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TRATAMIENTO QUIRUGICOCANCER COLON
R3CG MADRID M. EDUARDOCMN MANUEL A. CAMACHO
IMSS, PUEBLA, PUEBLA
INTRODUCCION. . .
◦ ENFERMEDAD NO METASTASICA
◦ ENFERMEDAD METASTASICA
◦ ESPECIALES RECURRENCIA CONVERSION
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Clasificación◦ Pequeños <5mm
Forceps Biopsia en frio Biopsia en caliente (bipolar)
◦ Pedunculado
Excisional / Electrocoagulacion
◦ Largos o sésiles >10mm Excisional / Inyección de submucosa National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Recomendación 2-A en general.National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Principios de revisión de patología
◦ Radial (evaluación circunferencial de márgenes) CM:
Los márgenes de serosa no constituye margen quirúrgico. CM: Adventicia mas cercana a la penetración mas profunda del
tumor, creado por la disección roma o cortante.
◦ Invasión perineural (PNI): Asociado a peor pronostico, supervivencia. (29% vs 82%,
p:0.0005).
◦ Depósitos de tumor adicional. Depósitos en la grasa pericolica o perirectal lejos del borde
tumoral. Disminución de supervivencia.National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Evaluación de ganglios linfáticos.
◦ Mínimo 12 ganglios linfáticos (AJCC y CAP).
Detección de ganglio centinela o micrometastasis por inmunihistoquimica (citoqueratinas).
◦ Detección de la presencia de enfermedad metastasica (micrometastasis).
◦ Establecer pronostico y realizar decisiones terapéuticas.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Test de Mutación del KRAS:
◦ Predicción de la respuesta al tratamiento.
Test mutación BRAF
◦ Presentación peor pronostico
Test MSI
◦ Predisposición de Sx Lynch, para la decisión quimioterapeutica.National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
1.- ENFERMEDAD NO METASTASICA
◦ POLIPO NO MALIGNO
(pTis) In situ, no penetra submucosa.
◦ POLIPO MALIGNO
(pT1) Definido como lesión cancerosa que invade submucosa y muscular de la mucosa.
“..Se recomienda el marcaje de la lesión, si se tiene sospecha de cáncer o si el reporte de patología no se tiene hasta 2 semanas..”National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Manejo Cáncer pT1
◦ Manejo primario:
Diagnostico histológico. Polipectomia con tinción de “India Ink “submucosa. Determinación de riesgo (metástasis linfática):
Bajo Bien o moderadamente diferenciados sin invasion linfatica. Metastasis <5%.
Alto Pocodiferenciados y/o invasion linfovascular. Metastasis media 35%National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Lesiones pT1 de alto grado, requerirán cirugía: (colectomia con linfadenectomia).
Cáncer invasivo es visto a 1mm del margen
Poca diferenciación (Grado 3 diferenciación)
Evidencia de invasión linfovascular (linfo-venoso)
Invasión de submucosa o márgenes de excisión (nivel 4 invasión)National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
VIGILANCIA pT1
◦ Revisión: 3 meses por 1 año
6 meses por 2 años
Riesgo de actividad extramural sin txqx
TAC semestral por 3 años
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
1 .- ENFERMEDAD INVASIVA NO METASTASICA
◦ CANCER DE COLON
RESECABLE
OBSTRUCCION
SIN OBSTRUCCION
◦ NO RESECABLENational Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Principios de colectomia:
◦ Linfadenectomia
Nódulos linfáticos son el origen vía linfática.
Hallazgo clínico positivo fuera del sitio de resección, considerados sospechosos, deben ser biopsiados o removidos.
Mínimo de 12 ganglios deben ser examinados para establecer NNational Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Colectomia laparoscopica asistida:
El cirujano debe tener experiencia en este procedimiento.
No debe haber presencia de enfermedad en recto o adherencias.
No debe ser una enfermedad localmente avanzada.
No esta indicada en procesos obstructivos o perforaciones.
Requiere una exploración exhaustiva abdominal.
Considerar el marcaje preoperatorio de lesiones pequeñasNational Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Criterios de resecabilidad de las metástasis dentro de la cirugía.
◦ Hígado
Resección hepática Tx elección para metástasis hepáticas en CCR.
Resección completa, debe ser basada en territorios anatómicos y libres de enfermedad.
El tumor primario debe ser resecado. Intento curativo.
Metástasis no es óptimamente resecable, pensar en embolizacion pre operativa vía portal.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Pulmón
◦ Resección completa basada en la región anatómica.
◦ Resección del primario debe ser realizada.
◦ Re-reseccion debe ser seleccionada en pacientes.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
Evaluación para conversión de la enfermedad resecable.
◦ Re-evaluacion para la resección debe ser considerada posteriormente 2 meses de tx quimioterapéutico.
◦ La alta probabilidad de conversión son las que están distribuidas en sitios limitados.
◦ Cuando la lesión presenta situaciones de resecabilidad.
◦ Los regímenes de quimioterapia preoperativa son establecidos en pacientes con altas probabilidades de ser convertibles a resecable.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
MANEJO QUIRURGICO
◦ Procedimiento de preferencia Colectomia con resección en bloque de linfáticos regionales.
◦ La extensión de la colectomia se basara en la localización del tumor, aporte sanguíneo y distribución linfática.
◦ Nódulos sospechosos deben ser biopsiados o resecados.
◦ Resección completa del meso colon con ligadura vascular central, con mayor resección de mesenterio y nódulos.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
ABORDAJE LAPAROSCOPICO
◦ Barcelona group. Asociado amdoesto aumento en supervivencia, recuperacion rapido y menor estancia hospitalaria.
◦ COLOR Trial. Diferencia no significativa 2% a 3 años a favor tecnica abierta
◦ CLASIC Study. Sin resultados satisfactorios a 3 años.
◦ COST Study. Resultados similares.
◦ Recomendación únicamente en cirujanos con experiencia en la técnica.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
OPCIONES QUIRUGICAS POR ETAPA
◦ ETAPA I T2 NO MO
Reseccion amplia + anastomosis
◦ ETAPA II T3-4 NO MO
Reseccion amplia + anastomosis QT Adyuvante
◦ ETAPA III T1-4, N1-2, MO
Reseccionamplia + anastomosis QT AdyuvanteNational Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
SITUACIONES ESPECIALES
◦ SINCRONICO
◦ METASTASIS
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
National Comprehensive CancerNetwork, Version 3.2013,
R. Labianca, B. Nordlinger2, G. D. Beretta, Primary colon cancer: ESMO Clinical Practice Guidelines for diagnosis, adjuvant treatment and follow-up, clinical practice guidelines, Annals of Oncology 21 (Supplement 5): v70–v77, 2010
European Guidelines for quiality assurance in colorectal cancer screening and diagnosis. First Edition, 2012.
