Colorectal cancer. The bases for a comprehensive follow-up

Post-treatment surveillance testing of patients with colorectal cancer and the association with survival: protocol for a retrospective cohort study of the Surveillance, Epidemiology, and End Results (SEER)-Medicare database

INTRODUCTION

Although the colorectal cancer (CRC) mortality rate has significantly improved over the past several decades, many patients will have a recurrence following curative treatment. Despite this high risk of recurrence, adherence to CRC surveillance testing guidelines is poor which increases cancer-related morbidity and potentially, mortality. Several randomised controlled trials (RCTs) with varying surveillance strategies have yielded conflicting evidence regarding the survival benefit associated with surveillance testing. However, due to differences in study protocols and limitations of sample size and length of follow-up, the RCT may not be the best study design to evaluate this relationship. An observational comparative effectiveness research study can overcome the sample size/follow-up limitations of RCT designs while assessing real-world variability in receipt of surveillance testing to provide much needed evidence on this important clinical issue. The gap in knowledge that this study will address concerns whether adherence to National Comprehensive Cancer Network CRC surveillance guidelines improves survival.

METHODS AND ANALYSIS

Patients with colon and rectal cancer aged 66-84 years, who have been diagnosed between 2002 and 2008 and have been included in the Surveillance, Epidemiology, and End Results-Medicare database, are eligible for this retrospective cohort study. To minimise bias, patients had to survive at least 12 months following the completion of treatment. Adherence to surveillance testing up to 5 years post-treatment will be assessed in each year of follow-up and overall. Binomial regression will be used to assess the association between patients' characteristics and adherence. Survival analysis will be conducted to assess the association between adherence and 5-year survival.

ETHICS AND DISSEMINATION

This study was approved by the National Cancer Institute and the Institutional Review Board of the University of Central Florida. The results of this study will be disseminated by publishing in the peer-reviewed scientific literature, presentation at national/international scientific conferences and posting through social media.

Evaluation of Serum Carcinoembryonic Antigen Monitoring in the follow-up of Colorectal Cancer Patients with Metastatic Lymph Nodes and a Normal Preoperative Serum Level

The value of serial serum carcinoembryonic antigen (CEA) assay in the follow-up of colorectal cancer patients with metastatic lymph nodes and normal (≤ 5 ng/ml) preoperative CEA levels, was examined in this study. Thirty-eight patients were studied and compared with 22 patients with elevated CEA levels. The overall sensitivity of CEA for the diagnosis of recurrence was 36%. Postoperative CEA was strongly influenced by the site of recurrence. CEA monitoring showed the best results in patients who developed hepatic metastases (sensitivity 60%, specificity 94%, positive predictive value 60%, and negative predictive value 94%), and was ineffective for the detection of locoregional or pulmonary metastases. The results indicate that elevation of CEA in the postoperative course of these patients is an indicator of the presence of hepatic metastases. Postoperative CEA monitoring should not be omitted in Dukes C patients with normal preoperative levels, and is more reliable for the detection of liver metastases.

Mortality and Survival after Surgical Treatment of Colorectal Cancer in Patients Aged over 80 Years

OBJECTIVE

The purpose of this study was to identify the clinical factors and tumor characteristics that predict the outcome of colorectal cancer patients aged >80 years.

MATERIALS AND METHODS

The data of 186 patients aged >80 years with colorectal cancer were collected from a computer database, and the variables were analyzed by both uni- and multivariate analyses.

RESULTS

The 30-day mortality was 4% and the 90-day mortality 10%. The 1-year survival was 76%, and 27 (61%) of the 44 deaths were unrelated to cancer. The overall 5-year survival was 36%, the median survival 38 months, and the cancer-specific survival 40%. The recurrence rate after radical surgery was 22% and it was not affected by age. Kaplan-Meier estimates indicated that age, number of underlying diseases, radical operation, Union for International Cancer Control stage of the tumor, tumor size, number of lymph nodes involved, venous invasion, and recurrent disease were significant predictors of survival, but in the Cox regression model, only radical operation and venous invasion were independent prognostic factors for survival.

CONCLUSIONS

After good surgical selection, low early mortality and acceptable long-term survival can be achieved even in the oldest old patients with colorectal cancer. However, low early mortality seems to underestimate the effects of surgery during the first postoperative year.

Cost-effectiveness analysis of a colonoscopy screening navigator program designed for Hispanic men

Although Hispanic men are at higher risk of developing colon cancer compared to non-Hispanic white men, colonoscopy screening among Hispanic men is much lower than among non-Hispanic white men. University Health System (UHS) in San Antonio, Texas, instituted a Colorectal Cancer Male Navigation (CCMN) Program in 2011 specifically designed for Hispanic men. The CCMN Program contacted 461 Hispanic men 50 years of age and older to participate over a 2-year period. Of these age-eligible men, 370 were screened for CRC after being contacted by the navigator. Using participant and program data, a Markov model was constructed to determine the cost-effectiveness of the CCMN Program. An average 50-year-old Hispanic male who participates in the CCMN Program will have 0.3 more quality-adjusted life-years (QALYs) compared to a similar male receiving usual care. Life expectancy is also predicted to increase by 6 months for participants compared to non-participants. The program results in net health care savings of $1,148 per participant ($424,760 for the 370 CCMN Program participants). The incremental cost-effectiveness ratio is estimated at $3,765 per QALY in favor of the navigation program. Interventions to reduce disparities in CRC screening across ethnic groups are needed, and this is one of the first studies to evaluate the economic benefit of a patient navigator program specifically designed for an urban population of Hispanic men. A colorectal cancer screening intervention which relies on patient navigators trained to address the unique needs of the targeted population (language barriers, transportation and scheduling assistance, colon cancer, and screening knowledge) can substantially increase the likelihood of screening and improve quality of life in a cost-effective manner.

