Annals of Surgical Oncology Cite Track
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
10.1245/s10434-006-9243-1
Annals of Surgical Oncology 14:432-440 (2007)
© 2007 Society of Surgical Oncology
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Sjövall, A.
Right arrow Articles by Holm, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Sjövall, A.
Right arrow Articles by Holm, T.

Original Article

Loco-regional Recurrence from Colon Cancer: A Population-based Study

Annika Sjövall1, Fredrik Granath2, Björn Cedermark1, Bengt Glimelius3 and Torbjörn Holm1

1 Department of Surgery, P9:03, Karolinska University Hospital, Solna, Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176 Stockholm, Sweden
2 Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
3 Department of Oncology and Pathology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden

Correspondence: Address correspondence and reprint requests to: Annika Sjövall; E-mail: annika.sjovall{at}karolinska.se


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 STATISTICAL METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The survival after colon cancer surgery has not improved to the same extent as after rectal cancer treatment and studies on loco-regional recurrence after colon cancer surgery are scarce. The aim of this study was to assess the problem of loco-regional recurrence after potentially curative resections for colon cancer, regarding incidence, risk factors, management, and outcome.

Methods: All 1,856 patients submitted to potentially curative surgery for colon cancer in the Stockholm/Gotland region in Sweden between 1996 and 2000 were followed until January 2005 or until death. Follow-up data were prospectively collected. Risk factors for loco-regional recurrences were analyzed, treatment and outcome for patients with recurrence was studied.

Results: The cumulative 5-year incidence of loco-regional recurrence was 11.5%. Tumor locations in the right flexure and in the sigmoid colon, bowel perforation and emergent surgery were identified as independent risk factors for loco-regional recurrence. The risk also increased with increasing T- and N-stage.

The median survival for all 192 patients with loco-regional recurrence was 9 months. Surgery was performed in 110 (57%) patients. In 23 (12%) patients a complete tumor clearance was achieved and the estimated 5-year survival in this group was 43%.

Conclusion: Loco-regional recurrence from colon cancer is a significant clinical problem. A multidisciplinary treatment approach, including preoperative staging, a complete resection of the recurrence and more effective adjuvant treatments may improve the outcome.

Key Words: Colon cancer • Loco-regional recurrence • Population-based • Risk factors


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 STATISTICAL METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The survival in patients with colon cancer has improved in recent decades, but not to the same extent as in patients with rectal cancer.1,2 Specific trials and projects to improve treatment and outcome, like those performed in rectal cancer3–5 have not been launched, except regarding treatment with adjuvant chemotherapy.6 In Sweden, the 5-year survival rate after colon cancer treatment now falls below that after treatment for rectal cancer.

The liver is the dominating site of a tumor recurrence after colon cancer surgery and currently a lot of effort is made to improve survival in these patients with aggressive liver surgery, chemotherapy and local treatment modalities.7–12

There are few reports on patients with local recurrence after potentially curative resections in colon cancer and neither the incidence, the clinical course, the management nor the outcome has been well documented.13–16 Even the definition of a locally recurrent colon cancer is equivocal and may be referred to as a recurrence in the anastomosis, the peritoneum, the retroperitoneum or in intra-abdominal lymph nodes. Since local failures after rectal cancer surgery are generally considered to be correlated to sub-optimal surgery, it is important to define and assess the issue of locally recurrent colon cancer to achieve optimized surgical techniques and to improve outcome in these patients. In a previous population-based study from Stockholm, the outcome for colon cancer patients was reported and further efforts to improve the management of patients with colon cancer were called for.17

The aim of this study was to assess the problem of loco-regional recurrence after potentially curative resections for colon cancer within a defined population. More specifically, the incidence, different risk factors associated with a loco-regional recurrence, the clinical presentation, treatment and outcome were analyzed in order to find potential ways to decrease the risk and to improve the treatment results.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
STATISTICAL METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The Stockholm Colorectal Cancer Study Group has been working to improve the management and outcome in patients with colorectal cancer since 1980 and management protocols have been established. The Stockholm/Gotland region has a population of 1.9 million inhabitants with an annual colon cancer incidence of 41/100,000 inhabitants in 2002.

