Rectal cancer surgery – opportunities and challenges in the modern era

Aims: This thesis was designed to elucidate the opportunities and challenges faced by the surgeon and the patient in the era of modern rectal cancer surgery. Temporal changes in the treatment and survival of patients with rectal cancer during 2001-2012 were evaluated on the basis of a biobank database. The novel extralevator abdominoperineal excision (ELAPE) was compared to standard abdominoperineal excision (APE) in patients with locally advanced rectal cancer. The incidence, location and risk factors for local recurrence (LR) after modern multimodality treatment of rectal cancer were determined. To promote the assessment of postoperative bowel function in rectal cancer patients the low anterior resection syndrome (LARS) Score –questionnaire was translated to Finnish and validated. Patients and Methods: The material consisted of patients treated for rectal cancer at Turku University Hospital between 2001 and 2016. Data was collected retrospectively from prospectively maintained electronic medical records. Answers to the LARS Score –questionnaire and quality of life (QoL) -questionnairres were collected by mail. Results: The results of the current study showed that from 2001 to 2012, the overall survival and cancer spesific survival of patients with stage I-III rectal cancer significantly increased. In locally advanced rectal cancer, patients operated with ELAPE did not have a better long-term survival than patients operated with APE. In stage I-III rectal cancer treated with curative intent, the incidence of LR was 11%. There was a slight predominance of lateral LRs. As a long term functional result 54% of rectal cancer patients that underwent continence preservering surgery had major LARS. The Finnish LARS Score –questionnaire was shown to be a valid test in the assessment of postoperative bowel function and its impact on the QoL. Conclusions: With modern multimodality treatment the survival of patients with rectal cancer is excellent even though LR still sometimes occurs. Many of the survivors need guidance regarding LARS.Peräsuolisyöpäkirurgia – uusia mahdollisuuksia ja haasteita Tavoitteet: Tämän väitöstutkimuksen tavoitteena oli selvittää nykyaikaiseen peräsuolisyöpäkirurgiaan liittyviä mahdollisuuksia ja haasteita sekä kirurgin että potilaan näkökulmasta. Muutoksia peräsuolisyövän hoidossa ja hoidon jälkeisessä elossaoloajassa vuosien 2001–2012 aikana tutkittiin biopankkiaineiston pohjalta. Paikallisesti edenneen peräsuolisyövän hoidoksi käyttöön otetun laajennetun peräsuolen poistoleikkauksen (ELAPE) pitkäaikaistuloksia verrattiin perinteisen peräsuolen poistoleikkauksen (APE) tuloksiin. Tutkimuksessa selvitettiin lisäksi peräsuolisyövän modernin hoidon jälkeen todettavien paikallisuusiutumien ilmaantuvuutta, sijaintia ja riskitekijöitä. Peräsuolisyöpäpotilaiden leikkauksen jälkeistä suolen toimintaa arvioimaan kehitetty LARS-kysely suomennettiin ja validoitiin. Aineisto ja menetelmät: Tutkimuksen aineisto koostui Turun yliopistollisessa keskussairaalassa vuosien 2001 ja 2016 välillä hoidetuista peräsuolisyöpäpotilaista. Tiedot kerättiin takautuvasti sähköisestä sairauskertomuksesta. LARS-kyselyn ja elämänlaatukyselyiden vastaukset kerättiin potilailta postitse. Tulokset: Tutkimuksessa todettiin, että vuosien 2001 ja 2012 välillä levin-neisyysasteiden I–III peräsuolisyöpään sairastuneiden potilaiden kokonaiselossaolo ja tautispesifinen elossaolo paranivat merkitsevästi. ELAPE-tekniikalla leikattujen paikallisesti edennyttä syöpää sairastavien potilaiden pitkäaikaisennuste ei kuitenkaan ollut perinteisellä tekniikalla leikattuja parempi. Paikallisuusiutuma todettiin 11 %:lla radikaalitavoitteisesti hoidetuista levinneisyysasteen I-III peräsuolisyöpäpotilaista. Lantion sivuilla sijaitsevia uusiutumia oli hiukan muita sijainteja enemmän. Merkittäviä pitkäkestoisia ulostamiseen liittyviä oireita oli 54 %:lla potilaista, joiden peräaukko oli voitu peräsuolisyöpäleikkauksessa säästää. Suomennettu LARS-kysely todettiin validiksi leikkauksen jälkeisen suolen toiminnan ja sen elämänlaatuvaikutusten arvioinnissa. Johtopäätökset: Peräsuolisyövän nykyaikaisen yhdistelmähoidon tulokset elossaolon perusteella arvioituna ovat erinomaisia, vaikka paikallisuusiutumia edelleen ilmaantuu. Monet peräsuolisyövästä selviytyneet tarvitsevat tukea toiminnallisten suolioireiden helpottamiseksi

