Colon Cancer

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1 Colon Rectal Cancer Treatment Guideline KMHK

2 修訂日期修訂內容摘要 97 年 98 年 99 年 100 年 101 年 102 年大腸癌診療指引新制訂多科會議討論檢視後未修改多科會議討論檢視後未修改多科會議討論檢視後未修改大腸癌修訂紀錄 (1) 大腸直腸癌 MONITORING/SURVEILANCE Colonscopy 2-5 years: Obstruction lesion f new lesion, Q3-6m,Q12m 改 Q5Y (2) 結腸癌追蹤準則 : 對於有高度復發危險者, 腹部及骨盆腔電腦斷層檢查, 連續執行三年改二年 (3)High Risk Stage II Stage III 門診第一線用藥準則 (1): 5FU 500 mg/m 2 + Leucvin 100mg/ m 2 Weekly f 6 of 8 weeks 改 Weekly f 6 of 8 weeks2-3 cycle (4)High Risk Stage II Stage III IV 門診第一線用藥準則 (3): Capecitabine 1250 mg/m 2 劑量改 mg/m 2 bid(stage II 需自費 ) (5) 直腸癌治療準則 Lesion 5cm 改 8cm (6) 直腸癌 Stage B1 改 T2N0M0, 治療 Transanal posteri local excision + post-op radiotherapy and chemotheraopy 刪除 chemotheraopy 新增 LAR APR (7) 直腸癌 Stage B2 改 T3N0M0, Stage C 改 T1-3N1-2M0, Pre-operative chemotherapy (MMC and 5-FU) 改 LV and 5-FU 新增 LAR APR (8) 直腸癌 Stage B3, C3 T4 N0-2 M0 治療準則 Pre-op chemotherapy + radiotherapy, then AP low anteri resection ± intraoperative brachytherapy 改 Pre-op chemotherapy + radiotherapy, then OP low anteri resection ±then RT (1) 修訂 Pedunculated Sessile polyp(adenoma [tubular, Tubulovillous, Villous]) with Invasive cancer 治療準則 (2) 修訂 Colon cancer Appropriate f Resection(non- metastatic) 治療準則 (3) 修訂 Patient appropriate f intensive therapy (metastasis) 治療準則修訂頁次版本 C-3 C-4 C-6 C-7 C-11 C-12 C-12 C-14 C-6 C-7 C-10~ 年 (1) 修訂 Pedunculated Sessile polyp(adenoma [tubular, C Tubulovillous, Villous]) with Invasive cancer 治療準則 (2) 修訂 Suspected proven metastatic adeno- carcinoma fm large C-3 bowel (Duke`s D stage IV) 治療準則 (3) 修訂 Colon cancer Appropriate f Resection(non- metastatic) 治 C-4 療準則 (4) 修訂大腸癌 MONITORING/SURVEILANCE Abdominal CT C-5 sonography 2 years: Q6m 改 Q3-6m

3 104 年 (5) 修訂直腸癌 MONITORING/SURVEILANCE Pelvis CT/MRI C-6 sonography 2 years: Q6m 改 Q3-6m (6) 修訂結腸癌第四期合併肝轉移追蹤準則 C-8 (7) 修訂結腸癌 (Adjuvant therapy) 治療準則 C-9~10 (8) 修訂 Patient appropriate f intensive therapy (metastasis) 治療準 C-12~13 則 (9) 修訂 Rectal Cancer T3 N0 M0(high risk),t1-3 N1-2 M0 治療準則 C-14 (10) 修訂 Rectal Cancer stage B3,C3 T4N0-2M0 stage D Any T and N M1 治療準則 (1) 增訂大腸直腸癌目的參考文件範圍定義內容 C-1 (2) 增訂大腸癌簡易治療指引直腸癌簡易治療指引 C-2~3 (3) 增訂大腸直腸 AJCC 分期化療藥物文憲查證 C-18~21 5.0

