Publications by authors named "Elisabeth G Klompenhouwer"

23 Publications

  • Page 1 of 1

Radiofrequency versus microwave ablation for intraoperative treatment of colorectal liver metastases.

Eur J Surg Oncol 2021 Oct 16. Epub 2021 Oct 16.

Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.

Introduction: Intraoperative radiofrequency ablation (RFA) and the newer technique of microwave ablation (MWA) can both be of additional value in parenchyma preserving surgical treatment of colorectal liver metastases (CRLM). MWA is less influenced by the heat-sink effect of surrounding vessels and can generate more heat in less time but RFA is still widely used. True comparing studies are scarce.

Methods: This single centre retrospective cohort study analyzed patients who underwent ultrasound guided intraoperative ablation as a part of the surgical treatment of CRLM between 2013 and 2018. In September 2015, MWA was substituted for RFA. Outcomes included unsuccessful ablation rates at 1-year postoperative, 30-days major complication rates, progression free survival (PFS) and overall survival (OS). Logistic regression models were used for univariable and multivariable analyses to identify predictors of unsuccessful ablation.

Results: Forty-one patients underwent RFA of 98 lesions (median 2) and 79 patients underwent MWA of 193 lesions (median 2). The median diameter of the ablated lesions was 9 mm for both RFA and MWA. Unsuccessful ablation was observed in 7 metastases (7.1%) after RFA and 14 metastases (7.3%) after MWA (p = 1.000). Complications requiring re-intervention were observed after 8 procedures, 2 complications in the RFA group (4.9%) versus 6 complications in the MWA group (7.6%, p = 0.714), of which 6 were liver-related. Ninety-day mortality did not occur. Ablation technique was not associated with unsuccessful ablations. CRLM size was associated with unsuccessful ablation in the per lesion analysis (p < 0.001).

Conclusion: Intraoperative RFA and MWA were equally effective for treatment of small CRLM.
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http://dx.doi.org/10.1016/j.ejso.2021.10.012DOI Listing
October 2021

Stage I non-small cell lung cancer: Treatment modalities, Dutch daily practice and future perspectives.

Cancer Treat Res Commun 2021 21;28:100404. Epub 2021 May 21.

Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands. Electronic address:

Objectives: Several treatment modalities are available for patients with stage I non-small cell lung cancer (NSCLC). Over the past decade, these treatment modalities have been further investigated and might have changed current treatment regimens. In this review we present an overview of the treatment options, developments and future perspectives for stage I NSCLC. Furthermore, we describe the current use of these treatment modalities in the Netherlands.

Materials And Methods: A bibliographical search was performed in PubMed and the Cochrane Library for publications concerning treatment modalities for stage I NSCLC. In addition, evidence-based guidelines of the European Society for Medical Oncology (ESMO) and the National Comprehensive Cancer Network (NCCN) were studied.

Results: The guideline-recommended treatment for operable stage I NSCLC patients is a lobectomy with systematic lymph node dissection. Inoperable patients or those refusing surgery are offered stereotactic ablative radiotherapy (SABR). Percutaneous ablation, such as radiofrequency ablation, is a non-surgical minimally invasive technique offered to those who are ineligible for surgery or SABR. The role of systemic therapy is currently limited. However, the efficacy of immunotherapy is being investigated in clinical trials. In the Netherlands, an increasing use of SABR and a relative decrease in resection rates have been observed.

Conclusion: Surgery and SABR are currently the prevailing treatment modalities for stage I NSCLC patients. Despite optimization of treatment regimens, survival of patients with stage I NSCLC remains to be improved. Future studies are required to optimize treatment strategies, but also to investigate factors influencing treatment decision-making for patients with stage I NSCLC.
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http://dx.doi.org/10.1016/j.ctarc.2021.100404DOI Listing
May 2021

CBCT-based navigation system for open liver surgery: Accurate guidance toward mobile and deformable targets with a semi-rigid organ approximation and electromagnetic tracking of the liver.

Med Phys 2021 May 1;48(5):2145-2159. Epub 2021 Apr 1.

Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.

Purpose: The surgical navigation system that provides guidance throughout the surgery can facilitate safer and more radical liver resections, but such a system should also be able to handle organ motion. This work investigates the accuracy of intraoperative surgical guidance during open liver resection, with a semi-rigid organ approximation and electromagnetic tracking of the target area.

Methods: The suggested navigation technique incorporates a preoperative 3D liver model based on diagnostic 4D MRI scan, intraoperative contrast-enhanced CBCT imaging and electromagnetic (EM) tracking of the liver surface, as well as surgical instruments, by means of six degrees-of-freedom micro-EM sensors.

