Category Archives: Ann Surg Oncol

Factors Associated with Short-Term Mortality After Surgical Oncologic Emergencies.

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Factors Associated with Short-Term Mortality After Surgical Oncologic Emergencies.

Ann Surg Oncol. 2015 Nov 9;

Authors: Bosscher MR, Bastiaannet E, van Leeuwen BL, Hoekstra HJ

Abstract
BACKGROUND: The clinical outcome of patients with oncologic emergencies is often poor and mortality is high. It is important to determine which patients may benefit from invasive treatment, and for whom conservative treatment and/or palliative care would be appropriate. In this study, prognostic factors for clinical outcome are identified in order to facilitate the decision-making process for patients with surgical oncologic emergencies.
METHODS: This was a prospective registration study for patients over 18 years of age, who were consulted for surgical oncologic emergencies between November 2013 and April 2014. Multiple variables were registered upon emergency consultation, and the follow-up period was 90 days. Multivariate logistic regression analysis was performed to identify factors associated with 30- and 90-day mortality.
RESULTS: During the study period, 207 patients experienced surgical oncologic emergencies-101 (48.8 %) men and 106 (51.2 %) women, with a median age of 64 years (range 19-92). The 30-day mortality was 12.6 % and 90-day mortality was 21.7 %. Factors significantly associated with 30-day mortality were palliative intent of cancer treatment prior to emergency consultation (p = 0.006), Eastern Cooperative Oncology Group performance score (ECOG-PS) >0 (p for trend: p = 0.03), and raised lactate dehydrogenase (LDH) (p < 0.001). Additional factors associated with 90-day mortality were low handgrip strength (HGS) (p = 0.01) and low albumin (p = 0.002).
CONCLUSIONS: Defining the intent of prior cancer treatment and the ECOG-PS are of prognostic value when deciding on treatment for patients with surgical oncologic emergencies. Additional measurements of HGS, LDH, and albumin levels can serve as objective parameters to support the clinical assessment of individual prognosis.

PMID: 26553441 [PubMed – as supplied by publisher]

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Outcomes of Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma in the Netherlands: A Nationwide Retrospective Analysis.

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Outcomes of Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma in the Netherlands: A Nationwide Retrospective Analysis.

Ann Surg Oncol. 2015 Oct…

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Prognostic Value of the Circumferential Resection Margin in Esophageal Cancer Patients After Neoadjuvant Chemoradiotherapy.

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Prognostic Value of the Circumferential Resection Margin in Esophageal Cancer Patients After Neoadjuvant Chemoradiotherapy.

Ann Surg Oncol. 2015 Aug 28;

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Lymph Node Micrometastases are Associated with Worse Survival in Patients with Otherwise Node-Negative Hilar Cholangiocarcinoma.

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Lymph Node Micrometastases are Associated with Worse Survival in Patients with Otherwise Node-Negative Hilar Cholangiocarcinoma.

Ann Surg Oncol. 2015 Jul 16;

Authors: Mantel HT, Wiggers JK, Verheij J, Doff JJ, Sieders E, van Gulik TM, Gouw AS, Porte RJ

Abstract
BACKGROUND: Lymph node metastases on routine histology are a strong negative predictor for survival after resection of hilar cholangiocarcinoma. Additional immunohistochemistry can detect lymph node micrometastases in patients who are otherwise node negative, but the prognostic value is unsure. The objective of this study was to assess the effect on survival of immunohistochemically detected lymph node micrometastases in patients with node-negative (pN0) hilar cholangiocarcinoma on routine histology.
METHODS: Between 1990 and 2010, a total of 146 patients underwent curative-intent resection of hilar cholangiocarcinoma with regional lymphadenectomy at two university medical centers in the Netherlands. Ninety-one patients (62 %) without lymph node metastases at routine histology were included. Micrometastases were identified by multiple sectioning of all lymph nodes and additional immunostaining with an antibody against cytokeratin 19 (K19). The association with overall survival was assessed in univariable and multivariable analysis. Median follow-up was 48 months.
RESULTS: Micrometastases were identified in 16 (5 %) of 324 lymph nodes, corresponding to 11 (12 %) of 91 patients. There were no differences in clinical variables between K19 lymph node-positive and -negative patients. Five-year survival rates in patients with lymph node micrometastases were significantly lower compared to patients without micrometastases (27 vs. 54 %, P = 0.01). Multivariable analysis confirmed micrometastases as an independent prognostic factor for survival (adjusted Hazard ratio 2.4, P = 0.02).
CONCLUSIONS: Lymph node micrometastases are associated with worse survival after resection of hilar cholangiocarcinoma. Immunohistochemical detection of lymph node micrometastases leads to better staging of patients who were initially diagnosed with node-negative (pN0) hilar cholangiocarcinoma on routine histology.

