Surveillance/ Surveillance/ Screening Screening

Colonoscopy for Colonoscopy for Colorectal Colorectal CancerCancer

Dr. Jyothi Reddy, MDDr. Jyothi Reddy, MD

Dr. Akshra Verma, MDDr. Akshra Verma, MD

August 5, 2008August 5, 2008

Why screen?Why screen?

Accounting for more than 50,000 Accounting for more than 50,000 deaths annuallydeaths annually

70 to 80 % - Tumors can be resected 70 to 80 % - Tumors can be resected Curative or palliativeCurative or palliative Adjuvant radiation therapy, Adjuvant radiation therapy,

chemotherapychemotherapy Resection for localized diseaseResection 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%

Screening Colonoscopy Guidelines

Screening ModalitiesScreening Modalities

Colonoscopy – every 10 yearsColonoscopy – every 10 years FOBT-/FIT every yearFOBT-/FIT every year

Fecal Immuno Testing- detect human HbFecal Immuno Testing- detect human Hb Flexible Sigmoidoscopy- every 5 yearsFlexible Sigmoidoscopy- every 5 years Annual FOBT + Flex. Sigmoidoscopy every 5 Annual FOBT + Flex. Sigmoidoscopy every 5

yryr Air contrast barium enemaAir contrast barium enema Virtual colonoscopyVirtual colonoscopy

CT colonographyCT colonography Magnetic resonance colonographyMagnetic resonance colonography

RevisionRevision

30 year old male with no family 30 year old male with no family history colon colorectal cancerhistory colon colorectal cancer

Average risk screening - begin Average risk screening - begin Colonoscopy at age 50 and then Colonoscopy at age 50 and then every 10 yearsevery 10 years

RevisionRevision

30 year old male with a family 30 year old male with a family history of father diagnosed with history of father diagnosed with colorectal cancer at the age of 65colorectal cancer at the age of 65

Average risk screening but begin Average risk screening but begin Colonoscopy at age 40 and then Colonoscopy at age 40 and then every 10 yearsevery 10 years

RevisionRevision

30 year old male with a family 30 year old male with a family history of father diagnosed with history of father diagnosed with colorectal cancer at the age of 55colorectal cancer at the age of 55

Higher risk screening: Colonoscopy Higher risk screening: Colonoscopy at age 40 and then every 5 yearsat age 40 and then every 5 years

RevisionRevision

30 year old male with a family 30 year old male with a family history of both mother and father history of both mother and father diagnosed with colorectal cancer at diagnosed with colorectal cancer at the age of 65the age of 65

Higher risk screening: Colonoscopy Higher risk screening: Colonoscopy at age 40 and then every 5 yearsat age 40 and then every 5 years

Surveillance Surveillance RecommendationsRecommendations

RevisionRevision

55 year old male undergoes a 55 year old male undergoes a screening colonoscopy and one 0.5 screening colonoscopy and one 0.5 cm tubular adenomatous polyp is cm tubular adenomatous polyp is removed. removed.

Low risk – Repeat colonoscopy in 5 Low risk – Repeat colonoscopy in 5 yearsyears

RevisionRevision

55 year old male undergoes a 55 year old male undergoes a screening colonoscopy and four 0.5 screening colonoscopy and four 0.5 cm villous adenomatous polyp is cm villous adenomatous polyp is removed. removed.

High risk – Repeat colonoscopy in 3 High risk – Repeat colonoscopy in 3 yearsyears

RevisionRevision

55 year old male undergoes a 55 year old male undergoes a screening colonoscopy and one 0.5 screening colonoscopy and one 0.5 cm sessile tubular adenomatous cm sessile tubular adenomatous polyp with high grade dysplasia is polyp with high grade dysplasia is removed.removed.

Very high risk – Repeat colonoscopy Very high risk – Repeat colonoscopy in 3 monthsin 3 months

RevisionRevision

55 year old male undergoes a 55 year old male undergoes a screening colonoscopy and one 0.5 screening colonoscopy and one 0.5 cm sessile tubulvillous adenomatous cm sessile tubulvillous adenomatous polyp with no dysplasia is removed.polyp with no dysplasia is removed.

High risk – Repeat colonoscopy in 3 High risk – Repeat colonoscopy in 3 yearsyears

RevisionRevision

55 year old male undergoes a 55 year old male undergoes a screening colonoscopy and one 0.5 screening colonoscopy and one 0.5 cm sessile tubular adenomatous cm sessile tubular adenomatous polyp with no dysplasia is removed.polyp with no dysplasia is removed.

Low risk – Repeat colonoscopy in 5 Low risk – Repeat colonoscopy in 5 yearsyears

RevisionRevision

55 year old male undergoes a 55 year old male undergoes a screening colonoscopy and one 1.5 screening colonoscopy and one 1.5 cm pedunculated tubular cm pedunculated tubular adenomatous polyp is removed.adenomatous polyp is removed.

High risk – Repeat colonoscopy in 3 High risk – Repeat colonoscopy in 3 yearsyears

RevisionRevision 55 year old male undergoes a 55 year old male undergoes a

screening colonoscopy and three 1.5 screening colonoscopy and three 1.5 cm hyperplastic polyps are removed cm hyperplastic polyps are removed in the rectum.in the rectum.

