| 1. |
- Erlandsson, J., et al.
(author)
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Postoperative complications in relation to overall treatment time in patients with rectal cancer receiving neoadjuvant radiotherapy
- 2019
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In: British Journal of Surgery. - : WILEY. - 0007-1323 .- 1365-2168. ; 106:9, s. 1248-1256
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Journal article (peer-reviewed)abstract
- Background: The optimal timing of surgery for rectal cancer after radiotherapy (RT) is disputed. The Stockholm III trial concluded that it was oncologically safe to delay surgery for 4-8weeks after short-course RT (SRT), with fewer postoperative complications compared with SRT with surgery within a week. Other studies have indicated that an even shorter interval between RT and surgery (0-3 days) might be beneficial. The aim of this study was to identify the optimal interval to surgery after RT.Methods: Patients were analysed as treated, in terms of overall treatment time (OTT), the interval from the start of RT until the day of surgery. Patients receiving SRT (5x5Gy) were categorized according to OTT: 7 days (group A), 8-13 days (group B), 5-7weeks (group C) and 8-13weeks (group D). Patients receiving long-course RT (25x2Gy) were grouped into those with an OTT of 9-11weeks (group E) or 12-14weeks (group F). Outcomes assessed were postoperative complications and early mortality.Results: A total of 810 patients were analysed (group A, 100; group B, 247; group C, 192; group D, 160; group E, 52; group F, 59). Baseline patient characteristics were similar. There were significantly more overall complications in group B than in groups C and D. Adjusted odds ratios, with B as the reference group, were: 0.72 (95 per cent c. i. 0.40 to 1.32; P = 0.289), 0.50 (0.30 to 0.84; P = 0.009) and 0.39 (0.23 to 0.65; P < 0.001) for groups A, C and D respectively. Early mortality was similar in all groups. There were no significant differences between long-course RT groups.Conclusion: These results suggest that surgery should optimally be delayed for 4-12weeks (OTT 5-13weeks) after SRT.
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| 2. |
- Jestin, Pia, et al.
(author)
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Emergency surgery for colonic cancer in a defined population
- 2005
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In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 92:1, s. 94-100
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Journal article (peer-reviewed)abstract
- BACKGROUND: The aim of this study was to identify risk factors in emergency surgery for colonic cancer in a large population and to investigate the economic impact of such surgery. METHODS: Data from the colonic cancer registry (1997-2001) of the Uppsala/Orebro Regional Oncological Centre were analysed and classified by hospital category. Some 3259 patients were included; 806 had an emergency and 2453 an elective procedure. Data for calculating effects on health economy were derived from a national case-costing register. RESULTS: Patients who had emergency surgery had more advanced tumours and a lower survival rate than those who had an elective procedure (5-year survival rate 29.8 versus 52.4 per cent; P < 0.001). There was a stage-specific difference in survival, with poorer survival both for patients with stage I and II tumours and for those with stage III tumours after emergency compared with elective surgery (P < 0.001). Emergency surgery was associated with a longer hospital stay (mean 18.0 versus 10.0 days; P < 0.001) and higher costs (relative cost 1.5 (95 per cent confidence interval 1.4 to 1.6)) compared with elective surgery. The duration of hospital stay was the strongest determinant of cost (r(2) = 0.52, P < 0.001). CONCLUSION: Emergency surgery for colonic cancer is associated with a stage-specific increase in mortality rate.
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| 3. |
- Kodeda, Karl, et al.
