Skip to content

Colorectal Cancer

https://www.nice.org.uk/guidance/ng151/chapter/recommendations#tnm-classification https://www.acpgbi.org.uk/resources/?c=1070&type=143 https://www.acpgbi.org.uk/resources/?c=1070&type=143 <- Localised Colon Cancer ESMO https://www.acpgbi.org.uk/_userfiles/pages/files/metastatic_colorectal_cancer.pdf <- Metastatic Colorectal Cancer - ESMO https://onlinelibrary.wiley.com/doi/10.1111/codi.13704 <- Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) – Surgical Management

Classificaion and Management

Local Vs Metastatic

TNM

  • Tis - in situ
  • T1 - into inner layer of bowel
  • T2 - into muscle layer of bowel
  • T3 - into outer layer
  • T4a - into peritoneum

  • T4b - into nearby organs

  • N0 - no lymph nodes

  • N1a - 1 lymph node
  • N1b - 2-3 lymph nodes
  • N1c - no lymph nodes, but some nearby spread
  • N2a - 4-6 lymph nodes

  • N2b - more than 7 nodes

  • M0 - no spread

  • M1 - some spread
  • M1a - 1 distant site/organ
  • M1b - 2 distant sites/organs
  • M1c - distant sites/organs AND peritoneum

Staging

What makes you what stage?

  • 1 - T1 or 2. N0 M0
  • 2 - T3 or 4. N0 M0
  • 3 - N1 or 2. M0
  • 4 - M1

Local

Stage III Disease:

"The current standard of care for adjuvant therapy in stage III colon cancer is a combination of fluoropyrimidine and oxaliplatin": FOLFOX + CAPOX.

This is prefered to fluoropyrimidine monotherapy (previous standard of care) (FLOX) Shown in MOSAIC, NSABP C-07, XELOXA trials

"in addition, irinotecan, cetuximab and bevacizumab have not demon- strated clinical activity in the localised setting and therefore they should never be used as adjuvant treatment in this setting"

Stage II Disease

Major Factors that impact on risk of relapse:

pT4 stage or <12 lymph nodes assessed, both increase chance of recurrence

"Although the de Gramont is the only regimen that has demonstrated efficacy in the setting [I, B], capecitabine is an option, especially with contraindications for insertion of a central line [V]. It is also felt by the panel members that patients with high risk, patients with pT4 and/or <12 lymph nodes or accumulation of several intermediate risk factors, might be considered for the addition of oxaliplatin therapy based on a trend to an increased benefit, although this did not achieve statistical significance in the stage II high-risk subgroup analysis of the MOSAIC trial [I, B].72"

Metastatic Oncology

Historically ESMO Splits into 4 Groups

  • 0 - "Primarily Technically R0 Resectable Liver/Lung Mets with no relative contrindications":
    • Resection
    • Periop treatment with FOLFOX
  • 1 - "Potentially Resectable Metastatic Disease with Curative Intent":
    • Aim is long term survival/cure
    • Choose active "induction agent"
    • Options:
      • Targeted agent plus Cytotoxic Doublet
      • Targeted agent plus Cytotoxic Triplet
      • FOLFOXIRI +/- Bevacizumab (Bevacizumab is a "Targeted Agent")
  • 2 - "Disseminated Disease, Technically Never/Unlikely Resectable Indeterminate Intensive Treatment":
    • Aim is palliative
    • Choose: active first-line treatment with a high likelihood to induce metatastatic regression
    • Options:
      • Targeted agent (Bevacizumab) plus Cytotoxic Doublet - First Line
      • Alternative: FOLFOX/FOLFIRI plus an anti-EGFR antibody
      • Then later de-escalate to maintanence:
        • 5-FU/LV maintanence treatments

  • 3 - "Never Resectable Metastatic Disease":

    • Maximal shrinkage of mets isn't the aim here
    • Prevention of tumour progression and prolonging life with minimal treatment burden is
    • Options:
      • Combination Cytotoxic +/- Targeted Agent
      • Or FP in combo with bevacizumab
      • oxaloplatin/irinotecan-based combo with biological targeting

  • Duration?:

    • 3-6 months fixed (first induction then maintenance)
    • Or induction and maintenance until disease progression/toxicity

NICE

Surgery

Early Rectal Cancer (cT1-2,cN0,M0) offer one of:

  • Transanal Excision (TAE):
    • Transanal Minimally Invasive Surgery (TAMIS)
    • Transanal Endoscopic Microsurgery (TEMS)
  • Endoscopic Submucosal Dissection (ESD)

  • Total Mesorectal Excision (TME)

  • Rectal cancer, offer surgery to anyone with resectable:

    • cT1-2,N1-2,M0
    • cT3-4,any cN,M0
  • Locally advanced/recurrent rectal:
    • Consider referring to specialist centre to discuss exenterative surgery

Oncology

  • Don't offer preop radiotherapy to early rectal(cT1-2,N0,M0)
  • Do offer preop radio/chemo if rectal (cT1-2,N1-2,M0 or cT3-4,any cN,M0)
  • Offer preop SACT for people with cT4 colon cancer

  • Stage III Colon cancer (pT1-4,N1-2,M0) / Stage III Rectal Cancer (same TNM) who've received short course radiotherapy/no pre op, offer:

    • 1st Line: Capecitabine + Oxaliplatin for 3 months (CAPOX)
    • 2nd Line: Oxaliplatin + 5-Fluorouracil + Folinic Acid for 3-6 Months (FOLFOX) or
    • Other 2nd Line: Single Agent Fluoropyrimidine (Capecitabine is one of these) for 6 months

    - Test for RAS and BRAF V600E mutations in metastatic cancer