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
Asymptomatic
Patients
Low Risk
Colonoscopy
5yrs
High Risk
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

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 tubulvillous adenomatous 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 mucosa of the bowel wall, but no further.
Modified Duke B
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
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
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
Stage groupings
Stage 0
Tis N0 M0
Stage I
T1-2
Stage IIA T3
Stage IIB T4
Stage IIIA N1
Stage IIIB
T3-4
Stage IIIC
Any T N2
Stage IV
Any N M1
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 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. for your participation!!
Thank you
for your participation!!