1. Treatment options depend on the following: – The stage of the cancer – Whether the cancer has recurred – The patient’s general health

2. Surgical Management Total resection of tumor – optimal treatment

3. Pre-operative Procedure Thorough PEChest XRAY Liver Function Plasma CEA level Colonoscopy

4. Intraoperative Procedure Laparotomy Inspection of the liver, pelvis, and hemidiaphragm Palpation of the full length of the large bowel TOTAL RESECTION OF THE TUMOR

5. Postoperative Procedures RecoverySemiannual PEColonoscopy Yearly blood chemistry measurements Plasma CEA levels at 3-month intervals 5 years

6. Postoperative Procedures Recovery CT scans of the abdomen - annually for the first three postoperative years Endoscopic or radiographic surveillance of the large bowel - 3 years interval

7. Chemotherapy 5-FU – 15-20% of patients have partial response – Backbone of treatment – IV or oral (capecitabine) Similar efficacy – Radiosensitizer - when given with radiotherapy 5-FU + folinic acid (leucovirin) – Improves efficacy – Enhances binding to thymidylate synthase – Three-fold improvement in partial response – 6 mos. after resection (stage III) 40% decrease in recurrence rates 30% improvement in survival

8. Chemotherapy 5-FU + LV + Irinotecan (FOLFIRI regimen) – Topoisomerase 1 inhibitor – Improves response rates and survival of patients with metastatic disease – Diarrhea 5-FU + LV + Oxiplatin (FOLFOX regimen) – Platinum analogue – Improves response rate – Dose-dependent neuropathy, resolves following cessation of therapy FOLFIRI = FOLFOX

9. Chemotherapy Monoclonal antibodies – Effective for advanced colorectal cancer – Cetuximab and Panitumumab Directed against EGFR Benefit previously treated patients cetuximab – reverse cellular resistance to cytotoxic chemotherapy Acne-like rash – Bevacizumab Directed against VEGF Anti-angiogenesis HPN, proteinuria, increased likelihood of thromboembolic events

10. Treatment by Stage of Colon Cancer Stage 0 – cancer has not grown beyond the inner lining of the colon – polypectomy or local excision through the colonoscope – Colon resection may be necessary if the tumor is too big to be removed by local excision Stage I – cancer has grown through several layers of the colon, but has not spread outside the colon wall – Surgical resection American cancer society http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Treatment_by_Stage_of_Colon_Cancer.asp National Cancer Institute http://www.cancer.gov/cancertopics/pdq/treatment/colon/Patient/page1

11. Treatment by Stage of Colon Cancer Stage II – cancer has grown through the wall of the colon and may extend into nearby tissue – has not yet spread to the lymph nodes – Surgical resection is usually the only treatment needed – if cancer is likely to recur, radiation or chemotherapy may be recommended – Clinical trials of chemotherapy, radiation therapy, or monoclonal antibody therapy after surgery Stage III – more advanced stage – cancer has spread to nearby lymph nodes, but has not yet spread to other parts of the body – Surgical resection is the first treatment – Adjuvant chemotherapy with 5-FU and leucovorin – Radiation therapy: if cancer was large enough to grow into adjacent tissues American cancer society http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Treatment_by_Stage_of_Colon_Cancer.asp National Cancer Institute http://www.cancer.gov/cancertopics/pdq/treatment/colon/Patient/page1

12. Treatment by Stage of Colon Cancer Stage IV and Recurrent Colon Cancer – cancer has spread to distant organs and tissues such as the liver, lung, peritoneum, or ovary – segmental resection or diverting colostomy relieve or prevent blockage of the colon and to prevent other local complications – Surgery to remove parts of other organs, where the cancer may have recurred or spread – Radiation therapy or chemotherapy palliative therapy to relieve symptoms and improve quality of life – Clinical trials of chemotherapy and/or monoclonal antibody therapy – locally recurrent colon cancer: local excision – Liver recurrence Chemotherapy followed by resection Radiofrequency ablation or cryosurgery. Clinical trials of hepatic chemoembolization with radiation therapy American cancer society http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Treatment_by_Stage_of_Colon_Cancer.asp National Cancer Institute http://www.cancer.gov/cancertopics/pdq/treatment/colon/Patient/page1