Albert N. van Geel

Surgical treatment of lung metastases: The European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group study of 255 patients.

Several reports have shown a prolonged survival after surgical treatment of pulmonary metastases from soft tissue sarcomas. However, it is still unclear which prognostic factors predict a favorable outcome. Series are not comparable and the data are conflicting. Therefore, a multi‐institutional study was undertaken to analyze prognostic factors in selecting patients for resection of pulmonary metastases from soft tissue sarcomas.

Ultrasound-Guided Aspiration Biopsy for Detection of Nonpalpable Axillary Node Metastases in Breast Cancer Patients: New Diagnostic Method

Abstract. This study was designed to evaluate the accuracy of ultrasonography alone and in combination with fine-needle aspiration biopsy (FNAB) for detection of axillary metastases of nonpalpable lymph nodes in breast cancer patients. Ultrasonography was carried out in 150 axillas of 148 patients (mean age 57 years, range 30–80 years); and in 93 axillas lymph nodes were detected. Nodes were described according to their dimension and echo patterns and were compared with histopathologic results. FNAB was carried out in 81 axillas (122 nodes). The sensitivity of ultrasonography was highest (87%) when size (length >5 mm) was used as criterion for malignancy, but the specificity was rather low (56%). When nodes with a malignant pattern (echo-poor or inhomogeneous) were visualized, specificity was 95%. Ultrasound-guided FNAB had a sensitivity of 80% and a specificity of 100% and detected metastases in 63% of node-positive patients. It is concluded that FNAB is an easy, reliable, inexpensive method for identifying patients with positive nodes. In the case of negative findings, other diagnostic procedures to exclude lymph node metastases, such as sentinel node mapping, could be performed.

Prophylactic Mastectomy in BRCA1/2 Mutation Carriers and Women at Risk of Hereditary Breast Cancer: Long-Term Experiences at the Rotterdam Family Cancer Clinic

BackgroundBRCA1/2 mutation carriers and women from a hereditary breast(/ovarian) cancer family have a highly increased risk of developing breast cancer (BC). Prophylactic mastectomy (PM) results in the greatest BC risk reduction. Long-term data on the efficacy and sequels of PM are scarce.MethodsFrom 358 high-risk women (including 236 BRCA1/2 carriers) undergoing PM between 1994 and 2004, relevant data on the occurrence of BC in relation to PM, complications in relation to breast reconstruction (BR), mutation status, age at PM and preoperative imaging examination results were extracted from the medical records, and analyzed separately for women without (unaffected, n = 177) and with a BC history (affected, n = 181).ResultsNo primary BCs occurred after PM (median follow-up 4.5 years). In one previously unaffected woman, metastatic BC was detected almost 4 years after PM (primary BC not found). Median age at PM was younger in unaffected women (P < .001), affected women more frequently were 50% risk carriers (P < .001). Unexpected (pre)malignant changes at PM were found in 3% of the patients (in 5 affected, and 5 unaffected women, respectively). In 49.6% of the women opting for BR one or more complications were registered, totaling 215 complications, leading to 153 surgical interventions (71%). Complications were mainly related to cosmetic outcome (36%) and capsular formation (24%).ConclusionsThe risk of developing a primary BC after PM remains low after longer follow-up. Preoperative imaging and careful histological examination is warranted because of potential unexpected (pre)malignant findings. The high complication rate after breast reconstruction mainly concerns cosmetic issues.

Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial

Abstract Objective: To assess the medical and psychosocial effects of early hospital discharge after surgery for breast cancer on complication rate, patient satisfaction, and psychosocial outcomes. Design: Randomised trial comparing discharge from hospital 4 days after surgery (with drain in situ) with discharge after drain removal (mean 9 days in hospital). Psychosocial measurements performed before surgery and 1 and 4 months after. Setting: General hospital and cancer clinic in Rotterdam with a socioeconomically diverse population. Subjects: 125 women with operable breast cancer. Main outcome measures: Incidence of complications after surgery for breast cancer, patient satisfaction with treatment, and psychosocial effects of short stay or long stay in hospital. Results: Patient satisfaction with the short stay in hospital was high; only 4% (2/56 at 1 month after surgery and 2/52 at 4 months after surgery) of patients indicated that they would have preferred a longer stay. There were no significant differences in duration of drainage from the axilla between the short stay and long stay groups (median 8 v 9 days respectively, P=0.45) or the incidence of wound complications (10 patients v 9 patients). The median number of seroma aspirations per patient was higher for the long stay group (1 v 3.5, P=0.04). Leakage along the drain occurred more frequently in short stay patients (21 v 10 patients, P=0.04). The two groups did not differ in scores for psychosocial problems (uncertainty, anxiety, loneliness, disturbed sleep, loss of control, threat to self esteem), physical or psychological complaints, or in the coping strategies used. Before surgery, short stay patients scored higher on scales of depression (P=0.03) and after surgery they were more likely to discuss their disease with their families (at 1 month P=0.004, at 4 months P=0.04). Conclusions: Early discharge from hospital after surgery for breast cancer is safe and is well received by patients. Early discharge seems to enhance the opportunity for social support within the family. Key messages Early discharge from hospital after breast cancer surgery does not lead to an increase in the incidence of wound infection or seroma formation A short stay in hospital, with support from community nurses on the patients return home, is acceptable to patients Psychosocial rehabilitation is not influenced by early discharge Recovery in the family environment may facilitate discussion of the illness Patients recovering from surgery for breast cancer need not spend more than three days in hospital provided that they are in good physical condition and there is adequate nursing support available in the community

A prospective randomized trial of high versus low vacuum drainage after axillary dissection for breast cancer

BACKGROUND AND METHODS The influence of negative pressure on fluid production and complication rates after axillary dissection for breast cancer was studied in a prospective randomized trial. Patients were randomized for either a high or a low vacuum drainage system. Drainage volumes and complication rates were recorded. RESULTS No statistically significant differences were found between the low vacuum group (n = 68) and the high vacuum group (n = 73) in volume (728 ml versus 780 ml) and duration (9.5 days versus 10 days) of seroma production, number of wound complications (5 versus 6), or infections (3 versus 2). There was a significant positive relationship between body mass index and seroma production, independent of the drainage system (P = 0.002). The drainage volume of the separately drained breast wound after mastectomy and lumpectomy was larger for the high vacuum system (55 ml versus 100 ml, P = 0.02). Vacuum loss was more frequent in the high vacuum drain group (11 versus 2, P = 0.01), where as leakage around the drain occurred more often in the low vacuum group (18 versus 6, P = 0.004). CONCLUSION There are no differences in axillary fluid production or wound complication rates after axillary dissection and subsequent drainage between high and low vacuum drainage systems.

The composition of serous fluid after axillary dissection

OBJECTIVE To analyse the composition of the serous fluid formed after axillary dissection. DESIGN Descriptive study. SETTING University hospital and teaching hospital, The Netherlands. SUBJECTS 16 patients whose axillas were dissected as part of a modified radical mastectomy for stage I or II breast cancer. MAIN OUTCOME MEASURES Chemical and cellular composition of axillary drainage fluid on the first, fifth, and tenth postoperative days compared with the same constituents in blood and with reported data on the composition of peripheral lymph. RESULTS AND CONCLUSION On the first postoperative day the drainage fluid contained blood contents and a high concentration of creatine phosphokinase (CPK). After day one it changed to a peripheral lymph-like fluid but containing different cells, more protein, and no fibrinogen, making coagulation impossible. The reduction in the fluid production must be caused by other wound healing processes, such as formation of scars and connective tissue.

Determination of the Molecular Relationship Between Multiple Tumors Within One Patient Is of Clinical Importance

PURPOSE To determine the molecular relationship between multiple tumors within one patient and to evaluate the impact of this knowledge on clinical management. PATIENTS AND METHODS In 25 consecutive patients with multiple tumors, proven by histology and immunohistochemistry to be identical, molecular aberrations were determined. Each patient had at least one lesion in the lung or head and neck region. Loss of heterozygosity (LOH) and p53 aberration analyses were carried out, and similar aberration profiles suggest clonality and metastasis whereas different profiles suggest independent primary tumors. RESULTS The molecular determinations indicated that 12 patients had a probable second primary tumor and 10 patients had a metastasis of the first lesion. In three patients, both an independent primary tumor and a metastasis were present. The molecular findings determined the course of additional treatment in all 10 patients with metastases, in all three patients with both a second primary tumor and a metastasis, and in seven of 12 patients with a second primary tumor. CONCLUSION By comparing DNA alterations of multiple tumors within one patient, the relationship between the tumors can be assessed. This study shows that in 20 of 25 patients, knowledge of the nature of both lesions was essential in clinical decision making. Furthermore, after thorough analysis of the five cases where clinical decision making was not influenced, there was in retrospect no clear indication for LOH or p53 analysis. Because these molecular analyses can be performed on routine specimens, they can be applied in almost all patients.

