Preoperative multidisciplinary team assessment is associated with improved survival in patients with locally advanced colon cancer; a nationwide cohort study in 3157 patients.

INTRODUCTION: Multidisciplinary team (MDT) assessment is associated with improved survival in locally advanced rectal cancer, but the effect of an MDT assessment on survival in locally advanced colon cancer has not been reported. The aim of this national population-based cohort study was to establish if preoperative MDT assessment affects prognosis in patients with primary locally advanced colon cancer. MATERIAL AND METHODS: All patients in Sweden with locally advanced colon cancer, without metastatic disease, who underwent an elective colon resection between 2010 and 2017 were identified through the Swedish Colorectal Cancer Registry (SCRCR), and the cohort was linked to national registers. Data on patient characteristics, preoperative staging, surgical procedures, recurrence and survival were collected from SCRCR. The association between MDT assessment and colon cancer-specific survival was evaluated using Kaplan-Meier survival curves and Cox proportional hazards models. The multivariable analysis was adjusted for sex, age, ASA grade, CCI, time period, pN, region and preoperative MDT. RESULTS: MDT assessment was performed in 2663 patients (84.4%) of 3157 eligible patients. The 3-year colon cancer-specific survival was higher following MDT, compared with no MDT assessment (80% versus 68%). MDT assessment was independently associated with reduced colon cancer-specific mortality (HR 0.70, 0.57-0.84 95% CI). CONCLUSION: Preoperative MDT assessment is associated with an improved long-term survival in patients with locally advanced colon cancer and should be mandatory in patients with suspected locally advanced colon cancer.

Pre- and post-race serum cardiac troponin T concentrations in Standardbred racehorses.

Elevated cardiac troponin T (cTnT) concentrations may provide evidence of myocardial injury but physiological post-exercise release also occurs. Reference intervals are not fully established in horses making interpretation difficult. The aims of this study were to establish an upper reference limit for serum cTnT, compare pre-and post-race serum cTnT concentrations, and to evaluate factors that may influence these in a population of healthy, race-fit Standardbred racehorses. Serum samples were collected pre- (n = 108) and 1-2 h post-racing (n = 101) and analysed using a high sensitivity-cTnT assay. Reference limits with 90% confidence intervals (CI) were calculated by non-parametric methods using the bootstrap method. Effects of sex, age, racing speed, distance, placings and track surface were assessed by fitting generalized linear models with an identity link function and inverse Gaussian distribution. The upper reference limit for serum cTnT concentration was 27.4 ng/L (90% CI 13.1-32.0). The median serum cTnT concentration was significantly higher 1-2 h post-racing compared to pre-racing (P < 0.001). Age and sex did not significantly affect serum cTnT concentrations pre-racing (P = 0.5 and P = 0.11). Cardiac troponin T concentrations were significantly higher post-racing in females (P = 0.018). Racing speed and placings had no effect on serum cTnT concentrations post-race (P = 0.71 and P = 0.66). The study contributed towards establishing an upper reference limit for serum cTnT concentrations in a population of race-fit Standardbreds and evaluated factors that may have influenced the results obtained.

Postoperative complications in relation to overall treatment time in patients with rectal cancer receiving neoadjuvant radiotherapy.

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 4-8 weeks 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 (5 × 5 Gy) were categorized according to OTT: 7 days (group A), 8-13 days (group B), 5-7 weeks (group C) and 8-13 weeks (group D). Patients receiving long-course RT (25 × 2 Gy) were grouped into those with an OTT of 9-11 weeks (group E) or 12-14 weeks (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 4-12 weeks (OTT 5-13 weeks) after SRT.

Population-based study of surgical treatment with and without tumour resection in patients with locally recurrent rectal cancer.

