The informed patient

Colorectal CancerColon CancerRectal Cancer

R. Rosenberg, Th. Kocher, SwitzerlandU. Nitsche, R. Schmid, H. Friess, Germany

Publisher

© 2020 Falk Foundation e.V.All rights reserved. 4th revised edition 2020

Kantonsspital BasellandDepartment of SurgeryRheinstr. 264410 LiestalSwitzerland

Prof. Dr. med. Robert RosenbergMarie-Luise Fontana, Psycho-oncologyMaja Stoecklin, Stoma and incontinence care

Chirurgie BadenLanghaus 25400 BadenSwitzerland

Prof. Dr. med. Thomas Kocher

Klinikum rechts der IsarTechnical University ofMunichIsmaninger Str. 2281675 MunichGermany

1 Univ. Prof. Dr. med. Helmut Friess1 Asst. Prof. Dr. Dr. med. Ulrich Nitsche1 Asst. Prof. Dr. med. Matthias Maak2 Univ. Prof. Dr. med. Roland Schmid3 Prof. Dr. med. Sylvie Lorenzen4 Prof. Dr. Dipl. Psych. Peter Herschbach5 Dr. rer. nat. Sabine Langer-Freitag6 Dipl. oec. troph. Sabine Obermayer7 Karin Simons8 Dr. med. Silja Schwarz

1 Department of Surgery2 Department of Internal Medicine II3 Department of Internal Medicine III4 Department of Consultation-Liaison Therapy, Division of Psychosocial Oncology

5 Institute of Human Genetics6 Dietary Consultation, Department of Surgery7 Stoma and Incontinence Care, Department of Surgery8 Center for Prevention, Nutrition, and Sports Medicine

© Image sources: Diagrams – Asst. Prof. Dr. med. Matthias Maak,Images – Authors.

General design of the booklet:Prof. Dr. med. Robert Rosenberg

Authors and co-authors

Colorectal CancerColon CancerRectal Cancer

The informed patient

This booklet is dedicated to all patients with colorectal cancer.

Contents

1 Introduction: What you need to know 61.1 What are the colon and the rectum,

and where are they located? 71.2 What role do blood vessels and lymphatic

vessels play in colorectal cancer? 91.3 What is the structure of the intestinal wall? 91.4 How does digestion work? 101.5 How does an adenoma develop into cancer? 111.6 What research is being performed

on colorectal cancer? 13

2 Colorectal cancer 142.1 What is cancer? 152.2 What is colorectal cancer and

how common is it? 152.3 Risk factors for colorectal cancer 162.4 What are the signs of the disease? 162.5 How can colorectal cancer be detected early

(and prevented)? 172.6 What tests are available for the prevention

and early detection of colorectal cancer? 192.7 How do doctors test for colorectal cancer? 20

3 Tumor board 36

4 How is colorectal cancer treated? 404.1 Principles of treatment 414.2 How will I be prepared for surgery? 434.3 Open (classical) or laparoscopic

(minimally invasive) surgery? 434.4 What types of surgery are performed? 464.5 How does treatment proceed after surgery? 58

5 Risks and complications of surgery 605.1 What complications may occur after

colorectal surgery? 615.2 What are the long-term consequences

of surgery? 63

6 What is the purpose of pathology testing of excised tissue? 66

7 Will I need additional treatment after surgery? 74

7.1 When is chemotherapy recommended? 75

Contents

7.2 How does chemotherapy work? 777.3 What are the side effects? 787.4 When is radiation therapy recommended? 79

8 What is the likelihood of being cured? 82

9 What is the follow-up care for colorectal cancer? 84

9.1 General recommendations 859.2 What are the elements of follow-up care

for cancer? 85

10 Dietary recommendations following colorectal surgery 90

10.1 General information about nutrition after surgery 91

10.2 Dietary recommendations for patients with stomas 98

11 How do I live with a stoma? 10211.1 General recommendations 10411.2 One-piece ostomy system 10511.3 Two-piece ostomy system 10511.4 Tips and tricks 10711.5 Dietary recommendations 10811.6 Emotional impact of a stoma 109

12 Colorectal cancer and quality of life: How can psycho-oncology help? 110

13 Physical activity and colorectal cancer 11413.1 Risk reduction 11513.2 Improving your prognosis and well-being 11513.3 How should I exercise? 11613.4 Stoma patients 117

14 Are my family members at a higher risk of colorectal cancer? 118

14.1 General information 11914.2 Hereditary colorectal cancer 11914.3 Are my family and I at a higher risk

of colorectal cancer? 120

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Introduction:What you need to know

Appendix 1Cecum 2

Ascending colon 3Hepatic flexure 4

Transverse colon 5Splenic flexure 6

Descending colon 7Sigmoid colon 8

Rectum 9Superior mesenteric artery 10Inferior mesenteric artery 11

1.1 What are the colon and the rectum, and where are they located?

1.2 What role do blood vessels and lymphatic vessels play in colorectal cancer?

1.3 What is the structure of the intestinal wall?1.4 How does digestion work?1.5 How does an adenoma develop into cancer?1.6 What research is being performed on

colorectal cancer?

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Introduction: What you need to know

1.1 What are the colon and the rectum, and where are they located?

The colon and the rectum are located at the end of the digestive tract. The colon is about 1.5 m long and runs around the outer border of the abdomen. Digested food is transported from the small intestine into the ascending segment of the colon (called the ascending colon), after which it proceeds through the transverse colon and finally the descending colon. The descending colon runs down the left side of the abdomen into the lower abdomen. The colon makes a slight S-shaped bend in the lower left abdomen which is accordingly named the sigmoid colon (Fig. 1).

Fig. 1The colon and rectum

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The colon ends after the S-shaped bend and is followed by the 16-cm long rectum. The rectum is connected to the very end of the digestive tract, the anus, by the anal canal. The rectum can be divided into three segments: the upper, middle, and lower thirds of the rectum. This subdivision is important in clinical practice since rectal cancer requires different treatment approaches depending on which third of the rectum the cancer is located in (Fig. 2).

1 Upper third of the rectum2 Middle third of the rectum 3 Lower third of the rectum4 Anal canal5 Anus6 Sphincter

Fig. 2 The rectum

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1.2 What role do blood vessels and lymphatic vessels play in colorectal cancer?

Arteries provide blood to the gastrointestinal tract, and veins carry the blood through the liver and back to the heart. The superior mesenteric artery (10, Fig. 1) branches off directly from the abdominal aorta and provides blood to the ascending colon and the transverse colon through two different large branches. The blood supply to the de-scending colon and the sigmoid colon is provided by the inferior mesenteric artery (11, Fig. 1). This blood vessel also has a branch that supplies the upper third of the rec-tum, while the middle and lower thirds of the rectum are supplied by the internal iliac artery.

Lymphatic vessels are responsible for draining fluid (lymph) and small amounts of protein out of tissues. The lymphatic vessels in the colon and rectum run alongside the blood vessels and they converge at local lymph nodes (depicted as blue ovals in Fig. 1). It is very important that lymph nodes be removed during surgery for colorectal cancer, as a patient’s prognosis is highly dependent on whether the cancer has spread to the lymph nodes.

1.3 What is the structure of the intestinal wall?

The tissues of the intestinal wall have the same layout throughout the entire intestine. The intestinal wall is com-prised of the following layers, from the inside to the out-side:

1st layer: the intestinal mucosa. The mucosa is the inner lining of the intestines and contains cells that produce intestinal juice as well as cells for nutrient uptake and im-mune protection.

2nd layer: the submucosa. This is the layer where blood vessels, lymphatic vessels, and nerve fibers begin. A tumor is not called colorectal cancer until it penetrates the bound-ary between the mucosa and the submucosa. As soon as colorectal cancer enters this layer, it comes into contact

with blood vessels and lymphatic vessels. This means that some cancer cells may have already spread to lymph nodes or other organs at this stage, although this is very unlikely.

3rd layer: the muscle layer (muscularis propria). This layer contains muscle fibers running in both a circular and a longitudinal direction, which allow the intestines to con-tract and thus move forward the digested material.

4th layer: the outermost layer (serosa). The outer layer consists of loose connective tissue. In some segments of the intestines, the outer layer is comprised by the peritoneum.

The layout of the intestinal wall is crucial for classifying how deep the tumor has spread. The deeper a tumor pene-trates the intestinal wall – in other words, the number of layers it spreads to – the worse the prognosis. Deeper tumor spread increases the risk that tumor cells have gained access to lymph or blood vessels and have spread to other regions of the body (called metastasis).

