Šárka Bohatá, Vlastimil Válek
Petr Vítek, Ivana Mikoviny Kajzrlíková
Miroslav Ryska, Daniel Langer, Jaroslav Kalvach
Marek Sochor, Jiří Bartoš
Martin Svatoň, Miloš Pešek
Gabriela Krákorová, Hynek Mírka, Miloš Pešek
Colorectal cancer screening has a long tradition in the Czech Republic. High specificity of screening tests is a prerequisite for use in mass screening. Unlike individual diagnostics, there is a higher risk of false positivity than negativity in population screening because it leads to increased costs, unnecessary investigation, complications, and a negative impact on the quality of life of healthy people. Quantitative haemoglobin detection in stool is currently the most accurate method of determining occult bleeding suitable for colorectal cancer screening. Optimization of screening is addressed in all countries where faecal immunochemical test (FIT) has replaced guaiac tests and involves cut-off criteria for positivity, number of tests performed, combination of FIT with other biomarkers, and distribution and sample analysis. Standardization and harmonization of FIT is a prerequisite for population screening of colorectal cancer and the accuracy and reliability of quantitative detection of haemoglobin in the stool should be ensured by external quality control.
The golden standard for primary diagnosis of colorectal cancer is colonoscopy together with biopsy. Exact staging and the preoperative assessment are crucial for optimal management of colorectal carcinoma, influencing decision making in case of neoadjuvant treatment and also determining the prognosis. EUS depicts the anatomic layers of the rectal wall with a high degree of accuracy and thus enables precise determination of the tumor extent in relation to the different wall layers (T staging). EUS accuracy is about 85% for T staging and 70-75% for nodal staging. Compared with the other commonly used techniques, CT scan is more largely accessible, faster, inexpensive and less operator-dependent, however CT is not the first choice method for local staging, because the definition of the bowel wall layers is not possible, but is one of the preferred tools to evaluate mainly distant spread, because of its high reproducibility and availability. High-resolution MRI in hands of experienced radiologist plays a pivotal role and has become almost mandatory in the pretreatment assessment of primary rectal cancer. MRI is currently the only imaging modality that is highly accurate (with specificity 92%) in predicting whether or not it is likely that a tumor-free margin can be achieved and in determination of the local invasion depth. Especially in distal tumors MRI provides important information for surgeon's decision whether sphincter-sparing surgery is possible. In patients with advanced rectal cancer extramural vascular invasion of the tumor can be depicted, used as an independent negative prognostic factor for local and distant recurrence rate and shorter overall survival rate. MRI can determine which patients can be treated with surgery alone and which will require radiation therapy to promote tumor regression. MRI can differentiate patients with good therapy response from non-responders. Tumor regression grade assessment is an independent predictor of overall survival and overall symptom-free survival rates and also plays substantial role in patients with the local recurrence. In patients with rectal cancer who have received concurrent chemotherapy and radiation therapy before surgery, all methods have lower accuracy in prediction of the pathologic stage owing to overstaging or understaging. The factors related to this problem include fibrosis, desmoplastic reaction, oedema, inflammation, and viable tumor nets at a fibrotic scar from a previous tumor.
Endoscopic resection techniques include endoscopic polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection and full-thickness resection. These resection methods are curative in cases of superficial invasive colorectal cancer provided that favourable prognostic criteria are met. Endoscopic placement of self-expandable metallic stent is preferred treatment for palliation of malignant colonic obstruction except in patients treated with antiangiogenic drugs. Endoscopic dilation is an effective treatment of colorectal anastomotic stenosis. Endosponge placement is beneficial for patients with colorectal anastomotic dehiscence and presacral cavity.
The authors deal with some current aspects of surgical treatment of colorectal carcinoma. Right-side tumours including coecum, ascending colon, hepatic flexure, transversum and spleen flexure are clinically, biologically and genetically distinct from tumours in the left-handed localization, which includes a descending colon, sigma and rectum. Right-hand localization is a negative prognostic marker, especially for stage III and IV carcinomas. Regardless of right-handed treatment, compared to the left-hand side, it significantly increases the risk of death. There are currently no clear recommendations for indication for the protective ileostomy. Despite some proven benefits, the protective stoma probably only reduces the frequency of clinically manifest anastomotic leakage. The benefit of ileostomy should be carefully considered in the knowledge of possible risks and complications. The rate of anastomotic leakage in colorectal surgery is literally in the range of 1-19 % depending on the type of resection, respectively on anatomical localization of anastomosis. In the case of anastomotic leakage, a crucial role is played by early diagnosis with an active treatment approach which can minimize the consequences of anastomotic leakage. The surgical treatment of the most serious cases of anastomotic leakage plays a key role in surgical treatment, which needs to be repeated in many cases.