In Sweden, it is compulsory for the treating physician and the responsible pathologist to report all new cases of cancer to the National Cancer Registry at the time of diagnosis. Causes of death are reported to The Cause of Death Registry at the National Board of Health and Welfare. All healthcare consumption for each person in the region is reported to a registry at The Stockholm County Council including diagnoses according to the International Classification of Diseases (ICD) of the World Health Organization. In addition, since 1996 clinical data on all patients with an adenocarcinoma of the colon are prospectively reported to a database at the regional Oncologic Centre in Stockholm. This database includes information on patient characteristics, tumor location, tumor stage, emergent or elective surgery, postoperative morbidity and mortality, tumor histopathology, oncological treatments and follow-up data on recurrence and survival. The colon is defined as the large bowel from 15 cm above the anal verge, excluding the appendix. Tumors are classified as being located in the caecum, the ascending colon, the right flexure, the transverse colon, the left flexure, the descending colon or in the sigmoid colon. The database is continuously validated and updated through comparisons to the registers mentioned above and to medical records. Identification of individual patients in the registers is enabled through a personal identification number, which is unique to each individual person in Sweden. During the study period, primary surgery for colon cancer and management of recurrences were performed in nine different hospitals in the region; two university hospitals associated with Karolinska Institutet, four large community hospitals and three small community hospitals.

This study is based on all 2,855 patients in the Stockholm/Gotland region who were diagnosed with an adenocarcinoma of the colon between 1 January 1996 and 31 December 2000. For the purpose of this study, only patients who had a potentially curative resection of the primary tumor and survived for more than 30 days postoperatively were included. The operation was classified as potentially curative if both the surgeon and the pathologist reported tumor free margins of the specimen, and no synchronous distant metastases were detected. The reason for this selection was to avoid inclusion of patients with locally remaining tumor, where a progressive tumor growth is likely. Thus, 1,856 patients were eligible and were followed until January 2005 or until death. The median follow-up time was 60 (range 1–110) months.

Data on sex, age, elective versus emergent surgery, bowel perforation, T-stage, N-stage, tumor location and differentiation was analyzed, to assess risk factors associated with the development of a loco-regional recurrence.

The medical records were reviewed in all patients who were diagnosed with an abdominal tumor recurrence in a non-parenchymal organ, including the retroperitoneum and the abdominal wall, regardless of if any other recurrence was present. A loco-regional recurrence was classified as local if the tumor was located in the same abdominal quadrant as the primary tumor. Recurrences located in the peritoneum or retroperitoneum in a different quadrant than the primary tumor were classified separately and finally, combinations of local and peritoneal/retro-peritoneal recurrences outside the quadrant of the primary tumors were classified as a third possible option. This classification was based on unequivocal findings on computed tomography (CT) or magnetic resonance imaging (MRI) or of a tumor mass on clinical or intra-operative examination. The reason for including patients with peritoneal or retroperitoneal recurrences outside the abdominal quadrant of the primary tumor was the difficulty of distinguishing between these recurrences and true local recurrences in the tumor bed or anastostomosis when evaluating the medical records and CT/MRI findings retrospectively.

During the study period there was no standardized protocol for routine postoperative follow-up of patients with colon cancer in the region, but most patients were followed clinically at least yearly.

Information was retrieved from the medical records on whether the recurrence was primarily found due to symptoms or at a routine examination and on whether the patient had been evaluated by a multi-disciplinary team, including at least one surgeon and one oncologist, before any treatment of the local recurrence. Data were also assessed on whether any surgical treatment had been performed, the indication for surgery, and whether it was an elective or emergent procedure. In addition, the type of surgery performed was recorded and, when the tumor was resected, whether this was considered to be a complete tumor clearance or not. The surgical procedures were ranked in falling order; as complete or incomplete resections, as by-pass procedures, as stoma formations only or as exploratory laparotomies alone. Only the "highest ranked" operation performed in each patient was counted, as displayed in the results.

Information on adjuvant or palliative chemotherapy and/or radiotherapy, given alone or in combination with surgery was also recorded.

