People's Republic of China provincial Ministry of Health (2010)

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Diagnosis and treatment of colorectal cancer (2010 Edition)I. overviewIn recent years, with the continuous improvement of living standards,

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Diagnosis and treatment of colorectal cancer (2010 Edition)

I. overview

In recent years, with the continuous improvement of living standards, changes in diet and the diet structure and the aging of the population in China, colorectal cancer (colorectalcancer, CRC) the incidence and mortality rates keep rising trend. Among them, the incidence of colon cancer increased significantly. Most of the patients were found to belong to the middle and late stage.

In order to further standardize the diagnosis and treatment of colorectal cancer in China, improve the level of diagnosis and treatment of colorectal cancer in medical institutions, improve the prognosis of colorectal cancer patients, and ensure the quality of medical care and medical safety.

Two, diagnostic techniques and Applications

(a) clinical manifestations.

Early colorectal cancer can be no obvious symptoms, the development of the disease to a certain extent, the following symptoms:

1 changes in bowel habits.

2 stool (thin stool, mucous stool, etc.).

3 abdominal pain or abdominal discomfort.

4 abdominal mass.

5 intestinal obstruction.

6 anemia and systemic symptoms: such as weight loss, fatigue, low heat.

(two) physical examination.

1 general condition evaluation, superficial lymph nodes.

2 abdominal visual inspection and palpation, check whether the intestinal type, peristalsis, abdominal mass.

3 refers to the rectal examination: where suspected colorectal cancer must be used as a conventional rectal and rectal examination. To understand the size and texture of the tumor, the range of the diameter of the bowel wall, the activity of the basal part, the distance from the anal margin, the invasion of the tumor to the outside of the intestine, and the relationship with the surrounding organs. Refers to the inspection must be carefully touch, avoid misdiagnosis; soft touch, avoid extrusion, observe whether finger blood.

(three) laboratory examination.

1 blood: understand whether anemia.

2 urine routine: Observation of hematuria, combined with urinary tract imaging to understand whether the tumor invasion of the urinary system.

3 stool routine: check should be noted that there is no red blood cells, pus cells.

4 fecal occult blood test for diagnosis of gastrointestinal bleeding has important value.

(four) endoscopy.

Colonoscopy and sigmoidoscopy are suitable for colorectal lesions with low location.

All patients with suspected colorectal cancer are recommended for colonoscopy or electronic colonoscopy, except for the following:

1 general condition is poor, difficult to bear;

2 acute peritonitis, intestinal perforation, extensive adhesions in the abdominal cavity and complete intestinal obstruction;

3 perianal or severe intestinal infection, radiation enteritis;

4 women during pregnancy and menstrual period.

Endoscopy before, must be prepared to check on a liquid diet, laxatives, or cleaning enema, the intestinal cavity drain stool.

Endoscopy report must include: into the mirror depth, tumor size, location, shape, from the anal margin of local infiltration, colonoscopy of suspicious lesions to pathology biopsy.

Because the colon may appear shrinkage in the inspection, therefore endoscopy in tumor from anus distance may have errors, the proposed combined CT or barium enema clear lesion.

(five) imaging examination.

1 barium enema examination of the colon, especially the double contrast examination of air and barium, is an important method for the diagnosis of colorectal cancer. However, patients with suspected intestinal obstruction should be carefully chosen.

2.B type ultrasound: ultrasonic examination can be used to understand whether the patient has recurrence and metastasis, and has the advantages of convenience and fast.

3.CT examination: CT examination is clear the depth of bowel wall invasion, and distant metastasis sites spread outside the wall. Currently, CT examination of colorectal lesions is recommended for the following areas:

(1) staging of colorectal cancer;

(2) finding recurrent tumors;

(3) evaluation of tumor response to various treatments;

(4) to clarify the internal structure of the internal and external compression lesions found in barium enema or endoscope;

(5) to evaluate the discovery of barium examination of the abdominal mass, clear the mass source and its relationship with the surrounding organs.

4.MRI examination: the indications of MRI examination and CT examination. The MRI examination is recommended for the following cases: (1) preoperative staging of rectal cancer; (2) evaluation of liver metastases from colorectal cancer; (3) suspected peritoneal and hepatic lesions.

5 by transrectal ultrasound: rectal or endoscopic ultrasonography is recommended for the diagnosis and staging of middle and low rectal cancer.

6.PET-CT: is not recommended for routine use, but can not be used as an effective adjunct to routine detection of metastatic lesions.

7 excretory urography: preoperative routine examination is not recommended, only for patients with a greater likelihood of invasion of the urinary tract.

(six) serum tumor markers.

CEA and CA19-9 should be detected in patients with colorectal cancer before diagnosis, treatment, evaluation of curative effect and follow-up. It is suggested that CA242 and CA72-4 should be detected. AFP should be recommended in patients with liver metastases, and patients with ovarian metastasis should be recommended to detect CA125.

(seven) histopathological examination.

Pathological biopsy is the basis for the treatment of colorectal cancer. Standardized colorectal cancer treatment in patients with biopsy proven invasive carcinoma. Because of the limitations of biopsy, biopsy pathology can not determine the depth of infiltration, diagnosed as high-grade intraepithelial neoplasia cases, it is recommended that clinicians to other clinical conditions, to determine treatment options. Detection of K-ras gene status in tumor tissues in patients with recurrent or metastatic colorectal cancer.

(eight) open exploration.

In the following cases, open laparotomy is recommended:

1 after a variety of diagnostic methods can not be clearly diagnosed and highly suspected colorectal cancer.

2 intestinal obstruction, conservative treatment ineffective.

3 suspected intestinal perforation.

4 conservative treatment ineffective gastrointestinal bleeding.

(nine) diagnosis of colorectal cancer.

Colorectal cancer diagnostic procedures see figure -1.

(ten) differential diagnosis of colorectal cancer.

1 colon cancer should be identified with the following diseases:

(1) ulcerative colitis. This disease can appear diarrhea, mucus, pus and blood stool, stools, abdominal distension, abdominal pain, weight loss, anemia and other symptoms associated with infection can have fever and other symptoms of poisoning, and colon cancer symptoms similar to colonoscopy and biopsy is an effective identification method.

