3ObjectivesReview screening options and recommendations for colorectal cancerUnderstand criteria for referral for genetic testing in patients with colon cancerLearn about current surgical options for patients with colorectal cancer
4Colon and Rectal cancer Epidemiology:In 2014:96,830 colon cancer diagnosed40,000 rectal cancer diagnosedLifetime risk 1/20 (5%)3rd leading cause of cancer related deaths in US50,310 expected to die of CRC in the US this yearWorldwide- responsible for over 650,000 deaths annually (WHO)
5Colon and Rectal cancer Both incidence and deaths from colon and rectal cancer have been decliningExcept in those <50 yrsDeath rate decreasing>1 million survivors in the USDecreased death rate . There are a number of likelyreasons for this. One is that polyps are being found by screening and removed before theycan develop into cancers. Screening is also allowing more colorectal cancers to be foundearlier when the disease is easier to cure. In addition, treatment for colorectal cancer has improved over the last several years. As a result, there are now more than 1 million survivorsof colorectal cancer in the United States.Except in those
6Screening for colorectal cancer Why screen?Cost effective-large number of incident cases, long duration of disease manifestation, and high mortalitysimple methods for detection and reasonable treatment optionsSaves lives-screening for CRC not only detects cancer earlier, but also allows the clinician to intervene and change the course of the disease.
8Screening Problems with screening- multiple methods lead to considerable confusion regarding which method is best and the optimal timing .confusion causes physicians to reduce the importance paid to CRC screeningThis reduces the number of patients who ultimately get screened
9Screening Physician Recommendation From National Cancer Institute: Patients indicate as the single most important factor in deciding to undergo screeningFrom National Cancer Institute:>42% of patients were unaware of potential screening optionsonly 35% of respondents were aware that colonoscopy could actually detect CRCNational surveys effort from NCI
10Screening methods Fecal Occult Blood Test (FOBT) only screening test which has shown efficacy in prospective randomized controlled trialsFecal Immunochemical based stool Tests (FIT)more specific for hemoglobin, this test avoids some of the false positive results of FOBTDNA stool Assays (sDNA)Cells shed from the polyp/cancer contain DNA mutations that can be used as a biological marker for cancer detection
11Screening Serum Markers Barium Enema (double contrast) Two most studied- CEA, CA 19-9CEA used as biologic marker for progression of cancer, but only 30% sensitivity rate for detectionCA 19-9 not been found usefulBarium Enema (double contrast)Good sensitivity for cancer %, questionable for polyps 32-60% depending on size
12Screening CT Colonography Must undergo complete bowel prep and have air/CO2 insufflated though a rectal catheter to distend the entire colonMay use barium per rectum to “tag” any residual stool in the colon
13Screening Drawbacks to CT colonography nontherapetic modality, and positive findings require interventionNo standardized protocolDifficult to detect low rectal lesionsPt still takes the prep
14Screening Colonoscopy considered the gold standard test for detection considered to have the highest sensitivity and specificitythere are NO randomized controlled trials
15ScreeningMultiple societies/ organizations have recommendations, all that differ slightlyMost agree that for average risk, screening should begin at age 50Screening ends by age 85, with a range of 75-85
16ScreeningMethodIntervalSocietyTests that detect CancerFecal Occult Blood Testing or FITYearlyUSPSTF, ASGE, USMSTFFecal DNAUnspecifiedUSMSTFTests that detectCancer and PolypsDouble Contrast Barium EnemaEvery 5 yearsCT ColonographyFlexible SigmoidoscopyFlexible ColonoscopyEvery 10 yearsUnited States Preventive Services Task Force (USPSTF), American Society of Gastrointestinal Endoscopy (ASGE) , U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF)
17Colorectal Carcinoma Cancer Environmental Factors Genetic SusceptibilityCancerAge/Time
21Genetic Susceptibility Hereditary Non-Polyposis Colon Cancer2-5% of all colorectal cancersLynch 1Colorectal cancers onlyLynch 2Colorectal cancersOther cancers (Endometrial, ovarian, pancreatic, gastric, transitional cell of kidney/ureter)
22HNPCC 3 – 2 – 1 Rule Amsterdam II criteria Most common inherited colon cancer syndromeAmsterdam IIcriteria3 – 2 – 1 Rule3- family members with CRC or HNPCC associated CA(2 first degree)2- generations involved1- family member < 50 years
23HNPCC Bethesda guidelines: Individuals with 2 HNPCC-related cancer Meet Amsterdam criteriaIndividuals with 2 HNPCC-related cancerIndividual with CRC and1st degree relative with HNPCC-related CA <45yoor1st degree relative with adenoma < 40yoIndividual with R-side CRC with undiff pattern <45yoIndividual with CRC or endometrial CA <45yoIndividual with signet cell CRC <45yoIndividual with adenoma <45yo
