Колоректальный рак: диагноз и клинический менеджмент

Colorectal Cancer: Diagnosis and Clinical Management, First Edition. Edited byJohn H. Scholefield and Cathy Eng. John Wiley & Sons, Ltd. Published (2014).

Часть I: Диагноз

Глава 1. Эпидемиология
Epidemiology
Mala Pande and Marsha L. Frazier
Стр. 1–26

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As the third most common cancer in men and the second most common cancer in women worldwide, colorectal cancer has a significant global burden. Colorectal cancer incidence and death rates vary by geographic region, with higher incidence but lower mortality in developed counties than in developing countries. Cancer incidence increases with age, and rates vary by sex and race/ethnicity. Many factors are known to increase or decrease the risk of developing colorectal cancer, and other risk factors are suspected. The epidemiology and key risk factors of colorectal cancer are reviewed in this chapter.

Глава 2. Скрининг колоректального рака
Screening for colorectal cancer
Robert JC Steele and Paula McDonald
Стр. 27–50

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Screening for colorectal cancer has a sound theoretical and practical basis. Population-based randomized controlled trials of guaiac faecal occult blood test screening have consistently demonstrated reductions in disease-specific mortality. However, quantitative faecal immunological tests for haemoglobin are rapidly replacing the guaiac-based tests, owing to numerous studies that testify to their superiority. There is also great interest in endoscopy as a primary screening modality, and there is good evidence that flexible sigmoidoscopy may serve as an appropriate means of screening populations. Much recent research has focused on improving participation in screening programs and much recent work on novel approaches to screening, A peripheral blood-based maker that performs to a sufficiently high standard remains elusive.

Глава 3. Лечение аденом
Management of adenomas
Sunil Dolwani, Rajvinder Singh, Noriya Uedo and Krish Ragunath
Стр. 51–65

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Colorectal adenomas are thought to be precursor lesions in the development of colorectal cancer. Appropriate management includes detection, characterization, estimation of likelihood of malignancy, and appropriate decision-making. Detection rate of colorectal adenomas is used as a marker of quality of colonoscopy. Characterization of adenomas utilizes morphological and surface appearances. Other factors such as size, location, access, and number also impact on decision-making. Techniques of resection commonly utilized are snare polypectomy and endoscopic mucosal resection (EMR). Endoscopic management of adenomas using the above principles has been proven to achieve good outcomes. Resection of colorectal adenomas has been demonstrated to achieve overall reduction in development of and mortality due to colorectal cancer.

Часть II: Гистопатология

Глава 4. Как гистопатология меняет характер лечения мультидисциплинарной врачебной группы
How histopathology affects the management of the multidisciplinary team
Dipen Maru
Стр. 67–83

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Histopathology is critical at each stage of colorectal cancer. These include histological sub-typing of colonic polyps for risk assessment in screening population, confirming the diagnosis of invasive carcinoma and providing prognostic indicators for patient outcome and in deciding postoperative therapy options. Histopathology and immunohistochemistry interpretation by a pathologist is important for accurate reporting of the pathological parameters and their effective applications to improve the quality of care for a colorectal cancer patient. This chapter describes histopathology parameters of colon cancer, their clinical relevance, and importance of a pathologist in the multidisciplinary care of a colorectal cancer patient.

Часть III: Хирургическое лечение

Глава 5. Радикальная резекция толстой кишки
Radical colonic resection
Kenichi Sugihara, Yusuke Kinugasa and Shunsuke Tsukamoto
Стр. 85–103

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The surgical resection of colon cancer continues to lack international standardization. A long resection axially towards the intestinal tract is conventional surgery for colon cancer, while complete mesocolic excision (CME) with central vascular ligation (CLV) has been introduced as radical surgery following the same principles of total mesorectal excision for rectal cancer. In Japan, D3 lymph node dissection is a standard surgery for colon cancer, based on the studies that lymph node metastasis often advanced along the feeding vessels. In colon cancer surgery, the tumor should be along embryologic tissue planes in an intact peritoneal and fascial lined package. Central lymph node dissection by laparoscopic surgery is feasible without any increase of morbidity as well as open surgery.

Глава 6. Экстралеваторная брюшно-промежностная экстирпация (ELAPE) для рака нижних отделов прямой кишки поздних стадий
Extralevator abdominoperineal excision (ELAPE) for advanced low rectal cancer
Brendan J. Moran and Timothy J. Moore
Стр. 104–125

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Abdominoperineal excision has been associated with poorer oncological outcomes compared to low anterior resection for low rectal cancer. A refocus on this historical operation (APE) has led to the technique encompassing wider resection. The initial results show a reduction in CRM involvement and incidence of intraoperative perforation, which translates into reduced local recurrence rates and better survival outcomes. ELAPE is a standardized anatomically based surgical approach for low rectal cancer with emphasis on precise excision planes rather than being specific to patient positioning, sequence of surgery or laparoscopic, and open approaches. The technique represents an exciting development in improving outcomes for advanced low rectal cancer.

