T1 invasive carcinoma in a polyp

Only polypectomy is sufficient with radical resection (resection margin ≥1 mm) of a good to moderately differentiated T1 colon carcinoma without (lymph)angio-invasion. In all other cases, additional surgical resection should be considered (resection margin <1 mm, and/or poorly differentiated, and/or (lymph)angio-invasion).

 

For a sessile malignant polyp in which the resection margin cannot be assessed or the polyp has already been removed by piecemeal resection, a surgical resection should be considered.

 

If there is a clinically suspected malignant polyp - for the purpose of a possible additional resection if indicated - the polypectomy location should be marked distally with 2-3 markings. Markings can also be used to locate scars back in order to check residues or local recurrence.

 

In the case of additional surgery, a formal oncological colon resection should be performed with adequate mesocolic lymphadenectomy.

 

Additional surgical resection after endoscopic removal of a malignant polyp must always be a carefully weighed decision due to the relative high number needed to treat, in which the patient must be fully informed about the possible oncological benefit on the one hand, and the chance of complications on the other.

 

On endoscopic removal of a malignant polyp, staging and follow-up should take place in accordance with the recommendations for T1 colon carcinoma. Endoscopic follow-up of the polypectomy scar is recommended after 3 and then 6 months to assess local radicality. Follow-up after this period is in accordance with the Dutch guideline Coloscopy Surveillance.


Laparoscopic surgery

Laparoscopic surgery can be applied safely for both colon and rectal carcinoma with adequate patient selection, sufficient expertise, and adequate imaging equipment and instrumentation.

 

Given the learning curve for laparoscopic surgery is long, the surgeon should be adequately trained before independently performing this type of surgery. Each hospital should satisfy minimum requirements, as determined by the professional association, in order to safely perform minimally invasive colorectal resections.

 

The decision to a possible conversion is preferably made early in the procedure, given reactive conversion appears to be associated with a poorer outcome.

 

Laparoscopic resection of a colorectal carcinoma is recommended as alternative to the open procedure if both techniques are considered suitable for a patient. The choice for an open or laparoscopic resection must be a collaborative decision by the patient and surgeon after discussing the benefits and disadvantages of both techniques and the experience of the surgeon.


Peri-operative care

An enhanced recovery after surgery (ERAS) programme should be applied for optimal perioperative care with elective colorectal resections.


Obstructive colon carcinoma

For patients who present with obstruction complaints, most likely on the basis of an obstructing colon carcinoma, it is recommended that an abdominal CT is performed in order to determine the extent of the primary tumour and possible metastases.

 

In the case of an obstructive colon carcinoma on the left side of a patient without increased surgical risk and curative intent, an acute resection with end colostomy or acute resection with anastomosis and possible deviating ileostomy.

 

For an obstructive colon carcinoma on the left side, a deviating colostomy (e.g. via a small incision in the upper right abdomen) can be considered as a bridge to elective resection if there is an increased risk of surgery.

 

The use of a stent as a bridge to elective resection should be considered if there is an increased risk of surgery, if technically feasible and with the right expertise available, taking the risk of perforation with possible oncological disadvantage into consideration.

 

Placement of a stent for palliation should be considered in the case of a patient with obstruction colon carcinoma on the left side and extensive metastasis with a reduced life expectancy. If such a patient is still a candidate for systemic therapy, a deviating colostomy seems preferable.

 

Multimodal treatment of T4 colon carcinoma

In the case of T4 colon carcinoma, the target should be an R0 resection according to oncological principles (en-bloc).

 

Preoperative imaging and discussion in a multidisciplinary team is essential for decision-making in relation to possible referral to an expertise centre, neoadjuvant treatment, and planning of the resection. If necessary, interfacing specialisms (urology, gynaecology, IORT facilities) should be consulted.

 

Neoadjuvant therapy (both chemotherapy and chemoradiation) should be considered if the CT scan of the abdomen shows that a radical resection cannot initially be performed. It is determined within multidisciplinary consultation if chemotherapy or (chemo)radiation is administered.

 

If it appears peroperative that there is a fixed tumour process with risk of a non-radical resection, the tumour should be left in situ.

 

The guideline development group is of the opinion that if preoperative (chemo)radiotherapy is administered and there is doubt about the feasibility of an R0 resection, boost radiation using IORT may be considered.

 

Given tumour infiltration is difficult to distinguish peroperative from reactive benign adhesions, it is recommended to perform a multivisceral resection in case of doubt.

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).

 

Samenstelling werkgroep

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

Searches are available upon request. Please contact the Richtlijnendatabase.