Surgical treatment of colorectal cancer in patients aged over 80 years

PURPOSE

The aim of this study was to identify the clinical factors and tumour characteristics that predict the outcome in patients older than 80 years with colorectal cancer.

PATIENTS AND METHODS

One hundred and four patients with colorectal cancer aged over 80 years were identified from a computer database, and their clinical variables were analysed by both univariate and multivariate analyses.

RESULTS

All 104 patients underwent resective surgery, 87% radical and 13% palliative resection. Postoperative mortality was 5%, being associated with a number of coexisting diseases and the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 33%, the median survival was 31 months and the cancer-specific 5-year survival was 36%. The recurrence rate after radical surgery was 30%, being 13%, 25%, 44% and 100% in the Union for International Cancer Control stages I, II, III and IV. Kaplan-Meier estimates indicated that age, number of underlying diseases, radicality of operation, Dukes' staging, size of tumour, number of lymph node metastasis, metastasised disease, venous invasion and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion was an independent prognostic factor of survival.

CONCLUSIONS

Low mortality and acceptable survival can be achieved even in very elderly patients with colorectal cancer. Venous invasion is an independent predictor of survival.

Reoperation for recurrent colorectal cancer

Recurrence of colorectal carcinoma represents a significant challenge. As the majority of recurrences involve more than just the anastomosis, surgical resection is ordinarily a major undertaking. Curative resection may require resection of other organs and structures, resulting in complex reconstructive procedures and substantial morbidity. In addition, carefully selected patients with distant metastases to sites such as the liver and lungs may also undergo potentially curative resection. Long-term survival following curative surgery for recurrence, however, ranges from only 15 to 40%. In addition to resection for curative intent, some patients may benefit from palliative procedures designed to relieve symptoms. Surgery alone is not usually sufficient therapy in these patients. Chemotherapy and radiation therapy play a vital adjunctive role in the management of recurrent disease. This article strives to review the risk factors and patterns of recurrence, selection of individuals for resection of recurrent disease, and outcomes of surgical procedures.

How uncommon are isolated lung metastases in colorectal cancer? A review from database of 754 patients over 4 years

BACKGROUND

It is commonly thought that colon cancer metastases to the lungs without involvement of the liver are rare.

METHODS

We performed a retrospective review of all patients with colorectal cancer diagnosed between December 2003 and August 2007 in Singapore. Isolated lung metastases were determined as (1) Definite if there was confirmed histology or cytology of the lung lesion(s) in the absence of liver lesions on CT scan, and (2) Probable if there were only radiological evidence suggestive of lung metastases rather than lung primary also in the absence of liver lesions on CT scan.

RESULTS

There were 196 patients with rectal and 558 patients with colon cancer (369 left-sided and 189 right-sided). There were 13 definite isolated lung metastases, and the remaining 43 were probable. Twenty-three (12%) patients with rectal cancer and 33 (6%) patients with colon cancer had isolated lung metastases (OR 2.11, 95% CI 1.21-3.70). Patients with >or=pT3 lesions (OR 1.92, 95% CI 0.75-4.93) and >or=pN1 (OR 1.56, 95% CI 0.86- 2.83) were more likely to have isolated lung metastases.

CONCLUSION

The true incidence of isolated lung without liver metastases in colorectal cancer is likely to lie between 1.7% and 7.2%. While the incidence of isolated lung metastases is twice as common in patients with rectal cancer, it is still significant in patients with colon cancer. The absence of liver involvement should not preclude a search for lung metastases.

Outcomes of resection and non-resection strategies in management of patients with advanced colorectal cancer

BACKGROUND

The management of patients with surgically incurable bowel cancer at presentation is controversial. The aims of treatment are to optimise quality of life and prolong survival. It has been believed that the most effective palliation is achieved by resection of the primary cancer in order to pre-empt future complications. This study reviews and compares the outcomes of patients with incurable bowel cancer managed by resection and non-resection strategies over a 7-year period in a single District General Hospital.

PATIENTS AND METHODS

All patients with surgically incurable bowel cancer at presentation were identified from the prospectively collected local ACPGBI database. Survival, using Kaplan-Meier method and log-rank test, was compared between patients managed by resection of the primary, non-resectional intervention (surgery, stent & oncological treatments) and those managed with supportive care only. The primary endpoint of the study was survival on an intention to treat basis, compared using Kaplan-Meier and log-rank tests.

RESULTS

Of 646 consecutive newly diagnosed bowel cancer patients over a 7 year period 154 cases (24%) were deemed surgically incurable at presentation. Of these surgical resection was carried out in 45 patients (29%), non-resectional intervention was followed in 52 patients (34%) and supportive treatment alone in 57 patients (37%). Median survival of each group was as follows: resected patients 11 months (I.Q range 3-18 months), non-resectional intervention 7 months (I.Q range 2-15 months) and supportive care alone 2 months (I.Q range 1-8 months). Only one patient (2%) managed by non-resectional intervention required later surgery to treat primary tumour related complications. Survival was not significantly different between resection and non-resection treatments. The overall operative mortality for the resection group was 16% (7/45 cases), with an elective mortality of 14% (4/28 cases) and emergency mortality 18% (3/17 cases).

CONCLUSION

In an unselected bowel cancer population surgical resection of the primary tumour in patients presenting with incurable disease does not improve survival and is associated with a high risk of post-operative mortality.

Clinical characteristics and outcomes in patients with advanced rectal cancer: a national prospective cohort study

PURPOSE

At the time of diagnosis, approximately one third of patients with rectal cancer present with advanced disease. In this study we focus on a group of patients with primary advanced rectal cancer considered as not operable. We address various clinical aspects relevant for decision-making in a group of patients in need of palliative care.

