locally advanced colon cancer · – viability of bowel – location of obstruction – tumor...
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Locally Advanced Colon Cancer
Feiran Lou MD. MS. Richmond University Medical Center
Department of Surgery
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Case
34 yo man presented with severe RLQ abdominal pain X 24 hrs. No nausea/vomiting/fever. + flatus. No change in bowel habits. No weight loss. PM/SH: rheumatoid arthritis, never c-scope Meds: methothrexate X 2 years NKDA SH: No toxic habits FH: no hx cancers in immediate family, ?GI cancer in grandmother
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Case
Physical Exam 98, 138/70, 70, 12, 99% NAD Abd: soft, nondistended, right sided tenderness lower > upper, no rebound, no masses DRE: no gross blood, stool in vault, no palpable masses
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Case
Labs CBC 12.9/10.6/32.8/274 BMP, LFT, coags WNL
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OR Findings
• Dilated right colon • Slightly dilated appendix • Firm mass in hepatic flexure invading first
portion of duodenum frozen adenocarcinoma • Surrounding inflammatory changes,
lymphadenopathy • No liver masses, no peritoneal seeding Procedure • Exploratory laparoscopy converted open,
appendectomy, ascending to transverse colon bypass
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Postoperative Course
• Uncomplicated, diet advanced • D/C home POD 5
Path Hepatic flexure mass: adenocarcinoma, moderate differentiated Appendix: impacted fecalith, dilated distal end, no inflammation
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Outline
• Pathogenesis • Surgical Resection • Challenges in locally advanced tumors
– Obstruction – Visceral invasion
• Adjuvant therapy
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Colon Cancer Pathogenesis
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Staging
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Goals of Surgical Treatment
• Ideally R0 resection • Thorough abdominal exploration • Completely resect involved colonic segment with
2-5 cm margin • En bloc resection of any local structures or organs
invaded by the primary tumor • Removal of major vascular pedicle and lymphatic
drainage basins • Minimum of 12 lymph nodes required
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Locally Advanced Colon Cancer
• Obstruction – Bypass – Stent
• Invasion of adjacent organs – En bloc resection – Neoadjuvant therapy (?)
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Acute Obstruction
• Initial presentation in 7-29% of colorectal ca • Partial obstruction does not necessitate
urgent surgical intervention • Complete obstruction
– Viability of bowel – Location of obstruction – Tumor resectability – Goals of care
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Resection
• Right-sided lesions – Single-stage segmental colectomy
• Left-sided lesions – 1 vs. 2 vs. 3-stage procedures – Segmental vs. subtotal colectomy – Intraoperative colonic lavage?
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Palliation
• Diversion – Stoma – Bypass
• Stent – Left-sided obstruction – Technical success rates 66-100% – Luminal patency 68-288 days (106 days) – Complications: perforation (2-5%) and migration
(4-9%)
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Visceral Invasion
• To achieve R0 resection • Multivisceral resection done in 10% of
advanced colorectal cancer • Most commonly involved organs in colon ca:
– Small bowel – Bladder – Abdominal wall – Spleen – Duodenum, pancreas, stomach
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Accuracy of Intraoperative Assessment
• Tumor infiltration in 34% resected organs
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Outcomes
• Post operative complications 33% • Post operative mortality 7.5% • Curative resection in 65% • Histologic tumor infiltration 44% • Overall 5 year survival 51%
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Overall Survival
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Conventional Vs. Multivisceral Resection
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Chemotherapy
• Neoadjuvant? Pilot trials • 5-Fluorouracil with leucovorin • Capecitabine: PO prodrug • Monoclonal antibodies
– Bevacizumab, cetuximab, panitumumab (anti-EGFR)
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Adjuvant Chemotherapy
• First line: FOLFOX = 5-FU + LV + oxaliplatin X 6 months
• Second line: FOLFIRI = 5FU + LV + irinotecan • Stage III recurrence 15-50% chemotherapy
adjuvant therapy in all • Stage II: high risk tumors only perforation,
poor tumor differentiation, lymphovascular invasion, insufficient lymph node sampling
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Summary
• Locally advanced colon cancers present unique challenges in surgical treatment
• Definitive surgery (R0) may require en bloc multivisceral resection – Long term survival can be comparable to standard
resection
• After resection, adjuvant chemotherapy in stage III and high risk stage II patients improves survival
• Role of neoadjuvant chemotherapy remains to be defined
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• Emergency surgery (n=51) vs. stenting then resection (n=47)
• Acute malignant left-sided obstruction
Lancet oncol 12(4)344-352, 2011
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