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Rectal Cancer: Surgical Strategies and Histopathological Aspects
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Colorectal Surgery.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The management of rectal cancer has changed in many countries over the last two decades and resulted in improved survival for the majority of rectal cancer patients. In this thesis some surgical strategies and histopathological aspects to improve and clarify the management of rectal cancer patients are investigated.

Even in the era of TME surgery and radiotherapy, a higher local recurrence rate and shorter survival for rectal cancer patients operated with abdominoperineal resection is reported. In the first paper we describe a new strategy with partial anterior en bloc resection of either the prostate or the vagina, resulting in very low local recurrence rates and excellent long-term survival. Histopathological examination of the specimen lays the foundation for decision making on oncological therapy. A positive circumferential resection margin (CRM) has, in previous papers, been related to a high risk of local recurrence. In the second paper we show that a CRM ≤ 1 mm was not correlated with an increased risk of local recurrence when patients were managed in a multidisciplinary setting with preoperative radiotherapy and optimal TME surgery. As the complexity of rectal cancer management is increasing, demands on organizational structure are growing. In paper three we could show that long-term survival was increased for all rectal cancer patients after the centralization to a single unit. Whether or not to resect the primary rectal tumour in patients with metastatic disease is an ongoing debate in the literature. In paper four, we studied the national management of rectal cancer patients with primary metastatic disease. Nineteen per cent of rectal cancer patients present with Stage IV disease and, at a national level, there is a clear shift to a more selective and restrictive approach. The 30-day mortality was low for patients that underwent a resectional surgery, for patients having an exploratory laparotomy, however, it was high. Overall survival was improved over time even though up to one fourth of patients received no surgical treatment.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Uppsaliensis , 2011. , 57 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 652
Keyword [en]
Rectal cancer, APR, en bloc resection, CRM, centralization, stage IV, metastases, palliative surgery, local recurrence, survival
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-147869ISBN: 978-91-554-8020-2OAI: oai:DiVA.org:uu-147869DiVA: diva2:401099
Public defence
2011-04-16, Aulan, ingång 21, Centrallasarettet, Västerås, 13:15 (English)
Opponent
Supervisors
Available from: 2011-03-24 Created: 2011-03-01 Last updated: 2011-05-04Bibliographically approved
List of papers
1. Abdominoperineal excision with partial anterior en bloc resection in multimodal management of low rectal cancer: a strategy to reduce local recurrence.
Open this publication in new window or tab >>Abdominoperineal excision with partial anterior en bloc resection in multimodal management of low rectal cancer: a strategy to reduce local recurrence.
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2006 (English)In: Dis Colon Rectum, ISSN 0012-3706, Vol. 49, no 6, 833-40 p.Article in journal (Refereed) Published
Keyword
Abdomen/*surgery, Adult, Aged, Aged; 80 and over, Cohort Studies, Combined Modality Therapy, Dissection/*methods, Female, Humans, Male, Middle Aged, Neoplasm Recurrence; Local/*prevention & control, Perineum/*surgery, Prostate/surgery, Rectal Neoplasms/mortality/pathology/*surgery, Survival Rate, Treatment Outcome, Vagina/surgery
Identifiers
urn:nbn:se:uu:diva-10265 (URN)16619115 (PubMedID)
Available from: 2007-03-08 Created: 2007-03-08 Last updated: 2011-04-04
2. Is the circumferential resection margin a predictor of local recurrence after preoperative radiotherapy and optimal surgery for rectal carcinoma?
Open this publication in new window or tab >>Is the circumferential resection margin a predictor of local recurrence after preoperative radiotherapy and optimal surgery for rectal carcinoma?
2007 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 9, no 8, 706-712 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Circumferential resection margin (CRM) involvement has been correlated with a high risk of developing local recurrence. The aim of this study was to examine the prognostic significance of the CRM involvement after curative resection of rectal cancer in patients treated with preoperative radiotherapy and postoperative chemotherapy where indicated. METHOD: All patients with rectal cancer treated in a regional central unit from 1996 to 2004 were identified. A surgical resection was performed on 257 patients, and in 229 of these this was assessed as potentially curative. The CRM was examined in all patients. A CRM of < or = 1 mm was considered positive. RESULTS: A positive margin was seen in 19 (8%) patients. At a median follow up of 40 months, only four (1.7%) patients had developed local recurrence, one of whom had a positive CRM. In the four patients the tumour was 5 cm or less from the anal verge. There were no significant differences regarding local recurrence and survival between CRM positive and negative tumours. CONCLUSION: Rectal cancer managed by combined radiochemotherapy and surgery resulted in a low positive CRM rate and a low local recurrence rate. An involved CRM was not a predictor of local recurrence.