Approximately 40 % of patients with colorectal cancer will develop metastatic disease. Survival of patients with metastatic colorectal cancer has improved with the introduction of targeted therapies. Survival has also improved with utilization of molecular parameters (oncogens RAS, BRAF) and other factors such as sidedness of the primary tumor. The basics of intensive chemotherapy are regimens based on oxaliplatin and irinotecan. Targeted treatment increases the effectiveness of chemotherapy. A multidisciplinary approach to treatment is needed. In brief, we describe the basic strategy of systemic treatment in metastatic colorectal cancer
Tumor diseases are posed a significant risk of developing malnutrition. Nutritional therapy is an essential part of a comprehensive treatment strategy for malignancies. We have enough valid data supporting the meaningfulness of nutritional support to improve the clinical condition of patients and compliance with the treatment plan. The presence of active tumor causes the development of varied metabolic and humoral changes, interfering with the intake and processing of the individual nutrition components. This article summarizes the current view of nutritional intervention options in the conditions of the Czech Republic, including an overview of enteral and parenteral nutrition focusing on indication in various clinical situations.
Patients with advanced cancer, with limited prognosis, are the most demanding group of oncological patients. In that patients anticancer therapy isn't applied with curative intent, it is oriented to prolong life and to make better quality of life. Patients suffer from many physical symptoms, are suspended to psychic distress and have almost complicated social situation. These all factors worsen quality of life, complicate anticancer treatment and shorten life. In the last ten years grows knowledge about significance of early application of multimodality palliative care initiated in time of diagnosis of cancer and realized parallel to anticancer treatment. This concept was confirmed in many randomized trials. In a next future of scientific investigation and real clinical practice we have to figure out who will provide palliative care, which modalities are the most effective and which models of care between palliative care specialists and oncologist are the most suitable for patients. Review article documents our current knowledge about early palliative care in oncology.
Crizotinib – still „gold standard“ for patients with pulmonary adenocarcinoma with ALK translocation?
Crizotinib is a tyrosine kinase inhibitor targeting ALK translocation. Based on Profile 1007 and Profile 1014 trial, it has become the basis of treatment for patients with ALK translocation in the first as well as the second line of treatment. Its toxic profile is acceptable and usually well manageable. In the Czech Republic, due to the form of payment, it has been used exclusively in the second line, where we document the experience from our workplace with this drug. Currently, other drugs (ceritinib, alectinib) have proven to be effective in patients with ALK translocations, when it is a question of choosing a treatment plan, which is discussed in more detail in the discussion.
The inclusion of Lonsurf (trifluralin/tipiracil, TAS‑102) in the treatment of metastatic colorectal cancer
Fluoropyrimidines have represented the cornerstone of treatment of colorectal cancer for a long time. Lonsurf is an orally administered combination of a thymidine-based nucleic acid analogue - trifluridine and a thymidine phosphorylase inhibitor - tipiracil hydrochloride with trifluridine being the active cytotoxic component of this combination. Its triphosphate form is incorporated into DNA appearing to result in antitumor effects. Tipiracil hydrochloride is a strong inhibitor of the thymidine phosphorylase and, when combined with trifluridine prevents the rapid degradation of the trifluridine, allowing longer maintenance of adequate plasma concentration of the active drug. The results of the placebo-controlled, double-blind, phase 3 clinical trial RECOURSE confirmed the results of previous assessments of oral Lonsurf in patients with metastatic colorectal cancer, who had already undergone extensive treatment. Lonsurf was associated with a clinically relevant prolongation of overall survival in essentially all treatment subgroups. Combination of trifluridine and tipiracil is able to replace 5-fluorouracil in patients who have developed resistance to this treatment. It turns out that the combination with a biologic therapy or oxaliplatin and irinotecan has a great future in the treatment of not only metastatic colorectal cancer.
Afatinib is an oral preparation, a tyrosine kinase inhibitor of the second-generation EGFR. It is used in the treatment of unresectable locally advanced or metastatic non-small cell lung carcinoma in patients with positive mutations in the gene encoding the epidermal growth factor receptor (EGFR). Afatinib as the first tyrosine kinase inhibitor EGFR demonstrated overall survival compared to chemotherapy in patients with positive EGFR mutation on exon 19 (prolongation of median survival by 12.2 months using afatinib). The most common side effects are rash, diarrhea, stomatitis and paronychia. To cope with side effects, patients need to be cooperative and well informed. At the clinic of pneumology and phthisiology, we have witnessed a brief written lesson that is part of a medical report. In the case of diarrhea, adequate hydration, dietary precautions, and the use of loperamide, which should be provided to patients immediately upon initiation of treatment with afatinib. The case study demonstrates good controlled side effects in collaborating patients with high adherence to treatment. In line with the literature, a good therapeutic effect remains unaffected even when reducing the daily dose of afatinib by half.