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BackgroundGPs are well placed to enhance shared decision making (SDM) about treatment for patients with advanced cancer. However, to date, little is known about GPs’ views about their contribution to SDM.AimTo explore GPs’ perspectives on their role in SDM about palliative cancer treatment and the requirements they report to fulfil this role.Design and settingQualitative interview study among Dutch GPs.MethodGPs were sampled purposefully and conveniently. In-depth, semi-structured interviews were conducted, recorded, and transcribed verbatim. Transcripts were analysed by thematic analysis.ResultsFifteen GPs took part in this study. Most of them reported practices that potentially support SDM: checking the quality of a decision, complementing SDM, and enabling SDM. Even though most of the GPs believed that decision making about systemic cancer treatment is primarily the oncologist’s responsibility, they did recognise their added value in the SDM process because of their gatekeeper position, the additional opportunity they offer patients to discuss treatment decisions, and their knowledge and experience as primary healthcare providers at the end of life. Requirements for them to support the SDM process were described as: good collaboration with oncologists; sufficient information about the disease and its treatment; time to engage in conversations about treatment; a trusting relationship with patients; and patient-centred communication.ConclusionGPs may support SDM by checking the quality of a decision and by complementing and enabling the SDM process to reach high-quality decisions. This conceptualisation of the GP’s supporting role in SDM may help us to understand how SDM is carried out through interprofessional collaboration and provide tools for how to adopt a role in the interprofessional SDM process.

Objective: Patients treated for colon cancer report many symptoms that affect quality of life (QoL). Survivorship care aims at QoL improvement. In this study, we assess associations between symptoms and seeking supportive care and lower QoL and QoL changes overtime during survivorship care. Methods: A prospective cohort of colon cancer survivors. Questionnaires are administered at inclusion and 6 months later to evaluate symptoms, functioning and seeking supportive care including associations with QoL, using the EORTC QLQ-C30. Results: The mean QoL score at the first questionnaire was 82 (scale 1–100), which improved over time. Pain, bowel symptoms and problems in physical, role, cognitive or social functioning are associated with lower QoL at inclusion but are not associated with QoL changes over time. Seeking support for lower bowel symptoms, physical functioning or fatigue is associated with lower QoL. After 6 months, seeking support for upper bowel symptoms or physical functioning is associated with a tendency towards less QoL improvement. Conclusion: QoL of colon cancer survivors improves over 6 months, but seeking support for specific symptoms barely contribute to this improvement. Implications: This study confirms the importance of addressing symptoms, problems related to functioning and seeking supportive care during survivorship care.

Purpose: Adequately informing patients is considered crucial in cancer care, but need for information and information seeking behaviour of colorectal cancer (CRC) patients in the Netherlands are currently not well known. Methods: In a prospective study, patients participating in a specialty, hospital-based follow-up program completed three consecutive surveys over a 6-month period to analyse their information need and information seeking behaviour. Results: Patients (n = 259) felt well informed about their treatment (86%), disease (84%), and follow-up program (80%), but less well informed about future expectations (49%), nutrition (43%), recommended physical activity (42%), and heredity of cancer (40%). The need for more information on these subjects remained constant over the first five postoperative years. Patients who were younger, who had undergone chemotherapy, or who had comorbid conditions needed more information on several subjects. One in three patients searched for information themselves, mostly on the Internet. One in four patients consulted a health care provider for information, mostly their GP. Younger and more educated patients more often searched for information themselves, while patients undergoing chemotherapy more often consulted the hospital nurse. Information seeking behaviour remained constant over time. Conclusions: This study showed where current information provision is perceived as adequate and on which subject improvements can be made. It identifies information seeking behaviour and proposes ways to personalize information provision. Implications for Cancer Survivors: The GP is most frequently consulted for information; involving GPs in CRC follow-up could improve information provision on several subjects for several patients.

Background Primary health care use increases when cancer is diagnosed. This increase continues after cancer treatment. More generalist care is suggested to improve survivorship care. It is unknown to what extent cancer-related symptoms are currently presented in primary care in this survivorship phase. Objective To analyse primary health care utilization of colon cancer patients during and after treatment with curative intent. Methods In a prospective multicentre cohort study among patients with curatively treated colon cancer, we describe the primary health care utilization during the first 5 years of follow-up. Data were collected at general practitioner (GP) practices during 6 months. Results Of 183 included participants, 153 (84%) consulted their GP resulting in 606 contacts (mean 3.3, standard deviation 3.01) with on average 0.9 contact for colon-cancer-related (CCR) problems in the 6-month study period. Median time after surgery at inclusion was 7.6 months (range 0–58). Abdominal pain and chemotherapy-related problems were the most frequently reported CCR reasons. Of the CCR contacts, 83% was managed in primary care. As time after surgery passed, the number of CCR contacts declined in patients without chemotherapy and remained constant in patients who received chemotherapy. Conclusion Colon cancer survivors contact their GP frequently also for reasons related to cancer. Currently, a formal role for GPs in survivorship care is lacking, but nevertheless GPs provide a substantial amount of care. Working agreements between primary and secondary care are necessary to formalize the GP’s role in order to improve the quality of survivorship care.

