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Decision making in Early &
Advanced Colorectal Cancer
 More than 1 million people get colorectal cancer every year.
 Colorectal cancer is the second most common cause of cancer
in women and the third most common in men.
 It is the fourth most common cause of cancer death
after lung, stomach, and liver cancer.
 It is more common in developed than developing countries.
Epidemiology of colorectal cancer
What Are the Risk Factors
for Colorectal Cancer?
 Polyps (a noncancerous or precancerous growth associated with aging).
 Age >50 (average risk).
 Inflammatory bowel disease – chronic ulcerative colitis, Crohn’s disease.
 Diet high in saturated fats, such as red meat.
 Personal or family history of cancer colon.
 HNPCC – Lynch syndrome I, II
 Polyposis syndromes – FAP, Gardner’s syndrome, Turcot’s syndrome,
juvenile polyposis.
 Obesity.
 Smoking.
Sporadic
(average risk)
(75-80%)
Family history
(10-15%)
Hereditary non-polyposis
colorectal cancer
(HNPCC) (3-5%)
Familial adenomatous
polyposis (FAP)
(1-2%)
Rare
syndromes
(<0.1%)
What Are the Symptoms
of Colorectal Cancer?
 Symptoms could include:
 A change in bowel movements (diarrhea, constipation, never feeling
“relieved”, narrower stools).
 Blood in the stool (dark red).
 Abdominal discomfort.
 Loss of appetite.
 Weight loss for no known reason.
 Constant fatigue.
 Nausea and vomiting.
 Many people have no symptoms.
 Staging is a way of describing a cancer, such as the depth of the tumor
and where it has spread.
 Staging is the most important tool to determine patient’s prognosis
and the protocol of treatment.
 The colon cancer staging can be made according to the TNM staging
system from the WHO organization, the UICC and the AJCC.
 The Astler-Coller classification (1954) or the Dukes classification
(1932) are now less used.
Staging of Colorectal Cancer
Staging of Colorectal Cancer
Cancer
is in the
mucosa
Invasion of
muscularis
mucosa Beyond the
muscularis
mucosa
Spread to the
regional LN
What is the decision in the
following situations with
cancer colon ?
Polypectomy
Colonic Polyp with invasive cancer
 Single specimen
 Completely removed
 Free margins
 Fragmented spicemen
 Involved margins
 Unfavorable
histological features
Colectomy
 Sessile  Pedunculated
Follow up
 Follow up  Colectomy
 Adjuvant therapy and surveillance  according to pathological stage
Non metastatic cancer colon
Resectable
(non obstructing)
Locally
unresectable
Colectomy Colectomy Diversion
 Adjuvant therapy and surveillance  according to pathological stage
Resectable
(obstructing)
Resection
+
diversion
Stent Chemotherapy
Colectomy
Pathologicalstagedetermineadjuvanttherapyand surveillance
Tis, T1, N0, M0
T2, N0, M0
No Adjuvant therapy Surveillance by
Colonscopy in 1y
Advanced adenoma
Repeat in 1 y
No Advanced adenoma
Repeat in 3 y
T3, N0, M0
(no high risk features)
Advanced
No advanced
T3, N0, M0
(high risk for recurrence)
T4, N0, M0
Observe
Adjuvant therapy
(5FU/Leucovorin)
EX + CEA  3-6 m for 2y
6m for 5 years
PACT annually
PET CT not routinely recommended
Colonoscopy in
one year
T1-3, N1-2, M0
or T4, N1-2, M0
Adjuvant therapy
Adjuvant therapy
(5FU/Leucovorin)
Observe
Metastatic synchronous adenocarcinoma
Synchronous unresectable
metastasis of other sites
than liver, lung or
abdominal
Obstructing Resectable
ChemotherapyResection or diversion
or bypass or stenting
Synchronous
abdominal/Peritoneal
metastasis
Synchronous liver and
lung only
Chemotherapy
Non
Obstructing
UnresectableChemotherapy
Synchrouons or
staged colectomy
with liver or lung
resection
Resectable Unresectable
Neoadjuvant 
synchrounous or
staged colectomy with
liver or lung resection
Observation or
shortened course
chemotherapy
Colectomy 
chemotherapy 
staged resection of
metastatic ds
Observation or
shortened course
chemotherapy
 Conversion therapy
 Colon resection only
ObstructionBleeding
Re-evaluate for conversion
Every 2 months
Remained unresectable
↓
Chemotherapy
Conversion
↓
Synchronized or staged resection of colon and metastatic cancer
↓
Chemotherapy
Adjuvant therapy
(Folfox is preferred)
Synchronous liver and lung only
DocumentedMetachronousmetastasisbyCt, MRI,anda biopsy
Resectable
Previous adj.
