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Nilsson K, Klevebro F, Sunde B, Rouvelas I, Lindblad M, Szabo E, Halldestam I, Smedh U, Wallner B, Johansson J, Johnsen G, Aahlin EK, Johannessen HO, Alexandersson von Döbeln G, Hjortland GO, Wang N, Shang Y, Borg D, Quaas A, Bartella I, Bruns C, Schröder W, Nilsson M. Oncological outcomes of standard versus prolonged time to surgery after neoadjuvant chemoradiotherapy for oesophageal cancer in the multicentre, randomised, controlled NeoRes II trial. Ann Oncol 2023; 34:1015-1024. [PMID: 37657554 DOI: 10.1016/j.annonc.2023.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The optimal time to surgery (TTS) after neoadjuvant chemoradiotherapy (nCRT) for oesophageal cancer is unknown and has traditionally been 4-6 weeks in clinical practice. Observational studies have suggested better outcomes, especially in terms of histological response, after prolonged delay of up to 3 months after nCRT. The NeoRes II trial is the first randomised trial to compare standard to prolonged TTS after nCRT for oesophageal cancer. PATIENTS AND METHODS Patients with resectable, locally advanced oesophageal cancer were randomly assigned to standard delay of surgery of 4-6 weeks or prolonged delay of 10-12 weeks after nCRT. The primary endpoint was complete histological response of the primary tumour in patients with adenocarcinoma (AC). Secondary endpoints included histological tumour response, resection margins, overall and progression-free survival in all patients and stratified by histologic type. RESULTS Between February 2015 and March 2019, 249 patients from 10 participating centres in Sweden, Norway and Germany were randomised: 125 to standard and 124 to prolonged TTS. There was no significant difference in complete histological response between AC patients allocated to standard (21%) compared to prolonged (26%) TTS (P = 0.429). Tumour regression, resection margins and number of resected lymph nodes, total and metastatic, did not differ between the allocated interventions. The first quartile overall survival in patients allocated to standard TTS was 26.5 months compared to 14.2 months after prolonged TTS (P = 0.003) and the overall risk of death during follow-up was 35% higher after prolonged delay (hazard ratio 1.35, 95% confidence interval 0.94-1.95, P = 0.107). CONCLUSION Prolonged TTS did not improve histological complete response or other pathological endpoints, while there was a strong trend towards worse survival, suggesting caution in routinely delaying surgery for >6 weeks after nCRT.
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Affiliation(s)
- K Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - F Klevebro
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - B Sunde
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - I Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - M Lindblad
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - E Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro
| | | | - U Smedh
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg
| | - B Wallner
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå
| | - J Johansson
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - G Johnsen
- Department of Gastrointestinal Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim
| | - E K Aahlin
- Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø
| | - H-O Johannessen
- Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - G Alexandersson von Döbeln
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm; Medical Unit of Head, Neck, Lung and Skin Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - G O Hjortland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - N Wang
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm
| | - Y Shang
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm
| | - D Borg
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - A Quaas
- Institute of Pathology, University of Cologne, Cologne
| | - I Bartella
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - C Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - W Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - M Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm.
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von Döbeln GA, Klevebro F, Jacobsen AB, Johannessen HO, Nielsen NH, Johnsen G, Hatlevoll I, Glenjen NI, Friesland S, Lundell L, Yu J, Nilsson M. Neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for cancer of the esophagus or gastroesophageal junction: long-term results of a randomized clinical trial. Dis Esophagus 2019; 32:5078143. [PMID: 30137281 DOI: 10.1093/dote/doy078] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
NeoRes I is a randomized phase II trial comparing neoadjuvant chemoradiotherapy with neoadjuvant chemotherapy in the treatment of resectable cancer of the esophagus or gastroesophageal junction. Patients with biopsy-proven adenocarcinoma or squamous cell carcinoma, T1N1 or T2-3N0-1 and M0-M1a (AJCC 6th ed.), were randomized to receive three 3-weekly cycles of cisplatin 100 mg/m2 day 1 and fluorouracil 750 mg/m2/24 hours, days 1-5 with or without the addition of concurrent radiotherapy 40 Gy, 2 Gy/fraction, 5 days a week, followed by esophageal resection with two-field lymphadenectomy. Primary endpoint was complete histopathological response rate in the primary tumor. Survival and recurrence patterns were evaluated as secondary endpoints. Between 2006 and 2013, 181 patients were enrolled in Sweden and Norway. All three chemotherapy cycles were delivered to 73% of the patients allocated to chemoradiotherapy and to 86% of the patients allocated to chemotherapy. 87% of those allocated to chemoradiotherapy received full dose radiotherapy. 87% in the chemoradiotherapy group and 86% in the chemotherapy group underwent tumor resection. Initial results showed that patients allocated to chemoradiotherapy more often responded with complete histopathological response in the primary tumor (28% vs. 9%). Treatment-related complications were similar between the groups although postoperative complications were more severe in the chemoradiotherapy group. This article reports the long-term results. Five-year progression-free survival was 38.9% (95% CI 28.9%-48.8%) in the chemoradiotherapy group versus 33.0% (95% CI 23.6%-42.7%) in the chemotherapy group, P = 0.82. Five-year overall survival was 42.2% (95% CI 31.9%-52.1%) versus 39.6% (95% CI 29.5%-49.4%), P = 0.60. There were no differences in recurrence patterns between the treatment groups. This is to our knowledge that the largest completed randomized trial comparing neoadjuvant chemotherapy with neoadjuvant chemoradiotherapy followed by esophageal resection in patients with cancer in the esophagus or gastroesophageal junction. Despite a higher tumor tissue response in those who received neoadjuvant chemoradiotherapy, no survival advantages were seen. Consequently, the results do not support unselected addition of radiotherapy to neoadjuvant chemotherapy as a standard of care in patients with resectable esophageal cancer.
