Dr Rainer Kube
email: rainer.kube@gmail.com

P Mroczkowski

D Granowski

F Benedix

M Sahm

U Schmidt
email: schmidt@statconsult.de

I Gastinger

H Lippert

Anastomotic leakage after colon cancer surgery: a predictor of significant morbidity and hospital mortality, and diminished tumour-free survival

Keywords:

Aim

The objective of this study was to find out the effects of anastomotic leakage (AL) following resection of colon cancer upon perioperative outcome and long-term oncological result.

Patients and methods

Using the data base of a country-wide quality assurance study "Quality Assurance in Primary Colorectal Carcinoma" we analysed the data from the complete sub-population of 844 patients who had AL after resection of colon cancer. These were compared with corresponding data from 27 427 similar patients without AL. Hospital mortality, ALassociated post-operative morbidity and long-term outcome were investigated.

Results

Hospital mortality after AL was 18.6%, compared with 2.6% for patients without AI. ALrelated secondary complications occurred in 62.7% cases, while patients without AL had a corresponding rate of 19.9%. Those with AL had a poorer long-term oncological result, with a five-year survival rate of 51.0% (p < 0.001) and a five-year tumour-free survival rate of 63.0% (compare 74.6% without AL; p < 0.001).

Conclusions

Post-operative AL after resection of colon cancer is associated with significant morbidity and hospital mortality rates and a greater risk of a poor oncological outcome.

Introduction

In spite of recent developments in diagnosis, treatment and surgical technique, the problem of anastomotic leakage (AL) remains a major one. It is encountered frequently in routine surgical practice, and it is associated with an increase in early post-operative mortality [START_REF] Stumpf | Risk Factors for Anastomotic Leakage after Colorectal Surgery[END_REF][START_REF] Buchs | Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study[END_REF][START_REF] Kanellos | The failed intraperitoneal colon anastomosis after colon resection[END_REF][START_REF] Khan | The management and outcome of anastomotic leaks in colorectal surgery[END_REF]. For colorectal cancer, there are indications that AL worsens the long-term oncological result [START_REF] Law | Anastomotic leakage is associated with poor longterm outcome in patients after curative colorectal resection for malignancy[END_REF][START_REF] Mcardle | Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer[END_REF][START_REF] Walker | Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer[END_REF]. However, until now a corresponding tendency has not been demonstrated for colon carcinoma [START_REF] Branagan | Prognosis after anastomotic leakage in colorectal surgery[END_REF][START_REF] Fujita | Anastomotic leakage after colorectal cancer surgery: a risk factor for recurrence and poor prognosis[END_REF].

The objective of this research was to find out the peri-operative effects of AL in a large, multicentric analysis of a representative patient population. In addition, the influence of AL upon the long-term oncological result was investigated.

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Methods

-Study -

In the German multicentric study "Qualitätssicherung Kolon/Rektumkarzinome (Primärtumor)" (Quality Assurance in Primary Colorectal Carcinoma), data for patients with colorectal carcinoma were acquired prospectively by the An-Institut für Qualitätssicherung in der operativen Medizin at the University of Magdeburg. Data acquisition took place over a period of five years, from January 1st 2000 to December 31st 2004. These data represent the state of treatment of these patients in routine clinical practice, and they cover the entire spectrum of hospital types in Germany. A total of 346 institutions providing treatment at all levels took part in the study. The individual data were recorded on a standardised questionnaire at each participating hospital. This questionnaire comprises 68 questions to record the important aspects of peri-operative management of the patient: demographic characteristics, pre-and post-operative tumour status, tumour location, details of the operation and peri-operative treatment, pathological findings, hospital mortality the patient's status at discharge from hospital, and further treatment planned. The completed questionnaires were subjected to final checking by the hospital's local representative with responsibility for the study. Additionally, the data were also checked for completeness in an annual cross-check between the patients registered in the study and those registered at the hospitals, and plausibility checks were conducted by comparing the study data with the operation reports and patient narratives.

The study was conducted in accordance with the Declaration of Helsinki. Participation in the study was voluntary, and data were recorded anonymously. This was a purely observational study and thus had no influence upon the methods or the course of treatment. For this reason, a vote of the ethics committee was not required. All the patients gave written consent to the acquisition and anonymised evaluation of their data.

-Analysis -

The present analysis covered the set of patients who received an anastomosis after resection of colon carcinoma, i.e. -by definition -all carcinomas between the ileocaecal valve and a point 16 cm above the anal verge. The criterion for distinction between this and rectal carcinoma was provided by measurement of the distance between the lower edge of the tumour and the anal verge with a rigid rectoscope. An AL was recorded if any of the following criteria were met: (i) surgical procedure (relaparotomy performed), (ii) radiological Long-term outcome data were obtained with the help of a second questionnaire completed either by the patient's general practitioner or by the hospital at which the operation had taken place. A second questionnaire was completed by the patient's own doctor or, where appropriate, by the hospital; this include last contact with the patient, life status or cause of death (tumour-related, tumour-independent), any local recurrence, any distal metastasis, and as appropriate the time of recurrence and the method of detection (biopsy, endoscopy, imaging). In addition, information about the current tumour status was recorded (tumour-free, locally recurrent, distant metastases) and in cases of recurrence the time and method of detection (biopsy, endoscopy, imaging). The acquisition of follow-up data by the general practitioner was performed only with the written consent of the patient; a breakdown of patients according to their granting (or withholding) consent to the follow-up observation showed that those who withheld consent did not differ significantly from those who gave it, in respect of demographic variables (sex, body height and weight, age, body mass index or UICC (Union Internationale Contre le Cancer) tumour stage.

The set of patients with AL was investigated for the risk of development of AL-associated general or operation-specific secondary complications and for long-term outcome; this population was then compared with the patients without AL.

-Statistics -

The data were entered into an ACCESS data base and were evaluated with the statistical programme suite SPSS 12.0 (SPSS Inc., Chicago, IL, USA). For the descriptive statistics, frequency testing was performed for the various categorical variables. Differences among the variables in two-dimensional contingency tables were investigated by using the χ 2 test. Differences between groups were considered significant if a two-sided test yielded a p value below 0.05. Continuous variables, such as patient's age, were tested by using the robust t test.

The analyses of overall and tumour-free survival were performed by the Kaplan-Meier method, and survival curves were compared by the log-rank test. The significance threshold for the appearance of a type-1 error was set at 5%.

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Results

The study population included a total of 28 271 patients treated for colon cancer by resection with anastomosis. Of these, 3.0% (n = 844) developed an AL.

Post-operative course of disease -Hospital mortality

Hospital mortality was 18.6% (157 of 844) for patients with AL and only 2.6% (700 of 27 427). The risk of death for patients with an AL was thus 7.2 times higher than for those without this complication.

-

Morbidity

Of the patients with AL, 62.7% (529 / 844) developed secondary complications. The complication rate was 19.9% (5 479 / 27 424) for patient without AL. Tables 1 and2 show the frequencies of various kinds of general and operation-specific complications encountered.

-Hospital stay

The duration of stay in hospital was 2.3 times greater for patients with AL, and had a greater scatter (standard deviation, SD) than for those without it (Table 2).

-Recommendation for adjuvant chemotherapy at time of discharge

In the AL group, adjuvant chemotherapy in stage UICC III was less frequently recommended at time of discharge: 73.4% of patients in stage III without AL (N=5 959 / 8 118), but only 60.3% of patients with AL (N=140 / 232), had a recommendation for adjuvant chemotherapy (p < 0.001). Within the study it was not possible to determine whether chemotherapy was actually administered.

Long-term oncological outcome -Follow up

Follow-up information was available for 74.4% of the patients with AL (628 / 844) and for 77.6% of those without AL (21 296 / 27 427). The mean follow-up period was 23 months.

-Overall survival, tumour-free survival

The presence of AL was associated with a poorer long-term oncological outcome. The probability of 5-year overall survival was 51.0% in the group with AL, compared with 67.3% in the group without AL (p < 0.001; Figure 1). The worse long-term oncological outcome of

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Version 13.8.09 1300 7 the patients with AL was not only due to peri-operative mortality: even the probability of 5year tumour-free survival was 63.0% in the group with AL and was thus clearly lower than that in the group without AL, 74.6% (p < 0.001; Figure 2).

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Discussion

This study included 844 cases of AL and thus contains a body of data of sufficient size to yield a differentiated analysis of the effects of AL upon the peri-operative result and the oncological outcome.

-Peri-operative result -Patients with AL have a substantial hospital mortality rate and a high rate of morbidity associated with the AL. The results of the present study showed an increase in hospital mortality by a factor of 7.2 in comparison with patients who did not have AL (hospital mortality with AL, 18.6%; without AL, 2.6%). This is in agreement with published results.

McArdle et al. have reported a 30-day mortality for AL patients 16%, compared with 3.9% without AL [START_REF] Mcardle | Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer[END_REF], and Branagan et al. found corresponding rates as high as 29% and 4.3% [START_REF] Branagan | Prognosis after anastomotic leakage in colorectal surgery[END_REF].

Other groups, too, report a high early mortality associated with AL [START_REF] Buchs | Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study[END_REF][START_REF] Kanellos | The failed intraperitoneal colon anastomosis after colon resection[END_REF]; furthermore, the removal of an anastomosis following an anastomotic leak often results in a 'permanent' stoma [START_REF] Khan | The management and outcome of anastomotic leaks in colorectal surgery[END_REF].

In many cases, an AL is the origin of further post-operative complication, above all those involving sepsis. This is clear if the frequencies of general and operation-specific complications in AL patients are compared with the corresponding rates found among patients without AL (Tables 1 and2). In association with AL, pneumonia was 3.4 times, nonpneumonia pulmonary complications were 4.8 times, cardiac complications 3.4 times, renal complications 7.7 times and multi-organ failure was as much as 14.5 times more frequent than in its absence. Sepsis was more frequent by a factor of 23.7, wound infection 5.1, abscesses 18, enterocutaneous fistula 46, peritonitis 65.3 and complete rupture of the operation wound 7.2. Accordingly, the duration of post-operative hospital stay after the appearance of an AL was prolonged by a factor of 2.3. Some instances of documented enterocutaneous fistula without reported AL can be explained by assuming either that this was not a consequence of AL, but of some other intestinal injury, or that it was a consequence of delayed post-operative AL -which can occasionally occur [START_REF] Hyman | Anastomotic leaks after intestinal anastomosis: it's later than you think[END_REF] -or of unrecognised AL.

