Colonoscopy (preferably also with histology confirmation) is the preferred technique in order to detect or exclude colorectal carcinoma.

 

The guideline development group is of the opinion that the tumour should be routinely marked by tattoo; tattooing is essential with a planned laparoscopic resection of a clinically malignant appearing polyp.

 

A CT colography (virtual colonoscopy) is recommended as an (additional) diagnostic tool if:

  • colonoscopy is not possible
  • incomplete colonoscopy does not lead to diagnosis
  • colonoscopy has not lead to exact tumour localisation

 

The guideline development group is of the opinion that if complete visualisation of the colon is not conducted due to a stenosing tumour or other reason, a total colonoscopy should be performed within 3 months after surgery.


Additional imaging for rectal carcinoma

All patients with a rectal carcinoma should be discussed in a multidisciplinary oncological consultation.

(Re)staging MRI should be reported in a structured manner. The items a report should contain are indicated in the appendix MRI Proforma.

 

Local staging

In the case of superficial tumours, endorectal ultrasound (EUS) is the preferred technique above MRI for differentiation of T1 versus T2 tumours.

 

MRI forms part of the standard work-up for non-superficial tumours.

 

There is a free (non-invasive) mesorectal fascia if the distance between the tumour and mesorectal fascia is > 1 mm.

 

Node staging

The following criteria should be adhered to in determining the N-stage on the basis of MRI:

 

N0:

  • Absence of nodes in the mesorectum and extramesorectal.

 

N+:

  • Presence of nodes with a short axis diameter of 5-9 mm, combined with at least 2 of the following malignant morphological characteristics.
    • an irregular delineation
    • heterogenous texture
    • round shape
  • Absence of nodes with a small axis diameter of ≥9 mm.

 

N2

  • The presence of at least 4 nodes as mentioned under ‘N+’ is highly predictive for an N2 status.

 

Nx (e.g. if no MRI has been conducted)

  • All other cases (such as when no imaging has been performed)

 

Restaging after radiotherapy (CRT or 5x5Gy with postponed surgery)

Restaging after CRT should preferably be performed with MRI if this has consequences for the management plan.

 

If nodes are present on a restaging MRI, the same process can be followed as with primary staging MRI.


Imaging in the case of liver metastases and extrahepatic abnormalities

Treatment of the primary tumour

 

It is recommended to limit imaging diagnostics to a chest X-ray when detecting lung foci, given the low prevalence of lung metastases and the false-positive findings with routine chest-CT.

 

If lung metastasis is suspected on the chest X-ray, a chest-CT is indicated to accurately map the lung foci. To obtain a good starting situation for the liver at the time of resection of the primary tumour, a spiral CT or MRI of the liver should be performed.

 

If there is doubt as to the presence or nature of liver lesions, the imaging should be repeated after 3 months.

 

Follow-up after treatment of the primary tumour

If the liver cannot be evaluated easily by ultrasound, if there is an increase in CEA or if liver metastases are suspected on ultrasound, additional imaging (spiral CT or MRI) is recommended to evaluate the presence and treatment options of the liver metastases.

 

On the basis of practical considerations, it is recommended to also take an image of the entire abdomen in the follow-up period after treatment of the primary tumour if there is an indication for a liver CT.

 

In patients for whom treatment of colorectal liver metastases is being considered, MRI is preferred over CT due to better detection of lesions < 10 mm. There is currently no role for FDG PET as primary diagnostic modality in the detection of liver metastases. However, if there is doubt about the nature of lesions on CT or MRI imaging, additional FDG PET imaging may be considered.

 

Colorectal liver metastases

If there are colorectal liver metastases, which are considered locally treatable on the basis of chest CT, liver CT and abdomen CT scan, an FDG PET(-CT) should be considered as additional imaging to detect possible extrahepatic metastases that may lead to changes in treatment.

 

Suspected recurrence

If a recurrence is suspected on the basis of an increased serum CEA with negative conventional imaging (including diagnostic CT of the chest and abdomen), an FDG PET-CT should be considered.


Diagnostic laparoscopy for liver metastases

In routine practice, there is no role for diagnostic laparoscopy.

 

Imaging plays an important role in the work-up at three moments:

  1. at the time of diagnostics and treatment of the colorectal tumour (detection of synchronous liver metastases and evaluation of lung fields)
  2. during follow-up (detection of metachronous liver metastases) and
  3. in the determination of resectability (detection of liver metastases as well as extrahepatic abnormalities)

 

Punctions for liver metastases

It is recommended not to perform a cytological/histological punction if it appears that liver metastases found during imaging and on the basis of the status of the patient are resectable.