(2) appendicitis. Ileocecal carcinoma can be misdiagnosed as appendicitis due to local pain and tenderness. Especially the late ileocecal carcinoma, partial necrosis occurred often ulceration and infection, clinical manifestations of fever, white blood cell count increased, local tenderness or a palpable mass, often diagnosed appendiceal abscess, need to pay attention to identify.

(3) intestinal tuberculosis. Is more common in our country, the predilection site in ileum, cecum and ascending colon. Common symptoms include abdominal pain, abdominal mass, diarrhea, constipation alternately, some patients may have low fever, anemia, weight loss, fatigue, abdominal mass, similar to the symptoms of colon cancer. But the systemic symptoms of intestinal tuberculosis were more obvious, such as low fever or irregular fever, night sweats, emaciation, need to pay attention to identify.

Colonic polyps (4). The main symptoms are bleeding, some patients may also have pus like, similar to colon cancer, barium enema examination showed filling defect for colonoscopy and biopsy for pathological examination is an effective identification method.

(5) schistosome granuloma. Prevalent in endemic areas, has been rare. A few cases can be cancerous. According to the history of schistosome infection, were examined in feces, and barium enema and colonoscopy and biopsy can be identified with colon cancer.

(6) Amiba granulomatosis. Symptoms of bowel obstruction, abdominal mass and abdominal mass were similar to those of colon cancer. The patients for stool examination can find amebic trophozoites and cysts, barium enema examination often showed great unilateral defect or circular notch.

2 rectal cancer should be identified with the following diseases:

(1) hemorrhoids. Hemorrhoids and rectal cancer is not difficult to identify, often misdiagnosed due to serious inspection. Hemorrhoids generally as painless bleeding, blood red do not mix with the stool, rectal mucus and hematochezia often accompanied by mucus and blood stool and rectal irritation. The patient must be hematochezia routine digital rectal examination.

(2) anal fistula. Often the anal sinusitis and the formation of anal fistula and perianal abscess caused by. The patient had a history of perianal abscess, local swelling and pain, and the symptoms of rectal cancer were significantly different, it was easy to identify.

(3) amebic enteritis. The symptoms of abdominal pain, diarrhea, rectal lesions accompanied by tenesmus. Dark red or purplish red blood and mucus. Enteritis can cause granulation and fibrous tissue hyperplasia, thickening of the intestinal wall, intestinal lumen stenosis, easily misdiagnosed as rectal cancer, colonoscopy and biopsy as an effective means of identification.

(4) rectal polyps. The main symptoms were hematochezia, colonoscopy and biopsy are effective means of identification.

Three, pathological evaluation

(1) fixed specimens.

1 fixed liquid: recommended 13% neutral formalin fixed liquid using 10 to avoid the use of fixed liquid containing heavy metals.

2: more than the fixed amount of fluid must be fixed 10 times the volume of the specimen.

3 fixed temperature: normal room temperature.

4 fixed time: endoscopic resection of adenoma or biopsy specimens: 6 hours, less than 48 hours.

Surgical specimens: 12 hours, less than 48 hours.

(two) material requirements.

1 biopsy specimens.

(1) check the number of clinical specimens, from biopsy specimens must be drawn.

(2) each wax block contains no more than 5 biopsy specimens.

(3) the specimen is wrapped in gauze or Soft Pervious paper to avoid loss.

2 endoscopic resection of adenoma specimens.

(1) specimens from surgical flat fixed range marker.

(2) the size of the tumor was recorded, and the distance from the incisal margin.

(3) perpendicular to the intestinal wall, each of the 0.3cm parallel cut specimens, divided into the appropriate size of the tissue block, recommended by the same package buried in the direction of all materials. Record the orientation of the tissue block.

3 surgical specimens.

(1) intestinal wall and tumor.

The intestinal wall along the long axis, perpendicular to the intestinal wall removed tumor specimens, tumor tissues were fully considered, tumor size, infiltration depth, different texture and color areas were drawn (conventional 4), tumor infiltrating the depths of at least 1 pieces of the whole thickness of tumor and intestinal tissue, to determine the most deep tumor invasion time. Cut the tissue that can show the relationship between tumor and adjacent mucosa (Routine 2).

Resection of distal and proximal surgical margins. Circumferential margin was partially removed by surgeon.

The distance between the distal and proximal margin of the tumor was recorded.

The intestine contains samples such as ileocecal or anus, anus, should be in the ileocecal valve, and anus dentate line drawn (conventional 1) and the appendix (3: 2 pieces of conventional ring + blind end 1); as the tumor site, should fully display cut tissue lesions.

The line in the low rectal surgery need complete resection of the mesorectum, therefore needs a systematic examination of the pathologist surgical specimens, including membrane integrity, circumferential margin whether there is tumor invasion, which is an important index to evaluate the effect of total mesorectal excision surgery.

(2) lymph nodes.

The surgeon suggested according to the local anatomical see signs and intraoperative lymph node packet inspection, is conducive to the lymphatic drainage area of the location; before receiving the packet inspection orders or surgeon mark, pathologists in accordance with the following principles in the lymph node specimens:

All lymph nodes were collected (12 lymph nodes were recommended at least). The lymph nodes of patients who received preoperative treatment could be less than 12. All visible negative lymph nodes should be complete submission, the naked eye positive lymph nodes can cut part inspection.

(3) the recommended volume of tissue block: not more than 2 x 1.5 x 0.3cm.

(three) the principle and retention time of the sample.

1 preservation of the remaining specimens. From the remaining tissue preservation in fixed standard solution, and always maintain full fixed liquid volume and the concentration of formaldehyde, avoid dry specimens or because of insufficient or fixed liquid concentration decreased from decaying tissue for microscopic observation; according to the diagnostic requirements at any time to prepare for the supplementary materials; pathological diagnosis report issued after receiving clinical feedback review of specimen or supplementary materials.

2 remaining specimen processing time limit. Recommendations in the report issued by pathological diagnosis after 1 months, has not received the clinical feedback information, does not occur due to outside the hospital consultation opinions for review and other circumstances, can be handled by the hospital.

(four) pathological type.

1 early colorectal cancer.

Cancer cells confined to the submucosa of the colon are known as early colorectal cancer (pT1). The classification of the digestive tract tumors in WHO is called "high-grade intraepithelial neoplasia."".

2 general types of advanced colorectal cancer.

