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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