Colorectal carcinoma

Colorectal carcinoma is the second most frequent cause of cancer-related mortality in Italy, although rates are decreasing thanks to early diagnosis through screening tests and improved outcomes achieved with integrated therapeutic strategies. Staging, which defines the tumor’s location relative to the peritoneal reflection (intraperitoneal colon tumors or rectal tumors) and identifies possible distant metastases, is the first step in establishing the diagnostic-therapeutic pathway. 

Today, we have several therapeutic options available such as chemotherapy, targeted molecular therapy, and immunotherapy. Based on the biological characteristics of the tumor and the sites of disease, these treatments can be variably combined. 

DIAGNOSTIC PATHWAY AND TREATMENT STRATEGY DEFINITION 

FIRST VISIT:  

Patients may access the Medical Oncology 1, General Oncologic Surgery 2 – Colon-rectum, or Radiotherapy units through a first visit covered by the National Health Service (SSN), following a referral from their General Practitioner or a specialist from other external institutions. During the first visit—which must take place with the patient physically present—the patient’s clinical documentation is reviewed, also considering any intercurrent or previous conditions. Sometimes, during the visit, the tumor tissue used for diagnosis is requested for further diagnostic tests. Both patients with a recent diagnosis and those already followed elsewhere for diagnosis and therapy who are seeking a consultation may attend the first visit. 

DIAGNOSTIC PATHWAY: 

The diagnosis and staging of colon carcinoma include: 

• Patient examination 
• Colonoscopy or rectoscopy for biopsy and histological diagnosis 
• Blood tests including liver and kidney function and tumor markers 
• Chest-abdomen-pelvis CT scan with/without contrast medium 

For rectal carcinomas, locoregional staging of the disease (i.e., the relationship to surrounding organs, the presence of lymph nodes involved by the tumor, and the distance from the anal margin) is further refined with: 

• Lower abdomen MRI with contrast medium 
• Lower endoscopic ultrasound 

TREATMENT  

For each patient, we develop an individualized care plan based on the latest scientific standards. Whenever available, patients are always considered for participation in experimental clinical trials. Thanks to our active clinical research program, we often can offer innovative therapies, including treatments targeted to the tumor’s genetic features, immunotherapies, and approaches based on new mechanisms of action or novel strategies. 

Given the complexity and the need for integration of various disciplines (endoscopy, surgery, radiotherapy, medical oncology, radiology, pathology), throughout the diagnostic and therapeutic process, patient cases are appropriately discussed during a multidisciplinary meeting. When useful, patients are invited to a multidisciplinary consultation where they interact simultaneously with a surgeon, oncologist, and radiotherapist to discuss the treatment plan. 

TREATMENT OF LOCALIZED OPERABLE DISEASE 

For intraperitoneal colon and rectosigmoid junction tumors without metastases, surgery is the first therapeutic step, always performed within a reasonably short time. In selected cases, preoperative systemic treatments can be proposed, although these are a minority. 

Patients with rectal neoplasms are discussed in a multidisciplinary setting since the use of preoperative treatments (chemotherapy, radiotherapy, or chemoradiotherapy) in preparation for surgery is more frequent and requires careful coordination among staff from different departments. In very selected cases of rectal tumors with an excellent response to preoperative chemoradiotherapy, the possibility of foregoing surgical treatment is carefully analyzed and discussed with the patient. 

TREATMENT OF OPERATED DISEASE 

Adjuvant (precautionary) treatment (aimed at reducing the risk of recurrence): 

After surgery, some patients are recommended to undergo adjuvant treatment, which is a therapy aimed at eliminating any tumor cells not removed with surgery, thus reducing the likelihood of disease recurrence. 

Adjuvant therapy is started within 4-8 weeks, and its duration may be 3 or 6 months based on the characteristics of the operated disease. Through a network system with oncology centers throughout the national territory, we can refer patients to the most suitable oncology facility closest to their home. This allows the patient to continue treatment without disrupting their daily life. 

TREATMENT OF METASTATIC DISEASE 

Surgical treatment: 

For a small group of colon tumors, surgery is the best option even in the presence of metastases. Usually, these cases can require perioperative chemotherapy, and the choice of regimen depends on disease burden, surgical feasibility (resectability), and the molecular characteristics of the disease. 

Systemic treatment: 

In colorectal cancers with multiple sites of disease, systemic treatment is based on the molecular and biological characteristics of each tumor. Most patients benefit from intravenous chemotherapy combining fluoropyrimidines (oral or infusion regimens) with oxaliplatin and/or irinotecan, associated with monoclonal antibodies bevacizumab (anti-VEGF) or panitumumab/cetuximab (anti-EGFR). A small group of colon tumors with a specific molecular characteristic called "microsatellite instability" benefit from immunotherapeutic treatments that stimulate the immune system against the tumor without using chemotherapy. 

Treatment duration and any possible changes to the chosen therapeutic regimens in case of disease progression will be assessed based on tolerability and effectiveness, as well as the patient's clinical condition. 

Whenever possible, the opportunity to participate in a clinical trial should be prioritized. In our facility, various study protocols are available that provide personalized combinations tailored to the tumor’s biological characteristics, to provide each patient with the most effective therapeutic strategy. 

OUTPATIENT FOLLOW-UP AND CLINICAL CHECK-UP PROTOCOL: 

For patients not requiring further active treatments, periodic check-ups are proposed, including examinations, blood tests, and radiological investigations, aimed at identifying disease recurrence and monitoring the side effects of completed treatments.