Showing papers by "Geerard L. Beets published in 2016"

Long-term Outcome of an Organ Preservation Program After Neoadjuvant Treatment for Rectal Cancer.

Abstract: Background The aim of this study was to establish the oncological and functional results of organ preservation with a watch-and-wait approach (W&W) and selective transanal endoscopic microsurgery (TEM) in patients with a clinical complete or near-complete response (cCR) after neoadjuvant chemoradiation for rectal cancer. Methods Between 2004 and 2014, organ preservation was offered if response assessment with digital rectal examination, endoscopy, and MRI showed (near) cCR. Watch-and-wait was offered for cCR, and two options were offered for near cCR: TEM or reassessment after three months. Follow-up included endoscopy and MRIs every three months during the first year, and every six months thereafter. Long-term outcome was assessed with Kaplan-Meier curves. Functional outcome was assessed with colostomy-free survival and Vaizey incontinence score (0 = perfect continence, 24 = totally incontinent). Results One hundred patients were included, with median follow-up of 41.1 months. Sixty-one had cCR at initial response assessment. Thirty-nine had near cCR, of whom 24 developed cCR at the second assessment and 15 patients underwent TEM (9 ypT0, 1 ypT1, 5 ypT2). Fifteen patients developed a local regrowth (12 luminal, 3 nodal), all salvageable and within 25 months. Five patients developed metastases, and five patients died. Three-year overall survival was 96.6% (95% confidence interval [CI] = 89.9% to 98.9%), distant metastasis-free survival was 96.8% (95% CI = 90.4% to 99.0%), local regrowth-free survival was 84.6% (95% CI = 75.8% to 90.5%), and disease-free survival was 80.6% (95% CI = 70.9% to 87.4%). Colostomy-free survival was 94.8% (95% CI = 88.0% to 97.8%), with a good continence after watch-and-wait (Vaizey = 3.4, SD = 3.9) and moderate after TEM (Vaizey = 9.7, SD = 5.1). Conclusions Organ preservation appears oncologically safe for selected rectal cancer patients with a cCR or near cCR after neoadjuvant chemoradiation when applying strict selection criteria and frequent follow-up, including endoscopy and MRI. The low colostomy rate and the good long-term functional outcome warrant discussing this option with the patient as an alternative to major surgery.

Diagnostic Accuracy of CT for Local Staging of Colon Cancer: A Systematic Review and Meta-Analysis

Abstract: OBJECTIVE. The purpose of this article is to determine the accuracy of CT in the detection of tumor invasion beyond the bowel wall and nodal involvement of colon carcinomas. A literature search was...

CT texture analysis in colorectal liver metastases: A better way than size and volume measurements to assess response to chemotherapy?

Abstract: BackgroundResponse Evaluation Criteria In Solid Tumors (RECIST) are known to have limitations in assessing the response of colorectal liver metastases (CRLMs) to chemotherapy.ObjectiveThe objective of this article is to compare CT texture analysis to RECIST-based size measurements and tumor volumetry for response assessment of CRLMs to chemotherapy.MethodsTwenty-one patients with CRLMs underwent CT pre- and post-chemotherapy. Texture parameters mean intensity (M), entropy (E) and uniformity (U) were assessed for the largest metastatic lesion using different filter values (0.0 = no/0.5 = fine/1.5 = medium/2.5 = coarse filtration). Total volume (cm3) of all metastatic lesions and the largest size of one to two lesions (according to RECIST 1.1) were determined. Potential predictive parameters to differentiate good responders (n = 9; histological TRG 1–2) from poor responders (n = 12; TRG 3–5) were identified by univariable logistic regression analysis and subsequently tested in multivariable logistic regress...

A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer

Abstract: Rectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5 %. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5–20 %) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients. In this multicentre randomised trial, patients with an intermediate risk T1-2 rectal cancer, that has been locally excised using an endoluminal technique, will be randomized between adjuvant chemo-radiotherapylimited to the mesorectum and standard completion total mesorectal excision (TME). To strictly monitor the risk of locoregional recurrence in the experimental arm and enable early salvage surgery, there will be additional follow up with frequent MRI and endoscopy. The primary outcome of the study is three-year local recurrence rate. Secondary outcomes are morbidity, disease free and overall survival, stoma rate, functional outcomes, health related quality of life and costs. The design is a non inferiority study with a total sample size of 302 patients. The results of the TESAR trial will potentially demonstrate that adjuvant chemoradiotherapy is an oncological safe treatment option in patients who are confronted with the difficult clinical dilemma of a radically removed intermediate risk early rectal cancer by polypectomy or transanal surgery that is conventionally treated with subsequent radical surgery. Preserving the rectum using adjuvant radiotherapy is expected to significantly improve morbidity, function and quality of life if compared to completion TME surgery. NCT02371304 , registration date: February 2015

Nodal staging in rectal cancer: why is restaging after chemoradiation more accurate than primary nodal staging?

