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Abstract Background It is helpful in planning treatment for patients with ductal carcinoma in situ (DCIS) if the size and grade could be reliably predicted from the mammography. The aims of this study were to determine if the type of calcification can be best used to predict histopathological grade from the mammograms, to examine the association of mammographic appearance of DCIS with grade and to assess the correlation between mammographic size and pathological size. Methods Mammographic films and pathological slides of 115 patients treated for DCIS between 1986 and 2000 were reviewed and reclassified by a single radiologist and a single pathologist respectively. Prediction models for the European Pathologist Working Group (EPWG) and Van Nuys classifications were generated by ordinal regression. The association between mammographic appearance and grade was tested with the χ2-test. Relation of mammographic size with pathological size was established using linear regression. The relation was expressed by the correlation coefficient (r). Results The EPWG classification was correctly predicted in 68%, and the Van Nuys classification in 70% if DCIS was presented as microcalcifications. High grade was associated with presence of linear calcifications (p < 0.001). Association between mammograhic- and pathological size was better for DCIS presented as microcalcifications (r = 0.89, p < 0.001) than for DCIS presented as a density (r = 0.77, p < 0.001). Conclusions Prediction of histopathological grade of DCIS presenting as microcalcifications is comparable using the Van Nuys and EPWG classification. There is no strict association of mammographic appearance with histopathological grade. There is a better linear relation between mammographic- and pathological size of DCIS presented as microcalcifications than as a density, although both relations are statistically significant.

Background: Rapid genetic counseling and testing (RGCT) in newly diagnosed high-risk breast cancer (BC) patients may influence surgical treatment decisions. To successfully integrate RGCT in practice, knowledge of professionals', and patients' attitudes toward RGCT is essential., Methods: Between 2008 and 2010, we performed a randomized clinical trial evaluating the impact of RGCT. Attitudes toward and experience with RGCT were assessed in 265 patients (at diagnosis, 6- and 12-month follow-up) and 29 medical professionals (before and after the recruitment period)., Results: At 6-month follow-up, more patients who had been offered RGCT felt they had been actively involved in treatment decision-making than patients who had been offered usual care (67% vs 48%, P = 0.06). Patients who received DNA-test results before primary surgery reported more often that RGCT influenced treatment decisions than those who received results afterwards (P < 0.01). Eighty-seven percent felt that genetic counseling and testing (GCT) should preferably take place between diagnosis and surgery. Most professionals (72%) agreed that RGCT should be routinely offered to eligible patients. Most patients (74%) and professionals (85%) considered surgeons the most appropriate source for referral., Conclusions: RGCT is viewed as helpful for newly diagnosed high-risk BC patients in choosing their primary surgery and should be offered routinely by surgeons., (© 2017 Wiley Periodicals, Inc.)