METHODS

Between January 1997 and December 2001, 4831 consecutive patients with rectal cancer were prospectively registered in the Norwegian Rectal Cancer Registry. In this national population-based cohort, 386 patients (8 percent) without surgical interventions were identified. These patients comprise the study population. Clinical characteristics and survivals were addressed.

RESULTS

Patients not surgically treated were significantly older compared with other treatment groups (median age, 80 years; interquartile range, 72-86 vs. median age, 71 years; interquartile range, 62-79 years) (P<0.001). Median survival time was 4.5 (range, 3.5-5.4) months, regardless of age, gender, or hospital category. Patients who received radiotherapy had a significantly increased survival (P<0.001) compared with patients not treated with radiation, with a median survival time of 10.2 (range, 7.3-12.1) months vs. 2.8 (range, 2.1-3.6) months, respectively. Use of chemotherapy was not associated with improved survival. In multivariate analysis, only stage of disease and radiotherapy were independent predictors of better survival.

CONCLUSION

Higher age and comorbidity seem to influence choice of treatment in this subgroup of patients with advanced rectal cancer disease. In nonsurgically treated patients, radiotherapy was associated with an improved survival. Our prospective, population-based cohort study emphasizes the dismal prognosis of these patients, which also should challenge our efforts and clinical approaches in palliative care.

Survival benefit in patients after palliative resection vs non-resection colon cancer surgery

AIM: To evaluate survival in patients undergoing palliative resection versus non-resection surgery for primary colorectal cancer in a retrospective analysis.

METHODS: Demographics, TNM status, operating details and survival were reviewed for 67 patients undergoing surgery for incurable colorectal cancer. Palliative resection of the primary tumor was performed in 46 cases in contrast to 21 patients with non-resection of the primary tumor and bypass surgery. Risk factors for postoperative mortality and poor survival were analyzed with univariate and multivariate analyses.

RESULTS: The two groups were comparable in terms of age, gender, preoperative presence of ileus and tumor stage. Multivariate analysis showed that median survival was significantly higher in patients with palliative resection surgery (544 vs 233 d). Differentiation of the tumor and tumor size were additional independent factors that were associated with a significantly poorer survival rate.

CONCLUSION: Palliative resection surgery for primary colorectal cancer is associated with a higher median survival rate. Also, the presence of liver metastasis and tumor size are associated with poor survival. Therefore, resection of the primary tumor should be considered in patients with non-curable colon cancer.

Incidence and patterns of recurrence after resection for cure of colonic cancer in a well defined population

BACKGROUND

The aim of this study was to determine the incidence and patterns of failure following potentially curative surgery of colonic cancer.

METHODS

Data were obtained from the cancer registry of the Côte-d'Or (France). Data on 2657 patients who had resection for cure of colonic cancer between 1976 and 2000 were analysed. Local and distant failure rates were calculated using the actuarial method and multivariable analysis was performed using a Cox model.

RESULTS

The 5-year cumulative rate was 12.8 percent for local recurrence and 25.6 percent for distant metastases. Five-year cumulative local recurrence rates were 4.9 percent for stage I, 11.0 percent for stage II and 23.5 percent for stage III tumours (P<0.001). The corresponding rates for distant metastases were 6.4, 21.4 and 48.0 percent (P<0.001). The 5-year cumulative rates for distant metastases were 31.7 percent for the period 1976-1980 and 21.1 percent for 1996-2000, and the local recurrence rates were 17.6 and 9.0 percent respectively. The decreases in rates of local recurrence and distant metastases were significant in multivariable analysis. Cancer extension and presenting features were related to patterns of failure. Tumour location was significantly associated with risk of local recurrence, whereas age and gross features were associated with risk of distant metastasis.

CONCLUSION

Recurrence following resection of colonic cancer remains a substantial problem. Follow-up is of particular importance in the 3 years after surgery.

Time trends in the treatment and survival of recurrences from colorectal cancer

BACKGROUND

Little is known about the management of recurrences from colorectal cancer at a population level.

MATERIALS AND METHODS

Data was obtained from the population-based cancer registry of Cote d'Or (Burgundy, France) over a 28-year period. Univariate and multivariate analyses were performed to analyse trends in treatment and survival for local recurrence and distant metastases.

RESULTS

The proportion of patients resected for cure increased from 6.7% (1976-1984) to 23.7% (1994-2003; P <0.001) for distant metastases and from 15.9% to 58.1% (P <0.001) for local recurrence. Age and period of diagnosis were independent factors associated with a resection for cure. Rectal cancer local recurrence was less often resected for cure than colon cancer local recurrence (P=0.05). Long-term survival was observed only after resection for cure: 5-year relative survival rates were 36.1% for local recurrence and 24.0% for distant metastases. In the multivariate analysis, survival decreased with age and increased over time but significantly only over the last study period. Surgical resection and palliative chemotherapy were other determinants of prognosis for distant metastases whereas surgical resection and palliative radiotherapy did influence the prognosis for local recurrence.

CONCLUSION

Substantial advances in the management of recurrences have been achieved over time. More effective treatments and mass screening represent promising approaches to decrease this problem.