(1) uplift type. The main body of the tumor to the lumen of the prominent, belong to this type.

(2) ulcer type. Depth of tumor formation or through muscle layer is the ulcer type.

(3) infiltrative type. The tumor spread to each layer of the intestinal wall, so that the local intestinal wall thickening, but the surface is often no obvious ulcer or uplift.

3 histological types.

(1) adenocarcinoma: papillary adenocarcinoma; the tubular adenocarcinoma and mucinous adenocarcinoma;; the signet ring cell carcinoma;

(2) undifferentiated carcinoma;

(3) adenocarcinoma;

(4) squamous cell carcinoma;

(5) small cell carcinoma;

(6) carcinoid.

4 the relationship between classification and histological type.

Table 1 the relationship between cell grade and histological type of colorectal cancer.

Table 1 Relationship between classification and histological type

Classification

Histological type

WHO

Four stage method

Low level

Grade I

II

Well differentiated (Guan Zhuang) adenocarcinoma, papillary adenocarcinoma

Moderately differentiated (Guan Zhuang) adenocarcinoma

High level

III

IV

Poorly differentiated (Guan Zhuang) adenocarcinoma, mucinous adenocarcinoma, signet ring cell carcinoma, undifferentiated carcinoma, medullary carcinoma

(five) pathology report.

1 pathological report contents and requirements of biopsy specimens:

(1) patients with basic information and information.

(2) if the intraepithelial neoplasia (dysplasia), grading report.

(3) if there is a type of cancer, histological type.

Clinicians should be aware of the depth of biopsy, and the biopsy pathology can not completely determine the depth of invasion, so the cancerous tissue may be confined to the mucosa of the cancer (high-grade intraepithelial neoplasia or mucosal carcinoma).

2 pathological report and requirement of endoscopic resection of adenoma specimens:

(1) patients with basic information and information.

(2) tumor size.

(3) intraepithelial neoplasia (dysplasia) classification.

If there is a cancer, the histological type, grade, depth of invasion, margin of resection and vascular invasion are reported.

PT1, III and IV grade differentiation, vascular invasion, positive margin, the clinical operation should be extended surgical resection. Other endoscopic resection is sufficient, but need regular follow-up after operation.

In the cancerous adenoma, there was infiltration of cancer cells through the muscularis mucosae to the submucosa (pT1).

The histological features of the patients with good prognosis include: Grade I or II differentiation, no vascular and lymphatic invasion, and "margin negative".

The histological features of poor prognosis include: Grade III or IV differentiation, vascular and lymphatic invasion, positive margin".

The positive margin is defined as the distance from tumor margin less than 1mm or electric knife edge showed cancer cells.

3 pathological report and requirement of surgical specimen:

(1) patients with basic information and information.

(2) general situation: tumor size, gross type, depth of invasion, visible from a tumor resection of proximal and distal ends of the length.

(3) the degree of tumor differentiation (tumor type and grade).

(4) the depth of tumor invasion (T stage) (T stage or ypT was determined by the viability of the tumor cells, and the cells were not considered to be tumor residues after neoadjuvant therapy.

(5) the number of detected lymph nodes and the number of positive lymph nodes (N stage).

(6) the condition of proximal margin and distal margin.

(7) it is suggested that the circumferential margin (if the tumor is very close to the margin) should be measured under a microscope and the distance between the tumor and the margin of the tumor should be reported. The margin of the tumor is within the margin of 1mm and the margin is positive.

(8) vascular invasion (represented by V blood vessels, V1 as a mirror of vascular infiltration, V2 for the naked eye vascular invasion, L on behalf of lymphatic vessels).

(9) nerve involvement.

(10) the status of the K-ras gene was identified as recurrent or metastatic colorectal cancer. If no surgical specimens were obtained from biopsy specimens.

The complete pathological report is based on the fact that the clinician fills out a detailed list of pathological diagnoses, describes the results of the surgery and related clinical findings and clearly identifies the lymph nodes. The mutual communication, trust and cooperation between clinicians and pathologists are the basis for establishing correct staging and guiding clinical treatment.

Appendix: TNM staging of colorectal cancer

American Joint Committee on cancer (AJCC) / International Union against cancer (UICC) colorectal cancer TNM staging system (2010 Edition)

Primary tumor (T)

Tx primary tumor could not be evaluated

T0 no evidence of primary tumor

Tis carcinoma in situ: confined to the epithelium or invaded the lamina propria

T1 tumor invades submucosa

T2 tumor invades the muscularis propria

T3 tumors penetrate the muscularis propria to reach the inferior layer of the peritoneum, or invasion of colorectal tissue without peritoneal coverage

T4a tumor penetrating peritoneum

T4b directly invade or adhere to other organs or structures

Regional lymph node (N)

Nx regional lymph nodes can not be evaluated

N0 without regional lymph node metastasis

N1 had 1-3 regional lymph node metastasis

N1a has 1 regional lymph node metastasis

N1b had 2-3 regional lymph node metastasis

There were deposit and N1c (TD, tumor) in the colon / rectum tissue surrounding the serosa, mesentery and peritoneum without lymph node metastasis

N2 has more than 4 regional lymph node metastasis

N2a 4-6 lymph node metastasis

N2b7 and more regional lymph node metastasis

Distant metastasis (M)

M0 without distant metastasis

M1 has distant metastasis

M1a distant metastases are confined to a single organ or site (such as the liver, lung, ovary, and non regional lymph nodes)

M1b distant metastases are located in more than one organ / site or peritoneal metastasis

Anatomical staging / prognostic group

Stage

T

N

M

Dukes

MAC

Tis

N0

M0

-

-

I

T1

N0

M0

A

A

T2

N0

M0

A

B1

II A

T3

N0

M0

B

B2

II B

T4a

N0

M0

B

B2

II C

T4b

N0

M0

B

B3

III A

T1-2

N1/N1c

M0

C

C1

T1

N2a

M0

C

C1

III B

T3-4a

N1/N1c

M0

C

C2

T2-3

N2a

M0

C

C1/C2

T1-2

N2b

M0

C

C1

III C

T4a

N2a

M0

C

C2

T3-4a

N2b

M0

C

C2

T4b

N1-2

M0

C

C3

IV A

Any T

Any N

M1a

-

-

IV B

Any T

Any N

M1b

-

-

Note: 1.cTNM is a clinical stage, pathological stage is pTNM; the Y prefix for receiving neoadjuvant therapy (preoperative) after tumor staging (such as ypTNM), pathological complete remission in patients with stage ypT0N0cM0, similar to the 0 or 1. Prefix R is used to treat a patient with recurrence after a disease-free interval (rTNM).

