Surveillance/ Screening Colonoscopy for Colorectal Cancer

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

2. 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%

3. Screening Colonoscopy Guidelines

4. 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

5. 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

6. 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

7. 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

8. 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

9. Surveillance Recommendations

10. 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

11. 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

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. Very high risk – Repeat colonoscopy in 3 months

13. Revision 55 year old male undergoes a screening colonoscopy and one 0.5 cm sessile tubulvillousadenomatous polyp with no dysplasia is removed. High risk – Repeat colonoscopy in 3 years

14. 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

15. 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

16. 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

17. Question 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 family history of colorectal cancer

18. Colorectal Cancer

19. Colorectal Cancer

20. Modified Duke Staging System • Modified Duke A • Tumor penetrates into the mucosaof the bowel wall, but no further. • Modified Duke B • B1:Tumor penetrates into,but not through the muscularispropria(the muscular layer) of the bowel wall. • B2: Tumor penetrates into and through the muscularispropriaof the bowel wall. • Modified Duke C • C1: Tumor penetrates into, but not through the muscularispropria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. • C2: Tumor penetrates into and through the muscularispropria 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).

21. Prognosis following Resection T1- submucosa, lamina propria T2- musc. propria T3-subserosa T4- adj organs N1- 1to3 LN N2 ->4 LN

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Question 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 family history of colorectal cancer

29. 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

30. Thank you for your participation!!