Clinical Practice Guideline for Cancer

of Colon and Rectum

.. 2547
10.9 100,000 7.3 100,000
50 1.6:1

12 2548

2548

1. ..
2. ..
3. ..
4. ....
5. ..
6. ..
7. .
8. ..
9. ..
10. ..
11. .. ..
12. ..

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1.
2.

3.
4.
5.
6.
7.
8.

..5
(Screening) ..6
1
(DRE)..........7
2
............................7
3
Double contrast barium enema..8
.9
(Colon cancer) 10
(Rectal cancer) 13
.16
(Complicated Colon and Rectum Cancer Surgery)
( Surveillance and Follow up ) 18
( Treatment of Recurrent Colorectal Cancer ) 19

... 20
Curative resection.23
Curative resection......24
Transanal Total Local Excision for Rectal Cancer...25
(Staging of Colon Cancer)...........................26
(Staging of Rectal Cancer)................................28
30
Adjuvant Chemotherapy for Colon Cancer33
Adjuvant Chemotherapy for Rectal Cancer...36
Chemotherapy regimens for Advanced or Metastatic Colorectal Cancer .........39
.42

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1.

2
(Strength of evidence)
(Consensus)

1
2A
2B
3

1
1,2A

1: ( randomized clinical trials

Meta analysis)

2A: 1 (
Phase II Cohort
Retrospective studies )

2 B:
1 2 A

2 B
1
3: 3
2
Randomized trial
3
: 1-2A
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2. (Screening)
(Early detection)
2
1. (High risk )
2. (Average risk )

(High risk)

1. 45
2.
2
3. Familial adenomatous polyposis Hereditary non-polyposis
colon cancer
4.

( )

(Average risk)

1. 50
2.
3. ulcerative colitis, polyp
4.

1. ( Digital Rectal Examination, DRE)
2. ( Fecal Occult Blood Test, FOBT )
3. Flexible Sigmoidoscopy 5
4. Double-contrast barium enema 5-10
5. (Colonoscopy) 10

1, 2 3

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1 (DRE)
Negative

Continue screening program

DRE
Positive
For
Tumour

Positive pathology

Treatment

Negative pathology

Re-biopsy

Biopsy
Negative pathology
Consult Expert

2
Negative

Repeat yearly

Positive

Colonoscopy or DCBE

FOBT

- NSAIDs

- 3
- Immunochemistry Guaiac-based nonrehydrated
-
- Double contrast barium enema

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3 Double contrast barium enema

Negative

Continue Screening program

DCBE
Colonoscopic Biopsy or Polypectomy
Positive
Colonoscopy not available

Colon

Surgery

Rectum Proctoscopic or sigmoidoscopic biopsy

Positive

Negative

Treatment

Rebiopsy or
Consult Expert

(Screening on demand)

Double contrast barium enema

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3.

1.
2. (DRE) Proctoscopy
3. Double contrast barium enema Colonoscopy
4.

5. Double contrast barium

enema Colonoscopy

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4. (Colon cancer)

(Clinical evaluation)
1. Chest x-ray
2. Liver ultrasonography CT abdomen
3. CEA

(Surgery)


(Bowel preparation)
1. Mechanical Bowel Preparation


2. Prophylactic Antibiotics
Gram negative Anaerobe
( )

(Adjuvant Therapy for Colon Cancer)

( )

1. Stage I Colon cancer ( T1-2 No Mo )

2. Stage II Colon cancer

2
(High-risk stage II Colon cancer) 2

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2.1 ( Stage II A Colon cancer with

high risk factors for systemic recurrence) T3 Colon cancer
Poorly differentiated Undifferentiated tumor
Lymphatic Vascular invasion
Tumor obstruction
Tumor perforation
Resected lymph node less than 12 nodes
Adjuvant chemotherapy ( )
2.2 (Stage II Colon cancer with
high risk for local recurrence)
T4 lesion
T3 with localized perforation
Positive margin closed margin
Adjuvant chemotherapy ( )
( )

3. Stage III Colon cancer

Stage III A T1-2 N1 M0
Stage III B T3-4 N1Mo
Stage III C any T N2 M0
Adjuvant chemotherapy
( ) T4 lesion ( )