Objective: Meta-analyses show that exercise interventions during cancer treatment reduce cancer-related fatigue. However, little is known about the cost-effectiveness of such interventions. Here we aim to assess the cost-effectiveness of the 18-week physical activity during cancer treatment (PACT) intervention for patients with breast and colon cancer. The PACT trial showed beneficial effects for fatigue and physical fitness., Design: Cost-effectiveness analyses with a 9-month time horizon (18 weeks of intervention and 18 weeks of follow-up) within the randomised controlled multicentre PACT study., Setting: Outpatient clinics of 7 hospitals in the Netherlands (1 academic and 6 general hospitals) PARTICIPANTS: 204 patients with breast cancer and 33 with colon cancer undergoing adjuvant treatment including chemotherapy., Intervention: Supervised 1-hour aerobic and resistance exercise (twice per week for 18 weeks) or usual care., Main Outcome Measures: Costs, quality-adjusted life years (QALY) and the incremental cost-effectiveness ratio., Results: For colon cancer, the cost-effectiveness analysis showed beneficial effects of the exercise intervention with incremental costs savings of €4321 and QALY improvements of 0.03. 100% of bootstrap simulations indicated that the intervention is dominant (ie, cheaper and more effective). For breast cancer, the results did not indicate that the exercise intervention was cost-effective. Incremental costs were €2912, and the incremental effect was 0.01 QALY. At a Dutch threshold value of €20 000 per QALY, the probability that the intervention is cost-effective was 2%., Conclusions: Our results suggest that the 18-week exercise programme was cost-effective for colon cancer, but not for breast cancer., Trial Registration Number: ISRCTN43801571., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Purpose: Fatigue is a common problem among colon cancer patients and typically increases during chemotherapy. Exercise during chemotherapy might have beneficial effects on fatigue. To investigate the short- and long-term effects of an exercise program in colon cancer patients during adjuvant treatment, the Physical Activity During Cancer Treatment study was conducted., Methods: In this multicenter randomized controlled trial, 33 colon cancer patients undergoing chemotherapy (21 men and 12 women) were randomly assigned to either a group receiving an 18-wk supervised exercise program (n = 17) or to usual care (n = 16). The primary outcome was fatigue as measured by the Multidimensional Fatigue Inventory and the Fatigue Quality List. Secondary outcomes were quality of life, physical fitness, anxiety, depression, body weight, and chemotherapy completion rate. Outcome assessment took place at baseline, postintervention (18 wk) and at 36 wk., Results: Intention-to-treat mixed linear model analyses showed that patients in the intervention group experienced significantly less physical fatigue at 18 wk and general fatigue at 36 wk (mean between group differences, -3.2; 95% confidence interval [CI], -6.2 to -0.2; effect size [ES], -0.9 and -2.7; 95% CI, -5.2 to -0.1; ES, -0.8, respectively), and reported higher physical functioning (12.3; 95% CI, 3.3-21.4; ES, 1.0) compared with patients in the usual care group., Conclusion: The Physical Activity During Cancer Treatment trial shows that an 18-wk supervised exercise program in colon cancer patients during chemotherapy is safe and feasible. The intervention significantly reduced physical fatigue at 18 wk and general fatigue at 36 wk. Considering the number of patients included in the present study, replication in a larger study population is required.

Purpose: Fecal incontinence is a major concern, and its incidence increases with age. Quality of life may decrease due to fecal incontinence after both sphincter-saving surgery and a rectal resection with a permanent stoma. This study investigated quality of life, with regard to fecal incontinency, in elderly patients after rectal-cancer surgery., Methods: All patients who underwent elective rectal surgery with anastomosis for rectal cancer between December 2008 and June 2012 at two Dutch hospitals were eligible for inclusion. The Wexner and the fecal incontinence quality of life (FIQoL) scores were collected. Young (<70 years of age) and elderly (≥70 years of age) patients were compared., Results: Seventy-nine patients were included, of whom 19 were elderly patients (24.1%). All diverting stomas that had been placed (n = 60, 75.9%) had been closed at the time of the study. There were no differences in Wexner or FIQoL scores between the young and the elderly patients. Also, there were no differences between patients without a diverting stoma and patients in whom bowel continuity had been restored. Elderly females had significantly worse scores on the FIQoL subscales of coping/behavior (P = 0.043) and depression/self-perception (P = 0.004) than young females. Elderly females scored worse on coping/behavior (P = 0.010) and depression/self-perception (P = 0.036) than elderly males. Young and elderly males had comparable scores., Conclusion: Quality of life with regard to fecal incontinency is worse in elderly females after sphincter-preserving surgery for rectal cancer. Patients should be informed of this impact, and a definite stoma may be considered in this patient group.

