Archives for March 2018

Programmes – IMPACT

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Please see below for IMPACT course programmes for 2018.

Basingstoke: 26th January 2018 IMPACT programmeBasingstoke

Yorkshire: 21st March 2018 IMPACTprogramme York

Scotland: 2nd May 2018 IMPACTprogramme Edinburgh

Newcastle: 17th September 2018 Pelican IMPACT draft programme 17.9.18 Newcastle NV

Greater Manchester: 23rd November 2018 V.2 Draft programme for IMPACT Manchester.pdf

Ireland: 10th December 2018 V.1 CO Draft programme for IMPACT Ireland.pdf

East Midlands (Derby): 25th January V.2 SR Draft programme for IMPACT E Midlands.pdf

 

 

Key messages from the faculty

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IMPACT: 25th January 2019/Derby

Colorectal Liver Metastases

  1. All patients with colorectal liver metastases should be discussed in a specialist hepatobiliary MDT
  2. All patients should have the results of their assessment and follow up scans as swiftly as possible, ideally the same day, acknowledging the significant anxiety experienced by patients at the time of a scan
  3. Pre-operative chemotherapy should be given for the minimum number of cycles required to achieve resectability, to avoid chemotherapy-associated liver injury
  4. Any liver resection should be parenchymal-sparing, to preserve liver volume and allow further interventions for recurrent disease
  5. All resected patients should be entered into a CT surveillance programme. Patients whose liver metastases have disappeared with chemotherapy will require more intensive surveillance, for a longer period of time
  6. Molecular testing should be carried out prior to anti-EGFR treatment using an extended RAS panel (KRAS 12/13/59/61/117/146 and NRAS 12/13/59/61) and thought should be given as to which sample is most appropriate to test e.g. biopsy, resection, metastasis. Multiple blocks should be tested together from larger specimens to maximise the chances of finding a mutation.
  7. Mismatch repair status should be available in all cases either by immunohistochemistry or MSI, in line with NICE guidance DG27.

Colorectal Lung Metastases

  1. Criteria for consideration of pulmonary metastasectomy of colorectal disease: control of primary, radically treatable oligometastastic disease, resectable disease, sufficient pulmonary reserve, disease stability
  2. Favourable prognostic features in patients undergoing pulmonary metastasectomy: longer disease free interval (< 1 year vs. >3 years), number of metastasis, complete resection, lack of nodal involvement
  3. Factors of uncertain prognostic importance: CEA level, tumour doubling time, histopathological markers, re-operation
  4. Investigate the possibility of a primary lung cancer rather than metastasis. Tissue morphological diagnosis is required to interpret molecular biomarkers.

Colorectal Peritoneal Metastases

  1. Best outcomes: Limited disease PCI <20, favourable biology (differentiation, time to recurrence), response to adjuvant or neo adjuvant chemotherapy, complete cytoreduction
  2. Effective and regular communication is helpful with patients; between units; and between teams
  3. A clear understanding by patient and local teams that the pathway is often lengthy (approx. 3 months) requiring repeated investigations and assessments during which time interaction with key workers is essential

Locally advanced or recurrent colorectal cancer

  1. Management of locally recurrent CRC is an MTE – Massive Team Endeavour: Referring team and MDT; receiving team and MDT; CNSs; Medical and clinical oncology; Palliative care; Radiology; IR; Pathology; Anaesthetics; different surgical specialties; medical physics and radiographers
  2. No clear single model or pathway: Tailored to individual patients; anatomy, classification of disease, and circumstances
  3. General oversight by specialist MDT where possible
  4. Early review and discussion between the planned ultimate surgical team and patients and their family is encouraged

Palliative Care

  1. Significant numbers of patients will have a reduced life expectancy and problematic symptoms. A study in 2016 showed that the most frequent symptoms reported are Worrying 65%; Lack of energy 59%; Drowsiness 54%; Bloated 53%; Pain 51; Insomnia 50%; the most severe are problems with sexual interest & loss of appetite.
  2. A study in 2017 showed that patients perceive they have unmet needs. These are predominantly psychological: fear of spread; worry about family; lack of control; anxiety; uncertainty; death & dying; depression; keeping positive. Over 50% had at least one psychological need.
  3. MDTs will see benefit if palliative care colleagues are fully integrated members of their MDT and service. Consider referring patients to palliative care early if they have metastatic or locally advanced disease. This can occur alongside other treatment processes and patients respond well to seeing a Palliative Medicine consultant in a hospital clinic.

