From the Guidelines
The management plan for a patient with multiple linear deep ulcerations on colonoscopy diagnosed as colon cancer should prioritize surgical resection followed by adjuvant chemotherapy with a fluoropyrimidine-based regimen, such as 5-fluorouracil (5-FU)/leucovorin (LV) plus oxaliplatin, to improve disease-free and overall survival. The initial step involves complete staging, including CT scans of the chest, abdomen, and pelvis, as well as baseline bloodwork including CEA levels 1. A multidisciplinary tumor board discussion is crucial to determine the best approach, considering the need for neoadjuvant therapy in locally advanced disease.
Key considerations in the management plan include:
- Surgical resection as the primary treatment, with the procedure type (right hemicolectomy, left hemicolectomy, or low anterior resection) depending on the tumor location.
- Adjuvant chemotherapy for stage III and high-risk stage II disease, with FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) being a standard regimen for 3-6 months 1.
- For metastatic disease, systemic therapy options such as chemotherapy combinations like FOLFOX or FOLFIRI, potentially with targeted agents based on molecular testing.
- Regular surveillance post-treatment, including:
- Colonoscopy at year 1 and thereafter every 3–5 years to identify metachronous adenomas and cancers 1.
- Ultrasonography of the liver every 6 months for 3 years and after 4 and 5 years 1.
- CT scan of the chest and abdomen for 3 years, especially in patients at higher risk for recurrence 1.
- CEA determination every 3–6 months for 3 years and every 6–12 months in years 4 and 5 after surgery if initially elevated 1.
This approach is guided by the principle of maximizing survival benefit and minimizing recurrence risk, as supported by the evidence from studies such as the one published in Annals of Oncology 1.
From the FDA Drug Label
Irinotecan hydrochloride injection is a topoisomerase inhibitor indicated for: First-line therapy in combination with 5-fluorouracil and leucovorin for patients with metastatic carcinoma of the colon or rectum. Patients with metastatic carcinoma of the colon or rectum whose disease has recurred or progressed following initial fluorouracil-based therapy
The plan of management for a patient with multiple linear deep ulceration on colonoscopy diagnosed as colon cancer may include irinotecan hydrochloride injection as part of the treatment regimen, specifically:
- First-line therapy in combination with 5-fluorouracil and leucovorin for patients with metastatic carcinoma of the colon or rectum
- Second-line therapy for patients with metastatic carcinoma of the colon or rectum whose disease has recurred or progressed following initial fluorouracil-based therapy The dosage and administration of irinotecan hydrochloride injection will depend on the specific regimen and the patient's condition, as outlined in the drug label 2.
From the Research
Diagnosis and Staging
- The patient has been diagnosed with colon cancer through colonoscopy, which has shown multiple linear deep ulceration on the colon 3.
- The next step would be to determine the segmental location of the tumor, which is crucial for surgical intervention and patient prognosis 3.
- Computed Tomography Colonography (CTC) can be used to accurately localize the tumor and complete the colonic examination, especially in cases where conventional colonoscopy is incomplete or impossible due to patient intolerance or stenosing cancer 3.
Treatment Planning
- The treatment plan for colon cancer typically involves surgical resection of the tumor, and the approach may vary depending on the location and stage of the cancer 4.
- A thorough history and physical examination, as well as clinical, radiographic, and biochemical assessment, are necessary to determine the best course of treatment 4.
- CTC can also be used to detect hepatic and lung metastases, which is important for staging and treatment planning 3.
Post-Surgical Follow-up
- After surgical resection, patients with a history of colon cancer require regular follow-up to detect any recurrence or metachronous disease 5.
- CTC can be used as a feasible and minimally invasive method for full exploration of the colon after surgical resection, allowing detection of cancer recurrence, metachronous disease, and distant metastases in one single study 5.
- However, the sensitivity of CTC in detecting anastomotic stenosis or small polyps may be limited, and conventional colonoscopy may still be necessary for confirmation and characterization of findings [(5,6)].