[Show abstract][Hide abstract] ABSTRACT: In patients with extremity soft tissue sarcomas (STSs) a correct histopathological diagnosis is considered important before surgical treatment. We evaluated the preoperative use and sensitivity of the various pathology techniques.
In a population-based study in patients operated for a newly diagnosed extremity STS between January 2000 and December 2003 the preoperative pathology work-up was evaluated. Data were retrieved from a national pathology database (PALGA). The sensitivity of the three techniques was assessed considering an examination affirmative when the conclusion of the pathology report stated the presence of mesenchymal malignancy.
The pathology reports of 573 patients were identified in the database. In 177 patients (31%) no pathology examination was done before resection of the tumour. In the remaining 396 patients the pathology procedure of first choice had been an incisional biopsy (IB) in 195 patients (49%), a core-needle biopsy (CNB) in 90 patients (23%) and a fine needle aspiration (FNA) in 111 patients (28%). An affirmative diagnosis was established in 95% of the patients following an IB, in 78% after a CNB and in 38% following FNA. After an initial CNB an additional IB was performed in 18 of the 90 patients improving the yield to 89%. After an initial FNA a subsequent histological biopsy was done in 53 of the 111 patients, increasing the sensitivity to 71%.
In this population-based study in patients treated for extremity STS, the proportion of patients operated without preoperative pathology evaluation was high. In the remaining patients an incisional biopsy was still the most commonly performed technique with the highest yield.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 07/2009; 36(1):95-9. DOI:10.1016/j.ejso.2009.05.004 · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The sentinel lymph node procedure is a widely accepted method for staging of patients with early breast cancer. This study evaluates the incidence of axillary relapse after negative sentinel node biopsy in the seven hospitals in the central part of the Netherlands.
This study concerns all patients with a T1-2 breast carcinoma who were staged with a sentinel lymph node biopsy in one of the hospitals in the region. Patients with a tumour-free sentinel node without additional axillary lymph node dissection and patients with a sentinel node containing micrometastases were prospectively included and data concerning tumour and primary treatment were recorded. After a median follow-up period of 46 months supplementary data were collected of all patients.
Between January 2002 and December 2003, 541 patients underwent a sentinel node biopsy of which the sentinel node was negative for metastatic disease. During the follow-up period three patients were diagnosed with an axillary recurrence. The incidence of axillary relapse after tumour negative sentinel node biopsy in this study is 0.6% (3/541). In 23 patients a distant metastasis developed. An event occurred in 11% of the patients with a micrometastasis in the sentinel node. This was not significantly different from the patients with a tumour-free sentinel node.
The results suggest that the sentinel lymph node procedure as performed in the region Middle Netherlands is a reliable and accurate instrument for staging of patients with early breast cancer. In our study we observed a non-significant different risk of distant disease in case of micrometastases compared to a tumour negative sentinel node.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 01/2009; 35(1):25-31. DOI:10.1016/j.ejso.2008.06.001 · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aggressive fibromatosis (syn. desmoid tumor) is a sporadically occurring neoplastic proliferation of fibroblasts originating from musculoaponeurotic planes, forming invasively growing masses without the capability to metastasize. The choice of treatment remains surgical resection with or without radiotherapy, and is characterized by high recurrence rates. Better understanding of the aetiology of aggressive fibromatosis is needed to be able to develop new treatment strategies to cope with the high recurrence rates.
Relevant studies were identified through a search of the electronic databases PubMed/ Medline. The following search terms were used: 'aggressive fibromatosis', 'desmoid tumor', 'adenomatous polyposis coli', 'APC', 'beta-catenin', 'Wnt', 'Wingless' and 'Wnt/Wingless'. Studies were selected for review on the basis of abstract reading. A hand search was performed by checking reference lists in selected articles.
The neoplastic nature of aggressive fibromatosis and the role of the adenomatous polyposis coli (APC) and beta-catenin signaling cascade in driving the onset and progression of this disease are discussed.
Mutations in either the APC or beta-catenin genes are likely to be a major driving force in the formation of these desmoid tumors. More research is needed to develop new treatment strategies.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 09/2008; 35(1):3-10. DOI:10.1016/j.ejso.2008.07.003 · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Retrpperitoneal sarcomas (RPS) are rare tumours for which extensive surgery is the primary treatment. Due to the anatomical localisation of RPS, effects on the urinary system are to be expected. To obtain adequate tumour free margins, a part of the urogenital system needs to be resected in 55% of the operated patients. Pre-operative urological work-up and planning of urogenital reconstructions facilitate management of postoperative urological complications in the treatment of RPS.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the result of treatment and long-term outcome of a population-based cohort of patients with retroperitoneal soft tissue sarcoma (RSTS).
Between 1 January 1989 and 1 January 1994, 143 patients diagnosed as having primary RSTS were selected from a national pathology database (PALGA) in the Netherlands. In this population-based group of patients, the result of surgery, overall survival (OS) and disease-free survival (DFS) were analysed as well as factors affecting OS and DFS. Median follow-up was 10.2 years.
Operative treatment resulted in a complete tumour resection in 55% of the patients (n=78), low- and intermediate-grade tumours were more often completely resected than high-grade tumours (P=0.016). Five- and 10-year cumulative OS was 39% and 21%, respectively, while DFS was 22% and 17%, respectively. In a multivariate analysis low malignancy grade (P=0.017) and a complete tumour resection (P<0.001) were associated with better OS.
Complete tumour resection and low malignancy grade were independent favourable prognosticators. However, these factors were related too, since surgical success was influenced by malignancy grade.
European Journal of Surgical Oncology 03/2007; 33(2):234-8. DOI:10.1016/j.ejso.2006.09.020 · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to examine in a large population based group of breast cancer patients treated in a regular care setting whether the introduction of the Sentinel Node Biopsy (SNB) led to detection of a higher percentage of patients with positive regional lymph nodes.
The study includes 3665 early breast cancer patients, aged 30-85 years, diagnosed in the period 1997-2002 and registered at the Regional Cancer Registry of the Comprehensive Cancer Centre Middle Netherlands. During this period the SNB was introduced. The outcome of staging was compared for groups staged with or without SNB. A logistic regression model was used to adjust for age, calendar period and tumour size.
Overall a quarter of all patients over the period 1997-2002 underwent a SNB as method of lymphatic staging. The use of SNB clearly increased over time: from 2% in 1998 to 65% in 2002. The percentage node positive patients also rose significantly; before introduction of the SNB 30% of all patients were diagnosed with positive lymph nodes, and after SNB introduction this percentage was 40%. The increase is largely explained by the increase of patients diagnosed with only micrometastases. Adjustment did not change the results.
In conclusion, introduction of the SNB in early breast cancer led to significant upstaging of breast cancer patients treated in a regular care setting, due to the detection of more micrometastases. Since the relevance of micrometastases for long term survival is not yet known, this upstaging potentially led to over treatment of patients. On the other side, for some patients axillary lymph node dissection was prevented by the SNB procedure, preventing comorbidity.
European Journal of Surgical Oncology 10/2006; 32(7):710-4. DOI:10.1016/j.ejso.2006.04.001 · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The main goal in treatment of ductal carcinoma-in-situ (DCIS) of the breast is to prevent local recurrences. Radiotherapy after breast-conserving surgery has been shown to decrease the recurrence rate, although whether all patients should be treated with radiotherapy remains a topic of debate. The aim of this study was to assess the local recurrence rate after conservative surgical treatment of DCIS without radiotherapy and to identify risk factors for local recurrence.
A total of 499 female patients with 502 DCIS lesions treated in the period 1989 to 2002 were retrospectively reviewed. Survival rates were calculated by the Kaplan-Meier method, and differences were tested by using the log-rank test. The association of variables with local recurrence was analyzed by using the chi2 test.
Treatment constituted of lumpectomy in 329 patients (65%). Thirty-eight patients (8%) had disease-positive margins, and for 41 patients (8%) the margin status was not known. Eighty tumors recurred, for a local recurrence rate of 13% after 4 years compared with 17% for patients treated with breast-conserving surgery only. Risk factors for ipsilateral recurrences were younger age (< 50 years), treatment with breast-conserving surgery only, and presence of disease-involved surgical margins.
Conservative treatment of DCIS results in high recurrences rates, and outcomes can be improved by performing more radical surgery. Because radiotherapy has been shown to be effective in preventing recurrent disease, and, to date, no subgroups have been identified in which radiation can be omitted, its use is recommended, especially in younger patients.
