Diagnosis

• Advise patient several test maybe necessary
• Stage 1: invading lamina propria and submucosa
• Stage 2: invading muscularis propria
• Stage 3: invading adventitia
• Stage 4: invasion of adjacent structures

Investigation

• Without co-morbidity: colonoscopy and biopsy of suspicious lesion
• With comorbidity: Flexi-sigmoidoscopy then barium enema, biopsy unless contra-indicated
• CT colonography offered where expertise sufficient, though must be followed by colonoscopy with biopsy to confirm
• Colorectal cancer staging: Contrast enhanced CT
• Rectal Cancer staging: MRI or endorectal USS if MRI contra-indicated
• Rectal Cancer recurrence predicted by MRI:
  • High: a breached resection margin, or low tumours encroaching into inter-sphincteric plane
  • Medium Any cT3b (invading adventitia) in which surgical margin not breached, Or any suspicious lymph node not threatening the resection margin OR presence of extramural vascular invasion
  • Low: cT1, cT2, cT3 and no lymph node involvement

Management

Acute large bowel obstruction

• Colonic stents: consider if acute large bowel, offer CT chest abdo pelvis to confirm mechanical obstruction and presence of metastasis
• If acute left sided large bowel obstruction offer stent (but not right sided nor low rectal):
  • Curable: offer either stent or emergency surgery as evidence equivocal
  • Non-curable: offer self-expanding stent, endoscopically or radiologically

Rectal cancer

• Low risk resectable per above criteria: do not offer short-course preoperative radiotherapy (SCPRT)
• Medium risk: do offer short-course preoperative radiotherapy (SCPRT)
• High risk: pre-operative chemotherapy to shrink tumour before resection
• Patients whose colon or rectal cancer appears unresectable: discuss risk of local recurrence and local toxicity after discussion in MDT
• Stage 1: MDT should decide treatment, little evidence of efficacy between options
• Stage 2 & 3: consider adjuvant chemotherapy to reduce recurrence

Colorectal cancer

• Stage 1: following excision MDT consider further treatment accounting for pathology and imaging
• Stage 2: adjuvant chemotherapy to reduce risk of recurrence
• Stage 3 (Dukes C): adjuvant chemotherapy using Capecitabine as monotherapy OR Oxaliplatin in combination with 5-fluorouracil and folinic acid
• Stage 4: Prioritise symptom management
  • Hepatic metastases: CT imaging, MDT to decide whether surgical resection is suitable
  • Non-Hepatic metastasis: Contrast enhanced CT chest abdo pelvis, brain only if indicated, and follow up by anatomical site specific MDT&
• Chemotherapy for advanced disease: Oxaliplatin and irinotecan in combination with fluoropyrimidines (FOLFOX), following full discussion regarding side effects
• Consider Raltitrexed who are intolerant to 5-fluorouracil and folinic acid
• Capecitabine & tegafur with uracil offered as first-line option tx of metastatic colorectal cancer
• Laparoscopy: maybe used as an acceptable alternative to open surgery

NICE Source: CG131 Colorectal cancer: diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.