4 C-1 1 目的 : 高雄市立小港醫院大腸直腸癌擬參考相關國內外治療指引與相關文獻, 依據現有的設施健保給付制度, 大腸直腸癌團對相關研究成果與臨床經驗修訂完成高雄市立小港醫院大腸直腸癌之診療共識 2 範圍 : 大腸直腸癌治療 3 參考文件 : 3.1 National Comprehensive Cancer Netwk. Clinical Practice Guideline in Oncology:Colon Cancers V National Comprehensive Cancer Netwk. Clinical Practice Guideline in Oncology:Rectal Cancers V 定義 : 泛指臨床科醫療人員皆可參考適用 5 內容 : 5.1 大腸直腸癌診斷及評估 5.2 糞便潛血反應 : 為大腸直腸癌篩檢廣泛使用之初步檢查方式, 以檢驗大便中是否有潛血反應 5.3 肛門指診 : 病人不需要任何準備, 由醫師戴手套以 Xylocaine Jelly 潤滑右手食指慢慢插入至直腸 7~8 公分, 直腸癌患者一半以上可以摸到硬塊, 是最簡單的檢查方法 5.4 肛門鏡檢 (Anoscopy): 長約 8 公分, 屬於硬的管狀器械, 由肛門插入以肉眼直接檢查 5.5 直腸乙狀結腸鏡檢 (Sigmoidoscopy): 此乃利用約 60 公分長的腸鏡, 從肛門進入直腸乙狀結腸作診斷, 約有 60% 的結腸癌可由此法發現, 檢查時應使肌肉放鬆, 採左側臥或膝胸臥式 5.6 結腸鋇劑灌腸攝影術 : 須做清潔灌腸後, 從肛門灌入鋇劑, 簡單省時, 對於結腸內之病灶, 雙對比鋇劑照影可偵測出較小的病變 5.7 大腸鏡檢查 (Colonoscopy): 須做清潔灌腸後, 由肛門進入結腸, 直接觀看整條大腸黏膜內部情形, 若發現瘜肉可同時切除, 如無法切除必須切片檢查, 且再確認其他結腸處有無同時發生之腫瘤病變 5.8 組織切片檢查 (Bioposy): 使用內視鏡檢查時對可疑的部分取出體外, 再作組織切片, 以判定是否為惡性腫瘤亦可先行瘜肉切除再作切片, 以確定是否有惡性變化及侵蝕至黏膜下肉層 5.9 腫瘤記號蛋白 (CEA): 又稱腫瘤胚胎抗原, 係從大腸直腸癌細胞分離出來的蛋白, 它在血中濃度會隨著大腸直腸癌的發生而升高, 臨床上腫瘤記

5 C-2 號蛋白用於手術後, 大腸直腸癌有否局部再發或遠端轉移之偵測參考 5.10 腹部及骨盆腔之電腦斷層掃描 (Abdominal and Pelvic CT): 藉由腹部及骨盆腔之電腦斷層掃描檢查, 可以整體評估腫瘤所在位置, 和腹腔與骨盆腔內腫瘤細胞侵犯鄰近組織與器官的情形, 以及是否已有肝臟等部位之轉移 5.11 核磁共振掃描 (MRI): 與電腦斷層掃描同為影像學之檢查, 當上述影像學檢查無法確定診斷時, 或病人因腎功能不全或對於電腦斷層顯影劑過敏時使用, 屬於第二線的檢查, 用來評估直腸癌局部侵犯深度及 CCRT 之反應 5.12 胸部 X 光檢查 (Chest X-ray ): 胸部 X 光片可以初步篩檢肺部有無病後灶, 評估腫瘤細胞是否已有肺部轉移的情形 5.13 全身正子攝影 (PET-CT): 利用腫瘤組織對放射性藥物 ( 氧化去氧葡萄糖 ) 的吸收與代謝, 轉換成體內分布影像, 並結合電腦斷層, 達到準確定位的功能, 屬全身性的檢查此檢查雖然比單獨電腦斷層掃描或單獨一正子放射更靈敏, 但仍有約 10 % 的偽陰性或偽陽性發生, 並非常規術前檢查 5.14 治療準則大腸癌簡易治療指引 AJCC/ 治療 OP C/T R/T Target 第 0 期大腸鏡息肉切除或手術切除後觀察第一期 (pt1-2n0) 手術定期追蹤第二期 low risk 手術定期追蹤或輔助性化療 (pt3n0) High risk 手術輔助性化療第三期 (pt1-4,n1-2) 第四期 (M1) 手術輔助性化療可切除原發處和轉移處同時切除術前化療再手術原發處切除化學治療化學治療轉移處切除

