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van Geffen EGM, Langhout JMA, Hazen SJA, Sluckin TC, van Dieren S, Beets GL, Beets-Tan RGH, Borstlap WAA, Burger JWA, Horsthuis K, Intven MPW, Aalbers AGJ, Havenga K, Marinelli AWKS, Melenhorst J, Nederend J, Peulen HMU, Rutten HJT, Schreurs WH, Tuynman JB, Verhoef C, de Wilt JHW, Marijnen CAM, Tanis PJ, Kusters M, On Behalf Of The Dutch Snapshot Research Group. Evolution of clinical nature, treatment and survival of locally recurrent rectal cancer: Comparative analysis of two national cross-sectional cohorts. Eur J Cancer 2024; 202:114021. [PMID: 38520925 DOI: 10.1016/j.ejca.2024.114021] [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: 01/02/2024] [Revised: 03/04/2024] [Accepted: 03/10/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND In the Netherlands, use of neoadjuvant radiotherapy for rectal cancer declined after guideline revision in 2014. This decline is thought to affect the clinical nature and treatability of locally recurrent rectal cancer (LRRC). Therefore, this study compared two national cross-sectional cohorts before and after the guideline revision with the aim to determine the changes in treatment and survival of LRRC patients over time. METHODS Patients who underwent resection of primary rectal cancer in 2011 (n = 2094) and 2016 (n = 2855) from two nationwide cohorts with a 4-year follow up were included. Main outcomes included time to LRRC, synchronous metastases at time of LRRC diagnosis, intention of treatment and 2-year overall survival after LRRC. RESULTS Use of neoadjuvant (chemo)radiotherapy for the primary tumour decreased from 88.5% to 60.0% from 2011 to 2016. The 3-year LRRC rate was not significantly different with 5.1% in 2011 (n = 114, median time to LRRC 16 months) and 6.3% in 2016 (n = 202, median time to LRRC 16 months). Synchronous metastasis rate did not significantly differ (27.2% vs 33.7%, p = 0.257). Treatment intent of the LRRC shifted towards more curative treatment (30.4% vs. 47.0%, p = 0.009). In the curatively treated group, two-year overall survival after LRRC diagnoses increased from 47.5% to 78.7% (p = 0.013). CONCLUSION Primary rectal cancer patients in 2016 were treated less often with neoadjuvant (chemo)radiotherapy, while LRRC rates remained similar. Those who developed LRRC were more often candidate for curative intent treatment compared to the 2011 cohort, and survival after curative intent treatment also improved substantially.
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Affiliation(s)
- E G M van Geffen
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J M A Langhout
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - S J A Hazen
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - T C Sluckin
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - S van Dieren
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - G L Beets
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - R G H Beets-Tan
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - W A A Borstlap
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - K Horsthuis
- Department of Radiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - M P W Intven
- Department of Radiotherapy, Division Imaging and Oncology, University Medical Centre Utrecht, the Netherlands
| | - A G J Aalbers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - K Havenga
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - A W K S Marinelli
- Department of Surgery, Haaglanden Medisch Centrum, Den Haag, the Netherlands
| | - J Melenhorst
- GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands; Department of Surgery and Colorectal Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - W H Schreurs
- Department of Surgery, Nothwest Clinics, Alkmaar, the Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - M Kusters
- Treatment and Quality of Life and Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands.