(author)
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Population-based data from the Swedish Colon Cancer Registry
- 2013
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In: British Journal of Surgery. - : Wiley-Blackwell. - 0007-1323 .- 1365-2168. ; 100:8, s. 1100-1107
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Journal article (peer-reviewed)abstract
- Background Evaluating the external validity of clinical trials requires knowledge not only of the study population but also of a relevant reference population. The main aim of this study was to present data from a large, contemporary, population-based cohort of patients with colonic cancer. Methods Data on patients diagnosed between 2007 and 2011 were extracted from the Swedish Colon Cancer Registry. The data, registered prospectively in a national population of almost 10 million, included over 99 per cent of all diagnosed adenocarcinomas of the colon. Results This analysis included 18889 patients with 19526 tumours (3 center dot 0 per cent had synchronous tumours). The sex distribution was fairly equal, and the median age was 74 center dot 1 (interquartile range 65-81) years. The overall and relative (cancer-specific) survival rates after 3 years were 62 center dot 7 and 71 center dot 4 per cent respectively. Some 88 center dot 0 per cent of the patients were operated on, and 83 center dot 8 per cent had tumours resected. Median blood loss during bowel resection was 200 (mean 311) ml, and the median operating time was 160min; 5 center dot 6 per cent of the procedures were laparoscopic. Preoperative chemotherapy was administered to 2 center dot 1 per cent of patients; postoperative chemotherapy was planned in 90 center dot 1 per cent of fit patients aged less than 75 years with stage III disease. In patients operated on in an emergency setting (21 center dot 5 per cent), the preoperative evaluation was less extensive, the proportion of R0 resections was lower, and the outcomes were poorer, in both the short and long term. Conclusion These population-based data represent good-quality reference points.
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| 4. |
- Martling, A., et al.
(author)
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Risk of second primary cancer in patients treated with radiotherapy for rectal cancer
- 2017
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In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 104:3, s. 278-287
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Journal article (peer-reviewed)abstract
- Background: Many patients with rectal cancer receive radiotherapy (RT) to reduce the risk of local recurrence. Radiation may give rise to adverse effects, including second primary cancers. In view of the divergent results of previous studies, the present study evaluated the risk of second primary cancer following RT in all randomized RT rectal cancer trials conducted in Sweden and in the Swedish ColoRectal Cancer Registry (SCRCR).Methods: Patients included in five randomized trials and the SCRCR were linked to the Swedish Cancer Registry. Cox regression models estimated the hazard ratio (HR) of second primary cancer among patients who received RT compared with those who did not.Results: A total of 13 457 patients were included in this study; 7024 (52.2 per cent) received RT and 6433 (47.8 per cent) had surgery alone. Overall, no increased risk of second primary cancer was observed with RT (HR 1.03; 95 per cent c. i. 0.92 to 1.15), independently of follow-up time and location within or outside of the irradiated volume. In the randomized trials, with longer follow-up (maximum 31 years), a slight increase was observed outside of (HR 1.33, 1.01 to 1.74) but not within (HR 1.11, 0.73 to 1.67) the irradiated volume. Irradiated men had a lower risk of prostate cancer than those treated with surgery alone (HR 068, 0.51 to 091).Conclusion: Overall, there was no increased risk of second primary cancer following RT for rectal cancer within or outside of the irradiated volume up to 20 years of follow-up. Men with rectal cancer who received RT had a reduced risk of prostate cancer.
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| 5. |
- Pettersson, D., et al.
(author)
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Impaired postoperative leucocyte counts after preoperative radiotherapy for rectal cancer in the Stockholm III Trial
- 2013
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In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 100:7, s. 969-U145
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Journal article (peer-reviewed)abstract
- Background: Radiotherapy (RT) in rectal cancer increases postoperative morbidity. A suggested reason is RT-induced bone marrow depression resulting in impaired leucocyte counts. The ongoing Stockholm III Trial randomizes patients with operable rectal cancers to short-course RT with immediate surgery (SRT), short-course RT with surgery delayed for 4-8 weeks (SRT-delay) and long-course RT with surgery delayed for 4-8 weeks (LRT-delay). This study examined differences between the randomization arms regarding leucocyte response and postoperative complications. Methods: Patients randomized in the Stockholm III Trial between October 1998 and November 2010 were included. Data were collected in a prospective register. Additional data were obtained by retrospective review of clinical records. Results: Of 657 randomized patients, 585 had data on leucocytes. The SRT arm had the highest proportion of postoperative complications (SRT, 52.5 per cent; SRT-delay, 39.4 per cent; LRT-delay, 41 per cent; P = 0.010). There was no association between low preoperative leucocyte count and postoperative complications (P = 0.238). Irrespective of randomization arm, patients with an impaired postoperative to preoperative leucocyte ratio had the highest rate of complications (low ratio, 56.6 per cent; intermediate ratio, 46.9 per cent; high ratio, 36.3 per cent; P = 0.010). The SRT arm had the highest proportion of low ratios (SRT, 48.9 per cent; SRT-delay, 22.8 per cent; LRT-delay, 22 per cent; P < 0.001). Conclusion: An impaired postoperative leucocyte response is associated with postoperative complications. The highest risk is with immediate surgery following short-course radiotherapy. Registration number: NCT 00904813 (http://www.clinicaltrials.gov).
