Karl Kodeda

Tumour differentiation grade is associated with TNM staging and the risk of node metastasis in colorectal cancer

Abstract Aim. The tumour differentiation grade has been shown by numerous multivariate analyses to be a stage-independent prognostic factor in colorectal cancer. The aim of this study was to explore the importance of differentiation grading for the staging of colorectal cancer and how it relates to the components of the TNM system. Material and methods. The study was a retrospective single-centre analysis of all patients undergoing surgical resection for colorectal cancer during the period 2002–2007 (n = 1239). The clinical parameters and pathology data of overall stage, differentiation grade, local tumour (T)-stage and metastasis status (M-stage) were included as well as the lymph node count of both assessed and metastatic nodes. The differentiation grade was correlated with demography, overall stage and each component of the TNM staging system. The correlation between differentiation grade and N-stage was also explored for the separate T-stages. Results. The tumour differentiation grade correlated significantly with the overall TNM stage (p < 0.0001). The grade significantly correlated with the T-stage and the risk of having lymph node metastasis (p < 0.0001). A high grade was associated with a higher positive lymph node count in stage III disease (p < 0.0002). For the T-stages, the risk of node metastasis was significantly linked to the tumour grade. A low grade (G1) T2 had a 17% risk of lymph node metastasis compared to a 44% risk for a high grade (G4) T2. Conclusion. Tumour differentiation is an important prognostic factor. It correlates significantly with the overall stage of the TNM system and also to each of its components. The risk of having lymph node metastasis for each T-stage also correlates with the tumour grade. The findings can be of importance in postoperative risk assessment or when considering local resection procedures like TEM.

Local recurrence of rectal cancer: a population‐based cohort study of diagnosis, treatment and outcome

Aim  Local recurrence is an important endpoint of rectal cancer treatment, but details of this form of treatment failure are less well described. The aim of this study was to acquire deeper knowledge of local recurrence regarding symptoms, diagnostic work‐up, clinical management, health‐care utilization and outcome.

A population-based cohort study on adherence to practice guidelines for adjuvant chemotherapy in colorectal cancer

BackgroundThe value of adjuvant chemotherapy in colorectal cancer is well studied, and guidelines have been established. Little is known about how treatment guidelines are implemented in the everyday clinical setting.MethodsThis national population-based study on nearly 34,000 patients with colorectal cancer evaluates the adherence to present clinical guidelines for adjuvant chemotherapy. Virtually all patients with colorectal cancer in Sweden during the years 2007–2012 and data from the Swedish Colorectal Cancer Registry were included.ResultsIn colon cancer stage III, adherence to national guidelines was associated with lower age, presence of multidisciplinary team (MDT) conference, low co-morbidity, and worse N stage. The MDT forum also affected whether or not high-risk stage II colon cancer patients were considered for adjuvant chemotherapy. Rectal cancer patients both in stage II and III were considered for adjuvant chemotherapy less often than colon cancer patients, but the same factors influenced the decision. Adjuvant chemotherapy was started later than eight weeks after surgery in 30% of colon cancer patients and in 38% of rectal cancer patients.ConclusionsIn Sweden, the adherence to national guidelines for adjuvant chemotherapy in colon cancer stage III is acceptable in younger and healthier patients. MDT conferences are of major importance and affect whether patients are recommended for adjuvant chemotherapy. Special consideration needs to be given to certain subgroups of patients, particularly older patients and patients with poorly differentiated tumors. There is a need to shorten the waiting time until start of chemotherapy.

A phase I/II study of neoadjuvant chemotherapy with Pemetrexed (Alimta) in rectal cancer

AIM The aim was to assess the feasibility of preoperative chemotherapy and possible tumour response using Pemetrexed (Alimta) in rectal cancer. METHOD The study was a prospective, non-randomized, single-centre phase I/II feasibility trial. 37 patients with resectable rectal cancer were recruited and given three 3-week cycles of preoperative Pemetrexed therapy. Tumour size and stage were assessed by MRI scans before and after chemotherapy. Treatment tolerability and response such as changes in tumour size and symptoms were assessed. RESULTS All patients completed the chemotherapy. Whilst mild side effects were frequent (grade 1, 34/37), the risk of severe effects was limited (grade 3 or 4, 4/37). Overall, there was a significant reduction in tumour size (p < 0.001). By RECIST criteria, one patient had tumour progression, 23/36 had stable disease and 12 patients had a response of up to 65%. There was also a significant decrease in the number of pre-treatment symptoms (p < 0.018) including reduction of bleeding and diarrhoea/constipation. CONCLUSION Preoperative (Neoadjuvant) treatment with Pemetrexed was feasible in studied patients. Serious side effects were limited and a radiological tumour response or stable disease was seen in a majority of patients.

A survey of surgeons’ perception and awareness of intraoperative time utilization

BackgroundSurgical teams’ awareness of the time needed to perform specific phases of a surgical procedure is likely to improve communication in the operating theatre and benefit patient safety. The aim of this study was to assess surgeons’ awareness of time utilization and the actual time needed to perform specific phases of an operation.MethodsA survey was conducted to examine the method and design for a larger study. Interviews were conducted with 18 surgeons, and surgical time was measured during 21 colon cancer resections. Correlation analyses were performed to explore the factors that might affect operating time.ResultsThe surgical phase with the greatest variation in time was dissection/resection (43–308 minutes). On a group level, no statistically significant differences were found between estimated and measured surgical procedural times for partial or full resections (160.4 versus 173.0 minutes, p = 0.539). However, interindividual variation was substantial. There was a positive significant correlation between long duration of dissection/resection and longer time to close the abdomen (r = 0.464, p = 0.039), as well as between long duration of a hand-sewn anastomosis and time needed to close the abdomen (r = 0.536, p = 0.018).ConclusionsIt can be difficult for a single surgeon to estimate the time required for a partial or full surgical procedure. A larger study might provide additional time estimates and identify variables that affect surgical time. The data could be of interest in the planning and scheduling of surgical resources, thus improving theatre team communication and patient safety.

Commentary on Rondelli et al

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