1.4 How does digestion work?

During the digestive process, food is broken down in the digestive tract with the help of enzymes, which allows the body to absorb the individual nutrients. In humans, diges-tion primarily takes place in the mouth, stomach, duode-num, and the rest of the small intestine. However, the ac-tual absorption of nutrients occurs almost exclusively in the duodenum and the small intestine. About 80% of the water in digested food is absorbed in the small intestine. An additional 19% of the water in digested food is ab-sorbed in the colon, which makes the digested material (called chyme) denser. The colon contains microorganisms called the gut flora that ferment vegetable fibers, making these foods easier to digest. Chemicals that cannot be fermented by either the digestive enzymes in the small intestine or by the microorganisms in the colon are excreted unchanged through the rectum. No digestion occurs in the rectum. The colon and rectum are not actually essen-tial digestive organs. After surgery, the remaining parts of the gastrointestinal tract can assume most of their func-

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tions. As a result, most patients experience a high quality of life and digestive function after colorectal surgery.

1.5 How does an adenoma develop into cancer?

Colorectal cancer is one of the best-studied forms of can-cer. Colorectal cancers usually arise from benign precursors called adenomas. The transformation of an adenoma to a cancer is called the “adenoma-carcinoma sequence” (Fig. 3) and is a process that can take several years. This transformation is caused by a series of genetic mutations in mucosal cells that alter the natural mechanisms which control their growth.

The cells begin to ignore the natural boundaries between tissues and proliferate into the intestinal wall, a process known as “invasive” tumor growth. The cancer cells may break free of their original tissues and be transported by blood or lymph to other sites in the body, where they form metastases.

It is thought to take about 5–10 years for an adenoma to develop into colorectal cancer. The risk of cancer increas-es with advancing age, and most colorectal cancer pa-tients are over 50 years old. However, genetic mutations may also be hereditary, meaning they are passed on from a patient’s parents. This may lead to cancer at an earlier age, and patients with a hereditary risk should take spe-cial precautions.

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Normal colonic mucosa.The purple line indi-cates a muscle layer called the muscularis mucosae. This layer divides the mucosa from the submucosa.

Early-stage adenoma.

Late-stage adenoma: still benign, but the cell exhibits changes.

Colorectal cancer.The tumor cells have spread to the submucosa.

Fig. 3 Adenoma-carcinoma sequence

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1.6 What research is being performed on colorectal cancer?

In addition to caring for patients, many academic hospi-tals also focus on research and teaching. Over time, both clinical studies and basic research help improve the treat-ment of all patients with colorectal cancer.

Clinical studies

In clinical research, drugs or treatment methods used for routine clinical practice are tested under controlled con-ditions. Patient care is always the highest priority in these studies. Despite many advances in the treatment of colorec-tal cancer, a large number of questions remain unan-swered, and studies are the only way to reliably address these issues. Participation in clinical studies is always vol-untary. One advantage to participating in a clinical study is the opportunity to be treated with the newest, most promising drugs and methods.

Basic research

Even though colorectal cancer is one of the best-re-searched types of cancer, many questions about how it

develops, grows, and metas-tasizes remain unanswered. A number of research teams around the world are trying to improve research into colorectal cancer in order to better understand how it de-velops, spreads, interacts with surrounding tissue, and metastasizes to other organs. It is hoped that this research will identify better ways to detect cancer early and to treat it (Fig. 4).

Fig. 4 Laboratory research

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Colorectal cancer

2.1 What is cancer?2.2 What is colorectal cancer and

how common is it?2.3 Risk factors for colorectal cancer2.4 What are the signs of the disease?2.5 How can colorectal cancer be detected early

(and prevented)?2.6 What tests are available for the prevention

and early detection of colorectal cancer?2.7 How do doctors test for colorectal cancer?

Colorectal cancer

2.1 What is cancer?

The term cancer refers to the development of malignant cells resulting from the transformation of healthy cells in the body. The typical characteristics of cancer cells are an abnormal appearance, invasion of surrounding tissues or organs, and the ability to spread to other organs and form metastases. Theoretically, cancer can develop in any part of the body. There are three main types of cancers that are classified by the type of tissue they come from:

1. Carcinomas arise from the skin, mucosa, or glandular tissue and represent the most common forms of cancer in humans. This group also includes colorectal cancer.

2. Sarcomas arise from connective tissue, bone and car-tilage, and nervous tissue.

3. Lymphomas and leukemias arise from white blood cells and bone marrow cells.

2.2 What is colorectal cancer and how common is it?

Colorectal cancer refers to cancer of the colon and of the rectum. Colorectal cancer is one of the most common forms of cancer in the Western world, whereas cancer of the small intestine and the anal canal are relatively rare. Currently, colorectal cancer is the second-most common form of cancer in Europe and the third-most common form worldwide. Every year, about 450,000 people in Europe suffer from colorectal cancer and about 230,000 die from it. Anybody can get colorectal cancer. Over the course of our lives, about 6 out of every 100 people will get colorectal cancer, or 1 out of every 17 people.

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Although colorectal cancer can develop in any segment of the colon or the rectum, it is most commonly found in the last 40 cm of the colon and the rectum (about 60% of all cases).

2.3 Risk factors for colorectal cancer

While the causes of colorectal cancer are not yet fully un-derstood, several specific factors are known to increase a person’s risk of developing colorectal cancer.

The following factors may increase the risk of colorectal cancer:

• Poor lifestyle habits such as a meat-rich, high-fat, low-fiber diet, tobacco consumption, alcohol con-sumption, being overweight, and a lack of exercise

• Inflammatory bowel disease (ulcerative colitis, Crohn’s disease)

• Certain types of colon polyps (adenomatous polyps) • Relatives with colorectal cancer or colon polyps

(adenomatous polyps) • Some other types of cancer such as endometrial

or ovarian cancer

2.4 What are the signs of the disease?

Colorectal cancer does not occur overnight, but rather takes months and years to develop and grow. As a result, the disease initially causes no or very few symptoms. Typical symptoms like rectal bleeding or abnormal bowel move-ments only emerge over time.

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Colorectal cancer may cause the following symptoms:

• Altered bowel movement patterns, alternation between constipation and diarrhea, very thin stools, or a frequent urge to defecate, often without being able to

• Bloody stools (never assume these are just hemorrhoids!)

• Recurring, cramp-like abdominal pain • Loud abdominal sounds, persistent flatulence,

stools with foul smell • Palpable abdominal masses • Non-specific symptoms such as reduced strength,

fatigue, and weight loss

Of course, these symptoms are not definitive proof of colorectal cancer and may be caused by other illnesses, which is why it is important to have them checked by a doctor.

2.5 How can colorectal cancer be detected early (and prevented)?

As with other types of cancer, the rule of thumb for colorectal cancer is that the earlier it is detected and treated, the better the chances of it being cured. Early detection can help prevent or cure colorectal cancer.

Early detection of colorectal cancer means utilizing the can-cer screening options provided by your general practition-er. This is especially important since there are no symp-toms or only a few non-specific symptoms as colorectal cancer starts to develop. Cancer screening programs differ from country to country. In Germany, for example, the early detection process for colorectal cancer consists of a conversation with your general practitioner to estimate your risk, an annual digital rectal examination, and a test for occult (invisible) blood in stool every year from age 50 to age 55 (see p. 19). Starting at age 55, every person

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with German health insurance is eligible for a colonosco-py for cancer screening, even people without symptoms.

A second colonoscopy is performed 10 years after the first (negative) test. People with a family history of colorectal cancer should have the very first colonoscopy even earlier, specifically 10 years younger than the age when the dis-ease was diagnosed in their relative.

In Austria, a consensus recommendation by the social se-curity agencies and professional associations calls for ear-ly detection by testing for occult (invisible) blood in stool in men and women (see p. 19) once per year from the age of 40, and by a colonoscopy from age 50, which should be repeated every 7–10 years if negative. The cost of the colonoscopy is covered by health insurance.

In Switzerland, colorectal cancer screening is recommend-ed for men and women starting at age 50. Swiss health insurance covers screening for colorectal cancer for every-one ages 50 and above. It also covers a fecal occult blood test every 2 years or a colonoscopy every 10 years. Please talk with your general practitioner or a gastroenterologist about which form of early detection screening would be appropriate based on your personal risk.

When detected early, colorectal cancer has a very good prognosis and can be cured.

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2.6 What tests are available for the prevention and early detection of colorectal cancer?

Digital rectal examination

During this procedure, a doctor probes the lower end of the rectum by inserting a finger through the anus and evaluating the anal sphincter and the prostate. If this test yields abnormal results, a colonoscopy must be performed for further investigation.

Test for hidden blood in stool (fecal occult blood test)

In the occult blood test, three consecutive stool samples are tested in the laboratory for blood that cannot be seen by the naked eye. However, detection of blood in stool does not automatically indicate colorectal cancer; rather, it is most commonly due to other causes like hemorrhoids, colon polyps, or gut inflammation. If blood is detected in stool, a colonoscopy must be performed for further in-vestigation.

