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E J Th Rutgers

Publications and source records attributed to E J Th Rutgers.

At least 19 recordsLinked to original sources
PubMed2006

The incidence and significance of micrometastases in lymph nodes of patients with ductal carcinoma in situ and T1a carcinoma of the breast.

AIM: To report the incidence and predictive value of positive axillary nodes in ductal carcinoma in situ (DCIS) and T1a carcinoma of the breast. METHODS: Cases from The Netherlands Cancer Institute were used to determine the incidence of lymph-node metastases. All consecutive patients with primary breast cancer that were treated between 1989 and 1998 and who had undergone axillary dissection were selected. Patients were identified with pure DCIS (n = 71), DCIS with small invasion (n = 12), invasive ductal/lobular carcinoma (IDC/ILC) < or =5 mm (n = 18) or tubular carcinoma < or =10 mm (n = 17). All archived lymph nodes of these patients were re-evaluated using immunohistochemistry (IHC). RESULTS: In DCIS the incidence increased from 1.4% with routine staining to 11% with IHC. For DCIS with small invasion it was 0 vs 27%, respectively. In IDC/ILC sized 2-5 mm the incidence rose from 6 to 12% and in tubular carcinoma < or =10 mm from 0 to 12%. All but one of the immunohistochemically detected metastases were isolated tumour cells (n = 9) or small (micro)metastases (n = 4). Maximally two nodes per patient were affected. None of the patients with positive lymph nodes died during follow-up (mean 102 months). CONCLUSIONS: Survival of our patients appeared not to be influenced by the finding of micrometastases in the lymph nodes by IHC. Immunohistochemistry of the sentinel node seems not contributive to further treatment in these patients.

Adenocarcinoma↗
PubMed2006

The sentinel node biopsy in patients with breast cancer; many controversies remain.

The sentinel node procedure has increasingly been used as a diagnostic tool for staging breast cancer. Although many institutes have embraced this procedure, many issues concerning the indications and the technique itself remain unsolved. In this review, several aspects regarding these controversies are discussed from the perspective of The Netherlands Cancer Institute. These include the definitions used to identify the sentinel node, the indications and contraindications for this procedure and the injection site of the tracer and blue dye. What are the clinical implications of a micro-metastasis in the sentinel node? What is the best treatment for patients with an involved axillary node? Should non-axillary sentinel nodes be pursued, and if so, what are the implications for further management of these patients? Finally, the current TNM system is discussed in perspective of the evolving sentinel node procedure. Although many questions remain to be solved, the regional recurrence rates are low when axillary clearance is omitted because of a tumor-free sentinel node.

Axilla↗
PubMed2005

Risk reduction of contralateral breast cancer and survival after contralateral prophylactic mastectomy in BRCA1 or BRCA2 mutation carriers.

The clinical outcome of contralateral prophylactic mastectomy (CPM) in women with a BRCA1 or BRCA2 mutation and a personal history of invasive breast cancer is unknown. We identified a cohort of 148 female BRCA1 or BRCA2 mutation carriers (115 and 33, respectively) who previously were treated for unilateral invasive breast cancer stages I-IIIa. In all, 79 women underwent a CPM, while the other women remained under intensive surveillance. The mean follow-up was 3.5 years and started at the time of CPM or at the date of mutation testing, whichever came last, that is, on average 5 years after diagnosis of the first breast cancer. One woman developed an invasive contralateral primary breast cancer after CPM, whereas six were observed in the surveillance group (P<0.001). Contralateral prophylactic mastectomy reduced the risk of contralateral breast cancer by 91%, independent of the effect of bilateral prophylactic oophorectomy (BPO). At 5 years follow-up, overall survival was 94% for the CPM group vs 77% for the surveillance group (P=0.03), but this was unexpectedly mostly due to higher mortality related with first breast cancer and ovarian cancer in the surveillance group. After adjustment for BPO in a multivariate Cox analysis, the CPM effect on overall survival was no longer significant. Our data show that CPM markedly reduces the risk of contralateral breast cancer among BRCA1 or BRCA2 mutation carriers with a history of breast cancer. Longer follow-up is needed to study the impact of CPM on contralateral breast cancer-specific survival. The choice for CPM is highly correlated with that for BPO, while only BPO leads to a significant improvement in overall survival so far.

BRCA1 Protein↗
PubMed2005

Guidelines to assure quality in breast cancer surgery.