BACKGROUND: Population-based studies of treatment of locally recurrent rectal cancer (LRRC) are lacking. The aim was to investigate the surgical treatment of patients with LRRC at a national population-based level. METHODS: All patients undergoing abdominal resection for primary rectal cancer between 1995 and 2002 in Sweden with LRRC as a first event were included. Detailed information about treatment, complications and outcomes was collected from the medical records. The patients were analysed in three groups: patients who had resection of the LRRC, those treated without tumour resection and patients who received best supportive care only. RESULTS: In all, 426 patients were included in the study. Of these, 149 (35·0 per cent) underwent tumour resection, 193 (45·3 per cent) had treatment without tumour resection and 84 (19·7 per cent) received best supportive care. Abdominoperineal resection was the most frequent surgical procedure, performed in 65 patients (43·6 per cent of those who had tumour resection). Thirteen patients had total pelvic exenteration. In total, 63·8 per cent of those whose tumour was resected had potentially curative surgery. After tumour resection, 62 patients (41·6 per cent) had a complication within 30 days. Patients who received surgical treatment without tumour resection had a lower complication rate but a significantly higher 30-day mortality rate than those who underwent tumour resection (10 versus 1·3 per cent respectively; P = 0·002). Of all patients included in the study, 22·3 per cent had potentially curative treatment and the 3-year survival rate for these patients was 56 per cent. CONCLUSION: LRRC is a serious condition with overall poor outcome. Patients undergoing curative surgery have an acceptable survival rate but substantial morbidity. There is room for improvement in the management of patients with LRRC.

Session 3: Beyond the boundaries of Total Mesorectal Excision - where surgeons fear to tread.

Approximately 10-15% of patients present with an advanced rectal cancer that extends beyond the conventional total mesorectal excision (TME) planes. In such cases extending the surgery to ensure resection with clear margins (R0 resection) is essential in order to achieve long-term cure. Professor Holm describes the techniques of beyond-TME exenterative surgery, the methods of patient selection and outcomes.

Pelvic local recurrence from colorectal cancer: surgical challenge with changing preconditions.

AIM: Although the rate of local recurrence (LR) after colorectal cancer surgery has decreased, it still poses major surgical and oncological challenges. The aims of this study, based on an audit from a tertiary referral centre, was to evaluate determinants associated with outcomes after surgery for pelvic LR and how these have changed over time. METHOD: Retrospective analysis of all resections for pelvic LR of colorectal cancer performed at the Karolinska University Hospital from January 2003 until August 2009 (period 1) and from September 2009 until November 2013 (period 2) . RESULTS: Ninety-five patients with pelvic LR were operated on with a curative intent. An R0 resection was achieved in 77% and an R1 resection in 23%. Lateral compartments were invaded in 48% and this proportion increased in resections performed in period 2 (37% vs 60%, P = 0.05). R1 resections were associated with a higher risk of local re-recurrence than R0 resections (64% vs 16%; OR = 8.90, 95% CI: 2.71-29.78). Lateral recurrences were associated with a lower R0-resection rate than nonlateral recurrences (63% vs 90%; OR = 0.20, 95% CI: 0.05-0.64) and a higher risk of treatment failure in terms of local re-recurrence or distant metastases, or death, as first event (hazard ratio [HR] = 1.75, 95% CI: 1.06-2.75). However, in a multivariate analysis only R1 resections remained a significant prognostic factor for treatment failure (HR = 2.37, 95% CI: 1.32-4.27). CONCLUSION: The proportion of lateral pelvic recurrences has increased over time. In comparison with non-lateral LRs, lateral LRs are more difficult to resect radically and are associated with worse overall and disease-free survival. However, with radical surgery many patients with pelvic locally recurrent colorectal cancer may be offered curative treatment.

Complete mesocolic excision in right-sided colon cancer does not increase severe short-term postoperative adverse events.

