Routine Follow-up Program Research Articles

Tekrarlayan İdrar Yolu Enfeksiyonu Olan Çocuklarda Tuvalet Alışkanlıklarının Değerlendirilmesi ve Böbrek Hasarı Gelişmesinde Rol Oynayan Risk Faktörlerinin Araştırılması

Objective: Urinary tract infection is one of the common infections in children. The patients with recurrent infection are at risk for permanent renal damage in later life. In this study, it was aimed to investigate the toilet habits and risk factors for renal scarring in children with recurrent urinary tract infection without congenital anomalies of the kidney and urinary tract.Materials and Methods: Patients between the ages of 6 and 18 with a diagnosis of recurrent urinary tract infection who were toilet trained were included in this study. Data of patients with congenital anomalies of kidney and urinary tract were excluded from the study. The detailed information on the voiding postponement, infrequent voiding, holding maneuvers and renal scarring were obtained from file records.Results: The 208 patients (146 girls, 62 boys) were included in this study. The more than half of the patients (n=132, 63.5%) had a habit voiding postponement, and one third (n=65, 31.3%) had holding maneuver. There was infrequent voiding in 47 (22.6%) patients. Renal scarring was determined in 38 (18.3%) patients. The frequencies of voiding postponement, holding maneuver and infrequent voiding were higher in patients with renal scarring than those of without [30 (78.9%)/102 (60%), p=0.048; 12 (31.6%)/53 (21.2%), p=0.039; 15 (39.5%)/32 (18.8%), p=0.009, respectively]. It was determined a significant positive association between renal scarring and voiding postponement with infrequent voiding [Odds ratio=3.21, p=0.011; Odds ratio=1.46, p=0.021; Odds ratio=3.43, p=0.001, respectively]. Conclusion: Toilets habits should be questioned in routine follow-up program in children with recurrent urinary tract infection. The development of true toilet habits may be useful to prevent the development of renal scarring in children.

Gastrointestinal function testing model using a new laryngopharyngeal pH probe (Restech) in patients after Ivor-Lewis esophagectomy.

BACKGROUNDThere is no established correlation between 24-h esophageal pH-metry (Eso-pH) and the new laryngopharyngeal pH-monitoring system (Restech) as only small case series exist. Eso-pH was not designed to detect laryngopharyngeal reflux (LPR) and Restech may detect LPR better. We have previously published a dataset using the two techniques in a large patient collective with gastroesophageal reflux disease. Anatomically, patients after esophagectomy were reported to represent an ideal human reflux model as no reflux barrier exists. AIMTo use a human reflux model to examine our previously published correlation in these patients. METHODSPatients after Ivor Lewis esophagectomy underwent our routine follow-up program with surveillance endoscopies, computed tomography scans and further exams following surgery. Only patients with a complete check-up program and reflux symptoms were offered inclusion into this prospective study and evaluated using Restech and simultaneous Eso-pH. Subsequently, the relationship between the two techniques was evaluatedRESULTSA total of 43 patients from May 2016 - November 2018 were included. All patients presented with mainly typical reflux symptoms such as heartburn (74%), regurgitation (84%), chest pain (58%), and dysphagia (47%). Extraesophageal symptoms such as cough, hoarseness, asthma symptoms, and globus sensation were also present. Esophageal 24-hour pH-metry was abnormal in 88% of patients with a mean DeMeester Score of 229.45 [range 26.4-319.5]. Restech evaluation was abnormal in 61% of cases in this highly selective patient cohort. All patients with abnormal supine LPR were also abnormal for supine esophageal reflux measured by conventional Eso-pH. CONCLUSIONPatients following esophagectomy and reconstruction with gastric interposition can ideally serve as a human reflux model. Interestingly, laryngopharyngeal reflux phases occur mainly in the upright position. In this human volume-reflux model, results of simultaneous esophageal and laryngopharyngeal (Restech) pH-metry showed 100% correlation as being explicable by one of our reflux scenarios.

The effects of Coronavirus disease-2019 (COVID-19) pandemic on routine antenatal care visits and complications of pregnancy.