Cost and effectiveness of follow-up examinations in patients with colorectal cancer resected for cure in a French population-based study

The cost of follow-up examinations for patients having undergone potentially curative surgery for colorectal cancer is considerable. The aim of this study was to provide a thorough assessment of the cost and effectiveness of the follow-up tests used during the 5 years after surgical resection for colorectal cancer and its recurrences. We studied medical and economic data from the records of 256 patients registered in the Herault Tumor Registry who underwent potentially curative surgical resection in 1992. Recurrence, curative recurrence, survival, and the cost of follow-up tests were assessed respectively for at least 5 years. We analyzed the cost and effectiveness of follow-up tests in patients who received either follow-up with carcinoembryonic antigen (CEA) monitoring as advocated by the 1998 French consensus conference recommendations (standard follow-up) or a more minimal follow-up schedule. Nine patients died in the postoperative period. The 5-year survival rates in the standard and minimal follow-up groups were 85% and 79%, respectively (p=0.25). Cost-effectiveness ratios were 2123 in Dukes' stage A patients, 4306 in Dukes' stage B patients, and 9600 in Dukes' stage C patients. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the standard follow-up group were 1238 and 2261.5, respectively. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the minimal follow-up group were 1478 and 573, respectively. There were no survivors 5 years after a recurrence when the recurrence was detected by physical examination, chest X-ray, and colonoscopy in either follow-up group. Dukes' classification is a poor indicator of patient selection. The follow-up tests should only include CEA monitoring and abdominal ultrasonography for the diagnosis of recurrence.

Non-curative surgery for colorectal cancer: critical appraisal of outcomes

BACKGROUND AND AIMS

The value of surgery for patients with incurable colorectal cancer is controversial. This study evaluated outcomes in patients undergoing non-curative surgery for colorectal cancer and aimed to identify patients who would benefit from palliative surgery.

PATIENTS AND METHODS

Demographics, tumour characteristics, operating details and outcomes were reviewed for 180 patients undergoing surgery for incurable colorectal cancer; palliative resection was performed in 150 cases. Seventeen patients died in the postoperative period. Risk factors for postoperative mortality and poor survival were analysed with univariate and multivariate analysis.

RESULTS

Multivariate analysis showed that operative mortality was significantly higher in patients with non-resection surgery and in those with ascites. Median survival of patients with resection was significantly longer than in those without resection (30 vs. 17 weeks). Other independent factors that were significantly associated poor survival were the presence of ascites, presence of bilobar liver metastasis and absence of chemotherapy and/or radiation therapy.

CONCLUSION

Non-curative surgery is associated with high mortality in patients without resection and in the presence of ascites. These two factors, together with the presence of bilobar liver metastasis and the absence of chemotherapy and/or radiation therapy, are associated with poor survival. In the presence of these factors the balance between the benefit and risk of surgery should be carefully considered before decision for operative treatment.

Isolated diaphragmatic metastasis originated from adenocarcinoma of the colon

Isolated diaphragmatic metastasis arising from colorectal cancer has been reported only one case in the literature presently. Here, we presented a new case and discussed the possible pathogenesis and the treatment options. A 42-year-old male patient had received anterior resection for sigmoid colon cancer. Although the increased serum CEA level was detected 20 months after the surgery, metastatic lesion could not be detected by repeated colonoscopy, CT scan, bone scan or PET scan for 35 months. We could detect a suspicious metastatic lesion on the liver by CT scan at 56 month after the surgery. During a second-look operation, we found a solitary metastasis on the diaphragm and removed it along with the 1 cm tumor-free resection margin. Although the prognosis associated with skeletal metastasis is poor, the complete resection of isolated diaphragmatic metastasis and subsequent appropriate adjuvant chemotherapy may achieve a cure the disease provided that other metastatic lesions are absent.

A retrospective study on the use of post-operative colonoscopy following potentially curative surgery for colorectal cancer in a Canadian province

Background

Surveillance colonoscopy is commonly recommended following potentially curative surgery for colorectal cancer. We determined factors associated with patients undergoing a least one colonoscopy within five years of surgery.

Methods

In this historical cohort study, data on 3918 patients age 30 years or older residing in Alberta, Canada, who had undergone a potentially curative surgical resection for local or regional stage colorectal cancer between 1983 and 1995 were obtained from the provincial cancer registry, ministry of health and cancer clinic charts. Kaplan-Meier estimates of the probability of undergoing a post-operative colonoscopy were calculated for patient, tumor and treatment-related variables of interest.

Results

A colonoscopy was performed within five years of surgery in 1979 patients. The probability of undergoing a colonoscopy for those diagnosed in the 1990s was greater than for those diagnosed earlier (0.65 vs 0.55, P < 0.0001). The majority of the difference was seen at one-year following surgery, consistent with changes in surveillance practices. Those most likely to undergo a colonoscopy were those under age 70 (0.74 vs 0.50 for those age 70 – 79, P < 0.0001), who underwent a pre-operative colonoscopy (0.69 vs 0.54, P < 0.0001), and who underwent a resection with reanastomosis (0.62 vs 0.47 for abdominoperineal resection, P < 0.0001) by a surgeon who performs colonoscopies (0.68 vs 0.54, P < 0.0001).

Conclusions

The majority of patients undergo colonoscopy following colorectal cancer surgery. However, there are important variations in surveillance practices across different patient and treatment characteristics.

Jaundice secondary to isolated porta hepatis metastasis in colorectal cancer: case report and review of the literature

Colorectal cancer occurs mainly after the age of 50. The liver is the most frequent site of metastases, although isolated metastases to the porta hepatis are rarely reported in the literature. From 1924 to 1993, only 16 cases of periportal lymph nodes metastases were reported. We report a case of jaundice secondary to porta hepatis metastases from primary colorectal cancer. The appearance of symptoms was concurrent with the elevation of carcinoembryonic antigen in our case. This emphasizes the importance of polymerase chain reaction to detect the small amount of carcinoembryonic antigen transcript in blood or in peritoneal fluid before the appearance of symptoms. Polymerase chain reaction allows the prediction of high risk of recurrence and the presence of micrometastases. More trials are needed to assess the outcome after treatment by adjuvant chemotherapy for micrometastases.

