Publications by authors named "R Aaltonen"

17 Publications

Characteristics of clinically node negative breast cancer patients needing preoperative MRI.

Surg Oncol 2021 Mar 31;38:101552. Epub 2021 Mar 31.

Department of Oncology, Turku University Hospital, Finland; University of Turku, Turku, Finland; Finnish Nuclear and Radiation Safety, Helsinki, Finland.

Background: International guidelines do not recommend magnetic resonance imaging (MRI) for all breast cancer patients at primary diagnostics. This study aimed to understand which patient or tumor characteristics are associated with the use of MRI. The role of MRI among other preoperative imaging methods in clinically node negative breast cancer was studied.

Material And Methods: Patient and tumor characteristics were analyzed in association with the use of MRI by multivariable logistic regression analysis in 461 patients. Primary tumor size was compared between MRI, mammography (MGR), ultrasound (US) and histopathology by Spearman correlation. The delays in surgery and diagnosis were analyzed among patients with or without MRI, and axillary reoperations were evaluated.

Results: Age (p < 0.0001), primary operation method (p < 0.0001), tumor histology (p < 0.0001) and HER2 status (p = 0.0064) were associated with the use of MRI. Spearman correlations between tumor size in histopathology and the difference in tumor size between histopathology and imaging methods were 0.52 in MGR, 0.66 in US and 0.36 in MRI (p < 0.0001 for all). A seven-day delay in surgical treatment was observed among patients with MRI compared to patients without MRI (p < 0.0001). Axillary reoperation rates were similar in patients with or without MRI (p = 0.57).

Conclusion: Patient selection through prearranged characterization is important in deciding on optimal candidates for preoperative MRI among breast cancer patients. MRI causes moderate delays in primary breast cancer surgery. Preoperative MRI is useful in the evaluation of tumor size but might be insufficient in detecting lymph node metastases.
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March 2021

Can a machine-learning model improve the prediction of nodal stage after a positive sentinel lymph node biopsy in breast cancer?

Acta Oncol 2020 Jun 9;59(6):689-695. Epub 2020 Mar 9.

Department of Oncology, Turku University Hospital, Turku, Finland.

The current standard for evaluating axillary nodal burden in clinically node negative breast cancer is sentinel lymph node biopsy (SLNB). However, the accuracy of SLNB to detect nodal stage N2-3 remains debatable. Nomograms can help the decision-making process between axillary treatment options. The aim of this study was to create a new model to predict the nodal stage N2-3 after a positive SLNB using machine learning methods that are rarely seen in nomogram development. Primary breast cancer patients who underwent SLNB and axillary lymph node dissection (ALND) between 2012 and 2017 formed cohorts for nomogram development (training cohort,  = 460) and for nomogram validation (validation cohort,  = 70). A machine learning method known as the gradient boosted trees model (XGBoost) was used to determine the variables associated with nodal stage N2-3 and to create a predictive model. Multivariate logistic regression analysis was used for comparison. The best combination of variables associated with nodal stage N2-3 in XGBoost modeling included tumor size, histological type, multifocality, lymphovascular invasion, percentage of ER positive cells, number of positive sentinel lymph nodes (SLN) and number of positive SLNs multiplied by tumor size. Indicating discrimination, AUC values for the training cohort and the validation cohort were 0.80 (95%CI 0.71-0.89) and 0.80 (95%CI 0.65-0.92) in the XGBoost model and 0.85 (95%CI 0.77-0.93) and 0.75 (95%CI 0.58-0.89) in the logistic regression model, respectively. This machine learning model was able to maintain its discrimination in the validation cohort better than the logistic regression model. This indicates advantages in employing modern artificial intelligence techniques into nomogram development. The nomogram could be used to help identify nodal stage N2-3 in early breast cancer and to select appropriate treatments for patients.
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June 2020

Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis.

BMJ 2018 02 27;360:k499. Epub 2018 Feb 27.

Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Objective: To estimate the regression, persistence, and progression of untreated cervical intraepithelial neoplasia grade 2 (CIN2) lesions managed conservatively as well as compliance with follow-up protocols.

Design: Systematic review and meta-analysis.

Data Sources: Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 1 January 1973 to 20 August 2016.

Eligibility Criteria: Studies reporting on outcomes of histologically confirmed CIN2 in non-pregnant women, managed conservatively for three or more months.

Data Synthesis: Two reviewers extracted data and assessed risk of bias. Random effects model was used to calculate pooled proportions for each outcome, and heterogeneity was assessed using I statistics.

Main Outcome Measures: Rates of regression, persistence, or progression of CIN2 and default rates at different follow-up time points (3, 6, 12, 24, 36, and 60 months).