The Dukes B period included two patients with a better prognosis (T3N0M0) and a poorer prognosis (T4N0M0), and the Dukes phase C was also the same (any TN1M0 and any TN2M0). MAC is a modified Astler-Coller staging.

2.Tis consists of tumor cells confined to the glandular basement membrane (epithelium) or the lamina propria (mucosa), which does not pass through the muscularis mucosae to the submucosa.

Direct invasion of 3.T4 include penetrating serosal invasion of other intestinal segments, and endoscopic diagnosis confirmed (such as colon cancer invasion of the sigmoid colon), or in the peritoneum or peritoneal bowel tumor, perforation of the intestinal wall after direct invasion of other natural primary organ or structure, such as the posterior wall of the descending colon tumor invading the left kidney or the lateral abdominal wall, or rectal cancer invading prostate, seminal vesicle, cervix or vagina.

4 on the other hand, the tumor was divided into cT4b with other organs or structures. However, if there is no tumor in the adhesion under microscope, the stage is pT3. The V and L sub stages were used to indicate the presence of vascular and lymphatic infiltrates, whereas PN was used to indicate perineural invasion (which may be site specific).

Four, surgical treatment

(a) surgical treatment of colon cancer.

1 surgical treatment of colon cancer.

(1) a comprehensive survey, from the far and near. The liver, gastrointestinal tract, uterus and appendages, pelvic peritoneum, and associated mesenteric lymph nodes and adjacent organs should be explored.

(2) suggested that adequate bowel resection, regional lymph node dissection, en bloc resection.

(3) recommended separation technology.

(4) surgical removal from distant and near. Treatment of trophoblastic tumor.

(5) recommended surgery to follow the principle of non tumor.

(6) after the removal of the tumor, replace the gloves and wash the abdominal cavity.

(7) if the patient has no bleeding, obstruction, perforation, and has lost the chance of radical surgery, no palliative resection of the primary tumor is necessary.

2 surgical treatment of early colon cancer.

(1) T1N0M0 colon cancer: local excision is recommended. Preoperative rectal cavity ultrasound belongs to the T1 or after local excision pathology showed T1, and features with complete resection if good prognosis (such as tissue differentiation, vascular invasion), then both the wide base or pedicle, surgical resection is not recommended. If there is a poor prognosis of the histological characteristics of the pedicle, or incomplete resection, the broken edge of the specimen can not be evaluated.

(2) the villous adenoma with a diameter of more than 2.5cm has a high rate of canceration.

(3) all patients had to undergo a full colonoscopy after surgery to exclude the presence of multiple adenomas or multiple cancers.

Note: local excision specimens must by surgeons flattening, fixed range marker and pathological examination after.

3 T2-4, N0-2, M0 colon cancer.

(1) the preferred surgical approach is the corresponding colectomy and regional lymph node dissection. Regional lymph node dissection must consist of three stations in the lymph nodes of the intestinal tract, the middle and the root of the mesentery. It is suggested that the root of the membrane should be labeled with lymph node and sent to the pathological examination. If there is any doubt that the lymph node metastasis beyond the scope of dissection must be completely removed, the patient who is unable to remove the tumor should be considered as palliative resection.

(2) with hereditary nonpolyposis colorectal cancer (hereditary nonpolyposis colorectal cancer, HNPCC) or a family history of colon cancer, obvious family history, at the same time or multiple primary colorectal cancer patients is recommended for more extensive resection of colon.

(3) combined with en bloc resection of the tumor invading the surrounding tissues and organs.

(4) new clinical diagnosis of colorectal cancer is highly suspected of malignancy, and for some reason, there is no pathological diagnosis, such as patients can tolerate the operation, it is recommended to laparotomy.

(5) laparoscopic assisted colectomy is recommended for the following conditions: surgical procedures performed by experienced surgeons;

The primary focus is on the transverse colon (unless clinical trials);

There was no serious effect on abdominal adhesion;

The local advanced or advanced disease manifestations;

The acute intestinal obstruction or perforation performance;

We can guarantee the full abdominal exploration.

(6) for resectable colon cancer with obstruction, the first stage resection and anastomosis, or the distal closure of the proximal end of the primary tumor resection, or the second stage resection after the operation, or the second stage resection after stent implantation. Palliative care should be given if the tumor is unresectable locally or cannot be tolerated clinically.

4 principles of surgical treatment of hepatic metastases.

Treatment of colorectal liver metastases.

5 principles of surgical treatment of pulmonary metastases.

(1) primary lesions must be treated with radical resection (R0).

(2) there was no resection of the pulmonary lesion without obstruction of the pulmonary metastasis.

(3) complete resection must take into account the extent of the tumor and the anatomic site, which must be maintained after pneumonectomy.

(4) some patients may be treated with partial resection.

(5) regardless of whether or not the pulmonary metastases can be removed, combined chemotherapy (preoperative chemotherapy and / or adjuvant chemotherapy) should be considered.

(two) surgical treatment of rectal cancer.

The principle of abdominal exploration in the treatment of rectal cancer.

1 local excision of rectal cancer (T1N0M0).

Treatment principles of early rectal cancer (T1N0M0) with early colon cancer.

Early rectal cancer (T1N0M0), such as transanal resection, must meet the following requirements: (1) invasion of the small bowel diameter of < < > > > > 30%;

(2) tumor size 3cm;

(3) margin negative (distance from tumor > 3mm);

(4) activity, not fixed;

(5) less than 8cm of anal margin;

(6) only for T1 tumors;

(7) endoscopic resection of polyps, with cancer invasion, or pathological uncertainty;

(8) no lymphatic vessel invasion (LVI) or perineural invasion;

(9) high middle differentiation;

(10) evidence of no lymphadenopathy before treatment.

Note: local excision specimens must by surgeons flattening, fixed range marker and pathological examination after.

2 rectal cancer (T2-4, N0-2, M0).

Radical surgical treatment. Low anterior resection for lower rectal cancer is recommended for low rectal cancer. Rectal cancer must follow the principles of total mesorectal excision of rectal cancer, as far as possible sharp free tumor distal mesorectum, together with mesangial resection. The intestinal wall distance of cutting edge of tumor is larger than 2cm, the mesorectum distance of cutting edge over 5cm or the total mesorectal excision of tumor. As far as possible to maintain the function of anal sphincter, urination and sexual function. Treatment principles are as follows:

(1) resection of the primary tumor to ensure sufficient margin, distal margin at least from the distal end of the tumor 2cm. In the lower rectal cancer (less than 5cm from the anus), the distal margin of the tumor was 1 to 2cm. It was suggested that intraoperative frozen pathological examination confirmed that the margin was negative.

(2) removal of lymphatic adipose tissue.

(3) pelvic autonomic nerve preservation.

(4) new adjuvant (preoperative) radiotherapy and chemotherapy is recommended for the interval of 4 to 8 weeks.

(5) the tumor invading the surrounding tissues and organs to fight the combined organ resection.

(6) rectal complications associated with intestinal obstruction, with a high degree of clinical suspicion of malignancy, and no pathological diagnosis, not involving anal sphincter problems, and patients who can tolerate surgery, are advised to laparotomy.

(7) for resectable rectal cancer with obstruction, we recommend the first stage resection and anastomosis, or Hartmann operation, or the second stage resection after the operation, or the removal of II after stent placement. Preoperative intestinal lavage in one-stage resection and anastomosis. If there is a higher risk of anastomotic leakage, it is recommended that Hartmann surgery or primary resection and anastomosis and prophylactic colostomy be performed.

(8) if the locally advanced unresectable tumors or patients can not tolerate surgery, recommended palliative treatment, including radiation therapy treatment, stent implantation bleeding cannot be controlled to treat intestinal obstruction and support treatment.

3 liver and lung metastasis of rectal cancer.

The treatment of liver and lung metastases in rectal cancer.

Five, medical treatment

(a) neoadjuvant therapy for colorectal cancer.

The purpose of neoadjuvant therapy is to improve the resection rate, improve the anal sphincter rate and prolong the disease-free survival of patients. Neoadjuvant chemoradiation is recommended only for rectal cancer of the anus < 12cm. In addition to colon cancer liver metastasis, colon cancer patients with preoperative neoadjuvant therapy is not recommended.

1 neoadjuvant chemoradiotherapy for rectal cancer.

(1) neoadjuvant chemotherapy with fluorouracil based neoadjuvant therapy for rectal cancer.

(2) T1-2N0M0 patients with or without chemotherapy and radiotherapy recommend direct surgery and do not recommend neoadjuvant therapy.

(3) T3 and / or N+ in patients with resectable rectal cancer, preoperative neoadjuvant chemoradiotherapy is recommended.

(4) T4 or locally advanced resectable rectal cancer must be treated with neoadjuvant chemoradiotherapy. After treatment must be re evaluated, and consider the feasibility of surgery.

Neoadjuvant chemotherapy is recommended as the first choice for continuous infusion of 5-FU, or 5-FU/ LV, or capecitabine monotherapy. Recommended chemotherapy duration of 2-3 months. Radiation therapy principles.

2 neoadjuvant chemotherapy for colorectal cancer with liver metastasis.

Colorectal cancer patients with liver metastasis and / or pulmonary metastases resectable or potentially resectable, recommended preoperative chemotherapy or chemotherapy combined with targeted therapy: Cetuximab (recommended for patients with wild type K-ras gene), or combined with bevacizumab.

The recommended chemotherapy (oxaliplatin + fluorouracil + FOLFOX leucovorin), or FOLFIRI (irinotecan plus fluorouracil + leucovorin), or CapeOx (capecitabine plus oxaliplatin). Recommended treatment time 2-3 months.

After treatment must be re evaluated, and consider the feasibility of surgery.

(two) adjuvant therapy for colorectal cancer.

Adjuvant therapy is not recommended for patients with stage I (T1-2N0M0) or contraindications to chemotherapy and radiotherapy.

1 adjuvant chemotherapy for colorectal cancer.

(1) adjuvant chemotherapy for stage II colorectal cancer. Stage II patients with colorectal cancer, should confirm whether the following risk factors: poor histological differentiation (Class III or IV), T4, lymphatic vascular invasion, preoperative intestinal obstruction, intestinal perforation / lymph node specimens is insufficient (less than 12).

Stage II colorectal cancer, no risk factors, it is recommended to follow up, or single drug fluorouracil chemotherapy.

Second stage colorectal cancer, there are high risk factors, it is recommended adjuvant chemotherapy. Chemotherapy is recommended for 5-FU/LV, capecitabine, oxaliplatin 5-FU/LV/ or CapeOx regimen. Chemotherapy should not exceed 6 months. The condition is recommended to detect tissue specimens of MMR or MSI, such as dMMR or MSI-H, does not recommend a single adjuvant chemotherapy of fluorouracil.

(1) adjuvant chemotherapy for stage II colorectal cancer. Adjuvant chemotherapy for stage III colorectal cancer. Chemotherapy is recommended for 5-FU/CF, capecitabine, FOLFOX or FLOX (oxaliplatin + fluorouracil + leucovorin) or CapeOx regimen. Chemotherapy should not exceed 6 months.

2 rectal cancer radiotherapy and chemotherapy.

T3-4 or N1-2 is less than or equal to 12cm from the anal margin of rectal cancer, recommended preoperative neoadjuvant chemoradiotherapy, neoadjuvant radiotherapy without preoperative chemoradiotherapy, recommendations, the recommended chemotherapy of fluorouracil monotherapy. Radiation therapy principles.

(three) chemotherapy for advanced / metastatic colorectal cancer.

At present, the treatment of advanced or metastatic colorectal cancer drugs: 5-FU/LV, irinotecan, oxaliplatin, capecitabine and targeted drugs, including cetuximab (recommended for patients with wild type K-ras gene) and bevacizumab.

1 detection of tumor K-ras status before treatment, EGFR is not recommended as a routine examination items.

2 combination chemotherapy should be used as a second-line treatment for patients with metastatic colorectal cancer who are resistant to chemotherapy. Recommend the following: FOLFOX/ FOLFIRI/CapeOx chemotherapy + cetuximab (recommended for patients with wild type K-ras gene), FOLFOX/ FOLFIRI/CapeOx + bevacizumab.

3 more than three lines of chemotherapy recommended in patients with clinical research. In the first and second line therapy did not use drugs targeting patients also can consider irinotecan combined with targeted therapy.

4 patients who could not tolerate combination chemotherapy, recommended 5-FU/LV + targeted drug, or 5-FU continuous infusion, or capecitabine monotherapy.

5 patients with advanced conditions if the general condition or organ function is poor, recommend the best support treatment, chemotherapy is not recommended.

6 if the recurrence is limited to the liver, it is recommended to consider local therapy for liver disease.

7 local recurrence of colorectal cancer, it is recommended to carry out multidisciplinary evaluation, to determine whether the opportunity to re resection, is suitable for preoperative chemoradiotherapy. If combined with radiotherapy, can be selected according to the patient's physical status of fluorouracil single drug or combination chemotherapy, such as only suitable for chemotherapy, the use of the principle of medication in patients with advanced.

(four) local / regional chemotherapy.

Intraoperative or postoperative regional chemotherapy and intraperitoneal hyperthermic perfusion chemotherapy are not routinely recommended.

Six, rectal cancer radiation treatment norms

(1) indications of radiotherapy for rectal cancer.

The main purpose of radiotherapy or chemoradiotherapy for rectal cancer is adjuvant therapy and palliative treatment. The indications for adjuvant therapy are mainly for the stage II to stage III rectal cancer. The indication of palliative treatment is local recurrence and / or distant metastasis of the tumor. For some patients who can not tolerate surgery or have a strong desire to protect the anus, you can try radical radiotherapy or chemotherapy.

Radiotherapy is not recommended for stage 1.I rectal cancer. However, after partial resection, there is one of the following factors, recommended radical surgery, such as refusal or inoperable, it is recommended that postoperative radiotherapy.

(1) postoperative pathological staging was T2;

(2) the maximum diameter of tumor was more than 4cm;

(3) tumors accounted for more than 1/3 of the intestinal tract;

(4) poorly differentiated adenocarcinoma;

(5) nerve invasion or tumor thrombus;

(6) margin positive or tumor margin < 3mm.

2 clinically diagnosed as stage II / III rectal cancer, preoperative radiotherapy or preoperative chemoradiotherapy is recommended.

3 after radical resection, the pathological diagnosis was stage II / III rectal cancer. If the patients were not treated with preoperative chemotherapy, postoperative radiotherapy and chemotherapy should be performed.

4 locally advanced non resectable rectal cancer (T4), preoperative radiotherapy and chemotherapy must be performed, re evaluation after radiotherapy and chemotherapy, for radical surgery.

5 local recurrence of rectal cancer, the first choice of surgery; if there is no surgery, chemotherapy may be recommended.

6 stage IV colorectal cancer: initial treatment for stage IV colorectal cancer, chemotherapy + radiotherapy recommended primary lesion after treatment, re assessment of resectability; metastasis was reduced in palliative radiotherapy.

7 recurrence and metastasis of rectal cancer: resectable local recurrence, it is recommended that the first surgical resection, and then consider whether the postoperative radiotherapy. In patients with non local recurrence, preoperative radiotherapy and chemotherapy were recommended, and surgical resection was performed.

(two) radiation therapy.

1 target definition.

High risk of recurrence of primary tumor and regional lymph drainage area.

(1) primary tumor recurrence risk area including tumor / tumor bed, mesorectal area and presacral region, low rectal cancer in the target area should include the ischiorectal fossa.

(2) the regional lymphatic drainage area including pelvic iliac vascular lymphatic drainage area, mesorectal area, internal iliac lymph drainage area and obturator lymph nodes.

(3) tumor and / or residual amount, the dose of irradiation reduced the whole pelvic irradiation.

(4) radiotherapy for pelvic recurrence.

In the past, there was no history of radiotherapy, it was suggested that the primary tumor recurrence area, regional lymph node drainage area (true pelvic area) and local radiotherapy.

Previous radiotherapy history, according to the circumstances decide whether radiotherapy.

2 irradiation technique.

According to the radiotherapy equipment in the hospital, different radiotherapy techniques, such as conventional radiotherapy, three-dimensional conformal radiotherapy, intensity modulated radiotherapy, image guided radiotherapy, etc..

(1) recommended CT simulation positioning, such as no CT simulation positioning, must be simulated conventional positioning. Recommended prone or supine position, bladder filling.

(2) Sanye and above must be exposed to the wild.

(3) if intensity modulated radiation therapy must be planned.

(4) local dose may be treated with intraoperative radiotherapy or external beam irradiation.

(5) radioactive particle implantation is not recommended for routine use.

3 irradiation dose.

There must be a clear definition of the dose of radiation, whether conventional radiation therapy or three-dimensional conformal radiotherapy or intensity-modulated radiation therapy. Three dimensional conformal radiation therapy and intensity modulated radiation therapy must be based on the definition of volume dose and the dose definition mode of the conventional irradiation.

(1) DT45-50.4Gy (1.8-2.0Gy), a total of 25 or 28 times, was recommended for primary tumor recurrence and regional lymphatic drainage. Preoperative radiotherapy such as the use of 5x5 Gy/5 /1 week or other split dose, effective biological dose must be greater than 30 Gy.

(2) tumor and / or residual, the dose of irradiation DT10-20Gy local shrinkage of the whole pelvic irradiation.

(three) chemotherapy and sequence of concurrent chemoradiotherapy.

1 chemotherapy regimens for synchronous radiotherapy. Recommended 5-FU or 5-FU analogs based program.

2 the order of chemoradiotherapy and adjuvant chemotherapy. In the second to third stage rectal cancer after radical operation, it is recommended that the first step should be followed by concurrent chemotherapy and radiotherapy plus adjuvant chemotherapy or 1-2 cycles of adjuvant chemotherapy, concurrent chemoradiotherapy and adjuvant chemotherapy.

Seven, the treatment of colorectal liver metastasis

Definition of liver metastasis from colorectal cancer.

1 international general classification:

Simultaneous liver metastasis. Liver metastases occurred within 6 months after radical resection of colorectal cancer at the time of diagnosis of colorectal cancer.

Metachronous liver metastasis. Liver metastasis after radical resection of colorectal cancer 6 months.

2 colorectal cancer patients with liver metastasis of colorectal cancer and primary hepatic metastasis after radical resection has great difference in diagnosis and treatment, so the standard according to the "liver metastasis and colorectal cancer after radical resection of liver metastases two aspects with colorectal cancer.

(two) diagnosis of liver metastases from colorectal cancer.

Diagnosis of liver metastasis in 1 colorectal cancer patients.

(1) to have been diagnosed with colorectal cancer, should be liver ultrasound and / or enhanced CT imaging examination for suspected liver metastasis patients underwent serum AFP and liver MRI. PET-CT examination is not recommended as a routine, may be appropriate when the illness needs.

(2) percutaneous needle biopsy of liver metastases is limited to the needs of patients.

(3) the need for routine liver exploration in colorectal cancer surgery to further exclude the possibility of liver metastases may be considered in patients with suspected liver nodules.

Diagnosis of hepatic metastasis after radical resection of primary colorectal cancer in 2 cases.

After radical resection of colorectal cancer patients, should be regular follow-up of liver ultrasound or / and enhanced CT scan, suspected liver metastasis patients should be underwent liver MRI examination, PET-CT scan is not routinely recommended.

(three) treatment of liver metastases from colorectal cancer.

Surgical resection of liver metastases is still the best way to cure liver metastasis of colorectal cancer, so patients should meet the conditions of the appropriate time for surgery. Patients with unresectable primary liver metastases should be carefully evaluated by a multidisciplinary approach to determine the timing of neoadjuvant chemotherapy and surgery, and to create opportunities for conversion to resectable lesions.

Indication and contraindication of 1 liver metastases.

(1) indication:

Primary or primary resection of colorectal cancer.

According to the anatomical basis of liver metastases can be completely and the range of lesions of liver resection (R0), and retain sufficient liver function, liver residual volume is more than 50% (resection of metastases synchronous primary and liver) or = 30% (resection of metastases stage primary and liver).

The patient's whole body condition is allowed, and there is no extrahepatic metastasis.

(2) contraindications:

Radical resection of primary colorectal cancer can not be achieved;

Unresectable extrahepatic metastasis;

Postoperative residual liver volume is not enough;

The general condition of patients can not tolerate surgery.

Treatment of 2 resectable colorectal liver metastases.

(1) surgical treatment.

Colorectal cancer with liver metastasis.

In the following cases, suggestions of colorectal cancer primary tumor and liver metastases: synchronous resection of liver metastases of small, mostly located in or limited to half liver, hepatic resection was lower than 50%, hilar lymph node and distant metastasis or other abdominal surgery can be used as can be.

In the following cases, primary resection of primary colorectal cancer and liver metastases:

A resection of primary colorectal cancer, resection of liver metastases, the timing of choice in 4 years after radical resection of colorectal cancer for 6 weeks.

If B is treated before liver metastases, resection of liver metastases can be extended to 3 months after primary resection.

C emergency surgery is not recommended for simultaneous resection of primary colorectal cancer and liver metastases.

D radical resection of recurrent colorectal cancer with resectable liver metastases is likely to be phased in liver metastases.

Hepatic metastasis after radical resection of colorectal cancer.

History of colorectal primary tumor radical resection with primary recurrence, can complete resection and hepatic resection volume less than 70% liver metastases (without cirrhosis), should be surgical resection of liver metastases, first neoadjuvant therapy.

Recurrence after resection of liver metastases.

In the case of the recurrence of liver metastases, two or even three or more liver metastases can be performed in the presence of systemic and hepatic conditions.

The choice of surgical approach and focal hepatic metastasis.

A of liver metastases after resection of hepatic vein at least 3 root in 1 and more than 50% residual liver volume (resection of metastases synchronous primary and liver) or = 30% (resection of metastases stage primary and liver).

B transfer of the surgical margin should be generally 1cm normal liver tissue, if the location of the transfer of special (such as adjacent to large vessels) do not have to be demanding, but still should comply with the principles of R0.

C is greatly limited to left or right hepatic liver metastases and cirrhosis, liver resection of the semi feasible rules.

D suggests that intraoperative ultrasonography is useful in the detection of liver metastases in patients with liver metastases who have not been diagnosed preoperatively.

(2) preoperative treatment.

Colorectal cancer with liver metastasis. In the primary lesions without bleeding, obstruction or perforation recommended preoperative treatment, the program can be FOLFOX, FOLFIRI or CapeOX, can be combined with molecular targeted drug therapy; general recommendations within 2 ~ 3 months to complete. Cetuximab is recommended for patients with wild-type K-ras gene. The use of bevacizumab, suggest the timing of surgery after the last use of bevacizumab for 6 weeks. It is not recommended to use a variety of targeted drugs.

Hepatic metastasis after radical resection of colorectal cancer. Primary resection had not received chemotherapy, or detection of hepatic metastases in patients with chemotherapy has completed 12 months ago, the preoperative treatment (ibid); hepatic metastasis was 12 months before the patients received chemotherapy, can also direct resection of liver metastases.

(3) adjuvant therapy after resection.

Patients with complete resection of liver metastases were treated with adjuvant chemotherapy after surgery. It was suggested that the duration of chemotherapy before and after surgery was 6 months. Postoperative chemotherapy suggested optional 5-FU/LV, capecitabine, oxaliplatin 5-FU/LV/ or CapeOx regimen. Preoperative treatment is recommended for patients with preoperative regimen.

Treatment of 3 patients with resectable colorectal liver metastases.

(1) in addition to hemorrhage and perforation or obstruction emergency need surgical resection of the primary tumors except for unresectable colorectal liver metastasis patients, should be discussed by multidisciplinary, careful selection of drugs (scheme and principle of treatment with 7.3.2 before surgery) for the treatment system, all creation into surgical treatment. During the course of treatment, the curative effect was evaluated every 6-8 weeks. Once the operation conditions were met, the operation was treated as soon as possible. Patients with resectable colorectal liver metastases are equivalent to 7.3.2 related principles.

(2) radiofrequency ablation.

