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Colon and Rectal Cancer Update

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Presentation on theme: "Colon and Rectal Cancer Update"— Presentation transcript:

1 Colon and Rectal Cancer Update
Molly M. Cone, MD Assistant Professor of Surgery Vanderbilt Medical Center November 14, 2014

2 Disclosures No disclosures

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

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

5 Colon and Rectal cancer
Both incidence and deaths from colon and rectal cancer have been declining Except in those <50 yrs Death rate decreasing >1 million survivors in the US Decreased death rate . There are a number of likely reasons for this. One is that polyps are being found by screening and removed before they can develop into cancers. Screening is also allowing more colorectal cancers to be found earlier 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 survivors of colorectal cancer in the United States. Except in those

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

7 Adenoma-Carcinoma Sequence
APC 5q x 8-10 years x K-ras 12p DCC 18q p53 17p

8 Screening 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 screening This reduces the number of patients who ultimately get screened

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

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

11 Screening Serum Markers Barium Enema (double contrast)
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) Good sensitivity for cancer %, questionable for polyps 32-60% depending on size

12 Screening CT Colonography
Must undergo complete bowel prep and have air/CO2 insufflated though a rectal catheter to distend the entire colon May use barium per rectum to “tag” any residual stool in the colon

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

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

15 Screening 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 Screening Method Interval Society Tests that detect Cancer Fecal Occult Blood Testing or FIT Yearly USPSTF, ASGE, USMSTF Fecal DNA Unspecified USMSTF Tests that detect Cancer and Polyps Double Contrast Barium Enema Every 5 years CT Colonography Flexible Sigmoidoscopy Flexible Colonoscopy Every 10 years United States Preventive Services Task Force (USPSTF), American Society of Gastrointestinal Endoscopy (ASGE) , U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF)

17 Colorectal Carcinoma Cancer Environmental Factors Genetic
Susceptibility Cancer Age/Time

18 Environmental factors
Diet: High fat Low fiber Red meat Low calcium Obesity Smoking Physical activity

19 Age

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

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

22 HNPCC 3 – 2 – 1 Rule Amsterdam II criteria
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 HNPCC Bethesda guidelines: Individuals with 2 HNPCC-related cancer
Meet Amsterdam criteria Individuals with 2 HNPCC-related cancer Individual with CRC and 1st degree relative with HNPCC-related CA <45yo or 1st degree relative with adenoma < 40yo Individual with R-side CRC with undiff pattern <45yo Individual with CRC or endometrial CA <45yo Individual with signet cell CRC <45yo Individual with adenoma <45yo

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

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

26 Treatment of colon cancer
Surgical principles Exploration- either lap or via open techniques Evaluate peritoneum, adjacent organs, and liver 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 Treatment for Colon Cancer
Laparoscopic vs. open? Literature- Laparoscopic colectomy is equivalent cancer related survival to open colectomy Benefits of laparoscopic methods for postoperative recovery

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

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

30 Rectal Cancer Differs from colon cancer Pelvic anatomy
Radiation therapy Surgical treatment options

31 Rectal Cancer Pre-op work-up
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 Rectal Cancer DRE information- Location Position Size Fixed vs. mobile

33 Rectal Cancer Determine the need for Neoadjuvant 5FU/Radiation
Endorectal ultrasound/MRI: the most important pre-operative component ERUS % 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
1975 trial comparing surgery with chemo, XRT, or both Surgery only- 55% recurrence 46% with chemotherapy, 48% with radiation therapy 33% with combined modality NIH Consensus Statement 1990 Stage II and III rectal adenocarcinoma should be treated with adjuvant chemoradiotherapy

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

36 Proctectomy for Rectal Cancer: Margins
Distal Mural Resection Margin 1-2 cm Tumors do not spread longitudinally in wall of rectum Radial Margin Critical to ensure complete tumor removal Pathologists must measure and report Mesorectal Margin

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

38 Preop vs. Postop Chemoradiotherapy
German rectal cancer trial update 2004 Preop XRT Postop XRT n Local pelvic failure 6% % Survival No difference Anastomotic leak No difference Toxicity (acute) Lower Higher Toxicity (late) Lower Higher So then the question was, when is the best time to give the radiation?

39 Neoadjuvant Therapy: Benefits
Shrink tumor prior to removal Downsizing Downstaging Sterilize margins prior to pelvic dissection More effective than postop XRT oxygenated field Better functional result Radiate only one side of anastomosis More patients complete treatment course

40 Dutch Rectal Cancer Trial NEJM 2001
Prospective, Randomized, n=1748 Pre-Op XRT vs. surgery alone (TME) Local pelvic failure (recurrence) XRT + Surgery Surgery 2.4% % yrs 5.8% % yrs Published in 2001/2011.

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

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

43 Robotic Surgery for Rectal Cancer
Pros- good visualization precise movements better ergonomics Cons- hard to move from one quadrant to another costly lack of stapler/vessel sealing device Especially in pts with increased BMI in a fixed space (pelvis)

44 Sphincter 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.

45 Abdominoperineal resection
Appropriate if tumor invades anal sphincter or levator ani

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

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


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

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