In patients where the recurrence was completely resected, follow-up information included if a new local recurrence was found later and whether distant metastases were present at diagnosis of the abdominal recurrence or if detected later.

The study was conducted in accordance with the regulations of the research ethical committee at the Karolinska Institutet in Stockholm.


   STATISTICAL METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 STATISTICAL METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Cumulative incidence of loco-regional recurrence was calculated using the Kaplan–Meier method. A proportional hazards regression model, including the variables mentioned above, was used to assess potential risk factors for the development of a loco-regional recurrence. The time from the primary surgery until the diagnosis of the loco-regional recurrence was used in this model. Resulting hazard ratios (HR) are presented with 95% confidence intervals (CI). In patients with a loco-regional recurrence, survival times were calculated from the date of diagnosis of the tumor recurrence until the time of death or end of follow-up, and survival curves were estimated using the Kaplan–Meier method.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 STATISTICAL METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The cumulative incidence of loco-regional recurrence in the 1,856 patients is displayed in Fig. 1Go. During the study period, 193 patients (10.4%) were diagnosed with a loco-regional recurrence, constituting an estimated incidence of loco-regional recurrence of 11.5% after 5 years. In 171 patients (88.6%), the diagnosis was verified by histopathology.


Figure 1
View larger version (13K):
[in this window]
[in a new window]

  		FIG. 1. Kaplan-Meier curve for cumulative incidence of loco-regional recurrence after potentially curative resection for colon cancer.

 
The median time from primary surgery to the diagnosis of the locally recurrent tumor was 18 (0.5–88) months.

Risk Factors
The different variables analyzed as potential risk factors associated with a loco-regional recurrence are shown in Table 1Go. Sex or age were not identified as risk factors and were thus not included in the model. Emergent procedures and bowel perforations were independently significantly associated with an increased risk of developing a loco-regional recurrence. Data on whether bowel perforations during emergent surgery were preoperative or intra-operative and possibly caused by the surgeon were not available, nor if the perforations were at the tumor site or in another part of the bowel. Patients with primary tumors in the right flexure and in the sigmoid colon had a significantly increased risk of developing a loco-regional recurrence as compared to all other locations.


View this table:
[in this window]
[in a new window]

  		TABLE 1. Multivariable analysis of risk factors for diagnosis of loco-regional recurrence after potentially curative colon cancer surgery
 
Table 2Go shows the number of examined lymph nodes in relation to the different tumor locations. A larger proportion of patients with tumors in the sigmoid colon had a very low (0–3) number of lymph nodes examined than patients with tumors in other locations, but this was not the case for tumors in the right flexure.


View this table:
[in this window]
[in a new window]

  		TABLE 2. Number of lymph nodes examined in relation to tumor location in 1,856 colon cancer specimens
 
The risk for loco-regional recurrence was significantly higher in patients with T4 tumors and lower in patients with T1 and T2 tumors as compared to patients with T3 tumors (Table 1Go). Similarly, an increasing N-stage was associated with an increasing risk for loco-regional recurrence. The median number of examined lymph nodes in all patients was six, which is remarkably low and involves a risk of patients being misclassified regarding N-stage. To reduce the risk of including such misclassified patients in the analysis, the multivariable analysis was also performed excluding all patients who had less than eight nodes examined. With N0 as reference, the adjusted hazard ratio for patients with stage N1 to develop loco-regional recurrence then increased to 2.63 (CI: 1.55–4.47), and for patients with stage N2 the hazard ratio was 5.98 (CI: 3.41–10.51). There was no additional increase in hazard ratio with higher N-stage, when also excluding all patients with less than 12 lymph nodes examined.

There was no statistically significant difference between high and moderate tumor differentiation, but patients with poorly differentiated tumors had a significantly higher risk than patients with highly differentiated tumors (Table 1Go).

Clinical Characteristics in Patients with Loco-regional Recurrence
The median age in the 193 patients with loco-regionally recurrent colon cancer was 74 (26–94) years. There were 96 men and 97 women. The locations of the recurrent tumors are displayed in Table 3Go. In 136/193 patients (70.5%) the recurrence was located in the same abdominal quadrant as the primary tumor.