Summary Background Colon cancer is associated with an increased risk of physical and psychosocial morbidity, even after treatment. General practitioner (GP) care could be beneficial to help to reduce this morbidity. We aimed to assess quality of life (QOL) in patients who received GP-led survivorship care after treatment for colon cancer compared with those who received surgeon-led care. Furthermore, the effect of an eHealth app (Oncokompas) on QOL was assessed in both patient groups. Methods We did a pragmatic two-by-two factorial, open-label, randomised, controlled trial at eight hospitals in the Netherlands. Eligible patients were receiving primary surgical treatment for stage I–III colon cancer or rectosigmoid carcinoma and qualified for routine follow-up according to Dutch national guidelines. Patients were randomly assigned (1:1:1:1)—via computer-generated variable block randomisation stratified by age and tumour stage—to survivorship care overseen by a surgeon, survivorship care overseen by a surgeon with access to Oncokompas, survivorship care overseen by a GP, or survivorship care overseen by a GP with access to Oncokompas. Blinding of the trial was not possible. The primary endpoint of the trial was QOL at 5 years, as measured by the change from baseline in the European Organistion for Research and Treatment of Cancer QLQ-C30 summary score. Here, we report an unplanned interim analysis of QOL at the 12-month follow-up. Grouped comparisons were done (ie, both GP-led care groups were compared with both surgeon-led groups, and both Oncokompas groups were compared with both no Oncokompas groups). Differences in change of QOL between trial groups were estimated with linear mixed-effects models. A change of ten units was considered clinically meaningful. Analysis was by intention to treat. This trial is registered with the Netherlands Trial Register, NTR4860. Findings Between March 26, 2015, and Nov 21, 2018, 353 patients were enrolled and randomly assigned. There were 50 early withdrawals (27 patient decisions and 23 GP withdrawals). Of the remaining 303 participants, 79 were assigned to surgeon-led care, 83 to surgeon-led care with Oncokompas, 73 to GP-led care, and 68 to GP-led care with Oncokompas. Median follow-up was 12·2 months (IQR 12·0–13·0) in all groups. At baseline, QOL was high in all trial groups. At 12 months, there was no clinically meaningful difference in change from baseline in QOL between the GP-led care groups and the surgeon-led care groups (difference in summary score –2·3 [95% CI –5·0 to 0·4]) or between the Oncokompas and no Oncokompas groups (−0·1 [–2·8 to 2·6]). Interpretation In terms of QOL, GP-led survivorship care can be considered as an alternative to surgeon-led care within the first year after colon cancer treatment. Other outcomes, including patient and physician preferences, will be important for decisions about the type of survivorship care. Funding Dutch Cancer Society (KWF).

Background Using advance care planning (ACP) to anticipate future decisions can increase compliance with people’s end-of-life wishes, decrease inappropriate life-sustaining treatment and reduce stress, anxiety and depression. Despite this, only a minority of older people engage in ACP, partly because care professionals lack knowledge of approaches towards ACP with older people and their families. Objective To explore older people’s and their families’ experiences with ACP in primary care. Methods We conducted qualitative, semi-structured, face-to-face interviews with 22 older people (aged >70 years, v/m: 11/11), with experience in ACP, and eight of their family members (aged 40–79 years, f/m: 7/1). Transcripts were inductively analysed using a grounded theory approach. Results We distinguished three main themes. (i) Openness and trust: Respondents were more open to ACP if they wanted to prevent specific future situations and less open if they lacked trust or had negative thoughts regarding general practitioners’ (GPs’) time for and interest in ACP. Engaging in ACP appeared to increase trust. (ii) Timing and topics: ACP was not initiated too early. Quality of ACP seemed to improve if respondents’ views on their current life and future, a few specific future care scenarios and expectations and responsibilities regarding ACP were discussed. (iii) Roles of family: Quality of ACP appeared to improve if family was involved in ACP. Conclusions Quality and accessibility of ACP may improve if GPs and nurses involve family, explain GPs’ interest in ACP and discuss future situations older people may want to prevent, and views on their current life and future.

Huisartsen hebben nog geen formele rol in de nazorgfase voor patienten met een coloncarcinoom, maar blijken al regelmatig kankergerelateerde klachten van deze patienten zelfstandig af te handelen. Het lijkt goed mogelijk de geprotocolleerde nazorg na een behandeling van coloncarcinoom te verleggen naar de huisartsenpraktijk. Daarom is onderzocht voor welke redenen patienten in deze fase de huisarts bezoeken en welke patient- en tumorkarakteristieken hiermee samenhangen.

Background Few older people benefit from advance care planning (ACP), due to several barriers related to primary care professionals, such as insufficient knowledge, negative beliefs and a lack of time. Information on overcoming these barriers is limited. We assumed primary care professionals experienced in ACP with older patients are likely to have learned how to overcome these barriers. Therefore we investigated how primary care professionals, experienced in ACP with older patients, overcome these barriers. Methods A qualitative study, based on semi-structured interviews, among a purposive sample of 14 Dutch primary care professionals experienced in ACP with older people. Transcripts were thematically analysed. Results We interviewed eight general practitioners (GPs), three nurses and three elderly care physicians, experienced in ACP with older people. Respondents overcame their own insufficient knowledge and skills, as well as their negative attitudes and beliefs by gaining experience through practicing ACP in their daily practices, exchanging and reflecting on those experiences with peers, pursuing continuing education, teaching and participating in research. To overcome patients’ and families’ lack of initiative and openness to ACP, respondents prepared them for further steps in ACP. To overcome a lack of time, respondents used tools and information communication technology, delegated parts of ACP to other primary care professionals, acquired financing and systematized documentation of ACP. Conclusions Primary care professionals can overcome barriers to ACP with older patients by practicing, reflecting on experiences and pursuing continuing education, by preparing patients and involving family and by investing in support to approach ACP more efficiently.

Background Advance care planning (ACP) is still used with only a minority of older patients due to a lack of knowledge regarding appropriate approaches to ACP with older people. General practitioners (GPs) may play a key role in ACP with older people. We explored their experiences with different approaches to ACP with older patients in daily practice. Methods A qualitative study among a purposive sample of 19 Dutch GPs based on semi-structured interviews. Results Approaches to ACP with older patients can be divided into two categories: systematic and ad-hoc. Systematic approaches consisted of discussing a fixed combination of topics during group information meetings, intakes, comprehensive geriatric assessments, and periodic assessments with community-dwelling older patients who are frail, cognitively impaired, or aged >75, and with older patients living in residential care homes. Meetings were aimed at making agreements in anticipation of future care, at providing information and at encouraging older people to take further steps in ACP. With ad-hoc approaches, respondents discussed only one or two topics related to the near future with deteriorating patients or when patients or family-initiated ACP. Systematic and ad-hoc approaches were used simultaneously or sequentially. Due to a lack of time and knowledge respondents seemed to underuse many occasions and topics. Conclusions Awareness of appropriate systematic and ad-hoc approaches to ACP, and the focus on providing information and encouraging older people to take further steps in ACP can support GPs and improve older patients’ access to ACP.