4. Stage IV Colon cancer, any T any N M1

4.1 Synchronous Liver Metastasis
4.1.1 Liver metastasis (Curative resection)
Adjuvant chemotherapy ( ) Liver metastasis
12

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4.1.2 Liver metastasis (Unresectable liver

metastasis) chemotherapy ( )
Palliative care
4.1.3 Radiofrequency ablation Liver metastasis
( 2 B)
4.2 Synchronous lung metastasis
4.2.1 Metastasis
( Staged operation) Adjuvant chemotherapy
( )
4.2.2 Palliative chemotherapy ( )
Palliative care
4.3 Other metastasis
Palliative chemotherapy ( ) Palliative care

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5 (Rectal cancer)

(Clinical evaluation)
1. Colonoscopy Double contrast Barium enema Virtual Colonoscopy
2. CT whole abdomen CT pelvis Liver ultrasonography MRI rectum
Liver ultrasonography
3. Endorectal ultrasonography ( )
4. Chest x-ray
5. CEA

1. Clinical staging C
cT2 Endorectal ultrasonography U uT3
2. specimen Pathological staging
p pT2 ( )

1. Neoadjuvant therapy Clinical staging

Adjuvant therapy
2. Neoadjuvant therapy Pathological staging
Adjuvant therapy
3. Transanal total local excision Nodal status Nx
4.

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Clinical staging
1. Clinical staging cT1-2 No Mo
2
- Transabdominal resection ( )
- Transanal total local excision ( )

1.1 Transabdominal resection

1.1.1 pT1-2 No Mo
-
1.1.2 pT3 No Mo pT1-3 N1-2 Mo
- Postoperative chemoradiotherapy ( . )(2B)

1.2 Transanal Total Local Excision

1.2.1 pT1Nx, Margin negative
-
1.2.2 pT2 Nx Margin negative
- Transabdominal resection
- Chemoradiotherapy
( )
1.2.3 pT1-2 Nx Unfavorable feature
Positive margin
Lymphovascular invasion
Poorly differentiation

- Transabdominal resection

- Chemoradiotherapy
( )

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2. Clinical staging cT3 No T-any N1-2

2

2.1 Preoperative neoadjuvant chemoradiotherapy ( .)

Transabdominal resection Adjuvant chemotherapy ( )
2.2 Transabdominal resection
2.2.1 pT1-2 No Mo
-
2.2.2 pT3 No Mo pT1-3 N1-2 Mo
- Postoperative adjuvant chemoradiotherapy (
.)(2B)

3. Clinical staging cT4 Locally unresectable

- Preoperative neoadjuvant chemoradiotherapy ( .)
- Post-operative adjuvant chemotherapy ( .)
- Palliative care

4. Clinical staging any T-any N-any M1

4.1 Resectable metastasis 2
4.1.1 Metastasis Curative resection
metastasis

- T1-2 N0 M1 Postoperative adjuvant chemotherapy ( )
- T3-4, N-any T-any, N1-2 Postoperative chemoradiotherapy (
.)
4.1.2 Preoperative Chemoradiotherapy Neoadjuvant therapy ( .)
Metastasis Curative resection
Postoperative adjuvant chemotherapy ( )
4.1.3 Radiofrequency ablation Liver metastasis
( 2 B )

4.2 Unresectable metastasis

Palliative chemotherapy ( ) Palliative chemotherapy
Palliative care
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6.
(Complicated Colon and Rectum Cancer Surgery)

6.1 (Obstruction)
6.2 (Perforation)
6.3 (Locally advanced)
6.4 (Peritoneal metastasis)

6.1

Acute abdomen series

- Colonoscopy
- Limited barium enema Gastrograffin enema
- CT whole abdomen


1.
1.1 Right hemicolectomy
1.2 Extended right hemicolectomy
2.
2.1 Staged operation
- Diverting colostomy with subsequent resection
- Resection with colostomy (Hartmanns procedure End-colostomy
with mucous fistula)
2.2 Bowel resection with primary anastomosis after intraoperative lavage
2.3 Bowel resection with primary anastomosis after manual decompression
2.4 Subtotal colectomy
2.5 Self-expanding metallic stenting
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3.
3.1 Proximal colostomy with subsequent resection with/without preoperative
chemoradiotherapy
3.2 Hartmanns procedure
3.3 Bowel resection with primary anastomosis after intraoperative lavage with
or without proximal protective ostomy
3.4 Transanal colonic decompression
- Rectal tube
- Self-expanding metallic stenting

