Authors: Mirjana Huic, Eleftheria Karampli, Silvia Florescu, Cipriana Mihaescu-Pintia
Internal reviewers: Laura Cacciani, Sophie Brunner, Esther Kraft
Removal of adenoma at colonoscopy and subsequent surveillance reduces the risk of development of colon cancer by approximately 80%. The remaining 20% are either newly formed, missed, or difficult to detect, e.g. flat adenoma.
Treatment of CRC should be taken by multidisciplinary teams working in special units.
Long-term survival relates to the stage of the primary tumour and the presence of metastatic disease. Long-term survival is only likely when the cancer is completely removed by surgery with adequate clearance margins and regional lymph node clearance.
Surgical resection of colonic segment containing tumor (preoperative evaluation to assess prognosis and surgical approach includes full colonoscopy, chest RTG, biochemical liver tests, plasma CEA level, and possible abdominal CT). Resection of isolated hepatic metastases possible in selected cases.
Adjuvant radiotherapy to pelvis (with or without concomitant 5FU chemotherapy) decreases local recurrence rate of rectal carcinoma, radiation may improve resectability and local control in patients with rectal cancer. Total mesorectal excition is more effective than conventional anteroposterior resection in rectal cancer.
Adjuvant chemotherapy (5FU/leucovorin plus oxaliplatin, or FOLFOX plus bevacizumab, or 5FU/leucovorin plus irinotecan, or FOLFIRI) decreases recurrence rate and improves survival in stage C (III); survival benefit is not clear in stage B (II) tumours; periodic determination of serum CEA level useful to follow up therapy and assess recurrence.
Follow up after curative resection: yearly liver tests, complete blood count, follow-up radiologic or routine screen interim; if polyps detected, repeat 1 year after resection.
Advanced tumours (locally unresectable or metastatic)
Systemic chemotherapy (5FU/leucovorin plus oxaliplatin plus bevacizumab), irinotecan usually in second treatment; antibodies to the EGF receptor (cetuximab, panitumumab for those with wild type KRAS and BRAF genes) appear to enhance the effect of chemotherapy to 68% and the median survival from 14 to 24 months; intraarterial chemotherapy (floxuridine (FUDR) and/or radiation therapy may palliate symptoms from hepatic metastases.
With appropriate selection of patients with a good performance status and in whom MRI and PET-CT scans do not demonstrate extrahepatic disease local treatment can prolong good quality survival (with surgical resection to gamma knife irradiation, radiofrequency, or cryoablation, or hepatic artery embolization. Small lesion can be ablated; larger lesions are best managed by partial hepatectomy or a combination approach: embolization is followed by hepatic regeneration before final resection. Long-term survival without recurrence is reported up to 20% of patients at 5-years with a single <4 cm lesion.
Advanced CRC is successfully palliated with little toxicity by 5FU and folinic acid regiments or oral capecitabine in approximately 30% of patient with a median of 12-14 months. The addition of irinotecan or oxaliplatin increases the proportion that benefit to 55% and extended median survival to 18 months but with increased toxicity.
Radiation therapy plus chemotherapy (5FU and mitomycin) leads to complete response in 80% when the primary lesion is <3 cm. For patients with large lesions or whose disease recurs after chemoradiotherapy, abdominoperineal resection with permanent colostomy is reserved.
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