Background Few older people benefit from advance care planning (ACP), due to several barriers related to primary care professionals, such as insufficient knowledge, negative beliefs and a lack of time. Information on overcoming these barriers is limited. We assumed primary care professionals experienced in ACP with older patients are likely to have learned how to overcome these barriers. Objective To investigate how Dutch primary care professionals experienced in ACP with older patients overcome these barriers. Methods A qualitative study, based on semi-structured interviews, among a purposive sample of 14 Dutch primary care professionals experienced in ACP with older people. Transcripts were thematically analysed. Results We interviewed eight general practitioners (GPs), three nurses and three elderly care physicians, experienced in ACP with older people. Respondents overcame their own insufficient knowledge and skills, as well as their negative attitudes and beliefs by gaining experience through practicing ACP in their daily practices, exchanging and reflecting on those experiences with peers, pursuing continuing education, teaching and participating in research. To overcome patients' and families' lack of initiative and openness to ACP, respondents prepared them for further steps in ACP. To overcome a lack of time, respondents used tools and information communication technology, delegated parts of ACP to other primary care professionals, acquired financing and systematized documentation of ACP. Conclusion Primary care professionals can overcome barriers to ACP with older patients by practicing, reflecting on experiences and pursuing continuing education, by preparing patients and involving family and by investing in support to approach ACP more efficiently.

Purpose: Colorectal cancer (CRC) survivors are currently included in a secondary care-led survivorship care programme. Efforts are underway to transfer this survivorship care to primary care, but met with some reluctance by patients and caregivers. This study assesses (1) what caregiver patients prefer to contact for symptoms during survivorship care, (2) what patient factors are associated with a preferred caregiver, and (3) whether the type of symptom is associated with a preferred caregiver. Methods: A cross-sectional study of CRC survivors at different time points. For 14 different symptoms, patients reported if they would consult a caregiver, and who they would contact if so. Patient and disease characteristics were retrieved from hospital and general practice records. Results: Two hundred and sixty patients participated (response rate 54%) of whom the average age was 67, 54% were male. The median time after surgery was seven months (range 0–60 months). Patients were divided fairly evenly between tumour stages 1–3, 33% had received chemotherapy. Men, patients older than 65 years, and patients with chronic comorbid conditions preferred to consult their general practitioner (GP). Women, patients with stage 3 disease, and patients that had received chemotherapy preferred to consult their secondary care provider. For all symptoms, patients were more likely to consult their GP, except for (1) rectal blood loss, (2) weight loss, and (3) fear that cancer had recurred, in which case they would consult both their primary and secondary care providers. Patients appreciated all caregivers involved in survivorship care highly; with 8 out of 10 points. Conclusions: CRC survivors frequently consult their GP in the current situation, and for symptoms that could alarm them to a possible recurrent disease consult both their GP and secondary care provider. Patient and tumour characteristics influence patients’ preferred caregiver.

Inleiding Huisartsen en specialisten in Brielle organiseren nazorg in de eerste lijn voor patienten die behandeld zijn voor kanker. Maandelijkse oncologiebijeenkomsten maken deel uit van het project. Doel van dit onderzoek is het in kaart brengen van de ervaringen van huisartsen die nazorg leveren aan patienten met darmkanker. Methode Een kwalitatief interviewonderzoek met huisartsen. Resultaten De bijeenkomsten met huisartsen en medisch specialisten vervullen een belangrijke rol in de communicatie en scholing. Doordat huisartsen beter op de hoogte zijn van het traject van diagnostiek tot overdracht, ervaren zij dat hun band met de patient verbetert. Laagdrempelig contact met de specialist maakt terugverwijzen makkelijker. De huisartsen zien de nazorg bij de kankerpatient als een gedeelde verantwoordelijkheid. Preventieve zorg, zoals veranderen van leefstijl bij darmkankerpatienten, is geen gemeengoed. Conclusie Huisartsen en specialisten zijn in staat om nazorg bij darmkanker te organiseren met behulp van gezamenlijke oncologiebijeenkomsten.

A strong effect of the chemical composition and imidization method on physical and especially on gas transport properties of polyimides was demonstrated. Two fluorinated diamines 6FpDA and bisAPAF were polymerized in different ratios, employing the fluorinated dianhydride 6FDA to get polyimides with nine different compositions. For all synthesized materials three imidization methods were used: azeotropic, thermal, and chemical. The 6FDA-6FpDA homopolymers showed significant differences in the gas transport properties, indicating the influence of the imidization route on the final properties of the polyimides. For polyimides containing bisAPAF, the chemical composition played an important role due to the exchange of the hydroxyl groups by acetate groups leading to different interchain interactions. The gas transport was mainly controlled by the chain packing for thermally and azeotropically imidized polymers with bisAPAF contents lower than 30 mol %. For bisAPAF contents above 50 mol % the gas transport wa...

Background. As colon cancer is increasingly becoming a chronic illness with a broad range of symptoms, there is a need for individually tailored care for these patients. Objective. To investigate patients' opinions about GP involvement in survivorship care and the use of eHealth applications, such as Oncokompas2.0, to support self-management. Oncokompas2.0 is an interactive website that monitors quality of life via participant-reported outcomes and provides feedback and personalized supportive care. Methods. We conducted a qualitative study using semi-structured interviews with patients diagnosed with stages I-III colon cancer treated with curative intent. Twenty participants (nine men, age range 49-86 years) were recruited in five Dutch hospitals by purposive sampling. Thematic data analysis was done by two coders. Results. Possible benefits of greater GP involvement include better accessibility of care and additional guidance. Participants considered an increased workload for the already busy GP as a disadvantage. Requirements for greater GP involvement were assurance of sufficient knowledge and expertise of the GP and easy access to secondary care. Most participants expected that Oncokompas2.0 would increase awareness of symptoms and concerns and provide more insight into support possibilities. Reservations mentioned were the expected loss of personal contact with health professionals and the feasibility of implementation in the total patient population. Conclusion. Colon cancer patients see some benefit of greater GP involvement and the use of Oncokompas2.0 to improve survivorship care. Our study results support initiatives to further explore GP-led survivorship care and the implementation of eHealth.

Porous, porous/gutter layer and porous/gutter layer/selective layer types of membranes were investigated for their gas transport properties in order to derive an improved description of the transport performance of thin film composite membranes (TFCM). A model describing the individual contributions of the different layers&rsquo, mass transfer resistances was developed. The proposed method allows for the prediction of permeation behaviour with standard deviations (SD) up to 10%. The porous support structures were described using the Dusty Gas Model (based on the Maxwell&ndash, Stefan multicomponent mass transfer approach) whilst the permeation in the dense gutter and separation layers was described by applicable models such as the Free-Volume model, using parameters derived from single gas time lag measurements. The model also accounts for the thermal expansion of the dense layers at pressure differences below 100 kPa. Using the model, the thickness of a silicone-based gutter layer was calculated from permeation measurements. The resulting value differed by a maximum of 30 nm to the thickness determined by scanning electron microscopy.

