Head of Department Prof. Dr Thomas Gruenberger is regarded as a leading figure in the field of liver and biliary tract surgery, as well as pancreatic and colorectal cancer surgery, in Vienna. His extensive expertise and dedication have made him a leading specialist in his field, and his work contributes significantly to the advancement of gastroenterological surgery. Prof. Dr Gruenberger heads the state-of-the-art Gruenberger private practice in Vienna. His areas of specialization include the treatment of liver diseases, biliary tract diseases, pancreatic tumors, and bowel and liver cancer.
With an impressive medical background and many years of experience, he has earned a reputation as an expert in complex surgical procedures. As a specialist in liver and biliary tract surgery, Prof. Dr Gruenberger has developed numerous innovative procedures to provide optimal treatment for patients with liver and biliary tract diseases. His advances in minimally invasive surgery have helped to shorten recovery times and improve patients’ post-operative quality of life. In pancreatic surgery, his focus is on precise diagnostic procedures and modern surgical techniques for treating pancreatic tumors.
His holistic approach takes into account both the effectiveness of the intervention and patients’ quality of life following the procedure. His multidisciplinary approach integrates the latest developments in oncology and surgery to create bespoke treatment plans for each patient. Prof. Gruenberger’s ongoing research in the field of hepatology and gastrointestinal surgery is reflected not only in his clinical work but also in numerous scientific publications. His commitment to training young doctors and surgeons helps to pass on his extensive knowledge and experience to the next generation.
Overall, Head of Department Prof. Dr. med. Thomas Gruenberger is a key figure in Vienna’s healthcare sector, whose dedication and expertise make a significant contribution to advancing medical care in the fields of hepatology, liver and biliary tract surgery, pancreatic surgery and the treatment of colorectal cancer. In particular, the diagnosis of metastatic colorectal cancer presents a challenge. This advanced cancer, which has spread beyond its original site in the bowel, requires a comprehensive and personalized approach to medical care. For this reason, the editorial team of the Leading Medicine Guide took the opportunity to speak with Prof. Dr. Gruenberger about this specific condition.
Metastatic colorectal cancer refers to an advanced form of bowel cancer in which cancer cells break away from the original site in the bowel and spread to other parts of the body. Metastases are secondary tumors that form in distant organs or tissues and are the result of advanced cancer. Colorectal cancer typically begins as a benign growth, known as a polyp, in the large intestine or rectum (the final section of the large intestine immediately before the anus). Over time, this polyp can develop into a malignant tumor. If cancer cells from this tumor enter the bloodstream or the lymphatic system, they can be carried to other organs or tissues and form metastases there. The spread of metastases can affect various organs, with the liver and lungs being common sites.
Colorectal carcinoma, commonly known as bowel cancer, presents with a variety of symptoms that can vary from person to person.
“Firstly, the symptoms depend on where the tumor is located. If the tumor is situated at the beginning of the large intestine, constant bleeding from the tumor usually leads to anemia. This results in symptoms such as tiredness, weakness, shortness of breath and dizziness. In the early stages of rectal cancer, the symptoms are similar to those of colon cancer. Typically, changes in bowel habits occur, with alternating diarrhea and constipation, sometimes painful bowel movements or a feeling of incomplete bowel emptying. In advanced rectal cancer, rectal bleeding, pain in the anal area, weight loss and bowel obstruction may occur. The time it takes for these symptoms to become noticeable varies from person to person and depends on factors such as the type of tumor, its location and its growth rate. If everyone were to attend regular screening and have a colonoscopy, it would actually be possible to largely eradicate bowel cancer. You should have your first screening from the age of 50 and then every five years, as bowel cancer cells do not grow very quickly and it takes time for a polyp to develop. However, if bowel cancer is detected too late – which, unfortunately, happens more often due to the later onset of symptoms associated with the more aggressive right-sided tumor – the cancer spreads rapidly to other organs such as the liver or lungs, or deposits develop on the peritoneum, known as ‘peritoneal carcinomatosis’, explains Prof. Dr Gruenberger clearly.
Significant progress has been made in the treatment of metastatic colorectal cancer in recent years, particularly through the introduction of new therapeutic approaches and drug combinations.
When bowel cancer metastasises, the cancer spreads beyond the bowel to other organs or tissues in the body. Typically, in bowel cancer, metastases are found in the liver and lungs. Metastatic bowel cancer can lead to further complications and limit treatment options. The prognosis generally worsens as the cancer spreads to other organs. “The development of metastases depends on the aggressiveness of the cancer, which is usually more aggressive on the right-hand side than on the left-hand side due to molecular differences. In the past, we operated on 80% of patients with metastases that had formed during the so-called follow-up period after the removal of the colorectal cancer. Today, in 80% of patients, it is exactly the opposite: we treat patients who are diagnosed with both colorectal cancer and metastases at the same time,” notes Prof. Dr Gruenberger.