24Genetic susceptibility Genetic testing should be considered whenIndividual meets Amsterdam criteriaIndividual meets Bethesda guidelinesTumor is MSI +
25Treatment of colon cancer Pre-operative workupColonoscopy- evaluate for other polyps/cancersCEA levelCT scan of chest/abd/pelvis
26Treatment of colon cancer Surgical principlesExploration- either lap or via open techniquesEvaluate peritoneum, adjacent organs, and liverResectionRemoval of primary lesion with “adequate” marginsRemoval of the zone of lymphatic drainage- defined by arterial blood supply, resected at or near origin
27Treatment for Colon Cancer Laparoscopic vs. open?Literature- Laparoscopic colectomy is equivalent cancer related survival to open colectomyBenefits of laparoscopic methods for postoperative recovery
28Survival After Operation 5 year survivalT1N0M0}Stage I95%T2N0M0T3N0M0Stage II80%TxN1M0Stage III40%Node +Distant metsTxNxM1Stage IV<5%
29Chemotherapy for Colon Cancer 5 year survivalT1N0M0}Stage I95%T2N0M0T3N0M0Stage II80%TxN1M0Stage III40%Node +Distant metsTxNxM1Stage IV<5%
30Rectal Cancer Differs from colon cancer Pelvic anatomy Radiation therapySurgical treatment options
31Rectal Cancer Pre-op work-up Very important, as stage effects order/components of treatmentColonoscopy- evaluate for other polyps/cancersCEA levelCT scan of chest/abd/pelvisEndorectal ultrasound or MRIPhysical exam/flex sig
32Rectal CancerDRE information-LocationPositionSizeFixed vs. mobile
33Rectal Cancer Determine the need for Neoadjuvant 5FU/Radiation Endorectal ultrasound/MRI:the most important pre-operative componentERUS % sensitivity for T stageMRI (with EndoCoil) 60-95% sensitivityBoth modalities are less sensitive for N stageDetermine the need for Neoadjuvant 5FU/RadiationStage II and III (T3, T4, and/or N+)
34Before the 1970’s rectal cancer was treated with surgery alone 1975 trial comparing surgery with chemo, XRT, or bothSurgery only- 55% recurrence46% with chemotherapy,48% with radiation therapy33% with combined modalityNIH Consensus Statement 1990Stage II and III rectal adenocarcinoma should be treated with adjuvant chemoradiotherapy
35Rectal cancerAt the same time- specifically in the 1990s, there became a realization that not all surgery was being performed equally“Total mesorectal excision”
36Proctectomy for Rectal Cancer: Margins Distal Mural Resection Margin1-2 cmTumors do not spread longitudinally in wall of rectumRadial MarginCritical to ensure complete tumor removalPathologists must measure and reportMesorectal Margin
37Total Mesorectal Excision A review of 51 surgical series showed that TME reduced the median local recurrence rate from 18.5 to 7.1%.
38Preop vs. Postop Chemoradiotherapy German rectal cancer trial update 2004Preop XRT Postop XRTnLocal pelvic failure 6% %Survival No differenceAnastomotic leak No differenceToxicity (acute) Lower HigherToxicity (late) Lower HigherSo then the question was, when is the best time to give the radiation?
39Neoadjuvant Therapy: Benefits Shrink tumor prior to removalDownsizingDownstagingSterilize margins prior to pelvic dissectionMore effective than postop XRToxygenated fieldBetter functional resultRadiate only one side of anastomosisMore patients complete treatment course
40Dutch Rectal Cancer Trial NEJM 2001 Prospective, Randomized, n=1748Pre-Op XRT vs. surgery alone (TME)Local pelvic failure (recurrence)XRT + Surgery Surgery2.4% % yrs5.8% % yrsPublished in 2001/2011.
41Rectal cancer surgeryLaparoscopic vs. open resection for rectal cancer1 major trial, 1 underway
42UK MRC CLASSIC Trial ACASOG Z6051 Trial Prospective, randomized, experienced surgeonsn=794 overalln=242 rectalDisease free survival and local control (3 years)No difference between laparoscopic and openLocal failure open lapAnterior resection 7% 8%APR 21% 15%________________________________________________ACASOG Z6051 TrialAmerican College of Surgeons Oncology Group650 pts, randomized, multi-center trial of open vs. HALS resection for rectal cancer
43Robotic Surgery for Rectal Cancer Pros-good visualizationprecise movementsbetter ergonomicsCons-hard to move from one quadrant to anothercostlylack of stapler/vessel sealing deviceEspecially in pts with increased BMI in a fixed space (pelvis)
44Sphincter Preservation Unless directly invaded by tumor, skeletal muscle is not at risk for tumor implantation.Therefore, there is no reason to excise the anus or levators… … if it will not improve oncologic outcome.
45Abdominoperineal resection Appropriate if tumor invades anal sphincter or levator ani
46Rectal Cancer Coloanal anastomosis Same dissection, but instead of removal of the anus, the colon is hand sewn to the anal mucosa
47TEMS/TAMIS Transanal Endoscopic Micro Surgery Can do full thickness excision of rectal wallIdeal forUnresectable adenomasCarcinoid tumorsT1 rectal cancerT2 rectal cancer?
49SummaryIn the past 3 decades significant changes in the diagnosis and treatment of colon and rectal cancer has resulted in:Decrease in incidenceDecrease in mortalityLess invasive procedures with shorter hospital stay