Surveillance After Colon Cancer Resection and Polypectomy Feiran Lou MD. MS. Kings County Hospital Center Department of Surgery
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Surveillance After Colon Cancer
Resection and Polypectomy
Feiran Lou MD. MS.
Kings County Hospital Center
Department of Surgery
Case
74 yo man with history of rectal cancer stage IV
(T2N1cM1a) presents with asymptomatic
recurrence of liver metastasis identified on
PET/CT
PMH: asthma, BPH
Allergies: NKDA
Meds: none
Cancer History
• 2012 concurrent rectal cancer and liver metastases
neoadjuvant chemoradiation therapy
• 2/6/13 low anterior resection, diverting loop
ileostomy, liver resection (left lateral
segmentectomy, multiple metastasectomies from
right lobe of liver)
• Ileostomy reversal and adjuvant FOLFOX in
another country
• 9/14 PET/CT recurrence in liver
• Labs WNL
• CEA 3.97
• Colonoscopy negative for disease
Course
• 10/1/14 Completion left lobectomy of liver,
diaphragm repair
• Pathology: metastatic adenocarcinoma (4.5
cm) consistent with colonic origin. Margin
negative for adenocarcinoma.
Post Operative Course
• Re-intubation for respiratory failure POD 5
• Line sepsis (enterobacter)
• Right pigtail placement for right pleural effusion
• Post operative ileus
• Discharged to acute rehab on POD 15
• Discharged to home on POD 27
Outline
• Definitions
• Principles of cancer surveillance
• Evidence on colon cancer surveillance
• Guidelines
• Surveillance after polypectomy
Definitions
• Screening vs. Surveillance
• Surveillance to detect:
– Recurrence vs. Metachronous tumors
– Metachronous polyps: 30-56%
– Second colon cancer 2-8%
Screening Cancer-
Free Surveillance Cancer Treatment Recur
Considerations for Cancer Surveillance
after Surgical Resection
• Who?
– Patients: stage IV??? Poor functional status???
– Clinicians: surgeons vs. oncologists vs. primary
physicians vs. specialized nurse practitioners
Considerations for Cancer Surveillance
after Surgical Resection
• Modality of recurrence detection
– History of physical exam
– Laboratory studies
– Endoscopies
– Imaging studies
– Specificity, sensitivity
– False positive/negatives
Chest CT Surveillance for Lung
Cancer
27%
5%
Considerations for Cancer Surveillance
after Surgical Resection
• Patterns/risks of recurrence
Months After Surgery
Considerations for Cancer Surveillance
after Surgical Resection
• So what?
• Efficacy of available treatments for recurrence • Colon cancer vs. pancreatic cancer
Considerations for Cancer Surveillance
after Surgical Resection
• Cost
• Quality of life: increased anxiety
More “intensive” surveillance ≠ better!
Colon Cancer Surveillance
• Stage I (T1-2, N0, M0): Colonoscopy at 1, 3, then every 5 years
• ≥ Stage II: – H&P every 3-6 mos for 2 yrs, then every 6 mos for
total of 5 yrs
– CEA every 3-6 mos for 2 yrs, then every 6 mos for a total of 5 yrs
– CT chest/abd/p annually for up to 5 yrs if high risk*
High risk = Lymphatic or venous invasion by
tumor, poorly differentiated tumors
Rec
urr
ence
Colon Cancer Recurrence Rate
Sargent D et al. Evidence for cure by adjuvant therapy in colon cancer: observations based on individual patient data from 20 898 patients on 18 randomized trials. J Clin Oncol. 2009;27:872-877
Colon Cancer Surveillance
• Stage I (T1-2, N0, M0): Colonoscopy at 1, 3, then every 5 years
• ≥ Stage II: – H&P every 3-6 mo for 2 yrs, then every 6 mos for total
of 5 yrs
– CEA every 3-6 mo for 2 yrs, then every 6 mos for a total of 5 yrs
– CT chest/abd/p annually for up to 5 yrs if high risk*
– Colonoscopy in 1 yr, 3 yr, then every 5 yrs
– PET-CT and routine blood tests (i.e. CBC, LFT) NOT recommended
High risk = Lymphatic or venous invasion by
tumor, poorly differentiated tumors
Rec
urr
ence
Metachronous
Does intensive surveillance improve
survival?
Does intensive surveillance improve
survival?
Comparable Groups?
• 259 patients
• Stages II and III colorectal ca
• Median follow-up 45 months
• Noninferiority if survival difference <15%
• Primary end point: overall survival
Surveillance Strategies
Overall Survival
Stage II Overall Survival
Stage III Overall Survival
Colon Ca. vs. Rectal Ca.
Rectal Cancer Colon Cancer
Current Evidence
• Intensive surveillance most likely leads to
improved survival
• “Ideal” surveillance regimen remains to be
defined
Advances in Cancer Surveillance
• Surveillance based on individualized risk and
patterns of recurrence
– Stage
– Pathology
– Molecular profile
• Cost-effectiveness analysis
• Patient-oriented outcomes
Neoplastic Polyps of the Colon
• Adenomas most common (50-65%)
• Cellular atypia
– Tubular (65-85%)
– Tubuloillous (10-25%)
– Villous (10%)
• 10-25% asymptomatic average risk >50 years
• Advanced adenomas 3.5-9.5%
• Precursor to 80% of sporadic colorectal cancers
Surveillance Colonoscopy after
Polypectomy
Polyp
Characteristics
High Risk Low Risk
Size ≥ 1 cm < 1 cm
Number ≥ 3 < 3
Histology High-grade dysplasia
Villous Features
Tubular
Low-moderate grade
dysplasia
Removal Sessile adenoma
removed piecemeal
Surveillance Colonoscopy after
Polypectomy
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