Colonoscopy

Colonoscopy is the best method to detect colorectal can-cer. It is the only method that allows a tissue biopsy to be collected that can be used to diagnose colorectal cancer (Fig. 5). Colonoscopy can also help diagnose adenomas, which are a precursor stage of cancer, and remove them before they advance to cancer. The introduction of colo-noscopy has made effective cancer prevention possible.

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Fig. 5Appearance of colorectal cancer by colonoscopy

2.7 How do doctors test for colorectal cancer?

If you are suspected of having colorectal cancer based on your symptoms or abnormal results from early detection screening, several different tests may be performed. These tests are performed to determine whether you actually have colorectal cancer (by detecting a tumor) and if yes, how advanced the cancer is (tumor staging).

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Testing methods used to detect colorectal cancer:

• Colonoscopy (imaging of the entire colon using a flexible tube)

• Sigmoidoscopy (imaging of the lower colon and the rectum using a flexible tube)

• Proctoscopy (imaging of the first 15–20 cm of the rectum using a rigid tube)

• Virtual colonoscopy • Colonic X-ray (barium enema)

Complete colonoscopy

Colonoscopy is the most reliable method for investigating the colon and is the most commonly used method for diag-nosing colorectal cancer. During colonoscopy, a flexible tube (endoscope) is inserted through the anus and used to illuminate and observe the interior of the colon. In order for the mucosa of the colon to be reliably evaluated, the bowel must be thoroughly cleansed beforehand by drink-ing a special mixture or taking a laxative to empty the co-lon. Colonoscopy is the only method that allows a tissue biopsy to be collected that can be used to reliably diag-nose colorectal cancer. The procedure can also be used to detect and remove adenomas, which are a precursor to cancer.

In most patients, colonoscopy is performed under seda-tion (meaning the patient is asleep). Sedation is induced using an anesthetic (usually propofol) that places the pa-tient into a deep sleep. The patient’s breathing and circu-lation are monitored continuously during the procedure.

In addition to collecting biopsy material for diagnosis, this procedure also reveals the location and size of colorectal cancer, allowing optimal planning of surgery (Fig. 6, 7).

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Fig. 6Facilities and equipment in a modern endoscopy unit

Sigmoidoscopy and proctoscopy

Sigmoidoscopy (imaging the last segment of the colon upstream of the rectum) and proctoscopy (imaging of the rectum) are reduced versions of colonoscopy. However, these procedures cannot fully replace a complete colonos-copy. Although 60% of all colorectal tumors are located in the lower segment of the colon or in the rectum, 40% of all colorectal tumors may still be missed if only sig-moidoscopy and proctoscopy are performed. Therefore, a complete colonoscopy should be performed whenever possible.

Sigmoidoscopy and proctoscopy are usually not performed under sedation, meaning patients are awake during the procedure.

Fig. 7Colon polyps (A, B)

and colorectal cancer (C)by colonoscopy

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Proctoscopy and endoscopic ultrasound of the rectum

Proctoscopy is used to examine the rectal mucosa and can detect the size and location of benign and malignant rec-tal tumors. It is possible to perform an ultrasound exam-ination of the rectum by inserting an ultrasound probe into the anus. This procedure, called endoscopic ultrasound, is used to determine the spread of a tumor through the layers of the intestinal wall and around the intestine as well as to evaluate adjacent lymph nodes (Fig. 8). It can also be used to visualize where the tumor is located relative to the anal sphincter. This procedure is important in rectal cancer in order to decide whether radiation therapy should be performed prior to surgery. When combined with a functional test of the anal sphincter, endoscopic ultra-sound can also help determine whether the sphincter can remain intact or whether an artificial opening must be created.

Fig. 8Endoscopic ultrasound of a rectal tumor

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Virtual colonoscopy

Computed tomography (CT colonography) or magnetic resonance imaging (MR colonography) are used to scan the body and are processed by special computer programs to three-dimensional reconstructions of the interior of the bowel (Fig. 9).

The advantage of these non-invasive examination tech-niques is that there is no need to insert an endoscope into the gastrointestinal tract. Hence, the gastrointestinal tract is not directly imaged using an endoscope but is re-constructed “virtually”. However, it is still necessary to cleanse the bowel before the procedure in order to obtain clear images of the intestinal wall. Some of the disadvan-tages of a virtual colonoscopy include exposure to radia-tion, a worse ability to identify inflammation and small polyps, and restrictions for patients with metal implants, cardiac pacemakers, or claustrophobia as well as the fact that suspicious findings can neither be removed nor ex-amined by biopsy. Therefore, conventional colonoscopy remains the preferred method for diagnosing colorectal cancer.

Capsule endoscopy

To address certain issues, the entire gastrointestinal tract can be examined using a technique called capsule endos-copy. During this procedure, the patient swallows a small video capsule which then takes pictures of the interior of the gastrointestinal tract at regular intervals as it is pro-pelled on its own through the tract by the pushing move-ment (peristalsis) of the digestive system. The images are then evaluated on a computer. This unique procedure is only used in special cases, typically to examine the small intestine.

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Colonic X-ray (barium enema)

In a barium enema, the colon is filled with contrast agent through the anus and viewed on X-ray images (Fig. 10). This examination procedure is inferior to colonoscopy and is only rarely used today.

Ultrasound

Ultrasound is the simplest method to obtain images of internal organs such as the liver, kidneys, or spleen; it is risk-free and painless. It is only recommended that you not eat or drink anything for several hours before the ex-amination to prevent gas from building in the gut, which improves the quality of the images. In patients with colo-rectal cancer, abdominal ultrasound is used to determine whether there are metastases in other organs. The main focus in this examination is the liver; the bowel itself is difficult to evaluate by ultrasound.

A

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Fig. 9Virtual colonoscopy with 3D reconstruction (A), computed tomography with vascular reconstruction (B), arrow indicates a narrowing (stenosis) of the intestine due to colorectal cancer

Fig. 10Barium enema identifying a narrowing caused by a tumor with the classical “apple core sign” (arrow)

B

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Computed tomography (CT)

Computed tomography is a special type of X-ray exami-nation that allows cross sections of the human body to be visualized (Fig. 11).

Modern CT devices do not expose patients to much ra-diation. For patients with colorectal cancer, CT of the ab-domen and pelvis allows not only the colorectal tumor itself to be examined but also any potentially enlarged lymph nodes or metastases to other organs. In order to differentiate the gastrointestinal tract from the rest of the abdomen, patients must drink a contrast agent about 1 hour before the procedure. The colon is filled with con-trast agent through the anus immediately before the ex-amination. During the examination itself, a contrast agent is injected into a vein to help visualize blood vessels and abdominal organs better. The goal of the procedure is not only to see the tumor but also to identify whether the tumor has spread to other organs.

Fig. 11Computed tomography device (A)

and image of colorectal cancer indicated by arrow (B)

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Fig. 12Magnetic resonance imaging of the pelvis showing a rectal tumor, arrows indicate the image of the rectal tumor.(A) transverse (horizontal) plane, (B) sagittal (vertical from the side) plane

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Magnetic resonance imaging (MRI)

Like computed tomography, magnetic resonance imag-ing allows the cross sections of the body to be visualized. However, this technique does not use X-rays but rather alternating magnetic fields. Magnetic resonance imaging reveals potentially enlarged lymph nodes and metastases in other organs and provides a particularly precise image of the anatomy and extent of rectal tumors. As mentioned above for endoscopic ultrasound of the rectum, the loca-tion of the tumor relative to the anal sphincter and the penetration of the tumor into the layers of the intestinal wall are crucial for planning treatment and surgery (Fig. 12). Usage of this technique is restricted in patients with car-diac pacemakers, metal implants, or claustrophobia. In ad-dition to visualizing the pelvis, this procedure is also im-portant for detecting changes to the liver.

Positron emission tomography (PET)

Since cancer cells grow faster than healthy cells and thus also have a greater need for energy and glucose, these properties can be used to detect tumors and metastases. Positron emission tomography uses a marker such as ra-dioactively-labeled glucose, which is taken up by meta-bolically active cells, including cancer cells. The labeled glucose is enriched in tumors, which can be visualized on the images generated by the procedure. In contrast to other imaging procedures such as CT or MRI, PET does not depict the anatomy of the body, but instead evalu-ates metabolism as well as the ability of (cancer) cells to divide and survive. PET examinations are not 100% specific for cancer and thus can only be used to address specific issues. They are not routinely used to diagnose colorectal cancer.

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Fig. 13Rectal tumor detected by positron emission tomography (PET) (A) and by combined PET/CT (B), arrows indicate the tumor

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Fig. 14Two liver metastases detected by positron emission tomography (PET) (A) and by combined PET/CT (B), arrows indicate the tumor

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These special issues may include screening the entire body for metastases, monitoring for recurrence of colorectal can-cer during follow-up care, or evaluating whether cancer responds to chemotherapy or radiation therapy in clinical studies (Fig. 13, 14).