PMID: 26178761 [PubMed – as supplied by publisher]

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Tumor Mitotic Rate Added to the Equation: Melanoma Prognostic Factors Changed? : A Single-Institution Database Study on the Prognostic Value of Tumor Mitotic Rate for Sentinel Lymph Node Status and Survival of Cutaneous Melanoma Patients.

Tumor Mitotic Rate Added to the Equation: Melanoma Prognostic Factors Changed? : A Single-Institution Database Study on the Prognostic Value of Tumor Mitotic Rate for Sentinel Lymph Node Status and Survival of Cutaneous Melanoma Patients.

Ann Surg Oncol. 2015 Jan 21;

Authors: Speijers MJ, Bastiaannet E, Sloot S, Suurmeijer AJ, Hoekstra HJ

Abstract
BACKGROUND: This study aimed to investigate the predictive value of the tumor mitotic rate per mm(2) (TMR) for sentinel lymph node (SLN) status and survival in intermediate and thick cutaneous melanoma.
METHODS: Patients treated for stage I and II melanoma with wide local excision and SLN biopsy between May 1995 and May 2013 were analyzed. In case of insufficient data regarding TMR, pathology slides were reanalyzed. Prognostic factors for SLN status and survival were analyzed with the emphasis on TMR, which was analyzed as a continuous variable, dichotomized (median value) and categorized by two methods.
RESULTS: The study analyzed 453 patients with complete TMR data. The median Breslow thickness was 2.20 mm, and 31.8 % of patients had tumor-positive sentinel lymph node biopsies (SLNBs). In the univariate analysis, TMR was associated with tumor-positive SLNB. This association was not significant in the multivariate analysis. Breslow thickness, primary tumor location on trunk and legs, and younger age were associated with tumor-positive SNLB. At a median follow-up of 47 months, 119 patients (26.3 %) had recurrent disease, and 92 (20.3 %) had died of melanoma. In the univariate analysis, TMR could be established as a significant prognostic factor for disease-free and disease-specific survival, but not in the multivariate analyses. Breslow thickness, ulcerated melanoma, and tumor-positive SLNB were significant prognostic factors for survival.
CONCLUSION: The study was unable to establish TMR as an independent prognostic factor associated with the presence of SLN metastasis. Regarding survival, increasing TMR showed a strong association with decreased survival in the univariate analysis, but this association was rendered nonsignificant by the importance of Breslow thickness and ulceration status in the multivariate model.

PMID: 25605514 [PubMed – as supplied by publisher]

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Mortality in Emergency Surgical Oncology.

Mortality in Emergency Surgical Oncology.

Ann Surg Oncol. 2014 Oct 25;

Authors: Bosscher MR, van Leeuwen BL, Hoekstra HJ

Abstract
PURPOSE: Cancer patients can experience problems related to their disease or treatment. This study evaluated reasons for presentation at the emergency room (ER) and outcome of surgical oncology patients.
METHODS: A retrospective chart review for all surgical oncology patients who presented at the ER of the UMCG for surgical consultation between October 1, 2012, and March 31, 2013.
RESULTS: A total of 200 cancer patients visited the ER for surgical consultation: 53.5 % with complications of (previous) cancer treatment, 25.5 % with symptoms caused by malignant disease, and 21.0 % with symptoms not related to cancer or cancer treatment. The 30-day mortality rate for patients with progressive disease was 25.5 %, and overall mortality rate was 62.8 %. The most frequent reason for ER presentation was intestinal obstruction (26.5 %), of which 41.5 % was malignant. Most cancer patients (59.5 %) did not undergo surgery during follow-up. The 30-day mortality for these patients was 14.3 % and overall mortality was 37.8 %. Most patients who died within the first 30 days after ER presentation had not undergone any surgery after presentation (89.5 %).
CONCLUSIONS: There is great variation in mortality rates for cancer patients presenting at the ER for surgical consultation. The mortality in this study was greatest for patients with progressive disease (30-day mortality 25.5 % and overall mortality 62.8 %), and the majority of patients who died within 30 days (89.5 %) had not undergone surgery after ER presentation. Surgery should only be performed in the acute setting when essential and when the expected outcome is favorable for the patient.

