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Wednesday, Aug 21st

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Chemotherapy in Colorectal Cancers

Staging of Colorectal Cancer

Stage T N M Dukes MAC
0 Tis N0 Mo
I T1 No Mo A A
  T2 No Mo A B1
Iia T3 No Mo B B1
Iib T4 No Mo B B2
IIIA T1 –T2 N1 Mo C C1
IIIB T3–T4 N1 Mo C C2/C3
IIIC Any T N2 Mo C C1/C2/C3
IV Any T Any N M1 D
NCCN Guidelines



Lymph Node Status in Colorectal Cancer
  • Less than one half of population–based samples have at least 12 lymph nodes removed and examined[1].
  • 12 sampling of nodes increased likelihood of higher–stage diagnosis in colorectal cancer[2]
    • 31% likelihood of stage III vs stage II diagnosis (P < .001).
  • Lymph node ratio (proportion of positive to examined lymph nodes) predictive of OS in resected node–positive rectal cancer[3]
    • Significant within AJCC N stage subgroups.
    • Significance independent of number of lymph nodes evaluated (< 15 or = 15) .
    • Lymph node ratio may be the lymph node measure most predictive of survival.
Symptoms of Colorectal Cancer
Early Stages
  • No Symptoms.
  • Abdominal Pain.
  • Flatulence (gas).
  • Minor changes in Bowel Movements.
  • Rectal Bleeding.
  • Anemia.
Late –stage Left–side Colon
  • Constipation or Diarrhea.
  • Abdominal Pain (colicky pain).
  • Obstructive Symptoms (nausea/vomiting).
Late–Stage Right–side Colon
  • Vague Abdominal Aching.
  • Anemia (iron loss by chronic microscopic bleeding).
  • Weakness.
  • Weight Loss.
Late–stage Rectum
  • Change in Bowel Movements.
  • Rectal Fullness.
  • Urgency.
  • Bleeding.
  • Tenesmus (urgency).
  • Pelvic Pain (later stage).
Diagnosis of Colorectal Cancer
  • Physical Examination (Early diagnosis can result in cure).
  • Fecal Occult Blood Test.
  • Digital Rectal Examination.
  • Radiologic Imaging to Check for Metastasis.
  • Barium Enema.
  • Sigmoidoscopy.
  • Colonoscopy.
  • Check your Blood for Carcinomembryonic Antigen (CEA).
  • Virtual colonoscopy.
Management
  • Surgery is primary treatment for cure
    • Laparoscopy vs.open surgical resection.
    • Colostomy– temporary/permanent.
  • Adjuvant chemotherapy (prior to liver resection).
  • Radiation therapy.
  • Fractionated steriotactic surgery.
  • Targeted therapies (immunotherapy, anti–angiogenesis therapy and cancer vaccines).
Surgical Approaches in the Treatment of Colorectal Cancer
  • Surgery for Resectable Colon Cancer
    • Colectomy with en bloc removal of regional LN.
    • Laparoscopic–assisted surgery may be feasible.
  • Surgery for Rectal Cancer
    • Transabdominal resection or transanal excision for certain patients with T1, T2 lesions.
    • Abdominal peritoneal resection or low anterior resection with TME for all others.
    • Preoperative or postoperative chemoradiotherapy for serosal invasion/regional node involvement.
Adjuvant Treatment According to Stage
  • Stage I
    • No adjuvant treatment.
  • Stage II
    • Treatment controversial.
  • Stage III
    • Consensus for treatment.
MOSAIC: FOLFOX4 vs LV5FU2
  • In 2,246 patients with resected stage II/III colon cancer provided 24% relative risk reduction in 4–y DFS.
  • More neutropenia, sensory neuropathy with FOLFOX4
    • Late recovery from neuropathy observed.
  • All–cause mortality equivalent between arms (0.5%).
Adjuvant Therapy for Stage II Disease: Where Do We Stand?
  • FDA approved FOLFOX4 for stage III disease only.
  • Main limitation for stage II clinical trials
    • Absolute benefit expected is about half the benefit in stage III.
    • Twice as many patients are needed.
    • Available studies not powered to detect a statistically significant benefit in this subgroup of patients.
Adjuvant Chemotherapy in Stage II Disease
  • Important to Discuss Potential Risks/Benefit with Patient.
  • Factors to Consider
    • Number of LN Analyzed.
    • Poor Prognostic Features.
    • Comorbidities.
    • Anticipated Life Expectancy.
  • Chemotherapy not Appropriate for All Patients.


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