Transcript Screening Colonoscopy

Surveillance/
Screening Colonoscopy
for Colorectal Cancer
Dr. Jyothi Reddy, MD
Dr. Akshra Verma, MD
August 5, 2008
Why screen?
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Accounting for more than 50,000 deaths
annually
70 to 80 % - Tumors can be resected
Curative or palliative
 Adjuvant radiation therapy, chemotherapy
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Resection for localized disease
five-year survival rate is 90 %
 Regional lymph node metastasis - 65%
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Screening Colonoscopy Guidelines
Screening Modalities
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Colonoscopy – every 10 years
FOBT-/FIT every year
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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
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Revision
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30 year old male with no family history colon
colorectal cancer
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Average risk screening - begin Colonoscopy at
age 50 and then every 10 years
Revision
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30 year old male with a family history of father
diagnosed with colorectal cancer at the age of 65
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Average risk screening but begin Colonoscopy
at age 40 and then every 10 years
Revision
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30 year old male with a family history of father
diagnosed with colorectal cancer at the age of 55
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Higher risk screening: Colonoscopy at age 40
and then every 5 years
Revision
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30 year old male with a family history of both
mother and father diagnosed with colorectal
cancer at the age of 65
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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
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55 year old male undergoes a screening
colonoscopy and one 0.5 cm tubular
adenomatous polyp is removed.
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Low risk – Repeat colonoscopy in 5 years
Revision
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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
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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
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55 year old male undergoes a screening
colonoscopy and one 0.5 cm sessile tubulvillous
adenomatous polyp with no dysplasia is
removed.
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High risk – Repeat colonoscopy in 3 years
Revision
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55 year old male undergoes a screening
colonoscopy and one 0.5 cm sessile tubular
adenomatous polyp with no dysplasia is
removed.
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Low risk – Repeat colonoscopy in 5 years
Revision
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55 year old male undergoes a screening
colonoscopy and one 1.5 cm pedunculated
tubular adenomatous polyp is removed.
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High risk – Repeat colonoscopy in 3 years
Revision
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55 year old male undergoes a screening
colonoscopy and three 1.5 cm hyperplastic
polyps are removed in the rectum.
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Repeat colonoscopy in 10 years
Question
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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
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Modified Duke A
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Modified Duke B
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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
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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
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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
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Localized disease- 90%
Regional lymph nodes metastasis- 65%
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Relapse
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Majority within 2 years
 More than 90 percent - within five years
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Most common sites of recurrence
Outside the colon
 Liver, the local site, the abdomen, and the lung
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Detecting Recurrence
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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
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Detecting Recurrence
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Carcinoembryonic antigen
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Useful for prognosis and recurrence
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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
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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
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Detecting Recurrence
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Annual chest CT scan – recommended
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Evidence is less clear
CBC, Liver panel, FOBT- not recommended
Annual chest x-ray – not recommended
PET scan
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Routinely-not recommended
Persistently elevated serum CEA and unrevealing
conventional diagnostic studies
Colonoscopy Recommendations
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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
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Colonoscopy Recommendations
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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
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Question
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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
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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!!