Presentation of the OREH project - organized holistic rehabilitation of patients with colon and rectal cancer

Celostna rehabilitacija vključuje aktivne postopke, s katerimi onkološkim bolnikom omogočimo najboljše telesno, duševno in socialno delovanje od diagnoze dalje. Številne klinične raziskave kažejo, da onkološko zdravljenje povzroča številne posledice, kar bolnikom prinaša mnogotere težave, zaradi katerih se njihovo življenje korenito spremeni. Celostna rehabilitacija za onkološke bolnike se danes v Sloveniji ne izvaja na ravni države. Bolniki so deležni rehabilitacije po onkološkem zdravljenju sporadično in v neenakomernem obsegu v posameznih ustanovah, kjer se zdravijo bolniki z rakom in v zdravstvenih domovih. V okviru projekta Organizirane celostne rehabilitacije bolnikov z rakom debelega črevesa in danke bomo poiskušali ugotoviti, ali je kakovost življenja bolnikov z rakom debelega črevesa in danke, ki so vključenih v interventno skupino boljša. S primerjavo interventne in kontrolne skupine bomo ugotovili tudi, kako je intervencija vplivala na trajanje njihove bolniške odsotnosti in na invalidsko upokojevanje. Na osnovi analize rezultatov bomo pripravili načrtovano oceno potreb po celostni rehabilitaciji za rak debelega črevesa in danke, ki bo podlaga za načrtovanje resursov na državni ravni.Comprehensive rehabilitation includes active procedures that enable oncology patients to have the best physical, mental and social functioning from diagnosis onwards. Numerous clinical studies show that oncological treatment causes many consequences, which brings many problems to patients, due to which their lives change radically. Comprehensive rehabilitation for oncology patients is currently not carried out at the national level in Slovenia. Patients receive rehabilitation after oncological treatment sporadically and to an uneven extent in individual institutions where cancer patients are treated and in medical centers. Within the framework of the project Organized comprehensive rehabilitation of patients with colon and rectal cancer, we will try to determine whether the quality of life of patients with colon and rectal cancer, who are included in the intervention group, is better. By comparing the intervention and control groups, we will also determine how the intervention affected the duration of their sick leave and disability retirement. Based on the analysis of the results, we will prepare a planned assessment of the needs for comprehensive rehabilitation for colon and rectal cancer, which will be the basis for resource planning at the national level

Locoregional disease control after external beam radiotherapy in 91 patients with differentiated thyroid carcinoma and pT4 tumor stage

Locoregional recurrence is common in patients with locally advanced differentiated thyroid carcinoma (DTC). Our aim was to find out the rate of locoregional control of the disease after external beam radiotherapy (EBRT) of the neck and mediastinum in patients with DTC and pT4 tumor. Patients and methods Altogether 91 patients (47 males, 44 females, median age 61 years) with DTC had EBRT of the neck and mediastinum as part of the multimodal treatment of pT4 tumor (63 cases pT4a, 28 cases pT4b) from the year 1973 to 2015. Data on clinical factors, histopathology and recurrence were collected. Disease-free, disease-specific and overall survival was calculated. Results Median tumor size was 5 cm (range 1%30 cm). Out of 91 patients, 23 had distant and 38 regional metastases. A total or near-total thyroidectomy, lobectomy, subtotal thyroidectomy and lymph node dissection was performed in 70%, 14%, 2% and 30% of cases, respectively. Thirteen percent of patients were not treated with surgery. All patients had EBRT and 39 had chemotherapy. Radioiodine (RAI) ablation of thyroid remnant and RAI therapy was applied in 90% and 40% of cases, respectively. Recurrence was diagnosed in 29/64 patients without a persistent disease: locoregional and distant in 16 and 13 cases, respectively. Five-year and ten-year disease-free survival rate was 64% and 48%, respectively. Conclusions The majority of patients with DTC and pT4 tumors who were treated with EBRT of the neck and mediastinum region as part of multimodal treatment have long-lasting locoregional control of the disease

