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Intensive postoperative surveillance in early vs. late-stage colon cancer
An 80-year-old woman with personal history of early-stage breast cancer, treated with lumpectomy and radiation 11 years ago, initially presented with lower gastrointestinal bleeding in June 2008. Her colonoscopy revealed a fungating, infiltrative and ulcerated partially obstructing large 7 cm mass in sigmoid colon.
The biopsy revealed well- to moderately differentiated invasive adenocarcinoma. CT abdomen and pelvis demonstrated a sigmoid annular lesion without definite evidence of distant metastatic disease. She subsequently underwent a sigmoid resection with primary anastomosis. She had pathological stage IIa colon cancer with the surgical specimen showing a 5 cm × 4 cm well-differentiated adenocarcinoma with direct extension to subserosal fat, 26 lymph nodes and margins were negative for tumor. Postoperatively, the patient recovered without complications and was discharged.
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Photos courtesy of M Ghesani, MD |
The patient was then lost to follow-up until November 2009, when she developed recurrent rectal bleeding. Colonoscopy revealed a mass measuring 2 cm in diameter located in the rectum at 5 cm from the anal verge. It was distant from the pervious anastomosis. Biopsy revealed moderately differentiated adenocarcinoma. The staging CT showed a suggestion of increased soft tissue density in very distal rectum posteriorly. There was no perirectal abnormality found. Thus, she has apparently developed a second primary cancer and is currently being evaluated for neoadjuvant concurrent chemoradiation treatment of her rectal cancer.
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Photos courtesy of M Ghesani, MD |
Discussion
A pooled analysis of the more than 20,000 patients enrolled in large adjuvant colorectal cancer randomized trials showed that about 80% of recurrences occur in the first three years after surgery. Surveillance following surgery after stage II and stage III colorectal cancer, therefore, aims to find earlier recurrences or metachronous lesions that are amenable to cure.
Several studies and meta-analyses compared low-intensity and high-intensity surveillance and concluded that the early intensive postoperative surveillance detects recurrences and improves survival. However, optimal combination and scheduling is still debated. Frequent history and examinations, carcinoembryonic antigen levels, yearly colonoscopies and imaging with the CT scan of the chest, abdomen and pelvis have been recommended by professional organizations.
Tsikitis et al performed a secondary analysis of the Clinical Outcome of Surgical Therapy trial (COST trial) that studied almost 800 patients with early (stage I and IIa) and late-stage (stage IIb and III) disease. They found that salvage rates for early and late-stage colon cancer with recurrence were the same (35.9% vs. 37%).
Single sites of recurrence did not significantly matter, but multiple sites of recurrence occurred more often in late-stage disease. Moreover, methods of the first detection of recurrence were not significantly different for carcinoembryonic antigen, CT, chest X-ray and colonoscopy for early vs. late-stage recurrence. They concluded that because patients with early stage colon cancer have similar sites of recurrence and receive similar benefits from postrecurrence therapy, they should receive similar surveillance.
The study generated an interesting reply from Michael Chao, MD, and Peter Gibbs, MD. In a correspondence published in The Journal of Clinical Oncology, they discussed the distinct aspects of the surveillance methods. Although endoscopies find locoregional recurrence, carcinoembryonic antigen levels and CT imaging more frequently detect distant recurrence. In a small single-institution case study of postoperative surveillance for early stage cancer, CT scans were performed at six and 18 months follow-up in selected high-risk patients. Out of 90 patients, 40 had abnormal imaging findings leading to additional imaging. The most frequent worrisome CT finding was isolated lung nodules. Three out of 40 patients ultimately had surgery: two women with benign complex ovarian cysts and one man with primary lung cancer. Although screening for stage II and stage III colon cancers exists and is described in an American Society of Clinical Oncology practice guideline, the appropriate strategy and the surveillance for early stage I and IIa colon cancer continues to be debated.
Incomplete distention and retained stool cause significant limitations in evaluating the rectum, as well as the rest of the colon. If the tissue in question contains air or is mobile on prone imaging, it can be easily identified as stool, as opposed to a more worrisome lesion.
However, prone imaging is not typically performed on routine CT scans. Furthermore, the presence of a rectal balloon or tube used for insufflation may obscure a lesion along the rectum by compression. Finally, orthopedic hardware can severely limit evaluation due to streak artifact.
Liana Makarian, MD, is an Oncology Fellow at St Luke’s-Roosevelt Hospital Center.
Neil Gupta, MD, is a Resident in Radiology, St. Luke’s-Roosevelt Hospital Center.
Munir Ghesani, MD, is Associate Clinical Professor of Radiology at Columbia University College of Physicians and Surgeons and Attending Radiologist at St. Luke’s-Roosevelt Hospital Center.
For more information:
- Chao M. J Clin Oncol. 2009; doi: 10.1200/JCO.2009.25.6156.
- Desch CE. J Clin Oncol. 2005;23:8512-8519.
- Pfister DG. N Engl J Med. 2004;350:2375-2382.
- Sargent DJ. J Clin Oncol. 2005;23:8664-8670.
- Silva A. Radiographics 2006:26;1085-1099.
- Tsikitis VL. J Clin Oncol. 2009;22:3671-3676.