Background
The incidence of skin cancer is rapidly increasing, leading to a growing amount of general practitioner (GP) consultations of patients with suspected skin lesions. It is essential that GPs ...have good training skills to differentiate between benign and malignant skin lesions. Dermoscopy in addition to clinical examination can help them to develop these skills.
Objectives
In this article, we examine the effect of a 2‐day training course in dermoscopy among Dutch GPs.
Methods
The educational intervention was designed as blended learning and consisted of a 2‐day training course on dermoscopy, clinical features, and management of patients with suspected skin lesions in primary care. Before the training course, all participants were required to take a test (T0). This test was repeatedly administered at the end of the second course day (T1) and within 6 months after completion of the course (T2). Outcomes were the specificity and sensitivity of recognizing skin lesions and the changes between the test moments.
Results
In total, 400 GPs participated in the training course. At T1, the specificity for detecting benign lesions was higher than at T0 (0.91 vs. 0.75). This specificity remains at the same level at T2, 6 months after the course (0.91 p < 0.001). The sensitivity for detecting malignant lesions stayed about the same level: 0.80 at T0 and 0.84 at T2 (p < 0.001).
Conclusions
The results of our study show a sustaining positive effect of a 2‐day training course on detecting benign skin lesions by GPs.
Urinary incontinence negatively influences the lives of 25-50% of elderly women, mostly due to feelings of shame and being limited in activities and social interactions. This study explores whether ...differences exist between types of urinary incontinence (stress, urgency or mixed) and severity of the symptoms, with regard to their effects on generic and condition-specific quality of life.
This is a cross-sectional study among participants of a randomized controlled trial in primary care. A total of 225 women (aged ≥ 55 years) completed a questionnaire (on physical/emotional impact and limitations) and were interviewed for demographic characteristics and co-morbidity. Least squares regression analyses were conducted to estimate differences between types and severity of urinary incontinence with regard to their effect on quality of life.
Most patients reported mixed urinary incontinence (50.7%) and a moderate severity of symptoms (48.9%). Stress urinary incontinence had a lower impact on the emotional domain of condition-specific quality of life compared with mixed urinary incontinence (r = -7.81). There were no significant associations between the types of urinary incontinence and generic quality of life. Severe symptoms affected both the generic (r = -0.10) and condition-specific (r = 17.17) quality of life.
The effects on condition-specific quality of life domains differ slightly between the types of incontinence. The level of severity affects both generic and condition-specific quality of life, indicating that it is not the type but rather the severity of urinary incontinence that is the main predictor of decreased quality of life.
OBJECTIVE:This meta-analysis determines whether increased lymph node yield improves survival in patients with esophageal cancer undergoing esophagectomy with or without neoadjuvant therapy.
...BACKGROUND:Esophagectomy involves resection of the esophagus and surrounding lymph nodes, which are commonly the first stations of cancer spread. The extent of lymphadenectomy during esophagectomy remains controversial, with several studies publishing conflicting results, especially in the era of neoadjuvant therapy.
METHODS:An electronic literature search was undertaken using Embase, Medline, and the Cochrane library databases (2000 to 2017). Articles with esophageal cancer patients undergoing esophagectomy with lymphadenectomy and investigating the effects of low and high lymph node yield on overall survival and disease-free survival were included. Meta-analysis of data was conducted using a random effects model. If the study divided the cohort into multiple groups based on lymph node yield, survival was compared between the lowest and highest lymph node yield groups. In addition to analysis of the entire cohort, subset analysis of only those patients receiving neoadjuvant therapy was also performed.
RESULTS:A total of 26 studies were included in this meta-analysis with a follow-up ranging from 15 to 94 months. For the analysis of overall survival, 23 studies were included. A meta-analysis showed that overall survival significantly improved in the high lymph node yield group hazard ratio (HR) = 0.81; 95% confidence interval (95% CI) = 0.74–0.87; P < 0.01. In the 10 studies describing disease-free survival, this was significantly improved in the high lymph node yield group (HR = 0.72; 95% CI = 0.62–0.84; P < 0.01). Subset analysis of neoadjuvant-treated patients demonstrated a survival benefit of high lymph node yield on overall survival (HR = 0.82; 95% CI = 0.73–0.92; P < 0.01).
CONCLUSION:This meta-analysis demonstrates the benefit of an increased lymph node yield from esophagectomy on overall and disease-free survival. In addition, a survival benefit of a high lymph node yield was demonstrated in patients receiving neoadjuvant therapy followed by esophagectomy.
OBJECTIVE:To evaluate the impact of lymph node yield (LNY) on survival in patients treated with neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for cancer.
BACKGROUND:The value of an ...extended lymphadenectomy after nCRT for esophageal cancer is debated. Recent reports demonstrate no association between LNY and survival. This association has not yet been evaluated in larger cohorts.