Modern Principles of Surgical Treatment of Colorectal Liver Metastases

Polovica bolnikov z rakom debelega črevesa in danke (RDČD) bo med boleznijo razvila jetrne zasevke. Pri nezdravljenih jetrnih zasevkih RDČD je prognoza slaba. Za te bolnike je radikalen kirurški poseg edino potencialno kurativno zdravljenje. V zadnjih letih se je preživetje bolnikov z jetrnimi zasevki izboljšalo zaradi številnih novosti v kirurškem zdravljenju in tudi zaradi razvoja številnih novih metod zdravljenja. V nekaterih raziskavah poročajo celo o 60-odstotnem 5-letnem preživetju. Več kot 4 zasevki, zasevek, večji od 5 cm, bilobarna bolezen in zunajjetrni zasevki niso več kontraindikacije za operacijo jetrnih zasevkov, ampak sta za odločitev o operaciji pomembna predvsem dva dejavnika: sposobnost doseči vsaj 1 mm širok varnostni rob ob ohranitvi vsaj 20 do 30 % zdravega jetrnega parenhima. Umrljivost po operaciji jetrnih zasevkov je pri ustreznem izboru bolnikov in dobri predoperativni pripravi manjša od 5 %.Approximately one half of patients with colorectal cancer will develop liver metastasis at some point in their clinical course. Untreated colorectal liver metastases have a bad prognosis and complete surgical resection is the only treatment that offers a chance of long term survival. In recent years, the survival of patients with colorectal liver metastasis has improved due to several advances in surgical techniques and development of other new methods of treatment. In some studies, 5-year survival is approaching 60%. More than four lesions, tumors larger than 5 cm, bilobar disease and extrahepatic disease are no longer considered as contraindications for surgery. Nowadays, the eligibility criteria for surgery are feasibility of R0 resection and making sure that at least 20-30% of the liver will remain intact. With careful selection of patients and proper preoperative care, the mortality rate after liver resection is estimated at less than 5 %

Early Lymphadenectomy in Melanoma Patients and Their Prognosis

Lymph node metastases are the most important prognostic factor in the patients with cutaneous melanoma and they are treated with radical lymphadenectomy. In the last 15 years, sentinel lymph node biopsy (SLNB) became the method of choice in staging regional lymph nodes in melanoma patients. The procedure provides the most accurate prognostic information and facilitates early lymphadenectomy in the patients with clinically occult regional metastases, however, therapeutic value of SLNB followed by completion lymph node dissection (CLND) in melanoma patients has not been proved. The reason might be prognostic heterogeneity of patients with positive sentinel lymph node (SN)hence, the aim of this study was to assess survival rates of these patients. For the purpose of this analysis, the patients with stage III melanoma were identified from the prospective melanoma database at the Institute of Oncology Ljubljana, Slovenia, which includes more than 1000 patients. Patients were divided into four groups: • delayed therapeutic lymph node dissection (TLND) • CLND after positive SLNB • synchronous primary melanoma and regional lymph node metastases • lymph node metastases for unknown primaries The worst 5-year overall survival (OS) had the patients with synchronous primary melanoma and regional lymph node metastases. The patients with SN metastases with a diameter of more than 5.0 mm had significantly worse OS than those with delayed TLND, while the patients with SLNB metastases with a diameter of 5.0 mm or less had significantly better OS than those with delayed TLND even after the patients with false positive SLNB (diameter less than 0.3 mm) were excluded. The group of patients with positive SLNB is contaminated with the false positive patients as well as with the patients with more aggressive disease. The majority of SN positive patients, however, have an OS benefit in comparison to the patients with delayed TLND

The role of neoadjuvant chemotherapy in patients with advanced (stage IIIC) epithelial ovarian cancer

Primary treatment of patients with advanced epithelial ovarian cancer consists of chemotherapy either before (neoadjuvant chemotherapy, NACT) or after primary surgery (adjuvant chemotherapy). The goal of primary treatment is no residual disease after surgery (R0 resection) what is associated with an improvement in survival of patients. There is, however, no evidence of survival benefits in patients with R0 resections after prior NACT. Methods. We retrospectively reviewed the records of patients who were treated with diagnosis of epithelial ovarian cancer at Institute of Oncology Ljubljana in the years 2005%2007. The differences in the rates of R0 resections, progression free survival (PFS), overall survival (OS) and in five-year and eight-year survival rates between patients treated with NACT and patients who had primary surgery were compared. Results. Overall 160 patients had stage IIIC epithelial ovarian cancer. Eighty patients had NACT and eighty patients had primary surgery. Patients in NACT group had higher rates of R0 resection (42% vs. 20%p = 0.011) than patients after primary surgery. PFS was 14.1 months in NACT group and 17.7 months after primary surgery (p = 0.213). OS was 24.8 months in NACT group and 31.6 months after primary surgery (p = 0.012). In patients with R0 resections five-year and eight-year survival rates were 20.6% and 17.6% in NACT group compared to 62.5% and 62.5% after primary surgery (p < 0.0001), respectively. Conclusions. Despite higher rates of R0 resections achieved by NACT, survival of patients treated with NACT was inferior to survival of patients who underwent primary surgery. NACT should only be offered to patients with advanced epithelial cancer who are not candidates for primary surgery