View this table:
[in this window]
[in a new window]

  		TABLE 3. Location of 193 cases of loco-regional recurrences after potentially curative colon cancer surgery
 
In one patient data on symptoms and management could not be assessed as the loco-regional recurrence was diagnosed at autopsy and thus this patient was excluded from further analysis. In 161 (83.9%) of the remaining 192 patients, the recurrence was discovered due to symptoms, and in 31 (16.1%), the recurrence was found at routine follow-up. Of these 31 patients, 27 later developed symptoms and only four had no symptoms when a complete resection of the recurrence was performed. The dominating symptoms were abdominal pain and bowel obstruction. Table 4Go shows the dominating symptoms and clinical findings at the time of diagnosis of the loco-regional recurrence.


View this table:
[in this window]
[in a new window]

  		TABLE 4. Initial dominating symptoms and findings in 192 patients with loco-regional recurrence after colon cancer
 
In 122 patients (63.5%) the loco-regional recurrence was the first tumor recurrence. In 91 patients (47.4%) it remained the only tumor manifestation while 70 patients (36.5%) had distant metastases before or synchronous to the loco-regional recurrence. Thirty-one patients (16.1%) later developed distant disease.

Management
In all, 70/192 patients (36.4%) were evaluated by a multidisciplinary team prior to treatment of the recurrence and in 17 of these no active treatment was given. In 122 patients the different treatments were recommended at the discretion of either the individual surgeon or the oncologist. An overview of the treatment of all 192 patients is displayed in Fig. 2Go. A surgical procedure, with or without additional radio-and/or chemotherapy, was performed in 110 patients (57.3%), whereof 17 (15.4%) had been preoperatively evaluated in a multidisciplinary setting. Palliative radio- and/or chemotherapy only was given to 25 patients (13.0%) and symptomatic treatment alone to 57 patients (29.7%).


Figure 2
View larger version (11K):
[in this window]
[in a new window]

  		FIG. 2. Treatment of 192 patients with loco-regional recurrence from colon cancer.

 
The surgery was performed as an elective procedure in 65 patients (59.1%) and as an emergent one in 45 (40.9%). The operation was planned with a curative intent, aiming at complete removal of the recurrence, in 49 patients and this goal was achieved in 21. In two additional patients the recurrent tumor could be completely resected during emergent surgery due to bowel obstruction and thus, a total of 23/192 patients (12.0%) had a potentially curative treatment. Six out of these 23 were evaluated by a multidisciplinary team prior to surgery.

In 39 patients the recurrent tumor could not be resected completely, either due to a locally non-resectable tumor or to peritoneal spread or distant metastases. Fifteen of these 39 patients had emergent surgery due to bowel obstruction.

Palliative procedures were performed in 48 patients; 19 had an intestinal by-pass, 19 had a stoma formation and a laparotomy only was performed in 10. The procedure was emergent in 28 patients having palliative surgery.

Ten patients (9.1%) died within 30 days after surgery and the postoperative mortality was higher after palliative procedures (14.6%) than after resective surgery (4.8%). Radio- and/or chemotherapy was given as an adjunct to surgery in 58 patients.

All patients who had a non-curative resection, a palliative operation or other, non-surgical treatments, had persistent symptoms, such as pain, bowel obstruction or fistulae.

Survival
The median survival for the 192 patients with a locally recurrent colon cancer was 9 (0–72) months from the date of diagnosis of the recurrence, and survival curves for patients submitted to a complete resection, incomplete resection or no resection are displayed in Fig. 3Go. In the 23 patients where a potentially curative resection of the recurrence had been performed, the estimated 5-year survival was 43%. Eleven patients in this group had no evidence of disease at the end of follow-up or death, after a median follow-up time of 25 (2–72) months, and four were alive with disease.


Figure 3
View larger version (16K):
[in this window]
[in a new window]

  		FIG. 3. Kaplan-Meier survival curve for 192 patients with loco-regional recurrence after potentially curative surgery for colon cancer.

 
In all patients who did not have a potentially curative resection the locally recurrent tumor progressed, with or without distant metastases, and none have survived 5 years.