AIM: The aim was to assess whether complete mesocolic excision (CME) in patients with right-sided colon cancer is related to short-term mortality or postoperative adverse events requiring reoperation. The complete mobilization of an integral mesocolon and central ligation of blood vessels are essential steps in CME surgery. The resultant specimen, with an intact mesocolic fascia and a high number of harvested lymph nodes, is believed to be oncologically favourable. However, it has been suggested that CME surgery may increase the risk of intra-operative severe adverse events, due to exposure of vital retroperitoneal organs and large blood vessels. METHOD: In a population-based, nested case-control study, all residents in the Stockholm County operated for right-sided colon cancer from 2004 until 2012 were identified from the Swedish Colorectal Cancer Registry. Patients who died within 90 days after surgery or were reoperated within 30 days after surgery, or during the index hospital stay, were defined as cases. Two controls per case were randomly sampled and individually matched for age, sex, TNM stage and emergency vs elective surgery. Exposure status (CME surgery) was assessed from original surgical reports. RESULTS: The estimated proportion of CME surgery was 14.8% (35 of 236) for cases and 19.5% (92 of 473) for controls. The unadjusted OR for short-term mortality or reoperation after CME surgery was 0.72 (95% CI: 0.47-1.10; P = 0.15). The ORs were lower in the late part of the study (0.51; 95% CI: 0.26-1.01) and in high volume hospitals (0.61, 95% CI: 0.35-1.06). CONCLUSIONS: The present study does not indicate that CME surgery is associated with an increased risk of severe adverse events such as 90-day mortality or reoperation.

Population-based study of factors predicting treatment intention in patients with locally recurrent rectal cancer.

BACKGROUND: Local recurrence of rectal cancer (LRRC) is associated with poor survival unless curative treatment is performed. The aim of this study was to investigate predictive factors for treatment with curative intent in patients with LRRC. METHODS: Population-based data for patients treated for primary rectal cancer between 1995 and 2002, and with LRRC reported as first event were collected from the Swedish Colorectal Cancer Registry and medical records. The associations between patient-, primary tumour- and LRRC-related factors and intention of the treatment for LRRC were determined. The impact of the identified predictive factors on prognosis after treatment with curative intent was also assessed. RESULTS: A total of 426 patients were included in the study, of whom 149 (35·0 per cent) received treatment with curative intent. Factors significantly associated with treatment of the LRRC with palliative intent were primary surgery with abdominoperineal resection (odds ratio (OR) 5·16, 95 per cent c.i. 2·97 to 8·97), age at diagnosis of LRRC at least 80 years (OR 4·82, 2·37 to 9·80), symptoms at diagnosis (OR 2·79, 1·56 to 5·01) and non-central location of the LRRC (OR 1·79, 1·15 to 2·79). The overall 5-year survival rate was 8·9 per cent for all patients and 23·1 per cent among those treated with curative intent. In patients treated with curative intent, factors associated with increased risk of death were age 80 years or more (hazard ratio (HR) 2·44, 95 per cent c.i. 1·55 to 3·86), presence of symptoms (HR 1·92, 1·20 to 3·05), non-central tumour location (HR 1·51, 1·01 to 2·26) and presence of hydronephrosis (HR 2·02, 1·18 to 3·44). CONCLUSION: Non-central location of the LRRC, presence of symptoms and age at least 80 years at diagnosis of the LRRC were associated with treatment with palliative intent.

Effect of ES products from Anisakis (Nematoda: Anisakidae) on experimentally induced colitis in adult zebrafish.

Inflammatory bowel disease (IBD) in developed countries is linked with elevated hygienic standards. One of the several factors involved in this question may be reduced exposure to the immunomodulatory effects of parasitic helminths. Several investigations on treatment of mice and humans with helminth-derived substances have supported this notion, but underlying mechanisms remain unclear. This study therefore dissects to what extent a series of immune-related genes are modulated in zebrafish with experimentally induced colitis following exposure to excretory-secretory (ES) products isolated from larval Anisakis, a widely distributed fish nematode. Adult zebrafish intrarectally exposed to the colitis-inducing agent TNBS developed severe colitis leading to 80% severe morbidity, but if co-injected (ip) with Anisakis ES products, the morbidity rate was 50% at the end of the experiment (48 hours post-exposure). Gene expression studies of TNBS-treated zebrafish showed clear upregulation of a range of genes encoding inflammatory cytokines and effector molecules and some induction of genes related to the adaptive response. A distinct innate-driven immune response was seen in both TNBS and TNBS + ES groups, but expression values were significantly depressed for several important pro-inflammatory genes in the TNBS + ES group, indicating protective mechanisms of Anisakis ES compounds on intestinal immunopathology in zebrafish.

