Surveillance/ Screening Colonoscopy for Colorectal Cancer Dr. Jyothi Reddy, MD Dr. Akshra Verma, MD August 5, 2008

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Surveillance/ Screening Colonoscopy for Colorectal Cancer Dr. Jyothi Reddy, MD Dr. Akshra Verma, MD August 5, 2008 Slide 2 Why screen? Accounting for more than 50,000 deaths annually Accounting for more than 50,000 deaths annually 70 to 80 % - Tumors can be resected 70 to 80 % - Tumors can be resected Curative or palliative Curative or palliative Adjuvant radiation therapy, chemotherapy Adjuvant radiation therapy, chemotherapy Resection for localized disease Resection for localized disease five-year survival rate is 90 % five-year survival rate is 90 % Regional lymph node metastasis - 65% Regional lymph node metastasis - 65% Slide 3 Screening Colonoscopy Guidelines Slide 4 Screening Modalities Colonoscopy every 10 years Colonoscopy every 10 years FOBT-/FIT every year FOBT-/FIT every year Fecal Immuno Testing- detect human Hb Fecal Immuno Testing- detect human Hb Flexible Sigmoidoscopy- every 5 years Flexible Sigmoidoscopy- every 5 years Annual FOBT + Flex. Sigmoidoscopy every 5 yr Annual FOBT + Flex. Sigmoidoscopy every 5 yr Air contrast barium enema Air contrast barium enema Virtual colonoscopy Virtual colonoscopy CT colonography CT colonography Magnetic resonance colonography Magnetic resonance colonography Slide 5 Revision 30 year old male with no family history colon colorectal cancer 30 year old male with no family history colon colorectal cancer Average risk screening - begin Colonoscopy at age 50 and then every 10 years Average risk screening - begin Colonoscopy at age 50 and then every 10 years Slide 6 Revision 30 year old male with a family history of father diagnosed with colorectal cancer at the age of 65 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 Average risk screening but begin Colonoscopy at age 40 and then every 10 years Slide 7 Revision 30 year old male with a family history of father diagnosed with colorectal cancer at the age of 55 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 Higher risk screening: Colonoscopy at age 40 and then every 5 years Slide 8 Revision 30 year old male with a family history of both mother and father diagnosed with colorectal cancer at the age of 65 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 Higher risk screening: Colonoscopy at age 40 and then every 5 years Slide 9 Surveillance Recommendations Asymptomatic Patients Low Risk Colonoscopy 5yrs High Risk Colonoscopy Sessile polyp HGD In 3months Pedunculated HGD with stalk normal In 1 year Tubulovillous or villous In 3 years >10 Adenomas Colonoscopy < 3yrs Consider FAP 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 Slide 10 Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm tubular adenomatous polyp is removed. 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 Low risk Repeat colonoscopy in 5 years Slide 11 Revision 55 year old male undergoes a screening colonoscopy and four 0.5 cm villous adenomatous polyp is removed. 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 High risk Repeat colonoscopy in 3 years Slide 12 Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm sessile tubular adenomatous polyp with high grade dysplasia is removed. 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 Very high risk Repeat colonoscopy in 3 months Slide 13 Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm sessile tubulvillous adenomatous polyp with no dysplasia is removed. 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 High risk Repeat colonoscopy in 3 years Slide 14 Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm sessile tubular adenomatous polyp with no dysplasia is removed. 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 Low risk Repeat colonoscopy in 5 years Slide 15 Revision 55 year old male undergoes a screening colonoscopy and one 1.5 cm pedunculated tubular adenomatous polyp is removed. 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 High risk Repeat colonoscopy in 3 years Slide 16 Revision 55 year old male undergoes a screening colonoscopy and three 1.5 cm hyperplastic polyps are removed in the rectum. 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 Repeat colonoscopy in 10 years Slide 17 Question A 63-year-old man underwent complete resection of a T3N0M0, stage II adenocarci- noma of the ascending colon A 63-year-old man underwent complete resection of a T3N0M0, stage II adenocarci- noma of the ascending colon No adjuvant therapy is planned. No adjuvant therapy is planned. No family history of colorectal cancer No family history of colorectal cancer Slide 18 Colorectal Cancer Slide 19 Slide 20 Modified Duke Staging System Modified Duke A Modified Duke A Tumor penetrates into the mucosa of the bowel wall, but no further. Tumor penetrates into the mucosa of the bowel wall, but no further. Modified Duke B Modified Duke B B1:Tumor penetrates into, but not through the muscularis propria (the muscular layer) of the bowel wall. 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. B2: Tumor penetrates into and through the muscularis propria of the bowel wall. Modified Duke C Modified Duke C 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. 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. 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 Modified Duke D The tumor, which has spread beyond the confines of the lymph nodes (to organs such as the liver, lung or bone). The tumor, which has spread beyond the confines of the lymph nodes (to organs such as the liver, lung or bone). Slide 21 Prognosis following Resection Stage groupings Stage 0TisN0M0 Stage IT1-2N0M0 Stage IIAT3N0M0 Stage IIBT4N0M0 Stage IIIAT1-2N1M0 Stage IIIBT3-4N1M0 Stage IIICAny TN2M0 Stage IVAny TAny NM1 N1- 1to3 LN N2 ->4 LN T1- submucosa, lamina propria T2- musc. propria T3-subserosa T4- adj organs Slide 22 Five-Year Survival after Resection Localized disease- 90% Localized disease- 90% Regional lymph nodes metastasis- 65% Regional lymph nodes metastasis- 65% Relapse Relapse Majority within 2 years Majority within 2 years More than 90 percent - within five years More than 90 percent - within five years Most common sites of recurrence Most common sites of recurrence Outside the colon Outside the colon Liver, the local site, the abdomen, and the lung Liver, the local site, the abdomen, and the lung Slide 23 Detecting Recurrence Physician office visit every three to six months for the first three years Physician office visit every three to six months for the first three years Development of new symptoms Development of new symptoms New abdominal pain/ distension New abdominal pain/ distension Hematochezia/melena Hematochezia/melena Change in bowel habits Change in bowel habits Fatigue Fatigue Weight loss Weight loss Slide 24 Detecting Recurrence Carcinoembryonic antigen Carcinoembryonic antigen Useful for prognosis and recurrence Useful for prognosis and recurrence Useful even if the CEA was not elevated at diagnosis Useful even if the CEA was not elevated at diagnosis Every 3 months for first 3 yrs Every 3 months for first 3 yrs Every 6 months for a total of 5 yrs Every 6 months for a total of 5 yrs Annual Abdominal CT scan for first 3 yrs Annual Abdominal CT scan for first 3 yrs high risk of recurrence (those with lymphatic or venous invasion, poorly differentiated tumors high risk of recurrence (those with lymphatic or venous invasion, poorly differentiated tumors Annual pelvic CT for rectal cancer Annual pelvic CT for rectal cancer Slide 25 Detecting Recurrence Annual chest CT scan recommended Annual chest CT scan recommended Evidence is less clear Evidence is less clear CBC, Liver panel, FOBT- not recommended CBC, Liver panel, FOBT- not recommended Annual chest x-ray not recommended Annual chest x-ray not recommended PET scan PET scan Routinely-not recommended Routinely-not recommended Persistently elevated serum CEA and unrevealing conventional diagnostic studies Persistently elevated serum CEA and unrevealing conventional diagnostic studies Slide 26 Colonoscopy Recommendations Synchronous colorectal cancers and polyps Synchronous