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S. Cascinu - Colorectal cancer - Guidelines and clinical case presentation (2-3 cases)

S. Cascinu - Colorectal cancer - Guidelines and clinical case presentation (2-3 cases)






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    S. Cascinu - Colorectal cancer - Guidelines and clinical case presentation (2-3 cases) S. Cascinu - Colorectal cancer - Guidelines and clinical case presentation (2-3 cases) Presentation Transcript

    • Stefano Cascinu Department of Medical Oncology Università Politecnica delle Marche Ancona, Italy Colorectal Cancer: ESMO or NCCN Guidelines?
      • Screening
      • Diagnosis
      • Staging
      • Adjuvant
      • Advanced disease
      • Follow-up
    • Screening: general population
      • FOBT:
        • reduces mortality by 25%
        • it should be offered to men and women aged 50 years until 74 years.
        • The screening interval shoud be 1-2 years.
    • Screening: high risk population
      • Lynch syndrome
      • Colonoscopy starting at age 20-25 every 1-2 years.
      • Endometrial and ovarian cancer screening may be performed yearly starting at 30-35 years.
      • Surveillance for other Lynch-associated cancers is recommended based on the family history (upper endoscopy and abdominal US).
      • FAP
      • Classic FAP:
        • Sigmoidoscopy every 2 years starting at age 12-14. Once adenomas are detected colonoscopy should be performed annually
      • Attenuated form:
        • Colonoscopy every two years starting at 18-20, lifelong. Once adenomas are detected it should be performed annually.
    • Diagnostic and staging workup
    • Diagnosis
      • Endoscopy plus biopsy
      • Virtual colonoscopy or CT colonography: not standard procedures but useful to precisely locate the tumor for the surgical approach in patients candidates for laparoscopy.
      • Physical examination
      • Laboratory data
        • Blood count; CEA, liver chemistry
      • Instrumental work-up
        • Preoperative: CT scan (chest and abdomen)
        • Surgical staging: assessment of the liver intraoperative US, nodal spread
    • A F D O J L U L V O A W N U T P and T H E R A P Y
    • Adjuvant therapy
      • Stage III, fit patients:
        • 6 months FOLFOX or XELOX
      • Stage III, unfit patients
        • 6 months Capecitabine or 5-fluorouracil
      • Stage III elderly patients (>70Years)
        • 6 months 5fluorouracil (?)
    • Adjuvant therapy
      • Stage II patients low risk
        • No adjuvant therapy
      • Stage II patients high risk (lymph-node sampling<12; poorly differentiated tumors; vascular or lymphatic or perineural invasion; tumor presentation with obstruction or perforation; pT4)
        • Adjuvant therapy with 5FU or FOLFOX
      • Stage II patients MSI
        • No adjuvant therapy or, if at high risk, FOLFOX
    • Follow-up
      • CT scan of chest and abdomen every 6-12 months
      • CEUS could substitute CT scan
      • Colonoscopy performed at 1 year and then every 3-5 years
      • PET/scan is not recommended
    • Advanced disease
      • Aggressive therapy
        • Symptomatic disease
        • Borderline resectable liver metastases
      • No aggressive therapy
        • Indolent disease
        • Elderly patients
      • Synchronous metastases:
      • Resectable
      • unresectable
      • Metachronous metastases
      • Resectable
      • Unresectable
    • Rectal cancer
    • Metastatic at diagnosis
    • staging Endoscopic ultrasound MRI for all rectal tumours
      • Preoperative therapy
      • Postoperative therapy
      • cT1-2 and some cT3 (a) above elevators, surgery alone
      • cT3 (b); cT4, N+ preoperative chemo- radiotherapy
      • Tis, T1 N0 local excision
      • T2 N0 wide surgical resection
      • T3/T4 N0 surgery and adjuvant therapy
      • T any N1/2 surgery and adjuvant therapy