Purpose: Female breast cancer patients carrying a BRCA1/2 mutation have an increased risk of second primary breast cancer. Rapid genetic counseling and testing (RGCT) before surgery may influence choice of primary surgical treatment. In this article, we report on the psychosocial impact of RGCT., Methods: Newly diagnosed breast cancer patients at risk for carrying a BRCA1/2 mutation were randomized to an intervention group (offer of RGCT) or a usual care control group (ratio 2:1). Psychosocial impact and quality of life were assessed with the Impact of Events Scale, Hospital Anxiety and Depression Scale, Cancer Worry Scale, and the EORTC QLQ-C30 and QLQ-BR23. Assessments took place at study entry and at 6- and 12-month follow-up visits., Results: Between 2008 and 2010, 265 patients were recruited into the study. Completeness of follow-up data was more than 90%. Of the 178 women in the intervention group, 177 had genetic counseling, of whom 71 (40%) had rapid DNA testing and 59 (33%) received test results before surgery. Intention-to-treat and per-protocol analyses showed no statistically significant differences between groups over time in any of the psychosocial outcomes., Conclusions: In this study, RGCT in newly diagnosed breast cancer patients did not have any measurable adverse psychosocial effects.

Background: Exercise started shortly after breast cancer diagnosis might prevent or diminish fatigue complaints. The Physical Activity during Cancer Treatment (PACT) study was designed to primarily examine the effects of an 18-week exercise intervention, offered in the daily clinical practice setting and starting within 6 weeks after diagnosis, on preventing an increase in fatigue., Methods: This multi-centre controlled trial randomly assigned 204 breast cancer patients to usual care (n = 102) or supervised aerobic and resistance exercise (n = 102). By design, all patients received chemotherapy between baseline and 18 weeks. Fatigue (i.e., primary outcome at 18 weeks), quality of life, anxiety, depression, and physical fitness were measured at 18 and 36 weeks., Results: Intention-to-treat mixed linear model analyses showed that physical fatigue increased significantly less during cancer treatment in the intervention group compared to control (mean between-group differences at 18 weeks: -1.3; 95 % CI -2.5 to -0.1; effect size -0.30). Results for general fatigue were comparable but did not reach statistical significance (-1.0, 95%CI -2.1; 0.1; effect size -0.23). At 18 weeks, submaximal cardiorespiratory fitness and several muscle strength tests (leg extension and flexion) were significantly higher in the intervention group compared to control, whereas peak oxygen uptake did not differ between groups. At 36 weeks these differences were no longer statistically significant. Quality of life outcomes favoured the exercise group but were not significantly different between groups., Conclusions: A supervised 18-week exercise programme offered early in routine care during adjuvant breast cancer treatment showed positive effects on physical fatigue, submaximal cardiorespiratory fitness, and muscle strength. Exercise early during treatment of breast cancer can be recommended. At 36 weeks, these effects were no longer statistically significant. This might have been caused by the control participants' high physical activity levels during follow-up., Trial Registration: Current Controlled Trials ISRCTN43801571, Dutch Trial Register NTR2138. Trial registered on December 9th, 2009.

Purpose: After total mesorectal excision (TME) with primary anastomosis for patients with rectal cancer, the quality of life (QoL) may be decreased due to fecal incontinence. This study aimed to identify predictors of fecal incontinence and related QoL., Methods: Patients who underwent TME with primary anastomosis for rectal cancer between December 2008 and June 2012 completed the fecal incontinence quality of life scale (FIQoL) and Wexner incontinence score. Factors associated with these scores were identified using a linear regression analysis., Results: A total of 80 patients were included. Multivariate analysis identified a diverting ileostomy (n = 58) as an independent predictor of an unfavorable outcome on the FIQoL subscale coping/behavior (P = 0.041). Ileostomy closure within and after 3 months resulted in median Wexner scores of 5.0 (interquartile range [IQR], 2.5-8.0) and 10.5 (IQR, 6.0-13.8), respectively (P < 0.001). The median FIQoL score was 15.0 (IQR, 13.1-16.0) for stoma closure within 3 months versus 12.0 (IQR, 10.5-13.9) for closure after 3 months (P = 0.001)., Conclusion: A diverting ileostomy is a predictor for an impaired FIQoL after a TME for rectal cancer. Stoma reversal within 3 months showed better outcomes than reversal after 3 months. Patients with a diverting ileostomy should be informed about the impaired QoL, even after stoma closure.

