Post on 27-Mar-2019
p 9
The results of operations for the cure of cancer of the breast performed at the Johns Hopkins hospital from
June 1889 to January 1894
Halsted WS
Ann Surg 1894
p 10
The results of operations for the cure of cancer of the breastperformed at the Johns Hopkins hospital from June 1889 to
January 1894
n=50
3/50 recidieven
p 11
Halsted-principe
Als borstkanker eerst uitzaait naar de lymfeklieren en vandaar naar elders.....
p 12
The results of operations for the cure of cancer of the breastperformed at the Johns Hopkins hospital from June 1889 to
January 1894
dan:
Amputatie van de mamma en bloc- met de regionale
lymfeklieren / banen
=
radicale mastectomie
p 13
The results of operations for the cure of cancer of the breast performed at the Johns Hopkins hospital from
June 1889 to January 1894
Halsted WS
Ann Surg 1894
p 14
Halsted paradigma:niet alleen bij borstkanker
oesofaguscarcinoom
tumor-en bloc met lymfadenectomie
p 15
Extended transthoracic resection compared withlimited transhiatal resection for adenocarcinoma of the
esophagus.Hulscher, NEJM 2002
TTE vs THE
114 vs 106
p 17
Extended transthoracic resection compared withlimited transhiatal resection for adenocarcinoma of the
esophagus.Hulscher, NEJM 2002
TTE vs THE
5 jrs overleving 70 vs 60%
p 18
chirurgische oncologietrends
Is meer echt beter?
Zo compleet mogelijke verwijdering van de
regionale lymfeklieren
p 19
Radical mastectomy versus radical mastectomy plus internalmammary dissection: five year results of an international co-
operative studyLacour, Cancer 1976
ook lymfeafvloed
p 20
Radical mastectomy versus radical mastectomy plus internalmammary dissection: five year results of an international co-
operative studyLacour, Cancer 1976
n=1580
morbiditeit >>
p 21
Radical mastectomy versus radical mastectomy plus internalmammary dissection: five year results of an international co-
operative studyLacour, Cancer 1976
n=1580
overall survival=
p 23
Extended transthoracic resection compared withlimited transhiatal resection for adenocarcinoma of the
esophagus.Hulscher, NEJM 2002
TTE vs THE
5 jrs overleving 70 vs 60%
p 24
Extended transthoracic resection compared withlimited transhiatal resection for adenocarcinoma of the
esophagus.Hulscher, NEJM
TTE
morbiditeit >>
p 26
The results of operations for the cure of cancer of the breastperformed at the Johns Hopkins hospital from June 1889 to
January 1894
n=50
3/50 recidieven(anno1895)
p 27
A study of the results of operations for the cure of cancer of the breast performed at the Johns Hopkins hospital from 1889 to 1931
Lewis, Ann Surg 1932
n=950
5-jrs overall survival22%
p 32
A study of the results of operations for the cure of cancer of the breast performed at the Johns Hopkins hospital from 1889 to 1931
Lewis, Ann Surg 1932
n=950
5-jrs overall survival22%
(78% overleden)
p 33
The radium treatment of carcinoma of the breastKeynes J, Br J Surg 1931
n=171lokale excisie en radium–naalden
3 jaar FU: 77% in leven (cNo)46% in leven (cN1)
p 34
Comparing radical mastectomy with quadrantectomy, axillarydissection, and radiotherapy in patients with small cancers of the
breast
Veronesi, NEJM 1981
349 vs 352
p 35
Comparing radical mastectomy with quadrantectomy, axillarydissection, and radiotherapy in patients with small cancers of the
breastVeronesi, NEJM 1981
p 36
Comparing radical mastectomy with quadrantectomy, axillarydissection, and radiotherapy in patients with small cancers of the
breastVeronesi, NEJM 1981
lokaal recidief
3/349 vs 1/352*
*in 1981 2002
p 39
Less is more?Borstkanker II
Mammasparende therapie: cosmetisch superieur
Schildwachtklierprocedure: morbiditeit oksel <<
p 40
Less is more?schildwachtklierprocedure
………bespaart ca. 50% van de vrouwen met
borstkanker een okselklierdissectie
p 42
Less is more?laparosopie
Systematic review on the short-term outcomeof laparoscopic resection for colon and
rectosigmoid cancerJ. J. Tjandra and M. K. Y. Chan
p 46
Lacy 2002 (Lancet) RCT: lap. vs. open colonchirurgie
Laparoscopisch = beter dan open
HR overlijden = 0.48 (0.23-1.01)HR recidief ziekte = 0.38 (0.19-0.82)
p 50
Buunen 2009 (Lancet oncology) RCT: lap. vs. open colonchirurgie
Laparoscopisch ≠ beter dan open
OS: 82 vs 84% (p=0.45)DFS, etc vergelijkbaar
p 51
Buunen 2009 (Lancet oncology) RCT: lap. vs. open colonchirurgie
Laparoscopisch ≠ beter dan open
“…. cannot rule out difference in favour of open colectomy.
……..however, difference in dfs betweengroups justifies implementation of
laparosopic surgery into daily practice”
p 53
Vgl.
"We are in possession of what I think to becompelling evidence that SaddamHussein has, and has had for a numberof years, a developing capacity for the production and storage of weapons of mass destruction.",
December 2002
p 57
voorbeeld 1Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with
small cancers of the breastVeronesi, NEJM 1981
*
2002
p 58
Voorbeeld 2Schildwachtklierprocedure niet 100% sensitief
3.5% van alle patienten met een “schone”SWK heeft toch lymfogene metastasen,
………..en dat accepteren we
p 62
meer is beter
Invloed van ziekenhuis- en chirurg volume
1. morbiditeit / mortaliteit
2. overleving
p 63
a systematic review of the impact of volume of surgeryand specialization om patient outcome.
Chowdhury Br J Surg 2007
long, pancreas, oesofagus, colorectaal, lever,
schildklier, ..
p 67
meer is beteroplossing?
concentratie van zorg is een probleem
spelers: IKC’s, UMC’s, alg. ziekenhuizen, patienten,
ziektekostenverzekeraars
p 71
chirurgisch oncoloog
grens aan de opbrengst van eigen handelen
recente winst vooral op niet chirurgische terreinen
p 72
chirurgisch oncoloog
grens aan de opbrengst van eigen handelen
recente winst vooral op andere terreinen
besef belang multidisciplinaire aanpak
p 73
Combination chemotherapy as an adjuvant treatment in operablebreast cancer
Bonadonna, NEJM 1976
CMF vs. –n=386
5% vs 24% recidief ziekte
(FU=27 mnd)
p 76
chirurgisch oncoloogin multidisciplinair team
TME trial + preoperatieve RT
6 vs 2% lokaal recidieven