Abstract: Purpose This study aims to explore the influence of chemoradiation treatment (CRT) on rectal cancer nodes and to generate hypotheses why nodal restaging post-CRT is more accurate than at primary staging.

Associations of sedentary time and patterns of sedentary time accumulation with health-related quality of life in colorectal cancer survivors

Abstract: Sedentary behavior (sitting/lying at low energy expenditure while awake) is emerging as an important risk factor that may compromise the health-related quality of life (HRQoL) of colorectal cancer (CRC) survivors. We examined associations of sedentary time with HRQoL in CRC survivors, 2–10 years post-diagnosis. In a cross-sectional study, stage I–III CRC survivors (n = 145) diagnosed (2002−2010) at Maastricht University Medical Center+, the Netherlands, wore the thigh-mounted MOX activity monitor 24 h/day for seven consecutive days. HRQoL outcomes were assessed by validated questionnaires (EORTC QLQ-C30, WHODAS II, Checklist Individual Strength, and Hospital Anxiety and Depression Scale). Confounder-adjusted linear regression models were used to estimate associations with HRQoL outcomes of MOX-derived total and prolonged sedentary time (in prolonged sedentary bouts ≥ 30 min), and usual sedentary bout duration, corrected for waking wear time. On average, participants spent 10.2 h/day sedentary (SD, 1.6), and 4.5 h/day in prolonged sedentary time (2.3). Mean usual sedentary bout duration was 27.3 min (SD, 16.8). Greater total and prolonged sedentary time, and longer usual sedentary bout duration were associated with significantly (P < 0.05) lower physical functioning, and higher disability and fatigue scores. Greater prolonged sedentary time and longer usual sedentary bout duration also showed significant associations with lower global quality of life and role functioning. Associations with distress and social functioning were non-significant. Sedentary time was cross-sectionally associated with poorer HRQoL outcomes in CRC survivors. Prospective studies are needed to investigate whether sedentary time reduction is a potential target for lifestyle interventions aiming to improve the HRQoL of CRC survivors.

MRI and diffusion-weighted MRI to diagnose a local tumour regrowth during long-term follow-up of rectal cancer patients treated with organ preservation after chemoradiotherapy

Abstract: Objectives To assess the value of MRI and diffusion-weighted imaging (DWI) for diagnosing local tumour regrowth during follow-up of organ preservation treatment after chemoradiotherapy for rectal cancer.

Automated and Semiautomated Segmentation of Rectal Tumor Volumes on Diffusion-Weighted MRI: Can It Replace Manual Volumetry?

Abstract: Purpose Diffusion-weighted imaging (DWI) tumor volumetry is promising for rectal cancer response assessment, but an important drawback is that manual per-slice tumor delineation can be highly time consuming. This study investigated whether manual DWI-volumetry can be reproduced using a (semi)automated segmentation approach. Methods and Materials Seventy-nine patients underwent magnetic resonance imaging (MRI) that included DWI (highest b value [b1000 or b1100]) before and after chemoradiation therapy (CRT). Tumor volumes were assessed on b1000 (or b1100) DWI before and after CRT by means of ( 1 ) automated segmentation (by 2 inexperienced readers), ( 2 ) semiautomated segmentation (manual adjustment of the volumes obtained by method 1 by 2 radiologists), and ( 3 ) manual segmentation (by 2 radiologists); this last assessment served as the reference standard. Intraclass correlation coefficients (ICC) and Dice similarity indices (DSI) were calculated to evaluate agreement between different methods and observers. Measurement times (from a radiologist's perspective) were recorded for each method. Results Tumor volumes were not significantly different among the 3 methods, either before or after CRT ( P =.08 to .92). ICCs compared to manual segmentation were 0.80 to 0.91 and 0.53 to 0.66 before and after CRT, respectively, for the automated segmentation and 0.91 to 0.97 and 0.61 to 0.75, respectively, for the semiautomated method. Interobserver agreement (ICC) pre and post CRT was 0.82 and 0.59 for automated segmentation, 0.91 and 0.73 for semiautomated segmentation, and 0.91 and 0.75 for manual segmentation, respectively. Mean DSI between the automated and semiautomated method were 0.83 and 0.58 pre-CRT and post-CRT, respectively; DSI between the automated and manual segmentation were 0.68 and 0.42 and 0.70 and 0.41 between the semiautomated and manual segmentation, respectively. Median measurement time for the radiologists was 0 seconds (pre- and post-CRT) for the automated method, 41 to 69 seconds (pre-CRT) and 60 to 67 seconds (post-CRT) for the semiautomated method, and 180 to 296 seconds (pre-CRT) and 84 to 91 seconds (post-CRT) for the manual method. Conclusions DWI volumetry using a semiautomated segmentation approach is promising and a potentially time-saving alternative to manual tumor delineation, particularly for primary tumor volumetry. Once further optimized, it could be a helpful tool for tumor response assessment in rectal cancer.