Improved survival after an educational project on colon cancer management in the county of Stockholm--a population based cohort study.

INTRODUCTION: Outcomes in rectal cancer have improved dramatically after the introduction of total mesorectal excision (TME). Recently, the TME concept has been transformed into that of complete mesocolic excision (CME) in an attempt to improve prognosis for patients with colon cancer. PATIENTS AND METHODS: Multidisciplinary team (MDT) workshops including the CME concept were held annually between 2004 and 2008 at the Karolinska University Hospital. The workshops focused on preoperative staging, surgery and histopathology and included lectures and live surgery sessions. To compare survival before and after the "Stockholm Colon Cancer Project" all patients diagnosed with a right sided colon cancer between January 1, 2001 and December 31, 2003 (Group 1) and from January 1, 2006 until December 31, 2008 (Group 2) in Stockholm were identified from the Swedish ColoRectal Cancer Registry (SCRCR). RESULTS: The proportion of patients having a tumour resection and the proportion having emergency surgery was higher in Group 1. There were more early tumours and more R0 resections in Group 2. Overall survival in all diagnosed patients and disease free survival after tumour resection was improved in the second time period. DISCUSSION: Surgical teaching programmes may have an impact on the management and outcome in colon cancer. The exact impact from the "Stockholm Colon Cancer Project" cannot be established, however it is likely that it contributed to the improved survival.

Remaining cancer cells within the fibrosis after neo-adjuvant treatment for locally advanced rectal cancer.

AIM: To analyse the incidence and distribution of remaining cancer cells within the fibrosis induced by preoperative chemo-radiotherapy (CRT) for locally advanced rectal cancer. METHODS: The histopathological specimens from 46 patients operated on with extensive surgery for locally advanced rectal cancer after CRT were examined. The extension of fibrosis in relation to the mesorectal fascia (MRF) and the distribution of cancer cells within the fibrosis was examined using routine haematoxylin-eosin staining. In addition, immunohistochemical staining with CK20 was done to examine if cancer cells were missed by routine pathological work up. RESULTS: All specimens showed CRT induced fibrosis. Two specimens showed complete response without viable cancer cells (ypT0). The fibrosis was limited inside the MRF in three cases, adherent to or involved the MRF in ten cases and in 33 cases the fibrosis was obvious outside as well as inside the fascia. Twenty-one cases showed fibrosis on the surgical resection margin, and in 9 of these cancer cells were found on the surgical margin (R1, R2-resection). 37 patients had R0 resections and among those 24 showed fibrosis beyond the MFR and 13 had scattered cancer cells in the fibrosis along or outside the MRF. CONCLUSIONS: The rate of remaining cancer cells within the fibrosis was high in patients with locally advanced rectal cancer treated with CRT. Frequently cancer cells were detected near the border of the fibrosis. A complete resection of the fibrosis is therefore recommended to achieve an R0 resection after neo-adjuvant treatment.

Tumour regression in the randomized Stockholm III Trial of radiotherapy regimens for rectal cancer.

BACKGROUND: The 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. METHODS: Patients 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. RESULTS: A 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 (11·8 versus 1·7 per cent; P = 0·001) and Dworak grade 4 tumour regression (10·1 versus 1·7 per cent; P < 0·001) than patients randomized to SRT without delay. Positive circumferential resection margins were uncommon (6·3 per cent) and rates did not differ between the two treatment arms. CONCLUSION: Short-course RT induces tumour downstaging if surgery is performed after an interval of 4-8 weeks.

Time to local recurrence as a prognostic factor in patients with rectal cancer.