Mobile-CEA - A Novel Surveillance Method for Patients with Colorectal Cancer

Objective The follow-up of the increasing number of cancer survivors threatens to overload the health care system. While short message system (SMS)-based communication is widely used in other areas of the health care system, there are no studies of its appliance in cancer surveillance. The aim of the current study was to analyze the acceptability, convenience and impact of a novel mobile phone messaging -based system (Mobile-CEA) on health personnel contacts in patients with colorectal cancer (CRC) during 2 years of follow-up. Methods The follow-up data of 52 curatively treated patients with CRC (22 Mobile-CEA-, 30 standard surveillance) was collected retrospectively from the electronic archives. Mobile-CEA patient satisfaction was measured by a tailored non-validated questionnaire. Health personnel satisfaction was assessed by personal interviews. Results Mobile-CEA surveillance group had less health personnel contacts than the standard surveillance group: median 3 (min 0-max 7) vs 5 (min 4-max 7) and 77.2% of the Mobile-CEA group had less than 4 contacts (minimum with the standard surveillance) to health personnel. There were no recurrences in either group. Mobile-CEA patients were satisfied with this novel follow-up method. Health personnel considered it as a practical and safe tool in CRC surveillance. Conclusion Mobile-CEA surveillance seems to be a promising and effective follow-up method for curatively treated patients with CRC. Further studies and experiences are needed.</p

Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up

To analyze the results of abdominoperineal excisions (APE) for locally advanced rectal cancer at our institution before and after the adoption of extralevator abdominoperineal excision (ELAPE) with a special reference to long-term survival.A retrospective cohort study conducted in a tertiary referral center. All consecutive patients operated for locally advanced (TNM classification T3-4) rectal cancer with APE in 2004-2009 were compared to patients with similar tumors operated with ELAPE in 2009-2016.Forty-two ELAPE and 27 APE patients were included. Circumferential resection margin (CRM) was less than 1 mm (R1-resection) in 10 (24%) of ELAPE patients and 11 (41%) of APE patients (p = 0.1358). Intraoperative perforation (IOP) occurred in 4 (10%) patients and 6 (22%) patients in ELAPE and APE groups, respectively (p = 0.1336). There were 3 (7%) local recurrences (LRs) in ELAPE group and 5 (19%) in APE (p = 0.2473). There were no statistical differences in adverse events, overall survival, or disease-free survival between ELAPE and APE groups.We found a non-significant tendency to lower rates of IOP and positive CRM as well as lower rate of LR in the ELAPE group. Long-term survival and adverse events did not differ between the groups. ELAPE is beneficial for the surgeon in offering better vicinity to the perineal area and better work ergonomics. These technical aspects and the clinically very important tendency to lower rate of LR support the use of ELAPE technique in spite of the lack of survival benefit

An easily adaptable validated risk score predicts cancer-specific survival in stage II colon cancer

Non peer reviewe

Trends in presentation, treatment and survival of 1777 patients with colorectal cancer over a decade: a Biobank study

Background: Most survival data in colorectal cancer (CRC) is derived from clinical trials or register-based studies. Hospital Biobanks, linked with hospital electronic records, could serve as a data-gathering method based on consecutively collected tumor samples. The aim of this Biobank study was to analyze survival of colorectal patients diagnosed and treated in a single-center university hospital over a period of 12 years, and to evaluate factors contributing to outcome.Material and methods: A total of 1777 patients with CRC treated during 2001–2012 were identified from the Auria Biobank, Turku, Finland. Longitudinal clinical information was collected from various hospital electronic records and date and cause of death obtained from Statistics Finland.Results: Cancer-specific, overall and disease-free survival was higher in patients diagnosed during 2004–2008 as compared with patients diagnosed in 2001–2003. Further improvement was not seen during years 2009–2012. Potential factors contributing to the improvement were introduction of multidisciplinary meetings, centralization of rectal cancer surgery, use of adjuvant chemotherapy and systematic preoperative radiotherapy of rectal cancer. The proportion of patients with stage I–IV CRC remained similar over the study period, but a marked decrease in non-metastatic rectal cancer with biopsy only (locally advanced disease) was observed. In stage I–III rectal cancer, Cox multivariate analysis suggested age, comorbidity, R1 resection, T staging and tumor grade as prognostic factors. In colon cancer, prognostic factors were age, comorbidity, gender and presence of lymph node metastases.Conclusions: Organizational changes in the treatment of CRC patients made since 2004 coincide with improved survival in CRC and a marked reduction in locally advanced rectal cancers. The clinical presentation of CRC has remained similar between 2001 and 2012.</p

Peräaukon levyepiteelisyöpä - monialaista yhteistyötä vaativa harvinainen maligniteetti

