Current%20standards%20of%20Care

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Current standards of Care for Colorectal Cancer
Joseph J. Nichols, Jr., MD
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Types of Colorectal Cancer
Adenocarcinoma 95 Lymphoma
0.5 Carcinoid Sarcoma Squamous cell
carcinoma Plasmacytoma Metastatic
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Screening for colorectal cancer
Protocols Digital rectal examination and
Hemoccult test Sigmoidoscopy and Hemoccult
test Barium enema Colonoscopy Virtual colonoscopy
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Surgical Options
The attempt of surgical excision is to provide
adequate margins of resection as well as to
remove the nodal basin associated with the area
of tumor which typically corresponds to the area
of arterial supply. Reconstruction following
excision is dependent on a well vascularized
anastomosis. Sentinel lymph node mapping in
colorectal cancer assists in identifying
micrometastatic disease but this has not been
shown to provide significant prognostic
information.
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Surgical Options
Indications for colostomy Indications for total
proctocolectomy Non-laparotomy
options Indications for Kraske
procedure Indications for transanal
excision Laparoscopic surgery Indications for
endoscopic surgery
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Indications for colostomy
A colostomy is necessary with any surgery that
will result in a nonfunctional anal sphincter. -
surgical removal or destruction of the
sphincter - preexisting conditions trauma, nerve
injury, infection, or Crohns disease
destroying sphincter function - severe damage
to the anorectum by radiation - patient
preference (paralysis, professional
limitations)
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Indications for total proctocolectomy
Any disease process where the remainder of the
colon poses an unacceptably high risk of
recurrence making follow up difficult Familial
polyposis Multiple prior colorectal
cancers Hereditary non-polyposis colon cancer
(HNPCC) Chronic ulcerative colitis
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Indications for Kraske procedure
Resection of mid to lower rectal cancers
This procedure involves opening the postanal skin
and the removal of the coccyx followed by
excision and reanastomosis of the rectum.
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Indications for transanal excision
Low lying tumors usually in the bottom two thirds
of the rectum. This is more easily performed in
the older population due to the ability of the
rectum to be pulled further into the pelvis. The
procedure is generally reserved for T1 and
favorable T2 lesions or in patients unable to
tolerate a laparotomy. A transrectal ultrasound
prior to any significant manipulation of the
tumor is preferable to assess invasion and lymph
node status.
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Laparoscopic surgery
The same oncologic principals are used as with
open surgery. There are three basic types -
Total laparoscopy where the specimen is
withdrawn through the anus. - Laparoscopic
with the specimen removed and the anastomosis
made through a smaller incision. - Hand-port
assisted laparoscopy where the procedure is
augmented by a larger incision with an
air-pressure sealed device used to insert the
surgeons hand into the abdomen to assist with
surgery.
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Indications for endoscopic surgery
Reserved for pedunculated polyps confined to the
head or proximal stalk of the polyp (Haggitts
levels 1-3)
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Types of therapy
- Preoperative chemoradiation therapy - Standard
of care for Dukes B2, C, and D rectal
cancers. - Postoperative chemoradiation therapy -
Indicated for all Dukes B2, C, and D rectal
cancers and Dukes B2, C, and D colon cancers
that are fixed in location (typically invasive
into the peritoneum or other fixed structure). -
Postoperative chemotherapy without radiation -
for Dukes C and D colon cancers with recent
indications for improved survival in B2
patients.
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Staging of Colorectal Cancer
Unlike other forms of cancer, colorectal cancer
is not staged by size. The primary prognostic
factors are depth of invasion, number of involved
lymph nodes, adequate margins of resection (2-5
cm), and tumor differentiation. Other factors
assessed are the mucin content, neural or
vascular invasion, DNA ploidy, oncogene analysis,
nuclear morphology, tumor budding, and
immunologic markers. The role of these factors
is still being investigated.
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Number of lymph nodes
The number of lymph nodes removed has been shown
to increase the accuracy of colorectal cancer
staging as well as to have improvement in the
prognosis. One review found that a minimum of 36
lymph nodes were required to give a 50
probability of accuracy in stage T1 and T2
lesions. Accuracy plummets to 25 if only 18
lymph nodes were examined. A decreased number of
lymph nodes may reflect the degree of resection
or the intensity with which the lymph nodes are
sought. Removing more colon will increase the
yield of lymph nodes but will not increase the
accuracy. Studies have found that typically
10-12 lymph nodes are examined in stage 1-3 with
an average of 7 nodes.
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The fairly consistent nodal drainage and the lack
of significance of micrometastasis has limited
the use of sentinel node mapping in colorectal
cancer.
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Screening following curative surgery
Other modalities sometimes indicated - useful to
follow for recurrence but of limited survival
advantage CEA CT scan MRI PET Second look
surgery
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Results
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Emerging technologies
Virtual Colonoscopy Compelling, emerging but
unproven. Immunochemical fecal. Better than
guiac tests. occult blood testing DNA stool
screening Does not detect all mutations. Lack of
trials. Capsule endoscopy Good for small
intestine but of minimal use in the
colon
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Code 40
Code 40
Extended
Right Colectomy
Right Colectomy
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Code 30
Code 30
Code 30
Transverse Colectomy
Sigmoid Colectomy
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Code 18.40
Code 19.40
Code 19.40
Left Colectomy
Low Anterior Resection
with LAR
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Abdominoperineal
Resection
CPT 45110
Code 20.50
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Total
Colectomy
Abdominal
CPT 44150
Code 18.50
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Ileoanal
Code 19.66
J
The ileum is of smaller caliber and requires
formation of a reservoir
Pouch
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Code 20.40
Coloanal
J
The colon will enlarge and may or may not benefit
from the formation of a reservoir
Pouch
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Code 19.57
Koch
The reservoir is made from the cecum and terminal
ileum and must be intubated to empty
Pouch