Follow-up after colorectal cancer surgery

Although most institutions offer some kind of follow-up to patients operated on for colorectal cancer, its value with respect to prolonged survival has been challenged. However, improved results of liver surgery and chemotherapy make it reasonable to assume that a follow-up programme leading to detection of more asymptomatic recurrences would result in improved survival. Liver metastases and extramural local recurrences are the most common secondary lesions and 5-year survival rates of about 30% are reported after radical resection. From these observations a survival benefit could be expected when follow-up is directed to these forms of recurrence. From six randomized studies, six comparative cohort studies and four meta-analyses it can be concluded that an intensive follow-up programme results in more recurrences being resected for cure and about a 10% higher 5-year survival rate compared with less intensive or no follow-up. However, the differences in the follow-up protocols make it difficult to conclude how a follow-up programme should be designed. Liver imaging and carcinoembryonic antigen assay should probably be included, while the yield of frequent colonoscopies is small. A follow-up regimen based on these principles is suggested. Future studies should focus on which tests are the most cost-effective for follow-up after colorectal cancer resection.

Follow-up strategies after curative resection of colorectal cancer

Consensus is lacking as to the best strategy for following patients who have undergone definitive surgical medical treatment for colon cancer. The goal of any surveillance program should be detection of recurrent disease at a sufficiently early time to allow subsequent curative therapy. Although periodic clinical examinations, laboratory tests, radiographic imaging, and carcinoembryonic antigen (CEA) testing have been utilized as a form of surveillance, such aggressive and costly intervention has not been validated through clinical studies. Four of the five randomized trials comparing such an intensive surveillance strategy to less frequent testing have not demonstrated the intensive approach to lead to an improvement in overall survival. Furthermore, intensive testing is both costly and has been shown not to improve quality of life. Further research designing appropriate postoperative testing is needed to guide physicians and patients after the curative resection of a colorectal cancer.

Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial

AIMS

This paper aims to evaluate the diagnostic efficacy and costs of follow-up tailored according to risk of recurrence compared with minimal surveillance.

METHODS

A total of 358 patients treated by surgery alone for colorectal cancer were prospectively divided into two groups of 200 and 158 patients considered at high and low risk of recurrence respectively, according to prognostic factors. They were further randomized into two subgroups: group 1, 192 patients undergoing risk-adapted follow-up, intensive and low-intensity; group 2, 145 patients undergoing minimal surveillance. Twenty-one cases dropped out. Median follow-up was 61.5 months and 42 months for cases at high risk (intensive follow-up) and at low risk (low-intensity follow-up) respectively.

RESULTS

At the end of the study, 52.6% of patients undergoing risk-adapted follow-up and 57.2% undergoing minimal follow-up had developed recurrence. In patients at high risk, a significant difference in the incidence of curative re-operations was observed between the subgroups undergoing risk-adapted follow-up and subgroups undergoing minimal surveillance (P<0.05). The actuarial 5 year survival of patients at high and at low risk of recurrence undergoing risk-adapted follow-up is significantly better than that of cases undergoing minimal follow-up. The economic costs for 34 patients in the intensive follow-up group and for the 57 patients in the low-intensity follow-up group who were free from disease after primary surgery was very similar.

CONCLUSIONS

Risk-adapted follow-up has significantly improved the targeting of curative re-operations and overall survival of patients independently of risk of recurrence and has allowed a reduction in the costs of following up of disease-free patients.

Follow-up of patients with colorectal cancer: numbers needed to test and treat

Follow-up after curative treatment of patients with colorectal cancer has as its main aims the quality assessment of the treatment given, patient support, and improved outcome by the early detection and treatment of cancer recurrence. How often, and to what extent, the final aim, improved survival, is indeed realised is so far unclear. A literature search was performed to provide quantitative estimates for the main determinants of the effectiveness of the follow-up. Data were extracted from a total of 267 articles and databases, and were aggregated using modern meta-analytic methods. In order to provide one more colorectal cancer patient with long-term survival through follow-up, 360 positive follow-up tests and 11 operations for colorectal cancer recurrence are needed. In the remaining 359 tests and 10 operations, either no gains are achieved or harm is done. As the third aim of colorectal cancer follow-up, improved survival, is realised in only few patients, follow-up should focus less on diagnosis and treatment of recurrences. It should be of limited intensity and duration (3 years), and the search for preclinical cancer recurrence should primarily be performed by carcino-embryonic antigen (CEA) testing and ultrasound (US). The focus of colorectal cancer follow-up should shift from the early detection of recurrence towards quality assessment and patient support. As support that is as good or even better can be provided by a patient's general practitioner (GP) or by specialised nursing personnel, there is no need for routine follow-up to be performed by the surgeon.

Results of laparoscopically assisted colon resection for carcinoma

BACKGROUND

Surgical resection is the primary treatment for colorectal carcinoma. Laparoscopically assisted colon resection technically is feasible for both benign and malignant disease. However, the role of laparoscopically assisted colon resection for carcinoma is controversial.

METHODS

We prospectively studied our first 100 patients with colorectal carcinoma who successfully underwent laparoscopically assisted colon resection for the carcinoma.

RESULTS

The pathologic stages were Dukes' categories A-16, B-52, C-25, and D-7. Operative mortality and morbidity were 2% and 22%, respectively. During a mean follow-up period of 40.3 months, recurrence by stage was zero patients with stage A disease, five patients with stage B disease, nine patients with stage C disease. Thirteen of these patients died as a result of their disease. At this writing, 60 patients are alive without evidence of disease, and 23 have completed the study disease free after more than 60 months. The 5-year survival probabilities by stage were 100% for stage A, 76.8% for stage B, and 51.7% for stage C.

CONCLUSIONS

Laparoscopically assisted colectomy for cancer can be performed safely. The recurrence rate after laparoscopically assisted resection appears to be at least as good as after open resection. Results from ongoing prospective, randomized trials are needed to confirm these findings.

[Colonoscopic follow-up of patients undergoing curative resection of colorectal cancer]

AIM

To investigate the role of colonoscopy in the follow-up of patients undergoing curative resection of colorectal cancer.