X-ray imaging of the lungs (chest X-ray)

This standard radiographic procedure is used in colorectal cancer both to provide a general assessment of the heart and lungs and to screen for potential metastases in the lungs. If suspicious masses are detected, a CT scan of the entire chest area will be performed to investigate further.

Blood tests

General blood tests are performed to gather information about the condition and function of different organs such as the kidneys or the liver. These tests may also be used during cancer treatment to measure molecules called tumor markers.

These are substances that are often produced at higher levels by cancer cells but are still very non-specific and may also be detected in healthy people. Negative or nor-mal tumor marker levels cannot be used to rule out a diagnosis of cancer, and similarly high levels of tumor markers are not proof of cancer.

Instead, tumor markers are useful for gauging the course of the disease after tumor removal in patients who had high levels of the markers before surgery. If the levels of a tumor marker rise again during follow-up care, this may be a sign of disease recurrence. The most important marker for colorectal cancer is CEA (carcinoembryonic antigen).

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Tests that may be used for staging (determining the extent of the disease):

• Blood tests, including tumor markers (CEA) • Abdominal ultrasound • Lung X-ray • CT scan of the chest, abdomen, and pelvis • MRI of the liver and pelvis • Ultrasound examination of the rectum

(endoscopic ultrasound)

In addition to the tests used to determine the extent of the disease, other tests are also always performed before surgery to gauge the risk of surgery. The highest priority is to ensure that surgery will not pose a risk to the patient.

Tests that may be used to determine the risk of surgery:

• Blood tests• Lung X-ray• Lung function tests• Heart tests (electrocardiography = ECG, stress ECG

tests, echocardiogram, cardiac catheter)• Angiography (blood vessel imaging)• Kidney and liver function tests• Discussion as part of anesthesia preoperative

evaluation

Talk with your doctor about which individual tests you will need.

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Tumor board

Tumor board

In order for a hospital in Germany to be certified as a colorectal cancer center, it must hold meetings called tu-mor boards in which doctors from different specialties dis-cuss every colorectal cancer patient at their facility. These meetings provide an opportunity for specialists from dif-ferent fields involved in cancer care to meet regularly and make the best treatment recommendation for each pa-tient (Fig. 15). Tumor boards guarantee rapid turnaround and the best treatment decisions at the highest level. The following specialists should participate in the tumor board to select the proper treatment strategy: surgeons, oncolo-gists, gastroenterologists, radiologists, interventional ra-diologists, nuclear medicine physicians, pathologists, and radiation therapists. In addition to the test results for the cancer itself, important topics for a treatment decision in-clude the patient’s current physical and mental states, other illnesses, current medications, and social environment.

Together, these experts decide a) whether a patient should undergo surgery immediately, b) whether pretreatment (called neoadjuvant therapy) before surgery (using radia-tion therapy and/or chemotherapy) is recommended to increase the patient’s chances of being permanently cured, or c) whether systemic therapy is required (chemotherapy, immunotherapy, or antibody therapy).

For patients with metastatic disease, the composition of chemotherapy and the ability to surgically remove the detected metastases together with the colorectal cancer are important topics. If surgical removal of metastases is not technically possible or not recommended, the tumor board will decide whether the colorectal cancer itself should be surgically removed before starting systemic ther-apy (chemotherapy). Based on the current science, this strategy should always be recommended for patients with symptomatic cancer: patients whose clinical examination reveals a possibility that the tumor will block the gastro-intestinal tract, or patients who lose so much blood be-cause of the tumor that they require blood transfusions

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for anemia. If the primary tumor in the colon is not caus-ing any symptoms during the metastatic phase, the tu-mor board will select the best strategy on a case-by-case basis.

If primary, or curative, surgery is not possible, the tumor board should discuss the clinical course of a patient’s can-cer during systemic therapy at 2- to 3-month intervals. This is because secondary surgical resection (surgical re-moval of the tumor and metastases after reducing the spread of the tumor) is currently possible using the med-ications now available. The need for another line of ther-apy after successful surgery should be discussed in the tumor board once the evaluation of the colorectal cancer by histology and pathology is complete.

Molecular tumor board

A tumor board is a panel of experts who focus on each pa-tient and his or her individual situation. In modern times, individual cases are not only discussed by organ-specific tumor boards but also by molecular tumor boards which are designed to provide each individual cancer patient with personalized oncological treatment. We now know that the biological properties of disease differ greatly not only from one form of cancer to another, but also from one patient to the next. A comprehensive molecular, cel-lular, and functional analysis of each tumor will hopefully be able to provide many patients tailored cancer therapy in the near future.

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Fig. 15An interdisciplinary tumor board

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How is colorectal cancer treated?4.1 Principles of treatment4.2 How will I be prepared for surgery?4.3 Open (classical) or laparoscopic

(minimally invasive) surgery?4.4 What types of surgery are performed?4.5 How does treatment proceed

after surgery?

How is colorectal cancer treated?

4.1 Principles of treatment

A treatment strategy for colorectal cancer patients can-not be defined until the patient’s disease has been fully and completely investigated. These investigations include colonoscopy, biopsy of cancer tissue to confirm the diag-nosis and to measure predictive and therapeutically im-portant markers, blood collection to measure colorectal cancer tumor markers (CEA, CA 19-9), and CT scans of the lungs and abdomen. Once complete, the results of all of these tests are discussed by the tumor board. These meet-ings provide an opportunity for specialists from different fields involved in cancer care to meet regularly and de-cide upon the best treatment recommendation for each patient (see also Chapter 3).

Surgery, or the removal of the tumor, is the only treatment option that provides the hope of curing colon cancer or rectal cancer. Accordingly, surgical removal of the tumor is the most important component in any treatment strategy.

It is typically only possible to cure colorectal cancer if the spread of cancer cells into other organs like the liver or lungs has been ruled out. For this reason, the extent of cancer spread must always be determined before surgery. The goal is to determine whether the disease is local (re-stricted to the bowel) or disseminated (already spread through the entire body). A cure is still possible with dis-seminated disease under certain circumstances.

In patients with colon cancer, surgery is almost always performed immediately after reaching the diagnosis, deter-mining the extent of the disease, and gauging the feasibil-ity of surgery (risk assessment of the planned operation). The cancer can only be cured by removing the entire tumor. After the operation, pathologists will examine the removed cancer tissue to gauge the spread of the primary tumor and the presence of lymph node metastases (see p. 66ff). Based on the results of this examination, your doctors may

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recommend additional prophylactic chemotherapy or no additional treatment.

For patients with rectal cancer, the extent of the disease, the feasibility of surgery, and the penetration of the tumor will also be investigated after diagnosis. Depending on the answers to these questions, small tumors should be re-moved immediately, whereas neoadjuvant therapy fol-lowed by surgical removal is recommended for large tumors. There are currently two main strategies for neoadjuvant therapy. The first strategy is radiation therapy of the rectal tumor over a period of 1 week with increasing daily doses. The second consists of a combination of single daily low-dose radiation treatments combined with chemotherapy which is usually well-tolerated, all for 5 weeks. As demon-strated in large studies, the aim of neoadjuvant therapy is to reduce the risk of local recurrence, meaning the like-lihood that the tumor comes back after surgery. You will need to talk with your doctor before surgery to decide whether neoadjuvant therapy is advisable and which reg-imen should be used. Radiation therapy has been shown to yield worse outcomes when performed after surgery in-stead of before. The issue of whether additional prophy-lactic chemotherapy is advisable after surgical removal of rectal cancer depends on several different tumor criteria and should be decided based on the results of the tissue examination.

You can see that a number of specialists are involved in treating colon and rectal cancer, who will work together to ensure you receive the best treatment possible. In mod-ern hospitals, every patient’s case is now discussed by tu-mor boards which bring many specialists together to de-termine the optimal treatment strategy. Patients who are not sure about the recommended treatment can also seek a second, non-binding opinion at any time from another hospital or colorectal cancer center.

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4.2 How will I be prepared for surgery?

In order to ensure that there are no complications to colorectal cancer surgery, patients must be prepared care-fully. This includes taking general measures to improve heart and lung function (quitting cigarette smoking, breathing exercises using a special breathing trainer, and walking up stairs). It is presently no longer necessary to completely empty the bowel before colon surgery in most cases. Patients benefit from this simplified preparation for surgery.

4.3 Open (classical) or laparoscopic (minimally invasive) surgery?

Two different surgical approaches are generally available in modern times for colon and rectal cancer. The first ap-proach is the classical (open) method using a “large” inci-sion in the abdomen. The other approach is the keyhole technique (laparoscopic surgery), in which a very small incision is made in the abdomen and surgery is performed in the abdomen using a camera and special miniature surgical instruments. Both techniques give experienced surgeons a good overview of the abdomen and thus allow the tumor to be safely removed.

