locally advanced colon cancer · – viability of bowel – location of obstruction – tumor...

Locally Advanced Colon Cancer

Feiran Lou MD. MS. Richmond University Medical Center

Department of Surgery

www.downstatesurgery.org

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

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

Labs CBC 12.9/10.6/32.8/274 BMP, LFT, coags WNL

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

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

Outline

• Pathogenesis • Surgical Resection • Challenges in locally advanced tumors

– Obstruction – Visceral invasion

• Adjuvant therapy

Colon Cancer Pathogenesis

Staging

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

Locally Advanced Colon Cancer

• Obstruction – Bypass – Stent

• Invasion of adjacent organs – En bloc resection – Neoadjuvant therapy (?)

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

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?

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%)

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

Accuracy of Intraoperative Assessment

• Tumor infiltration in 34% resected organs

Outcomes

• Post operative complications 33% • Post operative mortality 7.5% • Curative resection in 65% • Histologic tumor infiltration 44% • Overall 5 year survival 51%

Overall Survival

Conventional Vs. Multivisceral Resection

Chemotherapy

• Neoadjuvant? Pilot trials • 5-Fluorouracil with leucovorin • Capecitabine: PO prodrug • Monoclonal antibodies

– Bevacizumab, cetuximab, panitumumab (anti-EGFR)

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

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

• 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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