-Long-term result -

A substantial body of data is available on the long-term oncological outcome of rectal carcinoma. These show that AL has a negative influence upon long-term survival and is furthermore associated with an elevated rate of local recurrence and distant metastases [START_REF] Law | Anastomotic leakage is associated with poor longterm outcome in patients after curative colorectal resection for malignancy[END_REF][START_REF] Walker | Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer[END_REF][START_REF] Branagan | Prognosis after anastomotic leakage in colorectal surgery[END_REF][START_REF] Fujita | Anastomotic leakage after colorectal cancer surgery: a risk factor for recurrence and poor prognosis[END_REF][START_REF] Jung | Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery[END_REF]. Numerous groups have analysed the overall population of colorectal-carcinoma multicentric historical study of patients with colon and rectal carcinomas. The 5-year survival rate was 42% with and 66.9% without AL [START_REF] Mcardle | Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer[END_REF]. For the relatively long interval from 1971 to 1991, Walker et al. analysed 1722 patients with colon and rectal carcinomas at a single centre in Australia, where the AL rate was 5.1%. Among patients with AL, the overall five-year survival rate was 44.3%, compared with 64.0% for patients without AL [START_REF] Walker | Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer[END_REF].

There are only few data in the literature on the influence of AL upon the long-term oncological outcome for colon carcinoma, and such data as there are refer to small patient cohorts [START_REF] Branagan | Prognosis after anastomotic leakage in colorectal surgery[END_REF][START_REF] Fujita | Anastomotic leakage after colorectal cancer surgery: a risk factor for recurrence and poor prognosis[END_REF]. After analysing 1201 patients with an AL rate of 2.6% (n = 31), Branagan et al. reported finding no influence of AL after colon resection (if rectal carcinoma is considered separately) on the rate of local recurrence or on five-year overall survival [START_REF] Branagan | Prognosis after anastomotic leakage in colorectal surgery[END_REF]. A Japanese group described a similar finding after assessing the comparatively small patient population at their (single) centre; their analysis included only 12 cases of AL after colon resection [START_REF] Fujita | Anastomotic leakage after colorectal cancer surgery: a risk factor for recurrence and poor prognosis[END_REF].

According to the results present here, the presence of an AL is associated with a substantially poorer long-term oncological course of disease than is found in its absence. This is seen immediately in the five-year overall survival (51.0% with AL and 67.3% without it). The initial sharp drop in the survival curve (Figure 1) is striking; this is due principally to the higher rates of post-operative mortality among patients with AL. However, the probability of five-year tumour-free survival is also significantly worse for patients with AL (63.0%, compared with 74.6% without AL), even when the peri-operative mortality associated with the operation itself is excluded from the analysis (Figure 2). The causes of the poorer prognosis for patient with AL are not clear. In a highly detailed multivariate analysis of risk factors for anastomotic leakage following bowel resections for colon cancer already published by our group [12] it was shown that neither tumour-related factors (TNM stage, tumour grade) nor the patient's age is associated with an increase in the risk of AL, so that these factors are also not responsible for this effect. In the same study we found an increased risk of AL following resection of left-sided lesions. However, this factor does not provide a suitable explanation. Our group compared left-and right-side colon cancers using the same database, and found only a marginal difference in 5-year disease-free survival rate (74% and 73% respectively) [13]. Our data provide suggest that there may be an association with the lower rate of adjuvant therapy in the AL group. We found that adjuvant chemotherapy in UICC stage III was less frequently recommended in the AL group at the time of discharge for patients without AL (73.4%) than for those with AL (60.3%). A similar

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Version 13.8.09 1300 10 explanation was offered by Jung et al. [START_REF] Jung | Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery[END_REF]. This chemotherapy effect might be due to postoperative morbidity. Another reason could be the association with higher cardiac and hepatic comorbidity for the AL group, described recently by our study group [12]. Walker et al. [START_REF] Walker | Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer[END_REF] opined that the adverse impact of anastomotic leakage on long-term survival may be attributed not only to a reflection of the high post-operative morbidity associated with the development of intra-abdominal sepsis but also to an unknown inflammation-related immunological process that might enhance cancer recurrence. However, it is also possible that leaks occur as a consequence of other conditions, not detected in the data of the present study, that are themselves precursors of a poor outcome, making leakage prognostic rather than causative.

-Conclusion -

Our results show that post-operative AL is less frequent after resection of colon carcinoma than after corresponding rectal resection, but that it can also lead to significant morbidity and hospital mortality, thus worsening the long-term oncological outcome.

  -aided tomography or X-ray with contrast medium) or (iii) evidence from an autopsy.

  et al. investigated the long-term course of disease in a large (N = 2235)

  , Mroczkowski P, Steinert R et al. Risikofaktoren für die Entstehung von Anastomoseninsuffizienzen nach Kolonkarzinom-Resektionen. Eine multiple Analyse von 844 Patienten mit postoperativer Nahtinsuffizienz. [Anastomotic leakage following bowel resections for colon cancer: Multivariate analysis of risk factors.]. Chirurg 2009; Jun 18. [Epub ahead of print] 13 Benedix F, Kube R, Meyer F et al. Comparison of 17 641 patients with right-and leftsided colon cancer: Differences in epidemiology, perioperative course, histology and survival. Diseases Colon Rectum; accepted for publication 2009. M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS Version 13.8.09 1300

FiguresFigure 1 .Figure 2 .

 12 Figures

13 Tables Table 1 :

 Tables1 General post-operative complications

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	Complication	Without AL	With AL	p
	Pulmonary complications (pleural effusion, atelectasis) n (%) Pneumonia n (%) Cardiac complications n (%) Thrombosis n (%) Pulmonary embolism (%) Renal complications n (%) Urinary-tract infection n (%)	N = 844 951 (3.5) 1056 (3.9) 1161 (4.2) 111 (0.4) 128 (0.5) 340 (1.2) 1584 (5.8) M A N U S C R I P T N = 27 427 142 (16.8) <0.001 113 (13.4) <0.001 118 (14.0) <0.001 15 (1.8) <0.001 5 (0.6) 0.603 78 (9.2) <0.001 67 (7.9) 0.009
	Multi-organ failure n (%) A C C E P T E D 315 (1.1)	134 (15.9)	<0.001
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Table 2 :

 2 Specific post-operative complications and duration of hospitalisation

	Complication	Without AL	With AL	p
		N = 844	N = 27 427
	Post-operative haemorrhage n (%)	246 (0.9)	16 (1.9)	0.009
	Sepsis n (%)	153 (0.6)	120 (14.2)	<0.001
	Obstruction n (%)	220 (0.8)	25 (3.0)	<0.001
	Wound infection n (%)	791 (2.9)	15 (14.7)	<0.001
	Abscess n (%)	128 (0.5)	76 (9.0)	<0.001
	Enterocutaneous fistula n (%)	52 (0.2)	78 (9.2)	<0.001
	Peritonitis n (%)	93 (0.3)	165 (19.6)	<0.001
	Rupture of operation wound n (%)	321 (1.2)	73 (8.6)	<0.001
	Duration of hospital stay [days] mean ± SD	15.6 ± 7.7	35.3 ± 22.5	0.009

Acknowledgements

Data for this research were provided by the independently funded An-Institut. We thank the hospitals that participated in the study for providing the data.

Conflict of interest

None of the authors of this paper has any financial relationship that could lead, or have led, to a conflict of interest in connection with this work. The authors are employees of the respective institutions to which they are affiliated.

Authors' contributions

All authors contributed to the design of the study. Data were acquired by RK, IG and HL.


PhD K Avery

MSc R Hughes

MRCS A Mcnair

MD FRCS D Alderson

MD P Barham

Gen Surg

MD Jane M Blazeby
email: j.m.blazeby@bristol.ac.uk

Health-related quality of life and survival in the two years after surgery for gastric cancer

Keywords: gastrectomy, quality of life, decision making, informed consent

Background: This prospective study examined health-related quality of life (HRQL) and survival in patients with potentially curable gastric cancer.

Methods: Consecutive patients (n=58) selected for curative surgery completed a validated questionnaire (EORTC QLQ-C30) and site-specific module (QLQ-STO22) before surgery and regularly for two years afterwards. Changes of 10 or more points on a 0 to 100 scale were considered clinically significant.

Results: Some 30 patients were alive after two years (52%). In the first three months after surgery, HRQL was significantly reduced across all dimensions except emotional and cognitive functioning (mean reduction of 10 or more points). Functional aspects of HRQL recovered by six months in patients who subsequently were alive at two years, although at least a third of patients experienced specific symptoms, even six months after surgery, especially diarrhoea. For those dying within two years, some post-operative functional HRQL recovery occurred, but many symptoms were common.

Conclusions:

Potentially curative gastrectomy for cancer has a detrimental impact on HRQL that mostly recovers in patients surviving some two years. Patients who die within two years may experience limited post-operative recovery. It is recommended that patients receive HRQL information about the outcomes of surgery for gastric cancer.

Introduction

Gastric carcinoma is the fifth most common malignancy in the world and a leading cause of cancer death [START_REF] Pisani | Estimates of the worldwide mortality from 25 cancers in 1990[END_REF]. Surgical resection of the primary tumour and regional lymph nodes is the mainstay of cure and surgery may be combined with peri-operative chemotherapy or chemoradiation to improve longterm survival [START_REF] Cunningham | Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer[END_REF][START_REF] Macdonald | Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction[END_REF][START_REF] Sakuramoto | Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine[END_REF]. Gastrectomy is, however, associated with significant morbidity and median survival in the western world remains less than 24 months. Understanding the impact of radical gastrectomy on patient reported outcomes such as health-related quality of life (HRQL) is important. This information about HRQL outcomes can then form an important component of fully informed consent before surgery [START_REF] Blazeby | Health-related quality of life measurement in randomized clinical trials in surgical oncology[END_REF].

Current guidance in the UK states that in the process of obtaining consent, the patient should be informed of what they may experience as a result of an intervention, including any life style changes that may result [START_REF]Consent to treatment[END_REF][START_REF]Seeking patients' consent: The ethical considerations[END_REF]. Evaluating surgery with robust HRQL assessments is therefore critical. There is currently a lack of well-designed prospective studies with robust HRQL outcomes evaluating surgery for gastric cancer. The aim of this study was to document the short and long-term HRQL outcomes of potentially curative gastrectomy for cancer and to describe the HRQL trajectory of patients surviving or not surviving two or more post-operative years.

