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Richtlijn Colorectaal Carcinoom 2014 1 2 3 4 5 Richtlijn Colorectaal Carcinoom 6 en Colorectale Levermetastasen 7 Richtlijn Colorectaal2014 carcinoom en colorectale levermetastasen – NOG NIET GEAUTORISEERD 1 8 9 Inhoud 10 1 ALGEMEEN 4 11 2 SCREENING 6 12 3 DIAGNOSTIEK 8 13 3.1 Diagnostiek primaire tumor 8 14 3.2 Aanvullende beeldvorming rectumcarcinoom 13 15 3.3 Beeldvorming bij levermetastasen en extrahepatische afwijkingen 18 16 3.4 Diagnostische laparoscopie bij levermetastasen 24 17 4 PATHOLOGIE 26 18 4.1 Vereiste klinische gegevens 26 19 4.2 Minimale rapportage in conclusie 26 20 4.3 Minimum aantal lymfeklieren 28 21 4.4 TNM 29 22 4.5 CRM en kwaliteit chirurgie 30 23 4.6 Beoordeling na neoadjuvante therapie 32 24 4.7 Moleculaire analyses 33 25 4.7.1 Resistentiebepaling: KRAS-mutatieanalyse 33 26 4.7.2 MSI-onderzoek 34 27 4.8 Pathologie van leverresecties 36 28 5 PRIMAIRE BEHANDELING COLONCARCINOOM 38 29 5.1 T1 invasief carcinoom in een poliep 38 30 5.2 Laparoscopische chirurgie 42 31 5.3 Peri-operatieve zorg 45 32 5.4 Obstructief coloncarcinoom 49 33 5.5 Multimodale behandeling Bij T4 coloncarcinoom 55 34 6 ADJUVANTE SYSTEMISCHE THERAPIE 58 35 6.1 Stadium 58 36 6.2 Adjuvante chemotherapie voor het coloncarcinoom 58 37 6.3 Adjuvante chemotherapie voor het rectumcarcinoom 62 38 7 PRIMAIRE BEHANDELING RECTUMCARCINOOM 64 39 7.1 Neoadjuvante radiotherapie 64 40 7.2 Totale Mesorectale Excisie (TME) 70 41 7.3 Rectumsparende behandeling 73 42 7.3.1 cT1-2 74 43 7.3.2 cT2N0 met neoadjuvante therapie 77 44 7.3.3 cT3N0-1 met neoadjuvante therapie 78 45 7.3.4 ypT0-1 na (chemo)radiotherapie en lokale excisie 79 46 7.3.5 ypT2-3 na (chemo)radiotherapie en lokale excisie 80 47 7.3.6 Klinisch complete respons na chemoradiotherapie 81 48 7.4 Centralisatie van T4 en lokaal recidief 85 49 8 METASTATISCHE ZIEKTE 89 50 8.1 Chirurgische behandeling van colorectale levermetastasen 89 51 8.2 Lokale therapie bij niet resectabele levermetastasen 97 52 8.3 Peritonitis carcinomatosa 103 53 8.4 Systemische behandeling 105 54 8.4.1 Primair resectabele metastasen 105 55 8.4.2 Primair irresectabele maar potentieel resectabele metastasen. 106 56 8.4.3 Permanent irresectabele metastasen 108 57 Richtlijn Colorectaal carcinoom en colorectale levermetastasen – NOG NIET GEAUTORISEERD 2 58 59 9 DE OUDERE PATIËNT 116 60 10 NAZORG EN NACONTROLE 117 61 10.1 Follow-up 117 62 10.2 Signalering en behandeling van de gevolgen colorectaal carcinoom 122 63 10.2.1 Fecale incontinentie 122 64 10.2.2 Mictie problemen na rectumchirurgie 124 65 10.2.3 Seksueel disfunctioneren na de behandeling van een rectumcarcinoom 126 66 10.3 Ondersteunende zorg 127 67 11. COMMUNICATIE EN BESLUITVORMING 130 68 12. ORGANISATIE VAN ZORG 134 69 12.1 De diagnostische fase 134 70 12.2 De behandelfase 135 71 12.3 De nazorgfase 136 72 12.4 Ondersteunende zorg 138 73 Referenties 141 74 75 Richtlijn Colorectaal carcinoom en colorectale levermetastasen – NOG NIET GEAUTORISEERD 3 76 1 ALGEMEEN 77 Aanleiding 78 In 2011 is het verzoek vanuit de Landelijke Werkgroep Gastro-Intestinale Tumoren (LWGIT) gekomen 79 om de richtlijnen coloncarcinoom en rectumcarcinoom (beiden uit 2008) te reviseren. Naar aanleiding 80 