Modeling how substitution of sedentary behavior with standing or physical activity is associated with health-related quality of life in colorectal cancer survivors

Abstract: Purpose Previous research indicates that sedentary behavior is unfavorably associated with health-related quality of life (HRQoL) of colorectal cancer (CRC) survivors. Using isotemporal substitution modeling, we studied how substituting sedentary behavior with standing or physical activity was associated with HRQoL in CRC survivors, 2–10 years post-diagnosis.

Flap fixation reduces seroma in patients undergoing mastectomy: a significant implication for clinical practice.

Abstract: Seroma formation is a common complication following mastectomy for invasive breast cancer. Mastectomy flap fixation is achieved by reducing dead space volume using interrupted subcutaneous sutures. All patients undergoing mastectomy due to invasive breast cancer or ductal carcinoma in situ (DCIS) were eligible for inclusion. From May 2012 to March 2013, all patients undergoing mastectomy in two hospitals were treated using flap fixation. The skin flaps were sutured on to the pectoral muscle using polyfilament absorbable sutures. The data was retrospectively analysed and compared to a historical control group that was not treated using flap fixation (May 2011 to March 2012). One hundred and eighty patients were included: 92 in the flap fixation group (FF) and 88 in the historical control group (HC). A total of 33/92 (35.9 %) patients developed seroma in the group that underwent flap fixation; 52/88 (59.1 %) patients developed seroma in the HC group (p = 0.002). Seroma aspiration was performed in 14/92 (15.2 %) patients in the FF group as opposed to 38/88 (43.2 %) patients in the HC group (p < 0.001). Flap fixation is an effective surgical technique in reducing dead space and therefore seroma formation and seroma aspirations in patients undergoing mastectomy for invasive breast cancer or DCIS.

Magnetization transfer imaging to assess tumour response after chemoradiotherapy in rectal cancer

Abstract: Purpose Single-slice magnetization transfer (MT) imaging has shown promising results for evaluating post-radiation fibrosis. The study aim was to evaluate the value of multislice MT imaging to assess tumour response after chemoradiotherapy by comparing magnetization transfer ratios (MTR) with histopathological tumour regression grade (TRG).

Good and complete responding locally advanced rectal tumors after chemoradiotherapy: where are the residual positive nodes located on restaging MRI?

Abstract: Purpose Aim of this study was to evaluate the distribution of persistent mesorectal lymph node metastases on restaging MRI in patients with a good or complete response of their primary tumor (ypT0-2) after CRT for locally advanced rectal cancer.

Esophageal and Gastric Cancer Pearl: a nationwide clinical biobanking project in the Netherlands

Abstract: Esophageal and gastric cancer is associated with a poor prognosis since many patients develop recurrent disease. Treatment requires specific expertise and a structured multidisciplinary approach. In the Netherlands, this type of expertise is mainly found at the University Medical Centers (UMCs) and a few specialized nonacademic centers. Aim of this study is to implement a national infrastructure for research to gain more insight in the etiology and prognosis of esophageal and gastric cancer and to evaluate and improve the response on (neoadjuvant) treatment. Clinical data are collected in a prospective database, which is linked to the patients' biomaterial. The collection and storage of biomaterial is performed according to standard operating procedures in all participating UMCs as established within the Parelsnoer Institute. The collected biomaterial consists of tumor biopsies, blood samples, samples of malignant and healthy tissue of the resected specimen and biopsies of recurrence. The collected material is stored in the local biobanks and is encoded to respect the privacy of the donors. After approval of the study was obtained from the Institutional Review Board, the first patient was included in October 2014. The target aim is to include 300 patients annually. In conclusion, the eight UMCs of the Netherlands collaborated to establish a nationwide database of clinical information and biomaterial of patients with esophageal and gastric cancer. Due to the national coverage, a high number of patients are expected to be included. This will provide opportunity for future studies to gain more insight in the etiology, treatment and prognosis of esophageal and gastric cancer.

