for CL-SBO and to evaluate clinical predictors. METHODS: Patients who underwent surgery for suspected CL-BSO on computed tomography (CT) at a single center between 2013 and 2019 were evaluated retrospectively. Patients were divided into three groups by perioperative outcome, including viable bowel, reversible ischemia, and irreversible ischemia. Clinical and laboratorial variables at presentation were compared and postoperative outcomes were analyzed. RESULTS: Of 148 patients with CL-SBO, 28 (19%) had a perioperative viable small bowel, 86 (58%) had reversible ischemia, and 34 (23%) had irreversible ischemia. Patients with a higher age had higher risk for perioperative irreversible ischemia [odds ratio (OR): 1.03, 95% confidence interval (CI): 0.99-1.06]. Patients with American Society of Anaesthesiologists (ASA) classification ≥ 3 had higher risk of perioperative irreversible ischemia compared to lower ASA classifications (OR: 3.76, 95%CI: 1.31-10.81). Eighty-six patients (58%) did not have elevated C-reactive protein (> 10 mg/L), and between-group differences were insignificant. Postoperative in-hospital stay was significantly longer for patients with irreversible ischemia (median 8 d, P = 0.001) than for those with reversible ischemia (median 6 d) or a viable bowel (median 5 d). Postoperative morbidity was significantly higher in patients with perioperative irreversible ischemia (45%, P = 0.043) compared with reversible ischemia (20%) and viable bowel (4%). CONCLUSION: Older patients or those with higher ASA classification had an increased risk of irreversible ischemia in case of CL-SBO. After irreversible ischemia, postoperative morbidity was increased.

Is the clinical risk score for patients with colorectal liver metastases still useable in the era of effective neoadjuvant chemotherapy?

BACKGROUND: Several clinical risk scores (CRSs) for the outcome of patients with colorectal liver metastases have been validated, but not in patients undergoing neoadjuvant chemotherapy. Therefore, this study evaluates the predictive value of these CRSs in this specific group. METHODS: Between January 2000 and December 2008, all patients undergoing a metastasectomy were analyzed and divided into two groups: 193 patients did not receive neoadjuvant chemotherapy (group A), and 159 patients received neoadjuvant chemotherapy (group B). In group B, the CRSs were calculated before and after administration of neoadjuvant chemotherapy. Results were evaluated by using the CRSs proposed by Nordlinger et al., Fong et al., Nagashima et al., and Konopke et al. RESULTS: In groups A and B, the overall median survival was 43 and 47 months, respectively (P = 0.648). In group A, all CRSs used were of statistically significant predictive value. Before administration of neoadjuvant chemotherapy, only the Nordlinger score was of predictive value. After administration of neoadjuvant chemotherapy, all CRSs were of predictive value again, except for the Konopke score. CONCLUSIONS: Traditional CRSs are not a reliable prognostic tool when used in patients before treatment with neoadjuvant chemotherapy. However, CRSs assessed after the administration of neoadjuvant chemotherapy are useful to predict prognosis.

Anatomical versus nonanatomical resection of colorectal liver metastases: is there a difference in surgical and oncological outcome?

BACKGROUND: The increased use of neoadjuvant chemotherapy and minimally invasive therapies for recurrence in patients with colorectal liver metastases (CLM) makes a surgical strategy to save as much liver volume as possible pivotal. In this study, we determined the difference in morbidity and mortality and the patterns of recurrence and survival in patients with CLM treated with anatomical (AR) and nonanatomical liver resection (NAR). METHODS: From January 2000 to June 2008, patients with CLM who underwent a resection were included and divided into two groups: patients who underwent AR, and patients who underwent NAR. Patients who underwent simultaneous radiofrequency ablation in addition to surgery and patients with extrahepatic metastasis were excluded. Patient, tumor, and treatment data, as well as disease-free and overall survival (OS) were compared. RESULTS: Eighty-eight patients (44%) received AR and 113 patients (56%) underwent NAR. NAR were performed for significant smaller metastases (3 vs. 4 cm, P < 0.001). The Clinical Risk Score did not differ between the groups. After NAR, patients received significantly less blood transfusions (20% vs. 36%, P = 0.012), and the hospital stay was significantly shorter (7 vs. 8 days, P < 0.001). There were no significant differences in complications, positive resection margins, or recurrence. For the total study group, estimated 5-year disease-free and OS was 31 and 44%, respectively, with no difference between the groups. CONCLUSIONS: Our study resulted in no significant difference in morbidity, mortality, recurrence rate, or survival according to resection type. NAR can be used as a save procedure to preserve liver parenchyma.

Correlation of CT findings with intra-operative outcome in closed-loop small bowel obstruction (CL-SBO).

PURPOSE: To correlate CT-findings in patients with closed-loop small bowel obstruction (CL-SBO) with perioperative findings, to identify patients who require immediate surgical intervention. Secondary purpose was to substantiate the role of radiologists in predicting perioperative outcome. METHODS: Data were retrospectively obtained from patients with surgically confirmed CL-SBO, between September 2013 and September 2019. Three radiologists reviewed CTs to assess defined CT features and predict patient outcome for bowel wall ischemia and necrosis using a likelihood score. Univariate statistical analyses were performed and diagnostic performance parameters and interobserver agreement were assessed for each feature. RESULTS: Of 148 included patients, 28 (19%) intraoperatively had viable bowel and 120 (81%) had bowel wall ischemia or necrosis. Most CT characteristics, as well as the likelihood of ischemia and necrosis, found fair or moderate multirater agreement. Increased attenuation of bowel wall and mesenteric vessels on non-contrast-enhanced CT had a specificity for bowel ischemia or necrosis of 100% (sensitivity respectively 48% (p < 0.001) and 21% (p = 0.09)). Mesenteric edema had high sensitivity for ischemia or necrosis (90%), but specificity of only 26% (p < 0.001). For mesenteric fluid, sensitivity was 60% and specificity 57% (p = 0.004). Decreased enhancement of bowel wall in both arterial and PV-phase showed significant correlation, respectively a sensitivity of 58% and 42%, and specificity of 88% and 79% (both p < 0.001). Likelihood of both ischemia and necrosis were significantly correlated with perioperative outcome (p < 0.001). CONCLUSION: CT findings concerning mesenteric and bowel wall changes, as well as radiologists' judgement of likelihood of ischemia and necrosis are significantly correlated with perioperative outcome of bowel wall ischemia and necrosis in patients with CL-SBO.

Trends in treatment for synchronous colorectal liver metastases: differences in outcome before and after 2000.

BACKGROUND: The traditional treatment for stage IV colorectal cancer has changed from palliative chemotherapy toward an aggressive multimodality approach. In the current study outcome in patients who underwent surgery for synchronous colorectal liver metastases (CLM) in a single center was evaluated. METHODS: From January 1991 to May 2008 all consecutive patients with synchronous CLM who underwent curative resection of both primary and metastatic disease were included. Date of resection was divided into two groups: date of hepatic resection before and after the year 2000. RESULTS: Fifty patients (26%) with synchronous CLM were resected before 2000 and 142 patients (74%) underwent resection after 2000. The estimated 5-year disease-free survival before and after 2000 was 9% and 27%, respectively (P = 0.379). More patients who underwent resection after 2000 were treated with local therapy or underwent resection for intra-hepatic recurrence (62% vs. 28%, P = 0.033). The estimated 5-year survival before and after 2000 was 26% and 44%, respectively (P = 0.001). CONCLUSION: Survival rates in patients with synchronous CLM have been increased in the past decade. The introduction of new chemotherapeutic drugs and a more aggressive treatment approach in patients with liver recurrence were probably major factors in this progress.

The "liver-first approach" for patients with locally advanced rectal cancer and synchronous liver metastases.

PURPOSE: This study was designed to investigate the outcome of "the liver-first" approach in patients with locally advanced rectal cancer and synchronous liver metastases. METHODS: Patients with locally advanced rectal cancer and synchronous liver metastases were primarily treated for their liver metastases. If successful, patients underwent treatment for the rectal tumor. RESULTS: Twenty-three patients were included. One patient had liver resection without neoadjuvant chemotherapy followed by chemoradiotherapy. All remaining 22 patients underwent laparotomy after chemotherapy. Eighteen patients underwent partial liver resection and subsequent chemoradiotherapy for the rectal cancer. One patient underwent in one session a partial liver resection and a low anterior resection. Six patients were not treated according to protocol because of extensive disease. Sixteen patients (73 percent) completed the full treatment protocol and all are alive after a median period of 19 (range, 7-56) months. CONCLUSIONS: This is the first sizable report on the "liver-first approach" demonstrating that it may be considered the preferred treatment schedule for patients with locally advanced rectal cancer and synchronous liver metastases. It allows most patients to undergo curative resections of both metastatic and primary disease and can avoid useless rectal surgery in patients with incurable metastatic disease.

Local treatment for recurrent colorectal hepatic metastases after partial hepatectomy.

OBJECTIVE: The objective of the study was to identify patients who may benefit from local treatment in recurrent colorectal liver metastases. MATERIALS AND METHODS: A total of 51 consecutive patients were treated for hepatic recurrence(s) after an initial partial hepatic resection. Surgery was considered as the primary treatment option for eligible patients. Patients with a small liver remnant after major hepatectomy were treated with radiofrequency ablation (RFA) or stereotactic body radiation therapy (SRx). SRx was given as an outpatient, emerging local treatment option for patients with intra-hepatic recurrences not eligible for surgery or RFA. Partial liver resection was performed in 36 patients (70%), RFA in ten patients (20%), and SRx in five patients (10%). RESULTS: Median hospital stay was 7 (range, 3-62) days with a morbidity of 16% without in-hospital death. None of the patients received adjuvant chemotherapy. There was no difference in recurrence or survival between the three treatment modalities. Overall 5-year survival was 35% with an estimated median survival of 37 months. Patients with a disease-free interval between first hepatectomy and hepatic recurrence less than 6 months did not survive 3 years. CONCLUSIONS: Resection, RFA, and SRx can be performed safely in patients with recurrent colorectal liver metastases and offer a survival that seems comparable to primary liver resections of colorectal liver metastases.