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)

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