Key messages from the faculty

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