[Vpliv infuzije magnezijevega sulfata pred totalno tiroidektomijo na prehodno hipokalcemijo - randomizirana raziskava]

Background. Transient hypocalcemia is the most common complication after thyroidectomy. Normomagnesemia is needed for normal secretion of PTH and end-organ responsiveness. Our aim was to determine the influence of infusion of magnesium sulphate before thyroidectomy on the incidence of laboratory and clinical transient hypocalcemia. Methods. In our prospective study, 48 patients (5 men, 43 womenage 22-73 years, median 45 years), who underwent total or near-total thyroidectomy, were randomised preoperatively. Half of them received intravenously 4 ml of 1M magnesium sulphate at the beginning of the surgical procedure, the other half were the control group. Serum concentrations of calcium, ionised calcium, magnesium, phosphate, albumin and PTH were measured prior to surgery and on the first day after surgery. Results. Laboratory postoperative hypocalcemia was present in 27% of patients and 23% of patients had clinical signs and/or symptoms of postoperative hypocalcemia. The concentration of total calcium (p=0.024) and of albumin (p=0.01) was lower in the group that received magnesium sulphate. Conclusions.The patients who received infusion of magnesium sulphate before total thyroidectomy had lower concentration of total serum calcium and albuminin comparison to the control group. There was no statistical differencein the incidence of clinical transient hypocalcemia

Prognostični dejavniki in zdravljenje bolnikov s papilarnim mikrokarcinomom ščitnice

Papilarni mikrokarcinom ščitnice (PMKŠ) je po WHO opredeljen kot tumor, velik 1,0 cm ali manjši. V zadnjih letih narašča število preiskav ščitnice z ultrazvokom in število ultrazvočno vodenih tankoigelnih aspiracijskih biopsij, kar omogoča odkrivanje raka, še preden postane klinično zaznaven, zaradi česar narašča incidenca PMKŠ. Bolniki s PMKŠ imajo zelo dobro prognozo, zato se postavlja vprašanje, kako naj jih zdravimo, da bi jih pozdravili, a jim hkrati ne bi po nepotrebnem povzročili škode. Namen naše študije je bil ugotoviti, kateri dejavniki so pri naših bolnikih s PMKŠ povezani s ponovitvijo bolezni. Analizirali smo rezultate o 135 bolnikih s PMKŠ, ki so bili zdravljeni v letih 1976–2002 na Onkološkem inštitutu v Ljubljani. Srednja doba spremljanja bolnikov je bila od enega do 359 mesecev (srednja vrednost 85 mesecev). V tem obdobju se je pri sedmih bolnikih (5,2 %) bolezen ponovila, a nihče ni umrl zaradi bolezni. S statistično analizo z χ2-testom smo ugotovili, da je bila s pogostostjo ponovitve bolezni povezana le velikost tumorja. Z raziskavo smo potrdili opažanja drugih avtorjev, da imajo bolniki s PMKŠ dobro prognozo

Surgical treatment of breast cancer in patients aged 80 years or older – how much is enough?