Methods

Patient details

Between November 2000 and November 2004 consecutive patients with adenocarcinoma of the stomach were considered for this study. Patients with potentially curable tumours without a previous or concurrent malignancy, who could understand the language of the HRQL questionnaire and who could provide written informed consent were included. Excluded were patients undergoing emergency surgery, planned palliative gastrectomy or a bypass, patients undergoing peri-operative chemotherapy

Treatment details

The upper gastrointestinal cancer multi-disciplinary team of the Avon, Somerset and Wiltshire Cancer Network makes treatment decisions for all new patients with gastric cancer (population approximately 1.5 million). Potentially curative surgery was offered to fit patients without evidence of haematogenous or peritoneal metastasis and no perceived lymph node involvement outside the proposed surgical field.

Diagnosis and staging involved upper gastrointestinal endoscopic biopsies, computerized tomography of the chest and abdomen and staging laparoscopy with peritoneal cytology. Patients with tumours of the proximal stomach also underwent endoluminal ultrasonography. All gastrectomies were performed in the cancer centre (United Bristol Healthcare Trust) by a team of four consultant surgeons or trainees under consultant supervision. Depending upon the location of the tumour, the surgeon performed either total or subtotal gastrectomy. Reconstruction of the gastrointestinal tract was performed using the Roux en Y technique. After total gastrectomy all patients had a feeding jejunostomy inserted but not additional parenteral feeding was used. D2 lymphadenectomy was standard procedure, except where preoperative staging classified the tumours as T1N0M0, where D1 lymphadenectomy was performed.

All surgeons had visited the Gastric Surgery Division of the National Cancer Centre Hospital, Tokyo.

Clinical details and outcomes were recorded from hospital records, coding major complications as a second operation or readmission to the intensive care unit and all other complications as minor (infections, cardiorespiratory or gastrointestinal). In-hospital mortality was also recorded.

Health related quality of life questionnaires

Health-related quality of life was assessed with the validated European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire, EORTC QLQ-C30 (version 3.0), and the site-

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specific module for gastric cancer, EORTC QLQ-STO22 [START_REF] Aaronson | The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology[END_REF][START_REF] Vickery | Development of an EORTC specific quality of life module for use in patients with gastric cancer[END_REF][START_REF] Blazeby | Clinical and psychometric validation of a questionnaire module, the EORTC QLQ-STO 22, to assess quality of life in patients with gastric cancer[END_REF]. The core instrument assesses key functional aspects of HRQL and global quality of life and has symptom scales and individual items assessing symptoms that commonly occur in patients with cancer. The gastric module has five symptom scales (dysphagia/odynophagia, pain/discomfort, dietary restrictions, upper gastro-intestinal symptoms, emotional problems) and four single items. All QLQ-C30 and QLQ-STO22 responses were linearly transformed to scores from 0 to 100 according to the authors' guidelines. In multi-item function scales, higher scores can be interpreted as higher levels of functioning but, in symptoms scales/single-items, they reflect more symptoms [START_REF] Fayers | EORTC QLQ-C30 Scoring Manual[END_REF]. A change in any scale of at least 10 points is considered to be clinically relevant [START_REF] Osoba | Interpreting the significance of changes in healthrelated quality of life scores[END_REF].

Timing of questionnaire assessments

Patients were asked to complete questionnaires within a three-week period before surgery. Further HRQL assessments were performed six weeks after surgery, every three months in the first postoperative year, and at 18 and 24 months. Time windows of +/-two weeks were applied for each postoperative assessment. Questionnaires were distributed by post and completed by patients themselves.

After questionnaires were returned they were scrutinized for missing individual items and patients telephoned for these responses. If questionnaires were not returned at all, one phone call and one postal reminder were made. Where patients died or were too ill to complete a questionnaire, the HRQL assessment was classified as ineligible. HRQL assessments were classified as missing if this was due to patient refusal, patient non-response (not returned for unknown reasons) or administrative error (questionnaire not sent out or not requested within the correct time window).

Data analyses and statistical methods

Comparisons were made between patients surviving for two years and those dying within this time.

Mean scores and confidence intervals were calculated for HRQL functional scores at baseline and at

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6 six months for both groups of patients. Given the skewed nature of the data the non-parametric bootstrap bias corrected and accelerated method, based on 5000 iterations, was used to calculate 95% confidence intervals. These results were compared with standard means and confidence intervals and because they were similar, standard scores are presented. Given the heavily skewed symptom scores; the percentage of symptomatic patients at each time point was calculated. Symptomatic patients were defined as patients responding, 'a little', 'quite a bit' or 'very much' to symptom items and scales, whereas patients reporting 'not at all' were classified as asymptomatic. Percentage of symptomatic patients at baseline and 6 months post surgery are presented with 95% Wilson confidence intervals.

Graphs were plotted to show HRQL changes over time, but only where there were more than 10 available patients at a particular time point. Kaplan Meier survival analysis was performed. All

Results

Clinical outcomes

During the study period, 131 patients with gastric cancer were discussed at the multi-disciplinary team meeting and 58 selected for potentially curative gastrectomy. Four patients died in hospital after surgery. Of the 58 patients, 30 were alive two years after surgery and 28 had died. Table 1 and Figure 1 shows the baseline details, clinical outcomes and survival of patients undergoing surgery and living or dying within two years. Before surgery, most functional aspects of HRQL were higher (better) and most symptom scores were lower (less common) for patients surviving two or more years than in patients who subsequently died within two years (Tables 2 and3). At the first post-operative assessment (6 weeks), functional aspects of HRQL deteriorated by at least 10 points, except for emotional, social and cognitive function. The proportions of symptomatic patients, including those experiencing appetite loss, diarrhoea and eating restrictions, increased except for dysphagia scores. Recovery of physical, role and social function was seen to begin within three months and mean scores reached within 6 points of baseline mean scores by six months (Table 2). Six months after surgery, however, over 50% of patients still reported some degree of nausea and vomiting, diarrhoea, pain, reflux, dry mouth and sleep difficulties and over 70% reported fatigue and eating problems (Table 3). Mean physical function scores in the two years after surgery are shown in Figure 2. Results for social function and global quality of life scores show a similar pattern to Figure 2. Both cognitive and emotional function scores did not change before or after surgery (data not shown).

HRQL in patients dying within 2 years

At least half of the patients in this group died before the six month follow up. In patients living for six months but dying within two post-operative years, functional aspects of HRQL did generally recover briefly before deterioration (Figure 2). Symptom scores showed a mixed pattern with relief of dysphagia reported after surgery but persistent problems with appetite loss, diarrhoea and eating restrictions before death (data not shown).

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Discussion

Summary of the main findings

This prospective study examined HRQL and survival in patients selected for potentially curative gastric cancer surgery. Patients surviving two years generally recovered most aspects of HRQL within six months of surgery and thereafter only reported problems with a few specific symptoms. In the patients with a poor survival after surgery (dying within two years), however, although a brief post-operative recovery was observed at six months, 20% of patients died within six months of surgery during which HRQL recovery was not achieved. Surgery for gastric cancer, therefore, has a major impact on most aspects of HRQL and, even if this is only temporary, it is suggested that the information is given to patients before surgery during the process of shared treatment decision-making.

Previous research

Since the time of this study, the vast majority of Western patients with gastric cancer now receive neoadjuvant or adjuvant treatment with surgery and it is possible that this influences post-operative HRQL [START_REF] Cunningham | Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer[END_REF][START_REF] Macdonald | Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction[END_REF]. In this study the numbers receiving adjuvant chemotherapy or palliative radiotherapy were too small to draw meaningful conclusions. At present there is a lack of studies evaluating this, but prospective research into the impact of neoadjuvant chemotherapy before oesophagectomy on postoperative HRQL shows that pre-operative treatment has little effect on HRQL recovery [START_REF] Blazeby | Health-related quality of life during neoadjuvant treatment and surgery for localized esophageal carcinoma[END_REF][START_REF] Reynolds | Prospective evaluation of quality of life in patients with localized oesophageal cancer treated by multimodality therapy or surgery alone[END_REF]. It is likely, however, that post-operative chemotherapy significantly delays HRQL recovery, as is testified by the proportions of patients who did not complete the post-operative course of chemotherapy in the UK randomised trial [START_REF] Cunningham | Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer[END_REF]. This issue is currently being addressed in the new trial of peri-operative chemotherapy with or without a bevacizumab, which includes a comprehensive HRQL assessment [START_REF] Cunningham | STO3 A Randomised Phase II/III trial of Peri-operative Chemotherapy with or without Bevacizumab in Operable Adenocarcinoma of the Stomach and Gastro-Oesophageal Junction[END_REF].

Patients with gastric cancer may also be severely malnourishedand/or immunosuppressed and this may influence HRQL. These issues were not specifically assessed in this study but should be addressed in future work. The few studies assessing HRQL in patients undergoing gastrectomy alone

M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS

10 show similar results to those reported in the present paper in patients experiencing a survival benefit of surgery [START_REF] Zieren | Quality of life after surgical treatment of gastric carcinoma[END_REF][START_REF] Wu | Quality of life after curative gastrectomy for gastric cancer in a randomised controlled trial[END_REF]. Other studies, however, have excluded patients with recurrent disease, and many focus upon younger patients. The present study provides additional evidence about the impact of surgery for gastric cancer on HRQL, when cure is attempted but not achieved and it is relevant to every day clinical practice because it included all age patients. All these studies lack evaluation with a diseasespecific measure and it is recommended that this is used to obtain a detailed symptom profile after surgery [18].

Implications of the findings

One purpose of describing the impact of surgery for cancer on HRQL is to provide evidence for information provision for future patients. It is well known that patients want information about treatment outcomes, including data about the impact of treatment on lifestyle factors and expected recovery [START_REF] Rutten | Information needs and sources of information among cancer patients: a systematic review of research (1980-2003)[END_REF]. Robust documentation of the effects of surgical treatment for cancer on HRQL, therefore, is essential to meet these information needs. Documenting HRQL outcomes after surgery may also contribute to core information required for disclosure during the process of informed consent for surgery. This may be particularly important in jurisdictions that use a "reasonable patient" [START_REF] Skene | Informed consent: lessons from Australia[END_REF] legal standard of disclosure. Indeed, the UK General Medical Council consent guidelines mandate that surgeons share all the information patients want to reach a substantial understanding of surgery [START_REF]Consent: patients and doctors making decisions together[END_REF].