Background: Female breast cancer patients with a BRCA1/2 mutation have an increased risk of contralateral breast cancer. We investigated the effect of rapid genetic counselling and testing (RGCT) on choice of surgery., Methods: Newly diagnosed breast cancer patients with at least a 10% risk of a BRCA1/2 mutation were randomised to an intervention group (offer of RGCT) or a control group (usual care; ratio 2 : 1). Primary study outcomes were uptake of direct bilateral mastectomy (BLM) and delayed contralateral prophylactic mastectomy (CPM)., Results: Between 2008 and 2010, we recruited 265 women. On the basis of intention-to-treat analyses, no significant group differences were observed in percentage of patients opting for a direct BLM (14.6% for the RGCT group vs 9.2% for the control group; odds ratio (OR) 2.31; confidence interval (CI) 0.92-5.81; P=0.08) or for a delayed CPM (4.5% for the RGCT group vs 5.7% for the control group; OR 0.89; CI 0.27-2.90; P=0.84). Per-protocol analysis indicated that patients who received DNA test results before surgery (59 out of 178 women in the RGCT group) opted for direct BLM significantly more often than patients who received usual care (22% vs 9.2%; OR 3.09, CI 1.15-8.31, P=0.03)., Interpretation: Although the large majority of patients in the intervention group underwent rapid genetic counselling, only a minority received DNA test results before surgery. This may explain why offering RGCT yielded only marginally significant differences in uptake of BLM. As patients who received DNA test results before surgery were more likely to undergo BLM, we hypothesise that when DNA test results are made routinely available pre-surgery, they will have a more significant role in surgical treatment decisions.

Background and Aims: To evaluate wire-guided localization for nonpalpable breast cancer regarding procedure and surgery-related outcome in a nonteaching community hospital in the Netherlands., Material and Methods: A consecutive series of 117 patients who were treated with breast-conserving surgery after wire-guided localization for nonpalpable breast cancer between January 2006 and December 2010 was retrospectively analyzed. The patients' digital records were reviewed for patient, radiological, histological, and surgical characteristics. In order to quantify the excess resected tissue, a calculated resection ratio was determined by dividing the total resection volume by the optimal resection volume. The optimal resection volume was defined as a spherical tumor volume with an added 1.0 cm margin. The total resection volume was defined as the corresponding ellipsoid., Results: There were no procedure-related complications. There were two postoperative hemorrhages. Margins were clear in 92.3% of the cases after the first surgical procedure. Eight (6.8%) patients required two operations and one (0.9%) patient required three operations in order to obtain negative margins. Breast conservation was possible in 113 (96.6%) patients. The median calculated resection ratio was 1.87 (range 0.47-14.92)., Conclusions: This study proves that it is possible to obtain excellent results performing breast-conserving surgery for nonpalpable breast cancer regarding margin status, total amount of operations, and the ratio between tumor and resected tissue volume using wire-guided localization as a localization tool.

Objective: The aim of the study was to determine whether the introduction of the Enhanced Recovery after Surgery (ERAS) protocol in laparoscopic total mesorectal excision (TME) for rectal cancer offers additional advantages concerning postoperative hospital stay compared to laparoscopy and conventional care., Methods: A consecutive series of patients that underwent a laparoscopic TME for rectal cancer in a single institution between January 2004 and July 2009 were retrospectively included in this study. The ERAS protocol was introduced in this cohort in January 2007. The study cohort was divided in a conventional care group and an ERAS group. Both groups were compared for primary and secondary outcome measures. The primary outcome measure was postoperative length of hospital stay., Results: Seventy-six patients were included: 43 in the ERAS group and 33 in the conventional care (control) group. Median hospital stay was 7 days (range 2-83 days) in the ERAS group and 10 days (range 4-74 days) in the control group (p = 0.04). Return of bowel function occurred on days 2 and 3 respectively (p < 0.001). There were no significant differences between both groups concerning postoperative complications, readmission rate and reoperations. Thirty-day mortality was absent in both groups., Conclusion: These results suggest that the introduction of the ERAS protocol in laparoscopic TME leads to a further reduction in length of hospital stay.