IMPACT: 21st March/Yorkshire

Palliative Care

  1. Significant numbers of patients will have a reduced life expectancy and problematic symptoms: Most severe symptoms = problems with sexual interest & loss of appetite
  2. Patients perceive that they have unmet needs: fear of spread; worry about family; lack of control; anxiety; uncertainty; death & dying; depression; keeping positive. Over 50% had at least one psychological need. Association between perceived need psychological distress & QoL
  3. When to refer for palliative care / enhanced supportive care: Early palliative care group had higher QoL at 14 weeks, less depression, more had documented DNAR order, less late (within 14 days of death) chemotherapy. Significantly longer median survival (2.7 months)

Colorectal Liver Metastases

  1. All patients with colorectal liver metastases should be discussed in a specialist hepatobiliary MDT
  2. All patients should have the results of their assessment and follow up scans as swiftly as possible, ideally the same day, acknowledging the significant anxiety experienced by patients at the time of a scan
  3. Pre-operative chemotherapy should be given for the minimum number of cycles required to achieve resectability, to avoid chemotherapy-associated liver injury
  4. Any liver resection should be parenchymal-sparing, to preserve liver volume and allow further interventions for recurrent disease
  5. All resected patients should be entered into a CT surveillance programme. Patients whose liver metastases have disappeared with chemotherapy will require more intensive surveillance, for a longer period of time

Colorectal Lung Metastases

  1. Criteria for consideration of pulmonary metastasectomy of colorectal disease: control of primary, radically treatable oligometastastic disease, resectable disease, sufficient pulmonary reserve, disease stability
  2. Favourable prognostic features in patients undergoing pulmonary metastasectomy: longer disease free interval (< 1 year vs. >3 years), number of metastasis, complete resection, lack of nodal involvement
  3. Factors of uncertain prognostic importance: CEA level, tumour doubling time, histopathological markers, re-operation

Colorectal Peritoneal Metastases

  1. Best outcomes: Limited disease PCI <20, favourable biology (differentiation, time to recurrence), response to adjuvant or neo adjuvant chemotherapy, complete cytoreduction

Locally advanced or recurrent colorectal cancer

  1. Management of locally recurrent CRC is an MTE – Massive Team Endeavour: Referring team and MDT; receiving team and MDT; CNSs; Medical and clinical oncology; Palliative care; Radiology; IR; Pathology; Anaesthetics; different surgical specialties; medical physics and radiographers
  2. Communication challenges: Effective and regular communication is helpful with patients; between units; and between teams
  3. A clear understanding by patient and local teams that the pathway is often lengthy (approx. 3 months) requiring repeated investigations and assessments during which time interaction with key workers is essential
  4. No clear single model or pathway: Tailored to individual patients; anatomy, classification of disease, and circumstances
  5. General oversight by specialist MDT where possible
  6. Early review and discussion between the planned ultimate surgical team and patients and their family is encouraged

IMPACT: 26th January/Basingstoke

Colorectal liver metastases

Colorectal lung metastases ColorectalLung Metastases IMPACT EB v2

Colorectal peritoneal metastases Peritoneal Metastases IMPACT January FM

Colorectal peritoneal metastases Peritoneal Metastases IMPACT2

Colorectal peritoneal metastases Colorectal peritoneal metastases IMPACT pathology NC3

Locally advanced and recurrent colorectal cancer Locally recurrent CRC AHM

Palliative Care in Colorectal Cancer Palliative Care in colorectal cancer – IMPACT 1LB

Pathology IMPACT Pathology

Key papers – IMPACT

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Colorectal Liver Metastases

Local Treatment of Unresectable Colorectal Liver Metastases: Results of a Randomized Phase II Trial. Ruers T, Van Coevorden F, Punt CJ, Pierie JE, Borel-Rinkes I, Ledermann JA, Poston G, Bechstein W, Lentz MA, Mauer M, Folprecht G, Van Cutsem E, Ducreux M, Nordlinger B; European Organisation for Research and Treatment of Cancer (EORTC); Gastro-Intestinal Tract Cancer Group; Arbeitsgruppe Lebermetastasen und tumoren in der Chirurgischen Arbeitsgemeinschaft Onkologie (ALM-CAO); National Cancer Research Institute Colorectal Clinical Study Group (NCRI CCSG).

RE: Local Treatment of Unresectable Colorectal Liver Metastases: Results of a RandomizedPhase II Trial. Macbeth F, Farewell V, Treasure T.