6 C-3 C 不可切除化學治療 + 標靶治療 + 放射線治療原發處有阻塞症狀時先行腸道切除再評估轉移處是否可切除化學治療 + 標靶治療 + 放射線治療 *intraoperative radiation therapy(iort),if available,should be considered f patients with T4 recurrent cancers as an additional boost. 直腸癌簡易治療指引 stage Op C/T R/T T/T 第 0 期大腸鏡息肉切除或手術後觀察第一期 (pt1-2,n0) 1. 經腹部手術 Stage I 觀察 2. 經肛門手術 T1 N0 Margin negative 觀察 T1,N0 with risk fact T2,N0 經腹部手術第二期 (pt3-4,n0) 第三期 (Any pt,n1-2) 第三期 pt4 and / 局部無法切除 1 根除性手術放射及化學治療 (CCRT) 術後輔助性化學治療 2 放射及化學治療 (CCRT) 根除性手術術後輔助性化學治療放射及化學治療 (CCRT) 根除性手術術後輔助性化學治療原發處和轉移處同時切除第四期轉移型 ( 可切除 ) 術前化療再手術原發處切除化學治療化學治療轉移處切除

7 C-4 Colon Cancer Treatment Guideline 結腸癌治療準則 (Polyps) A personal family histy of bowel dis. Passage of blood per colon. Sigmoidoscopic colonscopic radiologic discovery of polyps. A polyp palpated by digital rectal exam. Blood-tinged mucus. A change in bowel habits. Tenesmus. Constipation. Increased frequency of bowel movement Blood in on the stool(either bright very dark in col) Colonscopy with polypectomy. Digital rectal exam. Sigmoidoscopy Colonscopy Barium enema Neoplastic Adenoma Tubular adenoma Villous adenoma Hemartomas Juvenile polyp Peutz-Jeghers polyps Inflammaty Inflammaty polyp Benign lymphoid Unclassified Hyperplastic Miscellaneous Lipoma Leiomyoma Carcinoid Benign Malignant Benign Treatment If polyps are large, flat, can`t be removed with a colonscopy abdominal surgery ACS(American Cancer Society):large polyps (>1cm)should be removed

8 C-5 Colon Cancer Treatment Guideline 結腸癌治療準則 (Polyps) CLINICAL WORKUP FINDINGS SURGERY PRESENTAYION Pedunculated Polyp with Invasive cancer Observe Pedunculated Sessile polyp (adenoma [tubular, Tubulovillous, Villous]) with Invasive cancer Pathology review Colonoscopy Marking of Cancerous polyp site(at time of colonoscopy within 2 weeks) Single specimen, Completely removed With favable Histologic features and clear margins Fragmented specimen Margin cannot be Assessed unfavable Histologic features *Observe:depend on physician judgement and discuss with patient Sessile polyp With invasive cancer Observe Colectomy with en bloc removal of regional lymph nodes Observe Colectomy with en bloc removal of regional lymph nodes

9 C-6 Colon Cancer Treatment Guideline 結腸癌治療準則 (Surgery) Liver metastases Resectable Unresectable (asymptomatic colon lesion with high liver burden) Hemicolectomy+ liver resection hemicolectomy followed by liver resection Chemotherapy ± Target therapy Colonscopy Chest X-ray Unresectable (symptomatic colon lesion with high liver burden) Limited bowel resection Suspected proven metastatic adenocarcinoma fm large bowel (Duke`s D stage IV) CT scan of involved areas(pelvis/abdomen/ thacic) CBC, platelets, Panel A CEA Needle aspiration/ biopsy of metastases Lung metastases 1-3 nodules Hemicolectomy,then thacotomy, resect nodules Multiple+ symptomatic colon lesion Multiple+ asymptomatic colon lesion Limited bowel resection Chemotherapy ± Target therapy Resectable Colon, Abdominal metastases resection Abdominal metastases Unresectable+ symptomatic colon lesion Limited bowel resection diverting colostomy Unresectable+ asymptomatic colon lesion Chemotherapy ± Target therapy

10 C-7 Colon Cancer Treatment Guideline 結腸癌治療準則 (Surgery) CLINICAL WORKUP FINDINGS SURGERY PRESENTAYION Resectable,nonobstructing Colectomy with en bloc removal of regional lymph nodes Colon cancer Appropriate f Resection(non -metastatic) Pathology review Colonoscopy CBC,platelets, Chemistry profile, CEA Chest/abdominal/ pelvic CT PET-CT scan is not routinely indicated Resectable,obstructing One-stage colectomy with en bloc removal of regional lymph nodes Resection with diversion Stent Diversion Colectomy with en bloc removal of regional lymph nodes Locally unresectable Diversion bypass surgery Medically inoperable Discuss with patient