AIMS: Survival after the local recurrence of rectal cancer is influenced by several factors. The aim of this study was to ascertain whether the time interval from primary surgery for rectal cancer to local recurrence diagnosis has any impact on survival. METHODS: Population-based data was collected from the Swedish Colorectal Cancer Registry. 7410 patients were operated with radical abdominal surgery for rectal cancer during the period 1995-2002. Of these, 386 (5%) developed a local recurrence as a first event. The patients were divided into two groups: early local recurrence (ELR), diagnosed <12 months after primary surgery, and late local recurrence (LLR), diagnosed ≥12 months after primary surgery. Kaplan-Meier curves and hazard ratios were calculated for survival analyses. Survival was calculated from the date of the local recurrence diagnosis to death or end of follow-up. RESULTS: Ninety-five patients had ELR and 291 patients LLR. Median time to local recurrence was 1.7 (0.1-7.9) years. Patients with a stage III primary tumour and non-irradiated patients were more common in the ELR compared with the LLR group. Factors that influenced survival were age at diagnosis of local recurrence (p < 0.001), stage of primary tumour (p = 0.027), and surgical resection of local recurrence (p < 0.001). Time to diagnosis of local recurrence had no influence on survival. CONCLUSIONS: No difference in survival from date of diagnosis of local recurrence was seen between patients with ELR and patients with LLR. All patients with local recurrence should therefore be assessed for potential curative surgery, disregarding time to local recurrence.

Local control and survival after extralevator abdominoperineal excision for locally advanced or low rectal cancer.

AIM: Conventional, synchronous combined, abdominoperineal excision (APE) for low rectal cancer is associated with intra-operative tumour perforation and tumour involvement of the circumferential resection margin (CRM+). Several studies have demonstrated worse rates of local recurrence and survival after APE than after low anterior resection (LAR). Extralevator APE (ELAPE) in the prone position may reduce the risk of perforation and involvement of resection margins and may therefore improve outcome. The aim of this study was to report the outcome after the introduction of ELAPE in a prospective study of consecutive patients from a single colorectal unit. METHOD: Between January 2000 and March 2013, 193 patients with low rectal cancer were treated with ELAPE at the Karolinska University Hospital, Stockholm, Sweden. All patients were recorded in the regional rectal cancer quality registry, where data on treatment and follow-up are prospectively reported. RESULTS: Preoperative staging with MRI assessed the tumour to be locally advanced (mrT4) in 126 (65%) of the 193 patients. The median tumour level above the anal verge was 3 cm. Intra-operative perforation occurred in 19 patients (10%) and histopathology revealed a positive CRM in 39 patients (20%). Until August 2013 [median follow-up 31 (0-156) months] local recurrence was detected in 12 patients. Five-year cancer specific survival was estimated to 68%. CONCLUSION: Good local control and survival may be achieved with ELAPE in patients with low, advanced rectal cancer.

Protein biomarkers in vernix with potential to predict the development of atopic eczema in early childhood.

BACKGROUND: Atopic eczema (AE) is a chronic inflammatory skin disease, which has increased in prevalence. Evidence points toward lifestyle as a major risk factor. AE is often the first symptom early in life later followed by food allergy, asthma, and allergic rhinitis. Thus, there is a great need to find early, preferentially noninvasive, biomarkers to identify individuals that are predisposed to AE with the goal to prevent disease development. OBJECTIVE: To investigate whether the protein abundances in vernix can predict later development of AE. METHODS: Vernix collected at birth from 34 newborns within the Assessment of Lifestyle and Allergic Disease During INfancy (ALADDIN) birth cohort was included in the study. At 2 years of age, 18 children had developed AE. Vernix proteins were identified and quantified with liquid chromatography coupled to tandem mass spectrometry. RESULTS: We identified and quantified 203 proteins in all vernix samples. An orthogonal projections to latent structures-discriminant analysis (OPLS-DA) model was found with R(2) = 0.85, Q(2) = 0.39, and discrimination power between the AE and healthy group of 73.5%. Polyubiquitin-C and calmodulin-like protein 5 showed strong negative correlation to the AE group, with a correlation coefficient of 0.73 and 0.68, respectively, and a P-value of 8.2 E-7 and 1.8 E-5, respectively. For these two proteins, the OPLS-DA model showed a prediction accuracy of 91.2%. CONCLUSION: The protein abundances in vernix, and particularly that of polyubiquitin-C and calmodulin-like protein 5, are promising candidates as biomarkers for the identification of newborns predisposed to develop AE.

The English national low rectal cancer development programme: key messages and future perspectives.

AIM: Adenocarcinoma of the lower rectum is clinically challenging because of the need to choose between a wide excision to achieve oncological clearance, on the one hand, and sphincter conservation to maintain anal function, on the other. The English National Low Rectal Cancer Development Programme (LOREC) was developed under the auspices of the Association of Coloproctology of Great Britain and Ireland and the English National Cancer Action Team to improve the outcome of low rectal cancer in England. METHOD: LOREC was initiated focusing on preoperative imaging, selective neoadjuvant therapy, optimal surgical treatment and detailed pathological assessment of the excised specimen. Its key elements were 1-day multidisciplinary team (MDT) workshops, cadaveric surgical training, surgical mentoring, pathological audit and radiological workshops. RESULTS: Overall, 147 (89.6%) of 164 MDTs from 151 National Health Service (NHS) Trusts (some with two MDTs) in England participated in 15 workshops in Basingstoke or Leeds. In addition, 112 surgeons attended a 1-day cadaveric training programme in Bristol, Newcastle or Nottingham, with the main focus on extralevator abdominoperineal excision and pelvic reconstruction, with input from anatomists and from colorectal and plastic surgeons. CONCLUSION: Optimal staging, selective preoperative chemoradiotherapy and precise surgery were considered as crucial to improve the outcome for patients with low rectal cancer.

Preoperative sexual function in women with rectal cancer.

BACKGROUND: Even though sexual dysfunction has been reported after rectal cancer treatment, information on preoperative sexual function is scarce, particularly in female patients. AIMS: To describe preoperative sexual function in women with rectal cancer, and to analyse potential sources of bias. METHODS: The Female Sexual Function Index (FSFI) was administered to women with newly diagnosed non-metastatic rectal cancer, irrespective of whether they were sexually active or not. FSFI total and domain scores were calculated for women with complete responses to the corresponding items. Data were compared for those who did and did not complete all the FSFI domains, and for women in the study cohort, and those who were eligible for inclusion but not included. RESULTS: Sexual inactivity was common. Mean FSFI total score was low (16.4 ± 10.6 SD) among the women who completed all six FSFI domains. The proportion of women who had a partner was higher in this group compared with those who did not complete all the domains (49 of 57 vs 7 of 25, p < 0.001). Eighty-two of the 157 women eligible for inclusion were included. Included women were younger (p = 0.002) and had less co-morbidity than those who were not included (p = 0.025). CONCLUSIONS: The low FSFI total score indicates sexual dysfunction. However, the use of FSFI in both women who are and who are not sexually active complicates interpretation of the data and may result in an information bias hampering internal validity. External validity may be limited by selection bias.

Impaired postoperative leucocyte counts after preoperative radiotherapy for rectal cancer in the Stockholm III Trial.

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).

Local recurrence after prone vs supine abdominoperineal excision for low rectal cancer.

AIM: Tumour-involved circumferential resection margins (CRMs) and intra-operative perforation (IOP) are well known risk factors for local recurrence after surgery for low rectal cancer. In conventional abdominoperineal excision (APE) the patient remains in the supine position for the perineal part of the procedure. However, turning the patient to the prone position may improve visualization which potentially might reduce the risk of involved CRMs and IOP and thus improve local control. The study was carried out to assess local recurrence rates after APE in relation to the positioning of the patient during the perineal part of the procedure. METHOD: This cohort study includes 466 patients having APE for low rectal cancer between 2001 and December 2010. Data were retrieved from the regional rectal cancer registry in Stockholm and from a retrospective review of patient files. RESULTS: An incomplete resection was reported in 12.4% after APE in the supine position and in 6.8% after APE in the prone position (P = 0.038). Corresponding figures for IOP were 12.4% and 4.0% (P < 0.001). Prone APE was associated with a 39% relative reduction in local recurrence events compared with APE in the supine position, although the difference was not statistically significant (hazard ratio 0.61, 95% CI 0.27-1.37). CONCLUSION: APE in the prone position reduced the incidence of incomplete resection and IOP, but the study did not find a statistically significant difference in local failure rates related to the position of the patient.