Imaging and Diagnostic Studies

• Colonoscopy revealed multiple polyps in his transverse colon.

• Biopsy revealed three polyps positive for adenocarcinoma of the colon.

• Staging CT scan revealed metastatic disease in the liver, lung, and bone.

• All other findings negative.

Because GW has stage IV colon cancer, how does this affect your treatment plan compared with stage I-III disease?

What is your treatment goal for him?

What nonpharmacologic and pharmacologic options are available to GW?

General Approach to Treatment

The treatment approaches for colorectal cancer reflect two primary treatment goals: curative therapy for localized disease (stages I to III) and palliative therapy for meta-

static cancer (stage IV). Surgical resection of the primary tumor is the most import-

ant part of therapy for patients in whom cure is possible. Depending on the stage of disease and whether the tumor originated in the colon or rectum, further adjuvant chemotherapy or chemotherapy plus radiation may be needed after surgery to cure these patients. In the metastatic setting, pharmacologic intervention is the main treatment option.

FIGURE 91-3. Stage I: Cancer is confined to the lining of the colon. Stage II: Cancer may penetrate the wall of the colon into the abdominal cavity but does not invade any local lymph nodes. Stage III: Cancer invades one or more lymph nodes but has not spread to distant organs. Stage IV: Cancer has spread to distant locations in the body, which may include the liver, lungs, or other sites. (From ht-

tp://www. cancer. gov/cancertopics/pdq/treatment/colon/Patient/page2.)

FIGURE 91-3. Stage I: Cancer is confined to the lining of the colon. Stage II: Cancer may penetrate the wall of the colon into the abdominal cavity but does not invade any local lymph nodes. Stage III: Cancer invades one or more lymph nodes but has not spread to distant organs. Stage IV: Cancer has spread to distant locations in the body, which may include the liver, lungs, or other sites. (From ht-

tp://www. cancer. gov/cancertopics/pdq/treatment/colon/Patient/page2.)

Nonpharmacologic Therapy Operable Disease (Stages I—III)

Surgery Individuals with stage I to III colorectal cancer should undergo a complete surgical resection of the tumor mass with removal of regional lymph nodes as a cur-

ative approach for their disease. Surgery for rectal cancer depends on the region of tumor involvement with attempts to retain rectal function as a goal of the surgical procedure. Overall, surgery for colorectal cancer is associated with a low morbidity and mortality rate. Common complications associated with colorectal surgery include infection, anastomotic leakage, obstruction, adhesion formation, and malabsorption syndromes.

Radiation Therapy There is currently no role for adjuvant radiation in colon cancer. However, patients who receive surgery for rectal cancer receive radiation therapy to reduce local tumor recurrence. Adjuvant radiation plus chemo-therapy is considered standard treatment for patients with stage II or III rectal cancer after the surgical procedure is complete. Preoperative radiation may be used to reduce the initial size of rectal cancers in order to make the surgical procedure easier.

Metastatic Disease (Stage IV)

Surgery Unlike stages I to III disease, the benefit of surgical resection in most patients with metastatic disease is limited to symptomatic improvement. Select patients who have from one to three small nodules isolated to the liver, lungs, or abdomen may have a prolongation of survival, though cure is rare. Five-year survival for patients who undergo surgical resection of metastases isolated to the liver is approximately double that of patients who are not surgical candidates with approximately 33% of patients alive

at 5 years. Alternatives to surgery include destroying the tumor through freezing and thawing (cryoablation), heat (radiofrequency), or alcohol injection though these ap-

23 25

pear to be less successful than surgical resection. ' Because the majority of these patients will relapse, many practitioners offer adjuvant chemotherapy to select patients following potentially curative resection, but further studies are needed to determine an

optimal treatment regimen. Additionally, neoadjuvant approaches to patients with isolated hepatic lesions will be discussed later in the chapter.

Radiation Symptom reduction is the primary goal of radiation for patients with advanced or metastatic colorectal cancer.

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