11 C-8 Colon Cancer Treatment Guideline 結腸癌治療準則 (Metastasis) Initial Therapy Therapy After First Progression Therapy After Second Progression FOLFOX ± bevacizumab CapeOX ± bevacizumab FOLFIRI ± bevacizumab FOLFIRI ± ziv-aflibercept (Cetuximab) (K-RAS WT only) + FOLFIRI; f patients not able to tolerate combination, consider single agent(cetuximab) (K-RAS WT only) Patient appropriate f intensive therapy FOLFIRI + bevacizumab FOLFIRI + cetuximab (K-RAS WT only) FOLFOX ± bevacizumab Or CapeOX ± bevacizumab Regafenib(K-RAS MT) (Cetuximab) (K-RAS WT only) + FOLFIRI; f patients not able to tolerate combination, consider single agent(cetuximab) (K-RAS WT only) Regafenib(K-RAS MT)

12 C-9 Colon Cancer Treatment Guideline 結腸癌治療準則 (Metastasis) Initial Therapy Therapy After First Progression Therapy After Second Progression Patient appropriate f intensive therapy 5-FU/leucovin Capecitabine ± bevacizumab FOLFOX ± bevacizumab CapeOX ± bevacizumab FOLFIRI ± bevacizumab FOLFIRI ± ziv-aflibercept (Cetuximab) (K-RAS WT only) + FOLFIRI; f patients not able to tolerate combination, consider single agent(cetuximab) (K-RAS WT only) Regafenib(K-RAS MT) FOLFOXIRI (categy 2B) FOLFOX ± bevacizumab CapeOX ± bevacizumab FOLFIRI ± bevacizumab FOLFIRI ± ziv-aflibercept

13 C-10 Colon Cancer Treatment Guideline 結腸癌治療準則 (Adjuvant therapy) PATHOLOGIC STAGE ADJUVANT THERAPY Tis;T1,N0,M0 T2,N0,M0 None T3,N0,M0 (no high-risk features) Observation Consider capecitabine ( UFUR) 5-FU/leucovrin T3,N0,M0 at high risk f Systemic recurrence T4,N0,M0 Capecitabine ( UFUR) 5-FU/leucovin FOLFOX CapeOx Observation T1-3,N1-2,M0 T4,N1-2 M0 FOLFOX CapeOx Capecitabine 5-FU/leucovin

14 C-11 Colon Cancer Treatment Guideline 結腸癌治療準則 (Follow up) MONITORING / SURVEILANCE Pretreatment 2 years 2-5 years >5 years Physical exam, including DRE ˇ Q3m Q6m Q12m Stool occult blood test ˇ Q12m CBC + panel A ˇ Q3-6m Q6m Q12m CEA ˇ Q3m Q6m Q12m Chest X-ray ˇ Q6m Q6m Q12m Abdominal CT sonography (f colon cancer) Pelvis CT / MRI sonography (f rectal cancer) ˇ Q3-6m Q12m ˇ Q3-6m Q12m Colonscopy ˇ Q12m Q5Y Q5Y

15 C-12 第一至第三期監測 : 前二年, 每三個月一次病史及理學檢查, 之後每六個月一次, 共計 5 年針對 T2 或腫瘤較大者, 前二年每三個月測一次 CEA, 之後每六個月一次, 共計五年對於有高度復發危險者, 每年須執行一次胸部, 腹部及骨盆腔電腦斷層檢查, 連續執行二年大腸鏡檢查 : 術後一年內 (1) 假如有異常, 則一年內須再重複一次 (2) 假如有息肉但非惡性, 則至少每 2-3 年再重複一次 (3) 術前因腸阻塞而無法做大腸鏡者, 應於術後 3-6 個月內執行正子攝影檢查 (PET Scan) 並不一定是必要的第四期併肝轉移監測 : 同時合併有肝轉移 :( 第四期大腸癌 ) 假如病人是第四期患者 : 前二年, 每三個月一次理學及 CEA 檢查, 之後 3-5 年間則每六個月一次胸部 / 腹部 / 骨盆腔電腦斷層, 前兩年每 3-6 個月一次, 之後三年每 6-12 個月一次大腸鏡檢查 : 術後一年內 (1) 假如有異常, 則一年內須再重複一次 (2) 假如有息肉但非惡性, 則至少每 2-3 年再重複一次術前因腸阻塞而無法做大腸鏡者, 應於術後 3-6 個月內執行

