Colorectal cancers

Colonoscopy is an endoscopic examination that is performed at the Division of Gastroenterology and Digestive Endoscopy; it allows the gastroenterologist to examine the inner wall of the intestine, starting from the rectum and going up to the colon, using the colonoscope, a probe mounted on a long, flexible tube and equipped with a video camera, which is inserted into the rectum and sends images back to a computer screen. The probe also allows the physician to take abnormal tissue fragments (thus to take biopsies) or to remove any polyps (or adenomas)-excrescences that form on the inner wall of the intestine and can develop into tumors-which will then undergo histological examination.

The procedure, which is usually done on an outpatient basis, can be uncomfortable or even painful, so a mild sedative. There is preparation in the days leading up to the examination, which is explained to the patient when booking the examination.

Virtual colonoscopy may be useful to complete the diagnosis when colonoscopy was not sufficient. It is performed at the Division of Radiodiagnostics and consists of a Low-dose radiation CT which allows the radiologist to obtain three-dimensional images of the intestines.

The procedure involves the oral administration of a contrast agent containing iodine and the introduction of a small rectal probe that causes no pain. However, this examination does not allow the removal of any polyps.

Once the presence of the tumor is established, the following may be necessary other instrumental examinations to assess the size, location, and possible spread of the disease to other organs.

To complete the diagnosis of colon cancer can be performed:

• CT scan of the abdomen and pelvis with contrast medium,
• Ultrasound of the abdomen,
• Chest X-ray.

For the diagnosis of rectal cancer, on the other hand, they may be necessary:

• MRI of the pelvis with contrast medium,
• Transrectal ultrasonography,
• Echo-endoscopy.

Through a blood test it is also possible to measure the amount of two particular proteins that may be produced by colorectal cancer cells (which is why they are called tumor markers): CEA (Carcino-Embryonic Antigen) and CA19-9. Their concentration is related to the extent of the tumor and usually increases as the tumor progresses, so these markers, when present, help to assess the severity of the disease, to follow the progress of the disease, and to evaluate the effectiveness of treatment.

Definitive diagnosis of colorectal cancer is obtained through histological examination, performed by an anatomo-pathologist on tissue samples taken during colonoscopy.

The removed polyps are analyzed for shape, size, and cellular characteristics so as to determine their benign or malignant nature. If the polyp is malignant (adenocarcinoma), the cells are evaluated according to their degree of similarity to healthy cells, speed of growth, and ability to invade surrounding tissues. These elements make it possible to define the tumor’s degree of malignancy, generally expressed on a scale of 1 to 3.

Histological examination also applies to tissue fragments taken during colonoscopy in suspicious areas. If the tumor has already infiltrated the intestinal wall or other structures, it may be a sign of more advanced disease and a possible risk of metastasis.

This step is critical because it provides accurate information that guides the choice of the most appropriate treatment, allowing the care pathway to be tailored and increasing the likelihood of success.

In the case of advanced or metastatic cancer, themolecular profile analysis of the tumor To identify possible alterations in disease genes. The information obtained from this analysis is important for establishing prognosis and planning the therapeutic strategy for each patient: indeed, certain alterations are associated with better or worse disease course and sensitivity to molecularly targeted drugs.

In particular, possible mutations in genes such as RAS and BRAF, which determine cell survival and proliferation, and mutations in MMR genes, which are involved in DNA repair functions.

Endoscopic treatment is often considered for early colorectal cancers, particularly carcinoma in situ or superficial tumors. These treatment options include:

• Endoscopic mucosal resection (EMR): is an endoscopic procedure to remove superficial or precancerous lesions of the rectum colon without the need for open surgery;
• Endoscopicextended submucosal dissection (ESD): is an advanced endoscopic technique to remove larger, invasive tumors that extend to the submucosa of the rectum.

Surgery is performed in almost all cases of colorectal cancer, especially if the disease is in the early stages. Depending on the location and extent of the tumor, surgery may be more or less conservative.

