Localized Colon Cancer Clinical Practice Guidelines (ESMO, 2020)

Localized Colon Cancer Guidelines (ESMO, 2020)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 03, 2020

The guideline on localized colon cancer was released on October 1, 2020 by the European Society for Medical Oncology.[1]

Invasive Screening  

A complete colonoscopy is the recommended method for colorectal cancer (CRC) screening in average-risk men and women. The optimal age range for testing is 50-74 years, with an optimal repetition interval for a negative test of 10 years.

Flexible sigmoidoscopy (FS) every 5–10 years may be an alternative for patients who refuse colonoscopy. The combination of FS with a yearly fecal occult blood test (FOBT) is recommended to reduce the risk of a right colon tumor.

Other invasive tests, including capsule colonoscopy, are not recommended for screening.

Noninvasive Screening  

Non-colonoscopic tests are recommended in average-risk men and women age ≥50 years who are not already taking part in colonoscopic screening programs. The optimal frequency of testing is every year and no later than every 3 years. When the test results are positive, a colonoscopy must be carried out at the earliest convenience. Fecal immunochemical testing (FIT) appears to be superior to high-resolution guaiac FOBT with respect to the detection rate and positive predictive value for adenomas and cancer.

Diagnosis  

In the absence of indications for urgent tumor resection, a total colonoscopy is recommended for diagnostic confirmation of colon cancer and to rule out synchronous tumors. If full colonoscopy is not possible, left-sided colonoscopy may be combined with computed tomography (CT) colonoscopy. If a complete colonoscopy is not done before or during the surgical procedure, it should be carried out within 3–6 months following tumor resection.

The recommended workup also includes the following:

  • Comprehensive physical examination

  • Laboratory studies: Complete blood count, coagulation studies, liver function panel, kidney function panel, albumin level, carcinoembryonic antigen (CEA) assay

  • Thoracic, abdominal, and pelvic CT with contrast

  • Contrast-enhanced magnetic resonance imaging (MRI), if needed, to evaluate the relationship of locally advanced tumors with surrounding structures or to define ambiguous liver lesions

Treatment  

En bloc endoscopic resection of the polyp is sufficient for noninvasive adenocarcinomas (pTis—ie, intraepithelial or intramucosal).

Invasive carcinoma (pT1) in a polyp requires a thorough review with the pathologist and surgeon. High-risk features mandating surgical resection with lymphadenectomy include lymphatic or venous invasion, grade 3 differentiation, and significant (grade >1) tumor budding.

Laparoscopic colectomy can be safe when technical expertise is available, in the absence of contraindications.

Obstructive CRCs can be treated in one- or two-stage procedures, as indicated.

Microsatellite instability/mismatch repair (MSI/MMR) status is the only validated molecular marker for adjuvant therapy decision making and should be determined in stage II CRC. In stage III, usage of MMR status is limited to detection and identification of Lynch syndrome.

Dihydropyrimidine dehydrogenase (DPD) genotyping or phenotyping is strongly recommended before initiating fluoropyrimidine-based adjuvant therapy.

Combinations of fluoropyrimidines—either 5-fluorouracil (5-FU) or capecitabine—and oxaliplatin constitute the bases for stage III colon cancer adjuvant treatment.

Duration of oxaliplatin-based adjuvant treatment of stage III colon cancer may be 3 or 6 months for CAPOX (capecitabine/oxaliplatin) or 6 months for FOLFOX (leucovorin/5-FU/oxaliplatin) also taking into consideration pathological risk characteristics, patient comorbidity, and risk assessment.

Start adjuvant chemotherapy as soon as possible after surgery and ideally not later than 8 weeks.

Followup 

History and physical examination and CEA level determination are advised every 3–6 months for 3 years and every 6–12 months at years 4 and 5 after surgery.

Colonoscopy must be carried out at year 1 and every 3–5 years thereafter, looking for metachronous adenomas and cancers.

CT scan of chest and abdomen every 6–12 months for the first 3 years can be considered in patients who are at higher risk of recurrence according to the TNM classification.

Other laboratory and radiological examinations are of unproven benefit and must be restricted to patients with suspicious symptoms.

For more information, see Colon Cancer and Colon Cancer Treatment Protocols. For more Clinical Practice Guidelines, please go to Guidelines.

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