Results: The system was evaluated during surgeries with 35 patients and resulted in an accurate and intuitive real-time visualization of liver anatomy and tumor's location, confirmed by intraoperative checks on visible anatomical landmarks. Based on accuracy measurements verified by intraoperative CBCT, the system's average accuracy was 4.0 ± 3.0 mm, while the total surgical delay due to navigation stayed below 20 min.

Conclusions: The electromagnetic navigation system for open liver surgery developed in this work allows for accurate localization of liver lesions and critical anatomical structures surrounding the resection area, even when the liver was manipulated. However, further clinically integrating the method requires shortening the guidance-related surgical delay, which can be achieved by shifting to faster intraoperative imaging like ultrasound. Our approach is adaptable to navigation on other mobile and deformable organs, and therefore may benefit various clinical applications.
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http://dx.doi.org/10.1002/mp.14825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251891PMC
May 2021

Renal biopsies performed before versus during ablation of T1 renal tumors: implications for prevention of overtreatment and follow-up.

Abdom Radiol (NY) 2021 01 20;46(1):373-379. Epub 2020 Jun 20.

Department of Urology, OLVG, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.

Purpose: To assess the difference between renal mass biopsy (RMB) performed either before or during the ablation procedure.

Methods: A retrospective multicenter study was performed in patients with a cT1 renal mass treated with ablation between January 2007 and July 2019, including a search in the national pathology database for patients with a RMB planned for ablation. Patient and tumor characteristics and information on malignant, benign, and non-diagnostic biopsy results were collected to establish rates of overtreatment and number of ablations avoided in case of benign or non-diagnostic histology.

Results: RMB was performed in 714 patients, of which 231 patients received biopsy before planned ablation, and 483 patients at the time of ablation. Pathology results before ablation were malignant in 63% (145/231), benign in 20% (46/231) and non-diagnostic in 17% (40/231). Pathology results at the time of ablation were malignant in 67.5% (326/483), benign in 16.8% (81/483) and non-diagnostic in 15.7% (76/483), leading to a total of 32.5% of ablation of benign or non-diagnostic lesions. Of the patients with a benign biopsy obtained before ablation, 80.4% (37/46) chose not to undergo ablation. Patients with inconclusive biopsy before planned ablation chose an informed individualized approach including ablation, repeated biopsy, or no intervention in 56%, 34% and 10%.

Conclusion: This study emphasizes the importance of obtaining a biopsy prior to the ablation procedure in a separate session to lower the rate of potentially unnecessary ablations.
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http://dx.doi.org/10.1007/s00261-020-02613-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864836PMC
January 2021

[Experiences with axillary reverse mapping].

Ned Tijdschr Geneeskd 2020 02 25;164. Epub 2020 Feb 25.

Amphia Ziekenhuis, afd. Chirurgie, Breda.

Axillary reverse mapping (ARM) is a technique by which the lymphatic drainage system of the upper extremities is mapped, so that the lymph channels and glands can be preserved during axillary lymph node dissection (ALND). This can lead to less postoperative morbidity, such as lymphoedema. A randomised multicentre study showed that there are statistically significantly fewer post-operative symptoms if the lymph channels and glands of the upper extremities are spared with this technique. Despite the declining indication for an ALND, ARM can have added value for the patients who do have to undergo ALND.
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February 2020

Adjuvant Hepatic Arterial Infusion Pump Chemotherapy After Resection of Colorectal Liver Metastases: Results of a Safety and Feasibility Study in The Netherlands.

Ann Surg Oncol 2019 Dec 22;26(13):4599-4607. Epub 2019 Oct 22.

Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, The Netherlands.

Background: The 10-year overall survival with adjuvant hepatic arterial infusion pump (HAIP) chemotherapy after resection of colorectal liver metastases (CRLMs) was 61% in clinical trials from Memorial Sloan Kettering Cancer Center. A pilot study was performed to evaluate the safety and feasibility of adjuvant HAIP chemotherapy in patients with resectable CRLMs.

Study Design: A phase II study was performed in two centers in The Netherlands. Patients with resectable CRLM without extrahepatic disease were eligible. All patients underwent complete resection and/or ablation of CRLMs and pump implantation. Safety was determined by the 90-day HAIP-related postoperative complications from the day of pump placement (Clavien-Dindo classification, grade III or higher) and feasibility by the successful administration of the first cycle of HAIP chemotherapy.

