7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

1/16

Treatment algorithm primarystage IV rectal cancer

ESSO advanced course rectal cancer

The Hague, 8 10 September 2008

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

2/16

Primary stage IV disease Synchronous metastases

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

3/16

Qs 2B AdGeneral What is the ideal work-up? What is considered resectable?

Is there an age- or morbidity limit?

Individual What treatment modalities should be used? In which order should they be applied?

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

4/16

ImagingStandard Rectum

MRI / CT / EUS

Liver CT/ MRI

Lungs CT/ X-ray

Additional Peritoneum

CT / Laparoscopy

General PET-CT

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

5/16

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

6/16

Treatment options - local Rectum TME resection (APR; LAR): after 5x5Gy or long-

course chemo-RT; primary

Local excision (TEM): Tis/1N0 carcinoma; aftercomplete remission upon chemo-RT Non-surgical: no treatment; stent; chemo-RT

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

7/16

Treatment options - metastasesSystemic 5FU/Capecitabine; Leucovorin; Oxaliplatin; Irinotecan Bevacizumab/Avastin; Cetuximab

Surgical Liver/Lung: resection; 2-stage resection Peritoneum: HIPEC

Local RFA / Cryo HAI

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

8/16

Special considerations Obstruction acute intervention mandatory

defunctioning stoma Frailty extra care for iatrogenic morbidity

restrictive therapy Complete remission after chemotherapy

resection mandatory in liver; rectum unknown

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

9/16

/MetastasesRectum / Primaryresectable Resectable afterchemotherapy Not resectable

Primary resectable 1 2 3

Locally advanced A B C

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

10/16

1. Resectable local and distantdisease

Short-course RT or none Neoadjuvant chemotherapy mandatory? One-stage surgical procedure preferable in

selected cases Adjuvant chemotherapy

Per-operative HAI? Also after neoadjuvant treatment?

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

11/16

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

12/16

3. Resectable local disease;metastases not resectable

Consider fully non-surgical management Palliative chemotherapy

Consider experimental therapy in trial

In case of peritoneal spread with no visceralorgan or skeletal disease, consider HIPEC

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

13/16

A. LARC and primary resectablemetastases

Induction therapy Long-course chemo-RT 5x5 followed by chemo in longer waiting period

(6-8 weeks) Re-staging incl. rectum

Consider TEM or Wait & See if complete remission

rectum Consider one-stage surgical procedure ( if extra-

anatomical pelvic resection is not needed? )

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

14/16

B. LARC and metastases demandinduction

Induction therapy Long-course chemo-RT 5x5 followed by chemo in longer waiting period

(6-8 weeks) Re-staging incl. Rectum

Consider combining resection with local ablative

therapy if metastases are still not resectable Consider transfer to C. if metastases are still not

resectable

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

15/16

C. LARC; metastases not resectable Consider fully non-surgical management

Chemo-RT for local control Re-staging incl. Rectum

Palliative chemotherapy Consider experimental therapy in trial

In case of peritoneal spread with no visceralorgan or skeletal disease, consider HIPEC

7/31/2019 Treatment Algorithm Primary Stage IV Rectal Cancer

16/16

/MetastasesRectum /

Primary resectable Resectable afterchemotherapy

Not resectable

Primary resectable (Neo)adjuvant

ResectionCurative

Neoadjuvant

ResectionPossibly curative

Systemic

ProblemsolvingPalliation

Locally advanced NeoadjuvantResectionCurative

NeoadjuvantResectionPossibly curative

SystemicProblemsolvingPalliation