therapy< 12m
Conversion therapy
Unresectable
Active
chemotherapy
No previous
Adj. therapy
Confirm by
PET-CT
No pervious
chemotherapy
Pervious
chemotherapy
Neoadjuvant Resection
Resection Resection
Previous adj.
therapy> 12m
Active chemotherapy
Reevaluate for conversion
every 2 months
Conversion
Resection
Active chemotherapy
No Conversion
Neoadj. chemo
What is the decision in the
following situations with
rectal cancer ?
Polypectomy
Rectal polyp with invasive carcinoma
 Single specimen
 Completely removed
 Free margins
 Fragmented spicemen
 Involved margins
 Unfavorable
histological features
 Sessile Peduculated
Observe  Observe  Look for
pathological stage
 Look for pathological
stage
T1, N0
↓
Transanal excision
T1-2, N0
↓
Transabdominal
resection
Free margins High risk features or T2
Observe
T1-2, N0, Mo T3-4 , N0, M0
or
T1-4, N1-2
Transanal excision
Adjuvant
therapy
Observe
Transabdominal resection
Clinical stage
Rectal cancerappropriate for resection
 T1-2, N0
Mentioned
before
Tranabdominal resection If resection
contraindicated
Chemotherapy
Adjuvant therapy
T3, N0
or
any T, N1-2 or T4 or
locally unresctable
Neoadjuvant chemo / RT
SynchronousmetastaticrectalCancer
Resectable
Symptomatic
Unresectable
Asymptomatic
Infusion
5FU + Pelvic
Radiotherapy
Synchronous or staged
resection of metastasis
and rectal lesion
↓
Adj. therapy
Neoadjuvant chemotherapy
Synchronous or
staged resection
of metastasis
and rectal lesion
↓
Adj. therapy
 Combined chemo
 Palliative Resection
 Laser recanalization
diversion stenting
Chemotherapy
Documentedmetachrounsmetastasis
Resectable Unresectable
Confirm by PET-CT
No pervious chemo Pervious chemo
Conversion
Resection
Active chemotherapy
Conversion therapy
Reevaluate every 2 m
No
conversion
Active chemotherapy
Resection
Adjvant
therapy
(folfox)
Neoadj.
chemotherapy
Resection
Neoadj.
chemotherapy
Resection
Resection
Active chemotherapy
Isolated pelvic/anastomotic recurrence
Potentially resectable Unresectable
Resection Preoperative 5-FU + RT
Chemotherapy ± RT Resection ± IORT
Chemotherapy ± RT
General principles for rectal
Cancer resection
 Local excision is the golden role in early stages (cT1 sm1/2).
 Transanal endoscopic microsurgery (TEM) is the standard procedure, if local
excision is chosen.
 Partial mesorectal excision is adequate for rectal cancer localized in the upper
third of the rectum (>10–15 cm from anal verge).
 Abdomino perineal resection (APR) is the preferred surgical approach in case
of tumour involvement of the anorectal junction and anal sphincter or as
salvage of local failures after local excision.
 Laparoscopic surgery might reveal equivalent results in terms of function and
relapse rate, compared with open surgery.
Take home message
 Patients with colorectal cancer should be staged and treated in a centre of
experience.
 Treatment strategy has to be decided by a multi-disciplinary team (MDT) before
treatment is started.
 Multidisciplinary team of CRC should involve (Surgical Oncologist, Medical
Oncologist, Radiation Oncologist, Radiologist, Pathologist, Oncology Nurse
Specialist, Social Worker, Nutritionist, Patient Navigator, Pharmacist)
specialists.
