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 Molly M. Cone, MD Assistant Professor of Surgery Vanderbilt Medical Center November 14, 2014.

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Presentation on theme: " Molly M. Cone, MD Assistant Professor of Surgery Vanderbilt Medical Center November 14, 2014."— Presentation transcript:

1  Molly M. Cone, MD Assistant Professor of Surgery Vanderbilt Medical Center November 14, 2014

2  No disclosures

3 o Review screening options and recommendations for colorectal cancer o Understand criteria for referral for genetic testing in patients with colon cancer o Learn about current surgical options for patients with colorectal cancer

4  Epidemiology: o In 2014: 96,830 colon cancer diagnosed 40,000 rectal cancer diagnosed o Lifetime risk 1/20 (5%) o 3 rd leading cause of cancer related deaths in US 50,310 expected to die of CRC in the US this year o Worldwide- responsible for over 650,000 deaths annually (WHO)

5 Both incidence and deaths from colon and rectal cancer have been declining Except in those <50 yrs

6  Why screen?  Cost effective- o large number of incident cases, long duration of disease manifestation, and high mortality o simple methods for detection and reasonable treatment options  Saves lives- o screening for CRC not only detects cancer earlier, but also allows the clinician to intervene and change the course of the disease.

7 DCC 18q 8-10 years x x

8  Problems with screening- o multiple methods lead to considerable confusion regarding which method is best and the optimal timing. o confusion causes physicians to reduce the importance paid to CRC screening  This reduces the number of patients who ultimately get screened

9  Physician Recommendation o Patients indicate as the single most important factor in deciding to undergo screening  From National Cancer Institute: o >42% of patients were unaware of potential screening options o only 35% of respondents were aware that colonoscopy could actually detect CRC

10  Fecal Occult Blood Test (FOBT) o only screening test which has shown efficacy in prospective randomized controlled trials  Fecal Immunochemical based stool Tests (FIT) o more specific for hemoglobin, this test avoids some of the false positive results of FOBT  DNA stool Assays (sDNA) o Cells shed from the polyp/cancer contain DNA mutations that can be used as a biological marker for cancer detection

11  Serum Markers o Two most studied- CEA, CA 19-9 CEA used as biologic marker for progression of cancer, but only 30% sensitivity rate for detection CA 19-9 not been found useful  Barium Enema (double contrast) o Good sensitivity for cancer- 85-97%, questionable for polyps 32-60% depending on size

12  CT Colonography o Must undergo complete bowel prep and have air/CO 2 insufflated though a rectal catheter to distend the entire colon o May use barium per rectum to “tag” any residual stool in the colon

13  Drawbacks to CT colonography o nontherapetic modality, and positive findings require intervention o No standardized protocol o Difficult to detect low rectal lesions o Pt still takes the prep

14  Colonoscopy o considered the gold standard test for detection o considered to have the highest sensitivity and specificity o there are NO randomized controlled trials

15  Multiple societies/ organizations have recommendations, all that differ slightly  Most agree that for average risk, screening should begin at age 50  Screening ends by age 85, with a range of 75- 85

16 United States Preventive Services Task Force (USPSTF), American Society of Gastrointestinal Endoscopy (ASGE), U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF) MethodIntervalSociety Tests that detect Cancer Fecal Occult Blood Testing or FITYearlyUSPSTF, ASGE, USMSTF Fecal DNAUnspecifiedUSMSTF Tests that detect Cancer and Polyps Double Contrast Barium EnemaEvery 5 yearsUSMSTF CT ColonographyEvery 5 yearsUSMSTF Flexible SigmoidoscopyEvery 5 yearsUSPSTF, ASGE, USMSTF Flexible ColonoscopyEvery 10 yearsUSPSTF, ASGE, USMSTF

17 EnvironmentalFactorsGeneticSusceptibility Age/Time Cancer

18  Diet: o High fat o Low fiber o Red meat o Low calcium o Obesity o Smoking o Physical activity


20 Sporadic (65-85%) Familial (10-30%) HNPCC (2-5%) FAP (1%) Rare CRC Syndromes (<0.1%)

21  Hereditary Non-Polyposis Colon Cancer  2-5% of all colorectal cancers o Lynch 1 Colorectal cancers only o Lynch 2 Colorectal cancers Other cancers (Endometrial, ovarian, pancreatic, gastric, transitional cell of kidney/ureter)

22 Most common inherited colon cancer syndrome  Amsterdam II criteria 3 – 2 – 1 Rule – 3- family members with CRC or HNPCC associated CA (2 first degree) – 2- generations involved – 1- family member < 50 years

23  Bethesda guidelines: o Meet Amsterdam criteria o Individuals with 2 HNPCC-related cancer o Individual with CRC and 1 st degree relative with HNPCC-related CA <45yo or 1 st degree relative with adenoma < 40yo o Individual with R-side CRC with undiff pattern <45yo o Individual with CRC or endometrial CA <45yo o Individual with signet cell CRC <45yo o Individual with adenoma <45yo