The outcome of breast cancer surgery, with respect to cosmetic results, loco regional control and prognostic information from nodal staging, may vary substantially. Optimal breast cancer care starts with a proper surgical act, which can only be performed when optimal imaging and preoperative diagnosis are available. Next, on the basis of all peroperative findings, the right surgical procedure should be indicated after multidisciplinary consultation and discussion, keeping the objective of the final outcome in mind. The surgical act itself is best performed by an experienced surgeon who has maintained their experience after sufficient training. The outcome of the different procedures can be measured according to simple criteria and prospective registration. All possible surgical procedures, the indication-objectives, the training-objectives and outcome measures are described.

Breast Neoplasms↗
PubMed2005

The impact of the physician on the accrual to randomized clinical trials in patients with primary operable breast cancer.

Randomized clinical trials (RCT) are the best way to define optimal treatment, but the accrual rates for hardly any trials have been reported. We analyzed retrospectively the participation of patients in eight phase III multicenter RTCs. Out of a total of 738 patients treated in a single institution for operable breast cancer over a 3-year period, 455 patients (62%) were eligible for at least one of the ongoing trials. Overall, 81% of the patients were informed and 47% of the eligible patients consented to participate. The accrual was 100% to a study with an aggressive combined modality treatment arm for patients with a poor prognosis. A low accrual rate was seen in two trials: 6% in the "elderly" trial comparing tamoxifen only with mastectomy and 10% to the "axilla" trial comparing surgery with radiotherapy to the axilla. The clinicians failed to inform most of these patients about the two trials. In the literature seven of the eight trials were reported; two of them (29%) failed to accrue enough patients.

Breast Neoplasms↗
PubMed2005

Changing patterns in diagnosis and treatment of ductal carcinoma in situ of the breast.

BACKGROUND: The increased incidence of ductal carcinoma in situ (DCIS) of the breast and the emergence of new diagnostic and therapeutic tools like mammographic screening, stereotactic core biopsy and reconstructive surgery prompted us to investigate how these developments influenced diagnosis and treatment. METHODS: Clinical and pathological characteristics of 403 patients with DCIS consecutively treated at The Netherlands Cancer Institute between 1986 and 2002 were evaluated and the effect of introduction of mammographic screening, stereotactic core biopsy and reconstruction on diagnosis and treatment was studied. RESULTS: Following the nationwide introduction of mammographic screening the number of non-symptomatic DCIS increased from 47 to 77%. Introduction of stereotactic core biopsy resulted in a rise of one-step procedures from 26 to 52%. Mastectomy rate did not change over time: 59% overall. However, reconstruction rate increased from 17 to 39%. CONCLUSION: This study shows a steep rise in diagnosis of non-symptomatic DCIS after introduction of screening. Further, the introduction of pre-operative diagnosis by stereotactic core biopsy resulted in a decrease of multiple surgical procedures. Mastectomy, with increasing application of breast reconstructions, remains an important treatment modality in the management of DCIS despite advancements in detection and diagnosis.

Adult↗
PubMed2004

Radio-guided surgery improves outcome of therapeutic excision in non-palpable invasive breast cancer.

Intratumoral injection of a radiocolloid for lymphatic mapping enables the therapeutic excision of clinically occult breast cancer with the aid of a gamma-ray detection probe. The aim of this study was to determine the success rate of radio-guided tumour excision in addition to a guide wire and to identify factors predicting clear margins. Sixty-five consecutive patients underwent radio-guided tumour excision after intratumoral injection of 99mTc-nanocolloid guided by ultrasound or stereotaxis. A localization wire was inserted after scintigraphy had been performed (group 1). The results were compared with retrospective data from 67 consecutive patients who underwent therapeutic wire-directed excision alone (group 2). Factors predicting clear margins (> or = 1 mm) were determined in a logistic regression model. Adequate margins were obtained in 83% of group 1 and in 64% of group 2 (P = 0.014). The invasive component was incompletely excised in two patients in group 1 and in 14 patients in group 2. Further surgery was performed in four patients in group 1 and in 14 patients in group 2. Factors predictive of clear margins were decreasing pathological tumour diameter (P = 0.035), increasing weight of the specimen (P = 0.046), absence of microcalcifications (P = 0.004) and absence of carcinoma in situ component (P = 0.024). Radio-guided excision was an independent predictor of complete excision of the invasive component (P = 0.012). The application of radio-guided surgery combined with wire localization seems to improve the outcome of therapeutic excision of non-palpable invasive breast cancer compared with wire-directed excision alone.