6.2
1. Caecum
Right hemi-colectomy with/without primary anastomosis
2.
2.1 Resection without
anastomosis
2.2 Caecum Subtotal colectomy
with/without anastomosis
3. Resection with Hartmanns
procedure

6.3
1. en bloc
2.

3. ( R2 resection ) Metallic clips

6.4
1. Palliative care
2. Palliative chemotherapy ( )
3. Intraperitoneal chemotherapy
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7.
(Surveillance and Follow up)

1. 3 2 6 5
2. CEA 3 2 6 5
3. Colonoscopy 1 3- 5
4. Colonoscopy 1 1

5. Colonoscopy

Double contrast barium enema

Colonoscopy 3-6
6. CT scan
Perineural Venous invasion Poorly differentiated
tumor
7. Lung Liver metastasis Chest x-ray CT chest CT
abdomen 3-6 2 6-12 5

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8.
(Treatment of Recurrent Colorectal Cancer)

8.1 (Anastomotic recurrence)

- Preoperative chemoradiotherapy (
) chemotherapy (
)
- Palliative chemotherapy
Palliative care

8.2 ( 2B)
-
Adjuvant chemotherapy ( )
Unresectable disease

8.3 Unresectable disease

- Palliative chemotherapy Palliative care ( )

CEA
Colorectal cancer
(Postoperative rising of CEA)
(Surveillance)
CEA
- Colonoscopy
- CT abdomen Liver ultrasonography CT pelvis
- Chest x-ray CT chest

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A. Familial Adenomatous Polyposis (FAP)

a. Genetic testing
Flexible sigmoidoscopy 1-2 (puberty)
b. FAP
Sigmoidoscopy 10-12 Polyp
Colectomy
c. FAP
Colonoscopy 40

d. FAP

- Extracolonic manifestation
- Prophylactic colectomy Proctocolectomy
- Attennated FAP Colonoscopy

B. Hereditary Non-Polyposis Colorectal Cancer

(HNPCC)
Amsterdam Criteria Colonoscopy
20-25 2 40

C.
Amsterdam Criteria HNPCC
a. 1 60
Colonoscopy 10 40

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b. 1 60

Colonoscopy 3-5 40
10

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22

D. (Inflammatory Bowel Disease IBS)

- Colonoscopy IBS 8-10

- Colonoscopy IBS Remission
- 2-4 10 .

- Surveillance 8-10 Pancolitis 15-20
Left - sided disease
-


Pancolitis 10 Colonoscopy 3 20
2 30
- Primary sclerosing cholangitis Orthotropic liver
transplantation Colonoscopy

E. Polyp Tubular Adenoma

Polyp Colonoscopic polypectomy
Polyp
1. Polyp 1-2 Polyp Malignancy Follow-up
Colonoscope 5
2. Polyp Sessile Non-invasive cancer
Polyp Colonoscope 3
3. Invasive cancer Polyp Colon resection

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Curative resection
1. 5 . Proximal Distal margin
2. Venous Lymphatic drainage
3. Caecum Ascending colon Right
hemicolectomy
4. Hepatic flexure Extended right
hemicolectomy Middle colic artery
5. Transverse colon
7.1 Hepatic flexure Extended right hemicolectomy
7.2 Hepatic Splenic flexure Transverse
colectomy Extended right hemicolectomy
7.3 Splenic flexure Left segmental colectomy
Subtotal colectomy
6. Splenic flexure Left hemicolectomy
Segmental resection Transverse / Descending colon
Subtotal colectomy
7. Descending colon Left hemicolectomy
Limited resection ( Left colic artery )
8. Sigmoid colon Sigmoid colon resection
9. Regional lymph node stage II
( T3-4, No ) Negative
12
10. Anastomosis
( Staple )
11. Laparoscopic colectomy

