Management of metastatic rectal carcinoma.pptx

Metastatic rectal carcinoma

1. Management of metastatic rectal carcinoma

2. OBJECTIVE Cure (if possible in very selected cases), P rolongation of life Palliation of symptoms Improvement of quality of life Delay disease progression and tumour shrinkage.

3. Possible scenarios 1.Patients with limited resectable disease 2.Patients with limited unresectable disease 3.Patients with widespread and aggressive disease

4. Treatment options Surgical resection Liver mets resection Lung mets resection Cytoreductive surgery Chemo/ radiotherpy Intraoperative radiation therapy Biological therapy Local Treatment options TARE TACE T hermal ablation (TA) Stereotactic body radiotherapy (SBRT)

5. Surgical resection

6. Resection for liver mets Surgical resection of R0-resectable ( resectable , leaving no tumour at the margin) CRLMs is a potentially curative treatment, with reported 5-year survival rates of 20%-45%. A study by Dhir et al found that among patients undergoing hepatic resection for colorectal metastasis, a negative margin of 1 cm or more had a survival advantage Surgery with or without perioperative chemotherapy should be offered to patients with mCRC who are candidates for potentially curative resection of liver metastases

7. Resectability Technically, resectability is not limited by number, size or bilobar metastatic involvement, if tumours may be resected leaving sufficient remnant organ (e.g. ≥30% remnant liver )

8. Recommendations Favourable oncological criteria (e.g. metachronous lesions, fewer metastases, unilobar disease, no extrahepatic disease), upfront resection should be done. U nfavourable oncological criteria (synchronous lesions, more than three metastases, bilobar disease, limited extrahepatic disease) and ‘ favourable surgical’ criteria (e.g. no vascular infiltration), perioperative ChemT .

9. Resection for pulmonary mets Radical (R0: negative margins) lung resection can be curative in selected cases.68 In selected patients with pulmonary oligometastatic disease unsuitable for surgery, stereotactic radiotherapy treatment may be indicated. 

10. Resection for peritoneal mets Cytoreductive surgery (CRS) plus systemic chemotherapy may be recommended for selected patients with colorectal peritoneal metastases

11. In the PRODIGE 7 trial, 15% of patients with isolated colorectal peritoneal metastases experienced no disease progression in the 5 years following surgery, indicating that CRS may be a curative option for an appropriately selected subgroup of patients. This recommendation applies to patients who have been deemed amenable to complete resection of colorectal peritoneal metastases, regardless of previous treatment, and who have no extraperitoneal metastases. hyperthermic intraperitoneal chemotherapy (HIPEC) 

12. Chemo/ radiotherapy

13. Systemic chemotherapy had 18-28% response rates One meta-analysis found that carefully selected patients with metastatic colorectal cancer may benefit from preoperative chemotherapy with curative intent.

14. Peri-operative chemotherapy is recommended with liver mets resection with un- favourable oncological criteria

15. Intraoperative radiation therapy Recommended in patients with large, bulky, fixed, unresectable cancers Radiation therapy for bone mets Stereotactic body radiation therapy may be recommended following systemic therapy for patients with oligometastases of the liver who are not considered candidates for resection For ‘extended’ liver metastases, external irradiation are contraindicated

16. Biological therapy

17. Cetuximab, a recombinant humanized monoclonal antibody that binds specifically to the epithelial growth factor receptor (EGFR), is recommended as part of combination therapy ( eg , with FOLFOX or FOLFIRI) for unresectable metastatic rectal cancer.

18. Anti-EGFR MoAb therapy (currently cetuximab and panitumumab) should only be considered for treatment of patients with mCRC who are identified as having tumors with no mutations detected after extended  RAS  mutation analysis

19. Local treatment options

20. The FDA has approved TARE for the treatment of unresectable metastatic liver tumors from primary colorectal cancer in combination with adjuvant intra-hepatic artery chemotherapy with floxuridine. Thermal ablation and stereotactic body radiotherapy may be used with liver mets resection

21. Thanks