Breast Neoplasms↗
PubMed2003

Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer.

Currently, breast cancer patients without clinically suspicious lymph nodes are candidates for sentinel lymph node procedures (SLNPs). The aims of this study were to investigate whether preoperative axillary ultrasonography and fine-needle aspiration cytology (FNA) can reduce the number of the more time-consuming SLNPs, and to identify a subset of quantitative nodal features to predict metastatic involvement. 268 axillae were ultrasonographically examined. FNA was performed on suspicious nodes (smallest diameter > or =5 mm or atypical cortex appearance). SLNP was omitted if a tumour-positive node was found on FNA. Length, width, maximum cortex thickness and appearance of cortex and hilus were ultrasonographically established. In 93 axillae (35%), at least one node was detected with ultrasound. FNA was performed once per axilla on 66 nodes; 37 (56%) contained tumour cells. 31% of all tumour-positive axillae (macro-+micrometastases) was found by ultrasound and FNA (37/121). 41% of all axillae containing macrometastases was found by ultrasound and FNA (36/87). SLNPs were reduced by 14% (37/268). Maximum cortex thickness is the main feature to predict metastatic involvement (area under Receiver Operating Characteristic (ROC) curve (A(Z))=0.87).

Adult↗
PubMed2003

Eight false negative sentinel node procedures in breast cancer: what went wrong?

AIMS: The purpose of the study was to evaluate the false negative sentinel node procedures in patients with breast cancer at our institution. METHODS: A total of 606 sentinel node biopsies were performed on 599 clinical N0 breast cancer patients between January 1997 and November 2001. RESULTS: The axillary sentinel node revealed metastasis in 204 (36.1%) of the 565 patients in whom it was identified and was false negative in eight patients. Two false negative results came to light by confirmatory axillary lymph node dissection during the learning phase. Tumour-positive lymph nodes were incidentally found in the axillary tail of the simple mastectomy specimen in two patients. Excision of a firm, non-radioactive, unstained but tumour-positive non-sentinel node occurred in three other patients. One patient developed an axillary recurrence 22 months postoperatively. Presumptive causes were surgical delay, pathological sampling error and tumour blocking. CONCLUSION: Intra-operative palpation of the axilla to identify suspicious lymph nodes is recommended. In a two-day protocol, surgery should be performed first thing in the morning. Seven slices of 50-150-micro m strike an acceptable balance between sensitivity and work load for the pathologist.

Adult↗
PubMed2003

Lymphatic mapping with tracer administration into the primary breast cancer.

There is an ongoing debate over the best tracer injection technique in lymphatic mapping for breast cancer. The technique of low tracer volume administration into the primary breast cancer is presented. The reasons that led to this approach are explained as well as its advantages. Excision of radioactivity that remains at the injection site in the breast cancer prevents the gamma ray scatter that may hamper retrieval of a sentinel node. The intralesional injection technique avoids potential injection of tracer fluid across a lymphatic watershed, it enables identification of extra-axillary sentinel nodes and allows probe-guided excision of non-palpable tumours.

Breast Neoplasms↗
PubMed2003

Cytoreductive surgery combined with intraoperative hyperthermic intrathoracic chemotherapy for stage I malignant pleural mesothelioma.

BACKGROUND: Malignant pleural mesothelioma (MPM) is a disease mostly confined to the thoracic cavity. Untreated, the median survival is <1 year. Cytoreductive surgery combined with intraoperative hyperthermic intrathoracic chemotherapy is used to kill residual tumor cells on the surface of the thoracic cavity while having limited systemic side effects. METHODS: From August 1998 to August 2001, 22 patients with stage I MPM were included in this study. Two patients were irresectable at operation because of extrathoracic tumor growth. Twenty procedures were performed. After cytoreduction, a perfusion was performed with cisplatin and doxorubicin at 40 degrees C to 41 degrees C for 90 minutes. Adjuvant radiotherapy was given to surgical scars and drainage tracts. RESULTS: There was no perioperative mortality, but significant morbidity was seen in 13 patients (65%), including bronchopleural fistula, diaphragm rupture, wound dehiscence, persistent air leakage, and chylous effusion. No hair loss or leucopenia was noticed. The median follow-up was 14 months. The median survival (Kaplan-Meier) was 11 months, with a 1-year survival of 42%. A favorable pharmacokinetic ratio was observed for both cisplatin and doxorubicin. CONCLUSIONS: Cytoreductive surgery combined with hyperthermic intrathoracic chemotherapy for stage I MPM is feasible. However, this treatment is accompanied by considerable morbidity. Survival data were less encouraging.

