The risk for rectal cancer recurrence and overall mortality is not increased in men previously diagnosed with prostate cancer: a report from the Swedish colorectal cancer registry.

INTRODUCTION: Limited data exists on oncological outcomes following rectal cancer surgery in men who have previously been diagnosed with prostate cancer (PC). This study aimed to assess overall mortality and rectal cancer recurrence in men previously diagnosed with PC who underwent bowel resection. METHODS: Data from the Swedish Colorectal Cancer Registry identified men who had rectal cancer surgery between 2000 and 2016, and the National Prostate Cancer Registry was used to identify those with a prior PC diagnosis. Cox regression analysis with propensity score matching was employed for data analysis. The primary outcome was overall mortality. Secondary outcome was recurrence for rectal cancer. RESULTS: Out of 13,299 men undergoing bowel resection for rectal cancer between 2000 and 2016, 1130 had a history of PC. Overall mortality did not significantly differ between men with and without a prior PC diagnosis. Cox regression analyses with propensity score matching revealed that men with previously diagnosed low- or intermediate-risk (HR, 0.79; 95% CI, 0.70-0.90) and high-risk PC (HR, 0.85; 95% CI, 0.74-0.98) had lower overall mortality after rectal cancer surgery compared with men without a PC. There was no significant difference in rectal cancer recurrence between men with a previous low or intermediate-risk PC (HR, 0.92; 95% CI, 0.74-1.14) or high-risk PC (HR, 0.73; 95% CI, 0.52-1.01) compared with those without PC history. CONCLUSION: Men undergoing rectal cancer surgery with a previous diagnosis of prostate cancer do not experience an increased risk of rectal cancer recurrence or overall mortality compared with men without a previous history of prostate cancer.

A Validation of the Swedish Colorectal Cancer Register - With Focus on Histopathology, Complications and Recurrences.

Background: There is an urgent need to evaluate the quality of healthcare systems to improve and deliver high-quality care. Clinical registries have become important platforms for performance measurements, improvements, and clinical research. Hence, the quality of data in registries is crucial. This study aimed to assess the validity of data in the Swedish Colorectal Cancer Register (SCRCR). Methods: Seven hundred patients from 12 hospitals were randomly selected and proportionally distributed among three different hospital categories in Sweden using two-stage cluster sampling. Validity was assessed by re-abstracting data from the medical files of patients reported to the SCRCR in 2015. Data on histopathology, postoperative complications, and a 3-year follow-up were selected for validation. Re-abstracted data were defined as source data, and validity was defined as the proportion of cases in the SRCRC dataset that agreed with the source data. Validity was expressed as the percentage of exact agreement of non-missing data in both data sets, and Cohen´s kappa coefficient (κ) was used to measure the strength of the agreement. Results: The median agreement of the categorical histopathology variables was 93.4% (κ = 0.83). The general postoperative complication variable showed substantial agreement (84.3%, κ = 0.61). Likewise, the variable for overall cancer recurrence showed an almost perfect agreement (95.7%, κ = 0.86), whereas specific variables for local recurrence and distant recurrence displayed only moderate and fair agreement (85.9% and 89.1%, κ = 0.58 and 0.34, respectively). Conclusion: Validation of the SCRCR data showed high validity of pathology data and recurrence rates, whereas detailed data on recurrence were not as good. Data on postoperative complications were less reliable, although the incidence and Clavien-Dindo grading of severe complications (grade 3b or higher) were reliable.

Importance of Arterial Vessel Length for Metastatic Lymph Node Retrieval and Survival in Standardized Left- and Right-Sided Colon Cancer Surgery.

