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圃錡蓝
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1 Colon Cancer Treatment Guideline KMHK

2 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年多科會議討論檢視後未修改年多科會議討論檢視後未修改年多科會議討論檢視後未修改年 (1) 大腸直腸癌 MONITORING/SURVEILANCE Colonscopy 2-5 years: Obstruction lesion f new lesion, C 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 C-4 C-6 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 C-7 劑量改 mg/m 2 bid(stage II 需自費 ) (5) 直腸癌治療準則 Lesion 5cm 改 8cm C-11 (6) 直腸癌 Stage B1 改 T2N0M0, 治療 Transanal posteri local excision + post-op radiotherapy and C-12 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) C-12 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 C-14 resection ± intraoperative brachytherapy 改 Pre-op chemotherapy + radiotherapy, then OP low anteri resection ±then RT 102 年 (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 Colon cancer T3,N0,M0 at high risk f Systemic recurrence T4,N0,M0 治療準則 (4) 修訂 Colon cancer T1-3,N1-2,M0 T4,N1-2 M0 治療準則 (5) 修訂 Patient appropriate f intensive therapy (metastasis) 治療準則 (6) 修訂 Rectal Cancer T3 N0 M0(high risk),t1-3 N1-2 M0 C-6 C-7 C-8 C-9 C-10~12 C-14~15 6.0

3 Colon Cancer Treatment Guideline 結腸癌治療準則 A personal family histy of bowel dis. Passage of blood per colon. Sigmoidoscopic colonscopic radiologic discovery of polyps. Benign Treatment 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 If polyps are large, flat, can`t be removed with a colonscopy abdominal surgery ACS(American Cancer Society):large polyps (>1cm)should be removed 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 C-1

4 Colon Cancer Treatment Guideline 結腸癌治療準則 Liver mets Resectable (1-4 discrete lesions) Unresectable (asymptomatic colon lesion with high liver burden) Hemicolectomy+ liver resection hemicolectomy + in 6wk, liver resection None Suspected proven metastatic adenocarcinoma fm large bowel (Duke`s D stage IV) Colonscopy Chest X-ray CT scan of involved areas(pelvis/abdomen/ thacic) CBC, platelets, Panel A CEA Needle aspiration/ biopsy of metastases Lung mets Unresectable (symptomatic colon lesion with high liver burden) 1-3 nodules Multiple Limited bowel resection Hemicolectomy,then thacotomy, resect nodules Hemicolectomy Respectable Abdominal mets Unresectable Limited bowel resection diverting colostomy C-2

5 Follow up f Colon Cancer 結腸癌治療準則 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 Q3m-6m Q6m Q12m CEA elevated at diagnosis ˇ Q3m Q6m Q12m Chest X-ray ˇ Q6m Q6m Q12m Abdominal CT sonography ˇ Q6m Q12m Pelvis CT / MRI ˇ Q6m Q12m Colonscopy ˇ Q12m Q5Y Q5Y C-3

6 結腸癌追蹤準則第一至第三期監測 : 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 : CEA 術前有上升者前二年, 每三個月一次, 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 C-4

7 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 C-5

8 Colon Cancer Treatment Guideline 結腸癌治療準則 CLINICAL WORKUP FINDINGS SURGERY PRESENTAYION Pedunculated Polyp with Observe Single specimen, Invasive cancer Completely removed Pedunculated Sessile polyp (adenoma [tubular, Tubulovillous, Villous]) with Pathology review Colonoscopy Marking of Cancerous polyp site(at time of With favable Histologic features and clear margins Fragmented specimen Sessile polyp With invasive cancer Observe Colectomy with en Bloc removal of Regional lymph nodes Invasive cancer colonoscopy within 2 weeks) Margin cannot be Assessed unfavable Histologic features Colectomy with en bloc removal of regional lymph nodes C-6

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

10 Colon Cancer Treatment Guideline 結腸癌治療準則 PATHOLOGIC STAGE ADJUVANT THERAPY Tis;T1,N0,M0 None T2,N0,M0 None T3,N0,M0 (no high-risk features) T3,N0,M0 at high risk f Systemic recurrence T4,N0,M0 Clinical trial Observation Consider capecitabine Or 5-FU/leucovrin Capecitabine 5-FU/leucovin FOLFOX CapeOx FLOX Clinical trial Or Observation ± UFUR C-8