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van der Valk MJM, van der Sande ME, Toebes RE, Breukink SO, Bröker MEE, Doornebosch PG, Maliko N, Neijenhuis PA, Marinelli AWKS, Peters FP, Peeters KCMJ, Beets GL, Marang-van de Mheen PJ, Hilling DE. Importance of patient reported and clinical outcomes for patients with locally advanced rectal cancer and their treating physicians. Do clinicians know what patients want? Eur J Surg Oncol 2020; 46:1634-1641. [PMID: 32336626 DOI: 10.1016/j.ejso.2020.04.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 10/31/2019] [Revised: 03/29/2020] [Accepted: 04/09/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Several factors are included in decision making for treatment of patients with locally advanced rectal cancer, including a trade-off between risks and gains of both clinical and functional outcomes. However, it is largely unknown which outcomes are most important to patients and whether this differs between patients and clinicians. METHODS Both clinicians and patients treated for locally advanced rectal cancer were invited to fill out an online questionnaire, including a choice-based conjoint experiment. Participants were presented 14 comparisons of two hypothetical case presentations, characterized by different treatments and outcomes of care (6 attributes) and were asked to select the case with the best outcome at that moment. Hierarchical Bayes Estimation was used to calculate the relative importance (RI) of each of the six attributes. RESULTS In total, 94 patients and 128 clinicians completed the questionnaire. For patients, avoiding surgery with permanent stoma was most important (RI 24.4, 95%CI 21.88-26.87) and a 2-year difference in disease-free survival was least important (RI 5.6, 95%CI 4.9-6.2). Clinicians assigned highest importance to avoiding severe and daily worries about cancer recurrence (RI 30.7, 95%CI 29.1-32.4), while this was ranked 4th by patients (RI 17.9, 95%CI 16.5-19.4, p < 0.001). CONCLUSION When confronted with different outcomes within one case description, patients find the duration of disease free survival the least important. In addition, considerable differences were found between the importance assigned by patients and clinicians to clinical and functional outcomes, most notably in avoiding surgery with permanent stoma and worries about recurrence.
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Affiliation(s)
- Maxime J M van der Valk
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands; Department of Surgery, Antoni van Leeuwenhoek-National Cancer Institute, Amsterdam, the Netherlands.
| | - Marit E van der Sande
- Department of Surgery, Antoni van Leeuwenhoek-National Cancer Institute, Amsterdam, the Netherlands
| | - Renee E Toebes
- Department of Surgery, Antoni van Leeuwenhoek-National Cancer Institute, Amsterdam, the Netherlands
| | - Stephanie O Breukink
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism, Maastricht, the Netherlands
| | - Mirelle E E Bröker
- Department of Surgery, IJsselland Hospital, Capelle a/d IJssel, the Netherlands
| | | | - Nansi Maliko
- Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands
| | | | | | - Femke P Peters
- Department of Radiotherapy, Antoni van Leeuwenhoek-National Cancer Institute, Amsterdam, the Netherlands; Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Antoni van Leeuwenhoek-National Cancer Institute, Amsterdam, the Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands; Department of Surgery, Antoni van Leeuwenhoek-National Cancer Institute, Amsterdam, the Netherlands
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3
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Simons JM, van Pelt MLMA, Marinelli AWKS, Straver ME, Zeillemaker AM, Pereira Arias-Bouda LM, van Nijnatten TJA, Koppert LB, Hunt KK, Smidt ML, Luiten EJT, van der Pol CC. Excision of both pretreatment marked positive nodes and sentinel nodes improves axillary staging after neoadjuvant systemic therapy in breast cancer. Br J Surg 2019; 106:1632-1639. [PMID: 31593294 PMCID: PMC6856822 DOI: 10.1002/bjs.11320] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 01/21/2019] [Revised: 03/10/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Marking the axilla with radioactive iodine seed and sentinel lymph node (SLN) biopsy have been proposed for axillary staging after neoadjuvant systemic therapy in clinically node-positive breast cancer. This study evaluated the identification rate and detection of residual disease with combined excision of pretreatment-positive marked lymph nodes (MLNs) together with SLNs. METHODS This was a multicentre retrospective analysis of patients with clinically node-positive breast cancer undergoing neoadjuvant systemic therapy and the combination procedure (with or without axillary lymph node dissection). The identification rate and detection of axillary residual disease were calculated for the combination procedure, and for MLNs and SLNs separately. RESULTS At least one MLN and/or SLN(s) were identified by the combination procedure in 138 of 139 patients (identification rate 99·3 per cent). The identification rate was 92·8 per cent for MLNs alone and 87·8 per cent for SLNs alone. In 88 of 139 patients (63·3 per cent) residual axillary disease was detected by the combination procedure. Residual disease was shown only in the MLN in 20 of 88 patients (23 per cent) and only in the SLN in ten of 88 (11 per cent), whereas both the MLN and SLN contained residual disease in the remainder (58 of 88, 66 per cent). CONCLUSION Excision of the pretreatment-positive MLN together with SLNs after neoadjuvant systemic therapy in patients with clinically node-positive disease resulted in a higher identification rate and improved detection of residual axillary disease.