MATERIAL AND METHODS

A prospective study was performed of 102 patients with colorectal cancer who underwent surgery with curative intention. Postoperative colonoscopic follow-up was a minimum of 5 years.

RESULTS

There were 62 males and 40 females. The mean duration of follow-up was 73.4 months. Synchronous polyps were found in 44.1% (114 in 45 patients) and metachronous polyps in 33.4% (64 in 34 patients). Synchronous carcinoma was detected in 7.8% (9 in 8 patients), metachronous carcinoma in 1.9% (2 in 2 patients) and suture recurrence in 4.9% (5 in 5 patients). Metachronous polyps developed in 55.5% of the patients with synchronous polyps and in only 15.8% of those with no synchronous polyps (p < 0.00005); the odds ratio was 6.67. Colonoscopy diagnosed 92 synchronous polyps and 64 metachronous polyps; of these, 34 were found to be significant(in 22 patients). Colonoscopy diagnosed 5 synchronous carcinomas; in 3 of these (polyps with non-invasive carcinoma) polypectomy constituted definitive therapy and in the remaining 2, curative resection was achieved. Colonoscopy diagnosed 2 stage C2 metachronous carcinomas at 63 and 94 months. Curative resection was achieved in both cases. Colonoscopic follow-up diagnosed 2 suture recurrences and resection was potentially curative.

CONCLUSIONS

Colonoscopy was found to play an essential role in 30% of the patients. The technique allowed the early diagnosis of synchronous carcinomas and curative treatment of metachronous carcinomas and demonstrated that the presence of synchronous polyps increases the risk of developing metachronous polyps.

Preoperative serum CD26 levels: diagnostic efficiency and predictive value for colorectal cancer

CD26 is an ectoenzyme with dipeptidyl peptidase IV activity expressed on a variety of cell types. Although the function of the high concentration of serum-soluble CD26 (sCD26) is unknown, it may be related to the cleavage of biologically active polypeptides. As CD26 or enzymatic activity levels were previously associated with cancer, we examined the potential diagnostic and prognostic value of preoperative sCD26 measurements by ELISA in colorectal carcinoma patients. We found a highly significant difference between sCD26 levels in healthy donors (mean 559.7 +/- 125.5 microg l(-1)) and cancer patients (mean 261.7 +/- 138.1 microg l(-1)) (P< 0.001). A cut-off at 410 microg l(-1)gave 90% sensitivity with 90% specificity which means that the diagnostic efficiency of sCD26 is higher than that shown by other markers, particularly in patients at early stages. Moreover, sCD26 as a variable is not related with Dukes' stage classification, age, gender, tumour location or degree of differentiation. With a follow-up of 2 years until recurrence, preliminary data show that sCD26 can be managed as a prognostic variable of early carcinoma patients. In addition, the origin of sCD26 is discussed.

Colorectal cancer follow-up: a reassessment of empirical evidence on effectiveness

Colorectal cancer is an important cause of death in the Western world, with a propensity of cancer recurrence even after resection with curative intent. Active follow-up has been advocated as a means to detect cancer recurrence at an earlier stage and thereby improve the survival of colorectal cancer patients. The present study assesses published evidence on the effectiveness of follow-up. Articles were obtained from a 20-year Medline search and from cross-references between articles. Articles were included, scored for quality, and extracted by explicit criteria. Regression analysis and chi-squared analysis was performed to assess (1) whether detection of recurrence at earlier asymptomatic disease stage leads to better post-treatment prognosis, and (2) whether active follow-up does improve overall (quality adjusted) survival, as compared to symptom-guided care only. The relationship between disease stage of recurrence (symptoms, number and size) and survival was analysed from 42 articles, 10 of which provided adequate data. Absence of symptoms and small number of recurrence were significantly related to better survival, smaller size insignificantly so. The potential of active follow-up seemed related to a marginally better outcome, larger gains being found in lower quality studies. Available data do suggest that survival gains vary between 0.5 and 2%, 1% seeming to be a best estimate of overall survival gain. Neither the notion that earlier detection of recurrences does significantly improve outcome, nor the hope that active follow-up provides a statistically and clinically significant gain in (quality adjusted) survival, are so far supported by adequate evidence. Colorectal cancer follow-up still fails to meet the criteria for evidence based medicine.

Is intensive follow-up really able to improve prognosis of patients with local recurrence after curative surgery for rectal cancer?

BACKGROUND

Because more than 90% of local recurrences after curative surgery for rectal cancer appear within the first 36 months after surgery, an intensive and strict follow-up program during this period could improve early diagnosis and, thus, prognosis of patients.

METHODS

Of the 216 patients who underwent surgery for rectal cancer, 127 entered an intensive follow-up program (median follow-up: 42 months); the clinical outcome of the remaining 89 patients was reconstructed with the help of their general practitioners.

RESULTS

Fifty eight (26.8%) of the 216 patients who were treated with curative surgery alone developed a local recurrence; pelvic recurrences were prevalent. Eleven (30.5%) of the 36 patients who had recurrence during follow-up, and 6 of the 22 who had not undergone follow-up, had a reoperation with curative intent; the median survival was 19 months vs. 8 months, respectively (P = ns). Four (44.4%) curative reoperations were performed on the 9 asymptomatic patients and in 13 (26.5%) of the 49 cases with symptomatic local recurrences. Median survival was 15 months vs. 14 months, respectively (P = n.s). All patients except one (living after 42 months from reoperation) died within 48 months.

CONCLUSIONS

In our study, adherence to a strict follow-up program unfortunately proved to be ineffective for improving long-term survival for patients who underwent reoperation with curative intent.

