What is the evidence-based management for a patient with adenocarcinoma in the sigmoid, transverse colon, and caecum?

Management of Multiple Colonic Adenocarcinomas

For a patient with adenocarcinoma in three locations (sigmoid, transverse colon, and caecum), subtotal colectomy is the recommended surgical approach to ensure complete removal of all tumors and prevent recurrence.

Surgical Management

Primary Surgical Approach

• Subtotal colectomy is the preferred surgical option for multiple synchronous colon cancers located in different segments (sigmoid, transverse colon, and caecum) 1
• The procedure should include excision of all primary tumors with safe margins and removal of associated vessels and mesocolon containing lymphatic channels and nodes 1
• A median laparotomy incision is recommended, followed by thorough examination of the liver, pelvis, and ovaries (in women) 1

Surgical Considerations

• Preoperative bowel preparation should include washout with a hypertonic solution combined with a low-residue diet and intravenous broad-spectrum antibiotics 1
• For an effective anastomosis, the vascular supply to adjacent bowel segments must be well maintained and not subject to undue traction 1
• Both mechanical and manual techniques for anastomosis (staples vs. stitches) give comparable results in experienced hands 1

Staging and Preoperative Assessment

• Complete clinical staging should include:

  • Clinical examination 1
  • Chest X-ray (AP and lateral) 1
  • Abdominal ultrasound 1
  • Complete colonoscopy (to rule out additional lesions) 1
  • CT scan of the liver if ultrasound is not satisfactory 1
  • Measurement of carcinoembryonic antigen (CEA) levels 1

• Prognostic factors that should guide therapeutic decisions include:

  • Presence or absence of distant metastases 1
  • Extent of bowel wall infiltration 1
  • Invasion of adjacent organs 1
  • Presence of metastatic locoregional nodes 1

Adjuvant Therapy

• For patients with stage III disease (node-positive), adjuvant chemotherapy with a fluorouracil-based regimen is recommended 2
• Oxaliplatin combined with fluorouracil/leucovorin (FOLFOX4) has shown significant improvement in disease-free survival compared to fluorouracil/leucovorin alone in stage III colon cancer 2
• The recommended regimen includes:
  • Oxaliplatin: 85 mg/m² (2-hour infusion) on day 1
  • Leucovorin: 200 mg/m² (2-hour infusion) on days 1 and 2
  • Fluorouracil: 400 mg/m² (bolus) followed by 600 mg/m² (22-hour infusion) on days 1 and 2
  • Cycle repeated every 2 weeks 2

Management of Potential Metastatic Disease

• If hepatic metastases are detected, surgical resection should be considered if:

  • The patient is a suitable surgical candidate
  • Complete resection is technically feasible
  • At least 30% of normal liver can remain in situ
  • There is no involvement of portal or sub-hepatic veins 1

• For hepatic metastases, each metastasis should ideally be surrounded by a margin of 1 cm of healthy liver tissue 1

Special Considerations

• In post-menopausal women, prophylactic bilateral oophorectomy is recommended during the primary surgery 1
• If the tumor has invaded neighboring organs, the resection should be performed en bloc 1
• For patients with Lynch syndrome, subtotal colectomy is specifically recommended 1

Follow-up and Surveillance

• Regular post-treatment surveillance is essential for early detection of recurrence
• CEA determination should be performed only if CEA was elevated at baseline and decreased following primary resection 3
• Abdominal and pelvic CT scans should be utilized when there are clinical indications of possible recurrence 3

Common Pitfalls to Avoid

• Inadequate lymph node sampling: A minimum of 6-8 nodes should be examined for proper staging 1
• Incomplete resection: When multiple tumors are present in different segments of the colon, limited resection of individual segments may lead to higher recurrence rates 1
• Delayed adjuvant therapy: Chemotherapy should be initiated within 6-8 weeks after surgery for optimal outcomes