Radiofrequency catheter ablation is recommended for patients with resectable colorectal liver metastases who are not suitable or unwilling to undergo surgical treatment. The maximum diameter of radiofrequency ablation of liver metastases is less than 3cm and a maximum of 3.

It is suggested that some of the larger hepatic metastases should be removed after ablation of residual liver volume, and radiofrequency ablation of the metastatic lesions with less than 3cm diameter is recommended.

(3) radiotherapy.

Unresectable liver metastases, if systemic chemotherapy, hepatic artery infusion chemotherapy or radiofrequency ablation ineffective, it is recommended radiation therapy.

(4) hepatic arterial infusion chemotherapy.

Patients with multiple liver metastases and unable to tolerate systemic chemotherapy.

(5) other treatment methods.

Including anhydrous alcohol injection, cryotherapy and Chinese medicine treatment, only as a part of comprehensive treatment.

Eight, the treatment of local recurrence of rectal cancer

(I) typing.

At present, type of local recurrence following recommended classification methods: according to the anatomic site of pelvic involvement: central type (pudendal anastomosis, mesorectum, soft tissue and rectal abdominoperineal resection after) prior to the invasion of urogenital type (including bladder, vagina, uterus, seminal vesicle and prostate) and backward type (involving the sacrum, anterior sacral fascia), lateral type (invasion of pelvic wall soft tissue and bony pelvis).

(two) treatment principle.

The evaluation according to the specific circumstances of patients and lesions, can be resected or potentially resectable patients for surgical treatment, radiotherapy and chemotherapy, and preoperative radiotherapy and adjuvant chemotherapy combined use; comprehensive treatment of unresectable patients suggested that radiotherapy and chemotherapy combination.

(three) surgical treatment.

1 Evaluation of resectability.

It is necessary to evaluate the possibility of radical resection of recurrent lesions before surgery. It is recommended to consider the use of preoperative chemoradiotherapy in terms of recurrence. According to the results of intraoperative exploration, it is necessary to verify the resectability of the lesion.

Non resectable local recurrent lesions include:

Extensive pelvic wall invasion;

Pelvic invasion;

External iliac artery involvement;

The tumor invasion to the sciatic notch and sciatic nerve invasion;

The infringement of the second sacral level and above.

2 surgical principles.

(1) we recommend the appropriate surgical procedures for colorectal surgery specialist according to the specific conditions of the patients and the patients with the disease.

(2) recommend the Department of Urology, Department of orthopedics, vascular surgery, obstetrics and Gynecology, etc., when necessary, to develop surgical procedures.

(3) surgical exploration must be far and near, and attention should be paid to distant metastasis.

(4) the principle of en bloc resection must be followed, as far as possible to achieve R0 resection.

(5) attention to the protection of the ureter during surgery (placement of ureteral stents as appropriate) and the urethra.

3 surgical resection of the lesion.

The operative methods included low anterior resection (LAR), abdominal perineal resection (APR), pelvic dissection, and so on.

(1) the central type: the proposed line APR to ensure that the R0 resection; previous anal sphincter surgery in the case of the disease is limited to consider LAR. APR postoperative perineal recurrence of the lesion, such as the limitations of the lesion can be considered perineal or sacral resection.

(2) forward type: under the condition of the patient's physical condition, removal of the affected organs may be considered.

(3) lateral type: resection of the involved ureter, internal iliac artery and piriformis.

(4) to type: abdominosacral resection of sacral invasion. The perineum incision can be covered by omentum or primary suture. The use of muscle flap when necessary (gracilis, gluteal muscle, rectus abdominis flap, latissimus dorsi etc.).

(four) principles of radiotherapy.

In patients with resectable local recurrence, surgical resection is recommended, and then the postoperative radiotherapy is considered. In patients with non local recurrence, preoperative radiotherapy and chemotherapy were recommended, and surgical resection was performed. See chapter for radiation therapy.

(five) chemotherapy principle.

For patients with resectable recurrence and metastasis, preoperative chemotherapy is not routinely recommended. Postoperative adjuvant chemotherapy is considered.

Nine, stoma rehabilitation treatment

(a) personnel, tasks, architecture.

Conditional hospital recommended ostomy therapist (specialist nurse). Responsibilities include all colostomy stoma therapists (colostomy, gastrostomy, urinary stoma, tracheal stoma) preoperative nursing, postoperative complicated wound treatment, incontinence care, stoma open clinic, contact patients and other professionals and business activities, the organization of colostomy stoma Association and conduct stoma visitor activity.

(two) preoperative psychological therapy.

It is recommended that the patient should be fully informed of the diagnosis, surgery, and nursing knowledge, to allow patients to accept the disease, and to have a comprehensive understanding of what is going to happen.

(three) preoperative stoma location.

Before the surgery, doctors, ostomy therapists, family members and patients were selected for the stoma.

1 Requirements: the patient can see, convenient care; have enough paste area; ostomy device affixed to the stoma skin without feeling.

2 common colostomy site as shown in Figure 1

Figure 1: common colostomy site

(four) after colostomy care.

1 the first day after the operation, we should observe the blood flow of the stoma.

2 ostomy supplies standard should have the properties of light, transparent, deodorant, prevention and protection of the surrounding skin, with the right to wear.

3 keep the skin around the stoma clean and dry. Patients who have been taking antibiotics, immunosuppressive agents and hormones for a long time should pay special attention to the fungal infection of the stoma.

Ten, follow up

After the treatment of colorectal cancer are recommended regular follow-up.

(a) medical history and physical examination every 1 months 1 times, a total of 2 years, and then every 6 months, a total of 5 years, a total of 5 years, every year after 1 times a year.

(two) monitoring CEA, CA19-9, every 3-6 months for 1 years, a total of 2 years, and then every 6 months, 1 times, a total of 5 years, after 5 years every year.

(three) abdominal / pelvic ultrasound, chest X-ray every 3-6 months for 1 years, a total of 2 years, and then every 6 months, a total of 5 years, a total of 5 years, every year after 1 times.

(four) abdominal / pelvic CT or MRI per year for 1 times.

(five) underwent colonoscopy after 1 years, if abnormal, within 1 years of review; such as no polyps, 3 years and 5 years of follow-up; 1, follow-up examination of colorectal adenoma resection was recommended.

(six) PET-CT is not a routine inspection item.

 

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