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Affiliation(s)
- G A von Döbeln
- Department of Oncology and Pathology, Karolinska Institutet and Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - F Klevebro
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet and Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - A-B Jacobsen
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - H-O Johannessen
- Department of Hepatic, Gastrointestinal and Paediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - N H Nielsen
- Department of Oncology, Norrland University Hospital, Umeå, Sweden
| | - G Johnsen
- Department of Gastrointestinal Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - I Hatlevoll
- Department of Oncology, St.Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - N I Glenjen
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - S Friesland
- Department of Oncology and Pathology, Karolinska Institutet and Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet and Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - J Yu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - M Nilsson
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet and Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
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Haug HM, Johnson E, Mala T, Førland DT, Søvik TT, Johannessen HO. Incarcerated paraesophageal hernia complicated by pancreatic damage and unusual comorbidity: Two retrospective case series. Int J Surg Case Rep 2018; 54:75-78. [PMID: 30529949 PMCID: PMC6288317 DOI: 10.1016/j.ijscr.2018.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/26/2018] [Indexed: 12/02/2022] Open
Abstract
We present two cases of paraesophageal hernia that both needed total gastrectomy due to gangrene. Both patients had clinical relevant comorbidities, respectively trisomy 21 and hereditary spastic paresis. Due to compression from the dilated stomach one of the patients developed ischemia of the pancreas with leakage of peptidases which in turn caused anastomotic dehisence and intraabdominal abscess. The pancreatic damage and anastomotic leakage was treated conservatively with repeated stenting and percutaeous drainage. Immediate diagnosis and treatment for incarcerated paraesophageal hernias are vital to reduce morbidity and mortality.
Introduction: About 1% of paraesophageal hernias (PEH) require emergency surgery due to obstruction or gangrene. We present two complicated cases of incarcerated PEH. Presentation of cases: A patient aged 18 with trisomy 21 was admitted after four days of vomiting and epigastric pain. CT scan revealed a large PEH. The stomach was massively dilated with compression of adjacent viscera and the celiac trunk. The stomach was repositioned laparoscopically and deflated by endoscopy in an attempt to avoid resection. During second look laparoscopy a gastrectomy was necessary. The patient was reoperated for intestinal obstruction, and treated for dehiscence of the esophagojejunostomy and a pancreatic fistula. A patient aged 65 with hereditary spastic paresis had two days history of emesis and epigastric pain. Upon arrival he was hemodynamically unstable and a CT scan revealed perforation of the herniated stomach. A subtotal gastrectomy without reconstruction was performed with vacuum closure of the abdomen. Later a gastrectomy was completed with a Roux-en-Y reconstruction. Except from reoperation for wound dehiscence after 14 days, the recovery was uneventful. Discussion: Trisomy 21 and hereditary spastic paresis may increase the risk of developing PEH. Challenges in regard to symptom evaluation may delay diagnosis. The pressure of the dilated stomach can give rise to ischemic and mechanical damage from compression of major blood vessels and organs. Urgent diagnosis and gastric deflation is required. Conclusions: In patients with known PEH or with comorbidity that may increase the risk of PEH, this diagnosis should be considered early on.
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Affiliation(s)
- H M Haug
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P.O. box 4950, 0424 Oslo, Norway.
| | - E Johnson
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P.O. box 4950, 0424 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway.
| | - T Mala
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P.O. box 4950, 0424 Oslo, Norway.
| | - D T Førland
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P.O. box 4950, 0424 Oslo, Norway.
| | - T T Søvik
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P.O. box 4950, 0424 Oslo, Norway.
| | - H O Johannessen
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, P.O. box 4950, 0424 Oslo, Norway.