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(Rectum) curative resection

1. (Upper rectum) 5 .
5 .
Adequate mesorectal excision
2. (Middle and Lower rectum)
5 . 2 . free margin
(Total mesorectal excision)
3. Distal free margin
Abdominoperineal resection
4. Transanal total local excision (
)
5. (Stapler)
6. (Laparoscopic colectomy)

7. Rectal cancer stage II ( T3-4 N0M0)

Negative 4

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Transanal Total Local Excision for Rectal Cancer
- Transanal Total Local Excision

- 30 %
- 3 .
- Free margin 3 .
- Mobile, Fix
- Anal verge 8 .
- Clinical staging T1 T2
- Clinical staging No
- Malignant polyp
- Lymphovascular Perineural invasion
- Well Moderately differentiated adenocarcinoma

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(Staging of Colon Cancer)
American Joint Committee of Cancer (AJCC) TNM system
Primary Tumor (T)
TX
Primary tumor cannot be assessed
To
No evidence of primary tumor
Tis
Carcinoma : intraepithelial or invasion of lamina propria
T1
Tumor invades submucosa
T2
Tumor invades muscularis propria
T3
Tumor invades through the muscularis propria into the subserosa or into non
peritonealized pericolic or perirectal tissues
T4
Tumor directly invades other organs or structures, and /or perforates viscera
peritoneum
Regional Lymph Nodes (N)
No
No regional lymph node metastasis
N1
Metastasis in 1 to 3 regional lymph nodes
N2
Metastasis in 4 or more regional lymph nodes
No lymph nodes
12 nodes suboptimally staged high risk group
Distant Metastasis (M)
MX
Distant metastasis cannot be assessed
Mo
No distant metastasis
M1
Distant metastasis
Histologic Grade (G)
GX
Grade cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiatied
G4
Undifferentiated

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Stage Grouping of colon cancer

stag
O
I
IIA
IIB
IIIA
IIIB
IIIC
IV

T
Tis
T1
T2
T3
T4
T1-T2
T3-T4
Any T
Any T

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N
No
No
No
No
No
N1
N1
N2
Any N

M
Mo
Mo
Mo
Mo
Mo
Mo
Mo
Mo
M1

28

(staging of rectal cancer )

American Joint Committee on Cancer (AJCC)
TNM system
Primary Tumor (T)
TX
Primary tumor cannot be assessed
To
No evidence of primary tumor
Tis
Carcinoma : intraepithelial or invasion of lamina propria
T1
Tumor invades submucosa
T2
Tumor invades muscularis propria
T3
Tumor invades through the muscularis propria into the subserosa,or into
non- peritonealized pericolic or perirectal tissues
T4
Tumor directly invades other organs or structures, and/or perforates
visceral peritoneum
Regional Lymph Nodes (N)
NX
Regional lymph nodes cannot be assessed
No
No regional lymph node metastasis
N1
Metastasis in 1 to 3 regional lymph nodes
N2
Metastasis in 4 or more regional lymph nodes
N0 lymph node 4
nodes suboptimally staged
Distant Metastasis (M)
MX
Distant metastasis cannot be assessed

Mo
M1

No distant metastasis
Distant metastasis

Histologic Grade (G)

GX
Grade cannot be assessed

G1
G2
G3
G4

Well differentiated
Moderately differentiated
Poorly differentiatied
Undifferentiated

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Stage Grouping of rectal cancer

stag
O
I
IIA
IIB
IIIA
IIIB
IIIC
IV

T
Tis
T1
T2
T3
T4
T1-T2
T3-T4
Any T
Any T

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N
No
No
No
No
No
N1
N1
N2
Any N

M
Mo
Mo
Mo
Mo
Mo
Mo
Mo
Mo
M1

30

( Colon Cancer )
/
( Local field irradiation )
CT abdomen / Surgical
clips

Local field irradiation

/ ( Surgical
clips ) 3-5
Linear accelerator Cobalt -60 unit
Conventional Radiation 3D-Conformal Radiation
1.8-2 Gy/ , 1 , 5 45-50
Gy/25-28 /5-51/2
45 Gy

( Rectal Cancer )

Whole pelvic irradiation ( Linear
accelerator ) -60 3-4 ( Multiple fields technique )
3 field technique ( Postero-anterior (PA) filed 2-Lateral fields ) 4 Field
technique ( Antero-posterior (AP), Postero-anterior (PA) 2-Lateral fields)
20 AP/PA-opposing
fields Cobalt-60
Whole pelvic irradiation : . Full bladder
PA/AP fields

Sacral promontory 1.5 L5-S1

Common iliac

perineum Obturator foramen
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2-5 Abdominoperineum
resection (APR) Perineum
Perineum

Pelvic inlet bony pelvis 1.5-2

2
2-Lateral field
PA/AP field

Rectum Perirectal tissue Sacrum

Coccyx Internal iliac
Presacral Sacrum
1.5-2

1/3 Symphysis pubis

Internal iliac
Symphysis pubis
External iliac

Linear accelerator Cobalt-60 unit

Conventional Radiation

1.8-2 Gy/ , 1 , 5 45-50

Gy/25-28
( Close positive margins (R1 R2 margins )
/ ( Surgical clips)
2 5.4-9 Gy/3-5 )

45 Gy

1. ( ECOG 2-4 )
Local field irradiation Conventional radiation
2. ( ECOG 0-1)
Whole pelvic irradiation / Local field irradiation Conventional
radiation 3D-Conformal RT Intra-operative radiation therapy

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: Intra-operative radiation therapy ( IORT)

10-20 Gy

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Adjuvant Chemotherapy for Colon Cancer
Adjuvant chemotherapy Colon cancer Stage III colon
cancer High-risk stage II colon cancer 6-8
Regimen
Regimen/Stage
II high risk
Mayo
+
Roswell-Park
+
Capecitabine
+*
Uracil/Tegafur/Leucovorin
+*
FOLFOX4
+*
de Gramont (LV5FU2)
+*
FOLFIRI
+
-
* 2B

III
+
+
+
+
+
+
-

IV postmetastectomy
+*
+*
+*
+*
+*
+*
+*

Bolus or infusional 5-FU/leucovorin

1. Mayo Regimen(1, 2)
- Leucovorin 20 mg/m2/day IV bolus, days 1-5
- 5FU 375-425 mg/ m2/day IV bolus after Leucovorin , days 1-5
- Repeat every 4-5 weeks for 6 cycles
2. Roswell Park regimen(3, 4)
- Leucovorin 500 mg/ m2/ day IV bolus once a week, for 6 weeks, followed by
2 weeks rest
- 5FU 500 mg/ m2/ day IV bolus after Leucovorin
- Repeat every 8 weeks for 4 cycles
Capecitabine(2)

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- 2,500 mg/ m2 /day divided into 2 doses, days 1-14, followed by 7 days rest
- Repeat every 3 weeks for 8 cyles
Uracil/Tegafur/ Leucovorin(3)
- Tegafur 300 mg/m2/day in 3 divided doses, day 1-28, followed by 7 days rest
- Leucovorin 60-90 mg/d in 3 divided , day 1-28, followed by 7 days rest
- Repeat every 5 weeks for 5 cycles.
FOLFOX 4(5)
- Oxaliplatin 85 mg/ m2/ day IV over 2 hour, day 1 simultaneously with
- Leucovorin 200 mg/ m2/ day IV over 2 hours, days 1 and 2
- 5FU 400 mg/ m2/ day IV bolus, then 600 mg/ m2/ day IV over 22 hours continuous
infusion, days 1 and 2
- Repeat every 2 weeks for 12 cycles
de Gramont (LV 5 FU2)(5)
- Leucovorin 200 mg/ m2/day IV infusion over 2 hours , days 1 and 2
- 5FU 400 mg/m2 IV bolus, then 600 mg/m2 IV over 22 hours continous infusion, days 1
and 2
- Repeat every 2 weeks for 12 cycles
FOLFIRI(6)
1) Irinotecan 180 mg/ m2/day IV infusion over 2 hours, day 1
- Leucovorin 200mg/ m2 IV infusion over 2 hours prior to 5FU, days 1 and 2
- 5FU 400 mg/ m2 IV bolus, then 600 mg/ m2 IV over 22 hours continuous
infusion,
days 1 and 2
- Repeat every 2 weeks for 12 cycles