Results: 36 studies that included 3160 women were identified (seven randomised trials, 16 prospective cohorts, and 13 retrospective cohorts; 50% of the studies were at low risk of bias). At 24 months, the pooled rates were 50% (11 studies, 819/1470 women, 95% confidence interval 43% to 57%; I=77%) for regression, 32% (eight studies, 334/1257 women, 23% to 42%; I=82%) for persistence, and 18% (nine studies, 282/1445 women, 11% to 27%; I=90%) for progression. In a subgroup analysis including 1069 women aged less than 30 years, the rates were 60% (four studies, 638/1069 women, 57% to 63%; I=0%), 23% (two studies, 226/938 women, 20% to 26%; I=97%), and 11% (three studies, 163/1033 women, 5% to 19%; I=67%), respectively. The rate of non-compliance (at six to 24 months of follow-up) in prospective studies was around 10%.

Conclusions: Most CIN2 lesions, particularly in young women (<30 years), regress spontaneously. Active surveillance, rather than immediate intervention, is therefore justified, especially among young women who are likely to adhere to monitoring.

Systematic Review Registration: PROSPERO 2014: CRD42014014406.
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February 2018

Reoperations for Female Stress Urinary Incontinence: A Finnish National Register Study.

Eur Urol Focus 2018 09 10;4(5):754-759. Epub 2017 Jun 10.

Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland; Obstetrics and Gynecology, University of Turku, Medical Faculty, Clinical Division, Turku, Finland.

Background: Subjective and objective cure rates after primary surgery for female stress urinary incontinence are good. Still, some women will undergo repeated operations for incontinence.

Objective: To study the reoperation rate after incontinence surgery and to compare the reoperation rates between different surgery types.

Design, Setting, And Participants: This national register-based study included all Finnish women who had surgery for stress urinary incontinence during a 23-yr study period (1987-2009), both in inpatient and outpatient hospital settings. Subcohorts for follow-up times of 5-yr and 10-yr were evaluated separately.

Outcome Measurements And Statistical Analysis: Primary operations, reoperation rate, patient age, time until reoperation.

Results And Limitations: A total of 38 500 women had surgery for stress urinary incontinence from 1987 to 2009. Two thousand and seventy-six women (7.2%) had a reoperation with a rate of 7.8/1000 woman-yr. The reoperation rate was 8.3/1000 women-yr after a Burch colposuspension and 4.8/1000 after a retropubic midurethral sling. In the 10-yr follow-up, reoperation was more common after a Burch compared with a retropubic midurethral sling (odds ratio: 1.6, 95% confidence interval: 1.3-1.9). There was no difference in the reoperation rate between retropubic and transobturator midurethral slings in the 5-yr follow-up.

Conclusions: Reoperation rate is lower after midurethral slings compared with Burch colposuspension.

Patient Summary: Mesh slings are surgically effective treatments for stress urinary incontinence. There are fewer reoperations after implanting these slings compared with older methods that do not use synthetic material. Different mesh slings have equally good results.
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September 2018

The Sentinel Node with Isolated Breast Tumor Cells or Micrometastases. Benefits and Risks of Axillary Dissection.

Anticancer Res 2017 07;37(7):3757-3762

Department of Oncology and Radiotherapy, Turku University Hospital, University of Turku, Turku, Finland

Background/aim: Sentinel lymph node (SLN) biopsy has become the standard procedure to identify metastases in axillary nodes in breast cancer. Even after careful SLN examination additional micrometastases and isolated tumor cells (ITCs) are sometimes found, resulting in a need for delayed axillary lymph node dissection (ALND). This study was undertaken to assess prognostic factors identifying additional axillary lymph node (ALN) metastases at delayed ALND.

Patients And Methods: To define the impact of late ALND regarding their outcome, 162 breast cancer patients with 169 operated breasts treated between 2010 and 2012 were evaluated, with follow-up through 2016. Data were collected on the patients, histology and biologic profile of the cancer, lymph node involvement, recurrence of breast cancer and adverse effects of ALND.

Results: With thorough examination and immunohistochemical stainings twenty-nine of 168 SLN biopsies (28 patients, 17% of the patients) showed micrometastases or ITC, and a full ALND was performed at a later time. During these ALNDs 13 to 31 lymph nodes were removed. Additional ALN metastases were found in three (10%) patients. Two (7%) of the 28 patients with triple-negative cancer deceased of metastatic breast cancer. Three patients (11%) reported adverse effects of ALND requiring physiotherapy due to pain, stiffness, swelling or arm oedema. Tumor factors such as molecular subtype (p=0.002), tumor size (p=0.004), and proliferation index (Ki-67) (p=0.003) correlated with higher numbers of ALN metastases.

Conclusion: Since most patients with micrometastases found in the primary operation showed no additional positive lymph nodes, completion ALND may not be required in patients with micrometastases or ITCs in the SLN. In our study, the predictive factors for additional ALN metastases were tumur size, molecular subtype and proliferation index. It is conceivable that the features of the primary tumor, rather than the amount of cancer cells in the SLN, might serve to identify patients in whom ALDN can be avoided.
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July 2017