Routine follow-up of pregnancy is a comprehensive care process starting from planning of pregnancy that involves rational and careful use of medical, psychological, and social support. In this study, our objective was to compare the adherence rate to routine antenatal follow-up program during the COVID-19 pandemic with that of previous years among pregnant women, in an effort to shed light on health policies to be developed similar events in the future. This retrospective cross-sectional study was carried out between March 11, 2019, when isolation measures were initiated in the context of precautionary steps taken in Turkey against the COVID-19 pandemic, and June 1, 2020, when the "normalization" was initiated. During the study period in 2020, the proportion of cesarean sections were higher, 61.1%, as compared to previous years (p=0.27). The stillbirths were numerically lower (1.2%, p=0.77), but the rate of spontaneous abortions was significantly higher (19.6%, p=0.009). The number of follow-up visits per pregnancy was lower than in previous years (3.8, p=0.02), although the proportion of patients visiting the outpatient units for regular controls to the overall patient group increased as compared to previous years (52.0%). During the flare-up of the COVID-19 pandemic (i.e. between March and June 2020), the rate of obstetric/neonatal morbidity and mortality except spontaneous abortion was not significantly higher as compared to the corresponding period in previous years. However, considering the potential increase in the risk of obstetric complications during a pandemic, specialized management programs targeting basic pregnancy follow-up services should be developed.

Routine follow-up after surgical treatment of lung cancer: is chest CT useful?

ABSTRACTObjective:To report the experience of a routine follow-up program based on medical visits and chest CT. Methods:This was a retrospective study involving patients followed after complete surgical resection of non-small cell lung cancer between April of 2007 and December of 2015. The follow-up program consisted of clinical examination and chest CT. Each follow-up visit was classified as a routine or non-routine consultation, and patients were considered symptomatic or asymptomatic. The outcomes of the follow-up program were no evidence of cancer, recurrence, or second primary lung cancer. Results:The sample comprised 148 patients. The median time of follow-up was 40.1 months, and 74.3% of the patients underwent fewer chest CTs than those recommended in our follow-up program. Recurrence and second primary lung cancer were found in 17.6% and 11.5% of the patients, respectively. Recurrence was diagnosed in a routine medical consultation in 69.2% of the cases, 57.7% of the patients being asymptomatic. Second primary lung cancer was diagnosed in a routine medical appointment in 94.1% of the cases, 88.2% of the patients being asymptomatic. Of the 53 patients who presented with abnormalities on chest CT, 41 (77.3%) were diagnosed with cancer. Conclusion:Most of the cases of recurrence, especially those of second primary lung cancer, were confirmed by chest CT in asymptomatic patients, indicating the importance of a strict follow-up program that includes chest CTs after surgical resection of lung cancer.

TRIM study protocol - a prospective randomized multicenter Trial to assess the Role of Imaging during follow-up after radical surgery of stage IIB-C and III cutaneous malignant Melanoma

BackgroundThe incidence of cutaneous malignant melanoma (CMM) is increasing worldwide. In Sweden, over 4600 cases were diagnosed in 2018. The prognosis after radical surgery varies considerably with tumor stage. In recent years, new treatment options have become available for metastatic CMM. Early onset of treatment seems to improve outcome, which suggests that early detection of recurrent disease should be beneficial. Consequently, in several countries imaging is a part of the routine follow-up program after surgery of high risk CMM. However, imaging has drawbacks, including resources required (costs, personnel, equipment) and the radiation exposure. Furthermore, many patients experience anxiety in waiting for the imaging results and investigations of irrelevant findings is another factor that also could cause worry and lead to decreased quality of life. Hence, the impact of imaging in this setting is important to address and no randomized study has previously been conducted. The Swedish national guidelines stipulate follow-up for 3 years by clinical examinations only.MethodsThe TRIM study is a prospective randomized multicenter trial evaluating the potential benefit of imaging and blood tests during follow-up after radical surgery for high-risk CMM, compared to clinical examinations only. Primary endpoint is overall survival (OS) at 5 years. Secondary endpoints are survival from diagnosis of relapse and health-related quality of life (HRQoL). Eligible for inclusion are patients radically operated for CMM stage IIB-C or III with sufficient renal function for iv contrast-enhanced CT and who are expected to be fit for treatment in case of recurrence. The planned number of patients is > 1300. Patients are randomized to clinical examinations for 3 years +/− whole-body imaging with CT or FDG-PET/CT and laboratory tests including S100B protein and LDH. This academic study is supported by the Swedish Melanoma Study Group.DiscussionThis is the first randomized prospective trial on the potential benefit of imaging as a part of the follow-up scheme after radical surgery for high-risk CMM.ResultsThe first patient was recruited in June 2017 and as of April 2020, almost 500 patients had been included at 19 centers in Sweden.Trial registrationClinicalTrials.gov, NCT 03116412. Registered 17 April 2017, https://clinicaltrials.gov/ct2/show/study/NCT03116412