BACKGROUND: We investigated the localization of lymph node metastases, and the role of arterial vessel and specimen lengths in left- and right-sided colon cancer surgery, for survival. METHODS: This was a prospective cross-sectional population-based study of specimens from patients who underwent standardized surgical resection for colon cancer in 2012-2015. The mesocolon of the specimens was divided into four sections for pathological analysis of lymph nodes. Multiple linear regression analysis was used to explore the relationship between lymph node counts and patient- and surgery-related factors. For survival analysis, a multivariable Cox regression method was used. RESULTS: A total of 317 patients (160 females) were included. Median (range) age was 74 (30-95) years. Median number of lymph node retrieval was 32 (8-198) and was associated with increased specimen length but not to arterial vessel length. One hundred and thirty-three (42%) patients had lymph node metastases. All patients had these located < 5 cm from the tumour. Ten, two, and three specimens had lymph node metastases around the central and peripheral ligation of the ileocolic artery and at the central ligation of the inferior mesenteric artery, respectively. The tumour stages in these specimens were T3-4N2M0-1. No statistically significant survival benefit was associated with longer arterial vessel length (p = 0.429). CONCLUSIONS: Neither retrieval of lymph nodes nor statistically significant survival was affected by vessel length in standardized left- and right-sided colon cancer surgery.

A comparative study of the pathological outcomes of robot-assisted versus open surgery for rectal cancer.

Purpose: The use of robot-assisted surgery for rectal cancer is increasing, but the pathological outcomes have not been fully clarified. We compared the surgical and pathological outcomes between robot-assisted and open surgery in specimens from patients operated on for rectal cancer. Methods: All patients who underwent resection for rectal cancer from 2016 to 2018 were included. Specimens were divided into 3 sections to analyze the pathology of the lymph nodes (LNs) (n=137). Results: The total specimen lengths were shorter in the robot-assisted group than in the open surgery group (mean± standard deviation: 29.1±8.6 cm vs. 33.8±9.9 cm, P=0.004) because of a shorter proximal resection margin (21.7±8.7 vs. 26.4±10.6 cm, P=0.006). The number of recruited LNs (35.8±21.8 vs. 39.6±16.5, P=0.604) and arterial vessel length (8.84±2.6 cm vs. 8.78±2.4 cm, P=0.891) did not differ significantly between the 2 surgical approaches. LN metastases were found in 33 of 137 samples (24.1%), but the numbers did not differ significantly between the procedures. Among these 33 cases, metastatic LNs were located in the mesorectum (75.8%), in the sigmoid colon mesentery (33.3%), and at the arterial ligation site of the inferior mesenteric artery (12.1%). The circumferential resection margin and the proportion of complete mesorectal fascia were comparable between the groups. Conclusion: There were no significant differences between the 2 surgical approaches regarding arterial vessel length, recruitment of LN metastases, and resection margins.

Risk factors for developing anorectal dysfunction after anterior resection.

BACKGROUND: Anterior resection (AR) may result in defecatory dysfunction and the cause is multifactorial. The aim was to explore if dysfunction could be related to the part of the colon used for anastomosis (sigmoid or descending) and to identify other possible risk factors for bowel dysfunction after AR. METHODS: This is a retrospective study based on prospectively registered data from a regional registry at the surgical department in Västmanland 1996-2019. Bowel function was registered at 1 year after AR or after stoma reversal. In total, 470 stage I-III rectal cancer patients had AR whereof 412 were included in this study. RESULTS: Clustering was seen in 57%, incontinence 29%, urgency 22%, and evacuatory dysfunction 16%. The part of the colon used for anastomosis, level of vascular tie, and gender were not significantly associated with defecatory dysfunction. The higher the anastomotic level, the lower the risk of incontinence (OR 0.75; CI 0.63-0.90; p < 0.001) and clustering (OR 0.78; CI 0.67-0.90; p < 0.001). Compared with patients without a loop-ileostomy, an increased risk of clustering (OR 1.89; 1.08-3.31; p = 0.03), incontinence (OR 2.48; 1.29-4.77; p < 0.01), and urgency (OR 4.61; CI 2.02-10.60; p < 0.001) was seen after loop-ileostomy closure. Preoperative radiotherapy had a negative impact on continence and clustering seen mainly in the unadjusted analysis. CONCLUSION: The part of the colon used for anastomosis was not a significantly associated functional outcome after anterior resection. Low anastomotic level and having had a diverting ileostomy were independent risk factors associated with negative functional outcomes.

Risk factors for poor health-related quality of life in patients with colon cancer include stoma and smoking habits.