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| 6. |
- Pettersson, D., et al.
(author)
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Interim analysis of the Stockholm III trial of preoperative radiotherapy regimens for rectal cancer
- 2010
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In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 97:4, s. 580-587
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Journal article (peer-reviewed)abstract
- BACKGROUND: To address issues regarding the fractionation of radiotherapy (RT) and timing of surgery for rectal cancer, a multicentre trial has randomized patients to preoperative short-course RT with two different intervals to surgery, or long-course RT with delayed surgery. The present interim analysis assessed feasibility, compliance and complications after RT and surgery. METHODS: Some 303 patients were randomized to either short-course RT (5 x 5 Gy) and surgery within 1 week (group 1), short-course RT and surgery after 4-8 weeks (group 2) or long-course RT (25 x 2 Gy) and surgery after 4-8 weeks (group 3). RESULTS: Demographic data were similar between groups and there were few protocol violations (5.0-6 per cent). Eight patients (2.6 per cent) developed radiation-induced acute toxicity. There were no significant differences in postoperative complications between groups (46.6, 40.0 and 32 per cent in groups 1, 2 and 3 respectively; P = 0.164). Patients receiving short-course RT with surgery 11-17 days after the start of RT had the highest complication rate (24 of 37). CONCLUSION: Compliance was acceptable and severe acute toxicity was low, irrespective of fractionation. Short-course RT with immediate surgery had a tendency towards more postoperative complications, but only if surgery was delayed beyond 10 days after the start of RT. Registration number: NCT00904813 (http://www.clinicaltrials.gov).
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| 7. |
- Pettersson, D., et al.
(author)
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Preoperative short-course radiotherapy with delayed surgery in primary rectal cancer
- 2012
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In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 99:4, s. 577-583
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Journal article (peer-reviewed)abstract
- Background: Short-course radiotherapy (SRT) with immediate surgery and long-course chemoradiotherapy (CRT) are currently the standard preoperative treatment options for rectal cancer. SRT with surgery delayed for 4-8 weeks (SRT-delay) is an option described for patients with locally advanced tumours who are not fit for CRT. This study examined early toxicity, response to radiotherapy (RT) and short-term outcomes of SRT-delay. Methods: Patients in the Stockholm region diagnosed with rectal cancer between January 2002 and December 2008, who received SRT (25 Gy over 5-7 days) and had surgery with resection of the primary tumour more than 4 weeks after the start of RT, were identified from a prospective register. Additional data were obtained by retrospective review of clinical records. Results: A total of 112 patients had SRT and delayed surgery. The reasons given for SRT included primary unresectable disease and co-morbidities. Severe RT-induced toxicity was noted in six patients (5.4 per cent). Signs of tumour regression were seen on magnetic resonance imaging in 74 per cent of patients reassessed after RT. Pathological stage (44.9 versus 60.7 per cent stage 0-II; P < 0.001), tumour category (11.9 versus 29.4 per cent T0-T2; P < 0.001) and node category (45.8 versus 63.6 per cent N0; P = 0.014) were significantly lower than those at initial assessment. Nine patients (8.0 per cent) had a complete pathological response. Conclusion: The SRT-delay schedule was a feasible alternative with low toxicity. The study indicated a downstaging effect of SRT if surgery was delayed.
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| 8. |
- Pettersson, D., et al.
(author)
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Tumour regression in the randomized Stockholm III Trial ofradiotherapy regimens for rectal cancer
- 2015
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In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 102:8, s. 972-978
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Journal article (peer-reviewed)abstract
- BackgroundThe Stockholm III Trial randomized patients with primary operable rectal cancers to either short-course radiotherapy (RT) with immediate surgery (SRT), short-course RT with surgery delayed 4-8 weeks (SRT-delay) or long-course RT with surgery delayed 4-8 weeks. This preplanned interim analysis examined the pathological outcome of delaying surgery. MethodsPatients randomized to the SRT and SRT-delay arms in the Stockholm III Trial between October 1998 and November 2010 were included, and data were collected in a prospective register. Additional data regarding tumour regression grade, according to Dworak, and circumferential margin were obtained by reassessment of histopathological slides. ResultsA total of 462 of 545 randomized patients had specimens available for reassessment. Patients randomized to SRT-delay had earlier ypT categories, and a higher rate of pathological complete responses (118 versus 17 per cent; P=0001) and Dworak grade 4 tumour regression (101 versus 17 per cent; P<0001) than patients randomized to SRT without delay. Positive circumferential resection margins were uncommon (63 per cent) and rates did not differ between the two treatment arms. ConclusionShort-course RT induces tumour downstaging if surgery is performed after an interval of 4-8 weeks.
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| 9. |
- Sjövall, A., et al.
(author)
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Colon cancer management and outcome in relation to individual hospitals in a defined population
- 2007
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In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 94:4, s. 491-499
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Journal article (peer-reviewed)abstract
- Background:The Stockholm and Gotland region in Sweden has a common management protocol for the treatment of colon cancer. The aim of this study was to assess the management and treatment of colon cancer in the region and to try to identify ways to improve the outcome further.Methods:Clinical data on all patients diagnosed with colon cancer in the region's nine hospitals between January 1996 and December 2000 were prospectively collected. Patients were followed until December 2004, and their management and outcome analysed.Results:Colon cancer was diagnosed in 2775 patients. An elective operation was performed in 2116 (76·3 per cent) patients and an emergency procedure in 590 (21·3 per cent). Emergency surgery was an independent risk factor for death. The crude overall cumulative 5-year survival was 46·2 per cent. A multivariable analysis of risk of dying and risk of local recurrence showed significant differences between hospitals. The number of lymph nodes examined in the specimens also differed between hospitals.Conclusion:Differences in the management and outcome of colon cancer in the nine hospitals, despite a common management protocol, indicate a need for improving collaboration between hospitals and multidisciplinary management.
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| 10. |
- Syk, Erik, et al.
(author)
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Radiological findings do not support lateral residual tumour as a major cause of local recurrence of rectal cancer
- 2006
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In: British Journal of Surgery. - West Sussex, United Kingdom : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 93:1, s. 113-119
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Journal article (other academic/artistic)abstract
- BACKGROUND: The aim of this study was to determine the sites of local recurrence following radical (R0) total mesorectal excision (TME) for rectal cancer in an effort to elucidate the reasons for recurrence. METHODS: Thirty-seven patients with recurrence following curative resection for rectal cancer were identified from a population of 880 patients operated on by surgeons trained in the TME procedure. Two radiologists independently examined 33 available computed tomograms and magnetic resonance images taken when the recurrence was detected. RESULTS: Twenty-nine of the 33 recurrences were found in the lower two-thirds of the pelvis. Two recurrent tumours appeared to originate from lateral pelvic lymph nodes. Evidence of residual mesorectal fat was identified in 15 patients. Fourteen of the recurrent tumours originated from primary tumours in the upper rectum; all of these tumours recurred at the anastomosis and 12 of the 14 patients had evidence of residual mesorectal fat. CONCLUSION: Lateral pelvic lymph node metastases are not a major cause of local recurrence after TME. Partial mesorectal excision may be associated with an increased risk of local recurrence from tumours in the upper rectum.
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