Objective To evaluate the introduction of a “time out consultation” with the general practitioner (GP) recommended to patients following the diagnosis of colorectal carcinoma (CRC) before start of treatment. Methods A prospective study using questionnaires to compare the number of GP consultations, with their content and outcomes before and after the introduction of an additional consultation with the GP to improve decision‐making and adequate support. Results 72 patients before and 98 patients after the introduction of the “time out consultation” participated. Introduction of the consultation increased the number of patients to contact their GP from 67% to 80%, but did not change kind or content of the consultations. Patients felt the consultation was comforting and were more satisfied with the GP after the introduction. There was no difference in outcomes measured by the questionnaires in all patients combined, but men, older patients and patients with palliative treatment options only did improve on specific outcomes after the introduction. Conclusion The introduction of the “time out consultation” did not change the kind or content of GP consultations before start of CRC treatment, but patients did feel more comforted and satisfied. Subgroups of patients benefited on specific outcomes.

ObjectivesAdvance care planning (ACP) with older people needs to be approached differently than ACP with patients with a terminal illness. ACP is still used with only a minority of older patients due to a lack of knowledge regarding appropriate approaches to ACP with older people. General practitioners (GPs) may play a key role in ACP with older people. Therefore, we explored their experiences with and views on approaches to ACP with older patients in daily practice.Design, setting and participantsA qualitative study among a purposive sample of 19 Dutch GPs based on semistructured interviews.ResultsApproaches to ACP with older patients can be divided into two categories: systematic and ad hoc. Systematic approaches consisted of discussing a fixed combination of topics with community-dwelling older patients who are frail, cognitively impaired or are aged >75 years, and with older patients living in residential care homes during group information meetings, intakes, comprehensive geriatric assessments and periodic assessments. Meetings were aimed at making agreements in anticipation of future care, at providing information and encouraging older people to take further steps in ACP. With ad hoc approaches, respondents discussed only one or two topics related to the near future. Ad hoc ACP was mainly done with deteriorating patients or when patients or family initiated ACP. Systematic and ad hoc approaches were used simultaneously or sequentially and were both used for initiating and following up on ACP. Due to a lack of time and knowledge of other occasions and topics than the ones respondents used, respondents seemed to underuse many occasions and topics.ConclusionsAwareness of appropriate systematic and ad hoc approaches for ACP, and the focus on providing information and encouraging older people to take further steps in ACP reported in this study can support GPs and improve older patients’ access to ACP.

PURPOSE Follow-up after colorectal cancer treatment with curative intent aims to detect recurrences and metachronous tumors in a timely manner. The objective of this study is to assess how recurrent disease presents and is diagnosed within scheduled follow-up according to the national guideline for the Netherlands. METHODS In a retrospective study of consecutive patients with colorectal cancer who were treated in 2 hospitals in the Netherlands, we identified patients with colon cancer who underwent surgery with curative intent between January 2007 and December 2012. Patients who developed recurrent disease were included for further analyses. RESULTS From a total of 446 patients who were been treated for colon carcinoma with curative intent, 74 developed recurrent disease (17%). In 43 of those patients (58%), recurrent disease was detected during a scheduled follow-up visit, with 41 (95%) being asymptomatic. Tumor marker testing, imaging, and colonoscopy identified all of these recurrences. In the remaining 31 patients with recurrent disease (42%), recurrence was found during non-scheduled interval visits; 26 (84%) of these patients were symptomatic. The most prevalent symptoms were abdominal pain, altered defecation, and weight loss. Patients with asymptomatic recurrences had a significantly higher overall survival compared with patients with symptomatic recurrences. CONCLUSIONS In this cohort, 42% of the recurrences after initial curative treatment for colon cancer were found during non-scheduled interval visits, mainly based on symptoms. Primary care physicians who take care of patients whose colon cancer might recur should be aware of the relatively high rate of symptomatic recurrences and of typical presenting symptoms.

Introduction: While close collaboration between general practitioners (GPs) and hospital specialists is considered important, the sharing of care responsibilities between GPs and oncologists during palliative chemotherapy has not been clearly defined. Objective: Evaluate the opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy. Design: We conducted semi-structured interviews using six hypothetical scenarios with purposively sampled GPs (n = 12) and oncologists (n = 10) in the Netherlands. Each represented an example of a clinical problem requiring different aspects of care: problems likely, or not, related to cancer or chemotherapy, need for decision support, and end-of-life care. Results: GPs and oncologists agreed that GPs should provide end-of-life care and that they should be involved in decisions about palliative chemotherapy; however, for the other scenarios most participants considered themselves the most appropriate provider of care. Themes that emerged regarding who would provide the best care for the patients in the different scenarios were expertise, continuity of care, accessibility of care, doctor–patient relationship, and communication. Most participants mentioned improved communication between the GP and oncologist as being essential for a better coordination and quality of care. Conclusion: GPs and oncologists have different opinions about who should ideally provide different aspects of care during palliative chemotherapy. Findings raise awareness of the differences in reasoning and approaches and in current communication deficits between the two groups of health professionals. These findings could be used to improve coordination and collaboration and, ultimately, better patient care as results demonstrated that both disciplines can add value to the care for patients with advanced cancer.Key pointsThis study identified contrasting opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy.Important themes that emerged were expertise, continuity of care, doctor-patient relations, accessibility of care, and communication.Although frequently using the same arguments, GPs and oncologists often considered themselves to be the most appropriate providers of palliative care.

Background/Aims: Several initiatives have started to transfer colorectal cancer follow-up (FU) from secondary to primary care. For this purpose, it is important to assess when and how recurrences of rectal carcinoma are detected after treatment with curative intent. Methods: Retrospective multicentre cohort study. Patients participating in an FU programme after curative intended treatment for rectal cancer stages I-III between 2007 and 2014. Results: Of the 378 patients, 64 (17%) developed recurrent disease (RD). Most were detected during scheduled FU consultations (n = 55) by (a combination of) radiological examinations and carcinoembryonic antigen levels, and were asymptomatic (n = 53); outside scheduled FU consultations, RD was detected during the treatment of postoperative complications or ostomy reversal (n = 5), or due to symptoms (n = 4). Most frequent sites of recurrence were liver (50%), lung (44%), multiple (22%) or locoregional (16%). Treatment of RD with curative intent was performed more frequently when detected during scheduled FU (60 vs. 22%). The only predictive factor for developing RD was stage III disease on initial presentation. Conclusions: The majority of rectal cancer patients are diagnosed with RD at an asymptomatic stage during scheduled FU consultations. Only a few patients presented with RD outside the FU programme. Arguably, general practitioners could order these same diagnostic tests during FU.