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Fig. 16Operating room layout for minimally invasive surgery(C1 = surgeon, C2 = assistant, E = gastroenterologist, N = surgical nurse, A = anesthesiologist)

Laparoscopic technique has increasingly been used for surgery in recent years and has the major advantage of requiring smaller abdominal incisions (Fig. 16, 17). This surgical technique is considered to be gentle to tissues and patients. The camera in the abdominal cavity provides an excellent view into the abdomen. Patients usually re-cover from laparoscopic surgery faster than from open surgery, and also usually experience less pain. This also lowers the risk of infected wounds and burst scars. With an experienced surgeon, the results of laparoscopic surgery are excellent. Nonetheless, classical surgical procedures with “large” abdominal incisions also yield very good out-comes in modern practice. Be sure to ask your doctor which technique is more suitable in your case.

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Fig. 17(A) Modern operating room with computer-guided instrument navigation for minimally invasive surgery (laparoscopic technique)(B) Da-Vinci® surgical robot, Kantonsspital Baselland, Liestal, Switzerland

Laparoscopic surgery usually takes longer. Laparoscopic surgery is also not suitable for every patient or every tu-mor. Previous operations, abdominal adhesions, or wide-

B

A

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spread cancer may sometimes hamper laparoscopic pro-cedures or may exclude them entirely. In this cases, it is possible to switch (convert) to open surgery, even during surgery itself.

You should talk with your doctor about which of these methods is the most suitable. Large-scale studies have shown that the results of both methods are equal in terms of treating cancer both for colon cancer and for rectal cancer. Many hospitals today are equipped with the newest technological advances and the proper expertise for laparoscopic surgery. Ask your doctor!

4.4 What types of surgery are performed?

Curative surgery involves the removal of the bowel segment containing the tumor together with its lymph drainage area and an adequate safety margin in all directions. The tumor should be removed all at once using the technique called “en bloc resection” and not in parts. It is also very important to remove the nearby draining lymphatic ves-sels, as these may contain lymph nodes to which the tu-mor has spread, which are crucial for a further prognosis.

The advances made in recent years in general preparation for surgery, understanding why bowel cleansing is required for surgery, giving antibiotics in the operating room, op-timizing anesthesia procedures using a wide range of painkillers, preventing blood clots, early mobilization, and early feeding after surgery have led to very low rates of complications after surgery.

Depending on the location of the tumor detected by co-lonoscopy, the following standard procedures – which may be performed as open (“classical”) or laparoscopic (minimally invasive) surgery – may be carried out:

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Colon cancer

1. Right hemicolectomy

If the tumor is located in the segment of the colon on the right-hand side of the body, this segment is removed in a procedure called right hemicolectomy (Fig. 18). The continuity of the colon is restored by surgically attaching the small intestine to the transverse colon or descending colon. This procedure thus leaves the small intestine, half of the colon, and the rectum in place, which allows nor-mal stools to be formed following an adaptation phase.

Fig. 18Right hemicolectomy

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2. Left hemicolectomy

If the tumor is located in the segment of the colon on the left-hand side of the body, this segment is removed in a procedure called left hemicolectomy (Fig. 19). After this segment is removed, the ascending colon or the trans-verse colon is surgically attached to the rectum. This proce-dure thus leaves the small intestine, much of the colon, and the rectum in place.

3. Removal of the junction between the colon and the rectum (sigmoidectomy)

If the tumor is located in the sigmoid colon, i.e. between the ascending colon and the rectum, sigmoidectomy is per-formed (Fig. 20). The continuity of the bowel is restored by surgically attaching the ascending colon to the rectum. Enough of the colon remains to allow for good stool quality.

Fig. 19Left hemicolectomy

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4. Rectal cancer

For rectal cancer surgery, the procedure used depends greatly on the location of the tumor. Before the opera-tion, doctors will check whether surgery that preserves the anal sphincter is possible, as this maintains continence. This is determined by evaluating the distance between the tu-mor and the anal sphincter and perineum (the space be-tween the legs). If the tumor is too close to these struc-tures, the entire rectum must be removed, which results in a lifelong requirement for an artificial opening (stoma). An excellent quality of life is even possible with a stoma. However, our goal is always to preserve the anal sphincter whenever possible, depending on the location of the tumor.

Fig. 20Removal of the junction between the colon and the rectum (sigmoidectomy)

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It is now possible to avoid a permanent stoma in 80% of cases, even for tumors located deep down in the pelvis. This can be achieved by preoperative chemoradiotherapy, that can usually greatly reduce the size of the tumor, as well as by the use of modern staplers and suturing tech-niques near the anal sphincter (called coloanal anasto-mosis).

4a. Removal of the rectum while preserving the sphincter (low anterior resection)

Low anterior resection involves the removal of the sigmoid colon and the segment of the rectum that contains the tumor (Fig. 21). This operation preserves enough healthy rectum to allow continence (deliberate control over bowel movements) to be maintained. After the segment of the rectum containing the tumor is removed, the descending colon is surgically attached to the rectum. When the tumor is removed, it is crucial that the fatty tissue surrounding the rectum – which contains blood vessels and the drain-ing lymphatic vessels – is also completely removed. This extremely important surgical technique is called partial or total mesorectal excision. This surgical procedure involves cutting between anatomically distinct layers that surround the rectum (similar to peeling an onion). This approach avoids important nerves in the lower pelvis that are im-portant for anal sphincter function, bladder control, and sexual function.

Because the reservoir function of the “new” rectum is limited, several different surgical techniques have been developed to restore the reservoir function; these are also called pouch formation (Fig. 22). Talk to your surgeon about this topic and have her or him inform you about the different options. The goal of these techniques is to form a reservoir that allows patients to again pass bowel movements that are well-formed, properly portioned, and controlled. It may be necessary to establish a temporary stoma (an artificial opening) for the small intestine de-pending on how closely the colon is attached to the anal sphincter, and on whether radiation therapy was carried

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out before surgery. Surgical connections of the colon heal worse when they are very close to the anal sphincter or when radiation therapy was performed beforehand. Accord-ingly, doctors try to protect this new surgical connection in the rectum by creating an artificial opening for the small intestine (a stoma) that will be closed again after 2–3 months. This temporary stoma keeps stool away from the new surgical connection in the rectum by using a temporary exit through the abdominal wall. Your surgeon will discuss with you whether you need a stoma.

Fig. 21Removal of the rectum while preserving the sphincter(lower anterior resection)

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Fig. 22Different methods for forming a reservoir (pouch) after removal of the rectum (A = transverse coloplasty, B = side-to-end anastomosis, C = colonic J-pouch)

4b. Complete removal of the rectum and the sphincter (abdominoperineal excision of the rectum = Miles’ operation)

Abdominoperineal excision, also known as Miles’ opera-tion, involves the complete removal of the sigmoid colon, rectum, and anal sphincter muscle, including the anus (Fig. 23). This operation is nearly identical to the low an-terior resection described in the previous section, except that no healthy rectum is available below the tumor to connect to the colon because the tumor is so close to the anal sphincter. Due to this problem, the anal sphincter must be completely removed together with parts of the perineum in order to completely remove the tumor.

A

B C

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Fig. 23Complete removal of the rectum and the sphincter(abdominoperineal excision of the rectum = Miles’ operation)

After the tumor has been completely removed, the inci-sion in the perineum is closed and the descending colon is attached to an opening in the skin of the lower left ab-domen to create a stoma. You probably cannot imagine living with a stoma since you’ve never been confronted with a problem like this. However, important studies and experience from a large number of patients demonstrate that living with a stoma is compatible with a very high quality of life. Because complete removal of the tumor is the highest priority, no compromises can be made during surgery.

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If complete removal of the rectum is planned, talk to your doctor, nurse, and specialized enterostomal therapy experts before your surgery (see p. 102ff). After surgery, you should receive enough instructions that you can re-turn to your usual daily activities, such as athletic activities (including swimming) and even intimate romantic rela-tionships.

Minimally invasive surgery

As previously mentioned, all of the operations described here can also be performed using minimally invasive (lap-aroscopic) techniques. The advantages and disadvantages of laparoscopic surgery are described in Chapter 4.3. In addition to the procedures already described, several other types of minimally invasive surgery are performed:

5. Limited removal of the colon

Laparoscopic surgery is very well suited for removing co-lon polyps that cannot be removed or fully removed by colonoscopy (called sessile adenomas). Using laparoscopic technique allows only a very short segment of the colon to be removed (Fig. 24). This type of surgery can be per-formed on any segment of the colon. This operation is monitored by endoscopy to ensure that only the segment of the colon containing the tumor is removed together with an adequate safety margin (called the rendezvous technique). Typically, only specialized centers perform this type of operation. In the past, these patients required open surgery with a large abdominal incision.