Results: A total of 20 patients, with a median age of 57 years (interquartile range [IQR] 51-64) were included. Grade III or higher HAIP-related postoperative complications were found in two patients (10%), both of whom had a reoperation (without laparotomy) to replace a pump with a slow flow rate or to reposition a flipped pump. No arterial bleeding, arterial dissection, arterial thrombosis, extrahepatic perfusion, pump pocket hematoma, or pump pocket infections were found within 90 days after surgery. After a median of 43 days (IQR 29-52) following surgery, all patients received the first dose of HAIP chemotherapy, which was completed uneventfully in all patients.

Conclusion: Pump implantation is safe, and administration of HAIP chemotherapy is feasible, in patients with resectable CRLMs, after training of a dedicated multidisciplinary team.
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http://dx.doi.org/10.1245/s10434-019-07973-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863781PMC
December 2019

A patient- and assessor-blinded randomized controlled trial of axillary reverse mapping (ARM) in patients with early breast cancer.

Eur J Surg Oncol 2020 01 5;46(1):59-64. Epub 2019 Aug 5.

Department of Surgery, Amphia Hospital, Breda, the Netherlands.

Background: Axillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement.

Methods: Peroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomized study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk.

Results: No significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p < 0.05). No axillary recurrence was found in both groups.

Conclusions: In contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity.
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http://dx.doi.org/10.1016/j.ejso.2019.08.003DOI Listing
January 2020

Diffusion-weighted imaging of hepatocellular carcinoma before and after transarterial chemoembolization: role in survival prediction and response evaluation.

Abdom Radiol (NY) 2019 08;44(8):2740-2750

Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, NL, The Netherlands.

Background: Survival outcomes of patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE) are heterogeneous. Measuring the apparent diffusion coefficient (ADC) using diffusion-weighted imaging (DWI) may improve overall survival prediction.

Aim: To assess the value of measuring the ADC before and after TACE in predicting overall survival.

Methods: A retrospective analysis was performed in HCC patients treated with TACE at a tertiary referral center between 2008 and 2017. The ADC values and changes in ADC value (ΔADC) of HCC lesions (≥ 1 cm) and liver parenchyma were assessed by DWI ≤ 3 months before and after first TACE. Pre- and post-TACE ADC values were compared with tumor response according to mRECIST and correlated with overall survival (OS) in a univariable and multivariable Cox-regression analysis.

Results: A total of 89 patients were included, mostly Child-Pugh A (85%) and BCLC stage B (53%) with a median OS of 21.7 months (95% CI 17.6-25.9). Tumor ADC increased from 1081 mm/s before (IQR 964-1225) to 1328 mm/s (IQR 1197-1560) after TACE (p < 0.001). Responders according to mRECIST showed a higher ΔADC after first TACE than non-responders (26 vs. 14%, p = 0.048). Pre-TACE ADC and ΔADC were not significantly associated with OS in both univariable and multivariable analysis, whereas response according to mRECIST remained an independent predictor of OS.

Conclusion: mRECIST was confirmed as an independent prognostic factor of OS, but pre- or post-TACE ADC measurements were not. Response according to mRECIST was associated with a higher increase in ADC than non-response.
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http://dx.doi.org/10.1007/s00261-019-02030-2DOI Listing
August 2019

Factors Affecting Oncologic Outcomes of 90Y Radioembolization of Heavily Pre-Treated Patients With Colon Cancer Liver Metastases.

Clin Colorectal Cancer 2019 03 13;18(1):8-18. Epub 2018 Sep 13.

Department of Interventional Oncology/Radiology, Memorial Sloan Kettering Cancer Center, New York, NY. Electronic address:

Introduction: The purpose of this study was to identify predictors of overall (OS) and liver progression-free survival (LPFS) following Yttrium-90 radioembolization (RAE) of heavily pretreated patients with colorectal cancer liver metastases (CLM), as well as to create and validate a predictive nomogram for OS.

Materials And Methods: Metabolic, anatomic, laboratory, pathologic, genetic, primary disease, and procedure-related factors, as well as pre- and post-RAE therapies in 103 patients with CLM treated with RAE from September 15, 2009 to March 21, 2017 were analyzed. LPFS was defined by Response Evaluation Criteria In Solid Tumors 1.1 and European Organization for Research and Treatment of Cancer criteria. Prognosticators of OS and LPFS were selected using univariate Cox regression, adjusted for clustering and competing risk analysis (for LPFS), and subsequently tested in multivariate analysis (MVA). The nomogram was built using R statistical software and internally validated using bootstrap resampling.