PMID: 25344307 [PubMed – as supplied by publisher]

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Fewer Cancer Reoperations for Medullary Thyroid Cancer After Initial Surgery According to ATA Guidelines.

Fewer Cancer Reoperations for Medullary Thyroid Cancer After Initial Surgery According to ATA Guidelines.

Ann Surg Oncol. 2014 Oct 15;

Authors: Verbeek HH, Meijer JA, Zandee WT, Kramp KH, Sluiter WJ, Smit JW, Kievit J, Links TP, Plukker JT

Abstract
BACKGROUND: Surgery is still the only curative treatment for medullary thyroid cancer (MTC). We evaluated clinical outcome in patients with locoregional MTC with regard to adequacy of treatment following ATA guidelines and number of sessions to first intended curative surgery in different hospitals.
METHODS: We reviewed all records of MTC patients (n = 184) treated between 1980 and 2010 in two tertiary referral centers in the Netherlands. Symptomatic MTC (palpable tumor or suspicious lymphadenopathy) patients without distant metastasis were included (n = 86). Patients were compared with regard to adequacy of surgery according to ATA recommendations, tumor characteristics, number of local cancer reoperations, biochemical cure, clinical disease-free survival (DFS), overall survival (OS), and complications.
RESULTS: Adherence to ATA guidelines resulted in fewer cancer-related reoperations (0.24 vs. 0.60; P = 0.027) and more biochemical cure (40.9 vs. 20 %; P = 0.038). Surgery according to ATA-guidelines on patients treated in referral centers was significantly more often adequate (59.2 vs. 26.7 %; P = 0.026). Tumor size and LN+ were the most important predictors for clinical recurrence [relative risk (RR) 4.1 (size > 40 mm) 4.1 (LN+) and death (RR 4.2 (size > 40 mm) 8.1 (LN+)].
CONCLUSIONS: ATA-compliant surgery resulted in fewer local reoperations and more biochemical cure. Patients in referral centers more often underwent adequate surgery according to ATA-guidelines. Size and LN+ were the most important predictors for DFS and OS.

PMID: 25316487 [PubMed – as supplied by publisher]

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Consequence of Restaging After Neoadjuvant Treatment for Locally Advanced Rectal Cancer.

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Consequence of Restaging After Neoadjuvant Treatment for Locally Advanced Rectal Cancer.

Ann Surg Oncol. 2014 Aug 26;

Authors: Bisschop C,…

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Deep Lymph Node Metastases in the Groin Significantly Affects Prognosis, Particularly in Sentinel Node-Positive Melanoma Patients.

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Deep Lymph Node Metastases in the Groin Significantly Affects Prognosis, Particularly in Sentinel Node-Positive Melanoma Patients.

Ann Surg Oncol. 2014 Jul 10;

Authors: Niebling MG, Wevers KP, Suurmeijer AJ, van Ginkel RJ, Hoekstra HJ

Abstract
BACKGROUND: In order to define patients eligible for only a superficial groin dissection or a combined superficial and deep groin dissection, this study aimed to determine the incidence of deep lymph node metastases (LNM) in patients with melanoma metastasized to the groin, to identify patient and melanoma factors that predict deep nodal involvement, and to analyze the impact of deep nodal involvement on survival and recurrence.
METHODS: Patients who underwent a combined superficial (inguinal) and deep (iliac and obturator) complete (CLND) or therapeutic lymph node dissection (TLND) of the groin between 1994 and 2012 were analyzed.
RESULTS: QueryDeep LNM were found in 8 of 62 CLND patients (13 %) and in 21 of 67 TLND patients (31 %). More than three superficial LNM was the only independent predictor for deep LNM in both CLND and TLND patients. The 5-year melanoma-specific survival (MSS) for CLND and TLND patients with deep LNM was 14.3 and 16.6 %, respectively, and was significantly worse (hazard ratio [HR] 3.39, 95 % CI 1.34-8.58, p = 0.010; and HR 2.01, 95 % CI 1.04-3.88, p = 0.039) compared with CLND and TLND patients without deep LNM (5-year MSS: 54.1 and 37.2 %, respectively). Distant recurrence was significantly associated with deep LNM in CLND patients (p = 0.032).
CONCLUSIONS: The present study showed that LNM in the deep area of the groin are fairly common in both CLND and TLND patients and significantly affect prognosis, especially in CLND patients. The number of superficial LNM is the only factor that was found to predict a finding of deep nodal metastases.