16 C-13 第四期併肺轉移監測 : 同時合併有肺部轉移 ( 第四期大腸癌 ) 假如病人是第四期患者 : CEA CT 與併肝轉移皆相同大腸鏡

17 C-14 Rectal Cancer Treatment Guideline 直腸癌治療準則 Anal bleeding Small-caliber stool Blood in/on the stool Bowel-habit changes Tenesmus Rectal tum Pathology review Chest X-ray Abdominal CT Sonography Pelvic CT MRI CEA Endectal ultrasound, if pelvic CT scan Enterostomal therapist Lesion 8cm closer anal verge, T1-3 Lesion >8cm fm anal verge, T1-3 Any rectal lesion T4 Metastatic disease

18 C-15 Rectal Cancer Treatment Guideline 直腸癌治療準則 Lesion less than 8cm about anal uerge T1 N0 M0 Transanal posteri local excision* Followed up T2 N0 M0 Transanal posteri local excision + post-op radiotherapy Pre-operative radiotherapy and chemotherapy followed by LAR AP resection LAR APR Followed up T3 N0 M0 (high risk) T1-3 N1-2 M0 Pre-operative chemotherapy (LV and 5-FU) + radiotherapy, followed by LAR AP resection LAR AP resection 5-FU/Leucovin 5-FU/Leucovin Folfox ± radiotherapy * If margin not free, consider RT abdominal surgery

19 C-16 Rectal Cancer Treatment Guideline 直腸癌治療準則 Me than 8cm about anal uerge T1 N0 M0 Low anteri resection Followed up T2 N0 M0 T3 N0 M0 (high risk) T1-3 N1-2 M0 Pre-op chemotherapy (5-FU+LV) +radiotherapy, follow by low anteri resection 5FU/Leucovin Low anteri resection 5FU/Leucovin Folfox ± radiotherapy

20 C-17 Rectal Cancer Treatment Guideline 直腸癌治療準則 F any rectal lesion, T4 Stage B3, C3 T4 N0-2 M0 Pre-op chemotherapy + radiotherapy, then OP low anteri resection ± then RT 5-FU/ Leucovin Folfox F metastatic disease Metastases resectable Resect metastases +low anteri AP resection Chemotherapy* ± Radiotherapy Stage D Any T and N M1 Metastases unresectable Low anteri AP resection No operation if asymptomatic Chemotherapy* ± Radiotherapy * Include Target Therapy

21 大腸直腸癌 AJCC 分期 C-18

22 C-19

23 C 大腸直腸癌化療藥物 5-FU/LV (slv5fu2) 1 mfolfox62.3 FOLFIRI4 XELOX5.6 Xeloda7 Leucovin 400 mg/m2 Oxaliplatin 130 mg/m2 5-FU 400 mg/m2 Xeloda mg/m2 5-FU 2400 mg/m2 po Oxaliplatin 85 mg/m2 Leucovin 400 mg/m2 5-FU 400 mg/m2 5-Fu 2400 mg/m2 Irinotecan 180 mg/m2 Leucovin 400 mg/m2 5-Fu 400 mg/m2 5-FU 2400 mg/m2 Xeloda mg/m2 po UFUR8.9 FOLFOX415 Avastin10 Erbitux11 UFUR mg po Oxaliplatin 85 mg/m2 Leucovin 200 mg/m2 f 2days 5-FU 400 mg/m2 f 2days 5-Fu 600 mg/m2 f 2days Avastin 劑量 5mg/kg Erbitux 為水劑 500 mg/m2 CCRT: 1.RT+5-FU/Leuconvin12: 5-FU400mg/m2 iv bolus + Leuconvin20 mg/ m2 iv bolus f 4 day during week 1 and 5 of RT 2.RT+Capecitabine13.14: Capecitabine 825mg/m2 twice daily 5 days/week + RT 5weeks