Tumor angiogenesis predicts recurrence with normal serum carcinoembryonic antigen in advanced rectal carcinoma patients

Many studies have established the usefulness of serum carcinoembryonic antigen (CEA) oriented serial monitoring for predicting recurrence and prognosis; however, few studies have so far investigated serum CEA-negative recurrence. The aim of this study was to elucidate the nature of CEA-negative recurrence regarding tumor angiogenesis. Fifty-seven patients with T3/T4 rectal cancer were divided into the two groups according to the serum CEA status. Angiogenesis was defined as the intratumoral vessel count by immunohistochemical staining using CD31. The CD31 count was significantly higher in the recurrent patients in both groups and the ratio of nodal involvement was significantly higher in the recurrent patients of the CEA-negative group. Local recurrence mainly developed in the CEA-negative group; however, the CD31 count did not predict the sites of recurrence nor the relapse period in the both groups. A multivariate analysis showed a high CD31 count >26) to be a prognostic factor not only for recurrence but also for survival (P = 0.001, 0.043, respectively). These results suggest that a high degree of tumor angiogenesis in sections of T3/T4 rectal cancer may therefore be an important predictor for CEA-negative recurrence.

Current treatment for colorectal cancer metastatic to the liver

Surgery is currently the only available treatment option which offers the potential for cure for patients with liver metastases from colorectal cancer. Of those who undergo a potentially curative operation for their primary tumour but subsequently recur, almost 80% will develop evidence of metastatic disease within the liver. Greater experience and improvements in technique in liver surgery, with an increasingly aggressive surgical approach to metastatic colorectal cancer to the liver, has resulted in prolonged disease-free survival with 5-year rates varying from 21% to 48%. In order to increase these numbers further and to treat patients not eligible for surgical therapy, new treatment modalities and strategies have been developed. This review presents an update of the current treatment for colorectal disease metastatic to the liver.

Treatment of local recurrence of rectal cancer

BACKGROUND

Treatment of local recurrence of rectal cancer remains a challenge. Preoperative irradiation and total mesorectal excision halve the risks of local failure, but increase morbidity and even mortality. The results of re-resection of recurrent rectal cancer suggest need to reexamine therapeutic strategies for initial treatment.

METHODS

Seventy-one patients operated on for rectal carcinoma without radiotherapy developed local recurrence (29 with metastatic disease). Thirty underwent a curative re-resection (8 had combined resection of metastases).

RESULTS

The incidence of asymptomatic recurrence was higher after anterior resection (38%) than after abdominoperineal resection (16%). The actuarial 5-year survival rate was 19%; 28% in asymptomatic patients and 8% in symptomatic (P = 0.04).

CONCLUSIONS

Early detection of recurrence of rectal cancer leads to an improved re-resection rate and survival. In patients who did not undergo radiotherapy at the time of the original resection, re-resection can be achieved safely. The place for radiation in the treatment of rectal cancer must be redefined.

Incidence and patterns of recurrence following curative resection for colorectal carcinoma

PURPOSE

This study was designed to determine incidence and patterns of recurrence after curative resection of colorectal carcinoma and to determine which variables are significant in predicting outcome.

METHOD

A retrospective review of 524 patients operated on by one surgeon from 1975 to 1992 was conducted. Variables recorded included age, gender, location, gross morphology, histology, stage of each primary and evidence of perforation and direct extension at time of original operation. Overall survival and pattern of recurrence were documented.

RESULTS

Overall recurrence rate was 27.9 percent. Anastomotic recurrence rate was 11.7 percent. Anastomotic recurrences were higher for rectal than colon lesions (20.3 vs. 6.2 percent; P = 0.001). Distant metastases developed in 14.4 percent of patients, 13.9 percent for colon carcinoma and 15.5 percent for rectal carcinoma. Average time for anastomotic recurrence was 16.2 months vs. 22.9 months for distant disease. T1,2,N0,M0 lesions had a 17.6 percent recurrence rate, T3,N0,M0 was 23.4 percent, and T1,2,3,N1,M0 was 43.7 percent (P = .001). Patients who did not undergo any intervention after diagnosis of recurrence survived an average of 28 months. Those who received palliative treatment survived an average of 39 months. Twenty-four percent of patients had reresection for cure, and 47 percent of these patients were alive at a mean of 80 months; those who died of their disease did so at an average of 53 months. Positive predictive factors for recurrence include site of lesion (rectum vs. colon), stage, invasion of contiguous organs, and presence of perforation. Age, gender, degree of differentiation, mucin secretion, and gross morphology were not found to be predictive factors in this study.

CONCLUSIONS

Recurrence after resection for rectal carcinoma is higher than after colon carcinoma. In those patients in whom reresection is possible, up to 50 percent may have long-term survival. Understanding patterns of recurrence and features that predispose to them may guide the physician in aggressive but more selective adjuvant therapy and recommendations for targeted surveillance in follow-up.

Operation in patients with incurable colon cancer--is it worthwhile?

PURPOSE

This study was designed to identify objective criteria that might help surgeons decide which patients with incurable colon cancer will benefit from palliative surgery and which will not.

METHODS

Charts of 68 patients with incurable colon cancer were reviewed. Fifty-seven patients underwent resection, six had a bypass of a nonresectable cancer, and five had no surgery at all. Time to death was the major end point of the study. Minor end points were postoperative morbidity and mortality. Independent variables analyzed were comorbidity, preoperative carcinoembryonic antigen, liver function tests, extent of liver metastases, stage and site of tumor, and tumor cell differentiation.

RESULTS

There were six postoperative deaths, and six patients had complications. Mean survival after palliative resection was 10.6 months, after bypass was 3.4 months, and after diagnosis in patients not operated on was 2 months. Patients with > 50 percent of their liver replaced by cancer had significantly worse survival than those with < 50 percent involvement (mean, 4.2 +/- 4 standard deviation (SD) vs. 14.4 +/- 10.6 SD; P < 0.003, Wilcoxon's rank-sum test). Tumor differentiation also influenced survival (poor, mean 8.4 +/- 8.2 SD; well/moderate, 12.5 +/- 9.2 SD; P < 0.02). No other variable had a significant effect on survival.