[Show abstract][Hide abstract] ABSTRACT: To assess quality of surgical treatment of ductal carcinoma in situ (DCIS) and to compare teaching and non-teaching hospitals that constitute the Comprehensive Cancer Centres of the Middle Netherlands (IKMN), we retrospectively reviewed 499 patients with 502 DCIS lesions treated in the period 1989-2002. In teaching hospitals fewer patients presented with clinical symptoms compared to non-teaching hospitals (15% versus 24.0%, p = 0.01). Finally, 65% of patients underwent breast-conserving surgery and 35% of patients a mastectomy (no significant differences between the two types of hospitals). In teaching hospitals 19% of the patients had a disease-involved or unknown surgical margins versus 13% in non-teaching hospitals (p = 0.04). Twenty patients (4%) received radiation therapy postoperatively with no differences between teaching and non-teaching hospitals (p = 0.98). Quality of surgical treatment is the most important prognostic factor in treatment of DCIS. The quality of excisions should be improved and the exact status of margins should be recorded in pathology reports.
[Show abstract][Hide abstract] ABSTRACT: The present AJCC/TNM staging system is of limited value for prediction of prognosis for patients with retroperitoneal sarcoma. The objective of the present study was to develop a postsurgical classification system that would enable comparison of outcomes for patients with primary retroperitoneal soft-tissue sarcoma.
Four classes were defined: I, low-grade/complete resection/no metastasis; II, high-grade/complete resection/no metastasis; III, any-grade/incomplete resection/no metastasis; and IV, any-grade/any resection/distant metastasis. The prognostic value of this classification system was analyzed in a population-based multicenter group(MCG) of patients with primary retroperitoneal soft-tissue sarcoma (n = 124) and in a cohort of patients treated in a single tertiary referral center (SCG; n = 107).
Overall 5-year survival rates were 55% in the SCG and 43% in the MCG (P = 0.02). Class III (incomplete resection) was more frequent in the MCG than in the SCG (33% vs. 16%; P = 0.02). In the SCG, stage-specific 5-year survival rates were 89%, 40%, 26%, and 17% for classes I, II, III, and IV, respectively (P < 0.001), in comparison with 68%, 46%, 24%, and 0% in the MCG (P < 0.001). In a comparison of class-specific survival between the groups, only class I patients in the SCG had significantly better survival than class I patients in the MCG (P = 0.048).
Classification based on grade, completeness of resection, and distant metastasis offers a reproducible prognostic tool that can be used to evaluate treatment strategies for primary retroperitoneal soft-tissue sarcoma. The probability of complete resection was significantly higher in the SCG than in the MCG. In patients with low-grade, completely resected sarcoma, there is a significant survival benefit with treatment in a high-volume tertiary center of excellence.
[Show abstract][Hide abstract] ABSTRACT: Evaluation of the results of partial liver resections for both benign and malignant abnormalities and the identification of risk factors for the development of complications.
All consecutive partial liver resections performed between January 1991 and October 2000 at the University Medical Centre Utrecht, the Netherlands, were reviewed for preoperative, peroperative and postoperative parameters. Risk factors were determined by means of a univariate analysis and a multiple logistic regression analysis. The 5-year survival rates were calculated using the Kaplan-Meier method.
A total of 133 patients (71 men and 62 women; median age: 58 years (range: 17-79)) underwent 137 hepatic resections for benign (n = 29) and malignant (n = 108) liver abnormalities. In total, 74 procedures (54%) were considered to be major hepatic resections and blood transfusion was required in 97 patients (71%). A total of 43 complications was observed in 32 patients (32/137; 23%). Eight patients died as a result of postoperative complications (8/137; 5.8%). Independent risk factors associated with the development of major complications were a major resection (OR: 3.6) and more than 2 peroperative units of packed cells (OR: 5.0). The principal indication for liver resection were colorectal metastases (n = 69). The 5-year survival rate after liver resection for colorectal metastases was 38% (95% CI: range 21-54) with a 5-year disease-free survival rate of 25% (range 10-41). The postoperative mortality in this group was 2.9%.
After partial liver resection for benign and malignant lesions the mortality was 5.8% and the morbidity 23%. The risk of postoperative morbidity was related to the number of peroperative units of packed cells and the extent of the resection.
Nederlands tijdschrift voor geneeskunde 03/2002; 146(5):210-3.
[Show abstract][Hide abstract] ABSTRACT: Locoregional recurrence of a retroperitoneal soft tissue sarcoma (RSTS) may offer a second chance of curative surgical treatment. In a population-based study the proportion of patients developing isolated locoregional recurrences (LR) was determined and the outcome of these patients was analysed.
In a retrospective nationwide study, data were collected on 142 patients treated between 1 January 1989 and 1 January 1994 for primary RSTS. In patients who had been treated radically for their primary sarcoma (77/142, 54%), the pattern of recurrence was evaluated. Factors predictive of survival for patients with LR were studied.
After a median follow-up of 86 (range 60-101) months, 32 patients (42%) had developed LR, and distant metastasis (DM) had been diagnosed in 17 patients (22%). Median disease-free interval between the initial operation and the establishment of LR or DM was 22 and 19 months, respectively. Five-year cumulative survival of patients with established LR was 37% in comparison with 11% for patients with DM (P=0.062). Factors predictive of favourable outcome in patients with LR were the absence of multifocal recurrence (n=13 P=0.01), lipomatous histomorphology (n=20 P=0.02), and a complete resection of recurrent sarcoma (n=17 P=0.04).
After a median follow-up of 7 years following radical treatment of a primary RSTS, 42% of the patients had developed isolated locoregional recurrences. A complete resection of recurrent disease, lipomatous histomorphology and the absence of multifocal growth influenced prognosis favourably.
European Journal of Surgical Oncology 10/2001; 27(6):564-8. DOI:10.1053/ejso.2001.1166 · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Successful surgical treatment of patients with retroperitoneal soft tissue sarcoma (RSTS) is based on pre-operative planning that starts with a correct pre-operative diagnosis. In a population-based study, we determined which patients were initially treated for assumed other conditions. The effect of an erroneous diagnosis on the installed treatment was analysed.
With the help of the Dutch Network and National Database for Pathology (PALGA), data were collected on 143 patients in the Netherlands in whom a primary RSTS was found and confirmed histologically between 1 January 1989 and 1 January 1994. Satisfactory clinical information was obtained on 138 patients, 64 males and 74 females (54%). The median age was 60 (range 18-88) years.
At the time of actual treatment 37% of the patients with RSTS were assumed to have another disorder (group 1 n=51), whereas 87 patients were diagnosed as having RSTS (group 2). In group 1, an acute presentation was more common (18 vs 2% P=0.002), and the tumour was less often palpable at physical examination (43 vs 69% P=0.004), while clinical work-up less frequently included CT-imaging (57 vs 89% P<0.001) and a biopsy (29 vs 77% P<0.001). Although tumours in group 1 were smaller (median diameter 13 vs 19 cm P<0.05), this was not reflected in a better operative result: less patients underwent complete tumour resection (51 vs 57%) and more patients underwent surgery for tumours that proved to be irresectable (14 vs 1% P=0.004).
(1) More than one-third of patients with RSTS are misdiagnosed and inappropriately treated; and (2) biopsies and cross-sectional imaging improve diagnosis.
European Journal of Surgical Oncology 03/2001; 27(1):74-9. · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose. In the clinical work-up of a retroperitoneal mass, the diagnosis of soft tissue sarcoma is often not considered. Incidence rates of various malignant and benign retroperitoneal tumours were studied to determine the incidence of soft tissue sarcoma in comparison with other neoplasms in the retroperitoneal space.Method. Nation-wide data on retroperitoneal tumours, collected prospectively over a 5-year period (1 January 1989- 1 January 1994), were supplied by the Netherlands Cancer Registry and The Dutch Network and National Database for Pathology.Results. Seven hundred and six patients with a primary retroperitoneal neoplasm were identified; 566 patients had a malignant tumour (80%). A soft tissue sarcoma (STS) was the most frequently diagnosed malignant tumour (n = 192), The agestandardised incidence of retroperitoneal STS was 2.5 per million person-years. The male/female ratio for STS was 0.73. In females, STS comprised 41%of all malignant retroperitoneal tumours, carcinoma of unknown primary tumour site (CUP) comprised 31%, and malignant lymphomas (ML) comprised 22%, whereas in males these values were 28% (STS), 30% (CUP), and 32% (ML), respectively.Discussion. Soft tissue sarcomas, albeit rare, are relatively common primary tumours in the retroperitoneum, especially in women.
[Show abstract][Hide abstract] ABSTRACT: Aims Successful surgical treatment of patients with retroperitoneal soft tissue sarcoma (RSTS) is based on pre-operative planning that starts with a correct pre-operative diagnosis. In a population-based study, we determined which patients were initially treated for assumed other conditions. The effect of an erroneous diagnosis on the installed treatment was analysed. Method With the help of the Dutch Network and National Database for Pathology (PALGA), data were collected on 143 patients in the Netherlands in whom a primary RSTS was found and confirmed histologically between 1 January 1989 and 1 January 1994. Satisfactory clinical information was obtained on 138 patients, 64 males and 74 females (54%). The median age was 60 (range 18–88) years. Results At the time of actual treatment 37% of the patients with RSTS were assumed to have another disorder (group 1 n=51), whereas 87 patients were diagnosed as having RSTS (group 2). In group 1, an acute presentation was more common (18 vs 2%P=0.002), and the tumour was less often palpable at physical examination (43 vs 69%P=0.004), while clinical work-up less frequently included CT-imaging (57 vs 89%P<0.001) and a biopsy (29 vs 77%P<0.001). Although tumours in group 1 were smaller (median diameter 13 vs 19 cm P<0.05), this was not reflected in a better operative result: less patients underwent complete tumour resection (51 vs 57%) and more patients underwent surgery for tumours that proved to be irresectable (14 vs 1%P=0.004). Conclusions (1) More than one-third of patients with RSTS are misdiagnosed and inappropriately treated; and (2) biopsies and cross-sectional imaging improve diagnosis.
European Journal of Surgical Oncology 02/2001; 27(1-27):74-79. DOI:10.1053/ejso.2000.1057 · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Immunohistochemistry (IHC) of serial sectioning is considered the gold standard for detection of melanoma activity in sentinel node (SN) biopsies. However, this is cost and labor intensive. In contrast, tyrosinase reverse transcription-polymerase chain reaction (RT-PCR) is simple and quick, but it is hampered by its extreme sensitivity. This study was performed to test whether a strategy that combines the two methods, using tyrosinase RT-PCR to preselect nodes for IHC, could be accurate and cost effective.
In 36 patients, SNs were identified by scintigraphy and patent blue uptake. Of each SN, one cross section was analyzed first by hematoxylin and eosin staining. Next, all nodes were examined by serial sectioning and IHC of one-half and tyrosinase RT-PCR of the other. Before comparison, all results were documented in a blinded manner. Material costs and workload estimates were noted per SN.
Fifty-five SNs were retrieved from the 36 patients. Hematoxylin and eosin staining of the first cross section revealed tumor positivity in 3 patients (6 SN). Tyrosinase RT-PCR was positive in 11 of the remaining 33 patients (19 of 49 SN). Of these same 11 patients, only 5 were shown to have tumor-positive SNs by using IHC on serial sections (7 SN). All these nodes had been positive for tyrosinase on PCR. For IHC, an average of 40 sections were prepared and examined per SN at a cost of $200(U.S.)/SN. In contrast, routine tyrosinase RT-PCR costs $37(U.S.)/SN, and takes 5% of the time necessary for IHC. A strategy including hematoxylin and eosin staining on the first cross section, followed by tyrosinase RT-PCR on half of each negative (half) node, could preselect nodes to be taken through serial sectioning. In these series, such a strategy would have prevented serial sectioning and IHC of 30 SN from 22 patients. Apart from a considerable gain in efficiency, this would have reduced material costs by a minimum of $6000 (U.S.). This discrepancy would be even higher if work intensity of analysts and pathologists were considered.
In routine analysis of SN biopsies in melanoma patients, tyrosinase RT-PCR can be used effectively to preselect nodes for further IHC of serial sections. This method seems both time and cost effective.
[Show abstract][Hide abstract] ABSTRACT: Controversy still surrounds the management of fulminant acute necrotizing pancreatitis. Because mortality rates continue to be high, especially in patients with fulminant acute pancreatitis and infected necrosis, aggressive surgical techniques, such as open management of the abdomen and "planned" reoperations, seem to be justified.
From 1988 through 1995, 28 patients with fulminant acute pancreatitis and infected necrosis were treated with open management of the abdomen followed by planned reoperations at our surgical intensive care unit.
All patients had infected necrosis with severe clinical deterioration: 12 patients had an Acute Physiology and Chronic Health Evaluation (APACHE) II score > or = 20 and 16 patients had a Simplified Acute Physiology Score (SAPS) > or = 15. Nineteen patients suffered from severe multiorgan failure; the remaining 9 patients needed only ventilatory and inotropic support. The mean number of reoperations was 17. In 14 patients, major bleeding occurred; fistula developed in 7. Later, 9 abscesses were drained percutaneously. The hospital mortality rate was 39%. Longterm morbidity in survivors was substantial, especially concerning abdominal-wall defects.
Open management of the abdomen followed by planned reoperations is an aggressive but reasonably successful surgical treatment strategy for patients with fulminant acute pancreatitis and infected necrosis. Morbidity and mortality rates were high, but in these critically ill patients, such high rates could be expected. Because management and clinical surveillance require specific expertise, management of these patients is best undertaken in specialized centers.
Journal of the American College of Surgeons 10/1998; 187(3):255-62. DOI:10.1016/S1072-7515(98)00153-7 · 5.12 Impact Factor