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Affiliation(s)
- J M Simons
- Department of Surgical Oncology, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands.,Department of Surgical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M L M A van Pelt
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A W K S Marinelli
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - M E Straver
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A M Zeillemaker
- Department of Surgical Oncology, Alrijne Hospital, Leiderdorp, the Netherlands
| | - L M Pereira Arias-Bouda
- Department of Nuclear Medicine, Alrijne Hospital, Leiderdorp, the Netherlands.,Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - L B Koppert
- Department of Surgical Oncology, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - K K Hunt
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M L Smidt
- Department of Surgical Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - E J T Luiten
- Department of Surgical Oncology, Amphia Hospital, Breda, the Netherlands
| | - C C van der Pol
- Department of Surgical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Surgical Oncology, Alrijne Hospital, Leiderdorp, the Netherlands
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van der Voort van Zyp JRN, Ceha HM, Niehe V, Marinelli AWKS, Putter H, Marijnen CAM. Acute toxicity after a diverting stoma and spacer prior to chemoradiation in locally advanced rectal cancer. Radiother Oncol 2015; 116:107-11. [PMID: 26187017 DOI: 10.1016/j.radonc.2015.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 07/28/2014] [Accepted: 06/04/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Chemoradiotherapy (CRT) followed by surgery is the standard of care for locally advanced rectal cancer (LARC). For grade ⩾3 acute diarrhea there is a relationship between dose and irradiated small bowel volume. The aim of this study was to evaluate whether combined placement of a diverting stoma and sigmoid spacer (DSSS) led to reduced irradiated small bowel volume and less grade ⩾3 acute diarrhea in the treatment of LARC. MATERIALS/METHODS Between 2003 and 2010, 54 of 189 LARC patients treated with CRT in two institutions had a DSSS prior to CRT. Data on patient and treatment characteristics and outcomes were collected retrospectively. Delineation of small bowel was performed with planning CT-scans. CTCAE version 4.0 was used for acute toxicity. RESULTS Patients with a DSSS had significantly less small bowel volume irradiated up to doses of 20Gy. This difference was not observed for the higher dose levels. CRT induced grade ⩾3 acute diarrhea was not different between the two groups (8.3% vs. 12.8%; p=0.41). CONCLUSION DSSS is not clearly beneficial to reduce grade ⩾3 acute diarrhea, and it must be considered whether placement of a DSSS is justified for this purpose.
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Affiliation(s)
| | - Heleen M Ceha
- Department of Radiation Oncology, Radiotherapy Center West, The Hague, The Netherlands
| | - Valerie Niehe
- Department of Radiology, Medical Center Haaglanden, The Hague, The Netherlands
| | | | - Hein Putter
- Department of Biomedical Statistics, Leiden University Medical Center, The Netherlands
| | - Corrie A M Marijnen
- Department of Clinical Oncology, Leiden University Medical Center, The Netherlands.