Progress and future direction in the management of advanced colorectal cancer G. M. Brown, M. J. Solomon First published: 13 April 2018

NICE Colorectal Cancer Quality Standard 20 [QS20], published August 2012

NICE guidance – Colorectal cancer: diagnosis and management (CG131), Last updated December 2014

Randomised multicentre trial of gadoxetic acid-enhanced MRI vs conventional MRI or CT in the staging of colorectal liver metastases, Zech CJ et al. British Journal of Surgery 2014, 101:613-21

Chemotherapy before liver resection of colorectal metastases – friend or foe? Lehmann K, Rickenbacher A, Weber A, Pestalozzi BC, Clavien PA. Annals of Surgery 2012, 255(2): 237-47.

One-millimeter cancer-free margin is curative for colorectal liver metastases: a propensity score case-match approach. Hamady ZZ, Lodge JP, Welsh FK, Toogood GJ, White A, John TG,. Rees M. Annals of Surgery 2014; 259(3):543-8.

Patient-reported outcomes after hepatic resection of colorectal liver metastases. Rees JR, Blazeby JM, Fayers P, Friend EA, Welsh FK, John TG, Rees M. J Clinical Oncology 2012; 30(12):1364-70.

Stereotactic body radiotherapy for liver metastases. Aitken KL, Hawkins MA, Clin Oncol (R Coll Radiol) 2015, 27(5):307-15

Impact of hepatobiliary service centralization on treatment and outcomes in patients with colorectal cancer and liver metastases  E. Vallance  J. vanderMeulen  A. Kuryba  I. D. Botterill  J. Hill  D. G. Jayne  K. Walker

First published: 2 March 2017 https://doi.org/10.1002/bjs.10501

Cited by: 2 https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.10501

Colorectal Lung Metastases

Radiofrequency ablation is a valid treatment option for lung metastases: experience in 566patients with 1037 metastases. de Baère T, Aupérin A, Deschamps F, Chevallier P, Gaubert Y, Boige V, Fonck M, Escudier B, Palussiére J.

Survival after radiofrequency ablation in 122 patients with inoperable colorectal lung metastases. de Baère T, Aupérin A, Deschamps F, Chevallier P, Gaubert Y, Boige V, Fonck M, Escudier B, Palussiére J.

Systematic review and meta-analysis – Gonzalez et al., Annals of Surgical Oncology 2013;20:572-9
2925 patients 25 studies, 27%-68% OS 5 years.

Pasturino U, Buyse M, Friedel G, et al., Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg. 1997 Jan;113(1):37-49.

Gonzalez M, Poncet A Combescure C et al., Risk Factors for survival after lung metastasectomy in colorectal cancer patients: systematic review and meta-analysis.  Ann Surg Oncol. 2013 Feb;20(2):572-9.

Surgery and ablative techniques for lung metastases in the Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) trial: is there equivalence? Treasure T et a., J Thorac Dis. 2016.

Prognostic factors after pulmonary metastasectomy of colorectal cancers: a single centre experience. Fournel L et al. J Thorac Dis. 2017.

Pulmonary metastasectomy: an overview Petrella F et al., J Thorac Dis 2017.

 

Pathology

Molecular testing key papers:

https://www.nice.org.uk/guidance/dg27

Molecular testing in advanced/metastatic disease

RAS testing of colorectal carcinoma—a guidance document from the Association of Clinical Pathologists Molecular Pathology and Diagnostics Group

Newton ACS Wong1, David Gonzalez2, Manuel Salto-Tellez3, Rachel Butler4, Salvador J Diaz-Cano5, Mohammad Ilyas6, William Newman7, Emily Shaw8, Philippe Taniere9, Shaun V Walsh10

Standards for integrated reporting in cellular pathology January 2017

Intra-tumoral heterogeneity of KRAS and BRAF mutation status in patients with advanced colorectal cancer (aCRC) and cost-effectiveness of multiple sample testing. Richman SD1, Chambers P, Seymour MT, Daly C, Grant S, Hemmings G, Quirke P.

Annual Report of the Chief Medical Officers 2016

Colorectal Peritoneal Metastases

Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. Verwaal VJ1, van Ruth S, de Bree E, van Sloothen GW, van Tinteren H, Boot H, Zoetmulder FA.

Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study. Elias D1, Gilly F, Boutitie F, Quenet F, Bereder JM, Mansvelt B, Lorimier G, Dubè P, Glehen O.

Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy improves survival in patients with colorectal peritoneal metastases compared with systemic chemotherapy alone R Mirnezami, A M Mehta, K Chandrakumaran, T Cecil, B J Moran, N Carr, V J Verwaal, F Mohamed & A H Mirnezami

Peritoneal metastases of lower GI tract origin… Ung L:  J Cancer Res Clin Oncol 2013; 139:1899-1908

Peritoneal carcinomatosis of colorectal cancer… Massalou D: American Journal of Surgery 2017; 213:377-87

External validation of models predicting the individual risk of metachronous peritoneal carcinomatosis from colon and rectal cancer. Segelman J: Colorectal Dis 2015; 18:378-85.

NICE guidance IPG 331 Cytoreduction surgery followed by hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis Feb 2010

NHS Commissioning A08/P/a  Cytoreduction surgery for patients with peritoneal carcinomatosis April 3013

Impact of surgical volume of centers on post-operative outcomes from cytoreductive surgery and hyperthermic intra-peritoneal chemoperfusion. Rahul Rajeev, Brittany Klooster, and Kiran K. Turag J Gastrointest Oncol. 2016 Feb; 7(1): 122–128

A Systematic Review and Meta-Analysis of Cytoreductive Surgery with Perioperative Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis of Colorectal Origin. Cao C, Yan TD, Black D, Morris DL. Ann Surg Oncol. 2009 Aug 12;16(8):2152–65

Prognosis of patients with peritoneal metastatic colorectal cancer given systemic therapy: an analysis of individual patient data from prospective randomised trials from the Analysis and Research in Cancers of the Digestive System (ARCAD) database. Franko J, Shi Q, Meyers JP, Maughan TS, Adams RA, Seymour MT, et al.  Lancet Oncol. 2016;17(12):1709–19

Local Recurrence

Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P.  Ann Surg. 2011 May;253(5):890-9.

Factors affecting outcomes following pelvic exenteration for locally recurrent rectal cancer. PelvEx Collaborators (83)

Anastomotic Leaks After Restorative Resections for Rectal Cancer Compromise Cancer Outcomes and Survival. Lu ZR, Rajendran N, Lynch AC, Heriot AG, Warrier SK. Dis Colon Rectum. 2016 Mar;59(3):236-44.

Beyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg. 2013 Jul;100(8):1009-14.

Beyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg. 2013 Jul;100(8):E1-33.

Other papers collected by Pelican

The Fundamental Difference Between Cancer Treatment and Patient Care

Advances in surgical management for locally recurrent rectal cancer: How far have we come? Daniel Jin-Keat Lee, Peter M Sagar, Gaitri Sadadcharam, and Kok-Yang Tan
World J Gastroenterol. 2017 Jun 21; 23(23): 4170–4180.

Effect of specialist decision-making on treatment strategies for colorectal liver metastases Jones RP1, Vauthey JN, Adam R, Rees M, Berry D, Jackson R, Grimes N, Fenwick SW, Poston GJ, Malik HZ.  Br J Surg. 2012 Nov;99(11):1605

Large variation in the utilization of liver resections in stage IV colorectal cancer patients with metastases confined to the liver AlibR.H.A.VerhoevencR.M.H. Roumend V.E.P.P. LemmenscA.M.Rijkenb, J.H.W.De Wilta

European Journal of Surgical Oncology (EJSO) Volume 41, Issue 9, September 2015, Pages 1217-1225

Regional and inter-hospital differences in the utilisation of liver surgery for patients with synchronous colorectal liver metastases in the Netherlands Lam-BoeraE.P. van der StokbJ. HuiskenscR.H.A., VerhoevendC.J.A., PunteM.A.G.,  ElferinkdJ.H, de WiltaC.Verhoefb

the CAIRO5/CHARISMA Group1
European Journal of Cancer Volume 71, January 2017, Pages 109-116

Treatment of colorectal peritoneal metastases requires multidisciplinary efforts Diane Goéré, Maximiliano Gelli

Lancet Oncology  Volume 17, No. 12, p1630–1631, December 2016

Onco-Surgical Management of Liver Metastases from Colorectal Cancer

Population-based study on resection rates and survival in patients with colorectal liver metastasis in Norway J.-H. Angelsen, A. Horn,  Sorbye,  G. E. Eide, I. M. Løes, A. Viste
BJS First published: 9 February 2017 DOI: 10.1002/bjs.10457

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: from novelty to routine in selected cases – B Moran.
Techniques in Coloproctology. September 2017, Volume 21, Issue 9, pp 767–769 | Cite as