Background: The Enhanced Recovery After Surgery (ERAS) protocol, which is developed to enhance postoperative recovery of patients treated with open colorectal surgery, has been widely adopted. The ERAS protocol has also been introduced in patients treated with laparoscopic colectomy, without data to support its additional value. We investigated whether laparoscopic colectomy in combination with the use of the ERAS protocol leads to a reduction of postoperative length of stay compared to laparoscopic colectomy with conventional care., Methods: We performed a comprehensive medical record review. Inclusion criteria were patients who had undergone a laparoscopic colectomy at a single center between April 2004 and September 2009 (n = 186). The ERAS protocol had been introduced at the end of 2006. We divided the patients in a pre-ERAS group (n = 77), and an ERAS group (n = 109). We compared the baseline characteristics of both groups. The primary outcome was postoperative length of stay., Results: We did not find significant differences in gender, age, body mass index (BMI), diabetes mellitus (DM), American Society of Anesthesiologists (ASA) classification, and diagnosis and type of surgery between the two groups. Median postoperative length of stay was 6 days (range = 2-28) in the pre-ERAS group and 4 days (range = 2-55) in the ERAS group (P = 0.007). Median return of bowel function was 3 days (range = 1-6) in the pre-ERAS group and 2 days (range = 1-5) in the ERAS group (P < 0.001). We did not find significant differences in postoperative procedure-related complications (wound infection, anastomotic leakage, abscesses), postoperative morbidity, 30-day readmission, 30-day reoperation, and 30-day mortality., Conclusions: The postoperative length of stay was significantly reduced in the ERAS group without differences in patient outcome. It is suggested that these results are the effect of a combination of the ERAS protocol with laparoscopic colectomy.

There is debate whether interval carcinomas differ from screen-detected tumours biologically. In this study, clinico-pathological parameters and the expression of well-validated biological markers were compared between 'true' interval carcinomas and screen-detected/missed carcinomas hypothesising that 'true' interval carcinomas show a more aggressive biological behaviour. The study group consisted of 92 consecutive postmenopausal women attending the breast screening programme and presenting with an invasive ductal carcinoma. All screening mammograms were re-reviewed. Sixteen patients had a 'true' interval carcinoma. Seven carcinomas were missed at screening, but detected on re-reviewing of the screening mammogram. Radiological characteristics were assessed from diagnostic mammograms. Data on patient- and tumour characteristics and follow-up data were recorded from hospital records. Median follow-up was 61 months. Immunohistochemistry for ER, PR, Her2/neu and p53 was performed on TMA sections. Univariate and multivariate logistic regression analyses were performed. In univariate analysis, 'true' interval carcinomas were significantly larger (odd ratios (OR) 7.2, 95% CI 1.8-28.1) and less frequently ER (OR 0.3, 95% CI 0.1-0.9) and PR (OR 0.3, 95% CI 0.1-1.0) positive. In multivariate analysis, 'true' interval carcinoma was independently associated with larger tumours (OR 7.0, 95% CI 1.4-36.2). A trend toward ER negativity was found (OR 0.3, 95% CI 0.1-1.1). 'True' interval carcinomas showed a trend toward a decreased relapse-free survival (HR 1.7 95% CI 0.9-3.1). Although 'true' interval carcinomas were significantly larger than screen-detected/missed interval carcinomas, it remains challenging to observe parameters that determine this difference between 'true' interval carcinomas and screen-detected lesions.