2) Irinotecan 180 mg/ m2/day IV infusion over 90 minutes, day 1

- Leucovorin 200mg/ m2 IV infusion over 2-hour infusion during irinotecan, day 1
- 5FU 400 mg/ m2 IV bolus, then 2.4-3 g/m2 IV over 46 hours continuous
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iinfusion
- Repeat every 2 weeks for 12 cycles
Regimen

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Adjuvant Chemotherapy for Rectal Cancer
1. Preoperative chemoradiotherapy Neoadjuvant chemoradiotherapy
1.1) 5FU 1000 mg/ m2/ day IV continuous IV x 5 days during 1st and 5th week of Radio
therapy(7)
1.2) 5 FU 400 mg/ m2/ day IV after leucovorin 20 mg/ m2/ day IV for 4 days during 1st
and 5th week of radiotherapy(8)
1.3) 5 FU 225 mg/m2/day over 24 hours, 7 days per week during radiotherapy (9)
1.4) 5 FU 350 mg/ m2/ day IV and leucovorin 20 mg/ m2/ day IV for 5 days during 1st and
5th week of radiotherapy(10)
1.5) Capecitabine 1650 mg /m2/day during radiotherapy ( 2B)(11)

2. Postoperative adjuvant chemotherapy for patients receiving preoperative

chemoradiotherapy
2.1) 5FU 500 mg/ m2/ day IV bolus, days 1-5, every 28 days for 4 cycles(7)
2.2 ) 5FU 380 mg/ m2/ day IV bolus, days 1-5 after Leucovorin 20 mg/ m2/ day IV bolus,
days 1-5 every 28 days for 4 cycles (12)
2.3) 5FU 500 mg/ m2/ day IV bolus after Leucovorin 500 mg/ m2/ day infusion over 2
hours
once a week, for 6 weeks, followed by 2 weeks rest, every 8 weeks for 3 cycles(13)
2.4) Capecitabine 2500 mg /m2/day in two divided doses, days 1-14, followed by 7 days
rest. Repeat every 3 weeks for 4 cycles.( 2B)(11)

3. Postoperative adjuvant regimens for patients not receiving preoperative therapy

3.1) 5FU Leucovorin 2 cycles then Concurrent chemoradiotherapy, followed by 5FU
Leucovorin 2 cycles dose
3.1.1) 5FU 425 mg/ m2/ day IV bolus after Leucovorin 20 mg/ m2/ day IV
bolus, days 1-5 and days 29-33(8)
3.1.2) followed by Concurrent chemoradiotherapy
chemotherapy 2

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a.) 5FU 400 mg/ m2/ day IV bolus after Leucovorin 20 mg/ m2/ day IV
bolus for 4 days during 1st and 5th week of Radiotherapy(8)
b.) 5FU 225 mg/ m2/ day continuous infusion for 24 hours 7 days /week
during Radiotherapy(9)
3.1.3 )
5FU 380 mg/ m2/ day IV bolus after Leucovorin 20 mg/m2/ day IV
bolus , days 1-5 , every 4 weeks, for 2 cycles(8)

3.2) 5FU +leucovorin 1 cycle then Concurrent chemoradiotherapy followed by

5 FU + Leucovorin 2 cycles dose (12)
3.2.1) 5 FU 500mg/ m2 IV bolus after Leucovorin 500 mg/ m2/ day IV infusion over
2
hours, once a week, for 6 weeks
3.2.2) followed by Concurrent chemoradiotherapy chemotherapy
2
a.) 5FU 400 mg/ m2 / day IV bolus after Leucovorin 20 mg/ m2 /day IV bolus,
days1-4, during 1st and 5th week of Radiotherapy(8)
b.) 5FU 225 mg/ m2/ day continuous infusion for 24 hours 7 days /week
during radiotherapy (9)
3.2.3) 5 FU + leucovorin dose 3.2.1
cycle 2 weeks rest

3.3 FOLFOX4 2 cycles then Concurrent chemoradiotherapy, followed by

FOLFOX4 2 cycles dose ( 2B)(12)
3.3.1) Oxaliplatin 85mg/m2/day IV over 2 hour, day 1 simultaneously with
- Leucovorin 200 mg/m2/day IV over 2 hours days 1 and 2
- 5FU 400 mg/m2 IV bolus,then 600 mg/m2 IV over 22 hours continuous
infusion, days 1 and 2
- Repeat every 2 weeks for 2 cycles
3.3.2 followed by Concurrent chemoradiotherapy chemotherapy
2

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a.) 5 FU 400 mg/ m2/day+leucovorin 20 mg/ m2/day for 4 days during 1st and 5th
week of radiotherapy(8)
b) 5 FU 225/m2/day continuous infusion for 24 hours 7 days /week during
radiation(9)
c) FOLFOX 4 3.3.1
Regimen

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Chemotherapy Regimens for Advanced or
Metastatic Colorectal Cancer
Regimens

1. Bolus or infusional 5FU/Leucovorin

1.1 Mayo Regimen(14)
- Leucovorin 20 mg/m2 IV bolus, days 1-5
- 5FU 375-425 mg/m2 IV bolus after Leucovorin , days 1-5
- Repeat every 4-5 weeks for 6 cycles
1.2. Roswell Park regimen(13)
- Leucovorin 500 mg/ m2 /day IV bolus once a week, for 6 weeks,
followed by 2 weeks rest
- 5FU 500 mg/ m2/ day IV bolus after Leucovorin
- Repeat every 8 weeks for 4 cycles
1.3 de Gramont(15)
- Leucovorin 200 mg/m2 IV infusion over 2 hours , days 1 and 2
- 5FU 400 mg/m2 IV bolus, then 600 mg/m2 IV over 22 hours
continous infusion, days 1 and 2
- Repeat every 2 weeks

2. Bolus or infusional 5FU/ Leucovorin + Bevacizumab

2B ( 12 )

3. Protracted IV 5FU(16)
- 5FU 300 mg/m2 /day, continuous infusion

4. Capecitabine(17)
- Capecitabine 2,500 mg/ m2/ day IV divided into 2 doses, days 1-14,
followed by 7 days rest
- Repeat every 3 weeks

5. Uracil/Tegafur Leucovorin(18)
- Tegafur 300 mg/m2/day in 3 divided doses, day 1-28, followed by 7 days
rest
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- Leucovorin 60-90 mg/d in 3 divided , day 1-28, followed by 7 days rest

- Repeat every 5 weeks

6. FOLFOX4*(19)
- Oxaliplatin 85 mg/m2 IV infusion over 2 hour, day 1 simultaneously with
- Loucovorin 200 mg/m2 IV infusion over 2 hours, days 1 and 2
- 5FU 400 mg/ m2 IV bolus, then 600 mg/ m2 IV over 22 hours continuous
infusion, days 1 and 2
- Repeat every 2 weeks for 12 cycles

7. FOLFOX4 + Bevacizumab ( 12 )
8. FOLFIRI* (20)
8.1) Irinotecan 180 mg/ m2 IV infusion over 2 hours, day 1
- Leucovorin 200mg/ m2 IV infusion over 2 hours prior to 5-FU, days 1
and 2
- 5FU 400 mg/ m2 IV bolus, then 600 mg/ m2 IV over 22 hours
continuous infusion, days 1 and 2
- Repeat every 2 weeks
8.2) Irinotecan 180 mg/ m2 IV infusion over 90 minutes, day 1
- Leucovorin 200mg/ m2 IV infusion over 2-hour infusion during
irinotecan, day 1
- 5-FU 400 mg/ m2 IV bolus, then 2.4-3 g/m2 IV over 46 hours
continuous infusion
- Repeat every 2 weeks

9. FOLFIRI + Bevacizumab ( 12 )
10.Irinotecan (21)
10.1). Irinotecan 125mg/ m2 IV infusion over 90 minutes, once a week for 4
weeks
- Repeat every 6 weeks
10.2. Irinotecan 300-350mg/ m2 IV infusion over 90 minutes, day 1
- Repeat every 3 weeks

11. IFL + Bevacizumab ( 12 )

12. Bevacizumab Cetuximab
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41

2

1. Regimen

2. Regimen *

..

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