كتاب
Localized Colon Cancer
- Recommendations
1. Diagnostic work-up for localized colon cancer
➡️ In the absence of a bowel obstruction or massive haemorrhage, which may constitute indications of an urgent tumour resection, a total colonoscopy is recommended for diagnostic confirmation of colon cancer as there are many advantages of endoscopy including determination and marking of the exact tumour location, biopsy of the lesion, and detection and removal of (further) synchronous precancerous or cancerous lesions.
Strong recommendation, High grade evidence (5).
➡️ In cases where complete colonic exploration cannot be carried out before
surgery, a complete colonoscopy should be carried out within 3 to 6 months.
Strong recommendation, Low grade evidence (5).
➡️ A complete work-up should be carried out to achieve an accurate histological diagnosis of the primary tumor, assess the baseline characteristics of the patient and determine the extent of the disease
Strong recommendation, High grade evidence (5)
➡️ Besides a comprehensive physical examination, blood tests including complete blood count and chemistry profile should be performed.
Strong recommendation, High grade evidence (5).
➡️ In addition, serum levels of CEA (although not sufficient for colon cancer diagnosis themselves in the absence of a confirmatory tumor biopsy) should be evaluated before surgery and monitored during the follow-up period to help the early detection of metastatic disease.
Strong recommendation, Low grade evidence (6-8)
➡️ CT of the thoracic, abdominal and pelvic cavities with i.v. contrast administration is the preferred radiological method for the evaluation of the extent of CRC.
Strong recommendation, High grade evidence (9,10)
➡️ Contrast-enhanced MRI constitutes the reference test for evaluation of the relationship of locally advanced tumors with surrounding structures or in defining ambiguous hepatic lesions.
Strong recommendation, High grade evidence (11).
➡️ FDG/PET,with or without integrated CT (PET/CT), does not add significant information to the CT scans on preoperative staging of CRC and is not recommended for routine use in staging of localized CRC except if assisting in interpretation of ambiguous findings.
Strong recommendation, High grade evidence (8,12).
2. MANAGEMENT OF LOCAL/LOCOREGIONAL DISEASE
General recommendations
➡️ En bloc endoscopic resection of the polyp is recommended and sufficient for non-invasive (pTis, i.e. intraepithelial or intramucosal) adenocarcinomas
Strong recommendation, Low grade evidence (13-15)
➡️ The presence of invasive carcinoma (pT1) in a polyp should require a thorough review with the pathologist and surgeon. High-risk features mandating surgical resection with lymphadenectomy include lymphatic or venous invasion, grade 2 or 3 differentiation, or tumour budding.
Strong recommendation, Low grade evidence (16-18)
➡️ Laparoscopic colectomy can be safely carried out for colon cancer when technical expertise is available in the absence of contraindications, in view of reduced morbidity, improved tolerance and similar oncological outcomes.
Conditional recommendation, Hogh grade evidence (19,20)
➡️ Obstructive CRCs can be treated in one- or two-stage procedures, as indicated.
Strong recommendation, Low grade evidence (21,22)
➡️ A standard surgical/pathological report should include specimen description and surgical procedure, tumour site and size, macroscopic tumour perforation, histological type and grade, extension into the bowel wall and adjacent organs, distance of cancer from resected margins (proximal, distal and radial), presence or absence of tumour deposits, lymphovascular and/or perineural invasion, tumour budding, site and number of removed and involved regional lymph nodes, and involvement of other organs.
Strong recommendation, Low grade evidence (16,23)
➡️ Adjuvant therapy options should be fully discussed with the patient, taking into consideration tumour risk of recurrence, expected benefit from chemotherapy and risk of complications.
Good Practice Statement
➡️ The risk of relapse after a colon cancer resection should be assessed by integrating the TNM staging, biologic profile and number of lymph nodes sampled.
Strong recommendation, low grade evidence (24).
➡️ Other additional clinicopathological features such as the histological subtype and grading, lymphatic or venous or perineural invasion, lymphoid inflammatory response ,involvement of resection margins and bowel obstruction should be taken into consideration for refining the risk assessment on stage II tumours.
Strong recommendation, low grade evidence (25-27).
➡️ It can be generalised that benefits of treatment with fluoropyrimidines alone or with oxaliplatin, seems to be more limited with a higher likelihood for toxicity in older patients.
Conditional recommendation, very low grade evidence (28).
Management of stage II and III disease
Stage III disease
· Combinations of fluoropyrimidines, either 5-FU or capecitabine, and oxaliplatin constitute the bases for stage III colon cancer adjuvant treatment
Strong recommendation, high grade evidence (29-31).
· The length of oxaliplatin-based adjuvant treatment of stage III colon cancer based on the IDEA data should be tailored to 3 or 6 months for CAPOX or 6 months for FOLFOX, and also taking into consideration pathological risk characteristics, patient comorbidity and risk assessment (see Annex 4).
Strong recommendation, high grade evidence (32).
· Further adaptation of the treatment according to risk subgroups: 3 months for CAPOX or 3-6 months for folfox (T 1-3 N1 disease), 3-6 months for CAPOX or 6 months for FOLFOx (T4 or N2 disease)based on IDEA collaboration should be made with caution, since this was based on a post-hoc analysis, non-significant for interaction (see Annex 4).
Strong recommendation,high grade evidence (32)
· For patients not fit for or not tolerating oxaliplatin, either capecitabine or LV5FU2 (de Gramont) infusion are acceptable alternative adjuvant regimens for a 6-month duration.
Strong recommendation, high grade evidence (32).
Stage II disease
· For patients with low-risk stage II colon cancer (see Annex 3), follow-up is recommended or consider capecitabine (6 mo) or 5-FU/leucovorin (6 mo)
Strong recommendation, high grade evidence (33-37).
Conditional recommendation, high grade evidence (33-37).
· Patients with high-risk stage II colon cancer (see Annex 3) are to be considered for 3 months of CAPOX, as the IDEA-pooled analysis showed non-inferiority of 3 months of CAPOX and inferiority of 3 months of FOLFOX when compared with 6 months of FOLFOX, with all the limitations of post-hoc analyses (see Annex 4).
Strong recommendation, high grade evidence (32).
· It is important to start adjuvant chemotherapy as soon as possible after surgery and ideally not later than 8 weeks.
Strong recommendation, high grade evidence (38-40).
➡️ Follow up (41-47)
· Intensive follow-up allows earlier detection of relapses in patients at risk
Strong recommendation, high grade evidence.
· History and physical examination and CEA level determination are advised every 3-6 months for 2 years and every 6 months for the following 3 years
Strong recommendation, high grade evidence.
· Colonoscopy must be carried out at year 1 and every 3-5 years thereafter, looking for metachronous adenomas and cancers.
Strong recommendation, moderate grade evidence.
l Perform CT scan of chest and abdomen every 6-12 months from date of surgery for a total of 5 years.
Strong recommendation, high grade evidence.
· Other laboratory and radiological examinations are of unproven benefit and must be restricted to patients with suspicious symptoms.
Conditional recommendation, very low grade evidence.
· Long-term follow-up, rehabilitation and survivorship care programmes should be implemented, aiming at detection of recurrent or new cancers, assessment and management of late and psychosocial effects and implementation of health promotion measures.
Strong recommendation, low grade evidence.