Results: Patients received RAE at a median of 30.9 months (range, 3.4-161.7 months) after detection of CLM. The median OS and LPFS were 11.3 months (95% confidence interval, 7.9-15.1 months) and 4 months (95% confidence interval, 3.3-4.8 months), respectively. Of the 40 parameters tested, 6 were independently associated with OS in MVA. These baseline parameters included number of extrahepatic disease sites (P < .001), carcinoembryonic antigen (P < .001), albumin (P = .005), alanine aminotransferase level (P < .001), tumor differentiation level (P < .001), and the sum of the 2 largest tumor diameters (P < .001). The 1-year OS of patients with total points of < 25 versus > 80 was 90% and 10%, respectively. Bootstrap resampling showed good discrimination (optimism corrected c-index = 0.745) and calibration (mean absolute prediction error = 0.299) of the nomogram. Only baseline maximum standardized uptake value was significant in MVA for LPFS prediction (P < .001; SHR = 1.06).

Conclusion: The developed nomogram included 6 pre-RAE parameters and provided good prediction of survival post-RAE in heavily pretreated patients. Baseline maximum standardized uptake value was the single significant predictor of LPFS.
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http://dx.doi.org/10.1016/j.clcc.2018.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884072PMC
March 2019

Transarterial Radioembolization Following Chemoembolization for Unresectable Hepatocellular Carcinoma: Response Based on Apparent Diffusion Coefficient Change is an Independent Predictor for Survival.

Cardiovasc Intervent Radiol 2018 Nov 5;41(11):1716-1726. Epub 2018 Jun 5.

Department of Radiology, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium.

Purpose: To evaluate whether response based on contrast-enhanced magnetic resonance imaging (MRI) and apparent diffusion coefficient (ADC) change at diffusion-weighted MRI after transarterial radioembolization (TARE) can predict survival, in patients with prior transarterial chemoembolization with drug-eluting beads (DEB-TACE) for hepatocellular carcinoma (HCC).

Methods: We identified all patients who received DEB-TACE prior to TARE for HCC between 2007 and 2016. Response on MRI was determined by modified RECIST (mRECIST) and ADC change relative to pre-TARE imaging (ADCratio). Kaplan-Meier and log-rank tests were used to correlate the response/disease and treatment variables to overall survival. Multivariable Cox regression models were used to correct for confounders.

Results: A total of 29 consecutive patients were included. Univariable analysis showed that response determined by mRECIST was a nonsignificant predictor of survival (p = 0.057), and response determined by ADCratio was a significant predictor of survival (p = 0.011). Number of prior DEB-TACE procedures (p = 0.037), female gender (p < 0.001) and BCLC C (p = 0.03) were related to worse survival. The number of prior DEB-TACE procedure was significantly higher in non-responders determined by ADCratio (p = 0.028). Multivariable analyses showed that response based on ADCratio was an independent predictor of survival (p = 0.041).

Conclusion: ADCratio following TARE is an independent predictor for survival in patients who previously underwent DEB-TACE for HCC.
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http://dx.doi.org/10.1007/s00270-018-1991-3DOI Listing
November 2018

Safety and Efficacy of Transarterial Radioembolisation in Patients with Intermediate or Advanced Stage Hepatocellular Carcinoma Refractory to Chemoembolisation.

Cardiovasc Intervent Radiol 2017 Dec 6;40(12):1882-1890. Epub 2017 Jul 6.

Department of Radiology, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium.

Introduction: Transarterial chemoembolisation (TACE) is the most widely used locoregional treatment for patients with an unresectable hepatocellular carcinoma (HCC). Transarterial radioembolisation (TARE) with yttrium-90 containing microspheres is an emerging interventional treatment that could be complementary or an alternative to TACE.

Aim: To evaluate the safety and efficacy of TARE in patients with HCC who are refractory to TACE with drug-eluting beads (DEB-TACE).

Methods: We identified all patients who received TARE for HCC following one or more sessions of DEB-TACE in the period 2007-2016. Grade ≥3 adverse events were graded according to Common Terminology Criteria for Adverse events. Response on MRI was determined on MRI by modified RECIST. Overall survival was estimated using the Kaplan-Meier method and was determined from the first TACE and from the TARE procedure.

Results: A total of 30 patients were included. Patients had a mean of 1.7 TACE procedures (range 1-4) prior to TARE. Grade 3 adverse events following TARE included: fatigue (20%), bilirubin increase (10%), cholecystitis (3.3%) and a gastric ulcer (3.3%). Response on MRI was achieved in 36.7%. Three patients (10%) were downstaged within the Milan criteria and received liver transplantation. The median overall survival after first TACE was 32.3 months (17.2-42.1 95% CI). The median overall survival after TARE was 14.8 months (8.33-26.5 95% CI).