Populacija starejših ljudi se veča, zato se povečuje tudi število bolnic z rakom dojke, ki so starejše od 80 let. Žal ni enotnega mnenja oziroma strokovnih priporočil o tem, kako zdraviti starejše bolnice z rakom dojk. Namen naše retrospektivneštudije je bil ugotoviti, kako kirurško zdravimo raka dojk pri bolnicah, starih 80 let ali več in kakšno je njihovo preživetje.Pregledali smo popise bolezni 154 bolnic z začetnim rakom dojke (povprečna starost 83 letrazpon od 80 do 90 let), ki so bile na Onkološkem inštitutu Ljubljana operirane vobdobju od leta 2000 do leta 2008 in so bile ob operaciji stare 80 let ali več. Zbrali smo podatke o obsegu bolezni, patomorfoloških značilnostih tumorja, načinu zdravljenja,obsegu operacije dojke in pazdušnih bezgavk, ponovitvi bolezni, vzroku smrti, dolžini preživetja in dolžini preživetjaglede raka dojk. Z univariatno in mutivariatno analizo smo ugotavljali povezavo med prognostičnimi dejavniki, vrsto zdravljenja in preživetjem glede raka dojk. Rak dojke je bilomejen na dojko v 28 %, v 47% so bili prisotni regionalni zasevki, obseg bolezni pa ni bil znan v 25 %. Tumorski stadij pT1/pT2 je imelo 75 % bolnic, pT3/pT4 pa je imelo 25 %bolnic. Kirurško zdravljenje je obsegalo: kvadrantektomijov 27 %, mastektomijo v 73 %, izpraznitev pazduhe v 57 %,biopsijo varovalne bezgavke v 18 %, brez posega v pazduho pa je bilo 25 % bolnic. Adjuvantno hormonsko zdravljenje je imelo 88 % bolnic (tamoxifen 53, aromatazni inhibitor 45,kombinacija obeh 37 bolnic), zdravljenje s citostatiki je imelo1,3 % bolnic, obsevanih pa je bilo 16 % bolnic. Ponovitev bolezni smo dokazali v 23 %, v času sledenja od 0,1 do 11 let(mediana 4,45 leta). Lokalno ponovitev bolezni smo dokazali v 10 %, reginalno v 6 % in oddaljene zasevke v 23 %. Petletno preživetje glede raka dojk je bilo pri lokalno omejenem raku 90 %, pri regionalno razširjenem pa 62 %. Ena od bolnicje umrla prvi dan po operativnem posegu zaradi srčnega infarkta. Zaradi raka dojk je umrlo 19 % bolnic, zaradi drugih vzrokov pa 12 % bolnic. Univariatna analiza je pokazala, da so bili z dolžino preživetja zaradi raka dojk povezani naslednji dejavniki: zdravljenje s hormoni pred operacijo, patološki Tstadij, patološki N stadij, operacija dojke, odstranitev vsehpazdušnih bezgavk, operacija bezgavk, estrogenski receptorji,stopnja diferenciacije tumorja, radikalnost kirurškega posega in kirurško zdravljenje v skladu s smernicami. Z multivariatnostatistično analizo smo ugotovili, da so bili patološki T stadij, patološki N stadij in estrogenski receptorji neodvisni prognostični dejavniki za dolžino preživetja zaradi raka dojk. Rezultati naše multivariatne analize kažejo, da so kirurgi ustrezno prilagodili obseg operativnega zdravljenja stadiju bolezni in splošnemu stanju bolnice. Kratko preživetje glede raka dojk je pokazatelj tega, da je rak dojke z zasevki v pazdušnih bezgavkah pri bolnicah, starih 80 let ali več, lahko agresivna bolezen.The population of older people is increasing and so is the population of breast cancer patients aged 80 years or older. Unfortunately there is no consensus or recommendations on how to treat older breast cancer patients. The aim of our retrospective study was to identify the most appropriate surgical treatment of breast cancer in patients aged 80 years or older and to determine their survival. We reviewed the medical records of 154 patients with early-stage breast cancer (mean age of 83 yearsranging from 80 to 90 years), who underwent surgery at the Institute of Oncology Ljubljana in the period from 2000 to 2008 when they were aged 80 years or older. We collected data on the extent of the disease, pathomorphology of the tumour, treatment method, extent of breast and axillary lymph node surgery, disease recurrence, cause of death, length of survival, and length of survival for breast cancer. Using univariate and multivariate analyses, we also determined the correlation between prognostic factors, type of treatment and survival. Breast cancer was growth in the breast in 28%, whereas 47% of patients were diagnosed with regional metastases, and the extent of the disease was unknown in 25%. 75% of patients were staged as pT1/pT2, while 25% had stage pT3/pT4 tumours. Surgical treatment comprised: quadrantectomy (in 27%), mastectomy (in 73%), axillary dissection (in 57%), sentinel lymph node biopsy (in 18%), and 25% of patients had no axillary surgery. A total of 88% of patients received adjuvant hormonal treatment (tamoxifen - 53 patients, aromatase inhibitor - 45 patients, a combination of both - 37 patients), while 1.3% of patients were treated with cytostatics, and 16% underwent biopsy. During follow-up of 0.1 to 11 years (median 4.45 years), disease recurrence was observed in 23%. Local recurrence of the disease was observed in 10%, regional recurrence in 6% and distant metastases in 23%. Five-year survival for breast cancer was 90% in locally limited cancer and 62% in regionally advanced cancer. One of the patients died on the first day after surgery due to a myocardial infarction. A total of 19% of all patients died of breast cancer, and 12% died of other causes. The univariate analysis showed that the length of survival of breast cancer patients was correlated with the following factors: treatment with hormones before surgery, pathological T-stage, pathological N-stage, breast surgery, lymph node surgery, oestrogen receptors, degree of tumour differentiation, radicality of surgery, and surgical treatment according to the established guidelines. Using the multivariate statistical analysis, we found that the pathological T-stage, pathological N-stage and oestrogen receptors were independent prognostic factors for the duration of survival of breast cancer patients. The results of our multivariate analysis show that surgeons adjusted the extent of operative treatment according to the stage of the disease and the general condition of the patient. Short survival for breast cancer indicates that, in patients aged 80 years or older, breast cancer with metastases in axillary lymph nodes can be a very aggressive disease