In the 39 patients, where an incomplete resection of the recurrence had been performed, the median survival was 14 (0.5–52) months, and in the 48 patients, having had a palliative procedure, the median survival was 7 (0–48) months. For the 25 patients, who had only radiation or chemotherapy, the median survival was 15 (0–52) months, and in the group of 57 patients, who had only symptomatic treatment, the median survival was 3 (0–30) months.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 STATISTICAL METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This study demonstrates that loco-regionally recurrent colon cancer is a significant clinical problem, causing severe disabling symptoms and a poor outcome. After a potentially curative resection of the primary tumor, the estimated 5-year incidence of loco-regional was 11.5%. In this study, only 6% (11/192) had no evidence of disease at the end of follow-up or death.

It has previously been shown that a complete tumor clearance at primary surgery has a crucial impact on the outcome.17–20 In addition to this, several other risk factors were identified in this study, increasing the risk of a loco-regional recurrence. Emergent surgery was such a factor, which is not surprising since worse outcomes after emergent colon cancer surgery has been reported by previous authors.21–23 Emergent surgery seems to be an independent risk factor for poor outcome, but the reasons for this have not been clarified. Technical difficulties and sub-optimal circumstances related to the emergent situation, as well as the skill and the level of specialization of the surgeon performing the procedure could be important. These data were not available in this study, although it is likely that the emergent procedures were more frequently performed by non-colorectal surgeons, which could have an impact on the outcome.24,25

Bowel perforation was also an independent risk factor. This emphasizes the importance of a non-traumatic surgical technique, avoiding tearing and rupture of the bowel. Primary tumors located in the right colon flexure and in the sigmoid colon had the highest risks of loco-regional recurrence. This has not, to our knowledge, been previously shown.13,16,26 All patients with tumors in the right flexure were operated on with a right hemicolectomy and the vast majority of patients with sigmoid tumors had segmental sigmoid resections. Data on the level of vessel divisions were not available in the database and the medical records did not usually give any detailed information on this. However, the operation notes revealed that it was common to leave at least the left branches of the middle colic artery when performing a right hemicolectomy, and to divide the sigmoid vessels and leave the inferior mesenteric artery when performing a sigmoid resection. Thus, regional lymph nodes close to the superior mesenteric artery and to the aorta were probably commonly left behind. This could be one explanation for the higher risk of recurrence in these regions, particularly since some authors have reported better survival after more extensive lymph node dissections.27 In the current study this theory was supported regarding tumors in the sigmoid colon, where significantly fewer lymph nodes were examined than for tumors in all other locations. When performing a right hemicolectomy, a lot of lymph nodes were probably harvested along the ileocolic vessels, whereas it may be presumed that nodes along the middle colic vessels, which might have been of larger importance for tumor clearance, were left behind when these vessels were preserved.

As in several previous studies, this study also demonstrates that more advanced tumors, in terms of increasing T- and N-stage, increases the risk of tumor recurrences.13,14,16 The median number of only six lymph nodes examined in each patient during the study period is a considerably lower number than recommended in the regional management program, where a minimum of 12 examined nodes are called for.28 The correlation between a high N-stage and risk for loco-regional recurrence increased if only patients with eight or more nodes examined were included. This may also support the importance of a careful surgical node clearance.

Once a loco-regional recurrence has developed, a complete resection of the recurrent tumor is a prerequisite for cure and this study showed a poor survival if this was not accomplished. A similar dismal prognosis has been reported in patients with locally recurrent rectal cancer.29,30 However, the local recurrence rate in patients with rectal cancer has gradually been reduced as a result of specific efforts to optimize management, including preoperative radiotherapy and educational projects focused on the TME (total mesorectal excision) technique.5,31,32 Some previous studies have reported local recurrence rates below 9% 5 years after seemingly curative resections for rectal cancer.3,32 The fact that the survival rate in Sweden after rectal cancer treatment is now better than after colon cancer treatment highlights the need for evaluation of possible improvement of the management in patients with colon cancer.1,2

Dedicated projects to improve the management in patients with colon cancer, similar to those in rectal cancer, have not been reported. Although rectal cancer surgery is now generally considered to be a matter for specialists, colon cancer surgery is still usually regarded as a simple operation, suited for general surgeons or residents. In addition, the problem of loco-regional recurrences after curative resections in colon cancer has not been addressed to the same extent as in rectal cancer.13–16 One problem is that the definition of a loco-regional recurrence from colon cancer is unclear. In the current study the definition was all abdominal recurrences in non-parenchymal organs. This was chosen to decrease the risk of excluding true local recurrences due to differences in the reports to the registries and difficulties in specific classification of the recurrences when evaluating the medical records.