Aims: To clarify MUC1 patterns in invasive ductal breast carcinoma and to relate them to clinicopathological parameters, coexpression of other biological markers and prognosis., Methods and Results: Samples from 243 consecutive patients with primary ductal carcinoma were incorporated into tissue microarrays (TMAs). Slides were stained for MUC1, oestrogen receptor (ER), progesterone receptor (PR), Her2/neu, p53 and cyclin D1. Apical membrane MUC1 expression was associated with smaller tumours (P = 0.001), lower tumour grades (P < 0.001), PR positivity (P = 0.003) and increased overall survival (OS; P = 0.030). Diffuse cytoplasmic MUC1 expression was associated with cyclin D1 positivity (P = 0.009) and increased relapse-free survival (RFS; P = 0.034). Negativity for MUC1 was associated with ER negativity (P = 0.004), PR negativity (P = 0.001) and cyclin D1 negativity (P = 0.009). In stepwise multivariate analysis MUC1 negativity was an independent predictor of both RFS [hazard ratio (HR) 3.5, 95% confidence interval (CI) 1.5, 8.5; P = 0.005] and OS (HR 14.7, 95% CI 4.9, 44.1; P < 0.001)., Conclusions: The expression pattern of MUC1 in invasive ductal breast carcinoma is related to tumour characteristics and clinical outcome. In addition, negative MUC1 expression is an independent risk factor for poor RFS and OS, besides 'classical' prognostic indicators.

Aims: To classify MUC1 according to five predefined expression patterns in ductal carcinoma in situ (DCIS) and related clinicopathological parameters, coexpression of other biological markers and prognosis., Methods and Results: With a manual tissue arrayer, 92% (n = 80) of the 87 DCIS samples were successfully targeted. Immunohistochemistry was carried out for MUC1, oestrogen receptor (ER), progesterone receptor (PR), Her2/Neu, p53 and cyclin D1. Entire membrane expression was related to Her2/neu negativity (P =0.042). Apical membrane expression was associated with low grade (P = 0.027), Her2/neu negativity (P = 0.014) and PR positivity (P = 0.005). Focal cytoplasmic expression was related to high grade (P = 0.006). Diffuse cytoplasmic expression was associated with high grade (P = 0.004), large tumour size (P = 0.046), Her2/neu positivity (P =0.042) and cyclin D1 positivity (P = 0.002). On the basis of these analyses the four patterns were reclassified as membranous or cytoplasmic expression. On multivariate analysis, cytoplasmic MUC1 expression (hazard ratio 8.5, 95% confidence interval 1.0, 73.0; P = 0.04) was the only independent predictor of local recurrence., Conclusions: Four patterns of MUC1 expression are recognized in DCIS that suggest a relationship to functional differentiation and can be simplified into two types that are clinically relevant and could therefore be helpful in the distinction between different subgroups of DCIS.

Background: The incidence of ductal carcinoma in situ (DCIS) has risen dramatically with the introduction of screening mammography. The aim was to evaluate differences in pathological and biological characteristics between patients with screen-detected and interval DCIS., Methods: From January 1992 to December 2001, 128 consecutive patients had been treated for pure DCIS at our institute. From these, 102 had been attending the Dutch breast cancer screening program. Sufficient paraffin-embedded tissue was available in 74 out of the 102 cases to evaluate biological marker expression (Her2/neu, ER, PR, p53 and cyclin D1) on tissue microarrays (TMA group). Differences in clinicopathological characteristics and marker expression between screen-detected and interval patients were evaluated. Screen-detected DCIS was classified as DCIS detected by screening mammography, when the two-year earlier examination failed to reveal an abnormality. Interval patients were classified as patients with DCIS detected within the two-year interval between two subsequent screening rounds., Results: Screen-detected DCIS was related with linear branching and coarse granular microcalcifications on mammography (p < .001) and with high-grade DCIS according to the Van Nuys classification (p = .025). In univariate analysis, screen-detected DCIS was related with Her2/neu overexpression (odds ratio [OR] = 6.5; 95%CI 1.3-31.0; p = .020), and interval DCIS was associated with low-grade (Van Nuys, OR = 7.3; 95% CI 1.6-33.3; p = .010) and PR positivity (OR = 0.3; 95%CI 0.1-1.0; p = .042). The multivariate analysis displayed an independent relation of Her2/neu overexpression with screen-detected DCIS (OR = 12.8; 95%CI 1.6-104.0; p = .018)., Conclusions: These findings suggest that screen-detected DCIS is biologically more aggressive than interval DCIS and should not be regarded as overdiagnosis.