Adult↗
PubMed2002

[Dutch Institute for Healthcare Improvement guideline, "Treatment of breast cancer"].

The first Dutch evidence-based guideline for the treatment of breast cancer has been developed to realise the optimal care of breast cancer patients in the Netherlands. This was possible due to the close cooperation of the Dutch Institute for Healthcare Improvement [Dutch acronym: CBO] and the Dutch Consultative Committee on Breast Cancer [Dutch acronym: NABON]. A broad, multidisciplinary working group was appointed to develop the guideline. This group consisted of surgeons, radiotherapists, internists, pathologists, a radiologist, a nuclear medicine specialist, a plastic surgeon and a clinical geneticist, all of whom had been given a mandate to represent their respective professional societies. In addition to these medical specialists, there were physiotherapists, oncology nurses, psychologists, staff from comprehensive cancer centres and the Dutch Institute for Healthcare Improvement and representatives from the Dutch Breast Cancer Association. This CBO guideline is divided into seven chapters: local treatment of operable breast cancer, systemic adjuvant treatment, locoregionally advanced disease, follow-up, locoregional recurrence, metastasised disease, and the psychosocial aspects of breast cancer. Although the guideline is not intended as a set of instructions that must be rigidly adhered to, deviations from the guideline must be motivated, principally on the basis of published scientific information. To obtain insight into the actual use of the guidelines 'Screening and diagnostics' and 'Treatment of breast cancer' the work group advocates a nationwide prospective registration of all breast cancer patients, including follow-up. Steps to this end have been undertaken. In this way, the CBO guideline will contribute to a further optimisation of breast cancer care in the Netherlands.

Breast Neoplasms↗
PubMed2002

Impact of non-axillary sentinel node biopsy on staging and treatment of breast cancer patients.

The purpose of this study was to evaluate the occurrence of lymphatic drainage to non-axillary sentinel nodes and to determine the implications of this phenomenon. A total of 549 breast cancer patients underwent lymphoscintigraphy after intratumoural injection of (99m)Tc-nanocolloid. The sentinel node was intraoperatively identified with the aid of intratumoural administered patent blue dye and a gamma-ray detection probe. Histopathological examination of sentinel nodes included step-sectioning at six levels and immunohistochemical staining. A sentinel node outside level I or II of the axilla was found in 149 patients (27%): internal mammary sentinel nodes in 86 patients, other non-axillary sentinel nodes in 44 and both internal mammary and other non-axillary sentinel nodes in nineteen patients. The intra-operative identification rate was 80%. Internal mammary metastases were found in seventeen patients and metastases in other non-axillary sentinel nodes in ten patients. Staging improved in 13% of patients with non-axillary sentinel lymph nodes and their treatment strategy was changed in 17%. A small proportion of clinically node negative breast cancer patients can be staged more precisely by biopsy of sentinel nodes outside level I and II of the axilla, resulting in additional decision criteria for postoperative regional or systemic therapy.

Adult↗
PubMed2002

[The scientific basis for population screening for breast cancer in the Netherlands].

A recent Cochrane review stated that there was a lack of evidence for a decrease in mortality as a result of population breast-cancer screening. The principal data were drawn from five Swedish randomized controlled trials and one Canadian trial. However, the studies cannot be so easily combined because there were important differences in the attendance rate, detection rate, technical quality, referral rate, clinical baseline situation and screening interval. For example, in one of the studies the women from the control arm underwent an annual clinical palpation carried out by a trained nurse or physician, which could have led to an underestimation of the screening effect. Further breast-cancer mortality might not be a good outcome measure because this was not reliably determined; only total mortality was to be observed. This is clinically and methodologically incorrect because breast-cancer mortality was meticulously studied, documented and validated. In the Cochrane review it is suggested that the randomisation was inadequate, but evidence for this was not supplied. The discussion about age differences as a marker for incorrect randomisation is out of date and has been revealed to be unjust. It seems likely that an important part of the decreasing trend in breast-cancer mortality in several countries (including the Netherlands) is due to screening programmes. However, the evaluation of breast-cancer mortality over the next five years is crucial, if greater certainty is to be gained about this.

Breast Neoplasms↗