Evaluation of respiratory complications in patients with X‐linked and autosomal recessive agammaglobulinemia

Congenital agammaglobulinemia is the first primary immunodeficiency disorder characterized by a defect in B lymphocyte development and subsequently decreased immunoglobulin levels. These patients are prone to suffer from recurrent infections mostly involving the respiratory tract. In this study, we aimed to describe in detail respiratory tract complications as the most prominent clinical feature among agammaglobulinemic patients. A total number of 115 patients were included. Demographic, clinical, and genetic data were collected from the patients' medical records. Among the available patients, pulmonary function tests (PFTs) and/or high-resolution computed tomography (HRCT) were performed. Respiratory tract complications (85.2%) especially pneumonia (62.6%) were the most prominent clinical features in our cohort. Among patients with abnormal PFT results (N=19), a mixed respiratory pattern was observed in 36.8%. HRCT was carried out in 29 patients; Bhalla scoring-based evaluation of these patients indicated excellent (44.8%), followed by good (34.5%) and mild (20.7%) results. Bronchiectasis was found in 13 patients undergoing HRCT (44.8%). We found significant inverse correlations between the Bhalla score and incidence rate of pneumonia, as well as the presence of bronchiectasis. Patients with abnormal PFT results had statistically significant higher bronchiectasis frequency and lower Bhalla scores compared to those with normal results. Forty-one patients were deceased, and here, respiratory failure was the most common cause of death (45.5%). High prevalence of respiratory tract infections among agammaglobulinemic patients and subsequent progression to permanent lung damage highlights the importance of implementing respiratory evaluation as part of routine follow-up program of agammaglobulinemic patients. Physicians should be aware of this and regularly monitor the respiratory function of these patients to allow for timely diagnosis and treatment initiation aiming to improve patients' prognosis and quality of life.

Adherence to a Follow-Up Program Is Improving Weight Loss

Background/Aim of Study: Identifying the effect of adherence to a routine postoperative follow-up program on weight loss after surgery. Methods: Eighty-six patients who underwent a bariatric procedure were included. According to their compliance to follow-up visits, patients were classified into two groups: the Drop-Out group (patients who did not attend the follow-up appointments n = 45) and regular follow-up group (patients compliant with their scheduled postoperative appointments n = 41). Both groups were compared in terms of weight loss at four fixed time points: time of operation (T0), next to last (T1), last follow-up appointments (T2), and time of interview (T3). Results: Weight decreased in the time interval between T0 and T2 without a significant difference between both groups. A significant difference, however, was observed during the time interval T2 to T3, as weight continued to decrease among the regular follow-up patients versus a rise within the Drop-Outs patients (62.7 ± 24.1% vs. 49.9 ± 22.9%; p = 0.014). Conclusion: Adherence to a follow-up program is crucial to improve and sustain weight loss.