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5
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Koper PCM, Marinelli AWKS, van den Berg HA, van Riet YEA, van der Sijp JRM, Struikmans H. [Breast-conserving surgery and radiotherapy as a one-day procedure]. Ned Tijdschr Geneeskd 2015; 159:A8195. [PMID: 25761290] [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] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A single dose of irradiation to the lumpectomy cavity alone after breast-conserving surgery in breast cancer patients has been available in the Netherlands since 2011. This new treatment modality is used in the Haaglanden Medical Centre in The Hague and in the Catharina Hospital in Eindhoven. The goal of intraoperative radiation therapy is to limit the patient burden caused by whole breast irradiation, while maintaining excellent local tumour control. The technique is used only in patients with a low probability of recurrent disease in the breast. Approximately 150 patients receive intraoperative radiation therapy each year In the Netherlands, an estimated 4,000 breast cancer patients were eligible in 2013 for this new treatment technique or another method of partial breast irradiation. In both hospitals the results are closely monitored. Only 15 of the first 200 patients experienced a side effect within a period of 3 months after intraoperative radiation therapy. These side effects were successfully treated either with antibiotics or with surgery.
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Gooiker GA, Veerbeek L, van der Geest LGM, Stijnen T, Dekker JWT, Nortier JWRH, Marinelli AWKS, Struikmans H, Wouters MWJM, Tollenaar RAEM. [The quality indicator 'tumour positive surgical margin following breast-conserving surgery' does not provide transparent insight into care]. Ned Tijdschr Geneeskd 2010; 154:A1142. [PMID: 20482902] [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] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To determine whether the quality indicator 'tumour positive surgical margin following breast-conserving surgery, consistently measured the quality of breast-cancer surgery independently of the different definitions used and differences in case mix, taking statistical random variation into account. DESIGN Descriptive study. METHODS Data was collected from 762 patients who underwent breast-conserving surgery for invasive or in situ carcinoma of the breast, in the period 1 July 2007 - 30 June 2008 in 1 of the 9 hospitals in the region of the Comprehensive Cancer Centre West in the Netherlands. We compared 3 definitions for 'tumour positive surgical margin': the one used by the Health Care Inspectorate, the one used by the organisation 'Zichtbare Zorg' ('transparent care') and the percentage of re-resection. For case mix correction we identified risk factors for tumour margin positivity with logistic regression. The results were presented in a funnel plot, using 95% confidence interval (CI) around the national standard of 20%. RESULTS Depending on the definition used, the tumour positive surgical margin rate of the total group varied from 11 to 21%. Individual hospital rates varied by up to 19%. In situ carcinoma was associated with higher tumour positive surgical margin rates. Results differed significantly between hospitals for all 3 definitions. However, the funnel plot showed that results for most hospitals fell within the 95% CI of the standard. Whether a hospital fell within the 95% CI of the standard depended upon on the definition used and case mix correction. CONCLUSION The lack of a single definition for the quality indicator 'tumour positive surgical margin following breast-conserving surgery' and the lack of case-mix correction undermine the validity of the indicator. Standardisation of definitions, uniform registration and the use of funnel plots can provide a more transparent insight into the quality of care.
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Affiliation(s)
- Gea A Gooiker
- Leids Universitair Medisch Centrum, Afd. Heelkunde, Leiden, The Netherlands
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Eshuis EJ, Bemelman WA, van Bodegraven AA, Sprangers MAG, Bossuyt PMM, van Milligen de Wit AWM, Crolla RMPH, Cahen DL, Oostenbrug LE, Sosef MN, Voorburg AMCJ, Davids PHP, van der Woude CJ, Lange J, Mallant RC, Boom MJ, Lieverse RJ, van der Zaag ES, Houben MHMG, Vecht J, Pierik REGJM, van Ditzhuijsen TJM, Prins HA, Marsman WA, Stockmann HB, Brink MA, Consten ECJ, van der Werf SDJ, Marinelli AWKS, Jansen JM, Gerhards MF, Bolwerk CJM, Stassen LPS, Spanier BWM, Bilgen EJS, van Berkel AM, Cense HA, van Heukelem HA, van de Laar A, Slot WB, Eijsbouts QA, van Ooteghem NAM, van Wagensveld B, van den Brande JMH, van Geloven AAW, Bruin KF, Maring JK, Oldenburg B, van Hillegersberg R, de Jong DJ, Bleichrodt R, van der Peet DL, Dekkers PEP, Goei TH, Stokkers PCF. Laparoscopic ileocolic resection versus infliximab treatment of distal ileitis in Crohn's disease: a randomized multicenter trial (LIR!C-trial). BMC Surg 2008; 8:15. [PMID: 18721465 PMCID: PMC2533646 DOI: 10.1186/1471-2482-8-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Accepted: 08/22/2008] [Indexed: 12/24/2022] Open