METHODS:All patients who underwent nCRT followed by esophagectomy between 2005 and 2014 were identified from the Netherlands Cancer Registry. The association between LNY and overall survival was analyzed using multivariable Cox regression analyses, adjusting for diagnosis year, referral, hospital volume, age, sex, malignancy history, tumor location, histology, cTN-stage, surgical approach, radicality, and ypTN-stage. Analyses were performed with LNY as categorized predictor (<15 vs ≥15 nodes) and continuous predictor (per 10 additionally nodes).
RESULTS:A total of 2698 patients were included with a median overall survival of 34 months (range 4–143). A higher LNY was significantly associated with improved overall survival, both as categorized predictor (hazard ratio 0.77, 95% confidence interval 0.68–0.86) and as continuous predictor (hazard ratio 0.84, 95% confidence interval 0.78–0.90). Furthermore, a higher LNY was associated with favorable hazard ratios across subgroups, including both squamous cell carcinoma and adenocarcinoma, both cN0 and cN+, both transthoracic and transhiatal approaches, and both ypN0 and ypN+.
CONCLUSIONS:This large population-based cohort study demonstrates an association between LNY and overall survival, indicating a therapeutic value of extended lymphadenectomy during esophagectomy. Therefore, an extended lymphadenectomy should be the standard of care after nCRT.
Individual variability in prognosis of esophageal cancer highlights the need for advances in personalized therapy. This systematic review aimed at elucidating the prognostic role of gene expression ...profiles and at identifying gene signatures to predict clinical outcome.
A systematic search of the Medline, Embase and the Cochrane library databases (2000-2015) was performed. Articles associating gene expression profiles in patients with esophageal adenocarcinoma or squamous cell carcinoma to survival, response to chemo(radio)therapy and/or lymph node metastasis were identified. Differentially expressed genes and gene signatures were extracted from each study and combined to construct a list of prognostic genes per outcome and histological tumor type.
This review includes a total of 22 studies. Gene expression profiles were related to survival in 9 studies, to response to chemo(radio)therapy in 7 studies, and to lymph node metastasis in 9 studies. The studies proposed many differentially expressed genes. However, the findings were heterogeneous and only 12 (ALDH1A3, ATR, BIN1, CSPG2, DOK1, IFIT1, IFIT3, MAL, PCP4, PHB, SPP1) of the 1.112 reported genes were identified in more than 1 study. Overall, 16 studies reported a prognostic gene signature, which was externally validated in 10 studies.
This systematic review shows heterogeneous findings in associating gene expression with clinical outcome in esophageal cancer. Larger validated studies employing RNA next-generation sequencing are required to establish gene expression profiles to predict clinical outcome and to select optimal personalized therapy.
OBJECTIVE:The aim of this study was to determine whether weekday of esophagectomy impacts 30-day mortality, and short- and long-term oncologic outcomes in esophageal cancer.
SUMMARY OF BACKGROUND ...DATA:Recent literature suggests a relationship between the weekday of esophagectomy and overall survival. This finding could impact clinical practice, but has not yet been validated in other studies.
METHODS:The Netherlands Cancer Registry database (2005–2013) identified all patients who underwent esophagectomy for esophageal cancer. The impact of weekday on 30-day mortality, the total number of resected lymph nodes, and R0 resection rates was evaluated with multivariable logistic regression analyses and for overall survival with Cox regression analyses.
RESULTS:In total, 3840 patients were included. Weekday was not significantly associated with 30-day mortality (P > 0.05), nor the total number of resected lymph nodes (P > 0.05), nor with R0 resection rates (P > 0.05). Also, weekday did not significantly influence overall survival using weekday as discrete variable Monday–Friday, hazard ratio (HR) 0.98, P = 0.140), as 2 weekday categories (Wednesday–Friday vs Monday–Tuesday, HR 0.97, P = 0.434), or with separate weekday categories (Tuesday vs Monday, HR 0.99, P = 0.826; Wednesday vs Monday, HR 1.06, P = 0.430; Thursday vs Monday, HR 0.92, P = 0.206; Friday vs Monday, HR 0.91, P = 0.140).
CONCLUSIONS:This large population-based cohort study in the Netherlands refutes the finding from a previous report that suggests that the weekday of esophagectomy in patients diagnosed with potentially curable esophageal cancer impacts overall survival. In addition, this study demonstrates that weekday of esophagectomy does not influence other outcomes including the 30-day mortality, total number of resected lymph nodes, and R0 resection rates.
Abstract
Background
Adequate postoperative pain management is essential to facilitate uneventful recovery after esophagectomy. Although epidural analgesia is the gold standard, it is not satisfactory ...in all patients. The aim of this study was to describe the efficacy and complication profile of epidural analgesia after minimally invasive esophagectomy (MIE).
Methods
A total of 108 patients who underwent a robot-assisted (McKeown) MIE for esophageal cancer were included from a single center prospective database (2012–2015). The number of patients that could receive epidural analgesia, the sensory block range per day, the number of epidural top-ups, the need for escape pain mediation (i.e. intravenous opioids), the highest pain score per day (numeric rating scale, 0–10), and epidural-related complications were assessed until postoperative day (POD) 4.
Results
Epidural catheter placement was achieved in 101 patients (94%). A complete sensory block was found in 49% (POD1), 42% (POD 2), 20% (POD3), and 30% (POD4) of patients. An epidural top-up was performed in 26 patients (24%), which was successful in 22 patients. Escape pain medication in the form of intravenous opioids were given at least once in 49 out of 108 patients (45%) on POD 1, 2, 3, or 4. Overall median highest pain scores on the corresponding days were 2.0 (range 0–10), 3.5 (range 0–9), 3.0 (range 0–8), and 4.0 (range 0–9). Epidural related complications occurred in 20 patients (19%) and included catheter problems (n = 11), hypotension (n = 6), bradypnea (n = 2), and reversible tingling in the legs (n = 1).
Conclusion
In conclusion, epidural analgesia is insufficient and escape pain medication is necessary in nearly half of patients undergoing MIE.
Disclosure
All authors have declared no conflicts of interest.
Background
The optimal treatment strategy for patients with esophageal adenocarcinoma (EAC) remains undetermined. This study compared outcomes in patients undergoing neoadjuvant chemotherapy (nCT) ...and neoadjuvant chemoradiotherapy (nCRT) for EAC.
Methods
Patients who underwent nCT or nCRT followed by surgery for EAC were identified from a prospective database (2000‐2017) and included. After propensity score matching, the impact of the treatments on postoperative complications, in‐hospital mortality, pathological outcomes, and survival rates were compared.
Results
Of the 396 eligible patients, 262 patients were analysed following matching with 131 patients in both groups. There were no significant differences between the nCT and nCRT groups for overall complications (59% vs 57%, P = 0.802) or in‐hospital mortality (2% vs 0%, P = 0.156). Patients who had nCRT had more R0 resections (93% vs 83%, P = 0.013), and higher pathological complete response rates (15% vs 5%, P < 0.001). No differences in 5‐year overall survival rates (nCT vs nCRT; 44% vs 33%, P = 0.645) were found.
Conclusion
In this study no differences between nCT and nCRT were seen in postoperative complications and in‐hospital mortality in patients treated for EAC. Inspite of improved complete resection and pathological response there was no difference in the overall survival between the treatment modalities.
Abstract
Background
MIE is becoming more common and is considered safe. There are few studies supporting laparoscopy in favor of laparotomy for the abdominal part of a three-field esophagectomy and ...long term survival data are scarce. The objective was to compare open esophagectomy (OE), with hybdrid thoracoscopic-laparotomic esophagectomy (HMIE) and minimally invasive esophagectomy (MIE) with regard to surgical outcomes, postoperative complications and survival.
Methods
A prospective database of esophageal resection for cancer at a single centre identified 243 OE, 688 HMIE and 80 MIE procedures. Propensity scores were used to match 80 patients in each group adjusting for age, gender, weight, clinical stage, neoadjuvant treatment, and year of surgery.
Results
Respiratory complications were more common after OE (49%) than after MIE (31%, P = 0.02). Median operative time was longer for MIE (330 minutes) versus HMIE or OE (both 300 minutes, P < 0.001). Median length of stay was shorter following MIE (12 days) compared with HMIE (14 days) and OE (15 days), P = 0.001. There were no significant differences between groups with respect to other complications, median number of lymph nodes examined (22–23 for all groups), or R0 resection rate (range 85–91%) for all groups. There was no difference in 5-year overall survival between groups.
Conclusion
Compared with OE and HMIE, MIE was associated with shorter length of stay and fewer respiratory complications, but longer operative time. Thus, there may be additional benefit for MIE without comprising oncological outcomes.
Disclosure
All authors have declared no conflicts of interest.
The aim of this population-based cohort study was to determine whether the addition of neoadjuvant chemoradiotherapy (nCRT) to surgery is associated with improved pathologic outcomes and survival in ...patients with cT2N0M0 esophageal cancer.
Patients who underwent nCRT followed by surgery or surgery alone for cT2N0M0 esophageal cancer were identified from The Netherlands Cancer Registry database (2005–2014). Accuracy of clinical staging was assessed using the resection specimen as gold standard. After propensity score matching, influences of both treatment strategies on radical resection (R0) rates and overall survival were compared.
In total 533 patients were included; 353 underwent nCRT followed by surgery and 180 underwent surgery alone. In the nCRT group 32% of patients achieved a pathologic complete response. Clinical understaging was observed in 62% of the patients in the surgery alone group based on pT-stage (n = 30, 27%), pN-stage (n = 26, 23%), or both (n = 55, 50%). Propensity score matching resulted in 78 patients who underwent nCRT plus surgery versus 78 who underwent surgery alone. In the nCRT group radical resections were more frequently observed (99% vs. 89% p = 0.031) and resulted in improved 5-year overall survival (46% vs. 33%, p = 0.017).
In this population-based study, clinical staging of cT2N0M0 esophageal cancer was highly inaccurate. Compared to surgery alone, neoadjuvant chemoradiotherapy was associated with higher radical resection rates and improved overall survival.
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