Treatment of Carcinoma of the Colon at the Hepatic Flexure

Preoperative Preparation

• The British Journal of Cancer recommends standard bowel preparation, including washout with hypertonic solution combined with low-residue diet, for patients with carcinoma of the colon at the hepatic flexure 1
• The British Journal of Cancer suggests intravenous broad-spectrum antibiotic prophylaxis as part of standard bowel preparation for patients with carcinoma of the colon at the hepatic flexure 1
• Marking of planned stoma sites is recommended, if applicable, for patients with carcinoma of the colon at the hepatic flexure 3

Surgical Approach

• The British Journal of Cancer recommends excision of the primary tumor with safe margins for patients with carcinoma of the colon at the hepatic flexure 4
• The British Journal of Cancer suggests excision of vessels and associated mesocolon containing lymphatic channels and nodes for patients with carcinoma of the colon at the hepatic flexure 4
• A median laparotomy incision is recommended for patients with carcinoma of the colon at the hepatic flexure 3
• Intraoperative examination of the liver, pelvis, and ovaries (in women), with sampling or frozen section of suspicious masses, is suggested for patients with carcinoma of the colon at the hepatic flexure 5

Adjuvant Chemotherapy

• The British Journal of Cancer recommends adjuvant chemotherapy for stage III disease, with a 6-month course of 5-fluorouracil (5-FU) plus folinic acid (FA) being standard (Level of Evidence A) 1, 4, 5, 6
• The British Journal of Cancer suggests that adjuvant chemotherapy remains experimental for stage II disease 1, 4, 6
• The British Journal of Cancer recommends no indication for adjuvant treatment for stage I disease (Level of Evidence B) 1, 4, 5, 6, 7

Management of Metastatic Disease

• The British Journal of Cancer recommends simultaneous or staged resection with the primary tumor for resectable liver metastases 1, 2, 4
• The British Journal of Cancer suggests technical requirements, including sufficient residual liver volume (>30% normal liver in situ), R0 resection margins with 1 cm healthy liver margin around each metastasis, for resectable liver metastases 8
• The British Journal of Cancer recommends neoadjuvant chemotherapy with high response rate regimens (5-FU/FA combinations with oxaliplatin or irinotecan) for initially unresectable metastases 8
• The British Journal of Cancer suggests re-evaluation every 2 months for potential conversion to resectability for initially unresectable metastases 8
• The British Journal of Cancer recommends that if using bevacizumab, the last treatment should be at least 6 weeks before surgery for initially unresectable metastases 8

Palliative Chemotherapy

• The British Journal of Cancer recommends chemotherapy for inoperable disease (Level of Evidence B) 1, 4, 5, 7
• The British Journal of Cancer suggests that 5-FU/FA or 5-FU/methotrexate ± FA combinations are superior to 5-FU alone (Level of Evidence A) for inoperable disease 7
• The British Journal of Cancer recommends that the addition of irinotecan to 5-FU/FA increases response rate and improves overall survival by 3 months (Level of Evidence B) for inoperable disease 7
• The British Journal of Cancer suggests that the addition of oxaliplatin to 5-FU/FA increases progression-free survival by 3 months (Level of Evidence B) for inoperable disease 7

Special Considerations

• The British Journal of Cancer recommends prophylactic bilateral oophorectomy in post-menopausal women 1, 2, 5
• The British Journal of Cancer suggests subtotal colectomy for patients with Lynch syndrome 1, 2, 5

Common Pitfalls to Avoid

• The British Journal of Cancer recommends avoiding inadequate lymph node harvest by ensuring CME technique with high vessel ligation to achieve adequate nodal staging 1, 2
• The British Journal of Cancer suggests avoiding incomplete resection of invaded organs by always performing en bloc resection rather than attempting to separate adherent structures 1, 2
• The British Journal of Cancer recommends considering neoadjuvant chemotherapy to improve resectability for borderline resectable metastatic disease 8
• The British Journal of Cancer suggests avoiding inadequate bowel preparation, which compromises anastomotic integrity 1, 2