Abstract
Background With the availability of infliximab, nowadays recurrent Crohn's disease, defined as disease refractory to immunomodulatory agents that has been treated with steroids, is generally treated with infliximab. Infliximab is an effective but expensive treatment and once started it is unclear when therapy can be discontinued. Surgical resection has been the golden standard in recurrent Crohn's disease. Laparoscopic ileocolic resection proved to be safe and is characterized by a quick symptom reduction. The objective of this study is to compare infliximab treatment with laparoscopic ileocolic resection in patients with recurrent Crohn's disease of the distal ileum with respect to quality of life and costs. Methods/design The study is designed as a multicenter randomized clinical trial including patients with Crohn's disease located in the terminal ileum that require infliximab treatment following recent consensus statements on inflammatory bowel disease treatment: moderate to severe disease activity in patients that fail to respond to steroid therapy or immunomodulatory therapy. Patients will be randomized to receive either infliximab or undergo a laparoscopic ileocolic resection. Primary outcomes are quality of life and costs. Secondary outcomes are hospital stay, early and late morbidity, sick leave and surgical recurrence. In order to detect an effect size of 0.5 on the Inflammatory Bowel Disease Questionnaire at a 5% two sided significance level with a power of 80%, a sample size of 65 patients per treatment group can be calculated. An economic evaluation will be performed by assessing the marginal direct medical, non-medical and time costs and the costs per Quality Adjusted Life Year (QALY) will be calculated. For both treatment strategies a cost-utility ratio will be calculated. Patients will be included from December 2007. Discussion The LIR!C-trial is a randomized multicenter trial that will provide evidence whether infliximab treatment or surgery is the best treatment for recurrent distal ileitis in Crohn's disease. Trial registration Nederlands Trial Register NTR1150
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Affiliation(s)
- Emma J Eshuis
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Verhoef C, de Wilt JHW, Brunstein F, Marinelli AWKS, van Etten B, Vermaas M, Guetens G, de Boeck G, de Bruijn EA, Eggermont AMM. Isolated hypoxic hepatic perfusion with retrograde outflow in patients with irresectable liver metastases; a new simplified technique in isolated hepatic perfusion. Ann Surg Oncol 2008; 15:1367-74. [PMID: 18239976 PMCID: PMC2277449 DOI: 10.1245/s10434-007-9714-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [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: 06/27/2007] [Revised: 10/30/2007] [Accepted: 10/31/2007] [Indexed: 12/16/2022]
Abstract
Background Isolated hepatic perfusion with high-dose chemotherapy is a treatment option for patients with irresectable metastases confined to the liver. Prolonged local control and impact on survival have been claimed. Major drawbacks are magnitude and costs of the procedure. We developed an isolated hypoxic hepatic perfusion (IHHP) with retrograde outflow without the need for a heart-lung machine. Patients and Methods Twenty-four consecutive patients with irresectable metastases of various origins were treated. IHHP inflow was via the hepatic artery, outflow via the portal vein with occlusion of the retrohepatic caval vein. Radiolabeled albumine was used for leakage monitoring. Melphalan was used at 1–2 mg/kg. A 25-minute perfusion period was followed by a complete washout. Local and systemic melphalan concentrations were determined. Results Compared with oxygenated classical IHP, the IHPP procedure reduced operation time from >8 h to 4 hours, blood loss from >4000 to 900 cc and saved material and personnel costs. Leakage was 0% with negligible systemic toxicity and 0% perioperative mortality. Tumor response: complete response (CR) in 4%, partial response (PR) in 58%, and stable disease (SD) in 13%. Median time to progression was 9 months (2–24 months); pharmacokinetics demonstrated intrahepatic melphalan concentrations more than 9 fold higher than postperfusion systemic concentrations. Conclusions IHPP is a relatively simple procedure with reduced costs, reduced blood loss, no mortality, limited toxicity, and response rates comparable to classic IHP. The median duration of 9 months of tumor control should be improved. Hereto, vasoactive drugs, will be explored in further studies.
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Affiliation(s)
- Cornelis Verhoef
- Department of Surgical Oncology, Erasmus University Medical Centre-Daniel den Hoed Cancer Centre, PO Box 5201, 3008 AE, Rotterdam, The Netherlands.
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9
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Vermaas M, Ferenschild FTJ, Verhoef C, Nuyttens JJME, Marinelli AWKS, Wiggers T, Kirkels WJ, Eggermont AMM, de Wilt JHW. Total pelvic exenteration for primary locally advanced and locally recurrent rectal cancer. Eur J Surg Oncol 2006; 33:452-8. [PMID: 17071043 DOI: 10.1016/j.ejso.2006.09.021] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Accepted: 09/21/2006] [Indexed: 12/24/2022] Open
Abstract
AIMS To report the role of total pelvic exenteration in a series of locally advanced and recurrent rectal cancers. METHODS In the period 1994-2004, TPE was performed in 35 of 296 patients with primary locally advanced and recurrent rectal cancer treated in the Daniel den Hoed Cancer Center; 23 of 176 with primary locally advanced and 12 of 120 with recurrent rectal cancer. All but one patient received pre-operative External Beam Radiation Therapy (EBRT). After 1997, Intra Operative Radiotherapy (IORT) was performed in case of a resection margin less than 2 mm. RESULTS Overall major complication rates were not significantly different between patients with primary and recurrent rectal cancer (26% vs. 50%, p=0.94). The hospital mortality rate was 3%. The 5-year local control and overall survival of patients with primary locally advanced rectal cancer were 88% and 52%, respectively. In patients with recurrent rectal cancer 3-year local control and survival rates were 60% and 32%, respectively. An incomplete resection, preoperative pain and advanced Wanebo stage for recurrent cancer were negative prognostic factors for both local control and overall survival. CONCLUSION TPE in primary locally advanced rectal cancer enables good local control and acceptable overall survival, thereby justifying the use of the procedure. Patients with recurrent rectal cancer showed a high rate of major complications, a high distant metastasis rate, and a poor overall survival.
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Affiliation(s)
- M Vermaas
- Department of Surgical Oncology, Erasmus MC--Daniel den Hoed Cancer Center, P.O. Box 5201, 3008 AE Rotterdam, The Netherlands
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Ferenschild FTJ, Vermaas M, Nuyttens JJME, Graveland WJ, Marinelli AWKS, van der Sijp JR, Wiggers T, Verhoef C, Eggermont AMM, de Wilt JHW. Value of intraoperative radiotherapy in locally advanced rectal cancer. Dis Colon Rectum 2006; 49:1257-65. [PMID: 16912909 DOI: 10.1007/s10350-006-0651-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [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] [Indexed: 12/20/2022]
Abstract
PURPOSE This study was designed to analyze the results of a multimodality treatment using preoperative radiotherapy, followed by surgery and intraoperative radiotherapy in patients with primary locally advanced rectal cancer. METHODS Between 1987 and 2002, 123 patients with initial unresectable and locally advanced rectal cancer were identified in our prospective database, containing patient characteristics, radiotherapy plans, operation notes, histopathologic reports, and follow-up details. An evaluation of prognostic factors for local recurrence, distant metastases, and overall survival was performed. RESULTS All patients were treated preoperatively with a median dose of 50 Gy radiotherapy. Surgery was performed six to ten weeks after radiotherapy. Twenty-seven patients were treated with intraoperative radiotherapy because margins were incomplete or </=2 mm. Postoperative mortality was 2 percent. The median follow-up of all patients was 25.1 months. The overall five-year local control was 65 percent and the overall five-year survival was 50 percent. Positive lymph nodes and incomplete resections negatively influenced local control and overall survival. Intraoperative radiotherapy improved five-year local control (58 vs. 0 percent, P = 0.016) and overall survival (38 vs. 0 percent, P = 0.026) for patients with R1/2 resections. CONCLUSIONS The presented multimodality treatment is feasible with an acceptable mortality and a five-year overall survival of 50 percent. Addition of intraoperative radiotherapy for patients with a narrow or microscopic incomplete resection seems to overrule the unfavorable prognostic histologic finding.