Follow-up at two years of age and early predictors of non-compliance in a cohort of very preterm infants

AimTo examine the rates of follow-up at two years of age and perinatal factors associated with non-compliance in an observational population-based cohort of very preterm children enrolled in a routine follow-up program. MethodData review of infants born between 2008 and 2012 in the Observatoire de La Grande Prématurité, Reunion Island cohort. All singletons born alive before 33weeks of gestational age and resident on the island at two years of age were included. Patients were considered compliant if they were timely evaluated between 20–28months of age, or non-compliant if they were not evaluated or evaluated after 28months of age. ResultsOf the 802 survivors (mean gestational age of 30.3±2.0months, mean birthweight of 1364±396g), 468 (58.4%) were examined between 20–28months, 119 (14.8%) after 28months of age, and 215 (26.8%) were never evaluated, respectively. In multivariate analysis, factors associated with non-compliance were higher parity (>2), past history of preterm delivery, maternal diabetes (preexisting or gestational), appropriate for gestational status, and centre of birth. ConclusionSustainable follow-up of vulnerable neonates remains a challenge in clinical practice. Early predictors of non-compliance can be used to define individualized and local follow-up strategies in these infants at high risk for developmental disabilities.

Semi-automatic lung segmentation of DCE-MRI data sets of 2-year old children after congenital diaphragmatic hernia repair: Initial results

In congenital diaphragmatic hernia (CDH), lung hypoplasia and secondary pulmonary hypertension are the major causes of death and severe disability. Based on new therapeutic strategies survival rates could be improved to up to 80%. However, after surgical repair of CDH, long-term follow-up of these pediatric patients is necessary. In this, dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) provides insights into the pulmonary microcirculation and might become a tool within the routine follow-up program of CDH patients. However, whole lung segmentation from DCE-MRI scans is tedious and automated procedures are warranted. Therefore, in this study, an approach to semi-automated lung segmentation is presented. Segmentation of the lung is obtained by calculating the cross correlation and the area under curve between all voxels in the data set and a reference region-of-interest (ROI), here the arterial input function (AIF). By applying an upper and lower threshold to the obtained maps and intersecting these, a final segmentation is reached. This approach was tested on twelve DCE-MRI data sets of 2-year old children after CDH repair. Segmentation accuracy was evaluated by comparing obtained automatic segmentations to manual delineations using the Dice overlap measure. Optimal thresholds for the cross correlation were 0.5/0.95 and 0.1/0.5 for the area under curve, respectively. The ipsilateral (left) lung showed reduced segmentation accuracy compared to the contralateral (right) lung. Average processing time was about 1.4s per data set. Average Dice score was 0.7±0.1 for the whole lung. In conclusion, initial results are promising. By our approach, whole lung segmentation is possible and a rapid evaluation of whole lung perfusion becomes possible. This might allow for a more detailed analysis of lung hypoplasia of children after CDH.

Response

First of all, we thank you for your critical and valuable comments concerning our study. The treatment of (malignant) genital diseases almost always restricts male sexual functioning, and therefore several instruments have been developed for examination. The questionnaire method (by the patient's self-report) itself may favor symptomatic patients, who are more likely to respond than asymptomatic patients. This may result in an overestimation of the prevalence of chronic testis pain and of sexual dysfunction (eg, ejaculatory problems) after testicular cancer treatment. With a view to similar results in a previous study (Pühse et al, 2010), we are confident that the reported prevalence is not influenced by a major selection bias. Methodically, there might be a recall bias concerning the exact extent of preoperative pain; the other parameters mentioned reflect the patients' actual discomfort (at different time points). We do not doubt that sexual function fluctuates over time (Tuinman et al, 2010), but chronic pain and its influence on sexual function persist for a long time after therapy. Following completion of primary cancer treatment and many years thereafter, specific symptoms continue to affect cancer survivors negatively (Harrington et al, 2010). The association of chronic pain and negative sexual function is the crucial point in our study. In andrology, comparative data were found in patients experiencing chronic pelvic pain syndrome (CPPS). Although a comparison with a benign disease must be handled with caution, CPPS patients differed from controls by reporting significantly less frequent sexual desire or thoughts, less frequent sexual activities, less arousal or erectile function, less orgasm function, and higher frequencies of genital pain during or after intercourse (Aubin et al, 2008). The assessment of these characteristics in subgroups (eg, patients with contralateral testicular intraepithelial neoplasia [TIN]) also may be of importance to learn what biases may exist in our understanding of our patients experiencing damage from cancer therapies. For this study, we explicitly excluded patients with contralateral tumor or TIN in order to have a more homogenous study population concerning contralateral testicular function. The aspects of sexual functioning that are predominated by cognition, perception, and emotion may be affected by the psychotraumatic experience of having cancer, but also by physiologic factors, like chronic pain (Kwan et al, 2005). The best way to assess whether the intensity of presurgical and postsurgical pain is confounding the patients' reporting is to carry out the survey at several time points before and after surgery and oncologic therapy, and during follow-up. Therefore, we introduced our questionnaire into the testis cancer routine follow-up program for a prospective evaluation of the problem. Improvement (or impairment?) of sexual function over time is multifactorial and has to be analyzed intraindividually over time. We have to clarify that (not only) pain is one of the causes that may result in sexual dysfunction due to the treatment for testis cancer. Identifying associations between cancer treatment and sexual dysfunction in men could be helpful to choose equally effective but less toxic treatment, and to optimize counseling for our testis cancer patients.