Inleiding De nazorg en follow-up na behandeling van colorectaal carcinoom vinden momenteel plaats in de tweede lijn. De huisarts zou deze zorg kunnen overnemen, maar uit onderzoek blijkt dat een deel van de patienten daar terughoudend op reageert. Methode De onderzoekers hebben een vragenlijstonderzoek gedaan onder patienten waarin deze voor veertien symptomen konden aangeven naar welke hulpverlener zij zouden gaan. Patient- en ziektekarakteristieken werden uit huisarts- en ziekenhuisdossiers gehaald. Resultaten Er waren 260 deelnemers, met een gemiddelde leeftijd van 67 jaar en een mediane tijd na behandeling van zeven maanden. Mannen, patienten ouder dan 65 jaar en patienten met een chronische comorbiditeit hadden vaker een voorkeur voor de huisarts. Vrouwen, patienten met stadium 3-ziekte en patienten die adjuvante chemotherapie hadden ondergaan, kozen vaker voor het ziekenhuis. Voor alle symptomen gingen patienten liever naar hun huisarts, behalve bij rectaal bloedverlies en gewichtsverlies, en wanneer ze bang waren dat de kanker was teruggekeerd. In die gevallen hebben ze geen voorkeur. Conclusie In de huidige situatie raadplegen patienten na behandeling voor colorectaal carcinoom vaak hun huisarts, waarbij ze voor alarmsymptomen ook de specialist bezoeken. Bij deze symptomen heeft de patient geen voorkeur voor een hulpverlener.

The focus of this contribution is the separation of carbon dioxide from biogas and hydrocarbon containing gaseous reaction products using a high flux flat sheet membrane. The thin selective layer of the membranes is made from the commercial blockcopolymer PolyActive™. The membrane material is manufactured reproducibly on a technical scale and installed into membrane modules. The modules were investigated in three pilot plants: two for the removal of carbon dioxide from methane and one for the separation of carbon dioxide from gaseous hydrocarbon streams. The pilot plant experiments confirmed a rapid approach to steady state operation and the dependence of the separation result on the employed pressure ratio. For the biogas applications it was shown that a single stage process is sufficient to achieve methane purities in excess of 95 mol% in the retentate at methane recoveries of 70%, as well as carbon dioxide mole fractions larger than 60 mol% in the permeate. Carbon dioxide could also be removed successfully from gaseous, hydrocarbon containing product streams employing the investigated high flux membranes. The employed simulation model for the modules predicted the experimental results well and proofed to be a valuable tool.

Datengetriebene Entscheidungen sind ein zentraler Erfolgsfaktor im E-Commerce. In der Praxis zielt das E-Commerce-Controlling im taglichen Doing aber haufig zu stark auf das retrospektive Reporting von Umsatzzahlen an das Management ab, anstatt die Grundlage fur ein schnelles, zahlenbasiertes Entscheiden in den Fachabteilungen zu liefern. Der vorliegende Beitrag stellt die Herausforderungen und Defizite im Status quo dar, definiert erforderliche Kennzahlengeruste und verdeutlicht die Bedeutung der Automatisierung von Prozessen, Visualisierungen und handlungsleitenden Cook Books bei der operativen Umsetzung eines konsequent zahlenbasierten Arbeitens im Online-Handel.

This contribution deals with an update of the progress in research and development of membranes for the recovery of volatile organic compounds from gas streams, as well as the progress in the related process engineering and the success of industrial companies implementing this technology.

Membrane gas separation is one of the most promising technologies for the separation of carbon dioxide (CO2) from various gas streams. One application of this technology is the treatment of flue gases from combustion processes for the purpose of carbon capture and storage. For this application, poly(ethylene oxide)-containing block copolymers such as Pebax® or PolyActive™ polymer are well suited. The thin-film composite membrane that is considered in this overview employs PolyActive™ polymer as a selective layer material. The membrane shows excellent CO2 permeances of up to 4 m3(STP)·(m2·h·bar)−1 (1 bar = 105 Pa) at a carbon dioxide/nitrogen (CO2/N2) selectivity exceeding 55 at ambient temperature. The membrane can be manufactured reproducibly on a pilot scale and mounted into flat-sheet membrane modules of different designs. The operating performance of these modules can be accurately predicted by specifically developed simulation tools, which employ single-gas permeation data as the only experimental input. The performance of membranes and modules was investigated in different pilot plant studies, in which flue gas and biogas were used as the feed gas streams. The investigated processes showed a stable separation performance, indicating the applicability of PolyActive™ polymer as a membrane material for industrial-scale gas processing.

Poly(epichlorohydrin) homopolymer (H-Hydrin) and poly[(ethylene oxide)- ran -(epichlorohydrin)] copolymer (C-Hydrin) are successfully chemically modified via azidation chemistry and characterized by 1 H-NMR, 13 C-NMR, FT-IR, GPC, DSC and TGA. UV cross-linking reaction is performed for modified Hydrin polymers and characterized by FT-IR, DSC, TGA, and gel content analysis. Gas transport properties of the initial and modified Hydrin polymers, and their derivatives cross-linked via nitrene reaction in the presence of UV irradiation are measured. The modified H-Hydrin homopolymers show higher permeabilities for CO 2 and H 2 than the unmodified H-Hydrin but lower CO 2 /N 2 , CO 2 /CH 4 and H 2 /N 2 selectivities. Likewise, the modified C-Hydrin copolymers have higher CO 2 and H 2 permeabilities than the unmodified C-Hydrin while maintaining similar CO 2 /N 2 , CO 2 /CH 4 and H 2 /N 2 selectivities. The increased gas permeabilities of Hydrin polymers after modification base on the decrease of glass transition temperatures ( T g s) which lead them to have higher polymer chain mobility and flexibility resulting in higher gas diffusivity. After cross-linking of modified C-Hydrin copolymers highly increased CO 2 /CH 4 and H 2 /N 2 selectivities and decreased CO 2 and H 2 permeabilities are observed.