Keyword
Rectal cancer, surgery, circumferential resection margin, local recurrence, survival
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-11653 (URN)10.1111/j.1463-1318.2007.01263.x (DOI)000249419200006 ()17535279 (PubMedID)
Available from: 2007-10-10 Created: 2007-10-10 Last updated: 2011-05-13Bibliographically approved
3. Centralization of rectal cancer surgery improves long-term survival
Open this publication in new window or tab >>Centralization of rectal cancer surgery improves long-term survival
2010 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 12, no 9, 874-879 p.Article in journal (Refereed) Published
Abstract [en]

Aim In 1996, rectal cancer surgery in the Swedish county of Vastmanland was centralized to a single colorectal unit. At the same time, total mesorectal excision and multidisciplinary team meetings were introduced. The aim of this audit was to determine the long-term results before and after centralization. Method All consecutive rectal cancer patients who underwent curative or palliative surgery at one of the county's four hospitals between 1993 and 1996 (n = 133, group 1) were compared with patients operated at the new centralized colorectal unit between 1996 and 1999 (n = 144, group 2). Results Preoperative radiotherapy was common in both groups, but in group 2, it was planned using MRI. Local recurrences were detected in 8% of all patients operated in group 1 vs 3.5% in group 2 (P = 0.043). The overall 5-year survival for all patients in group 1 was 38 vs 62% in group 2 (P = 0.003). According to multivariate analysis, the new colorectal unit was an independent predictor for improved long-term survival. Conclusion This population-based audit shows reduced local recurrence rate and prolonged overall survival for rectal cancer patients after centralization to a single colorectal unit with multidisciplinary management and increased subspecialization.

Keyword
Rectal cancer, surgery, centralization, survival
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-135406 (URN)10.1111/j.1463-1318.2009.02098.x (DOI)000280990100007 ()
Available from: 2010-12-07 Created: 2010-12-06 Last updated: 2011-04-04Bibliographically approved
4. Treatment strategies for patients with stage IV rectal cancer: a report from the Swedish Rectal Cancer Registry
Open this publication in new window or tab >>Treatment strategies for patients with stage IV rectal cancer: a report from the Swedish Rectal Cancer Registry
2012 (English)In: European Journal of Cancer, ISSN 0959-8049, E-ISSN 1879-0852, Vol. 48, no 11, 1616-1623 p.Article in journal (Refereed) Published
Abstract [en]

Background: The optimal treatment strategy for patients with stage IV rectal cancer is unclear. The aim of the present study was to describe trends and compare the different treatment strategies for this group of patients at a national level and over time.

Methods: Data from 2758 rectal cancer patients with (stage IV group) and 13 420 without metastases (stage I-III group) were available from the Swedish Rectal Cancer Registry between January 1995 and December 2006.

Results: Patients with stage IV disease increased from 15 to 19 per cent between 1995 and 2006 (p<0.001) and the frequency of patients not operated increased from 13 to 26 per cent (p<0.001). Postoperative 30 day mortality after bowel resection was 2 per cent and after exploratory laparotomy 9 per cent. Median survival for stage IV patients operated with bowel resection was 16.3 months, an exploratory laparotomy 6.1 months, and for patients having no surgery 4.6 months. Patients aged 60-69 years increased their survival over time, irrespective of the treatment given. In the multivariate analysis, an increased risk of death was associated with: age > 80 years, operation at a local hospital, treatment in earlier time periods, not receiving preoperative radio- or chemotherapy, and not having a bowel resection.

Conclusion: Survival for stage IV rectal cancer patients improved in the latest time period despite the great increase in non-operated patients. Patients aged > 80 years should be carefully assessed and staged before surgery. The survival advantage for stage IV rectal cancer patients who underwent primary tumour resection is probably due to selection bias.

Keyword
Rectal cancer; Stage IV; Surgery; Palliative; Oncology; Survival
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-147879 (URN)10.1016/j.ejca.2011.12.012 (DOI)000305781300004 ()
Available from: 2011-03-01 Created: 2011-03-01 Last updated: 2012-07-20Bibliographically approved

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