First indicators of relapse in breast cancer: evaluation of the follow-up program at our hospital

Guidelines for breast cancer patient follow-up have not been widely adopted in Japan. To assess our intensive follow-up program, we evaluated first relapse and its indicators in patients with breast cancer. Of 964 patients, 126 relapsed and 43 died in the median follow-up term of 45 months. Follow-ups were scheduled every 6-12 months for imaging and tumor marker (TM) evaluation. Of 126 relapsed patients, 30 (23.8%) had symptoms of relapse. First indicators of relapse in 96 asymptomatic patients were physical examination in 24 patients (19%); imaging, 57 patients (45.3%); and TMs, 15 patients (11.9%). The most sensitive indicators were physical examination for local relapse, ultrasonography for regional lymph nodes, scintigraphy for bone, computed tomography for lung, and TMs for liver metastasis. During intensive follow-up, 43% of relapsed patients were identified by symptoms or physical examination. These patients had poor prognosis compare to patients identified by imaging or TMs in overall survival and post-relapse survival (p = 0.009 and 0.019, respectively). In all 964 patients, the relapse rates for stage I, IIA, IIB, and III tumors were 7.4, 7.9, 19.9, and 43.5%, respectively. The percentage of first relapse detected by imaging or TMs for stage I, IIA, IIB, and III were 4.7, 5.1, 11.8, and 19.8%, respectively. The cost of our follow-up program for 10 years was approximately 290,000 yen per patient. A routine intensive follow-up program involving imaging and evaluation of TMs in all patients has low efficacy and high expenditure.

Discitis and sacroiliitis diagnosed 15 years after iatrogenic Mycobacterium xenopi inoculation

A patient was diagnosed with discitis and sacroiliitis due to Mycobacterium xenopi. He had a history of percutaneous nucleotomy performed 15years earlier (in 1992) at the Clinique du Sport, Paris, France, during an outbreak of nosocomial M. xenopi infection at that institution. In 1997, magnetic resonance imaging performed as part of the routine follow-up program for patients who had surgery at the Clinique du Sport during the outbreak was not interpreted as indicating discitis; this assessment was confirmed by our review of the images. Bone and joint infections due to atypical mycobacteria are rare and can develop very slowly. To our knowledge, this is the first reported case of M. xenopi discitis with secondary extension to the sacroiliac joint in an immunocompetent patient.