Introduction Follow-up to detect recurrence is an important feature of care after colon cancer treatment. Currently, follow-up visits are surgeon-led with focus on recurrence. To date, there is increasing interest for general practitioners (GPs) providing this care, as GPs might provide more holistic care. The present study assessed how surgeons, GPs, and patients evaluate current surgeon-led colon cancer follow-up and to list their views on possible future GP-led follow-up. Methods The study consists of a cross-sectional survey including colorectal surgeons, patients who participate or recently finished a follow-up programme, and GPs in the Netherlands. Results Eighty-seven out of 191 GPs, 113 out of 238 surgeons, and 186 out of 243 patients responded. Patients are satisfied about current surgeon-led follow-up, especially about recurrence detection and identification of physical problems (94% and 85% respectively). However, only 56% and 49% of the patients were satisfied about the identification of psychological and social problems respectively. Only 16% of the patients evaluated future GP-led follow-up positively. Regarding healthcare providers, surgeons were more positive compared to GPs; 49% of the surgeons, and only 30% of the GPs evaluated future GP-led follow-up positively (P = 0.002). Furthermore, several reservations and principle requirements for GP-led follow-up were identified. Discussion The results suggest an unfavourable view among patients and healthcare providers, especially GPs, regarding a central role for GPs in colon cancer follow-up. However, low satisfaction on psychosocial aspects in current follow-up points out a lack in care. Therefore, the results provide a justification to explore future GP-led care further.

A hybrid system consisting of a membrane unit and an amine-based process for CO2 removal in the oxidative coupling of methane is investigated experimentally and in simulations. Absorption processes with two different absorbents for removing 90 % of CO2 from the feed stream are regarded as benchmarks and compared to the membrane process with respect to potential energy, equipment, and cost reductions. The results show that a membrane unit using polyimide could assist with CO2 capture and lead to a reduction of the consumed energy per kilogram of CO2 by 40 % and also reduce the size of the absorption columns. Alternative processes with a two-step membrane cascade to enhance the recovery of product ethylene are also discussed.

Gas permeation is increasingly considered for high capacity applications. This contribution discusses the commonly employed membrane module types for flat sheet membranes and suggests a new module concept. The applications considered are the separation of CO2 from flue gas and hydrocarbon dewpointing of natural gas. Rigorous models for predicting the operating performance of the module types are described. Pilot plant experiments were conducted to validate the model for envelope type modules. Simulation studies were carried out to predict the performances of the different module types for the two examples and assess their advantages and disadvantages.

Objectives The aim of this study was to explore the perspectives of general practitioners (GPs) regarding their current and future role in survivorship care of patients with colon cancer, and to assess their perspectives on patients’ self-management capacities and the value of the eHealth application Oncokompas 2.0 used by patients. Setting GPs from the central part of the Netherlands were interviewed at their location of preference. Participants 20 GPs participated (10 men, 10 women, age range 34–65 years, median age 49.5 years). The median years of experience as a GP was 14.5 years (range 3–34 years). Results GPs indicated attempting to keep in contact with patients after colon cancer treatment and mentioned being aware of symptoms of recurrent disease. Most participants would have liked to be more involved and expected to be able to provide survivorship care of colon cancer. Requirements mentioned were agreements with secondary care and a protocol. GPs considered Oncokompas 2.0 , which stimulates patients to structure their own survivorship care, as a useful additional tool for a specific group of patients (ie, young and highly-educated patients). Conclusions Based on the perspectives of the GPs, survivorship care of colon cancer in primary care is deemed feasible and the use of an eHealth application such as Oncokompas 2.0 is expected to benefit specific groups of patients after colon cancer treatment.

Context Tijdens nacontrole van in opzet curatief behandelde colorectaal carcinoom (CRC) kan de tumormarker carcinogeen embryonaal antigeen (CEA) gebruikt worden. Internationale richtlijnen varieren aanzienlijk in welke onderzoeken wanneer moeten worden gedaan. Tevens verschillen de CEA-afkapwaarden en is het onbekend of periodieke bepaling van CEA alleen effectief genoeg is om een recidief te detecteren.

Aim It is questioned whether all separate fast track elements are essential for enhanced postoperative recovery. We aimed to determine which baseline characteristics and which fast track elements are independent predictors of faster postoperative recovery in patients undergoing resection for colon cancer. Method Data from the LAFA trial database were used. In this trial, fast track care was compared with standard perioperative care in 400 patients undergoing laparoscopic or open surgery for colonic cancer. During admission 19 fast track elements per patient were prospectively evaluated and scored whether or not they were successfully applied. To identify predictive factors six baseline characteristics and those fast track items that were successfully achieved were entered in a univariate and multivariate linear regression analysis with total postoperative hospital stay (THS) as the primary outcome. Results In 400 patients, two baseline characteristics and two fast track elements were found to be significant independent predictors of THS: female sex [B = 0.85; 95% CI 0.75‐0.96; reduction of 15% (CI 14‐25%) in THS], laparoscopic resection [B = 0.85; 95% CI 0.75‐ 0.96; reduction of 15% (CI 14‐25%) in THS], ‘normal diet at postoperative days 1, 2 and 3’ [B = 0.70; 95% CI 0.61‐0.81; reduction of 30% (CI 19‐39%) in THS] and ‘enforced mobilization at postoperative days 1, 2 and 3’ [B = 0.68; 95% CI 0.59‐0.80; reduction of 32% (CI 20‐ 41%) in THS]. Conclusion Evaluating only those fast track elements that were successfully achieved, enforced advancement of oral intake, early mobilization, laparoscopic surgery and female sex were independent determinants of early recovery.

Hydroxyl functionalized multi-walled carbon nanotubes (MWCNTs) were blended with polyacrylonitrile (PAN) to prepare ultrafiltration membranes by a phase inversion process. Three different concentrations of MWCNTs were used in PAN, i.e. 0.5, 1 and 2 wt%. The water flux of the membranes increased by 63% at 0.5 wt% loading of MWCNTs compared to neat PAN membranes. The water flux decreased upon further increase in the concentration of MWCNTs, but at 2 wt% loading it was still higher compared to pure PAN membranes. The surface hydrophilicity of the membranes was enhanced upon the addition of MWCNTs, as observed by contact angle measurements. The increased hydrophilicity might have an impact on the improved water flux. All the membranes showed a molecular weight cut off (MWCO) of approximately 50 kg/mol. Surface pore size analysis by scanning electron microscopy (SEM) showed no significant difference in the mean pore size of the nanocomposite membranes compared to the neat membranes. The cross section morphology was influenced by the introduction of MWCNTs where less but enlarged macrovoids were observed, particularly prominent at a loading of 2 wt% MWCNTs. The membranes containing 2 wt% MWCNTs showed 36% improvement in resistance against compaction compared to neat membranes. Furthermore, the tensile strength of the membranes at 2 wt% MWCNTs loading increased over 97% compared to neat ones.