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Flatmark K, Borgen E, Nesland JM, Rasmussen H, Johannessen HO, Bukholm I, Rosales R, Hårklau L, Jacobsen HJ, Sandstad B, Boye K, Fodstad Ø. Disseminated tumour cells as a prognostic biomarker in colorectal cancer. Br J Cancer 2011; 104:1434-9. [PMID: 21448171 PMCID: PMC3101945 DOI: 10.1038/bjc.2011.97] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The study was performed to determine detection rate and prognostic relevance of disseminated tumour cells (DTC) in patients receiving curatively intended surgery for colorectal cancer (CRC). METHODS The study population consisted of 235 patients with CRC prospectively recruited from five hospitals in the Oslo region. Bone marrow (BM) aspirates were collected at the time of surgery and the presence of DTC was determined by two immunological methods; immunomagnetic selection (using an anti-EpCAM antibody) and immunocytochemistry (using a pan-cytokeratin antibody). Associations between the presence of DTC and metastasis-free, disease-specific and overall survival were analysed using univariate and multivariate methods. RESULTS Disseminated tumour cells were detected in 41 (17%) and 28 (12%) of the 235 examined BM samples by immunomagnetic selection and immunocytochemistry, respectively, with only five samples being positive with both methods. The presence of DTC was associated with adverse outcome (metastasis-free, disease-specific and overall survival) in univariate and multivariate analyses. CONCLUSION The presence of DTC was associated with adverse prognosis in this cohort of patients curatively resected for CRC, suggesting that DTC detection still holds promise as a biomarker in CRC.
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Affiliation(s)
- K Flatmark
- Department of Tumor Biology, Norwegian Radium Hospital, Oslo University Hospital, Oslo 0424, Norway.
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Abstract
BACKGROUND AND AIMS The main aim was to examine constipation and anal incontinence in patients before and after resection for external rectal prolapse. MATERIAL AND METHODS Twenty patients had ligament preserving suture rectopexy and sigmoid resection (resection rectopexy) for external rectal prolapse by laparoscopic (n = 15) or open (n = 5) technique during 2001-2005. They were prospectively evaluated for constipation and anal incontinence using validated incontinence and KESS-constipation scores. RESULTS AND CONCLUSIONS Constipation score was significantly reduced from mean 7.7 (5.4-9.9) to 4.5 (2.5-6.4) after median 4 months (1-19) and to 4.3 (2.2-6.3) after median 17 months (4-51). Six and four patients were constipated preoperatively and 17 months postoperatively, respectively. The four symptoms feeling incomplete evacuation of stool, minutes in lavatory per attempt, use of enemas/digitation and painful evacuation effort were significantly reduced, whilst stool consistency increased. Fourteen patients (70%) had anal incontinence. Corresponding and significant reduction in their scores were from mean 12.5 (9.4-15.5) to 5.1 (2.1-8.1) and to 3.6 (1.3-5.9). Incontinence was improved in 13 and unaltered in one patient(s). Two patients with worse outcome had increased stool consistency and constipation scores. Resection rectopexy for rectal prolapse reduced anal incontinence and constipation.
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Affiliation(s)
- E Johnson
- Department of Gastroenterological Surgery, Ulleval University Hospital, Oslo, Norway.
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Abstract
Experimental data indicate a greater tolerance for endocavitary than for external beam irradiation of the normal rectal tissue in the rat. Increased tolerance has been attributed to temperature induced rectal hypoxia and a reduction of the dose to the mesentery. The general scarcity of experimental work in the field and the problems concerning hypoxia and dosimetry motivated the development of the current model. An 8 mm diameter endocavitary applicator was used for symmetrical dilatation and central introduction of the 192Ir source into the rectum of male Fischer F344 rats. Pulse oximetry and pO2-electrode readings from the intubated rectum gave no indication of radiobiological hypoxia. In vitro and in vivo thermoluminescence dosimetry (TLD) was supported by MRI based ferrous sulphate gel dosimetry. Using a 25 mm length source configuration the 90% isodose incorporated a 13 mm length segment of the rectum, and a 5.6% maximum deviation from the calculated dose was observed by the TLD and MRI based gel dosimetry. The ureters, the bladder and the skin were the only organs other than the target organ which received doses greater than 10% of the rectal dose. The model seems to be suitable for dose effect studies since endocavitary irradiation of the rat rectum can be performed without induction of local tissue hypoxia.
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Affiliation(s)
- H O Johannessen
- Department of Surgical Oncology, Norwegian Radium Hospital, Oslo, Norway
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