Colorectal cancer

Guidelines for management

Dr Ramdip Ray MBBS, MS, MRCS ( Eng )

Department of General Surgery Medical College, Kolkata

Guidelines reviewed
Association of Coloproctology of Great Britain & Ireland : 2001 Scottish Intercollegiate Guidelines Network (SIGN) : March 2003 American Society of Colon & Rectal Surgeons practice parameters : Feb 2005 Clinical practice guidelines of National Health & Medical Research Council, Australia : Dec 2005 Tata Memorial Hospital : Treatment guidelines

Levels of Evidence
Ia : Ib : IIa : IIb : Meta-analysis of RCTs At least one RCT At least one well-designed controlled study At least one other type of well-designed quasi-experimental study Well-designed non-experimental descriptive studies such as comparative studies, correlation studies and case studies Expert committee reports or opinions or clinical experiences of respected authorities

III :

IV :

Grading of Recommendations
A B C
At least one good quality specific RCT : Ia, Ib
Well-conducted clinical studies : IIa, IIb, III

Expert committee reports or clinical experience of respected authorities : IV

Types of Guidelines
Screening Diagnosis

Treatment
Follow up

Imaging for Stage

EUS to identify T1 rectal cancers,where local excision is being considered CT or MRI to assess involvement of adjacent organs in more advanced tumours CXR in all USG / CT for liver. Intra / post-op USG in emergency Full colonoscopy . Otherwise Ba-enema

C B

ACGBI

ASCRS

Chest X-ray
UK Colorectal Cancer Working Party :
CXR in all

The Australian ( NHMRC ) stand : CXR has low sensitivity for pulmonary mets, which does not justify its routine use in pre-op staging

Imaging for Operable Rectal CA

CT of abdomen & pelvis and EUS or MRI
MRI for T3 or T4 EUS for T1 or T2 especially for mid-, distal- rectal tumours

ASCRS

CT colonography
Significantly less discomfort and is rapidly replacing Ba-enema as the method of choice for colonic imaging
Aus

CEA

Should usually be checked pre-op

ASCRS

Access to Treatment
Patients should receive treatment within 4 weeks of making a diagnosis of colorectal cancer

ACGBI

Blood transfusion

Should not be withheld if indicated Preparations for transfusion in all patients undergoing surgery, unless patient refuses

No difference in prognosis after blood transfusion Busch et al 1993 :

Ib

Pre-op
Mechanical bowel preparation is recommended
C
ACGBI

Subcut. heparin and/or intermittent compression A Antibiotic prophylaxis in all

single dose intravenous antibiotics seems effective A

ACGBI

ACGBI

Resection margin
2 cm distal margin adequate for most rectal cancers 1 cm acceptable for smaller cancers of the low rectum without adverse histology
B
ASCRS

ASCRS

Proximal Vascular Ligation

Proximal ligation at origin of superior rectal artery adequate for most rectal cancers ( just distal to LCA ) With clinically involved lymph nodes, removal of suspicious nodal disease up to origin of IMA
B
ASCRS

ASCRS

TME
In lower two-thirds of rectum : TME
B
ACGBI

Tumours of the upper rectum : Mesorectum should be divided no less than 5 cm below the lower margin

T4 tumours
Treated with en bloc resection of adjacent organ, if sacrificable
B
ASCRS

Ovaries
Ovarian mets from rectal cancer in 6%, but no data for removal of grossly normal ovaries B If direct invasion : en bloc resection
ASCRS

Oophorectomy to be considered if ovary grossly abnormal in postmenopausal females or after pre-op pelvic RT Bilateral oophorectomy if only one ovary is involved, because high risk of occult mets

Inadvertant rectal perforation

Especially at site of cancer, worsens oncologic outcome Should be documented & considered in adjuvant treatment decisions
B
ASCRS

Rectal washout

Insufficient evidence

ASCRS

Local excision for T1

Curative local excision appropriate for carefully selected T1 rectal cancers B - well-differentiated - < 3cm diameter - <40 % circumference

ASCRS

Laparoscopy
Laparoscopic-assisted resection of rectal cancer feasible but requires expertise Oncologic effectiveness remains uncertain

ASCRS

Emergency
Primary resection of an obstructing or perforated carcinoma is recommended unless medically contraindicated - Stents may temporize & allow bowel preparation before surgery

ASCRS

Colon CA

Surgery is mainstay After adequate Surgery, locoregional failure is rare Hence, RT little role CT to prevent distant failure

Colon CA
Stage I : Surgery Stage II : Surgery maybe CTif elevated CEA/undifferen / IV
high S phase / less MSI / 18q del

Stage III : Surgery - CT A Stage IV : CT Surgery if resectable liver / lung mets B RT if residual / R1, R2 tumour

ACGBI

ACGBI

Chemotherapy for CA Colon

Preoperative or postoperative
5-FU / Levamisole FU / Leucovorin FOLFOX : Leucovorin / 5-FU / Oxaleplatin

Adjuvant therapy : Rectal CA

Adjuvant or Neoadjuvant Chemoradiation: Stages II & A III

Chemotherapy alone does not reduce local recurrence

ASCRS

Adjuvant vs Neo adjuvant CMT

CAO/ ARO / AIO-94 trial

800 patients Early results : no difference in morbidity,but higher sphincter preservation for preop CMT group Recent update : after preop CMT - reduction in local recurrence - less anastomotic stenosis - better sphincter preservation

Polish Colorectal Study Group trial

Long-course 50.4 Gy RT + bolus 5-FU/LV vs Short-course RT (25 Gy in 5 days) before TME Early data : long-course CMT arm - more acute toxicity - greater tumor shrinkage - similar sphincter preservation rate

NSABP R03 trial

Preoperative vs. postoperative CMT Early results: preoperative patients had greater sphincter-sparing surgery, but higher toxicity

Radiotherapy for Rectal CA

Preop or postop Short course : 2,500 cGy over 5 days or Long course : 5,040 cGy over 42 days Post-op RT : 40-50 Gy in 20-25 fractions
B
ACGBI

Outcome goals
Colorectal Cancer Units should audit and achieve: Operative mortality Wound infection Clinical leak rate : Emergency 15-25% Elective 4-7% : 10 % : B A
ACGBI

ACGBI

Anterior Resection 8% Ultra low pelvic anastomoses 15% B

ACGBI

Local recurrence rates : 10% ( rectal CA )within 2 yrs

ACGBI

Thank you