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A

BD

C

Fig. 24(A) Endoscopic resection assisted by laparoscopy(B) Laparoscopic wedge resection assisted by endoscopy(C) Laparoscopic, transcolonic resection assisted by endoscopy(D) Laparoscopic segmental resection assisted by endoscopyMinimally Invasive Interdisciplinary Therapeutical Intervention Group, Klinikum rechts der Isar, Prof. Dr. H. Feußner, Munich, Germany

6. Colorectal surgery through the anus (transanal endoscopic microsurgery = TEM)

A technique called transanal endoscopic mucosal resec-tion or full-thickness resection can be used as a less inva-sive alternative to low anterior resection or abdomino-perineal resection for tumors which are benign or in the early phase of malignancy (Fig. 25).

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Fig. 25Transanal excision of sessile rectal polyps or early rectal cancer

This technique does not require open abdominal surgery because the entire surgical procedure is performed through the anus. Specially designed instruments are used to cut out the benign or malignant tumor in the shape of a block with an adequate safety margin on all sides, after which the hole in the rectum is stitched back together (Fig. 26). The advantage of this technique is the fact that patients heal very quickly from surgery. The disadvantage is that it does not provide any information about wheth-er the cancer has spread to lymph nodes. Therefore, this technique should only be used for rectal tumors in the very early stage of malignancy, since the probability that the cancer has metastasized to lymph nodes is very low in this situation. If the rectal cancer is already larger, it must be removed radically, meaning together with the lymphatic vessels, using an abdominal incision as described above (see Fig. 21). This procedure should only be per-formed by specially-trained surgeons.

Fig. 26 (A, B)Transanal endoscopic microsurgery (TEM) for the

endoscopic removal of benign and malignant rectal tumors

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A

B

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4.5 How does treatment proceed after surgery?

For planned surgery, the follow-up treatment after sur-gery can usually be fast-tracked. The treatment strategy is based on the principle of “less stress means a faster recovery”. After surgery, patients spend a short amount of time under monitoring and are then brought directly to their room. The breathing tube used by the anesthesiol-ogist to provide artificial ventilation during surgery is re-moved while the patient is still in the operating room. Drainage tubes for secretions from abdominal wounds are rarely used nowadays and are removed soon after surgery. A stomach probe is also removed at the end of surgery. The urine catheter collecting urine from the bladder does not cause any pain and is removed a few days after surgery.

Patients are usually allowed to at least drink tea and eat soup on the first day after surgery, and may even be able to eat normal solid food. Intravenous fluids are continued for several days. Each patient is provided individually- optimized pain therapy which may be combined with an epidural catheter that provides pain management through a catheter near the spinal cord. During this phase, it is important that patients are actively involved in the recovery process.

While it is possible to be discharged back home from day 5 after surgery with close monitoring, doctors usually wait until the critical period through day 7 after surgery is com-plete, meaning that most patients are discharged around day 8.

Every patient should try to spend as much time as possi-ble out of bed, for example sitting in a chair or walking around. Compression stockings and/or heparin injections are necessary to prevent thrombosis. The sutures in the skin can typically be removed after 10 days.

In Germany, every cancer patient has the right to apply to the social services for rehabilitation after surgery if de-sired. In Switzerland, patients can apply for rehabilitation to their health insurance company.

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5

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Risks and complications of surgery5.1 What complications may occur after

colorectal surgery?5.2 What are the long-term consequences

of surgery?

Risks and complications of surgery

5.1 What complications may occur after colorectal surgery?

Every operation, even routine surgery, is associated with risks and hazards. Complications after surgery are caused not just by the surgical procedure itself, but even more so from heart, lung, and metabolic comorbidities. Therefore, all risk factors should be addressed before a patient under-goes surgery, and preventive measures should be taken to minimize the risks whenever possible. When these re-quirements are met, surgery is usually successful, and hos-pitalization can be kept short. A crucial component of preparation is an in-depth explanation by the doctor to the patient of the precise procedure for surgical prepara-tion, the surgical procedure itself, and post-surgical treat-ment. The patient should understand the purpose or need for specific actions. This discussion is necessary in order for the patient to be motivated to actively support the recovery process.

Thanks to modern surgical, anesthesia, and intensive care methods, even extended operations are typically less stress-ful to the body nowadays, and are associated with fewer risks and complications than even a few years ago. After surgery, you should not feel much pain, bowel activity should quickly return to normal, and you should be back on your feet in no time. Nonetheless, issues may still arise after major abdominal operations that not only impact patients’ well-being but also jeopardize their health and prolong their hospital stay. Serious complications of color-ectal surgery include the following:

Bleeding

Blood coagulation is performed during surgery with great care. The main risk of bleeding after surgery occurs during the first 24 hours after the operation. Small blood vessels or wounds that are not bleeding at the end of surgery may start to bleed after surgery. Although bleeding from

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larger vessels is extremely rare, it requires immediate at-tention. You will be monitored closely so that any such bleeding can be identified quickly. At 1%, the risk of bleeding after surgery is very low.

Leaky surgical connection (anastomotic leak)

Leaky stitches at the two newly connected ends of the colon are a relevant complication that typically occurs around day 7 after surgery. This can be caused by inade-quate blood supply to the area around the connection (anastomosis) that may cause the contents of the bowel to leak. There is a higher risk of leakage from the surgical connection in rectal operations near the anal sphincter and operations performed after radiation therapy.

The rate of anastomotic leaks after colorectal surgery should be below 2–3%, and 10–15% after rectal surgery. Warning symptoms of leaks are increasing abdominal pain and fever after surgery. Because the risk of anasto-motic leaks is higher after rectal surgery than other colorec-tal operations, it is sometimes necessary to prepare the bowel with a cleansing solution and an antibiotic the day before surgery. The creation of a temporary stoma may also be necessary for rectal surgery for this reason (see Chapter 11).

Wound infections

In every operation, there is a risk that the bacteria in the gut will contaminate the abdomen. To prevent this from occurring, special preventive measures (hygienic measures, antibiotics) are taken during every operation. Nonetheless, infected wounds near the abdominal incisions may occur in up to 5% of patients. While these infections are usually harmless, they may prolong hospitalization.

Postoperative ileus

The gut does not function properly right after colorectal surgery. This condition is called postoperative ileus and should be kept as short as possible after surgery. To keep

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this condition as short as possible, patients are given something to drink as early as the first day after surgery; in some circumstances they may also be temporarily given bowel-stimulating medications and urged to walk. Flatu-lence or bowel movements should return in the first 3–4 days after surgery.

Pain

Each patient experiences a different degree of pain after surgery. If you are pain-free, you can start walking soon after surgery, which lowers the increased risk of deep vein thrombosis or pneumonia caused by lying for a long time. This also allows you to start physical therapy sooner, which is important for recovery.

Good pain management helps improve breathing. For all of these reasons, patients are automatically given regular pain medication after surgery and are prescribed other medications if the pain continues. Although pain follow-ing surgery is a normal reaction of the body to the oper-ation, there is no reason to suffer through this pain with-out medication. Accordingly, every patient will receive an individually-optimized pain medication to make hospital-ization after surgery as restful as possible.

5.2 What are the long-term consequences of surgery?

The most common long-term consequences of colorectal surgery are digestion problems. These issues vary with the extent of the bowel segment removed. However, following a readjustment period, most colorectal operations should not have a major impact on stool quality.

Removal of segments of the intestine may lead to soft stools or diarrhea. Depending on how much of the colon was removed, the ability of the rest of the colon to solid-ify digested food may be limited, causing more water to be retained and excreted. However, as the body adjusts to this new situation, stool quality will improve over time

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and diarrhea will decrease. Even if diarrhea persists, it can be managed well using antimotility and other anti-diarrheal medications.

If your rectum was removed, you may experience an in-creased urge to defecate or even incontinence (inability to control flatulence or bowel movements) to differing de-grees during the initial phase. However, if these issues persist they can be improved with training.

A temporary or permanent stoma may also be a conse-quence of major colorectal surgery.

Rectal surgery in general may cause bladder dysfunction. Men may also occasionally experience sexual dysfunction (impotence) caused by stimulation or injury to nerves im-mediately adjacent to the area operated upon. These symp-toms are often temporary. Thanks to new surgical tech-niques and advances in existing techniques, long-term problems are very rare.

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Fig. 27 (A, B)Microscopic image of colorectal cancer

Upper panel:Transition from healthy colonic mucosa (right)

to adenocarcinoma (left)Lower panel:

Enlarged view of the adenocarcinoma from the panel above

What is the purpose of pathology testing of excised tissue?

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What is the purpose of pathology testing of excised tissue?

After surgery is complete, tissue from surgery is tested by a pathologist. Pathologists are doctors who are specialized in testing tissue samples (biopsies) taken before or during surgery using histology and molecular pathology methods.