PMID: 25008028 [PubMed – as supplied by publisher]

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Prognostic Impact of Clinicopathological Features and Expression of Biomarkers Related to (18)F-FDG Uptake in Esophageal Cancer.

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Prognostic Impact of Clinicopathological Features and Expression of Biomarkers Related to (18)F-FDG Uptake in Esophageal Cancer.

Ann Surg Oncol. 2014 Jun…

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Different recurrence pattern after neoadjuvant chemoradiotherapy compared to surgery alone in esophageal cancer patients.

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Different recurrence pattern after neoadjuvant chemoradiotherapy compared to surgery alone in esophageal cancer patients.

Ann Surg Oncol. 2013 Nov;20(12):4008-15

Authors: Smit JK, Güler S, Beukema JC, Mul VE, Burgerhof JG, Hospers GA, Plukker JT

Abstract
PURPOSE: To evaluate the rate and pattern of recurrences after neoadjuvant chemoradiotherapy (CRT) in esophageal cancer patients.
METHODS: We described survival and differences in recurrences from a single center between neoadjuvant CRT (carboplatin/paclitaxel and 41.4 Gy) and surgery alone for the period 2000-2011. To reduce bias, we performed a propensity score matched analysis.
RESULTS: A total of 204 patients were analyzed, 75 treated with neoadjuvant CRT and 129 with surgery alone. The pathologic response to neoadjuvant CRT was 69% with a complete response rate of 25%. After matching, baseline characteristics between the groups (both n = 75) were equally distributed. The 3- and 5-year disease-free survival was 53 and 42% in the neoadjuvant CRT group compared with 24 and 18% in the surgery-alone group (P = 0.011). After 3 and 5 years’ CRT, patients had an estimated locoregional recurrence-free survival of 83 and 73% compared with 52 and 49% in the surgery-alone group (P = 0.015). The distant recurrence-free survival was comparable in both groups. Locoregional recurrences were located less in the paraesophageal lymph nodes in the CRT group than in the surgery-alone group, 9 versus 21%, respectively (P = 0.041). With respect to differences in distant recurrences, we observed more skeletal recurrences in the surgery-alone group compared to CRT, 12 versus 1% (P = 0.009).
CONCLUSIONS: The neoadjuvant CRT regimen we used offers a significant improvement in outcome, with a different recurrence pattern compared with surgery alone. This effect is probably due to both the pathologic complete response and eradication of micrometastases in CRT group.

PMID: 23838922 [PubMed – indexed for MEDLINE]

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Loss of CD44 and SOX2 Expression is Correlated with a Poor Prognosis in Esophageal Adenocarcinoma Patients.

Loss of CD44 and SOX2 Expression is Correlated with a Poor Prognosis in Esophageal Adenocarcinoma Patients.

Ann Surg Oncol. 2014 May 16;

Authors: Honing J, Pavlov KV, Meijer C, Smit JK, Boersma-van Ek W, Karrenbeld A, Burgerhof JG, Kruyt FA, Plukker JT

Abstract
BACKGROUND: It has been suggested that markers associated with cancer stem cells (CSC) may play a role in esophageal cancer. Our aim was to investigate the expression pattern of proposed CSC markers ALDH1, Axin2, BMI1, CD44, and SOX2 in esophageal adenocarcinoma (EAC) and to relate their expression to survival.
METHODS: In this study we included 94 EAC patients and examined the expression of the above-mentioned markers by using immunohistochemistry on tissue microarrays. Expression was scored as positive or negative or categorized as low or high in terms of an immunoreactivity score (IRS). Expression rates were related to clinicopathologic characteristics and overall and disease-free survival (DFS).
RESULTS: In a multivariate analysis, negative expression of CD44 and of SOX2 were both significant prognostic factors for DFS [hazard ratio (HR), 1.73; 95 % confidence interval (CI), 1.00-2.96; P = 0.046 and HR, 2.06; 95 % CI 1.14-3.70 P = 0.016). When CD44 and SOX2 expression were analyzed together, negative SOX2 expression was an independent prognostic factor for DFS (HR, 1.91; 95 % CI 1.05-3.46; P = 0.034). Low IRS scores for ALDH1 or Axin2 were associated with a reduced median survival (12.8 vs. 28.7 and 12.1 vs. 25.5 months, respectively). However, these markers and BMI1 were not prognostic factors for survival.
CONCLUSIONS: Loss of CD44 expression and loss of SOX2 expression are prognostic factors of poor survival in EAC patients. This suggests a role of these proteins in EAC that requires further investigation.

PMID: 24833101 [PubMed – as supplied by publisher]

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Factors Influencing the Use of Sentinel Lymph Node Biopsy in the Netherlands.

Factors Influencing the Use of Sentinel Lymph Node Biopsy in the Netherlands.

Ann Surg Oncol. 2014 May 12;

Authors: Huismans AM, Niebling MG, Wevers KP, Schuurman MS, Hoekstra HJ

Abstract
BACKGROUND: In the US, whether a sentinel lymph node biopsy (SLNB) is performed depends on tumor and patient factors, including socioeconomic status (SES) and type of health care insurance. We analyzed which patient and tumor characteristics influenced the use of SLNB in a country where every patient has equal access to healthcare.
METHODS: Patients diagnosed with a cutaneous invasive melanoma of ≥1 mm between 2004 and 2011 and living in the northeastern part of the Netherlands were selected from the Netherlands Cancer Registry. Regression analysis was performed to assess the association of patient and tumor characteristics and SLNB use.
RESULTS: SLNB was performed in 42 % of the 2,413 included patients. The frequency of performing SLNB increased between 2004 and 2011 from 24 to 55 % (p < 0.001). Patients were less likely to undergo SLNB if they had a melanoma located in the head and neck area (p < 0.001), when they were over 55 years (p = 0.001), and if they had a low SES (p = 0.03). SLNB use was more likely when the diagnosis of melanoma was made in the university hospital (p = 0.045) or when the Breslow thickness was 2.01-4.0 mm (p = 0.03).
CONCLUSIONS: The use of SLNB has increased significantly between 2004 and 2011. However, in 2011 it was still performed in only 55 % of the Dutch patients with a melanoma ≥1 mm. In patients with head and neck melanoma, older patients, and patients with low SES, SLNB was less frequently performed. Patients with T3 melanomas and a diagnosis made in the university hospital more often had an SLNB performed.

PMID: 24819123 [PubMed – as supplied by publisher]

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Comparison of Two Preoperative Inspiratory Muscle Training Programs to Prevent Pulmonary Complications in Patients Undergoing Esophagectomy: A Randomized Controlled Pilot Study.

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Comparison of Two Preoperative Inspiratory Muscle Training Programs to Prevent Pulmonary Complications in Patients Undergoing Esophagectomy: A Randomized Controlled Pilot Study.

Ann Surg Oncol. 2014 Mar 7;

Authors: van Adrichem EJ, Meulenbroek RL, Plukker JT, Groen H, van Weert E

Abstract
BACKGROUND: Postoperative pulmonary complications (PPCs) are the most commonly reported complications after esophagectomy. The aim of this study was to examine the effect and feasibility of preoperative inspiratory muscle training-high intensity (IMT-HI), and IMT-endurance (IMT-E) on the incidence of PPCs in patients following esophagectomy for esophageal cancer (EC).
METHOD: A single-blind, randomized, clinical pilot study was conducted between 2009 and 2012. Forty-five participants were assigned to either IMT-HI or IMT-E. Effectiveness was assessed by analyzing PPCs, length of hospital stay (LOS), duration of mechanical ventilation, stay on the intensive care unit, and number of reintubations. Maximal inspiratory pressure and lung function changes were recorded pre- and post-training. Feasibility was assessed by IMT-related adverse events, training compliance, and patients’ satisfaction.
RESULTS: Thirty-nine patients could be analyzed, 20 patients in the IMT-HI arm and 19 patients in the IMT-E arm. The incidence of PPCs differed significantly between groups and was almost three times lower for the IMT-HI group (4 vs. 11 patients; p = 0.015). Other differences in favor of the IMT-HI group were LOS (13.5 vs. 18 days; p = 0.010) and number of reintubations (0 vs. 4 patients; p = 0.030). Both interventions proved to be equally feasible.
CONCLUSION: Preoperative IMT-HI showed to be a promising, effective, and feasible intervention to reduce PPCs in EC patients undergoing esophagectomy. Further research with a larger sample size is recommended.

PMID: 24604584 [PubMed – as supplied by publisher]

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Comparison of Two Preoperative Inspiratory Muscle Training Programs to Prevent Pulmonary Complications in Patients Undergoing Esophagectomy: A Randomized Controlled Pilot Study.

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Comparison of Two Preoperative Inspiratory Muscle Training Programs to Prevent Pulmonary Complications in Patients Undergoing Esophagectomy: A Randomized Controlled Pilot…

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Outcome of clinical stage III melanoma patients with FDG-PET and whole-body CT added to the diagnostic workup.

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Outcome of clinical stage III melanoma patients with FDG-PET and whole-body CT added to the diagnostic workup.
Ann Surg Oncol. 2013 Sep;20(9):3098-105
Authors: Niebling MG, Bastiaannet E, Hoekstra OS, Bonenkam… Continue reading

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mTHPC-mediated photodynamic therapy of early stage oral squamous cell carcinoma: a comparison to surgical treatment.

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mTHPC-mediated photodynamic therapy of early stage oral squamous cell carcinoma: a comparison to surgical treatment.
Ann Surg Oncol. 2013 Sep;20(9):3076-82
Authors: de Visscher SA, Melchers LJ, Dijkstra PU, Ka… Continue reading

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Residual Breast Tissue after Mastectomy: How Often and Where Is It Located?

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Residual Breast Tissue after Mastectomy: How Often and Where Is It Located?

Ann Surg Oncol. 2013 Dec 24;

Authors: Griepsma M, de Roy van Zuidewijn DB,…

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Survival after definitive (chemo)radiotherapy in esophageal cancer patients: a population-based study in the north-East Netherlands.

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Survival after definitive (chemo)radiotherapy in esophageal cancer patients: a population-based study in the north-East Netherlands.

Ann Surg Oncol. 2013…

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S-100B: a stronger prognostic biomarker than LDH in stage IIIB-C melanoma.

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S-100B: a stronger prognostic biomarker than LDH in stage IIIB-C melanoma.

Ann Surg Oncol. 2013 Aug;20(8):2772-9

Authors: Wevers KP, Kruijff S, Speijers MJ, Bastiaannet E, Muller Kobold AC, Hoekstra HJ

Abstract
BACKGROUND: In melanoma patients with nodal macrometastases, the distinction between good and poor prognosis is based on the presence of primary melanoma ulceration or metastatic involvement of 4 or more lymph nodes in the 7th edition of the American Joint Committee on Cancer (AJCC) classification. We hypothesized that biomarkers would increase the accurateness of staging in these patients. The aim was to assess and compare the prognostic impact of biomarkers S-100B and LDH and to determine the best timing of their measurement in stage IIIB-C melanoma.
METHODS: A total of 119 patients underwent therapeutic lymph node dissection (TLND) for nodal macrometastases with serum S-100B and LDH level measurements preoperatively. In 75 of them, S-100B and LDH were also measured on postoperative days 1 and 2. S-100B and LDH levels on days 0, 1, and 2 were compared for their association with disease-free survival (DFS) and disease-specific survival (DSS).
RESULTS: At a median follow-up of 17 (range 1-89) months, S-100B levels at all time points were associated with DFS. In multivariable analysis, preoperative S-100B and S-100B measured on day 2 showed the strongest association with DFS (hazard ratio [HR] 2.55, P = 0.007 and HR 3.80, P = 0.01). For DSS, the preoperative S-100B level was the strongest independent predictor (HR 2.81, P = 0.01). LDH measurements showed a significant association with DSS in univariate analysis only when measured preoperatively (HR 2.46, P = 0.01). In multivariable analysis, LDH measurement was not associated with melanoma prognosis.
CONCLUSIONS: The S-100B level measured preoperatively is, in contrast to LDH, one of the most important independent predictors of melanoma prognosis in patients undergoing TLND for nodal macrometastases.

PMID: 23512078 [PubMed – indexed for MEDLINE]

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