Background: Several biological markers have been related to prognosis in mammary ductal carcinoma. The aim of the study was to determine biological markers that could predict local recurrence following treatment for all stages of primary operable ductal carcinoma of the breast., Materials and Methods: A consecutive series of patients treated for pure ductal carcinoma in situ (DCIS, n = 110) and invasive ductal carcinoma (IDC, n = 243) was studied. Twenty-three patients with DCIS were excluded because of lack of original paraffin embedded tissue. All patients had been treated between July 1996 and December 2001. Median follow-up was 49.8 mo. From the original paraffin embedded tumors, tissue microarrays (TMAs) were constructed. On these TMAs, immunohistochemistry was performed for estrogen-receptor (ER), progesterone-receptor (PR), Her2/neu, p53, and cyclin D1. Main outcome was the event of LR. All analyses were stratified for diagnosis (DCIS or IDC) and pathological grade., Results: In univariate analyses, Her2/neu overexpression (hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.1-8.7, P = 0.032) and p53 overexpression (HR 3.5, 95% CI 1.3-9.3, P = 0.014) were associated with LR in patients treated for both DCIS and IDC. In multivariate analysis, p53 overexpression (HR 3.0, 95% CI 1.1-8.2, P = 0.036 and HR 4.4, 95% CI 1.5-12.9, P = 0.008) and adjuvant radiotherapy (HR 0.2, 95% CI 0.1-0.8, P = 0.026) were independent common predictors of LR in patients who had received treatment for both DCIS and IDC., Conclusions: p53 overexpression is a common predictor of LR following treatment for all stages of primary operable ductal carcinoma of the breast. This marker may help in planning optimal treatment and follow-up.

One of the most important predictors of local recurrence after local excision of ductal carcinoma in situ (DCIS) is margin status. The aim was to study the association between margin status and clinical, radiological, and pathological characteristics and to determine predictors of positive margins after local excision of small size (< or = 4 cm) DCIS. Data were tested for differences regarding margin status, and logistic regression was used to determine predictors of margin status. The population consisted of 105 cases. Overall, 51 cases (49%) had free margins and 54 cases (51%) had positive margins. Positive margins were more often associated with a mean mammographic tumor size of 2.1 cm (P = 0.044) and absence of fine granular calcifications (P = 0.004). Also, high-grade (P = 0.013) and a mean pathological size of 3.2 cm (P < 0.001) were associated with positive margins. The only independent predictor of margin status was pathological grade (P = 0.010).

The aim was to study the effect of compliance with guidelines on local recurrence (LR)-free survival in patients treated for ductal carcinoma in situ (DCIS). From January 1992 to December 2003, 251 consecutive patients had been treated for DCIS in two hospitals in the North Netherlands. Every case in this two-hospital sample was reviewed in retrospect for its clinical and pathological parameters. It was determined whether treatment had been carried out according to clinical guidelines, and outcomes in follow-up were assessed. In addition, all patients treated for DCIS in this region (n=1389) were studied regarding clinical parameters, in order to determine whether the two-hospital sample was representative of the entire region. In the two-hospital sample, 31.4% (n=79) of the patients had not been treated according to the guidelines. Positive margins were associated with LR (hazard ratio (HR)=4.790, 95% confidence interval (CI) 1.696-13.531). Breast-conserving surgery and deviation from the guidelines were independent predictors of LR (HR=7.842, 95% CI 2.126-28.926; HR=2.778, 95% CI 0.982-6.781, respectively). Although the guidelines changed over time, time was not a significant factor in predicting LRs (HR=1.254, 95% CI 0.272-5.776 for time period 1992-1995 and HR=1.976, 95% CI 0.526-7.421 for time period 1996-1999). Clinical guidelines for the treatment of patients with DCIS have been developed and updated from existing literature and best evidence. Compliance with the guidelines was an independent predictor of disease-free survival. These findings support the application of guidelines in the treatment of DCIS.

