Outcome in patients with critical limb ischemia in the ESES-trial : spinal cord stimulation versus optimal medical treatment

There has been a long history of interest in the effects of spinal cord stimulation (SCS) for critical limb ischemia (CLI), especially if meaningful revascularisation is not possible. In a randomized trial (ESES-trial), we compared two treatment regimens (best medical treatment and best medical treatment plus SCS). We did not find that spinal-cord stimulation was of benefit above that of best medical treatment. Amputation-free survival was not improved (p=0.86). The rates of amputation were similar in both groups (p=0.47) and were particularly high during the first 3 months.Quality of life showed poor scores compared with matched reference values of the general population, but there were no significant differences between the randomized treatment group during treatment. Although patients with a spinal-cord stimulator used significantly less pain medication (suggesting substantial pain relief from this treatment), similar pain reduction was seen in the medical and SCS-treatment groups. Over two years, the costs of SCS-treatment were higher as compared to best medical treatment alone (€36,600 vs. €28,700, p=0.009)

A prognostic model for amputation in critical lower limb ischemia

In a (negative) multicenter randomized trial on management for inoperable critical lower limb ischemia, comparing spinal cord stimulation and best medical treatment, a number of pre-defined factors were analyzed for prognostic value. We included a radiological arterial disease score, modified from the SVS/ISCVS runoff score. The purpose of this analysis was to evaluate clinical factors and commonly used circulatory measurements for prognostic modeling in patients with critical lower limb ischemia. We determined the incidence of amputation and its relation to various pre-defined risk factors. A total of 120 patients with critical limb ischemia were included in the study. The integrity of circulation in the affected limb was evaluated on five levels: suprainguinal, infrainguinal, popliteal, infrapopliteal and pedal. A total radiological arterial disease score was calculated from 1 (full integrity of circulation) to 20 (maximally compromised state). We used Cox regression analysis to quantify prognostic effects and differential treatment (predictive) effects. Major amputation occurred in 33% of the patients at 6 months and in 51% at 2 years. The presence of ischemic skin lesions and the radiological arterial disease score were independent prognostic factors for amputation. Patients with ulcerations or gangrene had a higher amputation risk (hazard ratio 2.38, p = 0.018 and 2.30, p = 0.036 respectively) as well as patients with a higher radiological arterial disease score (hazard ratio 1.17 per increment, p = 0.003). We did not observe significant interactions between prognostic factors and the effect of spinal cord stimulation. In conclusion, in patients with critical lower limb ischemia, the presence of ischemic skin lesions and the described radiological arterial disease score can be used to estimate amputation risk

COUNTERPOINT: Is N2 Disease a Contraindication for Surgical Resection for Superior Sulcus Tumors? No

Contains fulltext : 151991.pdf (publisher's version ) (Closed access

Rebuttal From Dr Li et al

Contains fulltext : 152649.pdf (publisher's version ) (Closed access

Patient selection for cardiac surgery: Time to consider subgroups within risk categories?

Background Medical guidelines increasingly use risk stratification and implicitly assume that individuals classified in the same risk category form a homogeneous group, while individuals with similar, or even identical, predicted risks can still be very different. We evaluate a strategy to identify homogeneous subgroups typically comprising predicted risk categories to allow further tailoring of treatment allocation and illustrate this strategy empirically for cardiac surgery patients with high postoperative mortality risk. Methods Using a dataset of cardiac surgery patients (n = 6517) we applied cluster analysis to identify homogenous subgroups of patients comprising the high postoperative mortality risk group (EuroSCORE ≥ 15%). Cluster analyses were performed separately within younger (< 75 years) and older (≥ 75 years) patients. Validity measures were calculated to evaluate quality and robustness of the identified subgroups. Results Within younger patients two distinct and robust subgroups were identified, differing mainly in preoperative state and indication of recent myocardial infarction or unstable angina. In older patients, two distinct and robust subgroups were identified as well, differing mainly in preoperative state, presence of chronic pulmonary disease, previous cardiac surgery, neurological dysfunction disease and pulmonary hypertension. Conclusions We illustrated a feasible method to identify homogeneous subgroups of individuals typically comprising risk categories. This allows a single treatment strategy – optimal only on average, across all individuals in a risk category – to be replaced by subgroup-specific treatment strategies, bringing us another step closer to individualized care. Discussions on allocation of cardiac surgery patients to different interventions may benefit from focusing on such specific subgroup