Post-treatment follow-up procedures in cervical cancer patients previously treated with radiotherapy

We investigated the role of physical examination, CT scan, chest X-ray, and Pap smear in the routine follow-up program for cervical cancer patients previously treated with radiotherapy. The records of women who had developed recurrent cervical cancer after radiotherapy were retrospectively reviewed. The optimal procedure for the detection of recurrence was evaluated according to the disease-free interval (DFI). Survival analysis was performed based on the Kaplan-Meier method and comparisons between groups were made using the log-rank test. A total of 146 recurrent cervical cancer patients were included in our database. The majority of recurrences were diagnosed either by symptoms, physical examination, or CT scan. The patients whose recurrent disease was detected by Pap smear, physical examination, or CT scan had a significantly longer survival than those detected by symptoms. When analyzed according to DFI, physical examination, and CT scan led to the detection of recurrence in patients with a DFI of 1-5 years. In contrast, chest X-ray and Pap smear only had a clinical impact on the diagnosis of recurrence in patients with a DFI of 1-2 years. Chest X-ray and Pap smear can be routinely performed for the first 2 years after radiotherapy, but can be omitted or used sparingly thereafter.

Implementation of a Routine Developmental Follow-up Program for Children with Congenital Heart Disease: Early Results

To describe the implementation of a routine developmental follow-up program for children with congenital heart disease, summarize the developmental outcomes of the first clinic visits of the referred patients, and determine what factors predict variability in early developmental outcomes. Infants with congenital heart disease who had cardiac surgery within the first 30 days of life, had a cyanotic lesion (with or without surgery) or were believed to be at risk for developmental delay due to comorbid conditions or perioperative complications such as seizures or stroke were referred to the program as part of standard clinical care. Patients were evaluated using the Bayley Scales of Infant and Toddler Development-III. This study reports results from 95 patients (January 2007-October 2009) who had their first developmental follow-up visit at less than 1 year of age. Patients were 7.2 ± 1.2 months at their first evaluation. Bayley scores (mean/standard deviation) for the entire group were: Cognitive 100.8 ± 11.9; Language 96.3 ± 12.7; and Motor 88.6 ± 18.6. Scores for language and motor achievement were significantly lower than population norms. 44% of children had at least one low score (defined as > 1 standard deviation below the mean). Of children meeting state criteria for early intervention services, 31% were not receiving any early intervention services. Risk factors for worse developmental outcomes (P < .05) included more open heart procedures, the presence of additional medical/genetic conditions, and the need for supplemental tube feedings. Developmental outcomes were not significantly related to gestational age, prenatal diagnosis, diagnostic category, or age at first surgery. Implementation of a routine developmental follow-up program for congenital heart disease patients is possible and useful in identifying those patients who would benefit most from early intervention.

Postoperative Follow-Up Strategy in Patients With Oral Squamous Cell Carcinoma

The duration of follow-up after treatment of oral squamous cell carcinoma and the frequency of routine visits are based on common usage rather than evidence-based practice. The purpose of this study was to determine the appropriate postoperative routine follow-up program in patients with oral squamous cell carcinoma. Three hundred four cases treated curatively mainly by surgery at Tokai University Hospital from 1994 to 2004 were analyzed. A secondary event was defined as a local recurrence, a regional recurrence, a distant metastasis, or a second primary cancer. To evaluate the follow-up program, data on the first tumor recurrence or first second primary tumor in the head and neck region or elsewhere in the body were used. Overall survival rate, disease-specific survival rate, relapse-free rate, and cumulative risk of developing a second primary cancer were estimated by the Kaplan-Meier product limit method. All relapse cases were detected within 3 years postoperatively, of which 86.3% were detected within 1 year. Most relapses were in the neck, and regional recurrences had a dismal salvage rate. Second primary cancers were constantly detected 1 to 10 years postoperatively. Follow-up should be performed more frequently in the first year, with 2 weekly follow-ups with monthly ultrasound examinations, and should be continued after 3 years to exclude the development of second primary cancers.

Optimizing Breast Cancer Follow-up: Diagnostic Value and Costs of Additional Routine Breast Ultrasound

