Result card

  • CUR20: How should adenomas/CRC be managed according to published algorithms/guidelines?
English

How should adenomas/CRC be managed according to published algorithms/guidelines?

Authors: Mirjana Huic, Eleftheria Karampli, Silvia Florescu, Cipriana Mihaescu-Pintia

Internal reviewers: Laura Cacciani, Sophie Brunner, Esther Kraft

Answers could be found also in previous Results card, CUR 18.

Standard treatment options for Stage 1 and II colon cancer include wide surgical resection and anastomosis. The potential value of adjuvant chemotherapy for patients with Stage II colon cancer remains controversial. Standard treatment options for Stage III colon cancer include surgery and adjuvant chemotherapy. Chemotherapy is also used for Stage IV and recurrent colon cancer treatment. Different drugs are available that are used alone and in combination with other drugs in different chemotherapy regiments. The best way to combine and sequence these agents is still not established. Management according to some guidelines {2,63,64}

 is summarised in the following Table 1. Due the fact that the best way to combine and sequence these agents is still not established, guidelines described below are slightly different according regiments used in 1st-  or 2nd -line treatment.

 

Table 1. Management of adenomas/CRC according the guidelines

NICE Guideline, 2011 {63}

 

                                

 

Stage I colorectal cancer

 

Surgical resection,  with further treatment to patients whose tumour had involved resection margins (less than 1 mm)

 

The colorectal multidisciplinary team (MDT) should consider further treatment for patients with locally excised, pathologically confirmed stage I cancer, taking into account pathological characteristics of the lesion, imaging results and previous treatments.

 

Follow-up after curative resection

 

Regular surveillance with: a minimum of two CTs of the chest, abdomen, and pelvis in the first 3 years and regular serum carcinoembryonic antigen tests (at least every 6 months in the first 3 years).

 

Advanced and metastatic colorectal cancer

 

FOLFOX (folinic acid plus fluorouracil plus oxaliplatin) as first-line treatment then single agent irinotecan as second-line treatment or

 

FOLFOX as first-line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan) as second-line treatment or

 

XELOX (capecitabine plus oxaliplatin) as first-line treatment then FOLFIRI (folinic acid plus fluorouracil plus irinotecan) as second-line treatment

SIGN Guideline,  2011

{64}

 

 

Laparoscopic and open surgery can be offered for resection of colorectal cancer.

 

All patients with Stage III colorectal cancer should be considered for adjuvant chemotherapy

 

Combination treatment with 5-FU/leucovorin/oxaliplatin or capecitabine and oxaliplatin or 5-FU/leucovorin/irinotecan is the preferred options in patients with good performance status and adequate organ function.

 

Consider raltitrexed for patients with metastatic colorectal cancer who are intolerant to 5-FU and leucovorin, or for whom these drugs are not suitable.

 

Second line chemotherapy should be considered for patients with metastatic colorectal cancer with good performance status and adequate organ function.

 

Irinotecan should be used as second line therapy following first line oxaliplatin (or vice versa).

 

Cetuximab should be considered in combination with 5-FU/leucovorin/ oxaliplatin or 5-FU/leucovorin/irinotecan chemotherapy for patients with unresectable liver metastases if patients fulfil the SMC criteria.

 

Rectal cancer

 

Patients considered to have a moderate risk of local recurrence with total mesorectal excision surgery alone, and in whom the CRM is not threatened or breached on MRI, could be considered for preoperative radiotherapy (25 Gy in five fractions over one week) and immediate TME surgery.

 

Patients who require down staging of the tumour because of encroachment on the mesorectal fascia should receive combination chemotherapy and radiotherapy, (BED >30 Gy) followed by surgery at an interval to allow cytoreduction.

EU Guideline, 2010 {2}

 

 

General requirements for treatment of colorectal cancer and pre-malignant lesions

Colorectal neoplasia should be managed by a multi-disciplinary team (VI - A).

 

The interval between the diagnosis of screen-detected disease and the start of definitive management should be minimised and in 95% of cases should be no more than 31 days (VI - B).

 

Colonoscopy should always be done with therapeutic intent i.e. the endoscopist carrying out screening or follow-up colonoscopy should have the necessary expertise to remove all but the most demanding superficial lesions (VI - A).

 

Management of pre-malignant colorectal lesions

Pre-malignant lesions detected at screening endoscopy should be removed (III - A).

Lesions that have been removed should be retrieved for histological examination (VI - A).

 

Colorectal lesions should only be removed by endoscopists with adequate training in techniques of polypectomy (V - A).

 

Large sessile lesions of the rectum should be considered for transanal surgical removal (II - B).

 

For large sessile rectal lesions, transanal endoscopic microsurgery (TEM) is the recommended method of local excision (II - B).