11 Colon Cancer Treatment Guideline 結腸癌治療準則 PATHOLOGIC STAGE ADJUVANT THERAPY T1-3,N1-2,M0 T4,N1-2 M0 FOLFOX CapeOx (both categy 1 and preferred) Other options include FLOX(categy 1) Capecitabine 5-FU/leucovin ±UFUR Xeloda C-9

12 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 FOLFOX ± bevacizumab CapeOX± bevacizumab, FOLFIRI ± bevacizumab FOLFIRI ± ziv-aflibercept Irinotecan ± bevacizumab Irinotecan±ziv-aflibercept (Cetuximab panitumumab) (KRAS WT gene Only) + irinotecan; f patients not able to tolerate combination, consider single agent(cetuximab panitumumab) (KRAS WT gene only) FOLFOX ± panitumumab (KRAS wild-type [WT] gene only) FOLFIRI + (cetuximab Panitumumab) (KRAS WT gene only) (Cetuximab panitumumab) (KRAS WT gene only)+irinotecan Clinical trial best supptive care C-10

13 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 FOLFIRI+ Bevacizumab FOLFIRI ± cetuximab Or panitumumab (KRAS WT gene only) FOLFOX ± bevacizumab Or CapeOX ± bevacizumab (Cetuximab panitumumab) (KRAS WT gene only) + Irinotecan;f patients not able to tolerate combination, consider single agent (cetuximab panitumumab) (KRAS WT gene only) (Cetuximab panitumumab) (KRAS WT gene only) + irinotecan; f patients not able to tolerate combination, consider single agent (cetuximab panitumumab) (KRAS WT gene only) FOLFOX CapeOX C-11

14 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 Irinotecan Irinotecan ± bevacizumab Irinotecan ± ziv-aflibercept Irinotecan + oxaliplatin ± bevacizumab FOLFIRI ± bevacizumab FOLFIRI ± ziv-aflibercept (Cetuximab panitumumab) (KRAS WT gene only) + irinotecan; f patients not able to tolerate Combination, consider single agent (cetuximab panitumumab) (KRAS WT gene only) FOLFOXIRI (categy 2B) (Cetuximab panitumumab) (KRAS WT gene only) + irinotecan f patients not able to tolerate combination, consider single agent (cetuximab panitumumab) (KRAS WT gene only) C-12

15 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 C-13

16 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 Followed up LAR APR T3 N0 M0 (high risk) T1-3 N1-2 M0 Pre-operative chemotherapy (LV and 5-FU) + radiotherapy, followed by LAR AP resection 5-FU/Leucovin f 4-6cycles ±UFUR LAR AP resection 5-FU/Leucovin f 4-6cycles ± radiotherapy C-14

17 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 Pre-op chemotherapy (5-FU+LV) T3 N0 M0 (high risk) T1-3 N1-2 M0 +radiotherapy, follow by low anteri resection 5FU/Leucovin f 6 cycles ±UFUR Low anteri resection 5FU/Leucovin f 6 cycles ± radiotherapy C-15

18 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 f 6 cycles F metastatic disease Metastases resectable Resect metastases +low anteri AP resection Radiotherapy + chemotherapy Stage D Any T and N M1 Metastases unresectable Low anteri AP resection No operation if asymptomatic Salvage Therapy C-16

19 Rectal Cancer Treatment Guideline 直腸癌治療準則 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 Q3m-6m Q6m Q12m CEA elevated at diagnosis ˇ Q3m Q6m Q12m Chest X-ray ˇ Q6m Q6m Q12m Abdominal CT sonography ˇ Q6m Q12m Pelvis CT / MRI ˇ Q6m Q12m Colonscopy ˇ Q12m Q5Y Q5Y C-17

20 直腸癌追蹤準則監測 : 前二年, 每三個月做一次病史及理學檢查, 之後, 每六個月做一次, 合計 5 年時間 T2 或腫瘤較大者, 假如病人有可能合併有潛在轉移的危險的話, 則前二年每三個月檢查一次血中 CEA 值然後每六個月抽血一次測 CEA 值, 連續 3~5 年的時間對於有高復發危險的病人, 建議每年安排一次胸部 ; 腹部及骨盆腔的電腦斷層, 時間則是連續 3 年大腸鏡檢查術後一年內要執行 (1) 若有異常則一年內應再重複執行此項檢查 (2) 若出現息肉但病理報告非惡性者, 則此後至少每 2-3 年再重複執行 (3) 若術前因為阻塞而無法做大腸鏡的病人, 則應在 3-6 個月內做大腸鏡檢查 C-18

Colon Cancer

Colon Cancer Colon Rectal Cancer Treatment Guideline KMHK 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: