Colorectaalcarcinoom Landelijke richtlijn, Versie: 3.0 Datum Goedkeuring: 16-04-2014 Methodiek: Evidence based Verantwoording: Landelijke werkgroep Gastro Intestinale Tumoren Inhoudsopgave Algemeen.......................................................................................................................................................1 Screening.......................................................................................................................................................4 Diagnostiek....................................................................................................................................................6 Diagnostiek primaire tumor................................................................................................................6 Aanvullende beeldvorming rectumcarcinoom..............................................................................9 Beeldvorming metastasen.........................................................................................................14 Laparoscopie bij levermetastasen....................................................................................................19 Puncties levermetastasen................................................................................................................19 Pathologie....................................................................................................................................................21 Vereiste klinische gegevens.............................................................................................................21 Minimale rapportage.........................................................................................................................22 Minimum aantal lymfklieren..............................................................................................................23 TNM..................................................................................................................................................24 CRM en kwaliteit chirurgie................................................................................................................25 Beoordeling na neoadjuvante therapie.............................................................................................27 Moleculaire analyses........................................................................................................................28 Mutatieanalyse...........................................................................................................................28 MSI-onderzoek...........................................................................................................................29 Pathologie van leverresecties..........................................................................................................31 Primaire behandeling coloncarcinoom.....................................................................................................33 T1 invasief carcinoom in poliep........................................................................................................33 Laparoscopische chirurgie...............................................................................................................36 Peri-operatieve zorg.........................................................................................................................39 Obstructief coloncarcinoom..............................................................................................................42 Multimodale behandeling bij T4........................................................................................................45 Primaire behandeling rectumcarcinoom...................................................................................................49 Neoadjuvante radiotherapie.............................................................................................................49 TME..................................................................................................................................................55 Rectumsparende behandeling.........................................................................................................57 cT1-2..........................................................................................................................................61 cT2N0 met neoadjuvante therapie.............................................................................................62 cT3N0-1 met neoadjuvante therapie..........................................................................................63 ypT0-1 na (chemo)radiatie en excisie........................................................................................65 ypT2-3 na (chemo)radiatie en excisie........................................................................................65 Respons na chemoradiotherapie...............................................................................................66 Follow-up...................................................................................................................................66 Centralisatie van T4 en lokaal recidief.............................................................................................67 Adjuvante systemische therapie...............................................................................................................70 Stadium............................................................................................................................................70 Adjuvante chemotherapie coloncarcinoom......................................................................................70 Adjuvante chemotherapie rectumcarcinoom....................................................................................74 Metastatische ziekte....................................................................................................................................76 Chirurgische behandeling.................................................................................................................76 Lokale therapie bij niet-resectabele metastasen..............................................................................83 Peritonitis carcinomatosa.................................................................................................................89 Systemische behandeling................................................................................................................90 Primair resectabele metastasen................................................................................................90 Primair irresectabele metastasen..............................................................................................91 Permanent irresectabele metastasen........................................................................................93 Duur van behandeling................................................................................................................97 Oudere patienten.......................................................................................................................97 i Inhoudsopgave De oudere patient........................................................................................................................................99 Nazorg en nacontrole................................................................................................................................100 Follow-up........................................................................................................................................100 Gevolgen van colorectaal carcinoom.............................................................................................104 Fecale incontinentie.................................................................................................................104 Mictieproblemen.......................................................................................................................107 Seksueel dysfunctioneren........................................................................................................109 Ondersteunende zorg.....................................................................................................................110 Communicatie en besluitvorming............................................................................................................113 Organisatie van zorg.................................................................................................................................117 Diagnostische fase.........................................................................................................................117 Behandelfase.................................................................................................................................118 Nazorgfase.....................................................................................................................................119 Ondersteunende zorg.....................................................................................................................120 Referenties.................................................................................................................................................123 Bijlagen......................................................................................................................................................219