A

B

A

B

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C

D

Fig. 27 (C, D)Microscopic image of colorectal cancerUpper panel:Adenocarcinoma surrounded by cancerous connective tissue(Elastica van Gieson staining)Lower panel:Mucus production in the adenocarcinoma(Alcian blue/periodic acid-Schiff; mucus stained blue)

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The tissue biopsy is subject to special preparation and dif-ferent tissue dyes and is then examined under a micro-scope (Fig. 27, A–D). During this test, the pathologist also examines all lymph nodes in the biopsy to determine the stage of the tumor. The depth of the tumor and the de-gree of tumor differentiation are of crucial importance. The important criteria for lymph nodes are the number in the tissue sample and to how many the tumor has spread. It is crucial that the cut edges of the excised tissue are cancer- free. It typically takes 3–5 days to analyze the tissue ex-cised during surgery. During surgery, the pathologist may perform a rapid biopsy test to determine whether the tu-mor has spread to the margins of the incision.

Examination of the tissue biopsy can provide the following important information:

1. Tumor location and size2. Tumor classification (TNM stage)3. Additional molecular pathology (genetic) tests

Your discharge letter should report the tumor classification that characterizes your colorectal cancer. This classifica-tion is reported using the UICC (Union for International Cancer Control) international criteria with the TNM classi-fication.

The TNM classification reflects the extent of spread of an individual tumor for each patient and is crucial for future treatment.

The classification is divided into the following items:

• T = Tumor: The T stage describes the extent of tumor spread to the individual layers of the intestinal wall. The T stage is subdivided into T1–T4.

• N = Lymph nodes: The N status describes the presence or absence of metastases in local lymph nodes. The pres-ence of metastases in local lymph nodes is always asso-ciated with a worse prognosis. If the cancer has spread to lymph nodes, chemotherapy is usually recommended after surgery. The N stage is subdivided into N0–N2.

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• M = Metastases: The M status indicates the presence or absence of distant metastases in other organs. The M stage is subdivided into M0 or M1.

4. UICC tumor staging

Based on the tumor findings and the resulting T, N, and M classifications, a tumor stage can be assigned to each cancer patient according to UICC criteria. These criteria differentiate between four stages (I–IV) (Fig. 28).

Stage I: T1 or T2 N0 M0

Stage II: T3 or T4 N0 M0

Stage III: any T N1 or N2(lymph node metastases present)

M0

Stage IV: any T any N M1 (distant metastases present)

4.1 Grading

Grading indicates the differentiation of the tumor. G1 denotes well-differentiated colorectal cancer, G2 denotes moderately differentiated cancer, and G3 denotes poorly differentiated cancer. The degree of differentiation de-scribes how similar the tumor tissue appears under the microscope compared with the original, healthy bowel tissue. G1 tumors are less biologically aggressive than G3 tumors.

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Fig. 28The four stages of colon cancer

5. R classification

The R classification describes how much of the cancer re-mains in the body (residual tumor status). This scale eval-uates the amount of tumor tissue remaining in the body and assesses whether cancer remains at the margins of the tissue removed. The greater the distance between the resection margin and the tumor, the better the patient’s prognosis.

This classification is divided as follows:

• R0 = The tumor is not visible with the naked eye or microscopically.

• R1 = Residual tumor can be detected by microscope.• R2 = Residual tumor can be detected by naked eye

(macroscopically).

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6. Other parameters in tumor classification

In addition to the mandatory parameters listed above, there are a number of other categories that can be in-cluded in the cancer formula. A lower-case “p” prefix means that the classification was based on pathological examination, which is the most accurate form of meas-urement (e.g. pT3). In contrast, a “c” denotes only a clin-ical appraisal based on imaging techniques (e.g. cN0, this is usually the case before surgery). The letters “L0/L1”, “V0/V1/V2” and “Pn0/Pn1” can also be added next to the TNM classification and denote spread of the cancer to lymphatic vessels, blood vessels (vascular), and along nerve sheaths (perineural).

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Will I need additional treatment after surgery?7.1 When is chemotherapy recommended?7.2 How does chemotherapy work?7.3 What are the side effects?7.4 When is radiation therapy recommended?

Will I need additional treatment after surgery?

7.1 When is chemotherapy recommended?

Adjuvant chemotherapy

Chemotherapy is recommended if spread of the cancer to the lymph nodes is detected by the biopsy examination or in a high-risk situation. In these cases, it is possible that some cancer cells may remain in the body after surgery despite complete removal of the tumor. The tumor may have already disseminated secretly. There is about a 50% probability that tumor cells are hidden somewhere in the body and cannot be detected using the standard methods of examination. In this situation, large, international stud-ies have shown that preventive (also called “adjuvant”) chemotherapy can greatly reduce the risk of recurrence. Your doctor will recommend chemotherapy to you in this situation. Why preventive? Since the tumor was complete-ly removed and we are basing our assumptions on the probability that tumor cells still remain somewhere in the body. In this situation, your doctors will assume that the cancer has been cured. Adjuvant chemotherapy reduces the absolute risk of cancer recurrence by about 3% in stage II (with risk criteria, including whether the tumor broke during surgery, whether the tumor had already mi-grated to other organs, or whether fewer than 12 lymph nodes were removed) and 10–15% in stage III depending on the number of lymph nodes affected and removed. There are also other special situations in which adjuvant chemotherapy is recommended. If there are findings point-ing to these situations, your doctors will discuss the risks and benefits of chemotherapy with you and you can reach a decision together.

Neoadjuvant chemoradiotherapy

For patients with locally advanced rectal tumors in the middle and lower thirds of the rectum, a treatment called “neoadjuvant” is typically performed before planned sur-gery. This treatment consists of a combination of chemo-

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therapy and radiation therapy of the tumor (chemoradio-therapy). This chemoradiotherapy is typically performed daily over a period of 5–6 weeks. The goal of this treat-ment is to lower the probability of cancer recurrence after successful surgery, an outcome that has been demon-strated in international studies. For rectal tumors located directly next to the sphincter, neoadjuvant chemoradio-therapy can often allow surgery that leaves the anal sphinc-ter intact and maintains bowel control, meaning you will not require a stoma. For neoadjuvant treatment of locally advanced rectal cancer, there is also the option of solely short-term radiation therapy for 5 days before surgery but without chemotherapy. Talk with your doctor about which regimen is best for you.

Palliative chemotherapy

“Palliative” chemotherapy is used when metastases have already been found, for example in the liver or the lung. The goal of chemotherapy in this situation is to improve quality of life and prolong survival. Patients with meta-static colorectal cancer can now live for many years with the disease thanks to different forms of chemotherapy that can be individually optimized to the patient’s cancer. Although unfortunately a cure is sadly often not possible, it is also not impossible. In some cases, metastases may be suppressed so well by chemotherapy that they can be removed by surgery, for example with liver and lung me-tastases. In these cases, there is a chance of a long-term cure from the disease. In order to provide each patient with the best chance of being cured or being able to live as long as possible without (chemo-)therapy, interdiscipli-nary tumor boards should always discuss the option of local treatment methods (surgery, radiation therapy, nu-clear medicine procedures, or radiofrequency ablation by a radiologist) in addition to chemotherapy. These differ-ent treatment options should therefore always be discussed at a dedicated colorectal cancer center with a high level of expertise.

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7.2 How does chemotherapy work?

The principle of chemotherapy is the destruction of cells that divide rapidly: namely, cancer cells. The medications (chemotherapeutic agents) are distributed by the blood-stream throughout the entire body (systemic therapy), which means that they target not only cancer cells but also healthy cells that divide rapidly. This feature can cause many side effects that will be described in detail later. As a result, treatment must be performed by a specially trained team consisting of a doctor (oncologist) and nurs-ing staff. The selection of a chemotherapy from the avail-able options (including 5-fluorouracil and folic acid, oxali-platin, irinotecan, capecitabine, and trifluridine/tipiracil) depends on both the stage of the disease and on the patient’s comorbidities and overall condition. These medi-cations are almost always combined into so-called regi-mens (e.g. FOLFOX regimen), but they can also be given individually (monotherapy). In theory, you can take chemo-therapy as an outpatient as long as you have no medical conditions that would require you to be hospitalized. Chemotherapeutic drugs are typically injected into a vein (intravenously). It is often beneficial and more comfortable to patients for a central venous port to be inserted below the clavicle; for regimens with 5-fluorouracil this is even a requirement. Only capecitabine and trifluridine/tipiracil are taken as tablets. Medications called antibody therapies may also be given to improve the effectiveness of a regimen. These therapies consist of proteins that bind to specific structures on the surface of cancer cells that are impor-tant for the growth of the cancer. This binding allows growth signals for the cancer cell or the tumor blood supply to be inhibited. There are antibodies which inhibit angiogenesis (= formation of new blood vessels), namely bevacizumab, aflibercept, and ramucirumab. Other an-tibodies target the epidermal growth factor (cetuximab and panitumumab). The molecular structure of the tu-mor and its location in the colon determine which anti-body should be given together with chemotherapy. Dur-ing the metastatic stage, response to treatment is the

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main determinant of the length of treatment. Depending on how well a patient tolerates treatment, it is usually con-tinued until best response, after which treatment switches to a low-dose maintenance therapy. There may also be a break in treatment known as a treatment holiday. In the adjuvant setting (meaning after surgery), either mono-therapy with 5-fluorouracil or capecitabine, or combina-tion therapy with oxaliplatin and 5-fluorouracil or cape-citabine is administered. Antibodies have no benefit in “adjuvant” therapy. According to the latest research, treat-ment is only required for 3 months if the cancer has al-ready spread to lymph nodes. Treatment should only last for 6 months in a high-risk situation in which the tumor has penetrated the abdominal wall or if it has spread to many lymph nodes. The shorter treatment period greatly reduces the rate of side effects, particularly neuropathy.