Conclusion: TARE is safe and can be effective in patients with an intermediate or advanced stage HCC who are refractory to TACE. This treatment strategy has the potential to downstage to liver transplantation.
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http://dx.doi.org/10.1007/s00270-017-1739-5DOI Listing
December 2017

Axillary reverse mapping in axillary surgery for breast cancer: an update of the current status.

Breast Cancer Res Treat 2016 08 21;158(3):421-32. Epub 2016 Jul 21.

Department of Surgery, Amphia Hospital, Molengracht 21, 4818, Breda, The Netherlands.

Axillary reverse mapping (ARM) is a technique by which the lymphatic drainage of the upper extremity that traverses the axillary region can be differentiated from the lymphatic drainage of the breast during axillary lymph node dissection (ALND). Adding this procedure to ALND may reduce upper extremity lymphedema by preserving upper extremity drainage. This review of the current literature on the ARM procedure discusses the feasibility, safety and relevance of this technique. A PubMed literature search was performed until 12 August 2015. A total of 31 studies were included in this review. The studies indicated that the ARM procedure adequately identifies the upper extremity lymph nodes and lymphatics in the axillary basin using blue dye or fluorescence. Preservation of ARM lymph nodes and corresponding lymphatics was proven to be oncologically safe in clinically node-negative breast cancer patients with metastatic lymph node involvement in the sentinel lymph node (SLN) who are advised to undergo a completion ALND. The ARM procedure is technically feasible with a high visualisation rate using blue dye or fluorescence. ALND combined with ARM can be regarded as a promising surgical refinement in order to reduce the incidence of upper extremity lymphedema in selected groups of patients.
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http://dx.doi.org/10.1007/s10549-016-3920-yDOI Listing
August 2016

Type and Extent of Surgery for Screen-Detected and Interval Cancers at Blinded Versus Nonblinded Double-Reading in a Population-Based Screening Mammography Program.

Ann Surg Oncol 2016 11 22;23(12):3822-3830. Epub 2016 Jun 22.

Department of Radiology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.

Background: This study aimed to compare the type and extent of surgery in patients with screen-detected and interval cancers after blinded or nonblinded double-reading of screening mammograms.

Methods: The study investigated a consecutive series of screens double-read in either a blinded (n = 44,491) or nonblinded (n = 42,996) fashion between 2009 and 2011. During a 2 year follow-up period, the radiology reports, surgical correspondence, and pathology reports of all the screen-detected and interval cancers were collected.

Results: Screen-detected breast cancer was diagnosed for 325 women at blinded and 284 women at nonblinded double-reading. The majority of the women were treated by breast-conserving surgery (BCS) at both reading strategies (78.2 vs. 81.7 %; p = 0.51). Larger total resection volumes were observed at BCS for ductal carcinoma in situ (DCIS) treatment for patients after blinded double-reading (p = 0.005). The proportions of positive resection margins after BCS were comparable for patients with DCIS (p = 0.81) or invasive screen-detected cancers (p = 0.38) for the two reading strategies. A total of 158 interval cancers were diagnosed. The proportions of patients treated with BCS were comparable for the two reading strategies (p = 0.42). The total resection volume (p = 0.13) and the proportion of positive resection margins after BCS (p = 0.32) for invasive interval cancer were comparable for the two cohorts. The BCS rate was higher for women after nonblinded double-reading (p = 0.04).

Conclusions: Blinded and nonblinded double-reading yielded comparable surgical treatments for women with screen-detected or interval breast cancer except for larger total resection volumes at BCS for screen-detected DCIS and a higher BCS rate for interval cancers at nonblinded double-reading.
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http://dx.doi.org/10.1245/s10434-016-5295-zDOI Listing
November 2016

Comparison of the diagnostic workup of women referred at non-blinded or blinded double reading in a population-based screening mammography programme in the south of the Netherlands.

Br J Cancer 2015 Sep 18;113(7):1094-8. Epub 2015 Aug 18.

Department of Radiology, Canisius Wilhelmina Hospital, PO Box 9015, 6500 GS Nijmegen, The Netherlands.

Background: To determine whether referred women experience differences in diagnostic workup at non-blinded or blinded double reading of screening mammograms.

Methods: We included a consecutive series of respectively 42.996 and 44.491 screens, double read either in a non-blinded or blinded manner between 2009 and 2011. This reading strategy was alternated on a monthly basis.

