Which CRC patients should be followed up with surveillance colonoscopy?

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The Australian Clinical Practice Guidelines for the prevention, early detection and management of CRC, 2nd edition, 2005 proposed that follow-up should be offered to all patients who have undergone curative surgery and are fit for further intervention if disease is detected. This includes patients who have had malignant polypectomy or curative endoscopic resection of Stage I CRC but excludes patients with Stage IV CRC if their treatment does not offer the possibility of cure.

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Risk factors for local recurrence following resection for colorectal cancer

Recent studies suggest that follow-up after CRC resection could perhaps be customised according to a patient’s individual risk.[1][2][3][4][5][6] For example, a number of studies have determined features of a primary CRC which increase the risk of local recurrence at the surgical anastomosis.[1][2][5][7][8] Most importantly though, anastomotic recurrence occurs far more often in rectal cancer patients than in colon cancer patients.[2][4] Local recurrence is also more likely to occur in patients undergoing local excision (including transanal endoscopic microsurgery) of their rectal primary cancers and unfortunately, many of these recurrences are associated with extra-colonic disease or local spread and are not curable.[5][9][10][11][12] With respect to this review, the vast majority of these rectal anastomotic recurrences are within reach of digital rectal examination or sigmoidoscopy and their detection does not require full colonoscopy.

The optimal combination and frequency of investigations in follow-up of patients after CRC resection has not been determined.[13] Importantly, the performance of annual colonoscopy has not been shown to improve five-year survival.[14] A meta-analysis by Tjandra et al concluded that intensive follow-up increased the re-resection rate for recurrent disease and improved overall survival but the survival advantage was not due to earlier detection of recurrence and cancer-related mortality was no better.[15]

The focus of the current chapter is on the use of surveillance colonoscopy. Although colonoscopy allows inspection of the anastomosis in passing, the principal purpose of surveillance colonoscopy after CRC resection is the detection of metachronous neoplasia. Thus, the above-mentioned risk factors for luminal/anastomotic recurrence are of limited relevance to the question of when surveillance colonoscopy should be performed following CRC surgery.

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Risk factors for metachronous neoplasia following resection for colorectal cancer

Having developed one CRC, patients are at risk for the development of metachronous polyps and their progression to metachronous cancers; Bouvier et al[16] reported the incidence of metachronous cancer as being 1.8% at five years, 3.4% at 10 years, and 7.2% at 20 years[16] with the greatest excess risk between one and five years post-surgery.

Preoperative colonoscopy is important to detect and treat synchronous polyps and cancers but may also assist in predicting which patients are more likely to develop future adenomas and cancers during follow-up. Some authors of both original studies and literature reviews have reported that the presence of synchronous polyps or cancers is a risk factor for metachronous CRC[17][18][19][20][21] and for metachronous adenomatous polyps.[21][22] However, in a recent population-based study by Bouvier et al,[16] using a cancer registry as the source of information, no patient or tumour characteristics could be identified to predict which CRC patients would develop a metachronous cancer. Other authors have likewise failed to identify any link between synchronous adenomas and the development of subsequent metachronous CRC.[23][24]

Primary tumour location is also a risk factor for the development of metachronous cancer. In a study of more than 500 CRC patients from a cancer registry database, patients whose first cancer was located proximal to splenic flexure were found to be at twice the risk for developing a metachronous cancer compared to those with a first cancer in the distal colon.[7]

Metachronous and synchronous tumours are features of Lynch syndrome (also known as hereditary non-polyposis colorectal cancer or HNPCC).[25][26] A propensity for metachronous and synchronous colorectal cancers with a predilection for the proximal colon and development of cancer at an early age are well recognised characteristics of Lynch syndrome.[27]

Thus, reported studies have disagreed about whether patients who have undergone CRC resection can be stratified with regard to their risk of future development of metachronous polyps and cancers. Even in those studies where a positive predictive factor was identified, the strength of the association with the development of future colonic neoplasia was insufficiently strong to exclude patients without the factor from colonoscopic surveillance.

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Patient groups at very high risk for metachronous neoplasia following resection for colorectal cancer

In certain patients who have undergone curative resection for CRC, clinical features, family history and the findings at the pre-operative colonoscopy may dictate the need for particularly intense post-operative surveillance colonoscopy (see Chapter 7 of the Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, 2nd edition, 2005).

In other groups of patients considered to be at increased risk of metachronous disease, consideration may be given following surgery to continuing with more frequent surveillance than would otherwise be recommended (e.g. initial post-operative colonoscopy at one year and then annually, second-yearly or third-yearly. These patients include those (i) whose initial diagnosis was made younger than 40 years of age, (ii) with probable or possible HNPCC (i.e. patients whose tumours are MSI-high and less than 50 years old at time of initial cancer diagnosis but not proved by genetic testing to have HNPCC), (iii) with hyperplastic polyposis and BRAF mutation and (iv) with multiple synchronous cancers or advanced adenomas at initial diagnosis.

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Evidence summary and recommendations

Practice point(s)
  • Patients with proved Lynch syndrome (HNPCC or hereditary non-polyposis colorectal cancer), should continue to have annual surveillance colonoscopy performed post-operatively because of the apparent rapid progression of neoplasia from adenoma to carcinoma.
  • Surveillance of the residual colonic mucosa in patients with cancer in FAP should follow recommendations in Chapter 7 of the Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, 2nd edition, 2005
  • Patients including those:
    1. Whose initial diagnosis was made younger than 40 years of age,
    2. With probable or possible HNPCC (i.e. patients whose tumours are MSI-high and less than 50 years old at time of initial cancer diagnosis but not proved by genetic testing to have HNPCC),
    3. With hyperplastic polyposis and BRAF mutation and
    4. With multiple synchronous cancers or advanced adenomas at initial diagnosis should be considered following surgery to continuing with more frequent surveillance than would otherwise be recommended (e.g. initial post-operative colonoscopy at one year and then annually, second-yearly or third-yearly.

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References

  1. 1.0 1.1 Chan CL, Bokey EL, Chapuis PH, Renwick AA, Dent OF. Local recurrence after curative resection for rectal cancer is associated with anterior position of the tumour. Br J Surg 2006 Jan;93(1):105-12 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16302179].
  2. 2.0 2.1 2.2 Manfredi S, Bouvier AM, Lepage C, Hatem C, Dancourt V, Faivre J. Incidence and patterns of recurrence after resection for cure of colonic cancer in a well defined population. Br J Surg 2006 Sep;93(9):1115-22 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16804870].
  3. Obrand DI, Gordon PH. Incidence and patterns of recurrence following curative resection for colorectal carcinoma. Dis Colon Rectum 1997 Jan;40(1):15-24 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9102255].
  4. 4.0 4.1 Aste H, Saccomanno S, Pugliese V, Santi L. Colonoscopy in patients previously submitted to partial colectomy for colorectal cancer. Acta Endoscopica. 1982;12(3):219-227.
  5. 5.0 5.1 5.2 Barillari P, Ramacciato G, Manetti G, Bovino A, Sammartino P, Stipa V. Surveillance of colorectal cancer: effectiveness of early detection of intraluminal recurrences on prognosis and survival of patients treated for cure. Dis Colon Rectum 1996 Apr;39(4):388-93 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8878497].
  6. Renehan AG, Egger M, Saunders MP, O'Dwyer ST. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 2002 Apr 6;324(7341):813 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11934773].
  7. 7.0 7.1 Gervaz P, Bucher P, Neyroud-Caspar I, Soravia C, Morel P. Proximal location of colon cancer is a risk factor for development of metachronous colorectal cancer: a population-based study. Dis Colon Rectum 2005 Feb;48(2):227-32 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15711864].
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  14. Schoemaker D, Black R, Giles L, Toouli J. Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients. Gastroenterology 1998 Jan;114(1):7-14 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9428212].
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