Mixed-matrix membranes (MMMs) are promising candidates to improve the competitiveness of membrane technology against energy-intensive conventional technologies. In this work, MMM composed of poly(octylmethylsiloxane) (POMS) and activated carbon (AC) were investigated with respect to separation of higher hydrocarbons (C3+) from permanent gas streams. Membranes were prepared as thin film composite membranes on a technical scale and characterized via scanning electron microscopy (SEM) and permeation measurements with binary mixtures of n-C4H10/CH4 under varying operating conditions (feed and permeate pressure, temperature, feed gas composition) to study the influence on separation performance. SEM showed good contact and absence of defects. Lower permeances but higher selectivities were found for MMM compared to pure POMS membrane. Best results were obtained at high average fugacity and activity of n-C4H10 with the highest selectivity estimated to be 36.4 at n-C4H10 permeance of 12 mN3/(m2·h·bar). Results were complemented by permeation of a multi-component mixture resembling a natural gas application, demonstrating the superior performance of MMM.

To investigate which perioperative treatment, ie, laparoscopic or open surgery combined with fast track (FT) or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer. Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care, both focusing on faster recovery. In a 9-center trial, patients eligible for segmental colectomy were randomized to laparoscopic or open colectomy, and to FT or standard care, resulting in 4 treatment groups. Primary outcome was total postoperative hospital stay (THS). Secondary outcomes were postoperative hospital stay (PHS), morbidity, reoperation rate, readmission rate, in-hospital mortality, quality of life at 2 and 4 weeks, patient satisfaction and in-hospital costs. Four hundred patients were required to find a minimum difference of 1 day in hospital stay. Median THS in the laparoscopic/FT group was 5 (interquar-tile range: 4-8) days; open/FT 7 (5-11) days; laparoscopic/standard 6 (4.5-9.5) days, and open/standard 7 (6-13) days (P < 0.001). Median PHS in the laparoscopic/FT group was 5 (4-7) days; open/FT 6 (4.5-10) days; laparoscopic/standard 6 (4-8.5) days and open/standard 7 (6-10.5) days (P < 0.001). Secondary outcomes did not differ significantly among the groups. Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity. Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program. If open surgery is applied, it is preferentially done in FT care. This study was registered under NTR222 (www.trialregister.nl)

The oxidative coupling of methane (OCM) to ethylene is a promising alternative for the oil based industry. In this process, beside the valuable product ethylene, unwanted by-products like CO2 are produced. Hence, the gas stream has to be refined further. The process is not applied in the industry yet, because of high separation costs. This article focuses particular on the CO2 purification of the OCM product stream. Therefore a case study was done for a design task of 90% CO2 capture from 25 vol% in the OCM product gas with an operation pressure of 32 × 105 Pa. Within the article is shown, how to resolve the lack of high separation cost for the purification and the development of an integrated, energy efficient CO2 capture process for the OCM refinery is described. Therefore a state of the art chemical absorption process using monoethanolamine (MEA) was developed and optimized for the base case. Therefore Aspen Plus® with the build-in rate based model for the mass transfer with an electrolyte NRTL – approach and chemical equilibrium reactions for the water–MEA–CO2 system as well as kinetic reactions based on the MEA-REA package was applied. In order to improve the energetic process performance, gas permeation with dense membranes was studied as process alternative. For this purpose a membrane unit was developed in Aspen Custom Modeler® (ACM). The solution-diffusion model with the free-volume-theory for gas permeation including Joule–Thomson effect as well as concentration polarization (Stunkel et al., 2009) was applied successfully. Furthermore several selective materials for a composite membrane with experimentally determined parameters were studied by this model and it was found, that a matrimide membrane provides the best selectivity performance for the OCM CO2 capture. Based on this material a membrane module was installed to form a hybrid separation process in combination with the amine based absorption process. The comparison of the state of the art process with the novel hybrid separation process shows an energy saving of more than 40% for the OCM CO2 capture. In the experimental study the stand alone performance of each unit, as well as the performance of the hybrid process were studied and the results are presented in this article.

Background Fast track surgery accelerates recovery, reduces morbidity and shortens hospital stay. It is unclear what the effects are of laparoscopic or open surgery within a fast track programme. The aim of this systematic review was to review the existing evidence. Method A systematic review was performed of all randomized (RCTs) and controlled clinical trials (CCTs) on laparoscopic and open surgery within a fast track setting. Primary endpoints were primary and overall hospital stay, readmission rate, morbidity and mortality. Study selection, quality assessment and data extraction were performed independently by two observers. Results Only two RCTs and three CCTs were eligible for final analysis, which reported on 400 patients. Data could not be pooled because of clinical heterogeneity. One RCT and one CCT stated a shorter primary hospital stay in the laparoscopic group of 3 and 2 days, respectively. In one RCT, the readmission rate was lower in the laparoscopic group; absolute risk reduction (ARR) 21.4% [95% confidence interval (CI): 6–42.3%] resulting in a number needed to treat (NNT) of 4.7 patients (95% CI: 2.4–176). Another study showed a 23% difference in favour of the laparoscopic group with regard to morbidity (95% CI: 6.3–39.1%), i.e. an NNT of 4.4 patients (95% CI: 2.6–15.9). There were no significant differences in mortality rates. Conclusion Due to the present lack of data, no robust conclusions can be made. A large randomized controlled trial is required to compare laparoscopic with open surgery within a fast track setting.