24  Genetic testing should be considered when o Individual meets Amsterdam criteria o Individual meets Bethesda guidelines o Tumor is MSI +

25  Pre-operative workup o Colonoscopy- evaluate for other polyps/cancers o CEA level o CT scan of chest/abd/pelvis

26  Surgical principles o Exploration- either lap or via open techniques Evaluate peritoneum, adjacent organs, and liver o Resection Removal of primary lesion with “adequate” margins Removal of the zone of lymphatic drainage- defined by arterial blood supply, resected at or near origin

27 Laparoscopic vs. open?  Literature- Laparoscopic colectomy is equivalent cancer related survival to open colectomy  Benefits of laparoscopic methods for postoperative recovery

28 Node + Distant mets T1N0M0 TxN1M0 T2N0M0 T3N0M0 TxNxM1 Stage I Stage III Stage II Stage IV } 95% 40% 80% <5% 5 year survival

29 Node + Distant mets T1N0M0 TxN1M0 T2N0M0 T3N0M0 TxNxM1 Stage I Stage III Stage II Stage IV } 95% 40% 80% <5% 5 year survival

30  Differs from colon cancer o Pelvic anatomy o Radiation therapy o Surgical treatment options

31  Pre-op work-up o Very important, as stage effects order/components of treatment Colonoscopy- evaluate for other polyps/cancers CEA level CT scan of chest/abd/pelvis Endorectal ultrasound or MRI Physical exam/flex sig

32  DRE information- o Location o Position o Size o Fixed vs. mobile

33  Endorectal ultrasound/MRI: o the most important pre-operative component ERUS- 67-95% sensitivity for T stage MRI (with EndoCoil) 60-95% sensitivity Both modalities are less sensitive for N stage Determine the need for Neoadjuvant 5FU/Radiation Stage II and III (T3, T4, and/or N+)

34  Before the 1970’s rectal cancer was treated with surgery alone o 1975 trial comparing surgery with chemo, XRT, or both Surgery only- 55% recurrence 46% with chemotherapy, 48% with radiation therapy 33% with combined modality o NIH Consensus Statement 1990 Stage II and III rectal adenocarcinoma should be treated with adjuvant chemoradiotherapy

35  At the same time- specifically in the 1990s, there became a realization that not all surgery was being performed equally o “Total mesorectal excision”

36  Distal Mural Resection Margin o 1-2 cm o Tumors do not spread longitudinally in wall of rectum  Radial Margin o Critical to ensure complete tumor removal o Pathologists must measure and report  Mesorectal Margin

37 A review of 51 surgical series showed that TME reduced the median local recurrence rate from 18.5 to 7.1%.

38  German rectal cancer trial update2004 Preop XRTPostop XRT n 405 392 Local pelvic failure6% 12% Survival No difference Anastomotic leak No difference Toxicity(acute)Lower Higher Toxicity(late)Lower Higher

39 Shrink tumor prior to removalShrink tumor prior to removal DownsizingDownsizing DownstagingDownstaging Sterilize margins prior to pelvic dissectionSterilize margins prior to pelvic dissection More effective than postop XRTMore effective than postop XRT oxygenated field oxygenated field Better functional resultBetter functional result Radiate only one side of anastomosisRadiate only one side of anastomosis More patients complete treatment courseMore patients complete treatment course

40  Prospective, Randomized, n=1748  Pre-Op XRT vs. surgery alone (TME)  Local pelvic failure (recurrence) XRT + SurgerySurgery 2.4% 8.3% 2 yrs 5.8% 11.4% 5 yrs

41  Laparoscopic vs. open resection for rectal cancer  1 major trial, 1 underway

42  Prospective, randomized, experienced surgeons n=794 overall n=242 rectal  Disease free survival and local control (3 years) o No difference between laparoscopic and open o Local failureopenlap Anterior resection 7% 8% APR 21% 15% ________________________________________________  ACASOG Z6051 Trial o American College of Surgeons Oncology Group o 650 pts, randomized, multi-center trial of open vs. HALS resection for rectal cancer

43  Pros- o good visualization o precise movements o better ergonomics  Cons- o hard to move from one quadrant to another o costly o lack of stapler/vessel sealing device

44  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.

45  Appropriate if tumor invades anal sphincter or levator ani

46  Coloanal anastomosis  Same dissection, but instead of removal of the anus, the colon is hand sewn to the anal mucosa

47  Transanal Endoscopic Micro Surgery o Can do full thickness excision of rectal wall o Ideal for Unresectable adenomas Carcinoid tumors T1 rectal cancer T2 rectal cancer?


49  In the past 3 decades significant changes in the diagnosis and treatment of colon and rectal cancer has resulted in: o Decrease in incidence o Decrease in mortality o Less invasive procedures with shorter hospital stay

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