It was also impossible to assess to what extent the loco-regional recurrences in this study were a result of sub-optimal surgery or whether they mainly resulted from intra-peritoneal or lymphatic spread not amenable to resection.

The local failure rate in this study is lower than in some of the previous reports on local failure from colon cancer.13,15,26 Since virtually all patients with a reported loco-regional recurrence were symptomatic, the true incidence of loco-regional recurrence would probably have been higher with a dedicated search for recurrences and a higher autopsy rate. A thorough assessment of the healthcare consumption of all 1,856 patients in the study however makes it likely that most of the clinically important loco-regional recurrences were identified. Whether an intensive routine follow-up strategy would improve the outcome is uncertain, but it may be of value,33–35 although this study does not allow any conclusions to be drawn as to whether routine follow-up would be of benefit. In the present study, only 31 patients with a loco-regional recurrence were found at routine follow-up. Data on the time interval between the first pathologic finding at routine follow-up until the debut of symptoms from the loco-regional recurrence could unfortunately not be safely established, since information on when the symptoms started were not reliably stated in most of the medical records.

Only 17 patients in whom surgery was performed were evaluated by both a surgeon and an oncologist prior to surgery. The actual proportion of patients evaluated at a true multidisciplinary team (MDT) conference, including also radiologists and pathologists, was even lower. To increase the proportion of complete resections of local recurrences it is likely of importance to have a detailed radiological assessment of the extent of tumor growth and a meticulous management plan, including adjuvant treatment strategies when indicated. Presence of distant disease may not be a definite contraindication to salvage surgery of a loco-regional recurrence, although the present study cannot support this. After resections of synchronous hepatic and pulmonary metastases survival rates similar to those after resections of isolated hepatic metastases have been published, indicating that tumor spread in more than one location does not necessarily exclude patients from curative surgery.36

As indicated above, several factors may have contributed to the incidence of loco-regional recurrence in this study and to the poor prognosis in patients with local failure. The preoperative radiological evaluation of the recurrent tumors, the surgical techniques during primary surgery and the extent of the resections of the recurrent tumors, the assessment of the specimen and the low proportion of patients evaluated at MDT meetings are all factors that may have been sub-optimal. In addition, as the proportion of stage III tumors increases with an increased number of examined lymph nodes, more patients may have received adjuvant chemotherapy with a more accurate histopathological assessment.

In 2004, the Stockholm Colorectal Cancer Study Group initiated a new project; "The Colon Cancer Project in Stockholm". This project includes workshops with radiologists, colorectal surgeons, pathologists and oncologists in an effort to optimize preoperative staging, surgical techniques, postoperative staging and oncological treatments in order to improve outcome in patients with colon cancer. One specific aim is to encourage specialization within all parts of the multidisciplinary setting. As surgery is a crucial part in colon cancer treatment, it seems important to stop considering colon cancer surgery a less demanding operation and instead strive for a meticulous sharp anatomical dissection, including a wide excision of the colon mesentery and a central vessel division.27,37

Whether this educational project will help to improve outcome remains to be seen, but previous efforts in rectal cancer treatment have proven successful.5,31,32

In conclusion, loco-regional recurrence from colon cancer is a significant clinical problem, which causes severe morbidity and poor survival. A complete resection of the recurrent tumor is a prerequisite for cure. A more specialized, multidisciplinary management, with improved preoperative staging, surgery, histopathology and adjuvant treatment may reduce the risk of recurrence. Once a local recurrence is detected, a new thorough multidisciplinary evaluation should be performed and all efforts directed towards a complete resection of the recurrence.


   ACKNOWLEDGMENTS
 
The present study was supported by the Stockholm Cancer Society. "The Colon Cancer Project in Stockholm" is supported by Tyco Healthcare. The authors thank the Stockholm Colorectal Cancer Study Group who made the registers available for this study and Toom Singnomklao for excellent help with the collection of data.

