Explanatory factors for variation in the use of breast conserving surgery and radiotherapy in the Netherlands, 1990-2001.

The use of Breast Conserving Surgery (BCS) followed by radiotherapy (BSC-RT) in pT1 (2cm) and pT2-tumours (2-5cm) was investigated in the Netherlands from 1990 to 2001. From the Netherlands Cancer Registry, patients were selected with invasive tumours <5.0cm. Trends were determined and explanatory factors were determined by multivariate logistic regression. Over the period 52,937 pT1-tumours and 36,285 pT2-tumours were diagnosed. The percentage BCS and BCS-RT in patients 80 years or older remained lowest. Multivariate logistic regression revealed that older age (70+), tumour size >2cm, positive clinical nodes and medium hospital size decreased the chance of BCS. For BCS-RT the same factors and negative pathological nodes decreased the chance of BCS-RT. Between regions large differences were seen. Cancer registry data are useful to monitor the guideline implementation strategies. Multidisciplinary treatment planning, surgeon and patient education could increase the use of BCS combined with RT in all age groups.

[Trends and variation in breast conserving surgery in the southeast and east of the Netherlands over the period 1990-2002]. / Trends en variaties in mammasparende operaties in Zuidoost- en Oost-Nederland in de periode 1990-2002.

OBJECTIVE: To give an overview of the trends and variation in breast-conserving surgery in patients with a breast tumour < or = 2 cm (pT1) or > 2 and < or = 5 cm (pT2), treated in general hospitals in the southeast and east of the Netherlands. DESIGN: Descriptive. METHOD: Data from the regional cancer registries of the Comprehensive Cancer Centre South (CS) and the Comprehensive Cancer Centre Stedendriehoek Twente (CST) were used to study trends and variations in the use of breast-conserving surgery in 12,985 pT1 tumours and 8,893 pT2 tumours in the period 1990-2002. RESULTS: The mean percentage of patients that underwent breast-conserving surgery from 1990-2002 was 54 in the CS region and 43 in the CST region. In patients < 50 years old with a pT1 tumour a decrease in the percentage of breast-conserving surgery from 73 to 64 was seen in the CS region, and in the CST region this percentage decreased from 72 to 51. In pT2 tumours a decrease from 47 to 37 was seen in the CS region and from 34 to 31 in the CST region. In patients of 50 to 69 years of age with a pT1 tumour, the percentage of breast-conserving surgery increased in the CS region from 67 to 74 and in the CST region from 54 to 61. In pT2 tumours it increased from 40 to 44 and from 25 to 37. In patients > or = 70 years the percentage of breast-conserving surgery in pT1 tumours increased from 37 to 59 in the CS region and in the CST region from 42 to 50. In pT2 tumours it increased from 20 to 31 in the CS region whereas it remained 17 in the CST region. The variation in breast-conserving surgery between hospitals in the period 1999-2002 was large. The percentage of breast-conserving surgery in patients with pT1 tumours varied between 47 and 86 in the hospitals in the CS region and between 54 and 71 in the CST region. In patients with a pT2 tumour the percentages varied between 25 and 43 in the CST region and between 16 and 64 in the CS region. CONCLUSION: More than 20 years after the introduction of breast-conserving surgery a large regional variation still exists in the use of this treatment, in the CS region in particular. There is also wide inter-hospital variation.

Fear for the intraabdominal abscess after laparoscopic appendectomy: not realistic.

BACKGROUND: The risk for intraabdominal abscess (IAA) after laparoscopic appendectomy (LA) is still a matter of debate. The aim of the present study was to evaluate postoperative complications after open (OA) and laparoscopic appendectomy, in particular in perforated appendicitis (PA). METHODS: In the period 1999-2002, 331 appendectomies were performed for histological proven appendicitis, 144 by the open and 187 by the laparoscopic technique. Parameters were conversion rate, perforation, wound infection, and IAA. RESULTS: Conversion to OA was done in 20 cases (10.7%). Perforated appendicitis led more frequently to conversion than simple appendicitis (23.5 vs 7.8%; p = 0.007). Perforated appendicitis was equally seen in the open and laparoscopic technique (15 vs 18%). Wound infections after OA, converted and LA for acute appendicitis were 3 of 144 (2.1%), 1 of 20 (5.0%) and 1 of 167 (0.6%), respectively (NS). IAA formation did not differ among the three procedures (3.5 vs 0 vs 3.6%). In PA the rate of IAA formation was increased. However, the risk was not influenced by the technique: Two patients after the OA, none after a converted procedure, and two patients after LA formed an abscess (9.5 vs 0 vs 7.7% [NS]). CONCLUSION: LA does not lead to more intraabdominal abscesses than the open technique; even for perforated appendicitis the laparoscopic technique can be used safely.

Adjuvant treatment for elderly patients with stage III colon cancer in the southern Netherlands is affected by socioeconomic status, gender, and comorbidity.

BACKGROUND: Adjuvant 5-fluorouracil-based chemotherapy significantly decreases mortality among patients with stage III colon cancer, but is less prescribed with rising age. We were interested in the pattern of adjuvant treatment and possible effects on survival among elderly patients. PATIENTS AND METHODS: All resected patients aged 65-79 with stage III colon carcinoma, diagnosed between 1995 and 2001 in the Comprehensive Cancer Centre South registry area in the Netherlands were included (n=577). We examined determinants of receipt of adjuvant chemotherapy and their relation to survival. RESULTS: The proportion of elderly patients receiving adjuvant chemotherapy increased from 19% in 1995 to 50% in 2001, but a large inter-hospital variation remained. In a multivariable analysis, females [odds ratio (OR) 0.5, P=0.006], patients with comorbidity [OR 0.5, P=0.005], and patients with a low socioeconomic status [OR 0.5, P=0.02] received less adjuvant therapy. Between 1995 and 2001 survival of elderly patients improved (hazard ratio 0.8, P=0.04). CONCLUSION: Although an increasing proportion of elderly patients with colon cancer are treated with adjuvant chemotherapy, many elderly patients still do not receive this treatment. As expected, receipt of adjuvant treatment decreased in the presence of comorbidity, but the clinical rationale for undertreatment of women and patients with low socioeconomic status is not clear.

Co-morbidity leads to altered treatment and worse survival of elderly patients with colorectal cancer.

BACKGROUND: The aim of this study was to evaluate the effects of co-morbidity on the treatment and prognosis of elderly patients with colorectal cancer. METHODS: The independent influence of age and co-morbidity on treatment and survival was analysed for 6931 patients with colorectal cancer aged 50 years or more diagnosed between 1995 and 2001 in the southern part of the Netherlands. RESULTS: Co-morbidity had no influence on resection rate. The use of adjuvant chemotherapy in patients with stage III colonic cancer was influenced by co-morbidity, especially a previous malignancy (odds ratio (OR) 0.2 (95 per cent confidence interval (c.i.) 0.1 to 0.6); P = 0.002) or chronic obstructive pulmonary disease (COPD) (OR 0.3 (95 per cent c.i. 0.1 to 0.9); P = 0.043). Co-morbidity also influenced use of adjuvant radiotherapy in patients with rectal cancer, especially the presence of hypertension in combination with diabetes (OR 0.5 (95 per cent c.i. 0.2 to 0.9); P = 0.031). Co-morbidity influenced survival (hazard ratio up to 1.6), when adjusted for age, sex, tumour stage and treatment. The greatest influence on survival of patients with colonic cancer was previous malignancy, cardiovascular disease and COPD, and that of patients with rectal cancer was COPD, hypertension, and hypertension in combination with diabetes. CONCLUSION: Elderly patients with co-morbidity were treated less aggressively and had a worse survival than those with no concomitant disease.

Minimally invasive femoral nail extraction.

INTRODUCTION: Case report about a minimally invasive technique for removal of a femoral antegrade nail (FAN). Femoral nails are introduced by minimally invasive techniques, but are often removed with more invasive surgery. MATERIALS AND METHODS: Four cases of young patients are described in whom the femoral nail was removed after consolidation by a minimally invasive extraction technique at the trochanteric site. By using a threaded wire for locating the proximal entrance of the femoral nail followed by reaming over the wire, the entrance of the nail in the trochanteric region is freed. Then the extraction bolt can be placed over the wire and the nail can be extracted through the same incision as it was inserted in, without enlarging the incision. DISCUSSION: This case report discusses a technique for minimally invasive femoral nail extraction, not the necessity of removing nails. Leaving out the endcap at the initial operation is the only preoperative condition, since the endcap blocks the entrance of the nail. This operation is done with fluoroscopic guidance. The difficult part is the reaming. The reamer must not be damaged when approaching the nail entrance. This minimally invasive femoral nail extraction technique is applicable for various types of femoral nails. CONCLUSION: Minimally invasive extraction of femoral nails is possible and needs more attention. The level of evidence is a level IV case series.

Improved survival of patients with rectal cancer since 1980: a population-based study.

The treatment of rectal cancer has changed over the last two decades as far as surgical techniques and radiotherapy are concerned. We studied the changes in patterns of care for patients with rectal cancer and the effect on prognosis. All patients with cancer of the rectum or rectosigmoid in South-east Netherlands, diagnosed in the period of 1980-2000, were included in our analyses (n=3635). The use of surgery as the only treatment decreased from 62% in the period of 1980-1989 to 42% in the period of 1995-2000, whereas the combination of surgery and radiotherapy increased from 26 to 40%. The use of postoperative radiotherapy decreased from 25 to 4%, while preoperative radiotherapy increased from 1 to 35%. Patients aged 75 years or older were less likely to receive radiotherapy. After adjustment for age, gender, tumour stage and tumour site, significant improvements in the relative risk of death were observed between the periods of 1995-2000 and 1980-1989 for patients under 60 years of age (Relative Risk (RR)=0.45; 95% Confidence Interval (CI)=0.35-0.58) and those 60-74 years old (RR=0.62; 95% CI 0.53-0.72). No improvement in the risk of death was found for patients aged 75 years and over. No improvements in the distribution of tumour stage were observed, making it very likely that the continuing increase in population-based survival among patients aged <75 years results from the shift from postoperative to preoperative radiotherapy, the development of the total mesorectal excision technique and the related tendency to subspecialisation of surgeons in colorectal cancer surgery.

Complications and feasibility of laparoscopic adhesiolysis in patients with chronic abdominal pain. A retrospective study.

BACKGROUND: A retrospective study was done to determine whether laparoscopic adhesiolysis benefits patients with chronic abdominal pain. Factors that influence complications and feasibility of laparoscopic adhesiolysis were evaluated. METHODS: 174 consecutive operations in 157 patients were retrospectively analyzed for factors which might influence the complication rate and the feasibility of laparoscopic adhesiolysis. RESULTS: In 128 out of 174 procedures a complete adhesiolysis was performed. We had to accept an incomplete adhesiolysis in 39 other patients and in 7 patients a primary conversion was needed. We noticed 16 major complications. Two patients died. Relief of pain was recorded in 80% of patients after short follow-up. The number of previous abdominal operations and patient age significantly affected the outcome of surgery. CONCLUSION: Laparoscopic adhesiolysis in patients with chronic abdominal pain seems to be a feasible and effective operation with considerable risk.

The introduction of mammographical screening has had little effect on the trend in breast-conserving surgery: a population-based study in Southeast Netherlands.

In addition to reducing breast cancer mortality, breast cancer screening programmes are expected to increase the proportion of patients who can undergo breast-conserving surgery. Trends in the use of breast-conserving surgery (BCS) in Southeast Netherlands between 1990 and 1998 were studied in relation to the gradual introduction of mammographical screening for women 50-69 years of age between 1992 and 1996. The characteristics of the tumours detected by the screening programme or outside of the programme were compared, to see whether this might clarify the observed trends. In the period 1990-1998, 4788 patients were diagnosed with invasive, operable breast cancer, of whom 2341 were 50-69 years of age. Although the screening programme resulted in a larger proportion of patients with small tumours and more favourable tumour characteristics, no increase was observed in the use of BCS for patients 50-69 years of age in the period 1990-1998 (64% in 1990 and 1998). Patients with a screening-detected tumour, however, were more likely to undergo breast conservation compared with those presenting clinically (68% versus 54%; P<0.0001). In conclusion, no increase in the proportion of breast-conserving surgical procedures was observed in Southeast Netherlands among patients 50-69 years of age in the period 1990-1998, during the introduction of mass mammographical screening for this group. Screening, however, resulted in a larger proportion of patients with small tumours with more favourable characteristics, who are better candidates for breast conservation.

Focal intraperitoneal fat infarction.

Focal intraperitoneal fat infarction, e.g. epiploic appendagitis and segmental omentum infarction, may mimic almost every acute abdominal condition. The symptoms of this benign and self-limiting disease will disappear without treatment. The etiology, symptoms, diagnosis (mainly with ultrasound and CT scan) and course of the disease are being described. An atypical case history with uneventful recovery without medical or surgical treatment is presented.

Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer.

The aim of this study was to investigate the nature and severity of the arm complaints among breast cancer patients after axillary lymph node dissection (ALND) and to study the effects of this treatment-related morbidity on daily life and well-being. 400 women, who underwent ALND as part of breast cancer surgery, filled out a treatment-specific quality of life questionnaire. The mean time since ALND was 4.7 years (range 0.3-28 years). More than 20% of patients reported pain, numbness, or loss of strength and 9% reported severe oedema. None of the complaints appeared to diminish over time. Irradiation of the axilla and supraclavicular irradiation were associated with a 3.57-fold higher risk of oedema (odds ratio (OR) 3.57; 95% confidence interval (CI) 1.66-7.69) causing many patients to give up leisure activities or sport. Women who underwent irradiation of the breast or chest wall more often reported to have a sensitive scar than women who did not receive radiotherapy. Women <45 years of age had an approximately 6 times higher risk of numbness of the arm (OR 6.49; 95% CI 2.58-16.38) compared with those > or = 65 years of age; they also encountered more problems doing their household chores. The results of the present study support the introduction of less invasive techniques for the staging of the axilla, sentinel node biopsy being the most promising.

The risk of nodal metastases in breast cancer patients with clinically negative lymph nodes: a population-based analysis.

A population-based study was performed to assess the likelihood of axillary lymph node metastases in patients with clinically negative lymph nodes, according to patient age, tumor size and site, estrogen receptor status, histologic type and mode of detection. Data were obtained from the population-based Eindhoven Cancer Registry. During the period 1984-1997, 7680 patients with invasive breast cancer were documented, 6663 of whom underwent axillary dissection. Of the 5125 patients who were known to have clinically negative lymph nodes and underwent axillary dissection, 1748 (34%) had positive lymph nodes at pathological examination. After multivariate analysis, histologic type, tumor size, tumor site and the number of lymph nodes in the axillary specimen remained as independent predictors of the risk of nodal involvement (P < 0.001). Lower risks were found for patients with medullary or tubular carcinoma, smaller tumors, a tumor in the medial part of the breast and patients with less than 16 nodes examined. This study gives reliable estimates of the risk of finding positive lymph nodes in patients with a clinically negative axilla. Such information is useful when considering the need for axillary dissection and to predict the risk of a false-negative result when performing sentinel lymph node biopsy.

Feasibility and first results of multimodality treatment, combining EBRT, extensive surgery, and IOERT in locally advanced primary rectal cancer.

PURPOSE: To assess the outcome of aggressive multimodality treatment with preoperative external beam radiation therapy (EBRT), extended circumferential margin excision (ECME) and intraoperative electron beam radiation therapy (IOERT) in patients with locally advanced primary rectal cancer. METHODS AND MATERIALS: Thirty-eight patients with primary locally advanced rectal cancer, but without distant metastases, received multimodality treatment. CT-scan showed extension to other structures in 15 patients (39%) and definite infiltration into the surrounding structures in 23 patients (61%). All patients received preoperative EBRT (dose range 25-61 Gy) and 82% received 50.4 Gy. The resection types were: 12 low anterior resections (31%), 14 abdomino-perineal resections (37%), 6 abdomino-transsacral resections (16%), and 6 pelvic exenterations (16%). The IOERT dose ranged from 10 to 17.5 Gy depending on the completeness of the resection. RESULTS: There was no perioperative mortality. The resection margins were microscopically negative in 31 patients (82%), microscopically positive in 4 (10%), and positive with gross residual disease in 3 patients (8%). Pelvic recurrences were observed in 5 patients (13%) including 3 IOERT infield failures. The overall 3-year local control, disease-free survival (DFS), and survival rates were 82%, 65%, and 72%, respectively. Negative resection margins were the most significant prognostic factor with regard to DFS (p = 0.0003) and distant control (p = 0.002) compared with cancer involved surgical margins. CONCLUSION: A high percentage of curative resections can be achieved in this group of patients with locally advanced rectal cancers. Adding IOERT to preoperative EBRT and ECME achieves high local control rates and possibly improves survival.

[Trends in incidence and treatment of ductal carcinoma in situ of the breast in southeast Netherlands]. / Trends in incidentie en behandelbeleid van ductaal carcinoma in situ van de mamma in Zuidoost-Nederland.

OBJECTIVE: To analyse the incidence and treatment of ductal carcinoma in situ (DCIS) of the breast in the population. DESIGN: Retrospective, descriptive. METHOD: The incidence of DCIS in the period 1975-1997 in 8 hospitals in southeastern North Brabant and northern Limburg, the Netherlands, was analysed, using data from the Eindhoven Cancer Registry. Changes in the treatment of DCIS in the period 1984-1997 were studied, using information from the Breast Cancer Documentation Project. RESULTS: Between 1975 and 1997, 448 cases of DCIS were detected in 442 women. After adjustment for age according to the European Standard Population, the incidence rate of DCIS increased from 0.3 per 100,000 in 1975 to 13.4 in 1997. Of the 87 patients with DCIS between 50 and 69 years of age in 1996 and 1997, 68% was detected by the screening programme. The proportion of patients with DCIS undergoing ablation of the breast was 53% during the period 1984-1989, and varied around 45% thereafter. The other patients underwent local excision. The proportion of patients receiving radiotherapy after local excision decreased from 78% in the period 1984-1989 to 24% in the period 1994-1995 and rose to 41% during the last few years. Substantial differences in the treatment of DCIS were observed between the 8 hospitals.

[Hemobilia as a complication of laparoscopic cholecystectomy]. / Hemobilie als complicatie van laparoscopische cholecystectomie.

A woman aged 38 displayed colicky pains and melaena two weeks after a laparoscopic cholecystectomy. The haemoglobin level was decreased, the serum hepatic enzyme levels were slightly increased. Diagnostic imaging examinations and finally, because of recurrent symptoms, an emergency laparotomy revealed a bleeding from a pseudoaneurysm of the proper hepatic artery next to the choledochus. The aneurysm was ligated. Seven months later the patient had no more symptoms. The possibility of haemobilia should be considered in every case of gastrointestinal bleeding after laparoscopic cholecystectomy.

The relationship between findings on pre-treatment mammograms and local recurrence after breast-conserving therapy for invasive breast cancer.

AIMS: This study was planned (a) to determine the correlation between findings on the pre-treatment mammogram and local recurrence after breast-conserving therapy (BCT), and (b) to analyse the relationship between mammographical features, specific pathological characteristics and the need for re-excision. METHOD: The size and outline of the lesion, the presence of suspect microcalcifications and signs of multifocality on pre-treatment mammograms of 39 patients with local recurrence after BCT and 126 randomly selected control patients without local recurrence were compared. Tissue slides of the primary tumour were reviewed to confirm the histological type and grade, the aspect of the margins, microscopic margin involvement, presence of vascular invasion and the presence and extent of an intraductal component. RESULTS: Among patients /=50 years, 67% of the patients with local recurrence had a non-circumscribed lesion compared to 9% of the control group (P<0.001). Suspect microcalcifications on the mammogram were associated with the finding of an extensive intraductal component, vascular invasion and a higher histological grade by the pathologist. Patients with a non-circumscribed density or a scirrhous lesion needed re-excision more often (30 and 33%, respectively) than those with a well-circumscribed density (9%). CONCLUSIONS: Although the number of patients was small, this study indicates that some mammographical features are associated with a higher risk of local recurrence after BCT and the need for re-excision. This was supported by the findings of the pathological review.

[The importance of steroid receptors for the prognosis and hormone treatment of breast cancer patients: a retrospective study in Southeastern Netherlands]. / De betekenis van steroïdreceptoren voor de prognose en de hormonale behandeling van patiënten met mammacarcinoom: een retrospectief onderzoek in Zuidoost-Nederland.

OBJECTIVE: To assess the effect of oestrogen (ER) and progesterone (PgR) receptors on the prognosis of patients with operable breast cancer and the decision to treat these patients with adjuvant tamoxifen. DESIGN: Retrospective. SETTING: Eight community hospitals in the Southeast Netherlands. METHOD: Using the registry of the Comprehensive Cancer Centre South, 2862 breast cancer patients were identified with stage I, II or IIIA tumours, treated during the period 1984-1992. RESULTS: ER and PgR status were known for 2393 (84%) and 1761 (62%) patients respectively. From 1991, over 80% of the postmenopausal, lymph node positive patients had received tamoxifen, irrespective of the steroid receptor status. Of all lymph node negative patients fewer than 3% received adjuvant systemic treatment. Among the lymph node negative patients the steroid receptor status was not a significant predictor of survival. Among the lymph node positive patients whose tumours were both ER-negative and PgR-negative, a 2.8-fold increased risk of death was found during the first four years after primary treatment. The risk of death was not increased if only the ER or only the PgR status was negative. CONCLUSION: This study shows that ER and PgR receptors are significant prognostic factors for survival in breast cancer patients with involved axillary lymph nodes. The prognostic effect appeared to be restricted to the first four years after primary treatment. Selection of patients for endocrine treatment should be based on the steroid receptor status, considering the importance of the steroid receptors for predicting the response to endocrine treatment.