A total of 2,546,325 breast cancer survivors are estimated to live in the United States. The organized breast cancer follow-up programs do not generally include breast ultrasound in asymptomatic women. The purpose of our prospective study was to investigate the efficacy of breast ultrasound in detecting previously occult recurrences. A total of 735 eligible patients with a history of breast cancer were recruited. We assessed the same patient population before (routine follow-up program) and after (study follow-up program) the introduction of an additional ultrasound examination. In the routine follow-up program 245 of 735 patients (33.3% [95% confidence-interval (CI): 29.9–36.7]) had an ultrasound due to abnormal local or mammographic findings. 490 of 735 patients (66.7% [95% CI: 63.3–70.1]) were initially considered asymptomatic and received an additional ultrasound exclusively within the study follow-up program. All positive examination results were followed by accelerated core needle biopsy. The routine follow-up program led to a biopsy in 66 of 735 patients (9.0%) revealing a recurrent cancer in 27 cases (3.7%). The study follow-up program with the additional ultrasound led to another 21 biopsies raising the total number of patients who had to undergo a biopsy from 9.0% (95% CI: 6.9–11.1) to 11.8% (95% CI: 9.5–14.2). Finally, we diagnosed a previously occult malignant lesion in an additional six patients following this protocol. Therefore, the rate of detected recurrences rose from 3.7% (95% CI: 2.3–5.0) in the routine follow-up program to 4.5% (95% CI: 3.0–6.0) in the study follow-up program ( p = 0.041). Negative side effects were the additional costs (the costs per detected malignancy in the routine follow-up program were $2455.69; the costs for each additionally detected malignancy in the study follow-up program were $7580.30), the higher overall biopsy rate (9.0 vs. 11.8%) and the elevated benign biopsies rate (59.1% vs. 71.4%). Regarding these results, the advantages and disadvantages of additional breast ultrasound must be discussed for every follow-up patient individually even today, as we can detect a significantly higher number of previously occult malignancies. (E-mail s@wojcinski.de)

Annual abdominal ultrasonographic examination after curative NSCLC resection

There is no established follow-up strategy in non-small cell lung cancer patients after complete resection. Follow-up regimens are different between nations, institutions, and surgeons. We tried to investigate the role of annual abdominal ultrasonographic examination in completely resected NSCLC patients. We reviewed 265 consecutive patients who had their NSCLC completely resected at our institution from July 1992 through December 2000 and were followed by a single surgeon. Annual abdominal ultrasonography was performed until 5 years after resection. Chest CT and abdominal CT are not included in our routine follow-up program. Instead, we used ultrasonography to survey the abdomen because abdominal ultrasonography is less costly than abdominal CT, is non-invasive, and does not require contrast media. A total of 892 ultrasonographic examinations were performed. Fifty-nine (22.3%) patients developed recurrence. Annual ultrasonography detected lesions suspicious of recurrence in 15 patients. Further work-up diagnosed NSCLC recurrence in 2 (0.8%) patients (multiple liver metastases in one and right adrenal metastasis in one). The two patients soon developed disseminated disease and died in less than a year. Annual abdominal ultrasonography in the follow-up protocol for completely resected NSCLC patients was not beneficial. Our experience in the present study may be used as valid evidence to exclude abdominal ultrasonography from future trials comparing follow-up regimens after complete resection of NSCLC. A better follow-up strategy needs to be established.

Endoscopic and ultrasonographic evaluation before and after Roux-en-Y gastric bypass for morbid obesity

Esophagogastric abnormalities are recognized prior and after bariatric procedures, but frequency and severity are debated. Liver and biliary tract findings are also of clinical importance, especially gallstones and liver steatosis. To compare pre-operative findings of hepatobiliary ultrasound and upper digestive endoscopy with post-operative results in patients submitted to open Roux-en-Y gastric bypass for morbid obesity. A total of 80 patients were enrolled 16.8 +/- 12.1 months after operation, all of them on routine follow-up program, and 8 were excluded. Retrospective analysis aimed at pre-operative clinical, endoscopic and ultrasonographic examinations and were prospectively repeated. Pre-operative endoscopical report was available in 42 cases, and 52 examinations were performed post-operatively. Frequency of esophagitis changed from 16.7% (7/42) to 15.4% (8/52), and of gastritis from 45.2% (19/42) to 21.2% (11/52). Gastric or gastrojejunal ulcers were initially present in 4.8% (2/42) and increased to 9.6% (5/52). Post-operatively, an unusual abnormality was silastic band erosion: 7.7% (4/52). Helicobacter pylori was present in 50.0% (21/42) before and 3.5% (2/52) after operation. Ultrasonographic study had been done before intervention in 63 subjects, and 57 were executed on follow-up. Liver steatosis occurred previously in 58.7% (37/63) and in 43.9% (25/57) later on. Only 12.7% (8/63) of the patients had undergone cholecystectomy before bariatric operation, 29.1%(16/55) suffered simultaneous resection of gallbladder because of stones during Roux-en-Y gastric bypass, and an additional 26.8% (10/36) developed gallstones post-operatively. Liver steatosis did not statistically improve, nor did inflammatory conditions of the upper digestive tube, despite reduction of H. pylori infections; gallbladder stones requiring intervention were common.

