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

Pathological stage determine adjuvant therapy and surveillance

Tis, T1, N0, M0T2, 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, M0or 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

Documented Metachronous metastasis by Ct, MRI, and a 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 cancer appropriate for resection

T1-2, N0

Mentioned before

Tranabdominal resection If resectioncontraindicated

ChemotherapyAdjuvant therapy

T3, N0or

any T, N1-2 or T4 or locally unresctable

Neoadjuvant chemo / RT

Synchronous metastatic rectal Cancer

Resectable

Symptomatic

Unresectable

Asymptomatic

Infusion5FU + 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

Documented metachrouns metastasis

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.