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Affiliation(s)
- Floris T J Ferenschild
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, 3008 AE Rotterdam, The Netherlands
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Vermaas M, Ferenschild FTJ, Nuyttens JJME, Marinelli AWKS, Wiggers T, van der Sijp JRMM, Verhoef C, Graveland WJ, Eggermont AMM, de Wilt JHW. Preoperative radiotherapy improves outcome in recurrent rectal cancer. Dis Colon Rectum 2005; 48:918-28. [PMID: 15785886 DOI: 10.1007/s10350-004-0891-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [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: 02/08/2023]
Abstract
PURPOSE When local recurrent rectal cancer is diagnosed without signs of metastases, a potentially curative resection can be performed. This study was designed to compare the results of preoperative radiotherapy followed by surgery with surgery only. METHODS Between 1985 and 2003, 117 patients with recurrent rectal cancer were prospectively entered in our database. Ninety-two patients were suitable for resection with curative intent. Preoperative radiation with a median dosage of 50 Gy was performed in 59 patients; 33 patients did not receive preoperative radiotherapy. The median age of the patients was respectively 66 and 62 years. RESULTS The median follow-up of patients alive for the total group was 16 (range, 4-156) months. Tumor characteristics were comparable between the two groups. Complete resections were performed in 64 percent of the patients who received preoperative radiation and 45 percent of the nonirradiated patients. A complete response after radiotherapy was found in 10 percent of the preoperative irradiated patients (n = 6). There were no differences in morbidity and reintervention rate between the two groups. Local control after preoperative radiotherapy was statistically significantly higher after three and five years (P = 0.036). Overall survival and metastases-free survival were not different in both groups. Complete response to preoperative radiotherapy was predictive for an improved survival. CONCLUSIONS Preoperative radiotherapy for recurrent rectal cancer results in a higher number of complete resections and an improved local control compared with patients treated without radiotherapy. Preoperative radiotherapy should be standard treatment for patients with recurrent rectal cancer.
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Affiliation(s)
- Maarten Vermaas
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, 3008 Rotterdam, The Netherlands
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van Veen RLP, Sterenborg HJCM, Marinelli AWKS, Menke-Pluymers M. Intraoperatively assessed optical properties of malignant and healthy breast tissue used to determine the optimum wavelength of contrast for optical mammography. J Biomed Opt 2004; 9:1129-36. [PMID: 15568932 DOI: 10.1117/1.1803547] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
We use spatially resolved diffuse remittance spectroscopy (DRS) for the measurement of absorption (mu(a)) and reduced scattering (mu(s)') coefficients of normal and malignant breast tissue in vivo during surgery. Prior to these measurements, the linearity of the measurement technique was evaluated on liquid optical phantoms. In addition, the reproducibility of in-vivo tissue measurements was determined on a healthy volunteer. We present results of the in-vivo measurement of optical properties in the wavelength range from 600 to 1100 nm performed during radical mastectomy. A total of 24 patients were included in the study. Both the absorption and reduced scattering properties show large variations. Significant differences in optical properties between normal (glandular plus lipid rich tissue) and tumor tissues are present in 74% of all patients. However, in some cases the tumor showed lower values than normal tissue, and in other cases this was the other way around. Thus, a general trend in optical properties is not observed. However, the average absorption contrast of all patients as a function of wavelength reveals an optimal contrast peak at 650 nm. We believe that this relates to a difference in vascular saturation between tumor and adjacent normal tissue.