If the tumor is small and in a very early stage, it is possible to remove it directly during colonoscopy, then endoscopically.

Even early and small rectal tumors, if their location permits, can be excised endoscopically through the anus.

If, on the other hand, the tumor has invaded part of the surrounding tissues, surgery is required, which, at the Candiolo Institute, is always performed, when possible, with minimally invasive, laparoscopic and robotic techniques, that is, using camera-equipped instruments that are introduced into the intestinal cavity through small incisions in the abdominal area. These procedures reduce hospital stay time and postoperative complications compared with traditional surgery.

The innovative minimally invasive surgery technologies available to the Institute-such as the 4K laparoscopic columns and the intraoperative fluorescence – offer the surgeon extremely detailed spatial orientation and enable him to perform maneuvers with the utmost precision in even complex surgeries.

During surgery to remove part or all of the colon (colectomy), tumor-affected segments of the colon and surrounding lymph nodes are removed, after which the ends of the interrupted bowel are rejoined. When the surgeon needs to remove the final part of the intestine, or when it is necessary to keep the operated section of intestine at rest to promote healing, the colon is diverted and put in communication with the outside through an opening(stoma) created by the surgeon on the abdomen and connected to a stool collection bag. This procedure, called colostomy, in most cases is temporary-and thus normal intestinal transit is restored at a later surgery-but in some cases it can also be permanent.

In any case, physical and psychological rehabilitation of the patient is necessary after this type of surgery.

At the Candiolo Institute, surgery is complemented by a protocol of post-operative clinical and care management called ERAS(Enhanced Recovery After Surgery), which promotes rapid recovery of patient autonomy after surgery, decreases hospitalization time and reduces the incidence of complications.

The protocol involves a team of different specialists (surgeon, anesthesiologist, dietitian, nurse, psychologist, physical therapist, social worker) who manage the patient’s journey in a coordinated manner, and is based on pain control, use of minimally invasive surgical techniques, preoperative counseling, and early postoperative rehabilitation.

It provides the patient with nutritional support that avoids pre-operative fasting, targeted anesthesia that allows him or her to feed rapidly by natural means, reduced use of tubes, drains, and IVs, and early mobilization.

The term chemotherapy refers to the drugs aimed at blocking or eliminating cancer cells Taking advantage of their faster reproduction rate than healthy ones. Because it interferes with the replication mechanisms of cells, chemotherapy also damages healthy cells in the body, causing side effects that fortunately in most cases disappear once the treatment is over.

Before therapy begins, the oncologist provides guidance on the drugs to be used and behaviors to be taken to alleviate side effects.

In colorectal cancer, chemotherapy can be given at different points in the course of treatment:

• after surgery (adjuvant chemotherapy) to reduce the risk of disease relapse (recurrence);
• before surgery (neoadjuvant chemotherapy) to reduce the tumor mass and facilitate surgical removal; in rectal cancers, neoadjuvant chemotherapy is combined with radiation therapy;
• when the tumor has spread to other organs, so it is metastatic, to relieve disease symptoms, improve quality of life and prolong survival. In selected cases the
  chemotherapy, by reducing the size of metastases, allows the integration of the following into the treatment
  Of metastatic disease other treatment strategies (surgery, interventional radiology,
  radiotherapy).

There are many chemotherapy drugs and they are often used in combination with each other.

The way chemotherapy is administered varies depending on the type of tumor and the drugs: it can be taken orally, in tablet form, but more often it is administered intravenously. The intravenous administration is performed on an outpatient basis and its duration can vary from minutes to hours depending on the drugs used.

The chemotherapy is given “in cycles”: each cycle lasts for a few days and is followed by a few weeks of rest. The number of cycles depends on the type of tumor and, of course, the response to the drugs, which can vary greatly from patient to patient.