Received for publication August 30, 2006. Accepted for publication August 31, 2006.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 STATISTICAL METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Birgisson H, Talback M, Gunnarsson U, Pahlman L, Glimelius B. Improved survival in cancer of the colon and rectum in Sweden. Eur J Surg Oncol 2005; 31:845–53.[CrossRef][Medline]
  2. Talback M, Stenbeck M, Rosen M, Barlow L, Glimelius B. Cancer survival in Sweden 1960–1998—developments across four decades. Acta Oncol 2003; 42:637–59.[CrossRef][Medline]
  3. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 1998; 133:894–9.[Abstract/Free Full Text]
  4. Martling A, Holm T, Johansson H, Rutqvist LE, Cedermark B. The Stockholm II trial on preoperative radiotherapy in rectal carcinoma: long-term follow-up of a population-based study. Cancer 2001; 92:896–902.[CrossRef][Medline]
  5. Wibe A, Eriksen MT, Syse A, Myrvold HE, Soreide O. Total mesorectal excision for rectal cancer—what can be achieved by a national audit?. Colorectal Dis 2003; 5:471–7.[CrossRef][Medline]
  6. Glimelius B, Dahl O, Cedermark B, et al. Adjuvant chemotherapy in colorectal cancer: A joint analysis of randomised trials by the Nordic Gastrointestinal Tumour Adjuvant Therapy Group. Acta Oncol 2005; 44:904–12.[CrossRef][Medline]
  7. Adam R. Chemotherapy and surgery: new perspectives on the treatment of unresectable liver metastases. Ann Oncol 2003; 14(Suppl 2):ii13–6.[Abstract]
  8. Tanaka K, Adam R, Shimada H, Azoulay D, Levi F, Bismuth H. Role of neoadjuvant chemotherapy in the treatment of multiple colorectal metastases to the liver. Br J Surg 2003; 90:963–9.[CrossRef][Medline]
  9. Penna C, Nordlinger B. Surgery and local treatments of liver metastases from colorectal cancer: how to improve results. Scand J Surg 2003; 92:90–6.[Medline]
  10. Poston GJ, Adam R, Alberts S, et al. OncoSurge: a strategy for improving resectability with curative intent in metastatic colorectal cancer. J Clin Oncol 2005; 23:7125–34.[Abstract/Free Full Text]
  11. Leonard GD, Brenner B, Kemeny NE. Neoadjuvant chemotherapy before liver resection for patients with unresectable liver metastases from colorectal carcinoma. J Clin Oncol 2005; 23:2038–48.[Abstract/Free Full Text]
  12. Masi G, Cupini S, Marcucci L, et al. Treatment with 5-fluorouracil/folinic acid, oxaliplatin, and irinotecan enables surgical resection of metastases in patients with initially unresectable metastatic colorectal cancer. Ann Surg Oncol 2006; 13:58–65.[Abstract/Free Full Text]
  13. Willett C, Tepper JE, Cohen A, Orlow E, Welch C, Donaldson G. Local failure following curative resection of colonic adenocarcinoma. Int J Radiat Oncol Biol Phys 1984; 10:645–51.[Medline]
  14. Read TE, Mutch MG, Chang BW, et al. Locoregional recurrence and survival after curative resection of adenocarcinoma of the colon. J Am Coll Surg 2002; 195:33–40.[CrossRef][Medline]
  15. Gunderson LL, Sosin H, Levitt S. Extrapelvic colon—areas of failure in a reoperation series: implications for adjuvant therapy. Int J Radiat Oncol Biol Phys 1985; 11:731–41.[Medline]
  16. Harris GJ, Church JM, Senagore AJ, Lavery IC, Hull TL, Strong SA, Fazio VW. Factors affecting local recurrence of colonic adenocarcinoma. Dis Colon Rectum 2002; 45:1029–34.[CrossRef][Medline]
  17. Sjövall A, Holm T, Singnomklao T, Granath F, Glimelius B, Cedermark B. Colon cancer management and outcome in relation to individual hospitals in a defined population. Br J Surg, in press.
  18. Averbach AM, Jacquet P, Sugarbaker PH. Surgical technique and colorectal cancer: impaction on local recurrence and survival. Tumori 1995; 81:65–71.[Medline]