BACKGROUND: Previous studies have shown that health-related quality of life (HRQoL) is associated with the prognosis of cancer patients. The aim of this study was to investigate risk factors for poor HRQoL in patients with colon cancer. METHODS: This was a prospective population-based study of patients with colon cancer included between 2012 and 2016. HRQoL was measured using the cancer-specific European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. Multiple linear regression analysis adjusted for age, sex, body mass index, smoking habits, American Society of Anesthesiologists physical status classification, emergency/elective surgery, resection with/without a stoma and tumour stage was used. RESULTS: A total of 67% (376/561) of all incident patients with colon cancer (196 [52.1%] females) was included. Mean (range) age was 73 (30-96) years. Patients with worse health (American Society of Anesthesiologists physical status 3 and 4), those with higher body mass index, smokers and those planned to undergo surgical treatment with a stoma were at a higher risk for poor HRQoL than the other included patients at baseline and 6-month follow-up. CONCLUSIONS: Patient characteristics such as smoking, high body mass index and worse physical health as well as treatment with a stoma were associated with lower HRQoL. Health care for such patients should focus on social and lifestyle behavioural support and stoma closure, when possible. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03910894).

Predicting life with a permanent end colostomy: A prospective study on function, bother and acceptance.

AIM: The factors that influence a patient's experience of a colostomy are not known. The aim of this study was to characterise stoma function, stoma-related bother and acceptance among patients operated for rectal cancer and to investigate if there were any preoperative personal factors with predictive impact on long-term stoma-related bother. METHODS: The QoLiRECT (Quality of Life in RECTal cancer) study is a prospective multicentre study of patients with rectal cancer. This was a subgroup analysis of patients with a permanent colostomy with a 2-year follow-up. Penalised regression models with shrinkage estimation were used to predict the 1-and 2-year bother using baseline data. The predictive value and the importance of the included variables were evaluated using bootstrap resampling techniques. RESULTS: A total of 379 patients were included. Overall stoma acceptance was high and a majority of patients were not bothered by their stoma; 77% and 83% at 1 and 2 years, respectively. The subgroup of patients with stoma-related bother had a high prevalence of difficulties, especially fear of leakage, and a low stoma acceptance in daily life. Both clinical and personal factors were associated with stoma-related bother. The most important factors were quality of life and physical health, but the prediction accuracy was low. CONCLUSIONS: Stoma-related bother was associated with overall stoma dysfunction. As stoma-related bother is a multifactorial problem, it was not possible to predict which patients will experience stoma-related bother. It is therefore of importance to prevent stoma-related symptoms and optimise stoma function to reduce long-term bother and increase stoma acceptance.

Loop-ileostomy reversal in a 23-h stay setting is safe with high patient satisfaction.

INTRODUCTION: This study aimed to determine whether day-case closure of loop ileostomy with discharge within 23 h was both feasible and accepted by patients. MATERIALS AND METHODS: We conducted a prospective pilot study where selected rectal cancer patients with diverting loop ileostomy underwent stoma closure in a 23-h stay setting. Patients were followed up on the third, seventh, and 30th postoperative day and phoned daily during the first week. A comparable group of 30 patients who underwent standard in-hospital stoma closure prior to the start of the study were selected retrospectively as historical controls. RESULTS: In total, 30 patients (median age, 67 years; range, 41-79 years) were included. All patients met discharge criteria and were discharged within 23 h of surgery, except one. In total, seven patients (23%) were admitted. Two of these patients underwent laparotomy because of anastomotic leakage and small bowel obstruction, respectively. The mean total length of stay was 1.7 days. Most patients (87%) were satisfied with the treatment without feeling neglected or anxious and preferred the 23-h stay setting. In the control group, the mean length of stay was 5 days. Seven patients (23%) were readmitted. Two of these patients underwent laparotomy because of small bowel obstruction and abscess, respectively. CONCLUSION: Ileostomy closure in a 23-h stay setting in selected patients with meticulous follow up is feasible and safe with high patient satisfaction. CLINICALTRIALS.GOV NUMBER: (NCT02774447).

Risk factors for small bowel obstruction after open rectal cancer resection.