Background: The objective of this study was to detect and quantify circulating tumour cells (CTC) in peripheral and portal blood of patients who had open or laparoscopic surgery for primary colonic cancer. Methods: Patients in the laparoscopic-group were operated on in a medial to lateral approach ("vessels first"), in the open-group a lateral to medial approach was applied. The enumeration of CTC was performed with the CellSearch System. Intra-operative samples were taken paired-wise (from peripheral and portal circulation) directly after entering the abdominal cavity (T1), after mobilisation of the tumour baring segment (T2), and after tumour resection (T3). Ploidy of both the CTC and tissue of the primary tumour was determined for chromosome 1, 7, 8 and 17. Results: Thirty-one patients were included; 18 patients had open surgery, 13 patients were operated on laparoscopically. The percentage of samples with CTC at T1 was 7% in peripheral blood and 54% in portal blood (p = 0.002). At T2, 4% and 31% respectively (p = 0.031). And at T3, 4% and 26% respectively (p = 0.125). The cumulative percentage of samples with CTC was significantly higher during open surgery as compared to the laparoscopic approach. Both the CTC and tissue of the primary tumour were diploid for chromosome 1, 7, 8 and 17. Conclusion: The detection rate and quantity of CTC is significantly increased intra-operatively and is significantly higher in portal blood compared to peripheral blood. Significantly less CTC were detected during laparoscopic surgery probably as result of the medial to lateral approach. (C) 2008 Elsevier Ltd. All rights reserved

The aim of this prospective double-cohort pilot study is to evaluate the feasibility and desirability of laparoscopic Nissen fundoplication (LNF) performed in day-care when compared with laparoscopic cholecystectomy (LC) in day-care. Patients who underwent a LNF in day-care were prospectively evaluated. LNF patients were treated according to LC in day-care protocol. Outcome parameters were EQ-5D, visual analogue scale (VAS), and patient satisfaction. From October 2005 to March 2008, 22 patients underwent LNF and 48 patients LC in day-care. After LNF, 21 out of 22 (95%) patients were discharged the same day. Seven (32%) patients were seen postoperatively in the Emergency Department with dysphagia or pain and two (9%) patients were readmitted. After LC, 45 out of 48 (94%) patients were discharged the same day. Six (12.5%) patients were seen postoperatively in the Emergency Department because of wound infection or pain and three (6%) were readmitted. EQ-5D and VAS scores were significantly worse after LNF in day-care (repeated measurements, p

PURPOSE: This study assessed long-term functional outcome and explored risk factors for fistula recurrence in patients surgically treated for cryptoglandular fistulas. METHODS: Three hundred ten consecutive patients were surgically treated for perianal fistulas. After exclusion of patients with inflammatory bowel disease or HIV, 179 patients remained. Patients were divided into two groups: those who received fistulotomy for low perianal fistulas and those who received rectal advancement flap for high perianal fistulas. Time to fistula recurrence was the main outcome and Cox proportional hazard models were used to assess the importance of various risk factors. Functional outcome was assessed using the Vaizey and colorectal functional outcome (COREFO) questionnaires. RESULTS: The median follow-up duration was 76 months (range, 7-134). The 3-year recurrence rate for low perianal fistulas treated by fistulotomy (n = 109) was 7 percent (95 percent confidence interval, 1-13 percent). In high transsphincteric fistulas treated by rectal advancement flap (n = 70), the recurrence rate was 21 percent (95 percent confidence interval, 9-33 percent). In both groups, soiling was reported at 40 percent. None of the seven potential risk factors examined were statistically significant. CONCLUSIONS: Fistula recurrence rate after fistulotomy was low. No clear risk factors were found. Overall functional outcome in terms of continence was good. However, a substantial amount of patients reported soiling.

Coal mines are emitting off-gases containing methane of varying content. For environmental as well as economical reasons the gas should be collected and put to further use, i.e., as a feed stock for gas engines or fuel cells. Certain concentration ranges of the coal mine gas require an adjustment of the methane content due to safety related and technical constraints. The application of gas permeation is one possibility to increase the methane content to the desired levels. Employing methane selective, silicone-based, high-flux membranes is currently being investigated by a German project consortium. Experimental results as well as simulation studies showed that selectivity and flux of the membrane are sufficient to increase the methane content to the desired value at a reasonable recovery.

Backgrounds and aim In recent decades, fibrin glue has appeared as an alternative treatment for high perianal fistulas. Early results seemed promising, with high success rates being reported. However, with increasing follow-up, the enthusiasm was tempered because of disappointing results. The aim of this retrospective study was to assess the additional value of fibrin glue in combination with transanal advancement flap, compared to advancement flap alone, for the treatment of high transsphincteric fistulas of cryptoglandular origin. Materials and methods Between January 1995 and January 2006, 127 patients were operated for high perianal fistulas with an advancement flap. After exclusion of patients with inflammatory bowel disease or HIV, 80 patients remained. A consecutive series of 26 patients had an advancement flap combined with obliteration of the fistula tract with fibrin glue. Patients were matched for prior fistula surgery, and the advancement was performed identically in all patients. In the fibrin glue group, glue was installed retrogradely in the fistula tract after the advancement was completed and the fistula tract had been curetted. Results Minimal follow-up after surgery was 13 months [median of 67 months (range, 13–127)]. The overall recurrence rate was 26% (n = 21). Recurrence rates for advancement flap alone vs the combination with glue were 13% vs 56% (p = 0.014) in the group without previous fistula surgery and 23% vs 41% (p = 0.216) in the group with previous fistula surgery. Conclusion Obliterating the fistula tract with fibrin glue was associated with worse outcome after rectal advancement flap for high perianal fistulas.

Aims: In colonic cancer the prognostic significance of extracapsular lymph node involvement (LNI) is not established and is therefore the objective of this study. Methods: Between January 1994 and May 2005, all patients who underwent resection for primary colonic cancer with lymph node metastasis were reviewed. All resected lymph nodes were re-examined to assess extracapsular LNI. In uni- and multivariate analysis disease-free survival (DFS) was correlated with various clinicopathologic factors. Results: One hundred and eleven patients were included. In 58 patients extracapsular LNI was identified. Univariate analysis revealed that pN-stage (5-year DFS pN1 vs. pN2: 65% vs. 14%, p = 0.176: 67% vs. 42%, p = 0.023) were significant prognostic indicators. Among these variables pN-stage (hazard ratio 3.5, 95% confidence interval [Cl]: 1.72-7.42) and extracapsular LNI (hazard ratio 1.98, 95% CI: 1.00-3.91) were independent prognostic factors. Among patients without extracapsular LNI, those receiving adjuvant chemotherapy had a significantly better survival (p = 0.010). In contrast, chemotherapy did not improve DFS in patients with extracapsular LNI. Conclusion: Together with pN2 stage, extracapsular LNI reflects a particularly aggressive behaviour and has significant prognostic potential. (C) 2007 Elsevier Ltd. All rights reserved