Localized Colon Cancer

Recommendations

Strength of the recommendation

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

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

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

Besides a comprehensive physical examination, blood tests including complete blood count and chemistry profile should be performed.

Strong

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

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

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

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

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

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

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

Obstructive CRCs can be treated in one- or two-stage procedures, as indicated.

Strong

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

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

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

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

Management of stage II and III disease

Stage III disease

Combinations of fluoropyrimidines, either 5-FU or capecitabine, and oxaliplatin constitute the basis for stage III colon cancer adjuvant treatment.

Strong

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

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

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

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

For patients with intermediate risk (non-MMR/MSI + any risk factor except pT4 or multiple intermediate risk factors, regardless of MSI) consider the addition of oxaliplatin (see Annex 3).

Conditional

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

Follow up

Intensive follow-up allows earlier detection of relapses in patients at risk

Strong

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

Colonoscopy must be carried out at year 1 and if advanced adenoma, repeat in 1 year, but if no advanced adenoma,  repeat after 3 years, then every 5 years

Strong

Perform CT scan of chest and abdomen every 6-12 months from date of surgery for a total of 5 years.

Strong

Other laboratory and radiological examinations are of unproven benefit and must be restricted to patients with suspicious symptoms.

Conditional

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