BACKGROUND: Small bowel obstruction (SBO) is observed in around 10% of patients with prior open abdominal surgery. Rectal resection causes the highest readmission rates. The aim of this study was to investigate risk factors for readmission for SBO and causes for SBO in patients who needed surgery following rectal cancer surgery. METHODS: A population-based registry with prospectively gathered data on 752 consecutive patients with rectal cancer who underwent open pelvic surgery between January 1996 and January 2017 was used. Univariable and multivariable regression analysis was performed, and the risk of SBO was assessed. RESULTS: In total, 84 patients (11%) developed SBO after a median follow-up time of 48 months. Of these patients, 57% developed SBO during the 1st year after rectal cancer surgery. Surgery for SBO was performed in 32 patients (4.3%), and the cause of SBO was stoma-related in one-fourth of these patients. In the univariable analysis previous RT and re-laparotomy were found as risk factors for readmission for SBO. Re-laparotomy was an independent risk factor for readmission for SBO (OR 2.824, CI 1.129-7.065, P = 0.026) in the multivariable analysis, but not for surgery for SBO. Rectal resection without anastomoses, splenic flexors mobilization, intraoperative bleeding, operative time were not found as risk factors for SBO. CONCLUSIONS: One-tenth of rectal cancer patients who had open surgery developed SBO, most commonly within the 1st postoperative year. The risk of SBO is greatest in patients with complications after rectal cancer resection that result in a re-laparotomy.

Prognostic factors for survival in stage IV rectal cancer: A Swedish nationwide case-control study.

PURPOSE: The aim was to identify patient-, tumor- and treatment-related prognostic factors for five-year survival in rectal cancer patients with synchronous stage IV disease. MATERIAL AND METHODS: This nationwide case-control study was based on the Swedish Colorectal Cancer Registry with supplementary information from medical records and the Swedish Inpatient Registry during the period 2000-2008. All resected rectal cancer patients with synchronous metastases that survived more than five years were included as cases. The control group consisted of corresponding patients who lived less than five years, matched in a 1:2 based on gender, age, resection of the rectal tumor, and the study period. RESULTS: A total of 405 patients were identified; 99 long-term survivors (LTS) and 182 short-term survivors (STS). Patient-related factors of symptoms and comorbidity did not differ between LTS and STS. Among the treatment-related factors, multiple site metastases (p = 0.007), bilobar liver metastasis (p = 0.002), and increasing number of liver metastasis (p < 0.001) were associated with STS. Prognostic treatment-related factors were preoperative radiotherapy (p = 0.001), metastasectomy (p < 0.001), and radical resection of the primary tumor (p = 0.014). In the multivariable analysis, the single most important factor for becoming a LTS was a metastasectomy (hazard ratio: 8.474, 95% confidence interval: 4.098-17.543). CONCLUSIONS: The most important prognostic factor for long-term survival in patients with stage IV rectal cancer was metastasectomy, especially liver surgery. With thorough selection of patients for metastasectomy more patients with metastasized rectal cancer may survive beyond five years.

Localization of mesenteric lymph node metastases in relation to the level of arterial ligation in rectal cancer surgery.

INTRODUCTION: For oncological reasons, central arterial ligation of the inferior mesenteric artery (IMA) is suggested in rectal cancer surgery although no conclusive evidence support this. We have therefore investigated the localization of lymph node metastases and compared central ligation of the IMA versus peripheral arterial ligation, in rectal cancer specimens. METHODS: This was a cross-sectional population-based study of consecutive recruited patients who underwent resection for rectal cancer in 2012-2015. Multiple linear regression analysis was used to explore the relationship between lymph node count and age, sex, body mass index, preoperative oncological treatment, type of surgery, tumour stage, and vessel and specimen length. RESULTS: 151 patients (54 women) were included, with median (range) age 70 (45-87) years. The median (range) number of lymph nodes retrieved was 25 (3-70), which was associated with body mass index, type of surgery and vessel length. Vessel length, median (range) 9.6 (5-14) and 9.2 (5-15) cm for reported central and peripheral arterial ligation, respectively, was associated with body mass index. In 39 of 42 samples, metastatic lymph nodes were located in the mesorectum, and 13 of 42 samples also had metastatic lymph nodes in the sigmoid mesentery. None were found around the ligated artery. CONCLUSION: To recruit all metastatic lymph nodes in rectal cancer surgery, it is important to include the sigmoid mesentery in the specimen, but not to perform a central ligation of the IMA compared with ligation of the SRA close to the left colic artery (LCA).