Surgery is the primary treatment method for bowel cancer, particularly in the early stages of the disease. It allows for the complete removal of the tumor and the surrounding lymph nodes to stop the cancer from progressing. “If surgery is an option, that is good news for the patient. However, surgery is not always possible, especially if the tumor is too advanced or has already spread throughout the body. Surgery is only advisable if the tumor and its metastases can be completely resected; the surgical risk should be assessed in an interdisciplinary setting. However, there have been tremendous advances in recent years in the development of new therapies, for example in chemotherapy and antibody therapy. “Around 5% of patients have microsatellite instability, for which a specific immunotherapy has been developed that can lead to complete tumor destruction in a high percentage of cases,” explains Prof. Dr Gruenberger encouragingly.
Patients with microsatellite instability (MSI) have genetic alterations that cause these repeated sequences in their genetic material to become unstable. This can lead to an increased susceptibility to certain types of cancer, particularly colorectal cancer, and may also indicate a family predisposition to cancer. The presence of MSI can also play a role in the selection of treatments, as certain therapies have been developed specifically for tumors with this instability.
There is no significant increase in the number of colorectal cancer patients. However, the causes are clear.
“In Austria, a relatively constant number of around 5,000 people are diagnosed with colorectal cancer each year; in Germany, the figure is around 60,000, due to the larger population. In Africa, for example, where many people are undernourished, there is virtually no colorectal cancer. It is a disease of modern civilisation – in the past, for instance, cases of colorectal cancer were also rare in Asia. Now that fast-food chains serving large amounts of meat have become widespread, the number of cases is rising there too. People who eat fish are significantly less likely to develop bowel cancer. Those who are physically active are also less affected, while obesity is a risk factor,” explains Prof. Dr Gruenberger.
By analyzing the genetic and molecular characteristics of the tumor, doctors can gain a better understanding of the specific properties of each patient’s cancer. “The basic fact is that colorectal cancer can be hereditary, so if there is a positive family history, a colonoscopy should be carried out before the age of 50!” urges Dr Gruenberger. The holistic treatment of patients with metastatic colorectal cancer requires a multidisciplinary approach in which various medical specialities work together. Optimal coordination between these specialities is crucial for providing the best possible care for patients.
“In addition, it has been found that the tumor often disappears completely with long-term therapy. This can then be effectively monitored using the ‘watch and wait’ method to determine whether a tumor forms again, which is the case in around a quarter of patients,” explains Prof. Dr Gruenberger, referring specifically to rectal tumors. “As for the hospital stay, it depends on whether the tumor is localized or metastatic. If it is localized and the patient receives pre-treatment radiotherapy, this varies between short-term and long-term sessions, each of which takes just two minutes on an outpatient basis. If chemotherapy is planned, this can be carried out as an inpatient procedure requiring a four-day stay, or on an outpatient basis, or even at home if tablets are taken. If surgery is planned, a hospital stay of around one week is to be expected, although minimally invasive robotic technology has reduced the length of stay for patients by two days. “Although the operation itself takes slightly longer, the procedure is much gentler on the patient,” says Prof. Dr Gruenberger, adding: “Patients undergoing minimally invasive surgery are less affected, and ultimately this is certainly reflected in longer survival rates, although this has not yet been evaluated. But the fact is that immunosuppression—the suppression of the immune system—is less severe with minimally invasive surgery than with open surgery. There are also fewer complications, simply due to the precise guidance of the robotic instruments during the operation. And complications are always a contributing factor to the potential development of a recurrence. In the case of localized colorectal cancer, depending on how advanced it is, 90% of patients remain recurrence-free over a five-year period, which is very good. If lymph node metastases have formed, the figure is 75–80%, and these patients require additional chemotherapy after surgery. In the case of metastatic colorectal cancer that has been completely removed, the survival rate is approximately five years.
The quality of life of patients with metastatic colorectal cancer is subject to a variety of factors.
These can vary greatly during and after treatment and depend on various factors. Key aspects include effective symptom management, which encompasses pain control, prevention of nausea and management of fatigue. Psychological support plays an equally important role, as the diagnosis and treatment are psychologically stressful. Anxiety, depression and other emotional challenges may arise and require appropriate care, whether through counseling or group support. Another significant factor is nutritional management, as patients with metastatic colorectal cancer often face weight loss, loss of appetite or digestive problems. Tailored nutritional management is crucial for maintaining quality of life. Similarly, exercise and rehabilitation play an important role in preserving physical function, reducing fatigue and enhancing general well-being. Social support from family, friends and support groups can improve emotional coping. A strong social network and the opportunity to share experiences with others affected by the condition are of great importance.
Call for better tumor boards.
In regular meetings, known as tumor boards, comprising doctors from various disciplines such as oncologists, surgeons, radiologists, pathologists and other specialists, individual patient cases are discussed and a personalized treatment plan is developed collaboratively. “There will certainly be even more innovative therapies. However, it is important that the patient has the right to a second opinion. This means that treatment must be able to be discussed within a well-composed tumor board, specifically with colleagues who are also up to date with the latest scientific developments regarding potential treatment methods and can therefore decide which sequence of therapies is the most promising. New forms of therapy are developed every year, and this offers great hope for an increase in cure rates at the metastatic stage. And finally, as a recommendation for prevention and supporting good health: “Eat fish once a week, and go for a walk up a hill once a week!” advises Prof. Dr Gruenberger at the end of our conversation.
Dear Professor Dr Gruenberger, thank you very much for this very important conversation!
