VII. Norms for the treatment of liver metastases from rectal cancer
(A) Definition of rectal cancer liver metastasis.
1. International common classification.
① Simultaneous liver metastasis. Liver metastases found at the time of diagnosis of rectal cancer or occurring within 6 months after radical resection of the primary rectal cancer.
② Heterochronic liver metastasis. Liver metastases occurring 6 months after radical resection of rectal cancer. Zheng Naiguo, Department of General Surgery, Guiyang Second Affiliated Hospital of Traditional Chinese Medicine
2. There is a big difference in diagnosis and treatment between liver metastasis at the time of diagnosis of rectal cancer and liver metastasis after radical resection of the primary site of rectal cancer, so this standard is elaborated in two aspects: “liver metastasis at the time of diagnosis of colorectal cancer” and “liver metastasis after radical resection of colorectal cancer”. (2) Liver metastasis of rectal cancer
(2) Diagnosis of liver metastasis of rectal cancer.
1. Diagnosis of liver metastasis at the time of diagnosis of colorectal cancer.
(1) For patients with confirmed rectal cancer, liver ultrasound and/or enhanced CT imaging should be performed, and for patients with suspected liver metastases, serum AFP and liver MRI should be added.
(2) Percutaneous needle biopsy of liver metastases should be used only when the condition requires.
(3) The liver must be routinely explored during surgery for rectal cancer to further exclude the possibility of liver metastasis, and intraoperative biopsy can be considered for suspicious liver nodules.
2. Diagnosis of liver metastasis after radical surgery for rectal cancer primary foci.
Patients with rectal cancer after radical surgery should be followed up regularly with liver ultrasound or/and enhanced CT scan, and patients suspected of liver metastasis should have liver MRI examination added, and PET-CT scan is not routinely recommended.
(iii) Treatment of rectal cancer liver metastases.
Complete surgical resection of liver metastases is still the best method to cure liver metastases from rectal cancer, so all eligible patients should receive surgical treatment at an appropriate time. For some patients whose initial liver metastases cannot be resected, the timing of neoadjuvant chemotherapy and surgery should be carefully decided through multidisciplinary discussion, so as to create every opportunity to transform them into resectable lesions.
1. Indications and contraindications for surgery of liver metastases.
(1) Indications.
(1) The primary lesion of rectal cancer can be or has been radically resected.
(2) According to the anatomical basis of the liver and the scope of the lesion liver metastases can be completely (R0) resected, and it is required to retain sufficient liver function, with residual liver volume ≥ 50% (simultaneous primary and liver metastases resection) or ≥ 30% (staged primary and liver metastases resection).
(3) The patient’s systemic condition allows for the absence of unresectable extrahepatic metastatic lesions.
(2) Contraindications.
(i) Radical resection cannot be obtained for the primary foci of rectal cancer.
(ii) The presence of unresectable extrahepatic metastases;
(3) Insufficient expected postoperative residual liver volume.
④The patient’s general condition cannot tolerate the surgery.
2. Treatment of resectable rectal cancer liver metastases.
(1) Surgical treatment.
(1) Rectal cancer combined with liver metastasis at the time of diagnosis.
In the following cases, simultaneous resection of primary rectal cancer and liver metastases is recommended: liver metastases are small and mostly located in the periphery or confined to half of the liver, liver resection is less than 50%, and surgical resection of hilar lymph nodes, abdominal cavity or other distant metastases can be considered.
Staged resection of primary rectal cancer foci and liver metastases is recommended in the following cases.
a The primary lesion of colorectal cancer is surgically removed first, and the liver metastases are removed in stages, and the timing is chosen to be 4-6 weeks after radical colorectal cancer surgery.
bIf the treatment is performed before the surgery of liver metastases, the resection of liver metastases can be delayed until 3 months after the resection of the primary lesion.
cSimultaneous resection of primary rectal cancer and liver metastases is not recommended for emergency surgery.
d Radically curable recurrent rectal cancer with resectable liver metastases tends to undergo staged resection of liver metastases.
②Liver metastases occur after radical rectal cancer surgery.
If the primary rectal lesion is radically resected and not accompanied by recurrence of the primary lesion, and the liver metastases can be completely resected and the amount of liver resection is less than 70% (without cirrhosis), the liver metastases should be surgically resected, and neoadjuvant therapy can be performed first.
(iii) Recurrence of liver metastases after resection.
If the systemic condition and liver condition allow, for recurrent lesions after resectable liver metastases, secondary, tertiary or even multiple resections of liver metastases can be performed.