The aim of this investigation was to study the efficacy of surgical therapy in patients with non-palpable ductal carcinoma in situ (DCIS) presenting as microcalcifications diagnosed by means of stereotactic large-core needle biopsy (SCNB). This is a retrospective study with a historical control group within a 12-year period. Two groups of consecutive patients diagnosed with DCIS (1991-2002) by means of needle-localised open breast biopsy (NLBB, n=49) and SCNB (n=51) were studied. Both groups were comparable for clinical, radiological and pathological characteristics. The therapeutic interval (time from presentation to definitive of therapy) was 62-days in the SCNB group versus 32-days in the NLBB group (p<0.001). In the SCNB group fewer surgical procedures were required for completion of surgical therapy (p=0.006) and after local excision the surgical margins were more often tumour free (p=0.002). It is postulated that the need for fewer surgical procedures and the greater frequency of tumour-free margins after local excision may be attributable to SCNB.

Study Objective: We validate the Ottawa Ankle Rules and 2 Dutch ankle rules in distinguishing clinically significant fractures from insignificant fractures and other injuries in patients with a painful ankle presenting to the emergency department., Methods: This prospective comparison of 3 ankle rules was conducted in the ED of a 580-bed community teaching hospital in Amsterdam from January 1998 to April 1999. Participants included 647 consecutive patients aged 18 years or older presenting with a painful ankle after trauma. All physicians received extensive and pictorial training on how to correctly score the respective items of the rules. The physician on call recorded these items derived from history and physical examination on a standardized data sheet. All patients subsequently underwent standard radiographic assessment. A radiologist and a trauma surgeon evaluated the radiographs blinded from the results of the data sheet form and the treatment given. The diagnostic performance of the 3 rules was measured in terms of sensitivity, specificity, and the reduction of radiographs. Receiver operating characteristic (ROC) curves were constructed, and the area under the ROC curves was calculated and compared., Results: Seventy-four fractures were seen, of which 41 were clinically significant. The Ottawa Ankle Rules had a sensitivity of 98% for identifying clinically significant fractures; the local rules scored 88% and 59%, respectively. The potential savings in radiographs for the 3 decision rules were 24%, 54%, and 82%, respectively. The area under the ROC curve was better for both the local rules (0.84 and 0.83) compared with the Ottawa Ankle Rules (0.76)., Conclusion: Because the identification of all relevant fractures is more important than a reduction in radiographs, the higher sensitivity of the Ottawa Ankle Rules makes these most suitable for implementation in The Netherlands.

Four previously healthy children, two boys aged 5 and one boy and one girl aged 4 more or less acutely developed a stumbling gait. The causes varied from benign such as postviral acute cerebellar ataxia and benign paroxysmal vertigo to potentially life-threatening such as intoxication with benzodiazepines and medulloblastoma. Treatment led to complete or partial recovery. (Sub)acute balance disorders in previously healthy children can be due to cerebellar ataxia, vestibular disorders and abnormal proprioception. Ancillary investigations are warranted in case of gradually developing ataxia, accompanying neurological deficits, suspicion of intoxication, recurrent or familial ataxia, no spontaneous remission or even progression. In children with an isolated cerebellar ataxia without these features, ancillary investigations may be avoided, although in such cases careful follow-up remains necessary.