Only then can patients autonomously give authorisation for a procedure to take place [START_REF] Faden | Understanding. In: A history and theory of informed consent[END_REF]. The best methods for communicating HRQL information, however, in clinical practice need to be determined but this study does provide some information that can be useful to inform patients [START_REF] Brundage | Communicating quality of life information to cancer patients: a study of six presentation formats[END_REF].

Study limitations

Although the present study was prospective and longitudinal with high compliance rates using validated multi-dimensional disease-specific questionnaires, the sample size was small. This precluded

M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS

11 formal significance testing between groups and it did not allow a separate analysis of the HRQL in patients undergoing total or subtotal gastrectomy. A larger study is needed to explore the differences in post-operative HRQL between total and sub-total gastrectomy. It is likely that HRQL differences in the types of resection and reconstruction in survivors of surgery will be mostly related to symptom profiles, which diarrhoea and eating restrictions predominating after total gastrectomy. Another potential impact on post-operative recovery of quality of life may be the use of fast track and minimal access surgery. A randomised trial has reported better HRQL after laparoscopic surgery for gastric cancer but quality of life assessments were completed by an observer, introducing possible bias, and more work is needed in this area [START_REF] Kim | Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial[END_REF].

Conclusions

In summary, gastrectomy for cancer has a temporary negative impact on most aspects of HRQL that typically recovers within the first post-operative year in patients surviving at least two years. Patients not experiencing survival beyond six months after surgery never recovery post-operative HRQL and every effort to identify these patients before surgery is needed. At present there is insufficient evidence to selectively deny patients with locally advanced cancers gastric surgery because of the risk of both poor survival and poor HRQL, however, larger and better-designed studies should be performed to further explore this issue. Until patient selection improves, it is recommended that these findings be used to inform patients about what to expect after surgery and to guide timely supportive post-operative interventions. Methods to inform patients of the likely HRQL impact of surgery currently do not exist.

  patients undergoing non-operative palliative treatment for gastric cancer. Ethical committee permission and written informed consent were obtained.

  analyses and graphs were performed using the Stata/IC 10.2 statistical software version (Stata Corporation, College Station, Texas, USA, 2005).

  M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS 7 Questionnaire compliance and missing data Before treatment, 97% of patients returned HRQL questionnaires. Overall compliance during follow up exceeded 80%. M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS 8 HRQL in patients surviving 2 years

Future

  Figure 1Kaplan-Meier survival estimates for patients undergoing potentially curative

Table 1 Baseline details and clinical outcomes of patients selected for potentially curative gastrectomy (n=58)

 1

	Patients	Patients dying	P
	surviving ≥ two	< two years,	value
	years, n=30	n=28

Table 2 Baseline and six month mean EORTC QLQ-C30 function scores and 95% confidence intervals in patients surviving or not surviving two years after planned curative gastrectomy

 2

		Patients surviving ≥ two years	Patients dying < two years
	Function a	Baseline (n=28)	Six months	Baseline (n=28)	Six months
			(n=28)		(n=13)
	Physical	85 (77 -94)	80 (72 -87)	76 (67 -85)	72 (56 -89)
	Role	70 (57 -83)	76 (66 -87)	54 (39 -70)	62 (42 -82)
	Social	72 (61 -83)	71 (61 -81)	69 (58 -80)	74 (57 -91)
	Emotional	71 (60 -82)	73 (63 -83)	71 (62 -80)	80 (65 -95)
	Cognitive	85 (76 -94)	82 (75 -89)	76 (66 -87)	74 (56 -92)
	Global QL	68 (58 -77)	69 (60 -78)	61 (50 -72)	67 (56 -78)

a A high score indicates better HRQL

  Wilson Confidence Interval, b A high score indicates more symptoms or worse problems

	Nausea and vomiting	36% (21 -54)	54% (35 -71)	39% (24 -58)	71% (45 -88)
	Pain	39% (24 -58)	69% (50 -83)	57% (39 -73)	57% (33 -79)
	Fatigue	68% (49 -82)	81% (62 -91)	86% (69 -94)	100% (78 -100)
	Appetite loss	50% (33 -67)	38% (22 -57)	50% (33 -67)	71% (45 -88)
	Diarrhoea	14% (6 -31)	54% (35 -71)	11% (4 -27)	43% (21 -67)
	Sleep difficulties	39% (24 -58)	54% (35 -71)	43% (27 -61)	46% (23 -71)
	Symp-ms QLQ-S-22 b
	Dysphagia	44% (28 -63)	36% (20 -55)	50% (33 -67)	57% (33 -79)
	Eating restrictions	59% (41 -75)	76% (57 -89)	75% (57 -87)	71% (45 -88)
	Reflux	67% (48 -81)	68% (48 -83)	61% (42 -76)	64% (39 -84)
	Dry mouth	56% (37 -72)	60% (41 -77)	39% (24 -58)	29% (12 -55)

a

Acknowledgements

Mrs Joanna Nicklin is thanked for her contribution collecting quality of life data. This project was funded by the Medical Research Council (JMB Clinician Scientist Award). KNL Avery was supported by a project grant from Cancer Research UK. The funders had no involvement in the study or the manuscript.

Conflict of Interest


Specialist Richard J E Skipworth
email: rskipworth@hotmail.com

R W Parks

N A Stephens

C Graham

D H Brewster

O J Garden

& S Paterson-Brown

The relationship between hospital volume and post-operative mortality rates for upper gastrointestinal cancer resections: Scotland 1982-2003

Keywords: Surgery, oesophageal cancer, gastric cancer, pancreatic cancer, hepatocellular cancer, mortality

Background: Centralisation of surgical treatment of cancer has resulted in improved outcomes. We aimed to determine evidence of benefit for specialised management of upper gastrointestinal cancer in high-volume centres in Scotland.

Methods

: Discharge records of patients undergoing oesophagectomy, gastrectomy, hepatectomy or pancreatectomy between 1982 and 2003 were identified. Hospital data were analysed on a year-by-year basis to derive 'hospital-years'. Hospital-years were divided into quartiles by volume, and were analysed with regard to in-hospital mortality during the operative admission [Chisquare test (χ 2 ) and Chi-square test for trend (χ 2 trend )].

Results: 10,625 patients and 982 in-hospital deaths were included. In-hospital mortality rates declined during the study period: oesophagectomy 11 . 7% to 7 . 9%; gastrectomy 11 . 2% to 7 . 2%; hepatectomy 11 . 1% to 3 . 0%; and pancreatectomy 8 . 3% to 4 . 9%. For all resections except gastrectomy, mortality decreased as quartile of hospital-year volume increased (oesophagectomy: χ 2 p = 0 . 006, χ 2 trend p = 0 . 001; hepatectomy: χ 2 p = 0 . 004, χ 2 trend p = 0 . 003; pancreatectomy: χ 2 p = 0 . 002, χ 2 trend p = 0 . 001). ORs of death were lower for oesophagectomy (OR = 0 . 58; 95%CI = 0 . 39, 0 . 88; p = 0 . 009) and pancreatectomy (OR = 0 . 35; 95%CI = 0 . 19, 0 . 64; p<0 . 001) in hospital-years within highest-volume quartiles compared with lowest. Scattergraphs of all resection types demonstrated inverse power relationships between number of resections per hospital-year and mortality.

Introduction

Studies have demonstrated improved survival of patients with different types of upper gastrointestinal (GI) cancer, including oesophageal, gastric, pancreatic and hepatocellular cancer, undergoing surgical resection in high-volume, specialist centres [START_REF] Kuo | Impact of hospital volume on clinical and economic outcomes for esophagectomy[END_REF][START_REF] Hannan | The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer[END_REF][START_REF] Begg | Impact of hospital volume on operative mortality for major cancer surgery[END_REF] . For this reason, the United Kingdom Department of Health Clinical Outcomes Group has recommended that patients with oesophageal and gastric cancer should be referred to specialist units serving a population of 1-2 million [START_REF]Guidance Group of the Clinical Outcomes Group. Guidance on Commissioning Cancer Services: Improving Outcomes in Upper Gastro-intestinal Cancers -The Manual[END_REF] .

Such units should each expect to manage at least 100 patients with oesophageal cancer and 150 patients with gastric cancer annually, with approximately 100 patients having resections. Similarly, patients with pancreatic cancer should be referred to specialist units serving a population of 2-4 million [START_REF]Guidance Group of the Clinical Outcomes Group. Guidance on Commissioning Cancer Services: Improving Outcomes in Upper Gastro-intestinal Cancers -The Manual[END_REF] . Such units should expect to discuss approximately 200 new patients annually.

In Scotland, the extent of centralisation and sub-specialisation of surgical practice, with subsequent effects on service provision and patient care, are largely unknown. However, we hypothesised that such forces may have resulted in a drive towards the development of high volume centres. In order to investigate changes in service demand and the effect of centralisation, we aimed to examine the use and outcome of elective upper GI cancer resection in Scotland between 1982 and 2003. In particular, we aimed to analyse postoperative in-hospital mortality rates for oesophagectomy, gastrectomy, hepatectomy and pancreatectomy performed electively for cancer, and examine the influence of hospital volume. C25. In-hospital mortality was defined as death during the admission for which the patient underwent surgery, and was not risk-adjusted.

Statistical Analysis:

Crude population-based rates (PBR) of cancer resection utilisation were calculated using revised mid-year population estimates from the General Register Office for Scotland 5 . Comparison between groups was performed using Pearson's Chi-square test ('χ 2 p') and linear-by-linear association ('χ 2 trend p'). Change in average annual hospital volume per year was assessed using Pearson's correlation coefficient. Within Scotland, few hospitals are likely to reach criteria for high volume according to international standards, but for analysis purposes, data from all hospitals for all 22 years of collection were analysed independently to derive 'hospital-years' i.e. one hospital would have 22 associated "hospital-year" mortality rates if it performed a resection every year for the entire study period. Thus, any individual hospital might be identified as a high-volume centre one year but a low-volume centre the next, or vice-versa.

