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Surveillance/ Screening Colonoscopy for Colorectal Cancer Dr. Jyothi Reddy, MD Dr. Akshra Verma, MD August 5, 2008 Why screen? Accounting for more than 50,000 deaths annually 70 to 80 % - Tumors can be resected Curative or palliative Adjuvant radiation therapy, chemotherapy Resection for localized disease five-year survival rate is 90 % Regional lymph node metastasis - 65% Screening Colonoscopy Guidelines Screening Modalities Colonoscopy – every 10 years FOBT-/FIT every year Fecal Immuno Testing- detect human Hb Flexible Sigmoidoscopy- every 5 years Annual FOBT + Flex. Sigmoidoscopy every 5 yr Air contrast barium enema Virtual colonoscopy CT colonography Magnetic resonance colonography Revision 30 year old male with no family history colon colorectal cancer Average risk screening - begin Colonoscopy at age 50 and then every 10 years Revision 30 year old male with a family history of father diagnosed with colorectal cancer at the age of 65 Average risk screening but begin Colonoscopy at age 40 and then every 10 years Revision 30 year old male with a family history of father diagnosed with colorectal cancer at the age of 55 Higher risk screening: Colonoscopy at age 40 and then every 5 years Revision 30 year old male with a family history of both mother and father diagnosed with colorectal cancer at the age of 65 Higher risk screening: Colonoscopy at age 40 and then every 5 years Surveillance Recommendations Asymptomatic Patients Low Risk Colonoscopy 5yrs High Risk Colonoscopy >10 Adenomas Colonoscopy < 3yrs Consider FAP Sessile polyp HGD In 3months Pedunculated HGD with stalk normal In 1 year Tubulovillous or villous In 3 years Sessile Adenomas Removed Piece Meal F/U in 2-6Months Once Complete Removal Surveillance As Per Endoscopist Hyperplastic Polyps As Avg Risk Unless R/O Hyperplastic Polyposis Syndrome Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm tubular adenomatous polyp is removed. Low risk – Repeat colonoscopy in 5 years Revision 55 year old male undergoes a screening colonoscopy and four 0.5 cm villous adenomatous polyp is removed. High risk – Repeat colonoscopy in 3 years Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm sessile tubular adenomatous polyp with high grade dysplasia is removed. Very high risk – Repeat colonoscopy in 3 months Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm sessile tubulvillous adenomatous polyp with no dysplasia is removed. High risk – Repeat colonoscopy in 3 years Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm sessile tubular adenomatous polyp with no dysplasia is removed. Low risk – Repeat colonoscopy in 5 years Revision 55 year old male undergoes a screening colonoscopy and one 1.5 cm pedunculated tubular adenomatous polyp is removed. High risk – Repeat colonoscopy in 3 years Revision 55 year old male undergoes a screening colonoscopy and three 1.5 cm hyperplastic polyps are removed in the rectum. Repeat colonoscopy in 10 years Question A 63-year-old man underwent complete resection of a T3N0M0, stage II adenocarcinoma of the ascending colon No adjuvant therapy is planned. No family history of colorectal cancer Colorectal Cancer Colorectal Cancer Modified Duke Staging System Modified Duke A Modified Duke B B1:Tumor penetrates into, but not through the muscularis propria (the muscular layer) of the bowel wall. B2: Tumor penetrates into and through the muscularis propria of the bowel wall. Modified Duke C Tumor penetrates into the mucosa of the bowel wall, but no further. C1: Tumor penetrates into, but not through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. C2: Tumor penetrates into and through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. Modified Duke D The tumor, which has spread beyond the confines of the lymph nodes (to organs such as the liver, lung or bone). Prognosis following Resection Stage groupings T1submucosa, lamina propria T2- musc. propria T3-subserosa T4- adj organs N1- 1to3 LN N2 ->4 LN Stage 0 Tis N0 M0 Stage I T1-2 N0 M0 Stage IIA T3 N0 M0 Stage IIB T4 N0 M0 Stage IIIA T1-2 N1 M0 Stage IIIB T3-4 N1 M0 Stage IIIC Any T N2 M0 Stage IV Any T Any N M1 Five-Year Survival after Resection Localized disease- 90% Regional lymph nodes metastasis- 65% Relapse Majority within 2 years More than 90 percent - within five years Most common sites of recurrence Outside the colon Liver, the local site, the abdomen, and the lung Detecting Recurrence Physician office visit every three to six months for the first three years Development of new symptoms New abdominal pain/ distension Hematochezia/melena Change in bowel habits Fatigue Weight loss Detecting Recurrence Carcinoembryonic antigen Useful for prognosis and recurrence Useful even if the CEA was not elevated at diagnosis Every 3 months for first 3 yrs Every 6 months for a total of 5 yrs Annual Abdominal CT scan for first 3 yrs high risk of recurrence (those with lymphatic or venous invasion, poorly differentiated tumors Annual pelvic CT for rectal cancer Detecting Recurrence Annual chest CT scan – recommended Evidence is less clear CBC, Liver panel, FOBT- not recommended Annual chest x-ray – not recommended PET scan Routinely-not recommended Persistently elevated serum CEA and unrevealing conventional diagnostic studies Colonoscopy Recommendations Synchronous colorectal cancers and polyps two or more distinct primary tumors separated by normal bowel Pre Op colonoscopy Obstructing tumor- Consider Preop CT colonography or Double contrast barium enema Post surgery- Colonoscopy within 6m Colonoscopy Recommendations Metachronous cancer: Nonanastomotic new tumors developing at least six months after the initial diagnosis Probability - 1.5 to 3% pt within 5 years Colonoscopy follow up at 3 years If no lesions, then every 5 years Question A 63-year-old man underwent complete resection of a T3N0M0, stage II adenocarcinoma of the ascending colon No adjuvant therapy is planned. No family history of colorectal cancer Answer Colonoscopy at 3 years If normal, then repeat every 5 years Screening of family members at age 40 Watch out for Hereditary nonpolyposis colorectal cancer Thank you for your participation!!