24 C-21 文獻查證 : 1 Haller DG, Rothenberg ML,Wong AO, et al. Oxaliplatin plus irinotecan compared with irinotecan alone as second-line treatment after single agent fluopyrimidine therapy f metastatic colectal carcinoma. J Clin Oncol 2008;26: Maindrault-Goebel F, degramont A, Louvet C, et al.evaluation of oxaliplatin dose intensity in bimonthly leucovin and 48-hour 5-fluouracil continuous infusion regimens (FOLFOX) in cancer. Annals of Oncology 2000;11: pretreated metastatic colectal 3 Douillard JY, Siena S, Cassidy J, et al. Randomized,phase III trial of panitumumab with infusional fluouracil,leucovin, and oxaliplatin (FOLFOX4) versus FOLFOX4 alone as first-line treatment in patients with previously untreated metastatic colectal cancer: the PRIME study.j Clin Oncol 2010;28: Cunningham D, Humblet Y, Siena S, et al. Cetuximab monotherapy and cetuximab plus irinotecan in irinotecanrefracty metastatic colectal cancer. N Engl J Med 5 Emmanouilides C, Sfakiotaki G, Androulakis N, et al.front-line bevacizumab in combination with oxaliplatin,leucovin and 5-fluouracil (FOLFOX) in patients with metastatic colectal cancer: a multicenter phase II study. BMC Cancer 2007;7:91. 6 Douillard JY, Siena S, Cassidy J, et al. Randomized,phase III trial of panitumumab with infusional fluouracil,leucovin, and oxaliplatin (FOLFOX4) versus FOLFOX4 alone as first-line treatment in patients with previously untreated metastatic colectal cancer: the PRIME study.j Clin Oncol 2010;28: Falcone A, Ricci S, Brunetti I, et al. Phase III trial of infusional fluouracil, leucovin, oxaliplatin, and irinotecan (FOLFOXIRI) compared with infusional fluouracil,leucovin, and irinotecan (FOLFIRI) as first-line treatment f metastatic colectal cancer: The Gruppo Oncologico Nd Ovest. J Clin Oncol 2007;25(13): al, T. K. e. (2002). Efficacy of al UFT as adjuvant chemotherapy to curative resection of colectal cancer:multicenter prospective randomized trial. Langenbeck s Arch Surg, 386. doi: /s x 9 at, T. A. e. (2006). Adjuvant Chemotherapy with Uracil Tegafur f Pathological Stage III Rectal Cancer after Mesectal Excision with Selective 10 Douillard JY, Siena S, Cassidy J, et al. Randomized,phase III trial of panitumumab with infusional fluouracil,leucovin, and oxaliplatin (FOLFOX4) versus FOLFOX4alone as first-line treatment in patients with previously untreated metastatic colectal cancer: the PRIME study. J Clin Oncol 2010;28: European studies showing equivalent efficacy f CapeOX used at a higher dose; however, European patients consistently tolerate capecitabine with less toxicity than American patients. 12 Tepper JE, O'Connell M, Niedzwiecki D, et al. Adjuvant therapy in rectal cancer: analysis of stage, sex, and local control--final rept of Intergroup J Clin Oncol 2002;20: Roh MS, Yothers GA, O'Connell MJ, et al. The impact of capecitabine and oxaliplatin in the preoperative multimodality treatment in patients with carcinoma of the rectum: NSABP R-04 [abstract]. J Clin Oncol 2011;29 (suppl):3503.available at: 14 Hofheinz R, Wenz FK, Post S, et al. Chemadiotherapy with capecitabine versus fluouracil f locally advanced rectal cancer: A randomized, multicentre, noninferiity,phase 3 trial. Lancet Oncol 2012;13: National Comprehensive Cancer Netwk. Clinical Practice Guideline in Oncology: Colon & Rectal Cancers V National Comprehensive Cancer Netwk. Clinical Practice Guideline in Oncology: Colon & Rectal Cancers V2.2015

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$(Microsoft Word - \244j\270z\252\275\270z\300\371_102\246~_.doc)$ Colon Cancer Treatment Guideline KMHK 大腸癌修訂紀錄修訂日期修訂內容摘要修訂頁次版本 97 年大腸癌診療指引新制訂 1.0 98 年多科會議討論檢視後未修改 2.0 99 年多科會議討論檢視後未修改 3.0 100 年多科會議討論檢視後未修改 4.0 101 年 (1) 大腸直腸癌 MONITORING/SURVEILANCE Colonscopy 2-5