A nationwide assessment of hepatocellular adenoma resection:Indications and pathological discordance

Hepatocellular adenomas (HCAs) are benign liver tumors associated with bleeding or malignant transformation. Data on the indication for surgery are scarce. We analyzed indications and outcome of patients operated for HCAs 50 mm (52%), suspicion of (pre)malignancy (28%), and (previous) bleeding (5.1%). No difference was observed in HCA-subtype distribution between small and large tumors. Ninety-six (43%) patients had a postoperative change in diagnosis. Independent risk factors for change in diagnosis were tumor size <50 mm (adjusted odds ratio [aOR], 3.4; p < 0.01), male sex (aOR, 3.7; p = 0.03), and lack of hepatobiliary contrast-enhanced magnetic resonance imaging (CE-MRI) (aOR, 1.8; p = 0.04). Resection for small (suspected) HCAs was mainly indicated by suspicion of (pre)malignancy, whereas for large (suspected) HCAs, tumor size was the most prevalent indication. Male sex, tumor size <50 mm, and lack of hepatobiliary CE-MRI were independent risk factors for postoperative change in tumor diagnosis

Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study

Background Delirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. Successful strategies or therapies to reduce the incidence of delirium are scarce. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients. Methods A single-center uncontrolled before-and-after study was conducted, including patients aged 70 years or older who underwent elective abdominal surgery for colorectal carcinoma or an abdominal aortic aneurysm between January 2013 and

Volume–outcome relationship of liver surgery: a nationwide analysis

Background: Evidence for an association between hospital volume and outcomes for liver surgery is abundant. The current Dutch guideline requires a minimum volume of 20 annual procedures per centre. The aim of this study was to investigate the association between hospital volume and postoperative outcomes using data from the nationwide Dutch Hepato Biliary Audit. Methods: This was a nationwide study in the Netherlands. All liver resections reported in the Dutch Hepato Biliary Audit between 2014 and 2017 were included. Annual centre volume was calculated and classified in categories of 20 procedures per year. Main outcomes were major morbidity (Clavien–Dindo grade IIIA or higher) and 30-day or in-hospital mortality. Results: A total of 5590 liver resections were done across 34 centres with a median annual centre volume of 35 (i.q.r. 20–69) procedures. Overall major morbidity and mortality rates were 11·2 and 2·0 per cent respectively. The mortality rate was 1·9 per cent after resection for colorectal liver metastases (CRLMs), 1·2 per cent for non-CRLMs, 0·4 per cent for benign tumours, 4·9 per cent for hepatocellular carcinoma and 10·3 per cent for biliary tumours. Higher-volume centres performed more major liver resections, and more resections for hepatocellular carcinoma and biliary cancer. There was no association between hospital volume and either major morbidity or mortality in multivariable analysis, after adjustment for known risk factors for adverse events. Conclusion: Hospital volume and postoperative outcomes were not associated

A multicomponent prehabilitation pathway to reduce the incidence of delirium in elderly patients in need of major abdominal surgery

__Background:__ Due to the increase in elderly patients who undergo major abdominal surgery there is a subsequent increase in postoperative complications, prolonged hospital stays, health-care costs and mortality rates. Delirium is

Clinical added value of MRI to CT in patients scheduled for local therapy of colorectal liver metastases (CAMINO): study protocol for an international multicentre prospective diagnostic accuracy study

Background: Abdominal computed tomography (CT) is the standard imaging method for patients with suspected colorectal liver metastases (CRLM) in the diagnostic workup for surgery or thermal ablation. Diffusion-weighted and gadoxetic-acid-enhanced magnetic resonance imaging (MRI) of the liver is increasingly used to improve the detection rate and characterization of liver lesions. MRI is superior in detection and characterization of CRLM as compared to CT. However, it is unknown how MRI actually impacts patient management. The primary aim of the CAMINO study is to evaluate whether MRI has sufficient clinical added value to be routinely added to CT in the staging of CRLM. The secondary objective is to identify subgroups who benefit the most from additional MRI.Methods: In this international multicentre prospective incremental diagnostic accuracy study, 298 patients with primary or recurrent CRLM scheduled for curative liver resection or thermal ablation based on CT staging will be enrolled from 17 centres across the Netherlands, Belgium, Norway, and Italy. All study participants will undergo CT and diffusion-weighted and gadoxetic-acid enhanced MRI prior to local therapy. The local multidisciplinary team will provide two local therapy plans: first, based on CT-staging and second, based on both CT and MRI. The primary outcome measure is the proportion of clinically significant CRLM (CS-CRLM) detected by MRI not visible on CT. CS-CRLM are defined as liver lesions leading to a change in local therapeutical management. If MRI detects new CRLM in segments which would have been resected in the original operative plan, these are not considered CS-CRLM. It is hypothesized that MRI will lead to the detection of CS-CRLM in >= 10% of patients which is considered the minimal clinically important difference. Furthermore, a prediction model will be developed using multivariable logistic regression modelling to evaluate the predictive value of patient, tumor and procedural variables on finding CS-CRLM on MRI.Discussion: The CAMINO study will clarify the clinical added value of MRI to CT in patients with CRLM scheduled for local therapy. This study will provide the evidence required for the implementation of additional MRI in the routine work-up of patients with primary and recurrent CRLM for local therapy.Imaging- and therapeutic targets in neoplastic and musculoskeletal inflammatory diseas