Repeat colonoscopy in 10 yearsRepeat colonoscopy in 10 years

QuestionQuestion

A 63-year-old man underwent A 63-year-old man underwent complete resection of a T3N0M0, complete resection of a T3N0M0, stage II adenocarci-noma of the stage II adenocarci-noma of the ascending colonascending colon

No adjuvant therapy is planned. No adjuvant therapy is planned. No family history of colorectal No family history of colorectal

cancercancer

Colorectal CancerColorectal Cancer

Colorectal CancerColorectal Cancer

Modified Duke Staging Modified Duke Staging SystemSystem

Modified Duke A Modified Duke A Tumor penetrates into the Tumor penetrates into the mucosamucosa of the bowel wall, but no further. of the bowel wall, but no further.

Modified Duke B Modified Duke B B1:Tumor penetrates B1:Tumor penetrates into,into, but not through but not through the the muscularis propria muscularis propria (the (the

muscular layer) of the bowel wall. muscular layer) of the bowel wall. B2: Tumor penetrates B2: Tumor penetrates into and through into and through the the muscularis propria muscularis propria of the of the

bowel wall. bowel wall. Modified Duke C Modified Duke C

C1: Tumor penetrates into, but not through the muscularis propria of the C1: Tumor penetrates into, but not through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the bowel wall; there is pathologic evidence of colon cancer in the lymph lymph nodes. nodes.

C2: Tumor penetrates into and through the muscularis propria of the bowel C2: Tumor penetrates into and through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the wall; there is pathologic evidence of colon cancer in the lymph nodes. lymph nodes.

Modified Duke DModified Duke D The tumor, which has spread beyond the confines of the lymph nodes (to The tumor, which has spread beyond the confines of the lymph nodes (to

organs such as the liver, lung or bone).organs such as the liver, lung or bone).

Prognosis following Resection

Stage groupings

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

N1- 1to3 LNN2 ->4 LN

T1- submucosa,lamina propriaT2- musc. propriaT3-subserosaT4- adj organs

Five-Year Survival after Five-Year Survival after ResectionResection

Localized disease- 90%Localized disease- 90% Regional lymph nodes metastasis- 65%Regional lymph nodes metastasis- 65%

RelapseRelapse Majority within 2 yearsMajority within 2 years More than 90 percent - within five yearsMore than 90 percent - within five years

Most common sites of recurrenceMost common sites of recurrence Outside the colonOutside the colon Liver, the local site, the abdomen, and the lungLiver, the local site, the abdomen, and the lung

Detecting RecurrenceDetecting Recurrence Physician office visit every three to Physician office visit every three to

six months for the first three years six months for the first three years Development of new symptomsDevelopment of new symptoms

New abdominal pain/ distensionNew abdominal pain/ distension Hematochezia/melenaHematochezia/melena Change in bowel habitsChange in bowel habits FatigueFatigue Weight lossWeight loss

Detecting RecurrenceDetecting Recurrence

Carcinoembryonic antigenCarcinoembryonic antigen Useful for prognosis and recurrenceUseful for prognosis and recurrence

Useful even if the CEA was not elevated at diagnosisUseful even if the CEA was not elevated at diagnosis Every 3 months for first 3 yrsEvery 3 months for first 3 yrs Every 6 months for a total of 5 yrsEvery 6 months for a total of 5 yrs

Annual Abdominal CT scan for first 3 yrsAnnual Abdominal CT scan for first 3 yrs high risk of recurrence (those with lymphatic or high risk of recurrence (those with lymphatic or

venous invasion, poorly differentiated tumorsvenous invasion, poorly differentiated tumors Annual pelvic CT for rectal cancerAnnual pelvic CT for rectal cancer

Detecting RecurrenceDetecting Recurrence Annual chest CT scan – recommendedAnnual chest CT scan – recommended

Evidence is less clearEvidence is less clear CBC, Liver panel, FOBT- not CBC, Liver panel, FOBT- not

recommendedrecommended Annual chest x-ray – not recommendedAnnual chest x-ray – not recommended PET scanPET scan

Routinely-not recommendedRoutinely-not recommended Persistently elevated serum CEA and Persistently elevated serum CEA and

unrevealing conventional diagnostic studiesunrevealing conventional diagnostic studies

Colonoscopy Colonoscopy RecommendationsRecommendations

Synchronous colorectal cancers and Synchronous colorectal cancers and polypspolyps two or more distinct primary tumors two or more distinct primary tumors

separated by normal bowelseparated by normal bowel Pre Op colonoscopyPre Op colonoscopy Obstructing tumor- Consider Preop CT Obstructing tumor- Consider Preop CT

colonography or Double contrast colonography or Double contrast barium enemabarium enema

Post surgery- Colonoscopy within 6mPost surgery- Colonoscopy within 6m

Colonoscopy Colonoscopy RecommendationsRecommendations

Metachronous cancer: Metachronous cancer: Nonanastomotic new tumors developing Nonanastomotic new tumors developing

at least six months after the initial at least six months after the initial diagnosisdiagnosis

Probability - 1.5 to 3% pt within 5 yearsProbability - 1.5 to 3% pt within 5 years Colonoscopy follow up at 3 yearsColonoscopy follow up at 3 years If no lesions, then every 5 yearsIf no lesions, then every 5 years

QuestionQuestion

A 63-year-old man underwent A 63-year-old man underwent complete resection of a T3N0M0, complete resection of a T3N0M0, stage II adenocarci-noma of the stage II adenocarci-noma of the ascending colonascending colon

No adjuvant therapy is planned. No adjuvant therapy is planned. No family history of colorectal No family history of colorectal

cancercancer

AnswerAnswer

Colonoscopy at 3 yearsColonoscopy at 3 years If normal, then repeat every 5 yearsIf normal, then repeat every 5 years Screening of family membersScreening of family members at age

40 Watch out for Hereditary Watch out for Hereditary

nonpolyposis colorectal cancer nonpolyposis colorectal cancer

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