Глава 7. Неоадъювантная терапия без хирургии для ректального рака ранних стадий?
Neoadjuvant therapy without surgery for early stage rectal cancer?
Thomas D. Pinkney and Simon P. Bach
Стр. 126–149

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Treatment of early stage rectal cancer is still in its infancy. Minimally invasive schedules are alternatives to radical surgery. New methods of risk stratification are required to precisely match patients with appropriate treatment combinations to maximize cure and minimize side effects from overtreatment. Combining local excision with radiotherapy to improve oncological outcomes is a logical strategy based upon previous experience gained from trials of pre-operative radiotherapy and radical resection. It may even be possible to manage rectal cancer non-operatively in cases of complete pathological response following radiation therapy. This chapter discusses the evidence that underlies these components of treatment and presents management of early-stage rectal cancer.

Глава 8. Минимально инвазивная хирургия для ректального рака и робототехника
Minimally invasive surgery for rectal cancer and robotics
David Jayne and Gregory Taylor
Стр. 150–162

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There is a growing enthusiasm for laparoscopic rectal cancer surgery based on the documented advantages over open surgery in terms of quicker recovery, shorter hospital stay, and fewer post-operative complications. Robotic-assisted rectal cancer surgery has been introduced and promises to extend the boundaries of the current laparoscopic approach. Although preliminary, the evidence suggests that conversion to open operation may be markedly reduced with robotic assistance, which in turn may indicate that the robot facilitates difficult pelvic rectal dissection. This chapter explores the evidence base underlying both laparoscopic and robotic-assisted rectal cancer surgery and presents practical tips for successful and safe rectal cancer resection using both minimally invasive modalities.

Глава 9. Хирургическое лечение рака анального канала
Surgery for anal cancer
John H. Scholefield
Стр. 163–176

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This chapter gives an overview of the aetiology, presentation, and classification of anal squamous carcinoma (SCC) and the other less common anal tumors. The treatment of anal SCC has changed dramatically during the last ten years and the rationale for these changes is discussed. The identification of anal pre-cancerous lesions and strategies for their management are described.

Часть IV: Онкология

Глава 10. Полемика об адъювантной химиотерапии
Controversies in adjuvant chemotherapy
Stephen Staal, Karen Daily and Carmen Allegra
Стр. 177–199

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Of the approximately 150,000 new cases of colorectal cancer expected in the United States in 2012, close to 80% will be localized to the primary site or involve only the regional lymph nodes. Overall, the former can expect a 90%, the latter a 70% survival, due in part to adjuvant chemotherapy programs which have, since the late 1980s, been a standard approach for high risk, localized colorectal cancer. How to best individualize treatment is perhaps the major area of controversy and the most active area of ongoing research. There have been no improvements to outcome since the development of fluoropyrimidine/oxaliplatin based chemotherapy over ten years ago. The use of irinotecan and incorporation of newer targeted biological agents into the cytotoxic backbone have proven disappointing. New therapeutic opportunities will arise from an improved understanding of the molecular details of colon cancer, the tumor microenvironment, and host factors, offering a rational strategy for elimination of microscopic residual tumor. The need for better prognostic and predictive patient profiling is a clear message from the recent failure of large adjuvant trials.

Глава 11. Длительная против кратковременной лучевой терапии ректального рака
Long- versus short-course radiotherapy for rectal cancer
Manisha Palta, Christopher G. Willett and Brian G. Czito
Стр. 200–217

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There is significant debate regarding the optimal neoadjuvant radiotherapy regimen for resectable rectal cancer patients. In much of Northern Europe the use of short-course preoperative radiotherapy (RT) alone (25 Gy in 5 fractions), followed by total mesorectal excision (TME) approximately 1 week later, has become standard practise, supported by multiple randomized control trials comparing TME alone to preoperative short-course RT preceding surgery. In the United States and other parts of Europe, the use of long-course conventionally fractionated with concurrent administration of fluoropyrimidine-based chemotherapy is favored. This chapter presents current data regarding these regimens and respective advantages/disadvantages of each approach.

Глава 12. Больше не обязательно лучше — ограниченные опции для химиотерапевтической радиосенсибилизации
More treatment is not necessarily better – limited options for chemotherapeutic radiosensitization
Daedong Kim
Стр. 218–226

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The addition of chemotherapy (CT) to preoperative radiotherapy (RT) as a radiosensitizer improves the therapeutic efficacy of RT, and also targets occult systemic micrometastases early in the treatment course. In an attempt to improve the efficacy of downstaging and the control of the distant spread of locally advanced rectal cancer (LARC), the integration of novel cytotoxic drugs and biological targeted agents in combined therapy has been explored. However, the efficacies of such intensive CRT regimens are disappointing and the optimal schedule of CRT and adjuvant chemotherapy, in which combination and sequence, continues to be investigated.

Глава 13. Полемика о запущенном заболевании — хирургические подходы для удаления метастазов
Controversies in advanced disease – surgical approaches for metastatic resection
Amanda B. Cooper, Thomas A. Aloia, Jean-Nicolas Vauthey and Steven A. Curley
Стр. 227–242

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Colorectal cancer still remains one of the most common causes of cancer-related deaths in the United States. Approximately 50% of colorectal cancer patients will develop liver metastases and surgical resection is the most effective treatment. This highlights the importance of understanding surgical approaches to metastatic liver disease, which have evolved to include adjunctive procedures such as portal vein embolization and radiofrequency ablation, increasing the number of patients eligible for potentially curative surgical management. Innovations in treatment sequencing, such as perioperative chemotherapy and the liver-first approach to managing synchronous liver metastases, have also improved survival for these patients. These adaptations in surgical management come with new risks, such as chemotherapy-induced liver damage.

Глава 14. Полемика о химиотерапии колоректального рака поздних стадий
Controversies in chemotherapy in advanced colorectal cancer
Ludmila Katherine Martin and Tanios Bekaii-Saab
Стр. 243–260

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In the last decade, numerous therapies have been developed for the treatment of metastatic colorectal cancer (mCRC), and patients now survive on average 24 months. With multiple treatment options available, controversy has arisen over the most effective utilization of these agents, in order to achieve the best clinical outcome while preserving quality of life. Sequential versus combination therapy, first-line therapy for KRAS wild-type disease, conversion therapy, and chemotherapy-free intervals are areas of ongoing debate discussed in this chapter.

Часть V: Исходы

Глава 15. Какова роль наблюдения для колоректального рака?
What is the role of surveillance for colorectal cancer?
Daedong Kim
Стр. 261–271

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Surveillance after curative surgery and/or adjuvant therapy is an important component of postoperative care for patients with localized colorectal cancer (CRC). If detected early, recurrent disease may be amenable to surgical resection and this provides the rationale for a periodic follow-up strategy. There is considerable controversy about the optimal frequency, essential type of tests, and the required duration of follow-up to optimally detect recurrence. There is still no consensus as to the ideal method for follow-up in CRC patients. Large-scale, adequately powered, multicenter studies are underway to decide what constitutes optimal surveillance for patients after primary therapy. Future randomized trials need to focus on study design that identifies the contribution of the specific elements of surveillance to outcomes in detail, and also on risk stratification and the duration of surveillance.

Часть VI: Заметки

Глава 16. Молодой пациент с колоректальным раком — обсуждение генетического консультирования
The young patient with colorectal cancer – genetic counseling discussion
Sarah Bannon, Maureen E. Mork and Miguel A. Rodriguez-Bigas
Стр. 273–285

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This chapter presents clinical vignettes of young patients suffering from colorectal cancer (CRC). While the median age of colorectal cancer (CRC) diagnosis is 70 years, approximately 17% of CRC cases are diagnosed in individuals under 50. Hereditary non-polyposis CRC (HNPCC), also referred to as lynch syndrome (LS), accounts for 2-3% of all CRCs. Familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP), inherited adenomatous polyposis conditions, account for approximately 2% of CRC cases. The chapter presents two criteria for offering genetic testing/counseling: (i) CRC in three individuals, one of whom is a first-degree relative of the other two; and (ii) personal or family history of a cancer or cancers known to be associated with specific genes or mutations, such as sebaceous skin lesions and endometrial cancer at a young age. The genetic counseling process addresses psychosocial issues raised through the diagnosis of a hereditary cancer syndrome.

Глава 17. Лучшая практика поддерживающей терапии в течение химиотерапии
Best practices of supportive care while receiving chemotherapy
Maura Polansky
Стр. 286–291

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This chapter presents vignettes of patients suffering from diarrhea, nausea and vomiting induced by chemotherapy prescribed for treating colorectal cancer (CRC), and discusses the supportive care needed to treat such side effects. CRC patients with baseline bowel dysfunction, including diarrhea due to surgery (particularly low anterior resection, colostomy, ileostomy, subtotal colectomy), may be at increased risk of diarrhea from chemotherapy. Continuous infusion of high-dose octreotide has also been found to be effective for patients with diarrhea refractory to loperamide, diphenoxylate atropine and opiates. Patients with nausea/vomiting that is more severe than predicted, persists beyond the anticipated duration of delayed chemotherapy-induced nauseas/ vomiting or does not respond to anti-emetics should be evaluated for other potential causes.

Глава 18. Заметки о паллиативном лечении
Palliative care vignettes
Jenny Wei and Egidio Del Fabbro
Стр. 292–297

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This chapter presents vignettes of patients suffering from colorectal cancer (CRC) and needing palliative care. It is important that clinicians are well-versed in the equi-analgesic doses of opioids before electing an opioid switch. If in doubt, the palliative care team should be consulted for guidance. Octreotide has demonstrated superiority compared to anticholinergics in small randomized trials and is the medical management of choice for bowel obstruction due to malignancy. Although medical management alone is often effective, venting gastrostomy tubes have the advantage of allowing patients to derive some pleasure from the taste of liquids. Placement of a venting tube is feasible, even in patients with ascites and peritoneal carcinomatosis. As regards specific drug therapies for cachexia, no single agent has been found to be consistently effective. Systematic reviews suggest megestrol acetate improves appetite and weight but not quality of life (QOL).


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