hiervan is een landelijke richtlijnwerkgroep colorectaal carcinoom opgericht. Na een landelijke 81 knelpunteninventarisatie en prioritering van de ingebrachte knelpunten zijn elf uitgangsvragen 82 geformuleerd die volgens evidence based methodiek zijn uitgewerkt. Uit de ingezonden knelpunten 83 bleek dat revisie van de richtlijn colorectale levermetastasen tevens wenselijk was, waarna deze 84 richtlijn is gereviseerd en integraal in de richtlijn colorectaal carcinoom is opgenomen. De reeds 85 bestaande teksten van de drie richtlijnen zijn volgens consensus based methodiek door de 86 werkgroepleden herschikt, ontdubbeld en waar nodig van een update voorzien. Uiterlijk in 2016 wordt 87 door de eigenaars van de richtlijn bepaald of deze richtlijnteksten aan revisie toe zijn en welke 88 procedure dan vereist is. 89 90 Doelstelling 91 Deze richtlijn is zoveel mogelijk gebaseerd op wetenschappelijk onderzoek en/of consensus. Het is 92 een document met aanbevelingen ter ondersteuning van de dagelijkse praktijkvoering van 93 zorgverleners die betrokken zijn bij patiënten met (een mogelijk) coloncarcinoom, rectumcarcinoom of 94 colorectale lever- of longmetastase(n). De richtlijn geeft aanbevelingen over de diagnostiek, 95 behandeling, nacontrole en nazorg en organisatie van zorg. De richtlijn beoogt hiermee de kwaliteit 96 van de zorgverlening te verbeteren, het klinisch handelen meer te baseren op bewijs dan op 97 ervaringen en meningen, de transparantie van keuze voor behandelingen te vergroten en de 98 diversiteit van handelen door professionals te verminderen. 99 100 Doelpopulatie 101 Per jaar wordt het colorectaal carcinoom bij circa 13.000 nieuwe patiënten vastgesteld. Bij ongeveer 1 102 op de 3 patiënten van deze groep gaat het om een rectumcarcinoom. In Nederland staat het 103 colorectaal carcinoom zowel bij mannen als bij vrouwen op de derde plaats van de oncologische 104 aandoeningen qua incidentie. Bij mannen volgt het colorectaal carcinoom met 14% van het totaal 105 aantal tumoren, na prostaatcarcinoom (22%) en huidkanker (exclusief basaalcelcarcinoom) (14%). Bij 106 vrouwen staat deze aandoening met 13%, na mammacarcinoom (29%) en huidkanker (exclusief 107 basaalcelcarcinoom) (15%) op de incidentielijst. Naar verwachting zal het aantal patiënten bij wie de 108 diagnose colorectaal carcinoom gesteld wordt in 2020 gestegen zijn tot ongeveer 17.000, als gevolg 109 van een licht stijgende incidentie (met name bij mannen), de bevolkingsgroei en de vergrijzing. 110 Het colorectaal carcinoom komt iets vaker voor bij mannen dan bij vrouwen en negentig procent van 111 de patiënten is 55 jaar of ouder. Meer informatie is te vinden op www.cijfersoverkanker.nl 112 113 Deze richtlijn is van toepassing op alle volwassen patiënten met een (verdenking op) een primair 114 colorectaal carcinoom als voor patiënten met (uitgebreid) gemetastaseerde ziekte. Er wordt extra 115 aandacht besteedt aan de oudere patiënt. Voor volwassen patiënten met een verhoogd risico op 116 erfelijke darmkanker is een aparte richtlijn beschikbaar. 