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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.

Aims: Colorectal cancer is the second most common type of cancer in both women and men in Sweden. A National Quality Register for rectal adenocarcinoma in Sweden has included 97% of all rectal cancer patients since 1995. A previous study, based on data from the treatment program register in the Stockholm-Gotland region. found that women in Stockholm received preoperative radiotherapy (RT) less often than men [Martling A. Rectal cancer: staging, radiotherapy and surgery, ISBN: 91-7349-461-5. Stockholm: Karolinska Institute: 2003].(1) The aim of this study was to assess if women and men with rectal cancer receive equal treatment oil a national level, and whether any potential dissimilarity causes measurable consequences in Outcome. regarding postoperative morbidity and mortality, turnout, recurrence and Survival. Methods: All patients with rectal cancer included in the National Quality Register between 1995 and 2002 (11 774 patients) were analysed. Gender was correlated to treatment, postoperative morbidity and mortality, local recurrence and death. Results: The proportion of women selected for preoperative RT was significantly lower than that of men (42.5% vs. 50.1%, p < 0.001). After adjustment for other prognostic factors, the significant difference in the treatment strategy among women and men persisted. Postoperative mortality was significantly higher in men than in women and the gender difference was most pronounced in irradiated patients. RT improved local control significantly in both women and men but it had no effect oil cancer specific survival. Conclusions: For unknown reasons women less often received adjuvant RT than men. The opposite appeared to be a more adequate alternative. There is a need of improved selection criteria for RT in both men and women with rectal cancer.

Background:An audit of all patients with rectal cancer in Sweden was launched in 1995. This is the first report from the Swedish Rectal Cancer Registry (SRCR).Methods:Between 1995 and 2003, 13 434 patients treated for adenocarcinoma of the rectum were registered with the SRCR; there were approximately 1500 new patients annually.Results:Approximately half had an anterior resection, a quarter an abdominoperineal resection and 15 per cent a Hartmann's procedure. The median 30-day postoperative mortality rate was 2·4 per cent and the overall postoperative morbidity rate was 35·0 per cent. The 5-year cancer-specific survival rate was 62·3 per cent. The 5-year relative survival rate was 70·1 per cent after anterior resection, 59·8 per cent after abdominoperineal resection and 39·8 per cent after a Hartmann's procedure. The crude 5-year local recurrence rate was 9·5 per cent overall, 6·1 per cent after preoperative radiotherapy and 11·4 per cent after surgery alone. For 3868 patients who had a locally curative procedure the local recurrence rate was 7·4 per cent overall, 5·9 per cent for those who had radiotherapy and 10·2 per cent for those who did not. The local recurrence rate was 2·9 per cent (28 of 968) for stage I disease, 7·9 per cent (112 of 1418) for stage II, 13·9 per cent (188 of 1357) for stage III and 8·5 per cent (45 of 532) for stage IV.Conclusion:These good population-based results are due, in part, to the nationwide prospective quality assurance registration.

Eighty-five patients with endocrine pancreatic tumors associated with clinical syndromes of hormone excess were retrospectively analyzed regarding symptomatology, means of diagnosis, and results of surgical and medical treatment during follow-up of 3-18 years (median 8 years). The combination of angiography and computed tomography was most successful in pre-operative localization of both primary tumors and metastases. Surgery provided long term cure in 39 of 44 patients with benign islet cell lesions, the majority having insulinomas. Forty-one patients had malignant tumors, which at the time of diagnosis or operation were associated with liver and/or regional lymph gland metastases in 56% and 24%, respectively. Sixteen patients with metastatic disease and/or very large tumors were considered inoperable, 5 patients underwent palliative resection of their malignant tumors, while grossly radical tumor removal was accomplished in 20 patients. Long-term cure was achieved in 5 patients by excision of primary tumors and localized liver or lymph gland metastases. Half of the patients, particularly those with insulinoma, gastrinoma, or vipoma, showed response to streptozotocin, in combination with other cytostatics, for a median of 24 months or a response to interferon for a median of 10 months. The overall 5-year and 10-year survival among the patients with malignant islet cells tumors was 54% and 28%, respectively. Absence of liver metastases at time of operation/diagnosis, smaller size of the primary tumor, grossly radical tumor resection as well as response to medical therapy predicted the more favorable survival.

Among 33 patients with endocrine pancreatic tumors due to multiple endocrine neoplasia type 1 (MEN-1), 19 (58%) patients had hypergastrinemia, 7 (21%) patients had hyperinsulinism, and 7 (21%) patients had clinically non-functioning lesions. At least one gross tumor was found in all patients undergoing pancreatic surgery, including those with negative localization studies prior to operation. The patients also had additional macroscopic tumors as well as numerous microadenomas, and the lesions frequently were positive for immunostaining with multiple hormones, mainly pancreatic polypeptide, insulin, glucagon, and somatostatin. Duodenal endocrine lesions were found in 4 of 5 investigated patients and stained with gastrin and somatostatin antibodies. Distal, mainly subtotal pancreatic resection, was performed in 18 patients, eventually combined with caput tumor enucleation or duodenotomy, while a few patients underwent only tumor enucleation or a Whipple procedure. The long-term outcome of operation was most favorable in patients with hyperinsulinism; only 1 patient had clinical recurrence. Patients with hypergastrinemia experienced only transitory lowering of serum gastrin values after pancreatic surgery and 47% of them had or developed metastases. Such tumor spread was seen in 57% of the patients with non-functioning lesions. Nine patients died from progressive tumor disease during follow-up. Consistent with previous studies, we found that surgery is indicated in MEN-1 patients with hyperinsulinism even if a lesion is not visualized by radiology. In addition, these indications should be extended to also include patients with only biochemical markers of disease, including elevations of gastrin, as these indicate the presence of gross tumors.

A retrospective study was performed on 54 patients diagnosed as having adrenocortical carcinoma during 1974-1983. The initial symptoms were often diffuse: abdominal pain, weight loss, or fever, and more than 60% of the patients showed no evidence of overproduction of hormone. The median tumor diameter was 13 cm and almost half of the tumors had metastasized at diagnosis. A radical tumor resection could be performed in less than 50% of the patients, and at histopathological re-examination some tumors were not conclusively verified as malignant. Capsular invasion, nuclear pleomorphism and mitoses were found more commonly in patients who succumbed to the disease. Seven of 29 patients treated with chemotherapy showed an objective response and two of them are still alive and free of disease. The overall 5-year-survival rate was 19%, compared with 45% for patients with radically resected tumors. Patients with no biochemical signs of overproduction of adrenocortical hormone appeared to have a better prognosis than those with hormone excess. Together with increased use of ultrasound and computed tomography, a urinary steroid profile might hopefully contribute to earlier discovery of these often clinically silent tumors. However, it remains to be determined whether these diagnostic improvements, together with more aggressive surgery and adrenolytic chemotherapy, can improve the poor prognosis.