Efficacy of ultrasound B-scan compared with physical examination in follow-up of melanoma patients

The value of ultrasound B-scan for routine follow-up of melanoma patients still is not generally accepted. Therefore, the authors compared the efficacy of physical examination (PE) with ultrasound B-scan (UBS) for detection of regional tumor recurrence in melanoma patients. The aim of the current study was to evaluate whether early detection of metastases improves relapse-free and overall survival. For a period of 4 years, 829 consecutive melanoma patients were followed prospectively. Physical examination of 3011 patients and concomitant UBS of in-transit routes and regional lymph node basins were performed. Suspicious lesions were diagnosed by fine-needle aspiration cytology and pathology. During the study period, 242 (90.6%) of 267 patients with melanoma recurrences were first recognized by PE or UBS within the routine follow-up program. The sensitivities of both methods differed significantly (P = 0.001). Metastases were detected by PE in only 61 of 242 recurrences (25.2%, 95% confidence interval [CI]: 19.9-31.2%), whereas UBS revealed 240 recurrences (99.2%, 95% CI: 97.3-99.6%). The specificity was 98.4% (95% CI: 97.8-98.8%) and 98.3% (95% CI: 97.7-98.7%), respectively. Survival of 103 patients who presented with a first nodal melanoma recurrence was followed and analyzed by multiple Cox regression. Overall survival was affected by the diameter of the largest metastasis (P = 0.001) and the number of metastatic lesions (P = 0.012). The study found that ultrasound B-scan was highly effective in the early detection of regional melanoma metastases compared with physical examination. Earlier detection of such metastases seemed to result in improved overall survival.

Evaluation and biopsy of recurrent rectal cancer using three-dimensional endosonography.

The value of endorectal ultrasonography for postoperative follow-up of rectal cancer is limited by the inability to distinguish recurrent malignancy from benign lesions, e.g., fibrotic tissue. This study was conducted to investigate the role of three-dimensional (3D) endosonography for evaluation and biopsy of recurrent rectal cancer. Endorectal ultrasonography was performed in routine follow-up program after resection of rectal cancer. 3D volume scans were recorded using a bifocal multiplane 3D transducer (7.5/10 MHz) with a 100 degrees longitudinal and a 360 degrees transversal scan angle. For transrectal ultrasound-guided biopsy of pararectal lesions, a specially designed targeting device was attached to the endoprobe. Overall pararectal lesions were detected in 28 of 163 patients (17 percent) who were undergoing endorectal ultrasonography for follow-up after resection of rectal cancer. 3D image analysis facilitated assessment of suspicious pararectal lesions by contemporary display of three perpendicular scan planes or volume reconstructions of the scanned area. Ultrasound-guided biopsy was performed in all 28 patients with pararectal lesions identified by endorectal ultrasonography. Biopsy revealed recurrent disease or lymph node metastases in seven and two patients, respectively. Benign lesions explained the endosonographic findings in 17 patients. All patients with benign histology still have no evidence of recurrent disease after a median follow-up of seven months. Nonrepresentative material was obtained in only 2 of 28 patients (accuracy, 93 percent). Histology changed the endosonographic diagnosis in 28 percent of cases. 3D endosonography with ultrasound-guided biopsy improves the diagnosis of extramural recurrence after curative resection of rectal cancer. 3D image display allows precise control of the position of the biopsy needle within the target.