Лечение колоректального рака

Multidisciplinary treatment of colorectal cancer

Gunnar Baatrup (editor). 2015

Часть I. Мультидисциплинарное лечение колоректального рака

  1. Организация мультидисциплинарной команды
  2. Мультидисциплинарное лечение: влияние на исход

Часть II. Хирургия

  1. Введение в хирургию
  2. Хирургическая анатомия прямой кишки и TME образца (полное мезоректальное иссечение)
  3. Ранний ректальный рак низкого риска
  4. Ранний ректальный рак высокого риска  и (нео)адъювантная терапия для поздних стадий рака в дополнение к TEM хирургии
  5. Резекция Хартманна
  6. Низкая передняя ректальная резекция
  7. Брюшно-промежностная резекция прямой кишки (резекция Майлса)
  8. Локально распространенный и рекуррентный рак
  9. Реконструкции после неоадъювантной и брюшно-промежностной резекции

Часть III. Онкология

10. Введение в онкологию

Системная терапия пациентов с колоректальным раком: современное состояние

  1. Лучевая терапия и хеморадиация рака прямой кишки: современное состояние в Европе, США и Азии
  2. Кратковременные и длительные побочные эффекты адъювантного и неоадъювантного лечения ректального рака
  3. Химиорадиотерапия для локально распространенного рака прямой кишки T3/T4: что мы должны делать с полностью отвечающими пациентами?

Часть IV. Визуализация и стадийность

  1. Введение: дооперационная стадийность с помощью образных исследований
  2. MRI и CT для дооперационного T и N стадийности рака прямой кишки
  3. Эндоректальная ультрасонография опухолей прямой кишки

V часть. Патология

  1. Введение в патологию колоректального рака
  2. Ранний колоректальный рак
  3. Качество хирургии
  4. Стадийность колоректального рака (включая стадийность после неоадъювантной терапии)

VI часть. Паллиативная команда

  1. Мультидисциплинарное лечение колоректального рака
  2. Хирургическое лечение в паллиативной помощи
  3. Тошнота

Часть VII. Рекомендации

  1. Индивидуализированное лечение
  2. Местное лечение ректального рака

Part I. Multidisciplinary treatment of colorectal cancer

  1. Organizing the multidisciplinary team
  2. Multidisciplinary treatment: influence on outcomes

Part II. Surgery

  1. Introduction to surgery
  2. Surgical anatomy of the rectum and the TME specimen (total mesorectal excision)
  3. Low-risk early rectal cancer
  4. «High-risk» early rectal cancers and (neo) adjuvant therapy for advanced carcinomas in addition to TEM surgery
  5. Hartmann’s resection
  6. Low anterior rectal resection
  7. Abdominoperineal resection of the rectum (miles resection)
  8. Locally advanced and recurrent cancer
  9. Reconstructions after neoadjuvant and abdominoperineal resection

Part III. Oncology

  1. Introduction to oncology
  2. Systemic therapy for patients with colorectal cancer: state of the art
  3. Radiotherapy and chemoradiation for rectal cancer: state of the art in Europe, the USA and Asia
  4. Shortand long-term side effects from adjuvant and neoadjuvant treatment of rectal cancer
  5. Chemo-radiotherapy for locally advanced T3/T4 rectal cancer: what should we do with complete responders?

Part IV. Imaging and staging

  1. Introduction: preoperative staging by imaging
  2. MRI and CT for the preoperative T and N staging of rectal cancer
  3. Endorectal ultrasonography of rectal tumours

Part V. Pathology

  1. Introduction to the pathology of colorectal cancer
  2. Early colorectal cancer
  3. Quality of surgery
  4. Staging of colorectal cancer (including staging after neoadjuvant therapy)

Part VI. The palliative team

  1. Multidisciplinary treatment of colorectal cancer: the palliative team introduction
  2. Surgical treatment in palliative care
  3. Nausea

Part VII. Recommendations

  1. Individualised treatment
  2. Local treatment of rectal cancer

During the last 15–20 years, the treatment of colorectal cancer has changed dramatically. From involving almost only surgeons in the treatment, the scientific progress in adjuvant therapy, neoadjuvant therapy, diagnostics and pathology now set the demand for a broader approach when deciding the treatment for the individual patient.

The Calman and Hine report from 1995 [1] first argued for the multidisciplinary approach and has now been implemented in many countries throughout the world and in fact sets the golden standard for modern oncological treatment for all forms of cancer. In the field of rectal cancer, solid documentation exists for the efficacy of this approach in terms of local recurrence rates [2–4]. The reasons for this could be more accurate staging with MRI and ultrasound, the use of neoadjuvant radiochemotherapy – sometimes in selected patients – and, not at least, the evaluations of operative specimens in order to be sure that the correct operative technique has been used [5]. The effect on the improvement in surgical techniques, dissecting in the correct embryological planes, also plays a role for this improvement [6] not only in rectal but also in colonic cancer surgery [7] – although never proven in a proper randomised trial. The use of postoperative adjuvant chemotherapy [8] and the more aggressive approach to salvage surgery and other effective treatments for metastatic disease has become common practise [9]. Apart from these already-achieved improvements, we will, in the future, hear a lot about selective individual therapy based on tumour markers and individual genotypes [10, 11].

In the context of the multidisciplinary approach to colorectal cancer, it seems obvious to have multidisciplinary team conferences – the so-called MDT conference. This has during the last couple of years been introduced in every centre dealing with colorectal cancer treatment with its many different modalities and is in many places a part of the daily practice. Every speciality involved in the handling of these patients is represented – surgery, medical and radiation oncology, pathology, radiology, nuclear medicine, clinical genetics and specialised nurses. The structure on the meetings is locally organised and guidelines for MDT conferences have been launched [12]. In some places a dedicated co-ordinator is nominated and gets special salary for the job [13]. The conferences are ideal forums for discussion and not at least education of younger doctors, and communications between the specialities are thought to be improved [14, 15]. Even though one has to consider the time spent at these conferences and whether it really is cost-effective seen from the patient’s point of view [15]. The MDT approach for treatment strategy has been proven to enhance the quality of the operative specimens as regarded from the proportion of circumferential margin (CRM) positivity [16], but whether this is due to the MDT conference itself or just reflects the results of the MDT thinking is unknown. It has been proven that patients which have been objects for a MDT conference have a significant better survival, as compared to patients that did not [17]. These results are to be taken with great reserve due to the historical design of the study, which enhances the risk of bias considerably. During the same period, many new treatment modalities have been introduced such as better anaesthesia, better surgery and fast-track surgery. A proper randomised trial will never be performed due to lack of acceptance and equipoise – not at least among doctors but perhaps also among patients. It is strange that only this study evaluating the efficacy of MDT conference exists, but perhaps others are on their way, now that the MDT approach has gained broad acceptance.

The approach demands training both in organising and in uniforming the language of the different specialities. In this respect national guidelines might be important, although the level of evidences does not seem to improve during the years [18]. National MDT courses and training programmes have been introduced in several countries, and with this book as a backbone for this training, we probably can get even better – although it is difficult to prove. Anyway the MDT conference has probably come to stay.

References

  1. Calman K, Hine D. A policy framework for commissioning cancer services. London: Department of Health; 1995.
  2. Nicholls RJ, Tekkis PP. Multidisciplinary treatment of cancer of the rectum: a European approach. Surg Oncol Clin N Am. 2008;17(3):533–51, viii.
  3. Nicholls J. The multidisciplinary management of rectal cancer. Colorectal Dis. 2008;10(4):311–3.
  4. Valentini V, Glimelius B, Minsky BD, Van Cutsem E, Bartelink H, Beets-Tan RG, et al. The multidisciplinary rectal cancer treatment: main convergences, controversial aspects and investigational areas which support the need for an European Consensus. Radiother Oncol. 2005;76(3):241–50.
  5. Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, et al. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet. 2009;373(9666):821–8.
  6. Daniels IR, Fisher SE, Heald RJ, Moran BJ. Accurate staging, selective preoperative therapy and optimal surgery improves outcome in rectal cancer: a review of the recent evidence. Colorectal Dis. 2007;9(4):290–301.
  7. Hohenberger W, Reingruber B, Merkel S. Surgery for colon cancer. Scand J Surg. 2003;92(1):45–52.
  8. Gravalos C, Garcia-Escobar I, Garcia-Alfonso P, Cassinello J, Malon D, Carrato A. Adjuvant chemotherapy for stages II, III and IV of colon cancer. Clin Transl Oncol. 2009;11(8):526–33.
  9. Segelman J, Singnomklao T, Hellborg H, Martling A. Differences in MDT assessment and treatment between patients with stage IV colon and rectal cancer. Colorectal Dis. 2008;11(7):768–74.
  10. Prenen H, Tejpar S, Van Cutsem E. Impact of molecular markers on treatment selection in advanced colorectal cancer. Eur J Cancer. 2009;45(Suppl 1):70–78.
  11. Ortega J, Vigil CE, Chodkiewicz C. Current progress in targeted therapy for colorectal cancer. Cancer Control. 2010;17(1):7–15.
  12. Ruhstaller T, Roe H, Thurlimann B, Nicoll JJ. The multidisciplinary meeting: an indispensable aid to communication between different specialities. Eur J Cancer. 2006;42(15):2459–62.
  13. Soukop M, Robinson A, Soukop D, Ingham-Clark CL, Kelly MJ. Results of a survey of the role of multidisciplinary team coordinators for colorectal cancer in England and Wales. Colorectal Dis. 2007;9(2):146–50.
  14. Sharma A, Sharp DM, Walker LG, Monson JR. Colorectal MDTs: the team’s perspective. Colorectal Dis. 2008;10(1):63–8.
  15. Cheifetz RE, Phang PT. Evaluating learning and knowledge retention after a continuing medical education course on total mesorectal excision for surgeons. Am J Surg. 2006;191(5):687–90.
  16. Burton S, Brown G, Daniels IR, Norman AR, Mason B, Cunningham D. MRI directed multidisciplinary team preoperative treatment strategy: the way to eliminate positive circumferential margins? Br J Cancer. 2006;94(3):351–7.
  17. Macdermid E, Hooton G, Macdonald M, McKay G, Grose D, Mohammed N, et al. Improving patient survival with the colorectal cancer multi-disciplinary team. Colorectal Dis. 2009;11:291–5.
  18. Wille-Jorgensen P. Evidence-based colorectal surgery–facts, fiction or wishful thinking. Colorectal Dis. 2010;12(4):285–6.

 

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