 

It is recommended NOT to punction routinely to confirm diagnosis, if liver metastases appear irresectable on the basis of imaging and patient status.

 

It is recommended only to punction if histological confirmation of the diagnosis is necessary to determine the treatment plan.

Authorization date and validity

Last review : 16-04-2014

Last authorization : 16-04-2014

The validity of this guideline and its associated modules is five years. For various reasons, it may be necessary to edit modules sooner than intended. The National Working Group on Gastrointestinal Cancers therefore annually assesses the content of the guideline and its associated modules. By 2016 it is decided whether a new multidisciplinary working group should be installed to revise the entire guideline.

Initiative and authorization

Initiative : Nederlandse Vereniging voor Radiotherapie en Oncologie

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging van Maag-Darm-Leverartsen
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Klinische Geriatrie
  • Nederlandse Vereniging voor Nucleaire geneeskunde
  • Nederlandse Vereniging voor Pathologie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie
  • Vereniging Klinische Genetica Nederland

General details

All members were mandated by a scientific, professional or patient association. In the composition of the working group we tried to take national distribution, input from participants from both academic and general hospitals and representatives of various disciplines into account. Patients are also represented by delegation into the working group, as well as a focus group meeting.

Scope and target group

Goal

This guideline and its associated modules are - as much as possible - based on scientific research and / or consensus. It is a document with recommendations to support the daily practice of health care professionals involved in patients with (possible) colon cancer, rectal cancer or colorectal liver or lung metastases. It provides recommendations for diagnosis, treatment, follow-up and organization of care. The guideline and its associated modules are thus seeking to improve the quality of care, to increase transparency of choice for treatment and reduce diversity.

 

Target population

Each year colorectal cancer is identified in approximately 13,000 new patients. Rectal carcinoma occurs in about 1 in 3 patients of this. In the Netherlands, the colorectal cancer in both men and women rank third place in incidence of oncological diseases. The expected number of patients diagnosed with colorectal cancer are increased in 2020 to about 17,000, reflecting a slight increase in incidence (especially in men), population growth and aging.

Colorectal cancer is slightly more common in men than in women and ninety percent of patients 55 years or older. More information about the Dutch population can be found at the Netherlands Cancer Registry: www.cijfersoverkanker.nl

This guideline is applicable to all adult patients with (suspected) a primary colorectal carcinoma and patients with metastatic disease. Particular attention is given to the elderly. A separate guideline is available for adult patients with an increased risk of hereditary colon cancer.

Target Audience

This guideline and its associated modules are intended for all professionals involved in the diagnosis, treatment and rehabilitation of patients with (metastatic) colorectal cancer, such as surgeons, general practitioners, consultants, internists, gastroenterologists, (specialist) nurses, clinical geneticists, paramedics, pathologists, radiologists and radiotherapists. The complete guideline is used to develop a patient education text from the Dutch patients Consumer Federation (NPCF).

 

Members of the guideline panel

Name

Function

Hospital

Mandated

Mw. prof. dr. C.A.M. Marijnen chair

Radiotherapist

LUMC Leiden

NVRO

Mw. prof. dr. R.G.H. Beets-Tan

Radiologist

MUMC Maastricht

NVVR

Mw. S. de Bruijn

Specialist nurse

Renier de Graaf hospital Delft

V&VN

Mw. dr. A. Cats

Gastroenterologist

NKI-AVL Amsterdam

NVMDL

Prof. dr. E.F.I. Comans

Nuclear doctor

VUMC Amsterdam

NVNG

Dr. A.R. van Erkel

Intervention radiologist

LUMC Leiden

NVVR

Mw. dr. M.A.M. Frasa

Clinical chemist

Groene Hart hospitalGouda

NVKC

Mw. C. Gielen

Specialist nurse

MUMC Maastricht

V&VN

Dr. E.J.R. de Graaf

Surgeon

IJsselland hospital Capelle a/d IJssel

NVVH

Mw. dr. M. Hamaker

Geriatrician

Diakonessenhuis Utrecht

NVKG

Mw. dr. J.E. van Hooft

Gastroenterologist

AMC Amsterdam

NVMDL

Mw. H.J.A.M.. Kunneman

Researcher

LUMC Leiden

n.v.t.

Mw. dr. M.E. van Leerdam

Gastroenterologist

NKI-AVL Amsterdam

NVMDL

Dr. H. Martijn

Radiotherapist

Catharina-hospital Eindhoven

NVRO

Mw. dr. A.M. Mendez

Romero

Radiotherapist

EMC Cancer Insititute Rotterdam

NVRO

Mw. prof. dr. I.D. Nagtegaal

Pathologist

UMCN St Radboud Nijmegen

NVVP

Dr. L.A. Noorduyn

Pathologist

Lab. Voor Pathologie Dordrecht e.o.

NVVP

Mw. A. Ormeling

Patient

Stomavereniging

NFK

Drs. T.A.M. van Os

Klinisch Geneticus

AMC Amsterdam

VKGN

Dr. F.T.M. Peters

Gastroenterologist

UMCG Groningen

NVMDL

Mw. J. Pon

Patient

NFK/SPKS

NFK

Mw. dr. J.E.A. Portielje

Medical oncologist

Haga hospital Den Haag

Gerionne

Prof. dr. C.J.A. Punt

Medical oncologist

AMC Amsterdam

NIV

Mw. dr. H. Rütten

Radiotherapist

UMCN Radboud Nijmegen

NVRO

Prof. dr. H.J.T. Rutten

Surgeon

Catharina-hospitalEindhoven

NVVH

Prof. dr. J. Stoker

Radiologist

AMC Amsterdam

NVVR

Dr. P.J. Tanis

Surgeon

AMC Amsterdam

NVVH

Dr. J.H. von der Thüsen

Pathologist

MC Haaglanden Den Haag

NVVP

Prof. dr. H.M.W. Verheul

Medical oncologist

VUMC Amsterdam

NIV

Prof. dr. C. Verhoef

Surgeon

EMC Cancer Insititute Rotterdam

NVVH

Dr. Tj. Wiersma

General practitioner

NHG

NHG

 

 

Name

Function

Location

Mw. drs. A.Y. Steutel

process manager

Utrecht

Drs. T. van Vegchel

process manager

Amsterdam

Mw. S. Janssen-van Dijk

secretary

Rotterdam

M.P.  van den Berg

Researcher

Bilthoven

P.F. van Gils

Researcher

Bilthoven

Mw. J. Robays

Methodologist

Brussels

Mw. drs. Y Smit

Methodologist

Germany

Mw. A. Suijkerbuijk

Researcher

Bilthoven

Mw. dr. L. Veerbeek

Methodologist

Groningen

Mw. dr. L. Verheye

Methodologist

Brussels

Mw. dr. G.A. de Wit

Researcher

Bilthoven

 

Patient involvement

Two patient experts have been part of the guideline development group. One on behalf of the Dutch Ostomy Association and on behalf of SPKS/NFK. Based on a focus group meeting experiences of patients regarding care were collected. The guideline also has been used to develop a patient education text for the Dutch patients Consumer Federation (NPCF).

Method of development

Evidence based

Implementation

Promoting the use of recommendations begins with a broad (digital) distribution of the guideline, using direct mailing and an article published in the Dutch Journal of Oncology. In other journals or training sessions, for example, the guideline is brought to the attention. An implementation plan for this guideline contains the key recommendations and an overview of barriers and facilitators for implementation.

Methods and proces

The working group met in July 2012 for the first time. Based on an initial list of problems by working group members a survey among professionals involved in patients with colorectal carcinoma was held. Through this survey, sixty professionals supplied and prioritized possible subjects for revision. Also, a focus group meeting was held, collection patients' experiences. The eleven most relevant questions were answered, and translated into English. Also, alle recommendations were translated into English.

 

Each clinical question was andwered by a subgroup within the development group. External methodologists provided the literature search, review, critical assessment, evidence tables and a draft literature review. Workgroup members suggested other considerations and recommendations.

Responsibility

The Comprehensive Cancer Organisation the Netherlands (IKNL) promotes that people with cancer and their families have access to a consistent and qualitatively adequate care as close to home as possible. IKNL was established to improve treatment, care and clinical research in oncology. It also has a role in setting up and supporting networks for palliative care. IKNL supports multidisciplinary guideline development for oncology and palliative care and facilitates the maintenance, management, implementation and evaluation of these guidelines.

AGREE was used to check the methodological quality of the guideline.

Search strategy

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