Odds ratios (OR) of in-hospital death (with 95% confidence intervals) were calculated. Curve-fitting and non-linear regression of scattergraphs was performed following exclusion of those hospital-years with a mortality rate of zero. 1b).

Gastrectomy also demonstrated a significant change in the percentage of resections performed in the highest-volume centres, although there was no evidence of a linear trend (1982 -37 . 1%, 2003 -36 . 6%; χ 2 p<0 . 001; χ 2 trend n.s.).

Post-Operative In-Hospital Mortality:

Annual mortality rates fluctuated considerably from year to year. However, when the 22-year mortality data were analysed using averages over several years (5-year averages plus the average of the last 2 years of the study), it was observed that the mortality rates of all For each type of resection, the relationship between the number of resections performed in each hospital-year and post-operative in-hospital mortality rate was best defined by equations involving an inverse power function (Figure 3a-d).

Solving these equations for y values of published recommended mortality rates [START_REF] Hannan | The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer[END_REF][START_REF] Begg | Impact of hospital volume on operative mortality for major cancer surgery[END_REF][START_REF]Guidance Group of the Clinical Outcomes Group. Guidance on Commissioning Cancer Services: Improving Outcomes in Upper Gastro-intestinal Cancers -The Manual[END_REF][5][START_REF] Allum | behalf of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, the British Society of Gastroenterology, and the British Association of Surgical Oncology. Guidelines for the management of oesophageal and gastric cancer[END_REF] indicated that surgical units must perform at least 19 oesophagectomies or 16 gastrectomies per year to ensure average mortality rates of less than 10%, or at least 51 oesophagectomies or 41 gastrectomies per year to ensure average in oesophagectomy 1;10-12 , gastrectomy 2 , hepatectomy 3;13;14 , pancreatectomy 3;14-16 , colectomy 2 , pelvic exenteration 3 , pneumonectomy [START_REF] Begg | Impact of hospital volume on operative mortality for major cancer surgery[END_REF] , paediatric cardiac surgery 17 , carotid endarterectomy 18 and abdominal aortic aneurysm (AAA) repair 19 . Cancer patients treated in high-volume hospitals have been shown to experience reduced rates of post-operative complications and improved 5-year survival 20;21 .

In North America, selective hospital referral strategies based on minimum volume standards, processes of care and direct outcome measurement have been proposed as methods of reducing mortality following oesophagectomy, pancreatectomy, AAA repair, coronary artery bypass grafting and percutaneous coronary interventions [START_REF] Birkmeyer | The Leapfrog Group's Patient Safety Practices, 2003: The potential benefits of universal adoption[END_REF] . However, the potential association between increased hospital volume and improved surgical outcomes remains a controversial issue in which a number of negative studies have also been published 23;24 . Factors that may have contributed to the decline in mortality in high volume centres would have included the development of specialist multidisciplinary teams with improved patient selection [START_REF] Davies | ARTICLE IN PRESS 22 meeting improves staging accuracy and treatment selection for gastroesophageal cancer[END_REF] , and advances in surgical, anaesthetic and post-operative care [START_REF] Robertson | Ventilatory and intensive care requirements following oesophageal resection[END_REF] . However, some of these changes will have also taken place in low volume centres, and thus some temporal improvement in mortality rates may have occurred inevitably outwith the influence of hospital volume.

Volume-Outcome Relationship in

Analysis of data by quartile of hospital-year volume demonstrated that operations performed during highest-volume hospital-years were significantly associated with reduced post-operative mortality for oesophagectomy, hepatectomy and pancreatectomy, compared with the lowest volume hospital-years. However, the relationship between volume and outcome was not straightforward. The "unusually" high mortality rate observed within hospital-years performing 2 hepatectomies (i.e. second volume quartile -see However, the increase from 5 . 3% to 6 . 9% in the mortality rate of pancreatic cancer patients treated in hospital-years performing 6 or more pancreatectomies (i.e. the highest volume quartile -see Table 2) compared with hospital years performing 3 to 5 pancreatectomies (the third quartile) is more difficult to explain.

Possible explanations include variation in patient fitness; poor patient selection; differences in surgical technique; differing thresholds for operating on patients with disease which is at the limit of resectability; and radicality of the surgery (i.e. lymphadenectomy and multivisceral resection) which expose patients to higher risks of post-operative morbidity and mortality. These factors have not been analysed in the present study.

Gastrectomy data do not appear to demonstrate a significant effect of hospital volume on mortality. However, other reasons may also have contributed to the lack of a positive volume-outcome relationship. Firstly, the number of gastric resections declined by approximately 50% over the study period, presumably secondary to the decreasing incidence of gastric cancer in Western Europe.

Secondly, the majority of hospitals performing gastrectomy in Scotland are still of relatively low volume. This finding would be consistent with arguments proposed by other authors that cancer centres in Scotland are not yet of sufficient critical mass [START_REF]Cancer Scenarios: An aid to planning cancer services in Scotland in the next decade[END_REF] . It could also be argued that the reduction in gastric resection for benign disease over the study period has impacted on training, thus reducing any potential volume-outcome relationship still further.

M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS

15 Perhaps the strongest evidence for a significant effect of hospital volume on patient outcome was the inverse power relationship observed between hospitalyear volume and in-hospital mortality rate for all types of resection. Solving the curve equations for recommended mortality rates provided 'ideal volume parameters' for centres offering different types of upper GI cancer resection. It could be argued that these 'ideal volume parameters' are likely to be an overestimate as all hospital-years with a mortality rate of zero must be excluded to generate the curve equations. However, although zero post-operative deaths should represent our ultimate goal, it must also be appreciated that the concept of a hospital offering long-term surgical treatment of upper GI cancer with zero mortality remains a theoretical one that lies outwith the bounds of current medical practice. Therefore, the observed inverse curves are unlikely to ever touch the Xaxis. In any case, these curves imply that centralisation and specialisation improve patient outcome, but that a sufficient number of high-volume centres

have not yet been established to treat satisfactorily upper GI cancer in Scotland.

Another important point raised by scattergraph analysis is that the chosen method of statistical interrogation may affect the overall conclusions of a volumeoutcome study. Although analysis of mortality data by quartile of hospital-year volume could demonstrate no significant results for gastrectomy, scattergraph analysis appeared to demonstrate an inverse relationship between in-hospital mortality rate and the number of gastric resections performed per hospital-year.

M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS 16

Comparisons With Other Studies: The findings of the present study would appear to contradict those of the Scottish Audit of Gastric-Oesophageal Cancer (SAGOC), which did not find a significant relationship between higher hospital volume and reduced inpatient mortality or long-term survival following oesophagectomy and gastrectomy [START_REF] Gilbert | Scottish Audit of Gastric and Oesophageal Cancer: Report 1997-2000 -A Prospective Audit[END_REF] . This discrepancy may lie in the potential advantages and disadvantages of the two studies. Although the data of the present study were collected retrospectively, and misclassification and coding bias remain potential problems, the data are believed to be of high quality [START_REF] Harley | Quality of Scottish Morbidity Record (SMR) data[END_REF] . The one significant disadvantage of the present study is that it has not allowed for risk adjustment by case-mix [START_REF] Wouters | High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data[END_REF]

  Post-operative in-hospital records and mortality data for all elective oesophageal, gastric, hepatic and pancreatic cancer resections performed in Scotland between 1982 and 2003 were obtained from Information Services Division (ISD) Scotland, a support service of NHS Scotland. The database used was SMR1/01, an episode-based record relating to all inpatients and day cases discharged from non-obstetric and non-psychiatric specialties. Admissions during which an inpatient underwent elective surgical resection and also died were identified. Operation codes used to identify patients were those of the Office of Population Censuses and Surveys (OPCS) Classification of Surgical Operations (3 rd Revision) for patients treated before January 1989, and OPCS Classification of Surgical Operations and Procedures (4 th Revision) for later patients: oesophagectomy OPCS3 291.2 and OPCS4 G01/G02/G03; gastrectomy OPCS3 422/423 and OPCS4 G27/G28; hepatectomy OPCS3 500 . 1/500 . 3/509 . 4 and OPCS4 J02/J03; and pancreatectomy OPCS3 531/532 and OPCS4 J55/J56/J576/J58. Cancer diagnosis codes used to identify patients were those of the World Health Organization (WHO) International Classification of Diseases (ICD): Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, 9th Revision for patients treated before April 1996, and WHO International Classification of Diseases and Related Health Problems, 10th Revision for later patients: oesophageal cancer ICD9 150 and ICD10 C15; gastric cancer ICD9 151 and ICD10 C16; cancer of liver and intra-hepatic bile ducts ICD9 155 and ICD10 C22; and pancreatic cancer ICD9 157 and ICD10 M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS 6

  less than 5%. Furthermore, a unit must perform at least 24 hepatectomies or 33 pancreatectomies per year to ensure average mortality rates of less than 5%. During the last five years of the study(1999-2003), only 4 of the 22 hospitals offering oesophagectomy performed more than 19 oesophageal resections in a year, and only 2 hospitals achieved this statistic in all 5 years. Furthermore, only 2 of the 28 hospitals offering gastrectomy performed more than 16 gastric resections in a single year, and no hospitals achieved this number in all 5 years. No hospitals performed either 51 oesophagectomies or 41 gastrectomies in a year, or achieved the COG recommendation of 100 annual oesophagogastric resections. Only 1 of the 8 hospitals offering hepatectomy between 1999 and 2003 performed more than 24 resections annually, but it achieved this in all 5 years. The same centre was only 1 of 11 hospitals offering pancreatectomy that ever performed more than 33 resections in a year (in 2001). Between 1999 and 2003, the average in-hospital mortality rates in this centre were 1.5% for hepatectomies and 5.1% for pancreatectomies. Relationship in Non-Upper GI Surgery: Increased hospital volume has been shown to be associated with reduced post-operative mortality

  Upper GI Surgery in Scotland:The results of the present study support the concept that post-operative in-hospital upper GI cancer patient mortality is decreased in Scotland when resection is performed in high-volume centres, particularly in patients with oesophageal, hepatic and pancreatic cancer. In closer detail, our results show that between 1982 and 2003, the post-operative in-hospital mortality rates of oesophagectomy, hepatectomy and pancreatectomy decreased in the face of dramatically increased population-resection. Over the same time period, the percentage of resections being performed in high volume centres also increased significantly.