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Affiliation(s)
- R L P van Veen
- Erasmus Medical Center, Daniel den Hoed Cancer Center, Department of Radiation Oncology, Photodynamic Therapy and Optical Spectroscopy Programme, P.O. Box 2040, 3008 CA, Rotterdam, The Netherlands
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van Etten B, Brunstein F, van IJken MGA, Marinelli AWKS, Verhoef C, van der Sijp JRM, Guetens G, de Boeck G, de Bruijn EA, de Wilt JHW, Eggermont AMM. Isolated hypoxic hepatic perfusion with orthograde or retrograde flow in patients with irresectable liver metastases using percutaneous balloon catheter techniques: a phase I and II study. Ann Surg Oncol 2004; 11:598-605. [PMID: 15172933 DOI: 10.1245/aso.2004.09.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated hepatic perfusion for irresectable metastases confined to the liver has reported response rates of 50% to 75%. Magnitude, costs, and nonrepeatability of the procedure are its major drawbacks. We developed a less invasive, less costly, and potentially repeatable balloon catheter-mediated isolated hypoxic hepatic perfusion (IHHP) technique. METHODS In this phase I and II study, 18 consecutive patients with irresectable colorectal or ocular melanoma hepatic metastases were included. Two different perfusion methods were used, both with inflow via the hepatic artery, using melphalan 1 mg/kg. In the first eight patients, the portal vein was occluded, and outflow was via the hepatic veins into an intracaval double-balloon catheter. This orthograde IHHP had on average 56% leakage. In next 10 patients, we performed a retrograde outflow IHHP with a triple balloon blocking outflow into the caval vein and allowing outflow via the portal vein. The retrograde IHHP still had 35% leakage on average. RESULTS Although local drug concentrations were high with retrograde IHHP, systemic toxicity was still moderate to severe. Partial responses were seen in 12% and stable disease in 81% of patients. The median time to local progression was 4.8 months. CONCLUSIONS We have abandoned occlusion balloon methodology for IHHP because it failed to obtain leakage control. We are presently conducting a study using a simplified surgical retrograde IHHP method, in which leakage is fully controlled, which translates into high response rates.
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Affiliation(s)
- Boudewijn van Etten
- Department of Surgical Oncology, Erasmus University Medical Center-Daniel den Hoed Cancer Center, PO Box 5201, 3008 AE Rotterdam, The Netherlands
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Abstract
After the diagnosis of a locally recurrent rectal cancer, imaging is the first step to estimate the extent and location of the local tumour growth and the presence or absence of distant metastases. The aim of the treatment is a R0 resection (microscopically tumour free circumferential margin) by multimodality treatment consisting of pre-operative radiation, extended resection and intra-operative radiotherapy by either electron beam irradiation or with high dose rate brachytherapy. Filling the pelvic cavity with vital tissue such as an omentoplasty should considered carefully. With this treatment the overall three-year survival rate of a group of 33 patients was 60% with a local control rate of 73%. The combination of chemotherapy as a radiosensitizer resulted in an increase of R0 resections by 20%. Introduction of TME surgery and pre-operative radiotherapy has created a new situation with limited possibilities due to dose-accumulation toxicity of the radiotherapy and extensive scarring of the tissues making estimation of the extent of the tumour growth more difficult. The prevention of local recurrence by proper selection of primary cases, the training of experienced surgeons and the optimal use of pre-operative radiotherapy is the way forward to improve results.
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Affiliation(s)
- T Wiggers
- Department of Surgical Oncology, Groningen University Hospital, PO Box 30.001, 9700 RB Groningen, the Netherlands.
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de Vries MR, ten Hagen TLM, Marinelli AWKS, Eggermont AMM. Tumor necrosis factor and isolated hepatic perfusion: from preclinical tumor models to clinical studies. Anticancer Res 2003; 23:1811-23. [PMID: 12820463] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Affiliation(s)
- Mark R de Vries
- Department of Surgical Oncology, Erasmus Medical Center-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands. devries(a)-hlkd.azr.ni
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