Anastomotic leakage after anterior resection in patients with rectal cancer previously irradiated for prostate cancer.

INTRODUCTION: There are little data on the post-operative outcome of anterior resection (AR) for rectal cancer in men who had received radiotherapy for prostate cancer previously. The aim of this study was to assess the rate of anastomotic leakage (AL) after AR in these patients. METHODS: All men who underwent bowel resection because of rectal cancer between 2000 and 2016 and had been diagnosed previously with prostate cancer were identified by linking the Swedish Colorectal Cancer Registry with the National Prostate Cancer Register. The medical records of men who underwent AR and had previously received radiotherapy for prostate cancer were reviewed. RESULTS: In total, 13299 men had undergone a bowel resection for rectal cancer, 188 of whom had previously received radiotherapy for prostate cancer. Among those who had received radiation therapy, 59 men (31%) had an AR: 50 men (85%) received a diverting ileostomy, 42 men (71%) had an American Society of Anesthesiologists score of 1-2 and 36 men (61%) had tumour stage 1-2. AL was found in 12/59 men (20%), one of whom had a re-laparotomy. There was no 90-day mortality. CONCLUSIONS: In the combined national population-based registries, a minority of patients with rectal cancer had an AR after previous radiotherapy for prostate cancer. These patients were healthy with early cancer stages and, in this selected group of patients, the AL rate was much lower than that reported previously.

Effect of More vs Less Frequent Follow-up Testing on Overall and Colorectal Cancer-Specific Mortality in Patients With Stage II or III Colorectal Cancer: The COLOFOL Randomized Clinical Trial.

Importance: Intensive follow-up of patients after curative surgery for colorectal cancer is common in clinical practice, but evidence of a survival benefit is limited. Objective: To examine overall mortality, colorectal cancer-specific mortality, and colorectal cancer-specific recurrence rates among patients with stage II or III colorectal cancer who were randomized after curative surgery to 2 alternative schedules for follow-up testing with computed tomography and carcinoembryonic antigen. Design, Setting, and Participants: Unblinded randomized trial including 2509 patients with stage II or III colorectal cancer treated at 24 centers in Sweden, Denmark, and Uruguay from January 2006 through December 2010 and followed up for 5 years; follow-up ended on December 31, 2015. Interventions: Patients were randomized either to follow-up testing with computed tomography of the thorax and abdomen and serum carcinoembryonic antigen at 6, 12, 18, 24, and 36 months after surgery (high-frequency group; n = 1253 patients) or at 12 and 36 months after surgery (low-frequency group; n = 1256 patients). Main Outcomes and Measures: The primary outcomes were 5-year overall mortality and colorectal cancer-specific mortality rates. The secondary outcome was the colorectal cancer-specific recurrence rate. Both intention-to-treat and per-protocol analyses were performed. Results: Among 2555 patients who were randomized, 2509 were included in the intention-to-treat analysis (mean age, 63.5 years; 1128 women [45%]) and 2365 (94.3%) completed the trial. The 5-year overall patient mortality rate in the high-frequency group was 13.0% (161/1253) compared with 14.1% (174/1256) in the low-frequency group (risk difference, 1.1% [95% CI, -1.6% to 3.8%]; P = .43). The 5-year colorectal cancer-specific mortality rate in the high-frequency group was 10.6% (128/1248) compared with 11.4% (137/1250) in the low-frequency group (risk difference, 0.8% [95% CI, -1.7% to 3.3%]; P = .52). The colorectal cancer-specific recurrence rate was 21.6% (265/1248) in the high-frequency group compared with 19.4% (238/1250) in the low-frequency group (risk difference, 2.2% [95% CI, -1.0% to 5.4%]; P = .15). Conclusions and Relevance: Among patients with stage II or III colorectal cancer, follow-up testing with computed tomography and carcinoembryonic antigen more frequently compared with less frequently did not result in a significant rate reduction in 5-year overall mortality or colorectal cancer-specific mortality. Trial Registration: clinicaltrials.gov Identifier: NCT00225641.

Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings.

PURPOSE: Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics. METHODS: The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model. RESULTS: In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469). CONCLUSIONS: The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.

Low risk of intra-abdominal infections in rectal cancer patients treated with Hartmann's procedure: a report from a national registry.

PURPOSE: To describe the postoperative surgical complications in patients with rectal cancer undergoing Hartmann's procedure (HP). METHODS: Data were retrieved from the Swedish Colorectal Cancer Registry for all patients with rectal cancer undergoing HP in 2007-2014. A retrospective analysis was performed using prospectively recorded data. Characteristics of patients and risk factors for intra-abdominal infection and re-laparotomy were analysed. RESULTS: Of 10,940 patients resected for rectal cancer, 1452 (13%) underwent HP (median age, 77 years). The American Society of Anesthesiologists (ASA) score was 3-4 in 43% of patients; 15% had distant metastases and 62% underwent a low HP. The intra-abdominal infection rate was 8% and re-laparotomy rate was 10%. Multivariable logistic regression analysis identified preoperative radiotherapy (OR, 1.78; 95% CI, 1.14-2.77), intra-operative bowel perforation (OR, 1.99; 95% CI, 1.08-3.67), T4 tumours (OR, 1.68; 95% CI 1.04-2.69) and female gender (OR, 1.73; 95% CI, 1.15-2.61) as risk factors for intra-abdominal infection. ASA score 3-4 (OR, 1.62; 95% CI, 1.12-2.34), elevated BMI (OR, 1.05; 95% CI, 1.02-1.09) and female gender (OR, 2.06; CI, 1.41-3.00) were risk factors for re-laparotomy after HP. The rate of intra-abdominal infection was not increased after a low HP. CONCLUSIONS: Despite older age and co-morbidities including more advanced cancer, patients undergoing Hartmann's procedure had low rates of serious postoperative complications and re-laparotomy. A low HP was not associated with a higher rate of intra-abdominal infection. HP seems to be appropriate for old and frail patients with rectal cancer.

Correction to: Pretreatment quality of life in patients with rectal cancer is associated with intrusive thoughts and sense of coherence.

The original version of this article, unfortunately, contained errors.

Pretreatment quality of life in patients with rectal cancer is associated with intrusive thoughts and sense of coherence.

PURPOSE: Quality of life may predict survival. In addition to clinical variables, it may be influenced by psychological factors, some of which may be accessible for intervention. The primary objective of this study was to investigate the association of intrusive thoughts and the patients' sense of coherence with pretreatment quality of life in patients with newly diagnosed rectal cancer. METHODS: Patients were prospectively included in 16 hospitals in Sweden and Denmark. They answered an extensive questionnaire after receiving their treatment plan. Clinical data were retrieved from national quality registries for rectal cancer. RESULTS: Of 1248 included patients, a total of 1085 were evaluable. Pretreatment global health-related and overall quality of life was lower in patients planned for palliative compared with curative treatment (median 53 vs. 80 on the EuroQoL visual analogue scale, p < 0.001 and odds ratio 0.56, 95% confidence interval 0.36-0.88, respectively). Quality of life was associated with intrusive thoughts (odds ratio 0.33, 95% confidence interval 0.24-0.45) and sense of coherence (odds ratio 0.44, 95% confidence interval 0.37-0.52) irrespective of the treatment plan. CONCLUSIONS: Pretreatment quality of life was influenced by the intent of treatment as well as by intrusive thoughts and the patients' sense of coherence. Interventions could modify these psychological factors, and future studies should focus on initiatives to improve quality of life for this group of patients.

Computed Tomography Follow-Up Assessment of Patients with Low-Grade Appendiceal Mucinous Neoplasms: Evaluation of Risk for Pseudomyxoma Peritonei.