Results: The overall ultrasound-guided core needle biopsy (CNB) rate and stereotactic CNB (SCNB) rate per 1000 screens were higher at blinded than at non-blinded reading (7.5 vs 6.0, P=0.008 and 8.1 vs 6.6, P=0.009). Among women with benign workup, these rates were higher at blinded reading (2.6 vs 1.4, P<0.001 and 5.9 vs 4.7, P=0.013). The benign biopsy rates were higher at blinded double reading (P<0.001), whereas the positive predictive value of biopsy did not differ (P=0.103).

Conclusions: Blinded double-reading results in higher overall CNB and SCNB rates than non-blinded double reading, as well as a higher benign biopsy rate.
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http://dx.doi.org/10.1038/bjc.2015.295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4651120PMC
September 2015

Discrepant screening mammography assessments at blinded and non-blinded double reading: impact of arbitration by a third reader on screening outcome.

Eur Radiol 2015 Oct 18;25(10):2821-9. Epub 2015 Apr 18.

Department of Radiology, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands,

Objectives: To determine the value of adding a third reader for arbitration of discrepant screening mammography assessments.

Methods: We included a consecutive series of 84,927 digital screening mammograms, double read in a blinded or non-blinded fashion. Arbitration was retrospectively performed by a third screening radiologist. Two years' follow-up was performed.

Results: Discrepant readings comprised 57.2% (830/1452) and 29.1% (346/1188) of recalls at blinded and non-blinded double readings, respectively. At blinded double reading, arbitration would have decreased recall rate (3.4 to 2.2%, p < 0.001) and programme sensitivity (83.2 to 76.0%, p = 0.013), would not have influenced the cancer detection rate (CDR; 7.5 to 6.8 per 1,000 screens, p = 0.258) and would have increased the positive predictive value of recall (PPV; 22.3 to 31.2%, p < 0.001). At non-blinded double reading, arbitration would have decreased recall rate (2.8 to 2.3%, p < 0.001) and increased PPV (23.2 to 27.5%, p = 0.021), but would not have affected CDR (6.6 to 6.3 per 1,000 screens, p = 0.604) and programme sensitivity (76.0 to 72.7%, p = 0.308).

Conclusion: Arbitration of discrepant screening mammography assessments is a good tool to improve recall rate and PPV, but is not desirable as it reduces the programme sensitivity at blinded double reading.

Key Points: • Blinded double reading results in higher programme sensitivity than non-blinded reading. • Discrepant readings occur more often at blinded compared to non-blinded reading. • Arbitration of discrepant readings reduces the recall rate and PPV. • Arbitration would reduce the programme sensitivity at blinded double reading.
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http://dx.doi.org/10.1007/s00330-015-3711-6DOI Listing
October 2015

Blinded double reading yields a higher programme sensitivity than non-blinded double reading at digital screening mammography: a prospected population based study in the south of The Netherlands.

Eur J Cancer 2015 Feb 5;51(3):391-9. Epub 2015 Jan 5.

Department of Radiology, Canisius Wilhelmina Hospital, PO Box 9015, 6500 GS Nijmegen, The Netherlands.

Purpose: To prospectively determine the screening mammography outcome at blinded and non-blinded double reading in a biennial population based screening programme in the south of the Netherlands.

Methods: We included a consecutive series of 87,487 digital screening mammograms, obtained between July 2009 and July 2011. Screening mammograms were double read in either a blinded (2nd reader was not informed about the 1st reader's decision) or non-blinded fashion (2nd reader was informed about the 1st reader's decision). This reading strategy was alternated on a monthly basis. Women with discrepant readings between the two radiologists were always referred for further analysis. During 2 years follow-up, we collected the radiology reports, surgical correspondence and pathology reports of all referred women and interval breast cancers.

Results: Respectively 44,491 and 42,996 screens had been read either in a blinded or non-blinded fashion. Referral rate (3.3% versus 2.8%, p<0.001) and false positive rate (2.6% versus 2.2%, p=0.002) were significantly higher at blinded double reading whereas the cancer detection rate per 1000 screens (7.4 versus 6.5, p=0.14) and positive predictive value of referral (22% versus 23%, p=0.51) were comparable. Blinded double reading resulted in a significantly higher programme sensitivity (83% versus 76%, p=0.01). Per 1000 screened women, blinded double reading would yield 0.9 more screen detected cancers and 0.6 less interval cancers than non-blinded double reading, at the expense of 4.4 more recalls.