 Patients should be classified according to clinical stage TNM, involvement of
MRF, size, level and localization. Other factors, such as cN stage, and vascular
and nerve invasion are also relevant.
Decision making in early &amp; advanced colorectal cancer

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Decision making in early &amp; advanced colorectal cancer

  • 1. Decision making in Early & Advanced Colorectal Cancer
  • 2.  More than 1 million people get colorectal cancer every year.  Colorectal cancer is the second most common cause of cancer in women and the third most common in men.  It is the fourth most common cause of cancer death after lung, stomach, and liver cancer.  It is more common in developed than developing countries. Epidemiology of colorectal cancer
  • 3. What Are the Risk Factors for Colorectal Cancer?  Polyps (a noncancerous or precancerous growth associated with aging).  Age >50 (average risk).  Inflammatory bowel disease – chronic ulcerative colitis, Crohn’s disease.  Diet high in saturated fats, such as red meat.  Personal or family history of cancer colon.  HNPCC – Lynch syndrome I, II  Polyposis syndromes – FAP, Gardner’s syndrome, Turcot’s syndrome, juvenile polyposis.  Obesity.  Smoking.
  • 4. Sporadic (average risk) (75-80%) Family history (10-15%) Hereditary non-polyposis colorectal cancer (HNPCC) (3-5%) Familial adenomatous polyposis (FAP) (1-2%) Rare syndromes (<0.1%)
  • 5. What Are the Symptoms of Colorectal Cancer?  Symptoms could include:  A change in bowel movements (diarrhea, constipation, never feeling “relieved”, narrower stools).  Blood in the stool (dark red).  Abdominal discomfort.  Loss of appetite.  Weight loss for no known reason.  Constant fatigue.  Nausea and vomiting.  Many people have no symptoms.
  • 6.  Staging is a way of describing a cancer, such as the depth of the tumor and where it has spread.  Staging is the most important tool to determine patient’s prognosis and the protocol of treatment.  The colon cancer staging can be made according to the TNM staging system from the WHO organization, the UICC and the AJCC.  The Astler-Coller classification (1954) or the Dukes classification (1932) are now less used. Staging of Colorectal Cancer
  • 7. Staging of Colorectal Cancer Cancer is in the mucosa Invasion of muscularis mucosa Beyond the muscularis mucosa Spread to the regional LN
  • 8. What is the decision in the following situations with cancer colon ?
  • 9. Polypectomy Colonic Polyp with invasive cancer  Single specimen  Completely removed  Free margins  Fragmented spicemen  Involved margins  Unfavorable histological features Colectomy  Sessile  Pedunculated Follow up  Follow up  Colectomy  Adjuvant therapy and surveillance  according to pathological stage
  • 10. Non metastatic cancer colon Resectable (non obstructing) Locally unresectable Colectomy Colectomy Diversion  Adjuvant therapy and surveillance  according to pathological stage Resectable (obstructing) Resection + diversion Stent Chemotherapy Colectomy
  • 11. Pathologicalstagedetermineadjuvanttherapyand surveillance Tis, T1, N0, M0 T2, N0, M0 No Adjuvant therapy Surveillance by Colonscopy in 1y Advanced adenoma Repeat in 1 y No Advanced adenoma Repeat in 3 y T3, N0, M0 (no high risk features) Advanced No advanced T3, N0, M0 (high risk for recurrence) T4, N0, M0 Observe Adjuvant therapy (5FU/Leucovorin) EX + CEA  3-6 m for 2y 6m for 5 years PACT annually PET CT not routinely recommended Colonoscopy in one year T1-3, N1-2, M0 or T4, N1-2, M0 Adjuvant therapy Adjuvant therapy (5FU/Leucovorin) Observe
  • 12. Metastatic synchronous adenocarcinoma Synchronous unresectable metastasis of other sites than liver, lung or abdominal Obstructing Resectable ChemotherapyResection or diversion or bypass or stenting Synchronous abdominal/Peritoneal metastasis Synchronous liver and lung only Chemotherapy Non Obstructing UnresectableChemotherapy
  • 13. Synchrouons or staged colectomy with liver or lung resection Resectable Unresectable Neoadjuvant  synchrounous or staged colectomy with liver or lung resection Observation or shortened course chemotherapy Colectomy  chemotherapy  staged resection of metastatic ds Observation or shortened course chemotherapy  Conversion therapy  Colon resection only ObstructionBleeding Re-evaluate for conversion Every 2 months Remained unresectable ↓ Chemotherapy Conversion ↓ Synchronized or staged resection of colon and metastatic cancer ↓ Chemotherapy Adjuvant therapy (Folfox is preferred) Synchronous liver and lung only
  • 14. DocumentedMetachronousmetastasisbyCt, MRI,anda biopsy Resectable Previous adj. therapy< 12m Conversion therapy Unresectable Active chemotherapy No previous Adj. therapy Confirm by PET-CT No pervious chemotherapy Pervious chemotherapy Neoadjuvant Resection Resection Resection Previous adj. therapy> 12m Active chemotherapy Reevaluate for conversion every 2 months Conversion Resection Active chemotherapy No Conversion Neoadj. chemo
  • 15. What is the decision in the following situations with rectal cancer ?