Non-invasive MR assessment of macroscopic and microscopic vascular abnormalities in the rectal tumour-surrounding mesorectum

Abstract: To evaluate the MRI macroscopic and microscopic parameters of mesorectal vasculature in rectal cancer patients. Thirteen patients with rectal adenocarcinoma underwent a dynamic contrast-enhanced MRI at 1.5 T using a blood pool agent at the primary staging. Mesorectal macrovascular features, i.e., the number of vascular branches, average diameter and length, were assessed from baseline-subtracted post-contrast images by two independent readers. Mesorectal microvascular function was investigated by means of area under the enhancement-time curve (AUC). Histopathology served as reference standard of the tumour response to CRT. The average vessel branching in the mesorectum around the tumour and normal rectal wall was 8.2 ± 3.8 and 1.7 ± 1.3, respectively (reader1: p = 0.001, reader2: p = 0.002). Similarly, the tumour-surrounding mesorectum displayed circa tenfold elevated AUC (p = 0.01). Interestingly, patients with primary node involvement had a twofold higher number of macrovascular branches compared to those with healthy nodes (reader1: p = 0.005 and reader2: p = 0.03). A similar difference was observed between good and poor responders to CRT, whose tumour-surrounding mesorectum displayed 10.7 ± 3.4 and 5.6 ± 1.5 vessels, respectively (reader1/reader2: p = 0.02). We showed at baseline MRI of rectal tumours a significantly enhanced macrovascular structure and microvascular function in rectal tumour-surrounding mesorectum, and the association of primary mesorectal macrovascular parameters with node involvement and therapy response. • Vascular MRI reveals macrovascular and microvascular abnormalities in the rectal tumour-surrounding mesorectum. • Formation of highly vascular stroma precedes the actual tumour invasion. • High macrovascular parameters are associated with node involvement. • Mesorectal vascular network differs for good and poor responders.

Operative Verfahren bei hohen kryptoglandulären Analfisteln: Systematische Übersicht und Metaanalyse

Abstract: Perianale Fisteln, insbesondere hohe Analfisteln, stellen weiterhin eine chirurgische Herausforderung dar. Um die postoperativen Behandlungsergebnisse zu verbessern, wurden bereits viele Operationstechniken entwickelt und standig kommen neue hinzu. Es wurde ein systematisches Review mit Metaanalyse zu operativen Verfahren bei hohen kryptoglandularen perianalen Fisteln erstellt. In den Datenbanken Medline (Pubmed, Ovid), Embase und The Cochrane Library erfolgte eine Suche nach relevanten randomisierten kontrollierten Studien zu Operationsverfahren bei hohen kryptoglandularen Analfisteln. Zwei unabhangige Prufer wahlten anhand von Titel, Zusammenfassung und den beschriebenen Endpunkten Artikel fur die vorliegende Ubersichtarbeit aus. Der Hauptzielparameter war die Rezidiv-/Heilungsrate. Die Nebenzielparameter waren Stuhlkontinenzstatus, Lebensqualitat und Komplikationen. Es fanden sich nur wenige randomisierte Studien. Insgesamt konnte 14 Studien in die Ubersichtsarbeit aufgenommen werden. Nur fur die Gegenuberstellung von Mukosaverschiebelappen („mucosa advancement flap“) und Fistel-Plug konnte eine Metaanalyse durchgefuhrt werden, in der aber hinsichtlich der Rezidiv- und Komplikationsrate keine Uberlegenheit der einen oder anderen Technik nachgewiesen wurde. Der Mukosaverschiebelappen war zwar die am meisten untersuchte Technik, zeigte aber gegenuber keinem der anderen Verfahren einen Vorteil. Weitere in den randomisierten Studien untersuchte Techniken waren Fadendrainage, wirkstoffhaltige Fadendrainage, Fibrinkleber, autologe Stammzellen, Insellappenanalplastik, Rektumvollwandverschiebelappen, Ligatur des intersphinktaren Fistelgangs, Sphinkterrekonstruktion, sphinktererhaltende Fadendrainage und Techniken in Kombination mit Antibiotika. Keines dieser Verfahren scheint besser als die anderen zu sein. Es konnte keine bestes Operationsverfahren zur Behandlung hoher kryptoglandularer perianaler Fisteln ermittelt werden. Um die optimale Behandlung zu finden, mussen weitere randomisierte und kontrollierte Studien durchgefuhrt werden. Von allen beschriebenen Techniken ist der Mukosaverschiebelappen am intensivsten untersucht worden.