Conclusion: We advocate the use of blinded double reading in order to achieve a better programme sensitivity, at the expense of an increased referral rate and false positive referral rate.
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http://dx.doi.org/10.1016/j.ejca.2014.12.008DOI Listing
February 2015

Re-attendance at biennial screening mammography following a repeated false positive recall.

Breast Cancer Res Treat 2014 Jun 19;145(2):429-37. Epub 2014 Apr 19.

Department of Radiology, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands,

We determined the re-attendance rate at screening mammography after a single or a repeated false positive recall and we assessed the effects of transition from screen-film mammography (SFM) to full-field digital mammography (FFDM) on screening outcome in women recalled twice for the same mammographic abnormality. The study population consisted of a consecutive series of 302,912 SFM and 90,288 FFDM screens. During a 2 years follow-up period (until the next biennial screen), we collected the breast imaging reports and biopsy results of all recalled women. Re-attendance at biennial screening mammography was 93.2 % (95 % CI 93.1-93.3 %) for women with a negative screen (i.e., no recall at screening mammography), 65.4 % (95 % CI 64.0-66.8 %) for women recalled once, 56.7 % (95 % CI 47.1-66.4 %) for women recalled twice but for different lesions and 44.3 % (95 % CI 31.4-57.1 %) for women recalled twice for the same lesion. FFDM recalls comprised a significantly larger proportion of women who had been recalled twice for the same lesion (1.9 % of recalls (52 women) at FFDM vs. 0.9 % of recalls (37 women) at SFM, P < 0.001) and the positive predictive value of these recalls (PPV) was significantly lower at FFDM (15.4 vs. 35.1 %, P = 0.03). At review, 20 of 52 women (39.5 %, all with benign outcome) would not have been recalled for a second time at FFDM if the previous hard copy SFM screen had been available for comparison. We conclude that a repeated false positive recall for the same lesion significantly lowered the probability of screening re-attendance. The first round of FFDM significantly increased the proportion of women recalled twice for the same lesion, with a significantly lower PPV of these lesions. Almost 40 % of repeatedly recalled women would not have been recalled the second time if the previous hard copy SFM screen had been available for comparison at the time of FFDM.
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http://dx.doi.org/10.1007/s10549-014-2959-xDOI Listing
June 2014

Treatment of temporal artery pseudoaneurysms.

Vascular 2014 Aug 11;22(4):274-9. Epub 2013 Jun 11.

Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan, The Netherlands.

Purpose: To give an overview of the etiology and diagnostic process of superficial temporal artery pseudoaneurysms and to evaluate different treatment modalities.

Basic Methods: PubMed was used for searching multiple databases for relevant clinical studies.

Principal Findings: A total of 62 studies were included, harboring 82 patients. Surgical excision is the most frequently described treatment, but less invasive treatment modalities as coiling and thrombin injections are gaining popularity. Surgical treatment was successful in all cases (67/67). Endovascular treatment was successful in 69% (9/13); the five cases treated with thrombin injection were all successful. Complementary, a description of our experience with thrombin injection is given.

Conclusions: Limited evidence of minimal invasive treatment for superficial temporal artery pseudoaneurysm is available. Based on this review combined with our limited experience, we suggest thrombin injections to be considered as the future primary treatment modality. In the case of unsuccessful exclusion of the aneurysm, surgical excision can be performed.
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http://dx.doi.org/10.1177/1708538113487335DOI Listing
August 2014

The clinical relevance of axillary reverse mapping (ARM): study protocol for a randomized controlled trial.

Trials 2013 Apr 25;14:111. Epub 2013 Apr 25.

Department of Radiology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands.

Background: Axillary lymph node dissection (ALND) in patients with breast cancer has the potential to induce side-effects, including upper-limb lymphedema. Axillary reverse mapping (ARM) is a technique that enables discrimination of the lymphatic drainage of the breast from that of the upper limb in the axillary lymph node (LN) basin. If lymphedema is caused by removing these lymphatics and nodes in the upper limb, the possibility of identifying these lymphatics would enable surgeons to preserve them. The aim of this study is to determine the clinical relevance of selective axillary LN and lymphatic preservation by means of ARM. To minimize the risk of overlooking tumor-positive ARM nodes and the associated risk of undertreatment, we will only include patients with a tumor-positive sentinel lymph node (SLN). Patients who are candidates for ALND because of a proven positive axillary LN at clinical examination can be included in a registration study.