  • 16. Polypectomy Rectal polyp with invasive carcinoma  Single specimen  Completely removed  Free margins  Fragmented spicemen  Involved margins  Unfavorable histological features  Sessile Peduculated Observe  Observe  Look for pathological stage  Look for pathological stage T1, N0 ↓ Transanal excision T1-2, N0 ↓ Transabdominal resection
  • 17. Free margins High risk features or T2 Observe T1-2, N0, Mo T3-4 , N0, M0 or T1-4, N1-2 Transanal excision Adjuvant therapy Observe Transabdominal resection
  • 18. Clinical stage Rectal cancerappropriate for resection  T1-2, N0 Mentioned before Tranabdominal resection If resection contraindicated Chemotherapy Adjuvant therapy T3, N0 or any T, N1-2 or T4 or locally unresctable Neoadjuvant chemo / RT
  • 19. SynchronousmetastaticrectalCancer Resectable Symptomatic Unresectable Asymptomatic Infusion 5FU + Pelvic Radiotherapy Synchronous or staged resection of metastasis and rectal lesion ↓ Adj. therapy Neoadjuvant chemotherapy Synchronous or staged resection of metastasis and rectal lesion ↓ Adj. therapy  Combined chemo  Palliative Resection  Laser recanalization diversion stenting Chemotherapy
  • 20. Documentedmetachrounsmetastasis Resectable Unresectable Confirm by PET-CT No pervious chemo Pervious chemo Conversion Resection Active chemotherapy Conversion therapy Reevaluate every 2 m No conversion Active chemotherapy Resection Adjvant therapy (folfox) Neoadj. chemotherapy Resection Neoadj. chemotherapy Resection Resection Active chemotherapy
  • 21. Isolated pelvic/anastomotic recurrence Potentially resectable Unresectable Resection Preoperative 5-FU + RT Chemotherapy ± RT Resection ± IORT Chemotherapy ± RT
  • 22. General principles for rectal Cancer resection  Local excision is the golden role in early stages (cT1 sm1/2).  Transanal endoscopic microsurgery (TEM) is the standard procedure, if local excision is chosen.  Partial mesorectal excision is adequate for rectal cancer localized in the upper third of the rectum (>10–15 cm from anal verge).  Abdomino perineal resection (APR) is the preferred surgical approach in case of tumour involvement of the anorectal junction and anal sphincter or as salvage of local failures after local excision.  Laparoscopic surgery might reveal equivalent results in terms of function and relapse rate, compared with open surgery.
  • 23. Take home message  Patients with colorectal cancer should be staged and treated in a centre of experience.  Treatment strategy has to be decided by a multi-disciplinary team (MDT) before treatment is started.  Multidisciplinary team of CRC should involve (Surgical Oncologist, Medical Oncologist, Radiation Oncologist, Radiologist, Pathologist, Oncology Nurse Specialist, Social Worker, Nutritionist, Patient Navigator, Pharmacist) specialists.  Patients should be classified according to clinical stage TNM, involvement of MRF, size, level and localization. Other factors, such as cN stage, and vascular and nerve invasion are also relevant.