④The choice of surgical modality for liver metastases.
aAt least one of the three hepatic veins is preserved after resection of liver metastases and the residual liver volume is ≥50% (simultaneous primary and liver metastases resection) or ≥30% (staged primary and liver metastases resection).
bThe surgical margins of the metastases should generally have 1 cm of normal liver tissue; if the metastases are in a special location (e.g., adjacent to large blood vessels), it is not necessary to be demanding, but the R0 principle should still be met.
c In the case of large metastases confined to the left or right half of the liver without cirrhosis, regular hemihepatectomy is feasible.
d Intraoperative ultrasonography is recommended for liver metastasis surgery to help detect liver metastatic lesions that are not diagnosed by preoperative imaging.
(2) Preoperative treatment.
(1) Combined liver metastases at the time of diagnosis of rectal cancer. Preoperative treatment is recommended when there is no bleeding, obstruction or perforation in the primary foci, and the regimen can be FOLFOX, FOLFIRI or CapeOX, which can be combined with molecular targeted drug therapy; generally recommended within 2 to 3 months. Cetuximab is recommended for patients with wild-type K-ras gene. When using bevacizumab, the timing of the procedure is recommended 6 weeks after the last dose of bevacizumab. The combination of multiple targeted drugs is not recommended.
(ii) Liver metastases occurring after radical rectal cancer surgery. Patients who have not received chemotherapy after resection of the primary site, or those who have completed chemotherapy 12 months before the discovery of liver metastases, can be treated preoperatively (in the same way as above); patients who have received chemotherapy within 12 months before the discovery of liver metastases can also have liver metastases removed directly.
(3) Adjuvant therapy after resection.
Postoperative adjuvant chemotherapy is recommended for patients with complete resection of liver metastases, and the recommended duration of chemotherapy before and after surgery is 6 months in total. The recommended postoperative chemotherapy regimen is either 5-FU/LV, capecitabine, 5-FU/LV/oxaliplatin or CapeOx. Patients with effective preoperative treatment are recommended to follow the preoperative regimen.
3. Treatment of unresectable colorectal cancer with liver metastases.
(1) Patients with unresectable colorectal cancer liver metastases other than those with combined bleeding, perforation or obstruction and other emergencies requiring surgical resection of the primary site should be treated systematically through multidisciplinary discussion and careful selection of protocols and drugs (the principles are the same as preoperative treatment in 7.3.2) to create all opportunities for conversion to operable treatment. The efficacy of treatment should be evaluated every 6-8 weeks during the course of treatment, and surgical treatment should be sought as soon as the conditions for surgical resection are met. Patients with liver metastases from rectal cancer converted to resectable are equivalent to the principles related to 7.3.2.
(2) Radiofrequency ablation.
(1) Radiofrequency ablation is recommended for patients with resectable rectal cancer liver metastases whose general condition is inappropriate or unwilling to receive surgical treatment, and the maximum diameter of liver metastases ablated by radiofrequency is less than 3 cm and up to 3 ablated at one time.
(2) When the expected postoperative residual liver volume is too small, it is recommended to remove part of the larger liver metastases first and perform radiofrequency ablation on the remaining metastases with a diameter of less than 3 cm.
(3) Radiotherapy.
If systemic chemotherapy, hepatic artery perfusion chemotherapy or radiofrequency ablation are not effective for liver metastases that cannot be surgically resected, radiation therapy is recommended.
(4) Hepatic artery perfusion chemotherapy.
It is limited to patients with multiple liver metastases and who cannot tolerate systemic chemotherapy.
(5) Other treatment methods.
They include anhydrous alcohol intratumoral injection, cryotherapy and Chinese herbal medicine, etc., which are only applied as part of the comprehensive treatment.
(8) Treatment specification of locally recurrent rectal cancer (a) Staging. At present, the following classification methods are recommended for the staging of local recurrence: central type (including anastomosis, rectal mesentery, perirectal soft tissue, perineum after combined abdominoperineal resection), anterior type (invading genitourinary system including bladder, vagina, uterus, seminal vesicle gland, prostate), posterior type (invading sacrum and presacral fascia), lateral type (invading soft tissue of pelvic wall or bony pelvis) according to the anatomical site of pelvic involvement. or bony pelvis). (ii) Principles of treatment. According to the specific assessment of patients and lesions, resectable or potentially resectable patients should be treated surgically and combined with preoperative radiotherapy, intraoperative radiotherapy and adjuvant radiotherapy; unresectable patients should be treated with a combination of radiotherapy and chemotherapy. (iii) Surgical treatment.
1. Evaluation of resectability.
The possibility of radical resection of recurrent lesions must be evaluated preoperatively. It is recommended that the decision to use preoperative radiotherapy be considered based on the extent of recurrence. It is recommended that the resectability of the lesion be verified on the basis of intraoperative exploratory findings and, if necessary, intraoperative cryopathology is feasible.
Unresectable local recurrent lesions include.
(i) extensive lateral pelvic wall invasion.
(ii) bony pelvic invasion.
③ extra-iliac vascular involvement.
④ invasion of the tumor into the large sciatic notch and invasion of the sciatic nerve.
⑤ Invasion of the 2nd sacral level and above. 2.
2. Surgical principles.
(1) It is recommended that the specialist colorectal surgeon should choose the appropriate surgical plan according to the specific conditions of the patient and the lesion, and use it in combination with preoperative radiotherapy, intraoperative radiotherapy and adjuvant radiotherapy.
(2) It is recommended that the surgical plan be developed jointly with urologists, orthopedic surgeons, vascular surgeons, obstetricians and gynecologists, etc., when necessary.
(3) Surgical exploration must be done from distant to near, paying attention to exclude distant metastases.
(4) The principle of whole-block resection must be followed, and R0 resection should be achieved as far as possible.
(5) Intraoperative care should be taken to protect the ureter (preoperative placement of ureteral stent as appropriate) as well as the urethra.
3. Surgical modalities for resectable lesions.
Surgical modalities include low anterior resection (LAR), combined abdominoperineal resection (APR), pelvic dissection, etc.
(1) Central type: APR is recommended to ensure R0 resection; LAR can be considered if the lesion is limited if previous anus-preserving surgery is performed; perineal field recurrence after APR can be considered for trans-perineal or trans-sacral resection if the lesion is limited.
(2) Anteriorly oriented type: If the patient’s physical condition allows, resection of the invaded organ and posterior hemipelvic clearance or total pelvic clearance can be considered.
(3) Lateral type: resection of the involved ureter, internal iliac vessels, and pear-shaped muscle.
(4) Posteriorly oriented type: combined ventral-sacral resection of the invaded sacrum. The perineal incision can be covered with a large omentum or closed in one stage. Muscle flaps (thin femoral muscle, gluteus, transverse rectus abdominis flap, latissimus dorsi, etc.) are used when necessary.
(iv) Principles of radiation therapy. For patients with resectable local recurrence, surgical resection is recommended before considering whether to perform postoperative radiotherapy. For patients with unresectable local recurrence, simultaneous preoperative radiotherapy is recommended, and surgical resection should be pursued. See the section on radiation therapy.
(E) Principles of chemotherapy. For patients with resectable recurrent metastases, preoperative chemotherapy is not routinely recommended, and postoperative adjuvant chemotherapy is considered.
IX. Enterostomy rehabilitation treatment
(a) Staff, tasks, and structure. Stoma therapists (specialist nurses) are recommended in hospitals where available. The duties of the stoma therapist include preoperative and postoperative care of all stomas (enterostomies, gastrostomies, urostomies, tracheostomies, etc.), management of complex wounds, care of urinary and fecal incontinence, opening of stoma specialist clinics, liaison with patients and other professionals and stoma suppliers, organization of stoma fellowships and stoma visitor activities.
(ii) Preoperative psychotherapy.
It is recommended to fully explain to the patient about the diagnosis, surgery and care, so that the patient accepts the fact of the disease and has a full understanding of what is going to happen. (iii) Preoperative stoma positioning.
It is recommended that the stoma site be selected preoperatively by the physician, the stoma therapist, the family and the patient.
1. Requirements: the patient can see it by himself and it is convenient for care; there is enough adhesive area; there is no discomfort when the stoma device is applied to the stoma skin.
2. Common stoma locations are shown in Figure 1
Figure 1: Common intestinal stoma location (d) Postoperative care of the intestinal stoma.
1. Open the stoma on the first postoperative day and pay attention to the blood flow of the stoma.
2. The criteria for selecting stoma appliances should be lightweight, transparent, odor-resistant, leak-proof and protective of the surrounding skin, and worn appropriately by the patient.
3. Keep the skin around the stoma clean and dry. Patients taking antibiotics, immunosuppressants and hormones for a long time should pay special attention to fungal infections at the site of the stoma.
X. Follow up
Regular follow-up is always recommended after colorectal cancer treatment.
(a) Medical history and physical examination every 3-6 months for 2 years, then every 6 months for a total of 5 years, and once a year after 5 years.
(ii) Monitoring of CEA, CA19-9, once every 3-6 months for 2 years, then once every 6 months for a total of 5 years, and once a year after 5 years.
(iii) Abdominal/pelvic ultrasound and chest radiograph every 3-6 months for 2 years, then every 6 months for a total of 5 years, and annually after 5 years.
(iv) CT or MRI of the abdomen/pelvis once a year.
(e) Colonoscopy within 1 year after surgery, if abnormal, review within 1 year; if no polyps are seen, review within 3 years; then once every 5 years, resection is recommended for any colorectal adenoma that appears on follow-up examination.
(f) PET-CT is not a routinely recommended test. (End)