Management of Suspected Colorectal Carcinoma

Initial Diagnostic Workup

The National Comprehensive Cancer Network recommends complete colonoscopy as essential for diagnosis and to rule out synchronous lesions 3, 4
Pathology review of any biopsied or resected specimens is required to confirm invasive cancer, as stated by the National Comprehensive Cancer Network 3
Laboratory tests should include CBC, platelets, chemistry profile, and CEA level, according to the National Comprehensive Cancer Network 3
Chest, abdominal, and pelvic CT scans are necessary for staging, as recommended by the National Comprehensive Cancer Network and Annals of Oncology 3, 5
Endorectal ultrasound and/or pelvic MRI are recommended for rectal cancer to assess local invasion and guide preoperative treatment decisions, according to Annals of Oncology 2, 4
PET scan is not routinely indicated but should be considered before surgical resection for patients with suspected recurrence or isolated resectable metastases, as stated by the National Comprehensive Cancer Network 1, 6

En bloc resection with regional lymph node removal (at least 12 nodes should be examined) is the standard surgical approach for resectable colon cancer, according to the National Comprehensive Cancer Network 1, 3, 7
For obstructing tumors, one-stage colectomy with en bloc removal of regional lymph nodes is an option, as recommended by the National Comprehensive Cancer Network 3
For pedunculated or sessile polyps with invasive cancer, colectomy with lymph node removal is recommended if margins cannot be assessed or unfavorable histological features are present, according to the National Comprehensive Cancer Network 3

Total mesorectal excision (TME) is strongly recommended as it provides low local recurrence rates (<10%), as stated by Annals of Oncology 2, 4
Whenever possible, sphincter-preserving surgery (low anterior resection) should be employed, according to Annals of Oncology 2, 8
For early T1 rectal cancers meeting specific criteria, transanal excision may be appropriate, as recommended by the National Comprehensive Cancer Network 9
For locally advanced or fixed tumors, preoperative chemoradiotherapy followed by radical surgery is recommended, according to Annals of Oncology and the National Comprehensive Cancer Network 2, 9

Stage III (node-positive) patients should receive adjuvant chemotherapy with fluoropyrimidine-based regimens, as recommended by the National Comprehensive Cancer Network and Annals of Oncology 1, 5
Selected high-risk stage II patients may also benefit from adjuvant chemotherapy, according to Annals of Oncology 5

Preoperative therapy is preferred over postoperative therapy as it is more effective and less toxic, as stated by Annals of Oncology 2, 4
For locally advanced rectal cancer (T3-T4 or node-positive), preoperative chemoradiotherapy followed by surgery after 6-8 weeks is recommended, according to Annals of Oncology 2, 4, 8

For resectable synchronous liver or lung metastases, colectomy with synchronous or staged resection of metastases, or neoadjuvant chemotherapy followed by staged resection, is recommended, according to the National Comprehensive Cancer Network 3
For unresectable metastases, systemic therapy with FOLFOX or FOLFIRI with or without targeted agents is recommended, as stated by the National Comprehensive Cancer Network and Annals of Oncology 3, 10

History and physical examination every 3 months for 2 years, then every 6 months for the next 5 years, is recommended, according to the National Comprehensive Cancer Network 1, 6, 7
CEA testing (if elevated at baseline) every 3 months for 2 years, then every 6 months for 2-5 years, is recommended, as stated by the National Comprehensive Cancer Network 1, 6
Colonoscopy within 1 year of resection (or 3-6 months postoperatively) is recommended, according to the National Comprehensive Cancer Network 1, 6

History and rectosigmoidoscopy every 6 months for 2 years, is recommended, as stated by Annals of Oncology 2, 8
Complete colonoscopy within the first year if not done at diagnosis, is recommended, according to Annals of Oncology 2, 8

For elevated CEA or suspected recurrence, colonoscopy, chest/abdominal/pelvic CT scans, and physical examination, are recommended, as stated by the National Comprehensive Cancer Network 1, 6
For isolated recurrences (anastomotic site, liver, or lung), surgical resection should be considered if potentially curative, according to the National Comprehensive Cancer Network 1, 6
For local rectal cancer recurrence, preoperative chemoradiotherapy (if not previously given) followed by radical surgery, is recommended, as stated by Annals of Oncology 2, 8