Figure 1 :

 1 Figure 1: a) The average procedural volume of hospitals performing elective

Figure 2 :

 2 Figure 2: The average post-operative in-hospital mortality rates of elective upper

Figure 3 :

 3 Figure 3: Scattergraphs of in-hospital mortality rate against hospital-year volume

Table 2

 2

	) might be explained by

(6):963-969.

  . However, it seems likely that the aging trend of patients would tend to mitigate against reductions in post-operative mortality, Skipworth RJ, Wall L, Voss A, Preston T, Fearon KC. Objective physical activity and self-reported quality of life in patients receiving palliative chemotherapy. J Pain Symptom Manage. 2007; 33(6):676-685.

	ARTICLE IN PRESS ARTICLE IN PRESS ARTICLE IN PRESS ARTICLE IN PRESS ARTICLE IN PRESS
	suggesting that age-adjustment of cases might result in even greater decreases in mortality over time. In comparison, SAGOC was a 2-year M A N U S C R I P T care of upper GI cancer patients, further studies to investigate the effect of hospital volume on outcomes other than mortality (e.g. patient satisfaction 31 ), or of individual surgeon volume on patient outcome, are required. Furthermore, the development of outcome measures in patients receiving non-operative treatment (e.g. physical activity and quality-of-life 32 ) represents another significant gap area. In conclusion, surgically-treated patients with upper GI cancer are likely to fare better if they are managed within high-volume specialist units. These results add to a growing body of evidence supporting specialisation of surgery for upper GI malignancy. This conclusion has major implications for the delivery of cancer services in Scotland and the rest of Europe. M A N U S C R I P T M A N U S C R I P T 13. Glasgow RE, Showstack JA, Katz PP, Corvera CU, Warren RS, Mulvihill SJ. The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma. Arch Surg 1999; 134(1):30-35. 14. Dimick JB, Cowan JA, Jr., Colletti LM, Upchurch GR, Jr. Hospital teaching status and outcomes of complex surgical procedures in the United States. Arch Surg 2004; 139(2):137-141. 15. Lieberman MD, Kilburn H, Lindsey M, Brennan MF. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 1995; 222(5):638-645. M A N U S C R I P T 19. Holt PJ, Poloniecki JD, Gerrard D, Loftus IM, Thompson MM. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. Br J Surg 2007; 94(4):395-403. 20. Verhoef C, van de WR, Schaapveld M, Bastiaannet E, Plukker JT. Better survival in patients with esophageal cancer after surgical treatment in university hospitals: a plea for performance by surgical oncologists. Ann Surg Oncol 2007; 14(5):1678-1687. 21. Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg 2005; M A N U S C R I P T A N U S C R I P T 32. Dahele M, M Table and Figure Legends
	prospective study that involved approximately 1/7th of the patients included in the present analysis. The fluctuating nature of annual mortality rates emphasises the importance of considering mortality data over longer time periods. Secondly, SAGOC considered both elective and emergency procedures whereas we have analysed only elective cases. Data from colorectal cancer studies have shown a reduced risk of peri-operative death for high-volume surgeons when performing elective but not emergency surgery 30 . A C C E P T E D A C C E P T E D A C C E P T E D 18. Holt PJ, Poloniecki JD, Loftus IM, Thompson MM. Meta-analysis and systematic review of the relationship between hospital volume and outcome following carotid endarterectomy. Eur J Vasc Endovasc Surg 2007; 33(6):645-A C C E P T E D A C C E P T E D A C C E P T E D
	651.
	Future Work: The present study primarily investigated the effect of hospital
	volume on in-patient mortality. However, to promote ongoing improvement in the
	17 20 21 23 25

16. Parks RW, Bettschart V, Frame S, Stockton DL, Brewster DH, Garden OJ. Benefits of specialisation in the management of pancreatic cancer: results of a Scottish population-based study. Br J Cancer 2004; 91(3):459-465. 17. Hannan EL, Racz M, Kavey RE, Quaegebeur JM, Williams R. Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality. Pediatrics 1998; 101

Table 1 :

 1 The total numbers of resections and post-operative in-hospital deaths, and the average in-hospital mortality rates over the 22-year study period.

Table 2 :

 2 Post-operative in-hospital mortality rates for elective upper GI cancer resections according to quartile of hospital-year volume. a = statistically different from lowest volume quartile, p<0 . 01; b = statistically different from lowest volume quartile, p<0 . 001; c = statistically different from second volume quartile, p<0 . 01; d = statistically different from second volume quartile, p<0 . 001.

Acknowledgements

Many thanks to Fiona Irving, ISD, who kindly performed data extraction.

M A N U S C R I P T A C C E P T E D

Authors' Contributions

RJES, RWP, CG, NAS, DHB, OJG and SPB were all involved in data analysis and manuscript preparation. All authors had approval of the final manuscript.

Conflicts of Interest

There are no competing interests.

Role of the Funding Source

This study was not funded.

M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS

26 with recommended mortality rates (5% and 10% for oesophagectomy and gastrectomy; 5% for hepatectomy and pancreatectomy). Colour intensity of data points denotes number of ties.

M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS


MD Yvonne E A Van Riet
email: yvonne.v.riet@catharina-ziekenhuis.nl

A J G Maaskant
email: sabrina.maaskant@catharina-ziekenhuis.nl

G J Creemers

L Van Warmerdam
email: laurens.v.warmerdam@catharina-ziekenhuis.nl

F H Jansen
email: frits.jansen@catharina-ziekenhuis.nl

C J H Van De Velde
email: c.j.h.van_de_velde@lumc.nl

H J T Rutten
email: harm.rutten@catharina-ziekenhuis.nl

G A P Nieuwenhuijzen
email: grard.nieuwenhuijzen@catharina-ziekenhuis.nl

Identification of residual breast tumour localization after neo-adjuvant chemotherapy using a radioactive 125 Iodine seed

Keywords:

Introduction The use of neo-adjuvant chemotherapy has increased in the treatment of loco-regionally advanced primarily operable breast cancer. As a result of improved neo-adjuvant chemotherapy regimes the number of clinical as well as radiological responses have increased. In case of a complete response it is difficult to identify residual disease and to perform an adequate radical breast-conserving surgery. Therefore localization of the original tumour bed is mandatory. In this study we propose a novel technique with a seed containing radioactive 125 Iodine ( 125 I). The 125 I has a half-time of 60 days and is therefore still recognisable with a gamma probe after admittance of several courses of neo-adjuvant chemotherapy.

Material and Methods

In the period from July 2003 and November 2008, 47 consecutive patients had successful 125 I seed localization of a breast tumour before starting neo-adjuvant chemotherapy. Results The overall clinical response rate to neo-adjuvant chemotherapy was 100%. Complete clinical response occurred in 34 patients, partial clinical response occurred in 13 patients. Complete radiological response occurred in 18 patients, partial radiological response occurred in 29 patients. The initial surgical treatment consisted of breast-conserving surgery for all 47 patients, after a mean of 170 days (range:70 -220) after 125 I seed localization. In 19 patients pathology revealed no residual tumour, 23 patients showed a partial response. Only 3 lumpectomies were irradical. Conclusion: This study has shown that 125 I seed localization is a novel and highly successful technique in localizing the tumour bed in patients who receive neo-adjuvant chemotherapy for breast cancer leading to a high percentage of radical margins in case of breast-conserving surgery.

Introduction

The treatment of patients with locally advanced as well as primary operable breast cancer has evolved to include neo-adjuvant chemotherapy strategies. Despite the fact that several randomized trials found little or no survival advantage comparing neo-adjuvant to adjuvant chemotherapy, neo-adjuvant chemotherapy does permit the assessment of the response of the primary tumour to a particular chemotherapy regimen(1-3) Furthermore, neo-adjuvant chemotherapy substantially reduces the size of the primary tumour in a majority of cases, thus increasing the possibility of breast-conserving surgery. [START_REF] Van Der Hage | Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer Trial 10902[END_REF][START_REF] Fisher | Effect of preoperative chemotherapy on the outcome of women with operable breast cancer[END_REF][START_REF] Buchholz | Neo-adjuvant chemotherapy for breast carcinoma, multidisciplinary considerations of benefits and risks[END_REF][START_REF] Estevez | Evidence based use of neo-adjuvant taxane in operable and inoperable breast cancer[END_REF][START_REF] Nsabp Group | The effect on primary tumor response of adding sequential Taxotere to Adriamycin and cyclophosphamide: preliminary results from NSABP Protocol B-27[END_REF][START_REF] Rouzier | Breast-conserving surgery after neo-adjuvant anthracycline-based chemotherapy for large breast tumors[END_REF][START_REF] Bonadonna | Primary chemotherapy to avoid mastectomy in tumors with diameters of three centimetres or more[END_REF][START_REF] Chen | Breast conservation after Neo-adjuvant Chemotherapy: The M.D. Anderson Cancer Experience[END_REF][START_REF] Chen | Breast conservation after Neo-adjuvant Chemotherapy. A Prognostic Index for Clinical Decision-Making[END_REF][START_REF] Mauriac | Neo-adjuvant Chemotherapy for operable breast carcinoma larger than 3 cm: A unicentre randomized trial with a 124-month median follow-up[END_REF][START_REF] Kulkarni | HER2-positive early breast cancer and trastuzumab: a surgeon's perspective[END_REF][START_REF] Mathew | Neo-adjuvant chemotherapy for locally advanced breast cancer: A review of the literature and future directions[END_REF][START_REF] Shenoy | Practical advice on clinical decision making during neoadjuvant chemotherapy for primary breast cancer[END_REF] With the use of non-cross-resistant chemotherapy regiments, taxanes and biological response modifiers like Trastuzumab in the neo-adjuvant setting, complete clinical response rates of 65% have been documented. [START_REF] Estevez | Evidence based use of neo-adjuvant taxane in operable and inoperable breast cancer[END_REF][START_REF] Nsabp Group | The effect on primary tumor response of adding sequential Taxotere to Adriamycin and cyclophosphamide: preliminary results from NSABP Protocol B-27[END_REF][START_REF] Rouzier | Breast-conserving surgery after neo-adjuvant anthracycline-based chemotherapy for large breast tumors[END_REF][START_REF] Kulkarni | HER2-positive early breast cancer and trastuzumab: a surgeon's perspective[END_REF] A relative problem for breast conserving surgery after neo-adjuvant chemotherapy however is the inability to localize the residual disease in the primary tumour bed in case of complete clinical and radiological response. [START_REF] Buchholz | Neo-adjuvant chemotherapy for breast carcinoma, multidisciplinary considerations of benefits and risks[END_REF] As long as the original tumour site is still identifiable through radiological imaging, it is possible to conduct breast-conserving surgery using standard image-guided localization techniques. The standard technique being the hookwire technique where a thin, hooked wire is radiologically guided through the skin into the lesion and the surgeon performs a wire-guided excision of the tumour. Although this technique is the current standard technique for pre-operative localization of non-palpable breast lesions there are several disadvantages. [START_REF] Gray | Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of non-palpable breast lesions: radioactive seed versus wire localization[END_REF][START_REF] Gray | Radioguidance for nonpalpable primary lesions and sentinel lymph node(s)[END_REF] After neo-adjuvant chemotherapy an additional problem can be encountered if radiological imaging does not reveal any residual disease -as in case of complete radiologically response -and thus wire localization is not possible. Different therapeutical options ranging from no surgical treatment (only radiotherapy) to quadrantectomy and mastectomy are performed in this situation. [START_REF] Kulkarni | HER2-positive early breast cancer and trastuzumab: a surgeon's perspective[END_REF][START_REF] Mathew | Neo-adjuvant chemotherapy for locally advanced breast cancer: A review of the literature and future directions[END_REF][START_REF] Shenoy | Practical advice on clinical decision making during neoadjuvant chemotherapy for primary breast cancer[END_REF] Ideally the tumour bed is marked before starting the neo-adjuvant chemotherapy, to facilitate the localization during and after the administration of the neo-adjuvant chemotherapy. Implantation -using standard image guided techniques -of a single 125 Iodine ( 125 I) labelled titanium seed before the chemotherapy into the tumour bed puts up with these prerequisites. [START_REF] Gray | Radioguidance for nonpalpable primary lesions and sentinel lymph node(s)[END_REF][START_REF] Hughes | A multi-site validation trial of radioactive seed localization as an alternative to wire localization[END_REF] The 125 Iodine ( 125 I) labelled titanium seed has been described for the localisation of non palpable breast tumours. [START_REF] Gray | Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of non-palpable breast lesions: radioactive seed versus wire localization[END_REF][START_REF] Gray | Radioguidance for nonpalpable primary lesions and sentinel lymph node(s)[END_REF][START_REF] Hughes | A multi-site validation trial of radioactive seed localization as an alternative to wire localization[END_REF][START_REF] Pavlicek | Radiation safety with use of I-125 seeds for localization of non-palpable breast lesions[END_REF]. We used the 125 I seed to mark the tumour bed in patients who were planned to receive neo-adjuvant chemotherapy for breast

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5 cancer, and were considered to be treated with breast-conserving surgery. We document in this paper the clinical, radiological and pathologic responses to the neo-adjuvant chemotherapy as well as the feasibility of tumour retrieval and negative resection margins of the subsequent lumpectomy.

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Materials and Methods

Patients

All consecutive patients between July 2003 and November 2008 that received neo-adjuvant chemotherapy treatment to down size and/or down stage T2 -T3 tumours or when axillary lymph node metastases were included in this study. In addition breast conserving therapy should be expected to be possible, before or after downsizing Patients with inflammatory, bilateral, T4 and M1-tumours were excluded from the study. Data were collected prospectively.

Radioactive seed localization

After pathologic diagnosis was obtained and a neo-adjuvant treatment strategy was determined, a radioactive seed was placed into the tumour bed before start of the administration of chemotherapy.

Radioactive seed localisation was carried out as described by Gray et al.(14-16) using a titanium seed containing 7 Mbq of Iodine-125 ( 125 I). This radio nuclide has a half-life of 60 days and is a 27 keV source of gamma radiation. Because of these characteristics, 125 I is an excellent gamma source to use in combination with the technetium-99 (141 keV) used for sentinel lymph node biopsy. In radioactive seed localisation, the breast lesion was visualized by ultrasonography or mammography. The radioactive seed was introduced within an 18-gauche needle, guided into the lesion and using a stilette moved into the breast parenchyma centrally at the site of the lesion. Finally, the exact position of the seed was confirmed with mammography.

Chemotherapy

The neo-adjuvant chemotherapy regimen followed was either those outlined in prospective institutional trials that were open during the study period or either those according to Dutch Guidelines, and were generally doxorubicin and/or taxane based. Trastuzumab was added in patients with Her2Neu overexpression.

Clinical, radiological and pathological response

Initial clinical diameter and response to chemotherapy were assessed by the oncologist and the surgeon using a caliper. Initial radiological diameter and response to chemotherapy were determined by ultrasonography, mammography and/or MRI. Response was scored using RECIST criteria (Response Evaluation Criteria in Solid Tumours) [START_REF]New response evaluation[END_REF]. Patients in whom the initial tumour could not be radiologically

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7 identified after neo-adjuvant chemotherapy were defined as complete radiological responders, a regression of > 30% was considered to be a partial radiological response and a tumour diameter of > 20% of the initial tumour was considered to be progressive. All other patients were classified as having stable disease.

Operative technique

Breast conservation therapy was proposed to patients with a clinical post chemotherapy tumour diameter ≤ 3 cm, but breast volume and expected cosmetic outcome were taken into account.

Operation was planned 4-6 weeks after completion of the neo adjuvant chemotherapy. The handheld gamma probe (Neoprobe 2000) was set to detect a 27 keV source of 125 I and was placed over the anterior surface of the breast. The point of maximum activity marked the skin location directly overlying the seed and lesion; the gamma probe was used to guide the excision. The excised tissue volume was related to pre-chemotherapy tumour dimensions. In case of complete regression, pre-chemotherapy diameter was also taken into account when excising the tumour. Seed removal within the excision was ensured by detecting the 125 I source of radioactivity within the excised specimen and confirmed by detecting no 125 I activity remaining within the wound. All specimens were transported during the procedure to the radiology department for specimen radiology to determine the presence of the lesion and the seed and to evaluate the radiological radicality. Subsequently the breast specimen were transported to the pathology department for further examination according to the Dutch nationwide protocols. The 125 I seed was removed at the pathology department, placed in a lead container and sent to the nuclear department for further storage. Axillary lymph node dissection was performed in case of evidence of malignancy prior to neo-adjuvant chemotherapy. In case of clinically negative lymph node status prior to chemotherapy either a sentinel node biopsy performed before or after starting the chemotherapy according to local or study protocols at that time. In case of a positive sentinel node an axillary node dissection was performed after the chemotherapy.

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Results

Patient characteristics

Between July 2003 and November 2008 fifty one patients received neo adjuvant chemotherapy for primarily operable breast carcinoma after intra-lesional placement of a 125 I seed. Three patients requested mastectomy regardless the tumour regression and one patient terminated neo-adjuvant chemotherapy before completing the cycles and subsequently received a mastectomy. These four patient were excluded from the study. Hence, 47 patients were included in this evaluation and were planned for breast-conserving therapy. The patient's characteristics are as reported in Table 1. The pathologic diagnosis was obtained by means of ultrasound-guided or stereotactically true cut biopsy of the tumour. Receptor and Her2-neu status was retrieved from this material and shown in Table 1.

Lymph node status

After axillary ultrasound in all 47 patients and fine needle aspiration in case of suspicious lymph nodes, 25 patients appeared to be lymph node positive. A pre-chemotherapy sentinel node procedure was performed in 8 patients, five of them revealing lymph node involvement . Hence, 30 of the 47 patients (63.8%) were lymph node positive before initiation of the neo-adjuvant chemotherapy. No further axillary treatment was conducted in the three patients with a negative sentinel node outcome. In 14 node negative patients -before starting neo-adjuvant chemotherapy -axillary staging procedures were performed after finishing systemic treatment. observed. Six of the 14 node negative patients -before neo-adjuvant chemotherapy -had a sentinel node biopsy after neo-adjuvant chemotherapy, two of which appeared positive. These two patients had an axillary lymph node dissection, as well as 8 remaining patients who had no axillary staging procedure before neo-adjuvant chemotherapy. In 4 out of 8 positive lymph nodes were retrieved.

Clinical, radiological and pathological response

The clinical, radiological and pathologic post-chemotherapy regression according to the RECIST criteria is shown in Table 2. The overall clinical response rate to neo-adjuvant chemotherapy was 100%.

Complete clinical response occurred in 34 patients, partial clinical response occurred in 13 patients . No clinical progression occurred. The mean clinical tumour diameter decreased from 32mm (range:10-70 mm, SD:1.39) at initial presentation to a mean of 5mm (range:0-30mm, SD:0.80) after neo-adjuvant chemotherapy. Radiological response was determined by mammography in 7 patients, by ultrasonography in 14 patients, and in 33 patients by MRI as well. (Table 2) Complete radiological response occurred in 18 patients , partial radiological response occurred in 29 patients . Again, no radiological progression occurred. The mean radiological diameter decreased from 34mm (range:13-75mm, SD:1.34) at initial presentation to 8mm (range:0-32,SD:0.87) after neo-adjuvant chemotherapy.