Biological therapies, also called molecular targeted therap ies or target therapies, are targeted treatments that selectively act on specific targets found primarily in cancer cells. These targets-such as receptors, enzymes, or growth factors-are involved in the processes that promote uncontrolled cell growth, resistance to traditional therapies, and the formation of new blood vessels that feed the tumor.

An important target in colorectal cancer treatments is the EGFR (epidermal growth factor receptor) protein. When this receptor is blocked, activation of the RAS gene, which is implicated in tumor proliferation and spread, can be disrupted. This is where specific drugs, such as cetuximab and panitumumab, laboratory-produced monoclonal antibodies that mimic the action of the immune system, act.

Another strategy is to inhibit angiogenesis, which is the formation of new blood vessels that allow the tumor to grow and spread. In this case, drugs such as bevacizumab and aflibercept block vascular growth factor VEGF.

These therapies are administered intravenously and, in most cases, are combined with chemotherapy in patients with advanced or metastatic disease. The goal is to improve treatment efficacy, slow disease progression and, when possible, prolong survival while maintaining a good quality of life.

Immunotherapy is a therapeutic approach that does not act directly on cancer cells, but reactivates the immune system’s defenses, which are often weakened or blocked by the tumor itself.

In colorectal cancer, research is investigating drugs that can “take the brakes off” the immune system, allowing it to recognize and eliminate cancer cells again. These drugs, called immune checkpoint inhibitors, have proven effective only in a subpopulation of patients (about 15 percent) whose tumor has a defect in DNA repair mechanisms(mismatch repair deficiency, dMMR).

At present, immunotherapy in the colorectum is used in experimental settings and mainly in some cases of metastatic disease, but preliminary results indicate promising potential, paving the way for increasingly personalized therapies.

Radiation therapy consists of the use of high-energy radiation targeted at the level of the tumor mass. It does not require hospitalization and is administered in consecutive daily sessions, Monday through Friday.

Radiation therapy is not usually used for colon cancer., except when the disease is advanced (stage IV) or has developed metastases for palliative purposes.

It is, however, indicated for the treatment of cancers of the rectum, usually associated with chemotherapy, and can be used before surgery with a neoadjuvant, to reduce the extent of the tumor mass, or after surgery with an adjuvant, to reduce the risk of loval recurrence. It is also used for palliative purposes in Locally advanced rectal cancers, to relieve symptoms and slow tumor progression.

Treatment for colorectal cancer often involves side effects that impact quality of life more or less severely. However, they can be mitigated and in some cases prevented by specific treatments and/or appropriate lifestyle.

At the Candiolo Institute, the doctors and nurses of the multidisciplinary team are available to provide the patient with all the support he or she needs to manage the various side effects he or she will face in the course of treatment.

The impact of cancer in a person’s life also affects the psychological sphere: getting cancer is in fact always a traumatic event that affects all dimensions of a person and can generate anxiety, fear, anger, and depression.
At the Candiolo Institute, alongside cutting-edge therapies, the treatment and care pathway always includes qualified psycho-oncological support that helps patients cope positively not only with treatment but also with the delicate phase of physical and psychological recovery.
You can also participate in psychological support groups to compare yourself with others who have gone through or are going through the same experience.

The cancer patient is often a fragile patient, who needs help and support in his or her disease journey: when he or she experiences an ailment, whether related to the disease or a side effect of therapy, he or she should be able to receive a specialist’s opinion quickly, through a “fast track.”

For this reason, at the Candiolo Institute there is an assistance service every day, Monday through Friday from 8 a.m. to 5 p.m.: just call the secretary of the Oncology Day Hospital (011.993.3775) reporting the need for an urgent consultation, and the patient is quickly contacted by his or her specialist doctor.

The care pathway for a cancer patient is not just about the disease, but about the whole person. Coping with cancer means living with physical symptoms, such as pain or weight loss, and with an emotional impact that can be profound. Therefore, comprehensive support that takes into account both the body and the mind is essential.

At the Candiolo Institute, any patient who wants or needs it can count on a multidisciplinary team ready to take care of every aspect of his or her health and well-being, offering:

• Nutritional support, to maintain strength and energy during treatments

• psychological support, to deal with emotional difficulties and regain balance

• Physiotherapy, to preserve and recover mobility and quality of life

• Medication and management of venous access devices to ensure safety and comfort

• Pain therapy, to minimize physical suffering

• Management of any other conditions, for comprehensive and personalized care

Only 5% of colorectal cancer cases are caused by rare inherited genetic disorders.

The best known are:

• Familial Adenomatous Polyposis (FAP), due to mutations in the MUTYH gene, which increases the risk of developing other types of cancer in addition to colon cancer;
• Lynch syndrome, which increases the risk of developing colorectal cancer, as well as other cancers, before age 50.

The Candiolo Institute has an outpatient genetic counseling clinic where a geneticist, an expert in hereditary-familial cancers, offers cancer risk assessment counseling and genetic testing to patients who need it.

People at high genetic risk of developing colorectal cancer are placed in a specific diagnostic surveillance program.

The Social Service Department of the Candiolo Institute conducts information and orientation interviews for patients and their families on how to access services in the area and how to obtain welfare and social security benefits provided by law (disability, benefits for aids and prostheses, work leave, etc.).

The service operates on Wednesdays and Fridays from 9 a.m. to 1 p.m. – Phone: 011 993 3059

With the conclusion of the treatment course begins an equally important phase: follow-up.
During this period, through scheduled visits and examinations, the side effects of therapies, their effectiveness, and the patient’s functional recovery are monitored.
Follow-up plays a key role: it allows early detection of any recurrence and early intervention with the most appropriate therapies.

For the patient, each follow-up meeting is also a time for dialogue with their physician, to share concerns, symptoms, or new needs, and to receive reassurance and personalized guidance.

The specialist sets up a tailored follow-up schedule, establishing frequency and type of examinations based on the early stage of the disease and the treatments received.

Generally, for colorectal cancer, the follow-up program includes:

• Medical examination and blood tests

  • Every 3 months in the first 3 years

  • Every 6 months in the 4th and 5th year

  • Subsequently, once a year

• CT scan of chest and abdomen alternating with abdominal ultrasonography

  • Every 6 months in the first 3 years

  • Then annually until the 5th year

• Colonoscopy

  • Within 1 year after surgery

  • Then at 3 years old

  • Every 5 years thereafter

Follow-up typically extends for 5 to 10 years, with a closer follow-up frequency at the beginning, gradually thinning out over time, accompanying the patient on a surveillance course.

Due to the high number of cases treated each year, the Candiolo Institute is a national reference for taking care of colorectal cancer. Our experience enables us to deal with even the most complex situations, always with a personalized approach built on the clinical and personal profile of each patient.

Establishing the treatment plan always starts with an accurate and timely diagnosis. Patients have access to state-of-the-art imaging technologies that allow accurate assessment of the extent of the disease.

In addition, the Institute offers advanced and sophisticated laboratory investigations, including molecular and genomic analyses, which are critical for identifying biological features of cancer and guiding therapeutic decisions

When indicated, surgery is performed with minimally invasive techniques (laparoscopic or thoracoscopic), which reduce operative trauma, promote faster recovery, and improve postoperative quality of life. Every treatment choice is defined within the GIC, ensuring a consistent and integrated approach.

As an IRCCS, the Candiolo Institute combines clinical practice with a strong vocation for scientific research. Patients can be evaluated forinclusion in active clinical trials, which provide a real opportunity to access innovative therapies not yet available in standard practice. Collaboration between care and research is a distinctive value that translates into concrete opportunities for the patient.

The Interdisciplinary Care Group takes care of the person at every stage: from diagnosis to treatment to follow-up, with attention to nutritional support, psychological health, and reintegration into daily life. The organization of checkups, visits and treatment is designed to ensure continuity and serenity, always valuing the human dimension of care.