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Colorectal cancer is the third most common malignancy and represents the third most likely cause of cancer related deaths worldwide with approximately 10% of patients with locally advanced colon cancer (LACC) presenting with peritoneal involvement (T4a) or invasion of adjacent organs (T4b) at the time of diagnosis. Accurate pre-operative staging is paramount, and while CT and MRI scans are useful in identifying lymph nodal involvement and distant metastasis, there is an inherent inability to accurately differentiate true invasion from the simple, inflammatory adherence to the neighbouring structures with these existing imagining modalities. Despite the advanced nature of this disease, extended and multivisceral resections with clear margins (R0 resection) combined with appropriate adjuvant treatments have been shown to result in good oncological outcomes and offer patients a real chance of cure. There is emerging evidence in the use of neoadjuvant chemotherapy (NAC) and/or radiotherapy in T4a/T4b colon cancers, these therapies have been successfully utilised in patients with non-obstructing LACC and appear to be a safe and effective way to increase chances of achieving a R0 resection without significant morbidity or mortality. This review is focused on preoperative workup, conventional treatment strategies and controversies in advanced T4 colon cancers.

Current management and controversies in management of T4 cancers of the colon—a narrative review of the literature