The initial surgical treatment consisted of breast-conserving surgery for all 47 patients. Mean specimen volume was 107,25cm 3 (range:30-600cm 3 , SD:124,90) and a mean weight of 38,61g (range:10,80-216,00g, SD:44,90) In 19 patients pathology revealed no residual tumour, 23 patients showed a partial response . In this group 8 patients showed only minimal residual tumour cells in fibrotic tissue, 14 patients had residual tumours ranging in diameter from 0.5 to 5.0 cm and 1 patient had multifocal tumour locations throughout the specimen. Five patients had a tumour residue as large as the initial clinical and radiological size pre-chemotherapy and were scored as stable disease . In 44 patients the excision showed pathologically radical margins. Three patients displayed irradical margins. Two showed a complete clinical and radiological response but a partial pathological response. One patient showed focal irradicality for DCIS only and was treated with an extra radiotherapy boost. The other patient underwent a secondary mastectomy. The third patient showed a partial clinical and radiological response, but a stable disease on pathological examination with malignant skin infiltration which was irradical excised

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Discussion

In the recent years neo-adjuvant chemotherapy for locally advanced breast cancer is more used because the chemotherapy regimens are more effective and as a result of the downsizing of the tumour breast conserving surgery is possible in a majority of the patients.(1-13) Neo adjuvant endocrine therapy is even better tolerated and is thus an up coming alternative for specific groups of (postmenopausal) patients with the same intention as neo-adjuvant chemotherapy. [START_REF] Valenzuela | Neo-adjuvant hormonal therapy[END_REF][START_REF] Mieog | The advantages of preoperative systemic therapy in breast cancer[END_REF] In case of a complete clinical and/or radiological response adequate localisation for retrieving of the original tumour bed is difficult Identification of original tumour localization Different methods have been introduced to identify the original tumour localization after a radiological complete response. In the EORTC 10902 trial [START_REF] Van Der Hage | Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer Trial 10902[END_REF], in case of a complete clinical and radiological response tumour breast biopsy specimens were examined for the presence of microscopic residual tumour to correlate the clinical response with pathologic evaluation. As stated by Buchholz et al (3) this is a labour time intensive and complicated method. It requires careful planning and appropriate original mammograms including straight lateral views. At the University of Texas M. D. Anderson Cancer Centre, blunt metallic markers are being placed at the tumour site by ultrasonographic guidance during the course of neo-adjuvant chemotherapy in order to permanently mark the tumour bed.(8) Implantation of metallic markers has shown to be useful in marking the tumour bed [START_REF] Edeiken | US-guided implantation of metallic markers for permanent localization of the tumor bed in patients with breast cancer who undergo preoperative chemotherapy[END_REF], but this technique renders several disadvantages as well. First, to improve detection a minimum of four markers should be implanted. [START_REF] Edeiken | US-guided implantation of metallic markers for permanent localization of the tumor bed in patients with breast cancer who undergo preoperative chemotherapy[END_REF] Second, visualisation by ultrasound or mammography needs to be performed shortly before the operation. Finally, the surgeon has to operate based on the tumours' clock position, having no aid during the operation as to whether he approaches the tumour correctly. A hook-wire localisation of the metal markers can also be performed shortly before surgery, which means an additional procedure for the patient.

Advantages of 125 I seed lokalization

These difficulties are overcome by implantation of a 125 I seed in the breast lesion before start of chemotherapy and subsequently performing a lumpectomy guided by the radioactive seed localization.

The general advantages of radioactive seed localization as compared to wire localization, which is the current standard technique for non palpable lesions, are the following. [START_REF] Gray | Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of non-palpable breast lesions: radioactive seed versus wire localization[END_REF][START_REF] Pavlicek | Radiation safety with use of I-125 seeds for localization of non-palpable breast lesions[END_REF] Because the entry site of

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12 the seed is not an issue in the excision, the radiologist can choose the site that is best for precise placement without consideration of the incision site. Likewise, because the surgeon can precisely locate the seed on the skin, the incision can be made at a location closest to the lesion and thus avoid excessive dissection and tissue loss. Finally, because the radioactive seed is entirely surrounded and contained within the breast parenchyma, the possibility of displacement during confirmatory mammograms and patient transfers is being eliminated. A specific advantage in case of neo-adjuvant chemotherapy is the half life of the 125 I nuclide being 60 days. As shown in our study, breast-conserving surgery of the original tumour site guided by 125 I seed appeared to be possible even after a mean of 170 days after localization of the tumour site prior to chemotherapy.

The need of a histological confirmation of a representative excision

Van der Hage et al (1) suggested in his overview that radiological measurements should be implemented mandatory in the assessment of tumour response to have objective data to measure the degree of tumour response. Ultrasound has been shown to be an accurate method to measure the size of breast tumours [START_REF] Bosch | Pre-operative estimation of the pathological breast tumour size by physical examination, mammography and ultrasound: a prospective study on 105 invasive tumours[END_REF] and has proven reliable in quantifying tumour response. [START_REF] Seymour | Ultrasound assessment of residual abnormalities following primary chemotherapy for breast cancer[END_REF][START_REF] Loo | Dynamic contrast-enhanced MRI for prediction of breast cancer response to neoadjuvant chemotherapy: initial results[END_REF] MRI is more frequently considered as the standard radiological imaging technique in breast cancer size assessment before, during and after neo-adjuvant chemotherapy. [START_REF] Londero | Locally advanced breast cancer: comparison of mammography, sonography and MR imaging in evaluation of residual disease in women receiving neo-adjuvant chemotherapy[END_REF][START_REF] Belli | MRI accuracy in residual disease evaluation in breast cancer patients treated with neoadjuvant chemotherapy[END_REF] Although the small size of the series , superiority of MRI in predicting residual multifocal and multicentric disease has been described.(25) A negative predictive value of 67% in overestimation of tumour size is reported by Londero et al, with a potential decrease in the rate of breast conserving therapy. [START_REF] Londero | Locally advanced breast cancer: comparison of mammography, sonography and MR imaging in evaluation of residual disease in women receiving neo-adjuvant chemotherapy[END_REF] In our study the absence of a residual mass on clinical as well as radiological examination did not exclude the possibility of a small residual viable tumour. We were able to do a thorough follow-up because of precise localization of the tumour bed, even in cases of complete radiological or pathological response. In the 34 patients with no palpable tumour residue, radiological examination showed complete regression in only 17 patients and on pathological examination 16 patients had a complete response, but 3 had stable disease. In 18 cases of complete radiological response there was no palpable mass on clinical examination but pathological examination revealed in only half of the cases a complete response. Alternatively, in some cases a residual mass on clinical or radiological examination was found to be entirely or almost completely fibrotic without pathologic evidence of viable tumour. In twenty nine patients with a partial radiological response, 9

Triple negative breast cancer

In this consecutive series, neo-adjuvant chemotherapy was effective and radioactive seed localization was successfully performed in all 47 patients. In over 50% of the patients the original tumour could not be visualized or palpated after neo-adjuvant chemotherapy. This high response rate may be partly due to the great amount of triple negative breast cancers in our group. Forty-two percent were triple negative and in addition in almost 30% l of the tumours there was a Her2neu over-expression. High complete pathological response rates after neo-adjuvant chemotherapy are known for these subsets of breast cancer. [START_REF] Cleator | Tripple -negative breast cancer: therapeutic options[END_REF][START_REF] Liedtke | Response to neo-adjuvant therapy and long-term survival in patients with triplenegative breast cancer[END_REF] Pathological margin status In those cases of complete clinical and radiological response the 125 I seed was the only remaining evidence of the original tumour site. The rate of positive margins in our study was 6%, which is at least comparable to the 8% rate reported by Gray et al [START_REF] Gray | Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of non-palpable breast lesions: radioactive seed versus wire localization[END_REF][START_REF] Gray | Radioguidance for nonpalpable primary lesions and sentinel lymph node(s)[END_REF][START_REF] Hughes | A multi-site validation trial of radioactive seed localization as an alternative to wire localization[END_REF][START_REF] Pavlicek | Radiation safety with use of I-125 seeds for localization of non-palpable breast lesions[END_REF] and is well below the rate of 50,9% for excisions utilizing wire localization that was reported by Velanovic et al. [START_REF] Velanovich | Comparison of mammographically guided breast biopsy techniques[END_REF], both studies in non-palpable breast tumours. In a another prospective randomized trial of radioactive seed localization versus wire localization of non-palpable breast lesions, Hughes et al [START_REF] Gray | Radioactive seed localization of no-npalpable breast lesions is better than wire localization[END_REF] found that radioactive seed localization resulted in a 35% relative improvement in the rate of negative margins in the first specimen and a 62% relative improvement in the rate of re-operation for positive margins.

Although this low rate of positive margin status is very promising in breast-conserving treatment after neo-adjuvant chemotherapy, thorough clinical as well as radiological follow up is mandatory. Long term results on local recurrence will influence the decision making on this treatment modality.

23

Stable disease 5

Radical excision 44

Irradical excision

  125 I seed localization The pre-chemotherapy radioactive seed localization was successful in all 47 patients and position within the tumour bed was confirmed by means of mammography. No clinical complications occurred as a result of implantation of the 125 I seeds. On post chemotherapy imaging the 125 I seed was detected in all 47 patients and no migration of the seeds as compared to earlier imaging had occurred. At the time of the operation the 125 I seeds were in situ for a mean of 174 days (range:70 -220, SD:42.90). Specimen radiography confirmed presence of the 125 I seed within the excised lump in all 47 patients. Pathological axillary response Axillary lymph node dissection was performed in the 30 patients proven lymph node positive before starting neo-adjuvant chemotherapy as mentioned above. There were still tumour positive lymph nodes M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS 9 on pathological investigation in 15 patients, in the other 15 patients a complete axillary response was

  secondary mastectomy. All patients with breast-conserving therapy received adjuvant hormonal treatment and radiotherapy according to the Dutch national guidelines.

  complete pathological response. Because of these conflicting results in clinical, radiological and pathological examination, a histological confirmation of a representative excision is mandatory.

14 Conclusion

 14 The described technique of radioactive seed localization has shown to be safe and effective in localizing the tumour bed in patients who receive neo-adjuvant chemotherapy for breast carcinoma, solving the problem that has emerged with the increasing rate of complete responses and thus enabling the possibility of precise and long-lasting localization of the tumour bed and eventually planning for breast-

Table 1

 1 Patient characteristics

	Characteristics
		mean	range	SD
	Age (yrs)	47	28-68	9,34
	Clinical diameter (mm)	32	10-70	1,39
	Radiological diameter (mm)	34	13-75	1,34
	Lymph node	No of patients
	N1	30	After cytology or sn procedure
	N0	17
	Histologic type
	Ductal	42
	Lobular	3
	Undifferentiated/mixed	2
	Hormone receptor status
	ER + / PR +	22
	ER -/ PR -	20
	ER + / PR -	5
	Her2-Neu status
	Overexpression	14
	No overexpression

Table 2

 2 Pre-and post chemotherapy results of clinical, radiological and histological examination

		Clinical		Radiological		Histological
		examination		examination		examination
	pre -chemotherapy		Total	Mammo	US	MRI
				n=47	n=47	n=37
	Mean size (mm)	37	40	25	38	30
	Range (mm)	10-70	7-77	7-60	13-60	10-77
	post-chemotherapy		Total	Mammo	US	MRI
				n=7	n=14	n=37
	Mean size (mm)	5	8	22	17	8
	Range (mm)	0-30	0 -32	0-32	0-27	0-32
		0,80	0,87
	Complete response	34	18	4	4	18	19
	Partial response	13	29	3	10	19

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