117 118 Doelgroep 119 Deze richtlijn is bestemd voor alle professionals die betrokken zijn bij de diagnostiek, behandeling en 120 begeleiding van patiënten met een colorectaal carcinoom, zoals chirurgen, huisartsen, IKNL- 121 consulenten, internisten, MDL-artsen, MDL-verpleegkundigen, klinisch genetici, paramedici, 122 pathologen, radiologen, radiotherapeuten en verpleegkundig (specialist)en. 123 Tevens is de richtlijn gebruikt bij het ontwikkelen van een patiëntenvoorlichtingstekst vanuit de 124 Nederlandse patiënten consumenten federatie (NPCF). Naast informatie over diagnostiek en 125 behandeling geven we in deze richtlijn informatie over hoe de patiënt de verschillende ingrepen kan 126 beleven. 127 Richtlijn Colorectaal carcinoom en colorectale levermetastasen – NOG NIET GEAUTORISEERD 4 128 Werkwijze werkgroep 129 De werkgroep is in juli 2012 voor de eerste maal bijeengekomen. Op basis van een eerste 130 inventarisatie van knelpunten door werkgroepleden is een knelpunteninventarisatie gehouden door 131 middel van een enquête onder professionals die betrokken zijn bij patiënten met een colorectaal 132 carcinoom. Middels deze enquête hebben zestig professionals knelpunten geprioriteerd en/of 133 ingebracht. Daarnaast zijn aan de hand van een focusgroep bijeenkomst ervaringen van patiënten 134 voor wat betreft zorgverlening geïnventariseerd. De meest relevante knelpunten zijn uitgewerkt tot elf 135 uitgangsvragen. 136 Omdat in België ook een revisie van de richtlijn coloncarcinoom werd opgestart is samenwerking 137 gezocht en gevonden waardoor de beantwoording van de uitgangsvragen op het gebied van het 138 coloncarcinoom kon worden verdeeld. 139 Op het moment dat duidelijk werd dat de richtlijn colorectale levermetastasen in deze revisie 140 meegenomen werd is op dit gebied extra expertise aan de werkgroep toegevoegd. Ook is specifieke 141 kennis over de oudere patiënt aan de werkgroep toegevoegd door middel van een aparte 142 uitgangsvraag op dit gebied. 143 144 Voor iedere uitgangsvraag werd binnen de richtlijnwerkgroep een subgroep geformeerd. Voor de 145 evidence based uitgangsvragen werd het literatuuronderzoek, de (kritische beoordeling), de evidence 146 tabellen en het opstellen van een concept literatuurbespreking verzorgd door externe methodologen. 147 Werkgroepleden pasten afzonderlijk of in subgroepen de concept literatuurbespreking en conclusies 148 aan en stelden overige overwegingen en aanbevelingen op volgens de internationaal gebruikte 149 CoCanCPG formats ‘PICO’, ‘overige overwegingen’ en ‘formuleren van aanbevelingen’. 150 Er is voor de consensus based revisie geen systematisch literatuuronderzoek verricht door een 151 methodologisch expert; de werkgroepleden beoordeelden zelf de bij hen bekende literatuur. Op basis 152 hiervan hebben de werkgroepleden de wetenschappelijke onderbouwing en conclusies, overige 153 overwegingen en aanbevelingen geformuleerd. 154 De werkgroep heeft gedurende een periode van ongeveer zeven maanden gewerkt aan de tekst voor 155 de conceptrichtlijn. De teksten zijn tijdens plenaire, veelal telefonische, vergaderingen besproken en 156 na verwerking van de commentaren geaccordeerd. 157 158 De conceptrichtlijn is begin juni 2013 naar alle betrokken wetenschappelijke-, beroeps- en 159 patiëntenverenigingen en landelijke en regionale tumorwerkgroepen gestuurd voor commentaar
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