7.3 What are the side effects?

As mentioned above, chemotherapy also limits the ability of healthy tissues to divide. Several different side effects can, but do not always, result from this process. Bone marrow, which produces white blood cells, red blood cells, and platelets, is particularly sensitive to chemotherapy, which often results in infections, anemia, or bleeding over the course of treatment. For this reason, blood tests must be performed regularly. A particularly important parame-ter in these tests are white blood cells (leukocytes) which help defend the body from infections. If leukocyte counts drop too low, it may be necessary to stop chemotherapy until their levels recover. Other side effects include nausea and vomiting. However, prophylactic injection of drugs called antiemetics (medications against nausea) are given before each chemotherapy and may effectively suppress nausea and vomiting. Loss of appetite, a distorted sense of taste, and diarrhea may also occur. These side effects go away once treatment is complete. One side effect that is stressful for many patients is hair loss. However, com-plete loss of hair is not expected for any of the medica-tion regimens currently used against colorectal cancer.

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Hair always regrows after the end of treatment. The anti-bodies listed above are generally tolerated well. Because they are proteins, allergic reactions are possible. Whereas cetuximab and panitumumab can cause acne-like skin rashes, be alert to the possibility of an increased risk for bleeding, thrombosis, and embolisms, delayed wound healing, high blood pressure, and reduced kidney func-tion with bevacizumab.

7.4 When is radiation therapy recommended?

Tumor cells can be attacked effectively using radiation therapy (radiotherapy). The electromagnetic waves used in this treatment are comparable to those used in X-rays, but contain much more energy. Like chemotherapy, this treatment is also performed by a specialized team (radia-tion therapy specialist, radiation oncology specialist). Radi-ation therapy kills many more tumor cells than chemother-apy. However, it only has local effects and cannot destroy micrometastases like chemotherapy can. These two pro-cedures (radiation therapy and chemotherapy) can also be combined (chemoradiotherapy). In this combination, chemotherapy primary bolsters the local effects of radia-tion therapy. Radiation therapy and chemoradiotherapy are often used on rectal cancer either before the planned surgery (neoadjuvant) or after surgery (adjuvant). Radia-tion therapy is only performed on colon cancer in excep-tional cases.

Several tests are required before starting radiation therapy to determine the volume and fields to be irradiated and to calculate the radiation dose in detail. The radiation therapy itself is then performed for several minutes for 5 days a week, usually over a period of 5–6 weeks. Short-er radiation regimens with larger individual doses are also used. Radiation therapy can usually be performed on an outpatient basis. The most common side effects of radia-tion therapy include gastrointestinal and bladder irritation (frequent bowel movements, frequent urination, urge to urinate or defecate, diarrhea) and irritated skin (redness,

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dryness). Should these side effects occur, they usually re-solve within several days to weeks after radiation therapy.

Discolored skin and hardening of the subcutaneous fat layer are occasionally observed as delayed reactions. Radia-tion therapy may also be beneficial as local treatment of metastases from colon or rectal tumors. For example, about 2 weeks of radiation therapy to treat painful bone metastases generally leads to rapid improvement of symp-toms and to long-term stabilization of the bones in the irradiated area. High-precision radiation therapy (stereo-tactic radiation therapy) with a slightly higher dose of ra-diation may lead to long-term management (reduction or prevention of further growth) of metastases in the liver, lungs, brain, or soft tissue. This very well tolerated method is used particularly when very few metastases (1–3) are located in each of these organs.

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8What is the likelihood of being cured?

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What is the likelihood of being cured? The prognosis and the likelihood of being cured depend primarily on whether the primary tumor and its associated lymph nodes could be completely removed. If the cancer is detected at an early stage and removed soon, the chances of being cured are very good. As a general rule, well above 50% of all colorectal cancer patients can be cured permanently with modern medicine. The prognosis becomes less favorable if the cancer has already metas-tasized to other organs like the liver, lungs, or the perito-neum by the time of diagnosis. At these late stages of cancer, the treatment strategy must be planned accord-ing to how widespread these metastases are.

For these patients, individual treatment strategies are often proposed in addition to established recommendations. A tumor board of cancer experts should decide which path is best. Many large hospitals hold special tumor confer-ences to discuss such complex cases (see Chapter 3).

A patient’s prognosis can be gauged using tumor staging. However, this estimate is very imprecise for any specific patient due to the influence of many other factors, so each patient still represents a unique situation. A patient’s phys-ical fitness and emotional attitude, as well as support in dealing with the anxiety triggered by the disease, can all have positive effects. Should you desire psychological support, oncology psychiatrists are available at any time.

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9

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What is the follow-up care for colorectal cancer?9.1 General recommendations9.2 What are the elements of follow-up care

for cancer?

What is the follow-up care for colorectal cancer?

9.1 General recommendations

Patients with UICC stage II or III colorectal cancer should receive follow-up care if new treatment for recurrence or metastases is a possibility due to age and general health status. Follow-up care for cancer should be planned and organized by a main coordinator (general practitioner or specialist) with consultation and advice from the other doctors involved in care (surgeons, gastroenterologists, on-cologists, radiation oncology specialists, radiologists, etc.).

Once your tumor has been removed by surgery, you will be informed about whether and how often regular follow- up care will be needed. The primary goal of follow-up care is to detect any new tumor growth (recurrence) or metastases and take steps to treat them as soon as pos-sible. There are usually good treatment options for can-cer recurrence or metastases as well. The first 2 years after cancer are especially important for follow-up care, since the risk of cancer recurrence is highest during this period.

Because the risk of cancer recurrence decreases every year, follow-up care for cancer can usually be stopped after 5 years.

9.2 What are the elements of follow-up care for cancer?

1. The basic elements of follow-up care include discus-sions with your doctor, physical examinations, and labo-ratory blood tests that include the tumor marker CEA. Depending on the follow-up schedule, these examinations should be held every 3–6 months during the first 3 years, and once per year during years 4 and 5. While follow-up screening for tumor recurrence is only required for 5 years, screening for new tumors (secondary tumors or new colon polyps) must continue.

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2. Colonoscopy is another basic element of follow-up care. If it was not possible to perform a complete colonoscopy before colorectal surgery (for example because the device could not move past the tumor or because it was an emergency surgery), the first colonoscopy is recom-mended 6 months after colorectal surgery. If a complete colonoscopy was performed before surgery, the first colo-noscopy after surgery will be performed after 12 months. If the colonoscopy findings are normal (no adenoma, no cancer), the future intervals can be extended to every 5 years, consistent with the recommended intervals for regular preventive colorectal cancer screenings.

3. For patients with rectal cancer, proctoscopy is also rec-ommended after 6, 12, 18, and 24 months. Naturally, any of these appointments can be skipped if a complete co-lonoscopy is planned for the same date. While the German recommendations only recommend proctoscopy at these appointments, the Swiss recommendations combine these examinations with endoscopic ultrasound or a pelvic MRI.

4. Abdominal ultrasound is recommended in Germany as a follow-up imaging procedure: every 6 months during the first 2 years, and once per year during years 3, 4 and 5. There are currently no consensus recommendations for routine computed tomography (CT) scans during follow- up care. A one-time CT scan of the lungs, abdomen, and pelvis after surgery is only recommended for patients with rectal cancer to collect a baseline image at 3 months after cancer-specific therapy (surgery or last dose of chemother-apy). In contrast, guidelines by both the Swiss Society of Gastroenterology (SGG) and the American National Com-prehensive Cancer Network (NCCN) recommend annual CT scans of the lungs and abdomen within the first 3–5 years after treatment for patients with stage II or III cancer. Routine chest X-rays and PET examinations are not recommended. A doctor may recommend an annual lung X-ray, but only for patients with rectal cancer.

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