Peräaukkosyöpä on harvinainen syöpäsairaus, jonka oireet saatetaan virheellisesti alkuun tulkita hyvänlaatuisiksi, esimerkiksi peräpukamavaivoiksi. Epäily taudista herää usein kliinisen tutkimuksen perusteella, ja diagnoosi varmistetaan biopsialla. Ennen hoidon aloitusta tehdään levinneisyyden selvittämiseksi vartalon varjoainetehosteinen positroniemissiotomografia-tietokonetomografia (FDG-PET-TT) ja lantion magneettikuvaus. Paikallisen peräaukkosyövän ensisijainen hoito on kemosädehoito, jonka avulla 80-90 \% potilaista saavuttaa täydellisen hoitovasteen. Kemosädehoidon jälkeen potilaita seurataan tiiviisti kliinisellä tutkimuksella ja kuvantamistutkimuksin. Mikäli tauti ei reagoi kemosädehoitoon tai uusiutuu paikallisesti, pyritään kirurgiseen hoitoon. Leikkaushoito on usein vaativaa ja edellyttää useiden kirurgisten alojen yhteistyötä. Myös levinneen peräaukkosyövän hoito kannattaa, koska tauti vastaa yleensä hyvin lääkehoitoon ja osa potilaista on pitkäaikaisselviytyjiä

Trends in presentation, treatment and survival of 1777 patients with colorectal cancer over a decade : a Biobank study

Background: Most survival data in colorectal cancer (CRC) is derived from clinical trials or register-based studies. Hospital Biobanks, linked with hospital electronic records, could serve as a data-gathering method based on consecutively collected tumor samples. The aim of this Biobank study was to analyze survival of colorectal patients diagnosed and treated in a single-center university hospital over a period of 12 years, and to evaluate factors contributing to outcome.Material and methods: A total of 1777 patients with CRC treated during 2001-2012 were identified from the Auria Biobank, Turku, Finland. Longitudinal clinical information was collected from various hospital electronic records and date and cause of death obtained from Statistics Finland.Results: Cancer-specific, overall and disease-free survival was higher in patients diagnosed during 2004-2008 as compared with patients diagnosed in 2001-2003. Further improvement was not seen during years 2009-2012. Potential factors contributing to the improvement were introduction of multidisciplinary meetings, centralization of rectal cancer surgery, use of adjuvant chemotherapy and systematic preoperative radiotherapy of rectal cancer. The proportion of patients with stage I-IV CRC remained similar over the study period, but a marked decrease in non-metastatic rectal cancer with biopsy only (locally advanced disease) was observed. In stage I-III rectal cancer, Cox multivariate analysis suggested age, comorbidity, R1 resection, T staging and tumor grade as prognostic factors. In colon cancer, prognostic factors were age, comorbidity, gender and presence of lymph node metastases.Conclusions: Organizational changes in the treatment of CRC patients made since 2004 coincide with improved survival in CRC and a marked reduction in locally advanced rectal cancers. The clinical presentation of CRC has remained similar between 2001 and 2012.Peer reviewe

Short-course preoperative radiotherapy increases pelvic fracture risk in rectal cancer

Introduction: Pelvic insufficiency fractures (PIFs) are adverse events associated with chemoradiotherapy (CRT) administered preoperatively in rectal cancer, with incidences of 0–33.6% reported in the literature. Data on PIFs after 5 × 5 Gy fractionated short-course radiotherapy (SCRT) using highly conformal radiotherapy techniques such as volumetric modulated arc therapy (VMAT) is limited. Methods: The Turku University Hospital colorectal cancer database was searched for patients operated on for stage I–III rectal cancer during the years 2014–2018. The hospital’s routine follow-up includes a 2-year computed tomography (CT) scan, which was systemically re-evaluated to detect PIFs. Only radiotherapy delivered using VMAT and image-guided approaches was included. Baseline demographics, tumor data, and dose-volume data were collected to identify risk factors for PIFs. Results: Median time to CT scan was 24 months. Among the 164 patients analyzed, the 2-year PIF incidence was 22.2% for SCRT (n = 12/54, OR 9.1 (CI95% 1.9–42.9), p = 0.004), 9.1% for CRT (n = 4/44, OR 3.2 (CI95% 0.6–18.3), p = 0.13) and 3.0% (n = 2/66, reference) for those operated on without radiotherapy. The PIF incidence was not explained by differences in dose-volume data in either the SCRT or CRT groups. Fracture risk was higher in women, up to 50% after SCRT. Conclusions: Every fifth patient treated with SCRT and rectal surgery presented with a PIF. Critical bony structures to be avoided during radiotherapy contouring could not be identified. Clinicians, especially those involved with the follow-up of rectal cancer, should be aware of this potentially debilitating and surprisingly common adverse event