The pedicled omentoplasty and split skin graft (POSSG) for reconstruction of large chest wall defects. A validity study of 34 patients

The aim of this study was to evaluate retrospectively the results of pedicled omentoplasty and split skin graft (POSSG) in reconstructing (full thickness) chest wall defects, and to define its role as a palliative procedure for local symptom control. Thirty-four patients with recurrent breast cancer (n = 25), radiation-induced necrosis (n = 5) or sarcoma (n = 4) of the chest wall were selected for the study. All patients underwent curative or palliative chest wall resection with reconstruction by pedicled omentoplasty and split skin graft (POSSG), between 1986 and 1994. Reconstructive outcome, complications, local tumour and symptom control following surgery was measured. The most common complication was shown to be partial necrosis of the omental flap (35%), followed by respiratory problems (26%), facial hernia (26%) and thoracic wound problems (15%), which were mostly treated in a conservative way (68%). The 3-year local tumour-free interval after POSSG in patients curatively treated for breast cancer is 16%. Seventy per cent of the patients who underwent palliative resection had longstanding relief of local pain, bleeding or foetor due to local tumour growth. It can be concluded that large (full thickness) chest wall defects after resection of local recurrence, primary malignancy or osteoradionecrosis of the chest wall can successfully be reconstructed by POSSG. Chest wall resection in patients treated with palliative intention is effective in local symptom control.

Re-irradiation and hyperthermia after surgery for recurrent breast cancer

PURPOSE Evaluation of efficacy and side effects of combined re-irradiation and hyperthermia electively or for subclinical disease in the management of locoregional recurrent breast cancer. METHODS AND MATERIALS Records of 198 patients with recurrent breast cancer treated with re-irradiation and hyperthermia from 1993 to 2010 were reviewed. Prior treatments included surgery (100%), radiotherapy (100%), chemotherapy (42%), and hormonal therapy (57%). Ninety-one patients were treated for microscopic residual disease following resection or systemic therapy and 107 patients were treated electively for areas at high risk for local recurrences. All patients were re-irradiated to 28-36Gy (median 32) and treated with 3-8 hyperthermia treatments (mean 4.36). Forty percent of the patients received concurrent hormonal therapy. Patient and tumor characteristics predictive for actuarial local control (LC) and toxicity were studied in univariate and multivariate analysis. RESULTS The median follow-up was 42months. Three and 5year LC-rates were 83% and 78%. Mean of T90 (tenth percentile of temperature distribution), maximum and average temperatures were 39.8°C, 43.6°C, and 41.2°C, respectively. Mean of the cumulative equivalent minutes (CEM43) at T90 was 4.58min. Number of previous chemotherapy and surgical procedures were most predictive for LC. Cumulative incidence of grade 3 and 4 late toxicity at 5years was 11.9%. The number of thermometry sensors and depth of treatment volume were associated with acute hyperthermia toxicity. CONCLUSIONS The combination of re-irradiation and hyperthermia results in a high LC-rate with acceptable toxicity.

Isolated limb perfusion for melanoma in-transit metastases: developments in recent years and the role of tumor necrosis factor alpha.

Purpose of review The treatment of in-transit metastasis of melanoma remains challenging and is essentially dictated by the biological behavior of melanoma. When lesions are large or numerous, isolated limb perfusion (ILP) is an attractive treatment modality. In this review an overview of literature on treatment options of melanoma in-transit metastases will be discussed. Recent findings Most recent studies report on tumor necrosis factor (TNF) and melphalan based ILP (TM-ILP) series or mixed series of TM-ILP and melphalan only based ILP (M-ILP). After TM-ILP complete response rates of 70% (range 44–90%) have been reported, while for M-ILP this is lower with complete response rates of 54% (range 40–76%). The only randomized trial comparing TM-ILP and M-ILP revealed no clear benefit of TNF at 3 months, but improved outcome at 6 months and in patients with bulky disease. Reports on isolated limb infusion (ILI) with melphalan and actinimycin D indicate lower response rates, but similar local control rates as M-ILP at lower cost. Summary ILP is an attractive treatment option in melanoma patients with multiple in-transit metastases. In our opinion TM-ILP is superior to M-ILP as it achieves higher response rates, especially in patients with bulky disease. When lesions are small and in the distal two-thirds of the leg only, ILI is a valuable alternative.