BACKGROUND: Low-grade appendiceal mucinous neoplasms are rare. Both classification and management vary. This study aimed to follow up on patients with a diagnosis of LAMN after primary surgery with computer tomography (CT) scans to examine the risk for the development of pseudomyxoma peritonei (PMP). METHODS: This population-based prospective study investigated patients who underwent appendectomy between 2007 and 2013 and had histology results demonstrating the presence of LAMN. The patients were followed up with a CT scan every 6 months for 2 years, until December 2015. RESULTS: The study investigated 41 patients (20 females) with a median age of 65 years (range 20-87 years). The entire appendix was processed and examined, with results showing that 12 were perforated, and 3 had a positive margin. Extra-appendiceal mucin on the surface of the appendix was found in ten cases, and in two cases, extra-mucinous epithelial cells were detected. During a median follow-up period of 5.1 years (range 2-8.6 years), none of the patients experienced the development of PMP. CONCLUSIONS: These data suggest that for patients with LAMN confined to the appendix, involvement of the appendectomy margin or perforation with mucin locally, even with epithelial cells, did not predict the development of PMP, and a conservative approach seems justified. No reoperation was needed, and regular follow-up evaluation with CT scans was sufficient.

Detection of Free Cancer Cells in Pelvic Lavage with Double Immunocytochemistry at Rectal Cancer Surgery.

BACKGROUND/AIM: The aim of the present study was to describe a double immunocytochemical staining method for detecting free cancer cells after rectal cancer surgery and to evaluate their extent and prognostic role. MATERIALS AND METHODS: Immunocytochemistry was performed using antibodies against cytokeratin 20/caudal-typehomeobox transcription factor 2 (CDX2) and mucin glycoprotein-2 (MUC2)/p53 protein. The study included 29 patients with infraperitoneal rectal cancer who underwent bowel resection and four controls. The pelvic lavage was retrieved at the start of laparotomy, after total mesorectal excision and after abdominal lavage with sterile water. RESULTS: Free cancer cells were detected with the double immunocytochemical method in the two controls with carcinomatosis and one control with sigmoidal cancer. None of the patients with rectal tumours had presence of free cancer cells. CONCLUSION: Immunocytochemical analysis of peritoneal lavage was feasible and negative in patients with infraperitoneal rectal cancer. Further studies are encouraged to investigate the clinical relevance in cases with free cancer cells after incomplete total mesorectal excision.

Lymphovascular and perineural invasion in stage II rectal cancer: a report from the Swedish colorectal cancer registry.

BACKGROUND: Adjuvant chemotherapy for stage II and III rectal cancer patients is a matter of discussion. The aim of the present study was to evaluate the prognostic value of lymphovascular (LVI) and perineural (PNI) invasion in stage II rectal cancer on a national level. MATERIALS AND METHODS: Clinico-pathological factors associated with disease-free survival (DFS) and time to recurrence in stage II rectal cancer patients were analyzed from patient data registered in the Swedish Colorectal Cancer Registry between 2006 and 2012. RESULTS: Of 2649 patients with TNM stage II disease, 1395 (53%) received preoperative radiotherapy and 456 (17%) preoperative chemoradiotherapy. LVI and PNI were detected in 387 (15%) and 269 (10%) patients, respectively. Adjuvant chemotherapy was planned in 14%, but more often if LVI or PNI was detected (25% and 31%, respectively, p < .001 for both). The three-year DFS and time to recurrence were 78% and 17%, respectively. Both LVI and PNI indicated worse outcome. In patients not receiving postoperative chemotherapy, the risks of recurrence after three years were 20% if LVI was seen and 22% if PNI was detected (p < .001 for both). In the absence of LVI and PNI, it was 13% and 12%, respectively. In a multivariate Cox regression analysis, patients with LVI (hazard ratio 1.44, 95% CI 1.09-1.90; p = .011) and PNI (hazard ratio 1.80, 95% CI 1.34-2.43, p < .001) had significantly increased risks of recurrence. CONCLUSIONS: Stage II rectal cancer patients with LVI and PNI have an increased risk of recurrence which emphasizes the need to properly evaluate the role of adjuvant chemotherapy particularly in these subgroups.