Sentinel lymph node biopsy in breast cancer : procedural issuses and prognostic impact of detecting micrometastases

The introduction of the sentinel lymph node biopsy (SLNB) in breast cancer patients raised several procedure-related clinical questions as well as questions regarding the implications of the obtained staging information. As a minimally invasive operative procedure as well as an enhanced pathological staging procedure SLNB has become standard of care in breast cancer patients. Part of the SLNB is the injection of a radiofarmacon during lymphoscintigraphy. Different injection techniques translate into different drainage patterns. Ultrasound (US) guided radiofarmacon injection provides a uniform procedure for both palpable and nonpalpable tumors with similar results for lymphoscintigraphic visualization and surgical retrieval rate of axillary and internal mammary sentinel lymph nodes (SLNs). When SLNs contain metastase(s), a supplementary axillary lymph node dissection (ALND) is advised. Intraoperative frozen section (FS) analysis of SLNs enables a prompt ALND during the first operation, sparing the patient a second operation. The yield of FS is limited, and discordant FS results (i.e. the absence of SLN metastases in the FS and the presence of metastases following the definitive pathology examination of SLNs) still necessitates a complementary ALND. While discordant FS results were in itself relatively common, the complementary ALND rarely results in postsurgical treatment adjustments. ALND is performed to obtain locoregional control as well as for staging purposesbut comes with significant morbidity. To reduce this ALND-related morbidity, there is a recent interest in the different lymphatic drainage patterns of the breast and arm within the axilla. The different lymphatic patterns may be visualized by doing “ARM”: axillary reverse mapping. ARM is a way of reducing morbidity by selectively removing lymph nodes from the axilla and sparing axillary nodes and lymphatic’s that drain the arm. In a feasibility study we observed the absence of metastases in the ARM lymph nodes in patients who had metastases in their SLNs, while the frequency of ARM-node involvement was 22% in patients who had axillary metastases proven by preoperative US guided cytology. The sensitivity of the SLNB procedure to detect axillary metastases is not 100%. False negative rates are reported in approximately 3% of the patients, implying that the latter proportion of patients will have metastases in the axilla despite a “clean” SLN. Expectedly, patients with a false-negative SLN may develop overt lymph node metastases during follow-up but the extent of the clinical problem is unknown. In a multi-institutional cohort analyses we learned that axillary relapse rates in N0 patients are low. The annual relapse rate was approximately 0.2%. In addition, axillary relapses were significantly more common in patients who underwent ablative surgery, most likely due to the radiotherapy in patients undergoing breast conserving therapy. There is a lively debate regarding the relevance of minimal SLN involvement. In a single and multi-institutional cohort, in terms of overall and disease free survival, we observed no significant differences between N0 and N1mi, while survival in N1 patients was significantly worse. Based on these results we conclude that the presence of lymph node micrometastases should in itself not be a reason to advocate adjuvant systemic treatmen

Two decades of axillary management in breast cancer

Background: Axillary lymph node dissection (ALND) in patients with breast cancer provides prognostic information. For many years, positive nodes were the most important indication for adjuvant systemic therapy. It was also believed that regional control could not be achieved without axillary clearance in a positive axilla. However, during the past 20 years the treatment and staging of the axilla has undergone many changes. This large population-based study was conducted in the south-east of the Netherlands to evaluate the changing patterns of care regarding the axilla, including the introduction of sentinel lymph node biopsy (SLNB) in the late 1990s, implementation of the results of the American College of Surgeons Oncology Group Z0011 study, and the initial effects of the European Organization for Research and Treatment of Cancer AMAROS study. Methods: Data from the population-based Eindhoven Cancer Registry of all women diagnosed with invasive breast cancer in the south of the Netherlands between January 1993 and July 2014 were used. Results: The proportion of 34 037 women staged by SLNB without completion ALND increased from 0 per cent in 1993-1994 to 69.0 per cent in 2013-2014. In the same period the proportion undergoing ALND decreased from 88.8 to 18.7 per cent. Among women with one to three positive lymph nodes, the proportion undergoing SLNB alone increased from 10.6 per cent in 2011-2012 to 37.6 per cent in 2013-2014. Conclusion: This population-based study demonstrated the radical transformation in management of the axilla since the introduction of SLNB and following the recent publication of trials on management of the axilla with a low metastatic burden