 

Consideration should be given to tertiary referral for patients with large sessile colorectal lesions (V - B).

 

Patients with large pre-malignant lesions not suitable for endoscopic resection should be referred for surgical resection (VI - A).

 

Appropriate precautions should be taken prior to endoscopic excision of colorectal lesions in patients on anticoagulants (V - C).

 

In patients with bare coronary stents, polypectomy should be delayed for at least one month from placement of the stents, when it is safe to discontinue clopidogrel temporarily (V - B).

 

In patients with drug-eluting coronary stents, polypectomy should be delayed for 12 months from placement of the stents, when it is safe to discontinue clopidogrel temporarily (V - B).

 

In patients with drug-eluting coronary stents, when early polypectomy is deemed essential, it can be delayed for only 6 months from placement of the stents, when it is probably safe to discontinue clopidogrel temporarily (VI - C).

 

Aspirin therapy can (IV – C) - and in patients with stents should - be continued prior to and during polypectomy (VI – B).

 

Management of pT1 colorectal cancer

If there is clinical suspicion of a pT1 cancer, a site of excision should be marked with submucosal India ink (VI - C).

 

Where a pT1 cancer is considered high-risk for residual disease consideration should be given to completion colectomy along with radical lymphadenectomy, both for rectal cancer (II - A) and colon cancer (VI - A). If surgical resection is recommended, consideration should be given to obtaining an opinion from a second histopathologist as variation exists in evaluating high risk features (VI - B).

 

After excision of a pT1 cancer, a standardised follow-up regime should be instituted (VI - A). The surveillance policy employed for high-risk adenomas is appropriate for follow-up after removal of a low-risk pT1 cancer (III - B).

 

Management of colon cancer

If a complete colonoscopy has not been performed either because the primary lesion precluded total colonoscopy, or for any other reason for failure to complete colonoscopy, the rest of the colon should be visualised radiologically before surgery if at all possible. This should be performed ideally by CT colography, or if this is not available, by high-quality double-contrast barium enema. If for any reason the colon is not visualised prior to surgery, complete colonoscopy should be carried out within 3 to 6 months of colectomy (VI - B).

 

Patients with a proven screen-detected cancer should undergo pre-operative staging by means of CT scanning of the abdomen and pelvis (V - B). Routine chest CT is not recommended (III - D).

 

Patients with screen-detected colon cancer that has not been adequately resected endoscopically should have surgical resection by an adequately trained surgeon (III - A).

 

Where appropriate, laparoscopic colorectal surgery should be considered (I - A).

 

Management of rectal cancer

If a complete colonoscopy has not been performed either because the primary lesion precluded total colonoscopy, or any other reason for failure to complete colonoscopy, the rest of the colorectum should be visualised radiologically before surgery if at all possible. This should be performed ideally by CT colography, or if this is not available, by high-quality double-contrast barium enema. If for any reason the colon is not visualised prior to surgery, complete colonoscopy should be carried out within 6 months to 1 year of excision of the rectal cancer (VI - B).

 

Patients with a proven screen-detected rectal cancer should undergo pre-operative staging by means of CT scanning of the abdomen and pelvis (VI - B). Routine chest CT is not recommended (III - D).

 

Patients with a proven screen-detected rectal cancer should ideally undergo pre-operative local staging by means of MRI scanning of the pelvis in order to facilitate planning of pre-operative radiotherapy (III - B), although high-quality multi-slice CT scanning may provide adequate information (VI - C).

 

All patients undergoing radical surgery for rectal cancer should have mesorectal excision (II - A) by an adequately trained specialist surgeon (VI - A).

 

Patients undergoing surgery for rectal cancer may be considered for laparoscopic surgery (I - B).

 

All patients undergoing surgery for rectal cancer (and certainly those predicted on imaging to have T3/4 cancers and/or lymph node metastases) should be considered for pre-operative adjuvant radiotherapy with or without chemotherapy (I - A).

 

Local excision alone should only be performed for T1 sm1 rectal cancers, and if the patient is fit for radical surgery (III - B).

In the patient in whom there is doubt about fitness for radical surgery, local excision of more advanced rectal cancer should be considered (III - B).

 

In patients in whom local excision for rectal cancer is planned, consideration should be given to pre-operative CRT (III - C).

 

If a local excision is carried out, and the pT stage is T1 sm3 or worse, then radical excision should be performed if the patient is fit for radical surgery (II- B).


Important
Partially
Huic M et al. Result Card CUR20 In: Huic M et al. Health Problem and Current Use of the Technology In: Jefferson T, Cerbo M, Vicari N [eds.]. Fecal Immunochemical Test (FIT ) versus guaiac-based fecal occult blood test (FOBT) for colorectal cancer screening [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali; 2014. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=206

References