  19. Martling A, Singnomklao T, Holm T, Rutqvist LE, Cedermark B. Prognostic significance of both surgical and pathological assessment of curative resection for rectal cancer. Br J Surg 2004; 91:1040–5.[CrossRef][Medline]
  20. Bokey EL, Chapuis PH, Dent OF, Mander BJ, Bissett IP, Newland RC. Surgical technique and survival in patients having a curative resection for colon cancer. Dis Colon Rectum 2003; 46:860–6.[CrossRef][Medline]
  21. Jestin P, Nilsson J, Heurgren M, Pahlman L, Glimelius B, Gunnarsson U. Emergency surgery for colonic cancer in a defined population. Br J Surg 2005; 92:94–100.[Medline]
  22. Carraro PG, Segala M, Cesana BM, Tiberio G. Obstructing colonic cancer: failure and survival patterns over a ten-year follow-up after one-stage curative surgery. Dis Colon Rectum 2001; 44:243–50.[CrossRef][Medline]
  23. McArdle CS, Hole DJ. Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg 2004; 91:605–9.[CrossRef][Medline]
  24. Dorrance HR, Docherty GM, O’Dwyer PJ. Effect of surgeon specialty interest on patient outcome after potentially curative colorectal cancer surgery. Dis Colon Rectum 2000; 43:492–8.[CrossRef][Medline]
  25. Prystowsky JB, Bordage G, Feinglass JM. Patient outcomes for segmental colon resection according to surgeon’s training, certification, and experience. Surgery 2002; 132:663–70. [discussion 670–2].[CrossRef][Medline]
  26. Phillips RK, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence following ‘curative’ surgery for large bowel cancer: I. The overall picture. Br J Surg 1984; 71:12–6.[Medline]
  27. Hohenberger W, Reingruber B, Merkel S. Surgery for colon cancer. Scand J Surg 2003; 92:45–52.[Medline]
  28. Stockholm Colorectal Cancer Study Group Vårdprogram Kolorektal Cancer Oncologic Centre: Stockholm–Gotland, 2003.
  29. Holm T, Cedermark B, Rutqvist LE. Local recurrence of rectal adenocarcinoma after ‘curative’ surgery with and without preoperative radiotherapy. Br J Surg 1994; 81:452–5.[Medline]
  30. Wiig JN, Larsen SG, Giercksky KE. Operative treatment of locally recurrent rectal cancer. Recent Results Cancer Res 2005; 165:136–47.[Medline]
  31. Kapiteijn E, Putter H, van de Velde CJ. Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 2002; 89:1142–9.[CrossRef][Medline]
  32. Martling A, Holm T, Rutqvist LE, Johansson H, Moran BJ, Heald RJ, Cedermark B. Impact of a surgical training programme on rectal cancer outcomes in Stockholm. Br J Surg 2005; 92:225–9.[CrossRef][Medline]
  33. Figueredo A, Rumble RB, Maroun J, et al. Follow-up of patients with curatively resected colorectal cancer: a practice guideline. BMC Cancer 2003; 3:26.[CrossRef][Medline]
  34. Jeffery GM, Hickey BE, Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2002:CD002200.
  35. Renehan AG, Egger M, Saunders MP, O’Dwyer ST. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 2002; 324:813.[Abstract/Free Full Text]
  36. Kobayashi K, Kawamura M, Ishihara T. Surgical treatment for both pulmonary and hepatic metastases from colorectal cancer. J Thorac Cardiovasc Surg 1999; 118:1090–6.[Abstract/Free Full Text]
  37. Slanetz CA Jr, Grimson R. Effect of high and intermediate ligation on survival and recurrence rates following curative resection of colorectal cancer. Dis Colon Rectum 1997; 40:1205–18; [discussion 1218–9].[CrossRef][Medline]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Sjövall, A.
Right arrow Articles by Holm, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Sjövall, A.
Right arrow Articles by Holm, T.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS