1
|
Ketel MHM, Klarenbeek BR, Abma I, Belgers EHJ, Coene PPLO, Dekker JWT, van Duijvendijk P, Emous M, Gisbertz SS, Haveman JW, Heisterkamp J, Nieuwenhuijzen GAP, Ruurda JP, van Sandick JW, van der Sluis PC, van Det MJ, van Esser S, Law S, de Steur WO, Sosef MN, Wijnhoven B, Hannink G, Rosman C, van Workum F. Nationwide Association of Surgical Performance of Minimally Invasive Esophagectomy With Patient Outcomes. JAMA Netw Open 2024; 7:e246556. [PMID: 38639938 PMCID: PMC11031683 DOI: 10.1001/jamanetworkopen.2024.6556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/31/2024] [Indexed: 04/20/2024] Open
Abstract
Importance Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association may lead to programs that promote better surgical performance of MIE and improve patient outcomes. Objective To investigate associations between surgical performance and postoperative outcomes after MIE. Design, Setting, and Participants In this nationwide cohort study of 15 Dutch hospitals that perform more than 20 MIEs per year, 7 masked expert MIE surgeons assessed surgical performance using videos and a previously developed and validated competency assessment tool (CAT). Each hospital submitted 2 representative videos of MIEs performed between November 4, 2021, and September 13, 2022. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit between January 1, 2020, and December 31, 2021, were included to examine patient outcomes. Exposure Hospitals were divided into quartiles based on their MIE-CAT performance score. Outcomes were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Transthoracic MIE with gastric tube reconstruction. Main Outcome and Measure The primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Multilevel logistic regression, with clustering of patients within hospitals, was used to analyze associations between performance and outcomes. Results In total, 30 videos and 970 patients (mean [SD] age, 66.6 [9.1] years; 719 men [74.1%]) were included. The mean (SD) MIE-CAT score was 113.6 (5.5) in the highest performance quartile vs 94.1 (5.9) in the lowest. Severe postoperative complications occurred in 18.7% (41 of 219) of patients in the highest performance quartile vs 39.2% (40 of 102) in the lowest (risk ratio [RR], 0.50; 95% CI, 0.24-0.99). The highest vs the lowest performance quartile showed lower rates of conversions (1.8% vs 8.9%; RR, 0.21; 95% CI, 0.21-0.21), intraoperative complications (2.7% vs 7.8%; RR, 0.21; 95% CI, 0.04-0.94), and overall postoperative complications (46.1% vs 65.7%; RR, 0.54; 95% CI, 0.24-0.96). The R0 resection rate (96.8% vs 94.2%; RR, 1.03; 95% CI, 0.97-1.05) and lymph node yield (mean [SD], 38.9 [14.7] vs 26.2 [9.0]; RR, 3.20; 95% CI, 0.27-3.21) increased with oncologic-specific performance (eg, hiatus dissection, lymph node dissection). In addition, a high anastomotic phase score was associated with a lower anastomotic leakage rate (4.6% vs 17.7%; RR, 0.14; 95% CI, 0.06-0.31). Conclusions and Relevance These findings suggest that better surgical performance is associated with fewer perioperative complications for patients with esophageal cancer on a national level. If surgical performance of MIE can be improved with MIE-CAT implementation, substantially better patient outcomes may be achievable.
Collapse
Affiliation(s)
- Mirte H. M. Ketel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Inger Abma
- IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | | | | | - Marloes Emous
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Suzanne S. Gisbertz
- Department of Surgery, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth Twee-Steden Hospital, Tilburg, the Netherlands
| | | | - Jelle P. Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Pieter C. van der Sluis
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marc J. van Det
- Department of Surgery, Hospital Group Twente (ZGT), Almelo, the Netherlands
| | - Stijn van Esser
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, School of Clinical Medicine, The University of Hong Kong, China
| | - Wobbe O. de Steur
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Bas Wijnhoven
- Department of Surgery, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| |
Collapse
|
2
|
Ketel MHM, Klarenbeek BR, Eddahchouri Y, Cheong E, Cuesta MA, van Daele E, Ferri LE, Gisbertz SS, Gutschow CA, Hubka M, Hölscher AH, Law S, Luyer MDP, Merritt RE, Morse CR, Mueller CL, Nieuwenhuijzen GAP, Nilsson M, Pattyn P, Shen Y, van den Wildenberg FJH, Abma IL, Rosman C, van Workum F. A Video-Based Procedure-Specific Competency Assessment Tool for Minimally Invasive Esophagectomy. JAMA Surg 2024; 159:297-305. [PMID: 38150247 PMCID: PMC10753443 DOI: 10.1001/jamasurg.2023.6522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/11/2023] [Indexed: 12/28/2023]
Abstract
Importance Minimally invasive esophagectomy (MIE) is a complex procedure with substantial learning curves. In other complex minimally invasive procedures, suboptimal surgical performance has convincingly been associated with less favorable patient outcomes as assessed by peer review of the surgical procedure. Objective To develop and validate a procedure-specific competency assessment tool (CAT) for MIE. Design, Setting, and Participants In this international quality improvement study, a procedure-specific MIE-CAT was developed and validated. The MIE-CAT contains 8 procedural phases, and 4 quality components per phase are scored with a Likert scale ranging from 1 to 4. For evaluation of the MIE-CAT, intraoperative MIE videos performed by a single surgical team in the Esophageal Center East Netherlands were peer reviewed by 18 independent international MIE experts (with more than 120 MIEs performed). Each video was assessed by 2 or 3 blinded experts to evaluate feasibility, content validity, reliability, and construct validity. MIE-CAT version 2 was composed with refined content aimed at improving interrater reliability. A total of 32 full-length MIE videos from patients who underwent MIE between 2011 and 2020 were analyzed. Data were analyzed from January 2021 to January 2023. Exposure Performance assessment of transthoracic MIE with an intrathoracic anastomosis. Main Outcomes and Measures Feasibility, content validity, interrater and intrarater reliability, and construct validity, including correlations with both experience of the surgical team and clinical parameters, of the developed MIE-CAT. Results Experts found the MIE-CAT easy to understand and easy to use to grade surgical performance. The MIE-CAT demonstrated good intrarater reliability (range of intraclass correlation coefficients [ICCs], 0.807 [95% CI, 0.656 to 0.892] for quality component score to 0.898 [95% CI, 0.846 to 0.932] for phase score). Interrater reliability was moderate (range of ICCs, 0.536 [95% CI, -0.220 to 0.994] for total MIE-CAT score to 0.705 [95% CI, 0.473 to 0.846] for quality component score), and most discrepancies originated in the lymphadenectomy phases. Hypothesis testing for construct validity showed more than 75% of hypotheses correct: MIE-CAT performance scores correlated with experience of the surgical team (r = 0.288 to 0.622), blood loss (r = -0.034 to -0.545), operative time (r = -0.309 to -0.611), intraoperative complications (r = -0.052 to -0.319), and severe postoperative complications (r = -0.207 to -0.395). MIE-CAT version 2 increased usability. Interrater reliability improved but remained moderate (range of ICCs, 0.666 to 0.743), and most discrepancies between raters remained in the lymphadenectomy phases. Conclusions and Relevance The MIE-CAT was developed and its feasibility, content validity, reliability, and construct validity were demonstrated. By providing insight into surgical performance of MIE, the MIE-CAT might be used for clinical, training, and research purposes.
Collapse
Affiliation(s)
- Mirte H. M. Ketel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Yassin Eddahchouri
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Edward Cheong
- The PanAsia Surgery Group, Mount Elizabeth Hospital, Singapore
| | - Miguel A. Cuesta
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Elke van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lorenzo E. Ferri
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Suzanne S. Gisbertz
- Amsterdam UMC location University of Amsterdam, Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Christian A. Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Michal Hubka
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Arnulf H. Hölscher
- Department for General, Visceral and Trauma Surgery, Elisabeth-Krankenhaus-Essen GmbH, Essen, Germany
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Misha D. P. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Robert E. Merritt
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus
| | | | - Carmen L. Mueller
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | | | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yaxing Shen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Inger L. Abma
- IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| |
Collapse
|
3
|
Kuijper SC, Besseling J, Klausch T, Slingerland M, van der Zijden CJ, Kouwenhoven EA, Beerepoot LV, Mohammad NH, Klarenbeek BR, Verhoeven RHA, van Laarhoven HWM. Assessing real-world representativeness of prospective registry cohorts in oncology: insights from patients with esophagogastric cancer. J Clin Epidemiol 2023; 164:65-75. [PMID: 37871837 DOI: 10.1016/j.jclinepi.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVES This study aimed to explore the real-world representativeness of a prospective registry cohort with active accrual in oncology, applying a representativeness metric that is novel to health care. STUDY DESIGN AND SETTING We used data from the Prospective Observational Cohort Study of Esophageal-Gastric Cancer Patients (POCOP) registry and from the population-based Netherlands Cancer Registry (NCR). We used Representativeness-indicators (R-indicators) and overall survival to investigate the degree to which the POCOP cohort and clinically relevant subgroups were a representative sample compared to the NCR database. Calibration using inverse propensity score weighting was applied to correct differences between POCOP and NCR. RESULTS The R-indicator of the entire POCOP registry was 0.72 95% confidence interval [0.71, 0.73]. Representativeness of palliative patients was higher than that of potentially curable patients (R-indicator 0.88 [0.85, 0.90] and 0.70 [0.68, 0.71], respectively). Stratification to clinically relevant subgroups based on treatment resulted in higher R-indicators of the respective subgroups. Both after stratification and calibration weighting survival estimates in the POCOP registry were more similar to that in the NCR population. CONCLUSION This study demonstrated the assessment of real-world representativeness of patients who participated in a prospective registry cohort and showed that real-world representativeness improved when the variability in treatment was accounted for.
Collapse
Affiliation(s)
- Steven C Kuijper
- Department of Medical Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Joost Besseling
- Department of Medical Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Thomas Klausch
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Marije Slingerland
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Laurens V Beerepoot
- Department of Medical Oncology, Elisabeth Tweesteden Ziekenhuis and EMBRAZE Cancer Network, Tilburg, The Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, Utrecht University Medical Center, Utrecht, The Netherlands
| | | | - Rob H A Verhoeven
- Department of Medical Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands; Department of Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands.
| |
Collapse
|
4
|
Somers T, Klarenbeek BR, Kouijzer IJE, Verhagen AFTM, Verkroost MWA. Surviving the nonsurvivable combination of a mycotic aneurysm progressing into a concomitant aorto-bronchial- and aorto-esophageal fistula, a case report. J Cardiothorac Surg 2023; 18:289. [PMID: 37828603 PMCID: PMC10571321 DOI: 10.1186/s13019-023-02387-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 09/30/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Aortic mycotic aneurysms are a rare but life-threatening condition and may be associated with aorto-bronchial- and aorto-esophageal fistulas. Although both very rare, they carry a high mortality and require (urgent) surgical intervention. Surviving all three conditions concomitantly is extraordinary. We describe a patient who underwent staged repair of such combined defects.
Collapse
Affiliation(s)
- Tim Somers
- Department of Cardio-thoracic Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10 (Route 615), Nijmegen, 6525 GA, Netherlands
| | | | - Ilse J E Kouijzer
- Department of Internal Medicine and Radboud Centre for Infectious diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ad F T M Verhagen
- Department of Cardio-thoracic Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10 (Route 615), Nijmegen, 6525 GA, Netherlands
| | - Michel W A Verkroost
- Department of Cardio-thoracic Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10 (Route 615), Nijmegen, 6525 GA, Netherlands.
| |
Collapse
|
5
|
Ketel MHM, Klarenbeek BR, Eddahchouri Y, Cuesta MA, van Daele E, Gutschow CA, Hölscher AH, Hubka M, Luyer MDP, Merritt RE, Nieuwenhuijzen GAP, Shen Y, Abma IL, Rosman C, van Workum F. Crowd-sourced and expert video assessment in minimally invasive esophagectomy. Surg Endosc 2023; 37:7819-7828. [PMID: 37605010 PMCID: PMC10520122 DOI: 10.1007/s00464-023-10297-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/02/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Video-based assessment by experts may structurally measure surgical performance using procedure-specific competency assessment tools (CATs). A CAT for minimally invasive esophagectomy (MIE-CAT) was developed and validated previously. However, surgeon's time is scarce and video assessment is time-consuming and labor intensive. This study investigated non-procedure-specific assessment of MIE video clips by MIE experts and crowdsourcing, collective surgical performance evaluation by anonymous and untrained laypeople, to assist procedure-specific expert review. METHODS Two surgical performance scoring frameworks were used to assess eight MIE videos. First, global performance was assessed with the non-procedure-specific Global Operative Assessment of Laparoscopic Skills (GOALS) of 64 procedural phase-based video clips < 10 min. Each clip was assessed by two MIE experts and > 30 crowd workers. Second, the same experts assessed procedure-specific performance with the MIE-CAT of the corresponding full-length video. Reliability and convergent validity of GOALS for MIE were investigated using hypothesis testing with correlations (experience, blood loss, operative time, and MIE-CAT). RESULTS Less than 75% of hypothesized correlations between GOALS scores and experience of the surgical team (r < 0.3), blood loss (r = - 0.82 to 0.02), operative time (r = - 0.42 to 0.07), and the MIE-CAT scores (r = - 0.04 to 0.76) were met for both crowd workers and experts. Interestingly, experts' GOALS and MIE-CAT scores correlated strongly (r = 0.40 to 0.79), while crowd workers' GOALS and experts' MIE-CAT scores correlations were weak (r = - 0.04 to 0.49). Expert and crowd worker GOALS scores correlated poorly (ICC ≤ 0.42). CONCLUSION GOALS assessments by crowd workers lacked convergent validity and showed poor reliability. It is likely that MIE is technically too difficult to assess for laypeople. Convergent validity of GOALS assessments by experts could also not be established. GOALS might not be comprehensive enough to assess detailed MIE performance. However, expert's GOALS and MIE-CAT scores strongly correlated indicating video clip (instead of full-length video) assessments could be useful to shorten assessment time.
Collapse
Affiliation(s)
- Mirte H M Ketel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Yassin Eddahchouri
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Miguel A Cuesta
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Elke van Daele
- Department of Digestive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Christian A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Arnulf H Hölscher
- Department for General, Visceral and Trauma Surgery, Elisabeth-Krankenhaus-Essen GmbH, Essen, Germany
| | - Michal Hubka
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, SE, USA
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Robert E Merritt
- Department of Surgery, Ohio State University - Wexner Medical Center, Columbus, OH, USA
| | | | - Yaxing Shen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Inger L Abma
- IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| |
Collapse
|
6
|
Klarenbeek BR, Fujiwara H, Scholte M, Rovers M, Shiozaki A, Rosman C. Introduction of Minimally Invasive transCervical oEsophagectomy (MICE) according to the IDEAL framework. Br J Surg 2023; 110:1096-1099. [PMID: 36960594 PMCID: PMC10416700 DOI: 10.1093/bjs/znad079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/03/2023] [Accepted: 02/21/2023] [Indexed: 03/25/2023]
Affiliation(s)
| | - Hitoshi Fujiwara
- Department of Surgery, Kyoto Prefectural University of Medicine Hospital, Kyoto, Japan
| | - Mirre Scholte
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Maroeska Rovers
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Atsushi Shiozaki
- Department of Surgery, Kyoto Prefectural University of Medicine Hospital, Kyoto, Japan
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| |
Collapse
|
7
|
Hofste LSM, Geerlings MJ, von Rhein D, Rütten H, Westenberg AH, Weiss MM, Gilissen C, Hofste T, van der Post RS, Klarenbeek BR, de Wilt JHW, Ligtenberg MJL. Circulating tumor DNA detection after neoadjuvant treatment and surgery predicts recurrence in patients with early-stage and locally advanced rectal cancer. Eur J Surg Oncol 2023; 49:1283-1290. [PMID: 36740555 DOI: 10.1016/j.ejso.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/30/2022] [Accepted: 01/24/2023] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients with early-stage and locally advanced rectal cancer are often treated with neoadjuvant therapy followed by surgery or watch and wait. This study evaluated the role of circulating tumor DNA (ctDNA) to measure disease after neoadjuvant treatment and surgery to optimize treatment choices. MATERIALS AND METHODS Patients with rectal cancer treated with both chemotherapy and radiotherapy were included and diagnostic biopsies were analyzed for tumor-specific mutations. Presence of ctDNA was measured in plasma by tracing the tumor-informed mutations using a next-generation sequencing panel. The association between ctDNA detection and clinicopathological characteristics and progression-free survival was measured. RESULTS Before treatment ctDNA was detected in 69% (35/51) of patients. After neoadjuvant therapy ctDNA was detected in only 15% (5/34) of patients. In none of the patients with a complete clinical response who were selected for a watch and wait strategy (0/10) or patients with ypN0 disease (0/8) ctDNA was detected, whereas it was detected in 31% (5/16) of patients with ypN + disease. After surgery ctDNA was detected in 16% (3/19) of patients, of which all (3/3) developed recurrent disease compared to only 13% (2/16) in patients with undetected ctDNA after surgery. In an exploratory survival analysis, both ctDNA detection after neoadjuvant therapy and after surgery was associated with worse progression-free survival (p = 0.01 and p = 0.007, respectively, Cox-regression). CONCLUSION These data show that in patients with early-stage and locally advanced rectal cancer tumor-informed ctDNA detection in plasma using ultradeep sequencing may have clinical value to complement response prediction after neoadjuvant therapy and surgery.
Collapse
Affiliation(s)
- Lisa S M Hofste
- Department of Human Genetics, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Maartje J Geerlings
- Department of Human Genetics, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Daniel von Rhein
- Department of Human Genetics, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Heidi Rütten
- Department of Radiation Oncology, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - A Helen Westenberg
- Institute for Radiation Oncology Arnhem, 6815, AD, Arnhem, the Netherlands
| | - Marjan M Weiss
- Department of Human Genetics, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Christian Gilissen
- Department of Human Genetics, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Tom Hofste
- Department of Human Genetics, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Rachel S van der Post
- Department of Pathology, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands
| | - Marjolijn J L Ligtenberg
- Department of Human Genetics, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands; Department of Pathology, Radboud University Medical Center, 6525, GA, Nijmegen, the Netherlands.
| |
Collapse
|
8
|
Ubels S, Verstegen MHP, Klarenbeek BR, Bouwense S, van Berge Henegouwen MI, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Nieuwenhuijzen G, Polat F, Schouten J, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C. Treatment of anastomotic leak after oesophagectomy for oesophageal cancer: large, collaborative, observational TENTACLE cohort study. Br J Surg 2023; 110:852-863. [PMID: 37196149 PMCID: PMC10364505 DOI: 10.1093/bjs/znad123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/16/2023] [Accepted: 04/13/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Anastomotic leak is a severe complication after oesophagectomy. Anastomotic leak has diverse clinical manifestations and the optimal treatment strategy is unknown. The aim of this study was to assess the efficacy of treatment strategies for different manifestations of anastomotic leak after oesophagectomy. METHODS A retrospective cohort study was performed in 71 centres worldwide and included patients with anastomotic leak after oesophagectomy (2011-2019). Different primary treatment strategies were compared for three different anastomotic leak manifestations: interventional versus supportive-only treatment for local manifestations (that is no intrathoracic collections; well perfused conduit); drainage and defect closure versus drainage only for intrathoracic manifestations; and oesophageal diversion versus continuity-preserving treatment for conduit ischaemia/necrosis. The primary outcome was 90-day mortality. Propensity score matching was performed to adjust for confounders. RESULTS Of 1508 patients with anastomotic leak, 28.2 per cent (425 patients) had local manifestations, 36.3 per cent (548 patients) had intrathoracic manifestations, 9.6 per cent (145 patients) had conduit ischaemia/necrosis, 17.5 per cent (264 patients) were allocated after multiple imputation, and 8.4 per cent (126 patients) were excluded. After propensity score matching, no statistically significant differences in 90-day mortality were found regarding interventional versus supportive-only treatment for local manifestations (risk difference 3.2 per cent, 95 per cent c.i. -1.8 to 8.2 per cent), drainage and defect closure versus drainage only for intrathoracic manifestations (risk difference 5.8 per cent, 95 per cent c.i. -1.2 to 12.8 per cent), and oesophageal diversion versus continuity-preserving treatment for conduit ischaemia/necrosis (risk difference 0.1 per cent, 95 per cent c.i. -21.4 to 1.6 per cent). In general, less morbidity was found after less extensive primary treatment strategies. CONCLUSION Less extensive primary treatment of anastomotic leak was associated with less morbidity. A less extensive primary treatment approach may potentially be considered for anastomotic leak. Future studies are needed to confirm current findings and guide optimal treatment of anastomotic leak after oesophagectomy.
Collapse
Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Moniek H P Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT Hospital Group, Almelo, The Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jeroen Schouten
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
9
|
Hofste LS, Geerlings MJ, Kamping EJ, Kouwenhoven ND, von Rhein D, Jansen EA, Garms LM, Nagtegaal ID, van der Post RS, de Wilt JH, Klarenbeek BR, Ligtenberg MJ. Clinical Validity of Tumor-Informed Circulating Tumor DNA Analysis in Patients Undergoing Surgery of Colorectal Metastases. Dis Colon Rectum 2023; 66:796-804. [PMID: 35857852 PMCID: PMC10191207 DOI: 10.1097/dcr.0000000000002443] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Accurate biomarkers to monitor tumor load and response in metastatic colorectal cancer patients undergoing surgery could optimize treatment regimens. OBJECTIVE This study aimed to explore the clinical validity of tumor-informed quantification of circulating tumor DNA in blood using ultradeep sequencing. DESIGN Resection specimens from 53 colorectal cancer patients were analyzed for tumor-specific mutations in 15 genes. These mutations were used to measure the presence of circulating tumor DNA in preoperatively collected plasma samples using hybrid capture-based sequencing. Additional postoperative measurements were performed 1 week after surgery in 16 patients. SETTINGS The study was conducted at the Radboud University Medical Center. PATIENTS A total of 53 colorectal cancer patients undergoing surgery of metastases were included. MAIN OUTCOME MEASURES The detection of circulating tumor DNA. RESULTS At least 1 tumor-specific mutation was detected in all tumor samples. In preoperative plasma samples, circulating tumor DNA was detected in 88% (37/42) of systemic treatment-naïve patients and in 55% (6/11) of patients who received preoperative chemotherapy. More specifically, circulating tumor DNA was detected in 0% (0/3) of cases with a subtotal or partial pathologic response and in 75% (6/8) of cases without a pathologic response in the resection specimen ( p = 0.06). In postoperative plasma samples, circulating tumor DNA was detected in 80% (4/5) of patients with an incomplete resection and in 0% (0/11) of those with a complete resection ( p = 0.003). LIMITATIONS The study was limited by the heterogeneity of the cohort and the small number of postoperative plasma samples. CONCLUSIONS These data indicate that tumor-informed circulating tumor DNA detection in the plasma of patients undergoing surgery for metastatic colorectal cancer is feasible and may have clinical value in response monitoring and predicting residual disease. Prospective studies are needed to establish the clinical utility of circulating tumor DNA analysis to guide treatment decisions in these patients. See Video Abstract at http://links.lww.com/DCR/B990 . VALIDEZ CLNICA DEL ANLISIS DE ADN DEL TUMOR CIRCULANTE INFORMADO POR EL TUMOR EN PACIENTES SOMETIDOS A CIRUGA DE METSTASIS COLORRECTALES ANTECEDENTES:Los biomarcadores precisos para monitorear la carga tumoral y la respuesta en pacientes con cáncer colorrectal metastásico que se someten a cirugía podrían optimizar los regímenes de tratamiento.OBJETIVO:Este estudio explora la validez clínica de la cuantificación informada por el tumor del ADN tumoral circulante en sangre mediante secuenciación ultraprofunda.DISEÑO:Se analizaron muestras de resección de 53 pacientes con cáncer colorrectal en busca de mutaciones específicas del tumor en quince genes. Estas mutaciones se usaron para medir la presencia de ADN tumoral circulante en muestras de plasma recolectadas antes de la operación usando secuenciación basada en captura híbrida. Se realizaron mediciones postoperatorias adicionales una semana después de la cirugía en dieciséis pacientes.AJUSTES:El estudio se realizó en el centro médico de la universidad de Radboud.PACIENTES:Se incluyeron un total de 53 pacientes con cáncer colorrectal sometidos a cirugía de metástasis.PRINCIPALES MEDIDAS DE RESULTADO:La detección de ADN tumoral circulante.RESULTADOS:Se detectó al menos una mutación específica de tumor en todas las muestras de tumor. En muestras de plasma preoperatorias, se detectó ADN tumoral circulante en el 88% (37/42) de los pacientes sin tratamiento sistémico previo y en el 55% (6/11) de los pacientes que recibieron quimioterapia preoperatoria. Más concretamente, en el 0% (0/3) de los casos con respuesta patológica subtotal o parcial y en el 75% (6/8) de los casos sin respuesta patológica en la pieza de resección ( p = 0,06). En muestras de plasma postoperatorio se detectó ADN tumoral circulante en el 80% (4/5) de los pacientes con una resección incompleta y en el 0% (0/11) de los que tenían resección completa ( p = 0,003).LIMITACIONES:El estudio estuvo limitado por la heterogeneidad de la cohorte y el pequeño número de muestras de plasma postoperatorias.CONCLUSIONES:Estos datos indican que la detección de ADN tumoral circulante informado por el tumor en el plasma de pacientes sometidos a cirugía por cáncer colorrectal metastásico es factible y puede tener valor clínico en el control de la respuesta y la predicción de la enfermedad residual. Se necesitan estudios prospectivos para establecer la utilidad clínica del análisis de ADN tumoral circulante para guiar las decisiones de tratamiento en estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B990 . (Traducción-Dr. Mauricio Santamaria ).
Collapse
Affiliation(s)
- Lisa S.M. Hofste
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maartje J. Geerlings
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eveline J. Kamping
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Daniel von Rhein
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erik A.M. Jansen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Linda M. Garms
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris D. Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - Marjolijn J.L. Ligtenberg
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
10
|
Valkema MJ, Vos A, van der Post RS, Ooms AHAG, Oudijk L, Eyck BM, Lagarde SM, Wijnhoven BPL, Klarenbeek BR, Rosman C, van Lanschot JJB, Doukas M. The effectiveness of neoadjuvant chemoradiotherapy in oesophageal adenocarcinoma with presence of extracellular mucin, signet‐ring cells, and/or poorly cohesive cells. The Journal of Pathology CR 2023. [DOI: 10.1002/cjp2.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/24/2023] [Accepted: 03/11/2023] [Indexed: 03/29/2023]
|
11
|
Ubels S, Lubbers M, Verstegen MHP, Bouwense SAW, van Daele E, Ferri L, Gisbertz SS, Griffiths EA, Grimminger P, Hanna G, Hubka M, Law S, Low D, Luyer M, Merritt RE, Morse C, Mueller CL, Nieuwenhuijzen GAP, Nilsson M, Reynolds JV, Ribeiro U, Rosati R, Shen Y, Wijnhoven BPL, Klarenbeek BR, van Workum F, Rosman C. Treatment of anastomotic leak after esophagectomy: insights of an international case vignette survey and expert discussions. Dis Esophagus 2022; 35:6566833. [PMID: 35411928 DOI: 10.1093/dote/doac020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/11/2022] [Accepted: 02/14/2022] [Indexed: 12/16/2022]
Abstract
Anastomotic leak (AL) is a severe complication after esophagectomy. Clinical presentation of AL is diverse and there is large practice variation regarding treatment of AL. This study aimed to explore different AL treatment strategies and their underlying rationale. This mixed-methods study consisted of an international survey among upper gastro-intestinal (GI) surgeons and focus groups with expert upper GI surgeons. The survey included 10 case vignettes and data sources were integrated after separate analysis. The survey was completed by 188 respondents (completion rate 69%) and 6 focus groups were conducted with 20 international experts. Prevention of mortality was the most important goal of primary treatment. Goals of secondary treatment were to promote tissue healing, return to oral feeding and safe hospital discharge. There was substantial variation in the preferred treatment principles (e.g. drainage or defect closure) and modalities (e.g. stent or endoVAC) within different presentations of AL. Patients with local symptoms were treated by supportive means only or by non-surgical drainage and/or defect closure. Drainage was routinely performed in patients with intrathoracic collections and often combined with defect closure. Patients with conduit necrosis were predominantly treated by resection and reconstruction of the anastomosis or by esophageal diversion. This mixed-methods study shows that overall treatment strategies for AL are determined by vitality of the conduit and presence of intrathoracic collections. There is large variation in preferred treatment principles and modalities. Future research may investigate optimal treatment for specific AL presentations and aim to develop consensus-based treatment guidelines for AL after esophagectomy.
Collapse
Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Merel Lubbers
- Department of Surgery, ZGT Hospital Group Twente, Almelo, The Netherlands
| | - Moniek H P Verstegen
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elke van Daele
- Department of Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lorenzo Ferri
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Peter Grimminger
- Department of Surgery, University Medical Center Mainz, Mainz, Germany
| | - George Hanna
- Department of Surgery, Imperial College, London, UK
| | - Michal Hubka
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, SE USA
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Donald Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, SE USA
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Robert E Merritt
- Department of Surgery, Ohio State University - Wexner Medical Center, Columbus, OH, USA
| | - Christopher Morse
- Department of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Carmen L Mueller
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | | | - Magnus Nilsson
- Department of Surgery, Department of Upper Abdominal Diseases, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - John V Reynolds
- Department of Surgery, Trinity St. James's Cancer Institute, Dublin, Ireland
| | - Ulysses Ribeiro
- Department of Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Raffaele Hospital IRCCS, Milan, Italy
| | - Yaxing Shen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
12
|
Hofste LSM, Geerlings MJ, von Rhein D, Tolmeijer SH, Weiss MM, Gilissen C, Hofste T, Garms LM, Janssen MJR, Rütten H, Rosman C, van der Post RS, Klarenbeek BR, Ligtenberg MJL. Circulating Tumor DNA-Based Disease Monitoring of Patients with Locally Advanced Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14184417. [PMID: 36139577 PMCID: PMC9497103 DOI: 10.3390/cancers14184417] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary The standard of care for patients diagnosed with locally advanced esophageal cancer is neoadjuvant chemoradiotherapy followed by surgery. There is a high clinical need to monitor response to neoadjuvant treatment and recognize patients at risk for recurrence to enable individual treatment strategies. Ultradeep sequencing-based detection of circulating tumor DNA in preoperative plasma of patients with locally advanced esophageal cancer can predict which patients have a high risk of recurrence after neoadjuvant chemoradiotherapy and surgery. Circulating tumor DNA-based prediction of the presence of distant metastasis might eventually be used to reconsider surgery and its associated morbidity in patients with detected circulating tumor DNA or stratify patients for adjuvant treatment. Abstract Patients diagnosed with locally advanced esophageal cancer are often treated with neoadjuvant chemoradiotherapy followed by surgery. This study explored whether detection of circulating tumor DNA (ctDNA) in plasma can be used to predict residual disease during treatment. Diagnostic tissue biopsies from patients with esophageal cancer receiving neoadjuvant chemoradiotherapy and surgery were analyzed for tumor-specific mutations. These tumor-informed mutations were used to measure the presence of ctDNA in serially collected plasma samples using hybrid capture-based sequencing. Plasma samples were obtained before chemoradiotherapy, and prior to surgery. The association between ctDNA detection and progression-free and overall survival was measured. Before chemoradiotherapy, ctDNA was detected in 56% (44/78) of patients and detection was associated with tumor stage and volume (p = 0.05, Fisher exact and p = 0.02, Mann-Whitney, respectively). After chemoradiotherapy, ctDNA was detected in 10% (8/78) of patients. This preoperative detection of ctDNA was independently associated with recurrent disease (hazard ratio 2.8, 95% confidence interval 1.1–6.8, p = 0.03, multivariable Cox-regression) and worse overall survival (hazard ratio 2.9, 95% confidence interval 1.2–7.1, p = 0.02, multivariable Cox-regression).Ultradeep sequencing-based detection of ctDNA in preoperative plasma of patients with locally advanced esophageal cancer may help to assess which patients have a high risk of recurrence after neoadjuvant chemoradiotherapy and surgery.
Collapse
Affiliation(s)
- Lisa S. M. Hofste
- Department of Human Genetics, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Maartje J. Geerlings
- Department of Human Genetics, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Daniel von Rhein
- Department of Human Genetics, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Sofie H. Tolmeijer
- Department of Medical Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Marjan M. Weiss
- Department of Human Genetics, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Christian Gilissen
- Department of Human Genetics, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Tom Hofste
- Department of Human Genetics, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Linda M. Garms
- Department of Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Marcel J. R. Janssen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Heidi Rütten
- Department of Radiation Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Rachel S. van der Post
- Department of Pathology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Bastiaan R. Klarenbeek
- Department of Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Marjolijn J. L. Ligtenberg
- Department of Human Genetics, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Department of Pathology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Correspondence: ; Tel.: +31-0024-3617-749
| |
Collapse
|
13
|
Verstegen MHP, Slaman AE, Klarenbeek BR, van Berge Henegouwen MI, Gisbertz SS, Rosman C, van Workum F. Outcomes of Patients with Anastomotic Leakage After Transhiatal, McKeown or Ivor Lewis Esophagectomy: A Nationwide Cohort Study. World J Surg 2021; 45:3341-3349. [PMID: 34373937 PMCID: PMC8476360 DOI: 10.1007/s00268-021-06250-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 12/24/2022]
Abstract
Background Anastomotic leakage has a great impact on clinical outcomes after esophagectomy. It has never been studied whether anastomotic leakage is of equal severity between different types of esophagectomy (i.e., transhiatal, McKeown and Ivor Lewis) in terms of postoperative mortality and morbidity. Methods All esophageal cancer patients with anastomotic leakage after transhiatal, McKeown or Ivor Lewis esophagectomy between 2011 and 2019 were selected from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) registry. The primary outcome was 30-day/in-hospital mortality. Secondary outcomes included postoperative complications, re-operation and ICU readmission rate. Results Data from 1030 patients with anastomotic leakage after transhiatal (n=287), McKeown (n=397) and Ivor Lewis esophagectomy (n=346) were evaluated. The 30-day/in-hospital mortality rate was 4.5% in patients with leakage after transhiatal esophagectomy, 8.1% after McKeown and 8.1% after Ivor Lewis esophagectomy (P=0.139). After correction for confounders, leakage after transhiatal resection was associated with lower mortality (OR 0.152–0.699, P=0.004), but mortality after McKeown and Ivor Lewis esophagectomy was similar. Re-operation rate was 24.0% after transhiatal, 40.6% after McKeown and 41.3% after Ivor Lewis esophagectomy (P<0.001). ICU readmission rate was 24.0% after transhiatal, 37.8% after McKeown and 43.4% after Ivor Lewis esophagectomy (P<0.001). Conclusion This study in patients with anastomotic leakage confirms a strong association between severity of clinical consequences and different types of esophagectomy. It supports the hypothesis that cervical leakage is generally less severe than intrathoracic leakage. The clinical impact of anastomotic leakage should be taken into account, in addition to its incidence, when different types of esophagectomy are compared by clinicians or researchers.
Collapse
Affiliation(s)
- Moniek H P Verstegen
- Department of Surgery and Radboud Institute of Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Annelijn E Slaman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery and Radboud Institute of Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Camiel Rosman
- Department of Surgery and Radboud Institute of Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery and Radboud Institute of Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| |
Collapse
|
14
|
van Workum F, Verstegen MHP, Klarenbeek BR, Bouwense SAW, van Berge Henegouwen MI, Daams F, Gisbertz SS, Hannink G, Haveman JW, Heisterkamp J, Jansen W, Kouwenhoven EA, van Lanschot JJB, Nieuwenhuijzen GAP, van der Peet DL, Polat F, Ubels S, Wijnhoven BPL, Rovers MM, Rosman C. Intrathoracic vs Cervical Anastomosis After Totally or Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer: A Randomized Clinical Trial. JAMA Surg 2021; 156:601-610. [PMID: 33978698 DOI: 10.1001/jamasurg.2021.1555] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Transthoracic minimally invasive esophagectomy (MIE) is increasingly performed as part of curative multimodality treatment. There appears to be no robust evidence on the preferred location of the anastomosis after transthoracic MIE. Objective To compare an intrathoracic with a cervical anastomosis in a randomized clinical trial. Design, Setting, and Participants This open, multicenter randomized clinical superiority trial was performed at 9 Dutch high-volume hospitals. Patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were included. Data collection occurred from April 2016 through February 2020. Intervention Patients were randomly assigned (1:1) to transthoracic MIE with intrathoracic or cervical anastomosis. Main Outcomes and Measures The primary end point was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality, and quality of life. Results Two hundred sixty-two patients were randomized, and 245 were eligible for analysis. Anastomotic leakage necessitating reintervention occurred in 15 of 122 patients with intrathoracic anastomosis (12.3%) and in 39 of 123 patients with cervical anastomosis (31.7%; risk difference, -19.4% [95% CI, -29.5% to -9.3%]). Overall anastomotic leak rate was 12.3% in the intrathoracic anastomosis group and 34.1% in the cervical anastomosis group (risk difference, -21.9% [95% CI, -32.1% to -11.6%]). Intensive care unit length of stay, mortality rates, and overall quality of life were comparable between groups, but intrathoracic anastomosis was associated with fewer severe complications (risk difference, -11.3% [-20.4% to -2.2%]), lower incidence of recurrent laryngeal nerve palsy (risk difference, -7.3% [95% CI, -12.1% to -2.5%]), and better quality of life in 3 subdomains (mean differences: dysphagia, -12.2 [95% CI, -19.6 to -4.7]; problems of choking when swallowing, -10.3 [95% CI, -16.4 to 4.2]; trouble with talking, -15.3 [95% CI, -22.9 to -7.7]). Conclusions and Relevance In this randomized clinical trial, intrathoracic anastomosis resulted in better outcome for patients treated with transthoracic MIE for midesophageal to distal esophageal or gastroesophageal junction cancer. Trial Registration Trialregister.nl Identifier: NL4183 (NTR4333).
Collapse
Affiliation(s)
- Frans van Workum
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Moniek H P Verstegen
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Walther Jansen
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Ewout A Kouwenhoven
- Department of Surgery, Ziekenhuisgroep (Hospital Group) Twente, Almelo, the Netherlands
| | - Jan J B van Lanschot
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | |
Collapse
|
15
|
van der Heijden JAG, Qaderi SM, Verhoeven R, Custers JAE, Klarenbeek BR, Maaskant-Braat AJG, de Wilt JHW. Transanal total mesorectal excision and low anterior resection syndrome. Br J Surg 2021; 108:991-997. [PMID: 33837383 DOI: 10.1093/bjs/znab056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bowel dysfunction after rectal cancer surgery is common, with some experiencing low anterior resection syndrome (LARS) is common after rectal cancer surgery. This study examined if transanal total mesorectal excision (TaTME) has a similar risk of LARS and altered quality of life (QoL) as patients who undergo low anterior resection (LAR). METHODS Patients who underwent TaTME or traditionally approached total mesorectal excision in a prospective colorectal cancer cohort study (2014-2019) were propensity score matched in a 1 : 1 ratio. LARS and QoL scores were assessed before and after surgery with a primary endpoint of major LARS at 12 months analysed for possible association between factors by logistic regression. RESULTS Of 61 TaTME and 317 LAR patients eligible, 55 from each group were propensity score matched. Higher LARS scores (30.6 versus 25.4, P = 0.010) and more major LARS (65 versus 42 per cent, P = 0.013; OR 2.64, 95 per cent c.i. 1.22 to 5.71) were reported after TaTME. Additionally, QoL score differences (body image, bowel frequency, and embarrassment) were worse in the TaTME group. CONCLUSIONS TaTME may be associated with more severe bowel dysfunction than traditional approaches to rectal cancer.
Collapse
Affiliation(s)
- J A G van der Heijden
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - S M Qaderi
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - R Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.,Amsterdam UMC, Department of Medical Oncology, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - J A E Custers
- Department of Medical Psychology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B R Klarenbeek
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - A J G Maaskant-Braat
- Department of Surgical Oncology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - J H W de Wilt
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | | |
Collapse
|
16
|
van den Boorn HG, Abu-Hanna A, Haj Mohammad N, Hulshof MCCM, Gisbertz SS, Klarenbeek BR, Slingerland M, Beerepoot LV, Rozema T, Sprangers MAG, Verhoeven RHA, van Oijen MGH, Zwinderman KH, van Laarhoven HWM. SOURCE: Prediction Models for Overall Survival in Patients With Metastatic and Potentially Curable Esophageal and Gastric Cancer. J Natl Compr Canc Netw 2021; 19:403-410. [PMID: 33636694 DOI: 10.6004/jnccn.2020.7631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Personalized prediction of treatment outcomes can aid patients with cancer when deciding on treatment options. Existing prediction models for esophageal and gastric cancer, however, have mostly been developed for survival prediction after surgery (ie, when treatment has already been completed). Furthermore, prediction models for patients with metastatic cancer are scarce. The aim of this study was to develop prediction models of overall survival at diagnosis for patients with potentially curable and metastatic esophageal and gastric cancer (the SOURCE study). METHODS Data from 13,080 patients with esophageal or gastric cancer diagnosed in 2015 through 2018 were retrieved from the prospective Netherlands Cancer Registry. Four Cox proportional hazards regression models were created for patients with potentially curable and metastatic esophageal or gastric cancer. Predictors, including treatment type, were selected using the Akaike information criterion. The models were validated with temporal cross-validation on their C-index and calibration. RESULTS The validated model's C-index was 0.78 for potentially curable gastric cancer and 0.80 for potentially curable esophageal cancer. For the metastatic models, the c-indices were 0.72 and 0.73 for esophageal and gastric cancer, respectively. The 95% confidence interval of the calibration intercepts and slopes contain the values 0 and 1, respectively. CONCLUSIONS The SOURCE prediction models show fair to good c-indices and an overall good calibration. The models are the first in esophageal and gastric cancer to predict survival at diagnosis for a variety of treatments. Future research is needed to demonstrate their value for shared decision-making in clinical practice.
Collapse
Affiliation(s)
| | - Ameen Abu-Hanna
- 2Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Nadia Haj Mohammad
- 3Department of Medical Oncology, University Medical Center Utrecht, Utrecht
| | | | - Suzanne S Gisbertz
- 4Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam
| | | | - Marije Slingerland
- 6Department of Medical Oncology, Leiden University Medical Center, Leiden
| | | | - Tom Rozema
- 8Department of Radiotherapy, Verbeeten Institute, Tilburg
| | - Mirjam A G Sprangers
- 9Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Rob H A Verhoeven
- 5Department of Surgery, Radboud University Medical Center, Nijmegen.,10Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht; and
| | - Martijn G H van Oijen
- 1Department of Medical Oncology, Cancer Center Amsterdam, and.,10Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht; and
| | - Koos H Zwinderman
- 11Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | |
Collapse
|
17
|
Baranov NS, Slootmans C, van Workum F, Klarenbeek BR, Schoon Y, Rosman C. Outcomes of curative esophageal cancer surgery in elderly: A meta-analysis. World J Gastrointest Oncol 2021; 13:131-146. [PMID: 33643529 PMCID: PMC7896422 DOI: 10.4251/wjgo.v13.i2.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/29/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND An increasing number of older patients is undergoing curative, surgical treatment of esophageal cancer. Previous meta-analyses have shown that older patients suffered from more postoperative morbidity and mortality compared to younger patients, which may lead to patient selection based on age. However, only studies including patients that underwent open esophagectomy were included. Therefore, it remains unknown whether there is an association between age and outcome in patients undergoing minimally invasive esophagectomy.
AIM To perform a systematic review on age and postoperative outcome in esophageal cancer patients undergoing esophagectomy.
METHODS Studies comparing older with younger patients with primary esophageal cancer undergoing curative esophagectomy were included. Meta-analysis of studies using a 75-year age threshold are presented in the manuscript, studies using other age thresholds in the Supplementary material. MEDLINE, Embase and the Cochrane Library were searched for articles published between 1995 and 2020. Risk of bias was assessed with the Newcastle-Ottawa Scale. Primary outcomes were anastomotic leak, pulmonary and cardiac complications, delirium, 30- and 90-d, and in-hospital mortality. Secondary outcomes included pneumonia and 5-year overall survival.
RESULTS Seven studies (4847 patients) using an age threshold of 75 years were included for meta-analysis with 755 older and 4092 younger patients. Older patients (9.05%) had higher rates of 90-d mortality compared with younger patients (3.92%), (confidence interval = 1.10-5.56). In addition, older patients (9.45%) had higher rates of in-hospital mortality compared with younger patients (3.68%), (confidence interval = 1.01-5.91). In the subgroup of 2 studies with minimally invasive esophagectomy, older and younger patients had comparable 30-d, 90-d and in-hospital mortality rates.
CONCLUSION Older patients undergoing curative esophagectomy for esophageal cancer have a higher postoperative mortality risk. Minimally invasive esophagectomy may be important for minimizing mortality in older patients.
Collapse
Affiliation(s)
- Nikolaj S Baranov
- Department of Surgery, Radboud University Medical Center, Nijmegen 6525GA, the Netherlands
| | - Cettela Slootmans
- Department of Surgery, Radboud University Medical Center, Nijmegen 6525GA, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen 6525GA, the Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud University Medical Center, Nijmegen 6525GA, the Netherlands
| | - Yvonne Schoon
- Department of Geriatrics, Radboud University Medical Center, Nijmegen 6525GA, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen 6525GA, the Netherlands
| |
Collapse
|
18
|
Geerlings MJ, Hofste LSM, Kamping EJ, Abdi Z, Tolmeijer SH, Garms LM, Klarenbeek BR, Ligtenberg MJL. Effect of Pneumatic Tube System Transport on Cell-Free DNA. Clin Chem 2020; 67:434-435. [PMID: 33280007 DOI: 10.1093/clinchem/hvaa285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Maartje J Geerlings
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lisa S M Hofste
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eveline J Kamping
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Zumaya Abdi
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sofie H Tolmeijer
- Department of Medical Oncology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Linda M Garms
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marjolijn J L Ligtenberg
- Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Pathology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
19
|
de Gouw DJJM, Maas MC, Slagt C, Mühling J, Nakamoto A, Klarenbeek BR, Rosman C, Hermans JJ, Scheenen TWJ. Controlled mechanical ventilation to detect regional lymph node metastases in esophageal cancer using USPIO-enhanced MRI; comparison of image quality. Magn Reson Imaging 2020; 74:258-265. [PMID: 32976957 DOI: 10.1016/j.mri.2020.09.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/08/2020] [Accepted: 09/20/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Artifacts caused by respiratory motion or ventilation-induced chest movements are a major problem for thoracic MRI, as they can obscure important anatomical structures such as lymph node metastases. We compared image quality of routine breathhold with intermittent apnea during controlled mechanical ventilation of patients under general anesthesia as the ideal situation without respiratory motion in the detection and characterization of regional lymph nodes in esophageal cancer. METHODS In this prospective study, 10 patients treated for esophageal cancer underwent ultrasmall superparamagnetic iron oxide (USPIO) enhanced MRI scans. Before neoadjuvant therapy, MRI scans were acquired with a routine breathhold technique. After neoadjuvant therapy, patients were scanned under general anesthesia immediately prior to surgery with controlled mechanical ventilation. The image quality was compared using a Likert scale questionnaire based on visibility of anatomical structures and image artifacts. RESULTS MRI with controlled mechanical ventilation and prolonged controlled apnea of 4 min was safe and feasible. All cardio-respiratory monitoring parameters remained stable during the apnea phases. Mediastinal and upper abdominal lymph nodes down to 2 mm in size could be visualized with all sequences. All image quality criteria, including visibility of thoracic structures and regional lymph nodes were scored higher using the controlled ventilation sequences compared to the routine breathhold phase. CONCLUSION USPIO-enhanced MRI with controlled mechanical ventilation is superior to routine breathhold MRI in visualizing lymph nodes, which warrants new motion reduction techniques to use MRI for the detection of lymph node metastases in patients with esophageal cancer.
Collapse
Affiliation(s)
- D J J M de Gouw
- Radboud University Medical Center, Department of Surgery, Nijmegen, the Netherlands.
| | - M C Maas
- Radboud University Medical Center, Department of Medical Imaging, Nijmegen, the Netherlands.
| | - C Slagt
- Radboud University Medical Center, Department of Anesthesiology, Pain and Palliative Medicine, Nijmegen, the Netherlands.
| | - J Mühling
- Radboud University Medical Center, Department of Anesthesiology, Pain and Palliative Medicine, Nijmegen, the Netherlands.
| | - A Nakamoto
- Osaka University Graduate School of Medicine, Department of Radiology, Suita, Japan.
| | - B R Klarenbeek
- Radboud University Medical Center, Department of Surgery, Nijmegen, the Netherlands.
| | - C Rosman
- Radboud University Medical Center, Department of Surgery, Nijmegen, the Netherlands.
| | - J J Hermans
- Radboud University Medical Center, Department of Medical Imaging, Nijmegen, the Netherlands.
| | - T W J Scheenen
- Radboud University Medical Center, Department of Medical Imaging, Nijmegen, the Netherlands.
| |
Collapse
|
20
|
Scholte M, de Gouw DJJM, Klarenbeek BR, Grutters JPC, Rosman C, Rovers MM. Selecting esophageal cancer patients for lymphadenectomy after neoadjuvant chemoradiotherapy: a modeling study. BMJ Surg Interv Health Technol 2020; 2:e000027. [PMID: 35047787 PMCID: PMC8749286 DOI: 10.1136/bmjsit-2019-000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Two-thirds of patients do not harbor lymph node (LN) metastases after neoadjuvant chemoradiotherapy (nCRT). Our aim was to explore under which circumstances a selective lymph node dissection (LND) strategy, which selects patients for LND based on the restaging results after nCRT, has added value compared with standard LND in esophageal cancer. DESIGN A decision tree with state-transition model was developed. Input data on short-term and long-term consequences were derived from literature. Sensitivity analyses were conducted to assess promising scenarios and uncertainty. SETTING Dutch healthcare system. PARTICIPANTS Hypothetical cohort of esophageal cancer patients who have already received nCRT and are scheduled for esophagectomy. INTERVENTIONS A standard LND cohort was compared with a cohort of patients that received selective LND based on the restaging results after nCRT. MAIN OUTCOME MEASURES Quality-adjusted life years (QALYs), residual LN metastases and LND-related complications. RESULTS Selective LND could have short-term benefits, that is, a decrease in the number of performed LNDs and LND-related complications. However, this may not outweigh a slight increase in residual LN metastases which negatively impacts QALYs in the long-term. To accomplish equal QALYs as with standard LND, a new surgical strategy should have the same or higher treatment success rate as standard LND, that is, should show equal or less recurrences due to residual LN metastases. CONCLUSIONS The reduction in LND-related complications that is accomplished by selecting patients for LND based on restaging results after nCRT seems not to outweigh a QALY loss in the long-term due to residual LN metastases. Despite the short-term advantages of selective LND, this strategy can only match long-term QALYs of standard LND when its success rate equals the success rate of standard LND.
Collapse
Affiliation(s)
- Mirre Scholte
- Operating Rooms, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Didi JJM de Gouw
- Surgery, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Bastiaan R Klarenbeek
- Surgery, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Janneke PC Grutters
- Operating Rooms and Health Evidence, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Camiel Rosman
- Surgery, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Operating Rooms and Health Evidence, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands
| |
Collapse
|
21
|
van Workum F, Klarenbeek BR, Baranov N, Rovers MM, Rosman C. Totally minimally invasive esophagectomy versus hybrid minimally invasive esophagectomy: systematic review and meta-analysis. Dis Esophagus 2020; 33:5827029. [PMID: 32350519 PMCID: PMC7455468 DOI: 10.1093/dote/doaa021] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/27/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
Minimally invasive esophagectomy is increasingly performed for the treatment of esophageal cancer, but it is unclear whether hybrid minimally invasive esophagectomy (HMIE) or totally minimally invasive esophagectomy (TMIE) should be preferred. The objective of this study was to perform a meta-analysis of studies comparing HMIE with TMIE. A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Articles comparing HMIE and TMIE were included. The Newcastle-Ottawa scale was used for critical appraisal of methodological quality. The primary outcome was pneumonia. Sensitivity analysis was performed by analyzing outcome for open chest hybrid MIE versus total TMIE and open abdomen MIE versus TMIE separately. Therefore, subgroup analysis was performed for laparoscopy-assisted HMIE versus TMIE, thoracoscopy-assisted HMIE versus TMIE, Ivor Lewis HMIE versus Ivor Lewis TMIE, and McKeown HMIE versus McKeown TMIE. There were no randomized controlled trials. Twenty-nine studies with a total of 3732 patients were included. Studies had a low to moderate risk of bias. In the main analysis, the pooled incidence of pneumonia was 19.0% after HMIE and 9.8% after TMIE which was not significantly different between the groups (RR: 1.46, 95% CI: 0.97-2.20). TMIE was associated with a lower incidence of wound infections (RR: 1.81, 95% CI: 1.13-2.90) and less blood loss (SMD: 0.78, 95% CI: 0.34-1.22) but with longer operative time (SMD:-0.33, 95% CI: -0.59--0.08). In subgroup analysis, laparoscopy-assisted HMIE was associated with a higher lymph node count than TMIE, and Ivor Lewis HMIE was associated with a lower anastomotic leakage rate than Ivor Lewis TMIE. In general, TMIE was associated with moderately lower morbidity compared to HMIE, but randomized controlled evidence is lacking. The higher leakage rate and lower lymph node count that was found after TMIE in sensitivity analysis indicate that TMIE can also have disadvantages. The findings of this meta-analysis should be considered carefully by surgeons when moving from HMIE to TMIE.
Collapse
Affiliation(s)
- Frans van Workum
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands,Address correspondence to: Frans van Workum, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | | | - Nikolaj Baranov
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Health Evidence and Operating Rooms, Radboudumc, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| |
Collapse
|
22
|
de Gouw DJJM, Rijpkema M, de Bitter TJJ, Baart VM, Sier CFM, Hernot S, van Dam GM, Nagtegaal ID, Klarenbeek BR, Rosman C, van der Post RS. Identifying Biomarkers in Lymph Node Metastases of Esophageal Adenocarcinoma for Tumor-Targeted Imaging. Mol Diagn Ther 2020; 24:191-200. [PMID: 32048177 PMCID: PMC7113228 DOI: 10.1007/s40291-020-00448-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Tumor-targeted imaging is a promising technique for the detection of lymph node metastases (LNM) and primary tumors. It remains unclear which biomarker is the most suitable target to distinguish malignant from healthy tissue in esophageal adenocarcinoma (EAC). OBJECTIVE We performed an immunohistochemistry study to identify viable tumor markers for tumor-targeted imaging of EAC. METHODS We used samples from 72 patients with EAC to determine the immunohistochemical expression of ten potential tumor biomarkers for EAC (carbonic anhydrase IX [CA-IX], carcinoembryonic antigen [CEA], hepatic growth factor receptor, epidermal growth factor receptor, epithelial membrane antigen [EMA], epithelial cell adhesion molecule [EpCAM], human epidermal growth factor receptor 2 [HER-2], urokinase plasminogen activator receptor, vascular endothelial growth factor-A [VEGF-A], and VEGF receptor 2). Immunohistochemistry was performed on tissue microarrays of LNM (n = 48), primary EACs (n = 62), fibrotic tissues (n = 11), nonmalignant lymph nodes (n = 24), and normal esophageal and gastric tissues (n = 40). Tumor marker staining was scored on intensity and percentage of positive cells. RESULTS EMA and EpCAM showed strong expression in LNM (> 95%) and primary EACs (> 95%). Significant expression was also observed for LNM and EAC using VEGF-A (85 and 92%), CEA (68 and 54%), and CA-IX (4 and 34%). The other tumor biomarkers showed expression of 0-15% for LNM and primary EAC. Except for VEGF-A, nonmalignant lymph node staining was scored as slight or absent. CONCLUSIONS High expression rates and correlation between LNM in EAC combined with low expression rates in healthy lymph nodes and esophagus tissues were observed for EpCAM and CEA, meaning these are promising targets for tumor-targeted imaging approaches for lymph nodes in patients with EAC.
Collapse
Affiliation(s)
- D J J M de Gouw
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - M Rijpkema
- Department of Radiology and Nuclear Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - T J J de Bitter
- Department of Pathology, Radboud university medical center, Geert Grooteplein Zuid 30, 6525 GA, Nijmegen, The Netherlands
| | - V M Baart
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - C F M Sier
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - S Hernot
- Laboratory for In vivo Cellular and Molecular Imaging, Vrije Universiteit Brussel, Brussel, Belgium
| | - G M van Dam
- Department of Surgery and department of Nuclear Medicine and Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - I D Nagtegaal
- Department of Pathology, Radboud university medical center, Geert Grooteplein Zuid 30, 6525 GA, Nijmegen, The Netherlands
| | - B R Klarenbeek
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - C Rosman
- Department of Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - R S van der Post
- Department of Pathology, Radboud university medical center, Geert Grooteplein Zuid 30, 6525 GA, Nijmegen, The Netherlands.
| |
Collapse
|
23
|
de Gouw DJJM, Scholte M, Gisbertz SS, Wijnhoven BPL, Rovers MM, Klarenbeek BR, Rosman C. Extent and consequences of lymphadenectomy in oesophageal cancer surgery: case vignette survey. BMJ Surg Interv Health Technologies 2020; 2:e000026. [PMID: 35047786 PMCID: PMC8749290 DOI: 10.1136/bmjsit-2019-000026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 01/03/2023] Open
Abstract
Objectives Lymph node dissection (LND) is part of the standard operating procedure in patients with resectable oesophageal cancer after neoadjuvant chemoradiotherapy regardless of lymph node (LN) status. The aims of this case vignette survey were to acquire expert opinions on the current practice of LND and to determine potential consequences of non-invasive LN staging on the extent of LND and postoperative morbidity. Design An online survey including five short clinical cases (case vignettes) was sent to 272 oesophageal surgeons worldwide. Participants 86 oesophageal surgeons (median experience in oesophageal surgery of 15 years) participated in the survey (response rate 32%). Main outcome measures Extent of standard LND, potential changes in LND based on accurate LN staging and consequences for postoperative morbidity were evaluated. Results Standard LND varied considerably between experts; for example, pulmonary ligament, splenic artery, aortopulmonary window and paratracheal LNs are routinely dissected in less than 60%. The omission of (parts of) LND is expected to decrease the number of chyle leakages, pneumonias, and laryngeal nerve pareses and to reduce operating time. In order to guide surgical treatment decisions, a diagnostic test for LN staging after neoadjuvant therapy requires a minimum sensitivity of 92% and a specificity of 90%. Conclusions This expert case vignette survey study shows that there is no consensus on the extent of standard LND. Oesophageal surgeons seem more willing to extend LND rather than omit LND, based on accurate LN staging. The majority of surgeons expect that less extensive LND can reduce postoperative morbidity.
Collapse
Affiliation(s)
| | - Mirre Scholte
- Operating Rooms, Radboudumc, Nijmegen, The Netherlands
| | - Suzanne S Gisbertz
- Surgery, Amsterdam UMC - Locatie AMC, Amsterdam, North Holland, The Netherlands
| | | | - Maroeska M Rovers
- Operating Rooms and Health Evidence, Radboud Universiteit, Nijmegen, The Netherlands
| | | | | |
Collapse
|
24
|
van den Boorn HG, Abu-Hanna A, Haj Mohammad N, Hulshof MC, Gisbertz SS, Klarenbeek BR, Slingerland M, Beerepoot LV, Rozema T, Sprangers MA, Verhoeven RHA, Zwinderman AH, van Oijen MG, Van Laarhoven HW. SOURCE: Prediction models for overall survival in patients with metastatic and potentially curable esophageal and gastric cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
301 Background: Prediction models in cancer care can provide personalized prediction outcomes and can aid in shared decision making. Existing prediction models for esophageal and gastric cancer (EGC), however, are mostly aimed at predicting survival after a curative treatment has already been completed. The aim of this study is to develop prediction models, called SOURCE, to predict overall survival at diagnosis in potentially curable and metastatic EGC patients. Methods: The data from 12,756 EGC patients diagnosed between 2014-2017 were retrieved from the prospective Netherlands Cancer Registry. Four Cox regression models were created for potentially curable and metastatic cancers of the esophagus and stomach. Predictors, including treatment type, were selected using the Akaike Information Criterion. The models were validated with temporal cross-validation on their concordance-index (c-index) and calibration. Results: The validated model’s c-index is 0.76 for potentially curable cancer. For the metastatic models, the c-indices are 0.71 and 0.70 for esophageal and gastric cancer, respectively. The calibration intercepts and slopes lie in the 95% confidence interval of 0 and 1, respectively. The included model variables are given in Table. Conclusions: The SOURCE prediction models show fair c-indices and an overall good calibration. The models are the first in EGC to include treatment as a predictor. The models predict survival at diagnosis for a variety of treatments and therefore could have a high clinical applicability. Future research is needed to demonstrate the effect on shared decision making in clinical practice. [Table: see text]
Collapse
Affiliation(s)
| | | | - Nadia Haj Mohammad
- Utrecht UMC, Utrecht University, Department of Medical Oncology, Utrecht, Netherlands
| | - Maarten C.C.M. Hulshof
- Amsterdam UMC, University of Amsterdam, Department of Radiotherapy, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Suzanne S. Gisbertz
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, Netherlands
| | | | | | | | - Tom Rozema
- Verbeeten Institute, Department of Radiotherapy, Tilburg, Netherlands
| | - Mirjam A.G. Sprangers
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | | | - Aeilko H. Zwinderman
- Department of Clinical Epidemiologic Biostatics, Academic Medical Center, Amsterdam, Netherlands
| | - Martijn G.H. van Oijen
- Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Hanneke W.M. Van Laarhoven
- Amsterdam UMC, University of Amsterdam, Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
25
|
Rottier SJ, van Dijk ST, van Geloven AAW, Schreurs WH, Draaisma WA, van Enst WA, Puylaert JBCM, de Boer MGJ, Klarenbeek BR, Otte JA, Felt RJF, Boermeester MA. Meta-analysis of the role of colonoscopy after an episode of left-sided acute diverticulitis. Br J Surg 2020; 106:988-997. [PMID: 31260589 PMCID: PMC6618242 DOI: 10.1002/bjs.11191] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/12/2019] [Accepted: 03/05/2019] [Indexed: 02/06/2023]
Abstract
Background Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT‐proven acute diverticulitis. Methods PubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT‐proven left‐sided acute diverticulitis. The prevalence was pooled using a random‐effects model and, if possible, compared with that among asymptomatic controls. Results Seventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent. Conclusion Routine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.
Collapse
Affiliation(s)
- S J Rottier
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands.,Departments of Surgery, Amsterdam UMC, Amsterdam, the Netherlands.,Department of Surgery, Tergooi Hospital, Hilversum, the Netherlands
| | - S T van Dijk
- Departments of Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - W H Schreurs
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - W A Draaisma
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - W A van Enst
- Knowledge Institute of Medical Specialists, Utrecht, the Netherlands
| | | | - M G J de Boer
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, the Netherlands
| | - B R Klarenbeek
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J A Otte
- Department of Internal Medicine, ZorgSaam Hospital, Terneuzen, the Netherlands
| | - R J F Felt
- Departments of Gastroenterology, Amsterdam UMC, Amsterdam, the Netherlands
| | - M A Boermeester
- Departments of Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| |
Collapse
|
26
|
de Gouw DJJM, Klarenbeek BR, Driessen M, Bouwense SAW, van Workum F, Fütterer JJ, Rovers MM, Ten Broek RPG, Rosman C. Detecting Pathological Complete Response in Esophageal Cancer after Neoadjuvant Therapy Based on Imaging Techniques: A Diagnostic Systematic Review and Meta-Analysis. J Thorac Oncol 2019; 14:1156-1171. [PMID: 30999111 DOI: 10.1016/j.jtho.2019.04.004] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/14/2019] [Accepted: 03/17/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Up to 32% of patients with esophageal cancer show a pathological complete response (ypCR) after neoadjuvant therapy. To prevent overtreatment, the indication to perform esophagectomy in these patients should be reconsidered. Implementing an organ-preserving strategy for patients with ypCR requires an accurate assessment of residual disease after neoadjuvant treatment. The aim of this study was to systematically review the effectiveness of imaging techniques used for detection of ypCR after neoadjuvant therapy but before resection in patients with esophageal cancer. METHODS A systematic literature search of the Medline, Embase, and Cochrane Library databases was performed from January 1, 2000, to December 13, 2017. Eligible studies were diagnostic studies that compared results of imaging modalities after neoadjuvant therapy to histopathological findings in the resection specimen after esophagectomy. Methodological quality was assessed by the Cochrane Quality Assessment of Diagnostic Accuracy Studies, version 2, model. Primary outcome measures were true positive, false-positive, false-negative, and true negative values of imaging techniques predicting ypCR. A meta-analysis was performed by pooling sensitivities and specificities by using a bivariate model. RESULTS A total of 4420 articles were identified. After exclusion of irrelevant titles and abstracts, 360 articles were reviewed in full text. In total, four imaging modalities (computed tomography [CT], positron emission tomography [PET-CT], endoscopic ultrasound [EUS], and magnetic resonance imaging [MRI]) were used for restaging. The meta-analysis was conducted with data from 56 studies involving 3625 patients. The pooled sensitivities of CT, PET-CT, EUS, and MRI for detecting ypCR were 0.35, 0.62, 0.01 and 0.80, respectively, whereas the pooled specificities were 0.83, 0.73, 0.99, and 0.83, respectively. The positive predictive value in detecting ypCR was 0.47 for CT, 0.41 for PET-CT, not applicable for EUS, and 0.61 for MRI. CONCLUSION Current imaging modalities such as CT, PET-CT, and EUS seem to be insufficiently accurate to identify complete responders. More accurate diagnostic tests are needed to improve restaging accuracy for patients with esophageal cancer.
Collapse
Affiliation(s)
- Didi J J M de Gouw
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Mitchell Driessen
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jurgen J Fütterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Health Evidence and Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
27
|
van Workum F, Berkelmans GH, Klarenbeek BR, Nieuwenhuijzen GAP, Luyer MDP, Rosman C. McKeown or Ivor Lewis totally minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction: systematic review and meta-analysis. J Thorac Dis 2017; 9:S826-S833. [PMID: 28815080 DOI: 10.21037/jtd.2017.03.173] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) has consistently been associated with improved perioperative outcome and similar oncological safety compared to open esophagectomy. However, it is currently unclear what type of MIE is preferred for patients with resectable esophageal cancer. METHODS Literature was searched in Medline, Embase and the Cochrane library combining relevant search terms. Articles that included patients undergoing totally minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) and compared McKeown with Ivor Lewis procedures were included. Studies were excluded if they included >10% of patients undergoing a procedure other than MIE McKeown or MIE Ivor Lewis (i.e., transhiatal resections). The primary outcome parameter was anastomotic leakage. Secondary outcome parameters were: other complications, reinterventions, reoperations, hospital length of stay, ICU length of stay, postoperative mortality, operative time, blood loss, R0 resection rate, lymph nodes examined, quality of life and costs. RESULTS Five studies with a total of 1,681 patients undergoing TMIE were included. There were no studies comparing HMIE McKeown versus HMIE Ivor Lewis. There were no randomized controlled trials and all included studies were cohort studies with a moderate risk of bias. No meta-analysis could be performed for R0 resection rate, survival, quality of life and costs because there was insufficient data available for these parameters. The incidence of anastomotic leakage did not differ between the groups [relative risk (RR) =1.39, 95% confidence interval (CI) =0.90-10.38, P=0.14]. TMIE Ivor Lewis was associated with a lower incidence of recurrent laryngeal nerve (RLN) trauma (RR =6.70, 95% CI =3.09-14.55, P<0.001), a shorter hospital length of stay [standardized mean difference (SMD) =0.17, 95% CI =0.06-0.28, P=0.002] and less blood loss (SMD =0.69, 95% CI =0.25-1.12, P=0.002). CONCLUSIONS TMIE Ivor Lewis is associated with improved outcome regarding RLN trauma, hospital length of stay and blood loss as compared to TMIE-McKeown, but the incidence of anastomotic leakage is not different. The evidence is limited, of low quality and at risk for bias. A randomized controlled trial is currently being performed in order to demonstrate whether a McKeown or Ivor Lewis procedure should be preferred in patients undergoing MIE.
Collapse
Affiliation(s)
| | - Gijs H Berkelmans
- Department of surgery, Catharina hospital, Eindhoven, the Netherlands
| | | | | | - Misha D P Luyer
- Department of surgery, Catharina hospital, Eindhoven, the Netherlands
| | - Camiel Rosman
- Department of surgery, Radboudumc, Nijmegen, the Netherlands
| |
Collapse
|
28
|
van Workum F, Bouwense SAW, Luyer MDP, Nieuwenhuijzen GAP, van der Peet DL, Daams F, Kouwenhoven EA, van Det MJ, van den Wildenberg FJH, Polat F, Gisbertz SS, Henegouwen MIVB, Heisterkamp J, Langenhoff BS, Martijnse IS, Grutters JP, Klarenbeek BR, Rovers MM, Rosman C. Intrathoracic versus Cervical ANastomosis after minimally invasive esophagectomy for esophageal cancer: study protocol of the ICAN randomized controlled trial. Trials 2016; 17:505. [PMID: 27756419 PMCID: PMC5069944 DOI: 10.1186/s13063-016-1636-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
Background Currently, a cervical esophagogastric anastomosis (CEA) is often performed after minimally invasive esophagectomy (MIE). However, the CEA is associated with a considerable incidence of anastomotic leakage requiring reintervention or reoperation and moderate functional results. An intrathoracic esophagogastric anastomosis (IEA) might reduce the incidence of anastomotic leakage, improve functional results and reduce costs. The objective of the ICAN trial is to compare anastomotic leakage and postoperative morbidity, mortality, quality of life and cost-effectiveness between CEA and IEA after MIE. Methods/design The ICAN trial is an open randomized controlled multicentre superiority trial, comparing CEA (control group) with IEA (intervention group) after MIE. All patients with esophageal cancer planning to undergo curative MIE are considered for inclusion. A total of 200 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is anastomotic leakage requiring reintervention or reoperation, and secondary outcomes are (amongst others) other postoperative complications, new onset of organ failure, length of stay, mortality, benign strictures requiring dilatation, quality of life and cost-effectiveness. Discussion We hypothesize that an IEA after MIE is associated with a lower incidence of anastomotic leakage requiring reintervention or reoperation than a CEA. The trial is also designed to give answers to additional research questions regarding a possible difference in functional outcome, quality of life and cost-effectiveness. Trial registration Netherlands Trial Register: NTR4333. Registered on 23 December 2013.
Collapse
Affiliation(s)
- Frans van Workum
- Department of Surgery, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Stefan A W Bouwense
- Department of Surgery, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands
| | | | - Donald L van der Peet
- Department of Surgery, VU University Medical Centre, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, VU University Medical Centre, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Ewout A Kouwenhoven
- Department of Surgery, Ziekenhuisgroep Twente, PO Box 7600, 7600 SZ, Almelo, The Netherlands
| | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, PO Box 7600, 7600 SZ, Almelo, The Netherlands
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, PO Box 9015, 6500 GS, Nijmegen, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | | | - Joos Heisterkamp
- Department of Surgery, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Barbara S Langenhoff
- Department of Surgery, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Ingrid S Martijnse
- Department of Surgery, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Janneke P Grutters
- Department of Health Evidence, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | | | - Maroeska M Rovers
- Department of Health Evidence, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| |
Collapse
|
29
|
de Korte N, Klarenbeek BR, Kuyvenhoven JP, Roumen RMH, Cuesta MA, Stockmann HBAC. Management of diverticulitis: results of a survey among gastroenterologists and surgeons. Colorectal Dis 2011; 13:e411-7. [PMID: 21819518 DOI: 10.1111/j.1463-1318.2011.02744.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The study aimed to investigate current management strategies for left-sided diverticulitis and compare them with current international guidelines. Differences between surgeons and gastroenterologists and between gastrointestinal and nongastrointestinal surgeons were assessed. METHOD A web-based survey of treatment options for uncomplicated and complicated diverticulitis was carried out among surgeons and gastroenterologists in the Netherlands. Only surgeons were asked about surgical strategy. RESULTS A total of 292 surgeons and 87 gastroenterologists responded, representing 92% of all surgical and 46% of all gastroenterology departments. Ninety per cent of respondents treated mild diverticulitis without antibiotics. About one-fifth (18% gastroenterologists; 19% surgeons) regarded a CT scan as mandatory in the initial assessment. Most surgeons and gastroenterologists used some form of bowel rest, would consider outpatient treatment and would perform a colonoscopy on follow up. For Hinchey Stage 3, 78% of surgeons would consider resection and primary anastomosis and laparoscopic lavage was viewed as a valid alternative by 30% of gastrointestinal and 2% of nongastrointestinal surgeons. For Hinchey stage 4, 46% of gastrointestinal and 72% of nongastrointestinal surgeons would always perform Hartmann's procedure. CONCLUSION The treatment of diverticulitis in the Netherlands shows major differences when compared with guidelines for all stages of disease.
Collapse
Affiliation(s)
- N de Korte
- Department of Surgery, Kennemer Gasthuis, Haarlem, The Netherlands.
| | | | | | | | | | | |
Collapse
|
30
|
Klarenbeek BR, Coupé VMH, van der Peet DL, Cuesta MA. The cost effectiveness of elective laparoscopic sigmoid resection for symptomatic diverticular disease: financial outcome of the randomized control Sigma trial. Surg Endosc 2010; 25:776-83. [DOI: 10.1007/s00464-010-1252-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 07/08/2010] [Indexed: 12/27/2022]
|
31
|
Morks AN, Klarenbeek BR, Flikweert ER, Peet DLVD, Karsten TM, Eddes EH, Cuesta MA, Graaf PWD. Current surgical treatment of diverticular disease in The Netherlands. World J Gastroenterol 2010; 16:1742-6. [PMID: 20380006 PMCID: PMC2852822 DOI: 10.3748/wjg.v16.i14.1742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 01/17/2010] [Accepted: 01/24/2010] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the development of diagnostic tools, indications for surgery and treatment modalities concerning diverticular disease (DD) in The Netherlands. METHODS Data were collected from 100 patients who underwent surgery for DD in three Dutch hospitals. All hospitals used the same standardized database. The collected data included patient demographics, patient history, type of surgery and complications. Patients were divided into two groups, one undergoing elective surgery (elective group) and the other undergoing acute surgery (acute group). RESULTS Two hundred and ninety-nine patients were admitted between 2000 and 2007. One hundred and seventy-eight patients underwent acute surgery and 121 patients received elective operations. The median age of the 121 patients was 69 years (range: 28-94 years), significantly higher in acute patients (P = 0.010). Laparoscopic resection was performed in 31% of elective patients. In the acute setting, 61% underwent a Hartmann procedure. The overall morbidity and mortality were 51% and 10%, and 60% and 16% in the acute group, which were significantly higher than in the elective group (36% and 1%). Only 35% of the temporary ostomies were restored. CONCLUSION This study gives a picture of current surgical practice for DD in The Netherlands. New developments are implemented in daily practice, resulting in acceptable morbidity and mortality rates.
Collapse
|
32
|
Klarenbeek BR, Veenhof AAFA, de Lange ESM, Bemelman WA, Bergamaschi R, Heres P, Lacy AM, van den Broek WT, van der Peet DL, Cuesta MA. The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis. BMC Surg 2007; 7:16. [PMID: 17683563 PMCID: PMC1955435 DOI: 10.1186/1471-2482-7-16] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Accepted: 08/03/2007] [Indexed: 12/16/2022] Open
Abstract
Backround Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis. Method Indication for elective resection is one episode of diverticulitis in patients < 50 years and two episodes in patient > 50 years or in case of progressive abdominal complaints due to strictures caused by a previous episode of diverticulits. The diagnosis is confirmed by CT-scan, barium enema and/or coloscopy. It is required that the participating surgeons have performed at least 15 laparoscopic and open sigmoid resections. Open resection is performed by median laparotomy, laparoscopic resection is approached by 4 or 5 cannula. Sigmoid and colon which contain serosal changes or induration are removed and a tension free anastomosis is created. After completion of either surgical procedure an opaque dressing will be used, covering from 10 cm above the umbilicus to the pubic bone. Surgery details will be kept separate from the patient's notes. Primary endpoints are the postoperative morbidity and mortality. We divided morbidity in minor (e.g. wound infection), major (e.g. anastomotic leakage) and late (e.g. incisional hernias) complications, data will be collected during hospital stay and after six weeks and six months postoperative. Secondary endpoints are the operative and the postoperative recovery data. Operative data include duration of the operation, blood loss and conversion to laparotomy. Post operative recovery consists of return to normal diet, pain, analgesics, general health (SF-36 questionnaire) and duration of hospital stay. Discussion The Sigma-trial is a prospective, multi-center, double-blind, randomized study to define the role of laparoscopic sigmoid resection in patients with symptomatic diverticulitis.
Collapse
|
33
|
van der Velden J, Merkus D, Klarenbeek BR, James AT, Boontje NM, Dekkers DHW, Stienen GJM, Lamers JMJ, Duncker DJ. Alterations in myofilament function contribute to left ventricular dysfunction in pigs early after myocardial infarction. Circ Res 2004; 95:e85-95. [PMID: 15528471 DOI: 10.1161/01.res.0000149531.02904.09] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Myocardial infarction (MI) initiates cardiac remodeling, depresses pump function, and predisposes to heart failure. This study was designed to identify early alterations in Ca2+ handling and myofilament proteins, which may contribute to contractile dysfunction and reduced beta-adrenergic responsiveness in postinfarct remodeled myocardium. Protein composition and contractile function of skinned cardiomyocytes were studied in remote, noninfarcted left ventricular (LV) subendocardium from pigs 3 weeks after MI caused by permanent left circumflex artery (LCx) ligation and in sham-operated pigs. LCx ligation induced a 19% increase in LV weight, a 69% increase in LV end-diastolic area, and a decrease in ejection fraction from 54+/-5% to 35+/-4% (all P<0.05), whereas cardiac responsiveness to exercise-induced increases in circulating noradrenaline levels was blunted. Endogenous protein kinase A (PKA) was significantly reduced in remote myocardium of MI animals, and a negative correlation (R=0.62; P<0.05) was found between cAMP levels and LV weight-to-body weight ratio. Furthermore, SERCA2a expression was 23% lower after MI compared with sham. Maximal isometric force generated by isolated skinned myocytes was significantly lower after MI than in sham (15.4+/-1.5 versus 19.2+/-0.9 kN/m2; P<0.05), which might be attributable to a small degree of troponin I (TnI) degradation observed in remodeled postinfarct myocardium. An increase in Ca2+ sensitivity of force (pCa50) was observed after MI compared with sham (DeltapCa50=0.17), which was abolished by incubating myocytes with exogenous PKA, indicating that the increased Ca2+ sensitivity resulted from reduced TnI phosphorylation. In conclusion, remodeling of noninfarcted pig myocardium is associated with decreased SERCA2a and myofilament function, which may contribute to depressed LV function. The full text of this article is available online at http://circres.ahajournals.org.
Collapse
Affiliation(s)
- J van der Velden
- Laboratory for Physiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|