Methods/design: The study will enroll 280 patients diagnosed with SLN biopsy-proven metastasis of invasive breast cancer with an indication for a completion ALND. Patients will be randomized to undergo standard ALND or an ALND in which the ARM nodes and their corresponding lymphatics will be left in situ. Primary outcome is the presence of axillary surgery-related lymphedema at 6, 12, and 24 months post-operatively, measured by the water-displacement method. Secondary outcome measures include pain, paresthesia, numbness, and loss of shoulder mobility, quality of life, and axillary recurrence risk.

Discussion: The benefit of ALND in patients with a positive SLN is a subject of debate. For many patients, an ALND will remain the treatment of choice. This multicenter randomized trial will provide evidence of whether or not axillary LN preservation by means of ARM decreases the side-effects of an ALND. Enrolment of patients will start in April 2013 in five breast-cancer centers in the Netherlands, and is expected to conclude by April 2016.

Trial Registration: TC3698.
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http://dx.doi.org/10.1186/1745-6215-14-111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663653PMC
April 2013

[Axillary reverse mapping. preserving nodes during an axillary lymph node dissection].

Ned Tijdschr Geneeskd 2013 ;157(22):A5646

Amphia Ziekenhuis, afd. Chirurgie, Breda.

A considerable percentage of breast cancer patients who have undergone an axillary lymph node dissection (ALND) experience postoperative complications, with lymphoedema occurring most frequently. Axillary Reverse Mapping (ARM) is a new technique in which the lymphatic drainage system of the upper extremity can be visualized during an ALND. If lymphoedema is caused by severing of the lymphatic drainage system or removal of its associated lymph nodes, the preservation of these structures should reduce the incidence of lymphoedema. Patients who might benefit from ARM are patients for whom a subsequent ALND is indicated following a positive sentinel lymph node diagnostic procedure, and perhaps also patients who have an indication for a primary ALND following neo-adjuvant chemotherapy. A multicenter RCT is to start in the near future, during which we will investigate whether the preservation of axillary lymph nodes results in reduced morbidity.
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August 2013

[A man with a bump on his forehead after a fall].

Ned Tijdschr Geneeskd 2013 ;157(8):A4231

Catharina ziekenhuis, Afd. Radiologie, Eindhoven, the Netherlands.

Unlabelled: An 84-year-old male patient presented with a swelling on his forehead which had developed gradually over a period of three weeks after a fall. Ultrasound examination revealed a complex fluid collection with a yin-yang flow pattern (revealed by colour Doppler imaging), which was suggestive of a pseudoaneurysm of the frontal branch of the superficial temporal artery. This was successfully treated with an injection of thrombin.

Diagnosis: traumatic pseudoaneurysm of the superficial temporal artery.
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April 2013

David procedure during a reoperation for ongoing chronic Q fever infection of an ascending aortic prosthesis.

Eur J Cardiothorac Surg 2012 Jul 24;42(1):e19-20. Epub 2012 May 24.

Department of Medical Microbiology, Laboratory for Pathology and Medical Microbiology (PAMM), Veldhoven, Netherlands.

Chronic Q fever infections, caused by Coxiella burnetii, are associated with cardiovascular complications, mainly endocarditis and vascular (graft) infections. We report a case of a patient with a C. burnetii infected thoracic aorta graft treated initially in a conservative way. However, surgical excision of the infected graft was eventually necessary. This case report highlights the challenges regarding the treatment of patients with chronic vascular C. burnetii infections. In the absence of practical guidelines, treatment is tailored to the individual patient. Furthermore, we want to emphasize the need to include chronic Q fever in the differential diagnosis in patients with culture negative aortitis, especially in the regions with Q fever epidemics in the recent past.
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http://dx.doi.org/10.1093/ejcts/ezs217DOI Listing
July 2012

[Intestinal ischaemia caused by acute mesenteric vein thrombosis].

Ned Tijdschr Geneeskd 2011 ;155(44):A3598

Afd. Radiologie, Catharina Ziekenhuis, Eindhoven, the Netherlands.

Acute mesenteric vein thrombosis is an uncommon cause of intestinal ischaemia, with a considerable morbidity and mortality rate. There is a delay in diagnosis owing to the fact that patients present with non-specific abdominal symptoms; there is often a low level of suspicion by the clinician. We discuss the case histories of a 23 year-old woman and a 49 year-old woman with intestinal ischaemia caused by acute mesenteric vein thrombosis. These patients presented at two different hospital emergency departments. In patients with acute, progressive abdominal complaints, mesenteric vein thrombosis must be included in the differential diagnosis, especially if there are thromboembolic risk factors. In such patients, CT angiography (CTA) must be performed during the arterial and portal-venous phase to evaluate the mesenteric circulation.
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January 2012
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