Management of large mediastinal masses: surgical and anesthesiological considerations

Large mediastinal masses are rare, and encompass a wide variety of diseases. Regardless of the diagnosis, all large mediastinal masses may cause compression or invasion of vital structures, resulting in respiratory insufficiency or hemodynamic decompensation. Detailed preoperative preparation is a prerequisite for favorable surgical outcomes and should include preoperative multimodality imaging, with emphasis on vascular anatomy and invasive characteristics of the tumor. A multidisciplinary team should decide whether neoadjuvant therapy can be beneficial. Furthermore, the anesthesiologist has to evaluate the risk of intraoperative mediastinal mass syndrome (MMS). With adequate preoperative team planning, a safe anesthesiological and surgical strategy can be accomplished

Results of neoadjuvant chemo(radio)therapy and resection for stage IIIA NSCLC in the Netherlands.

Introduction | Patients with stage IIIA non-small cell lung cancer (NSCLC) form a heterogenous group; concurrent chemoradiotherapy (CRT) remains the main treatment strategy, stage cT3N1 or cT4N0-1 may be eligible for surgery and potentially resectable stage IIIA (N2) NSCLC for neoadjuvant therapy followed by a resection.The reported survival rates after neoadjuvant treatment and resection vary widely. We evaluated treatment patterns and outcome of patients with stage IIIA NSCLC in the Netherlands. Material and Methods | Primary treatment data of patients with clinically staged IIIA NSCLC (according to the 7th edition of the TNM classification) between 2010 and 2016 were extracted from the Netherlands Cancer Registry. Patient characteristics were tabulated and 5-year overall survival (OS) was calculated and reported.Results | In total, 9,591 patients were diagnosed with stage IIIA NSCLC. Of these patients, 41.3% were treated with chemoradiotherapy and 11.6% by upfront surgery without neoadjuvant therapy. 428 patients (4.5%) received neoadjuvant treatment, CRT in 341 patients (80%) and chemotherapy in 87 patients (20%), followed by a resection. The 5-year OS was 26% after chemoradiotherapy, 40% after upfront surgery without neoadjuvant therapy and 54% after neoadjuvant treatment followed by a resection. Clinical overstaging was seen in 42.3% of the patients that were operated without neoadjuvant therapy.Conclusion | In the Netherlands, between 2010 and 2016, 4.5% of patients with stage IIIA NSCLC were selected for treatment with neoadjuvant therapy followed by a resection. The 5-year OS in these patients exceeded 50%, which is better than previously reported, however, outcome might be overestimated due to clinical overstaging.</p

The Relationship Between Volume or Surgeon Specialty and Outcome in the Surgical Treatment of Lung Cancer A Systematic Review and Meta-Analysis

Surgical oncolog

Results of neoadjuvant chemo(radio)therapy and resection for stage IIIA non-small cell lung cancer in The Netherlands

Introduction: Concurrent chemoradiotherapy remains the main treatment strategy for patients with stage IIIA non-small cell lung cancer (NSCLC); stage cT3N1 or cT4N0-1 may be eligible for surgery and potentially resectable stage IIIA (N2) NSCLC for neoadjuvant therapy followed by resection. We evaluated treatment patterns and outcomes of patients with stage IIIA NSCLC in The Netherlands. Material and Methods: Primary treatment data of patients with clinically staged IIIA NSCLC between 2010 and 2016 were extracted from The Netherlands Cancer Registry. Patient characteristics were tabulated and 5-year overall survival (OS) was calculated and reported. Results: In total, 9,591 patients were diagnosed with stage IIIA NSCLC. Of these patients, 41.3% were treated with chemoradiotherapy, 11.6% by upfront surgery and 428 patients (4.5%) received neoadjuvant treatment followed by resection. The 5-year OS was 26% after chemoradiotherapy, 40% after upfront surgery and 54% after neoadjuvant treatment followed by resection. Clinical over staging was seen in 42.3% of the patients that were operated without neoadjuvant therapy. Conclusion: In The Netherlands, between 2010 and 2016, 4.5% of patients with stage IIIA NSCLC were selected for treatment with neoadjuvant therapy followed by resection. The 5-year OS in these patients exceeded 50%. However, the outcome might be overestimated due to clinical over staging