CONCLUSION

Resection of primary colon cancer in patients with incurable disease has a relatively high postoperative mortality but is worthwhile as long as hepatic metastases occupy less than 50 percent of liver volume.

Follow-up in colorectal cancer patients: a cost-benefit analysis

BACKGROUND

No conclusive evidence exists concerning the effectiveness of follow-up programs after curative surgery for colorectal cancer, and presently cost-benefit analyses have not indicated that follow-up strategies increase survival or quality of life.

METHODS

Five hundred five patients who survived curative surgery for stage I-III colorectal adenocarcinoma were closely followed for at least 4 years.

RESULTS

One hundred forty-one (28%) patients had recurrence. Of these, 32 underwent one or more surgical procedures for cure, whereas 109 could only benefit from palliation. Eighteen were cured. The mean survival of all recurrent cases was 44.4 months. Of those operated on with curative intent, the mean survival was 69.3 months compared with 37.1 months in those operated on with palliative intent. Of those 18 patients who were cured by reoperative surgery, the average survival was 81.4 months. The overall follow-up cost was $1,914,900 (U.S.) for the 505 patients; $13,580 (U.S.) for each recurrence, $59,841 (U.S.) for each case treated for cure, and $136,779 (U.S.) for those effectively cured.

CONCLUSIONS

Careful postoperative monitoring is expensive yet effective when one considers that one-quarter of the detected recurrences were suitable for potentially curative second surgery; however, only 3.6% of the original group were effectively cured. Follow-up programs should be tailored according to the stage and site of the primary to reduce costs.

Surveillance after curative colon cancer resection: practice patterns of surgical subspecialists

BACKGROUND

In the literature, suggested strategies for the follow-up of colon cancer patients after potentially curative resections vary widely. The optimal regimen to monitor for recurrences and new primary tumors remains unknown. The nationwide cost impact of wide practice variation is also unknown.

METHODS

The 1,070 members of The Society of Surgical Oncology (SSO) were surveyed using a detailed questionnaire to measure the practice patterns of surgical experts nationwide. Respondents were asked how often they use nine separate methodologies in follow-up during years 1-5 postsurgery for TNM stage I, II, and III patients. Costs were estimated for representative less and more intensive strategies.

RESULTS

Evaluable responses were received from 349 members (33%). Office visit and carcinoembryonic antigen analysis were performed most frequently. SSO members generally see patients every 3 months in years 1-2, every 6 months in years 3-4, and annually thereafter. There was wide variability in test ordering patterns and moderate variation between SSO and previously surveyed American Society of Colon and Rectal Surgeons members. The charge differential between representative less and more intensive follow-up strategies for each annual U.S. patient cohort is approximately $800 million.

CONCLUSIONS

Actual practice patterns vary widely, indicating lack of consensus regarding optimal follow-up. The enormous cost differential associated with such variation is difficult to justify because there is no proven benefit of more intensive follow-up.

Follow-up after curative surgery for colorectal carcinoma. Randomized comparison with no follow-up

PURPOSE

This study investigated the value of intense follow-up compared with no follow-up after curative surgery of cancer in the colon or rectum.

METHODS

One hundred seven patients were randomized to no follow-up (control group; n = 54) or intense follow-up (follow-up group; n = 53) after surgery and early postoperative colonoscopy. Patients in the follow-up group were followed at frequent intervals with clinical examination, rigid proctosigmoidoscopy, colonoscopy, computed tomography of the pelvis (in patients operated with abdominoperineal resection), pulmonary x-ray, liver function tests, and determinations of carcinoembryonic antigen and fecal hemoglobin. Follow-up ranged from 5.5 to 8.8 years after primary surgery.

RESULTS

Tumor recurred in 18 patients (33 percent) in the control group and in 17 patients (32 percent) in the follow-up group. Reresection with curative intent was performed in three patients in the control group and in five patients (four of whom were asymptomatic) in the follow-up group. In the follow-up group two asymptomatic patients with elevated carcinoembryonic antigen levels were disease-free three and five and one-half years after reresection and were the only patients apparently cured by reresection. No patient underwent surgery for metastatic disease in the liver or lungs. Symptomatic metachronous carcinoma was detected in one patient (control group) after three years. Five-year survival rate was 67 percent in the control group and 75 percent in the follow-up group (P > 0.05); the corresponding cancer-specific survival rates were 71 percent and 78 percent, respectively.

CONCLUSION

Intense follow-up after resection of colorectal cancer did not prolong survival in this study.

The value of serum carcinoembryonic antigen in predicting recurrent disease following curative resection of colorectal cancer

Carcinoembryonic antigen (CEA) estimations are used to facilitate early diagnosis of recurrent disease after treatment for colorectal cancer.

PURPOSE

This study was designed to determine the natural history of patients with normal and abnormal levels of CEA.

METHODS

Patients undergoing potential curative resection of colorectal tumors (Dukes Stage A-C) entered a prospective, randomized trial comparing two follow-up regimens (to be reported separately) had CEA levels measured every 3 months for two years; then every 6 months for the next three years. In the study protocol, a rise in CEA was not an indication for investigation to determine recurrence unless there was also other evidence of recurrent disease.

RESULTS

Three hundred eleven patients were followed for a median of 4.5 (range, 2-5) years. Recurrent disease developed in 98 (32 percent) patients, 57 of whom had an elevated CEA (sensitivity 58 percent), with a median lead time of six (range, 1-30) months from first abnormal CEA to diagnosis of recurrent disease by other means. The specificity, positive predictive value, and negative predictive value of CEA as an indicator of subsequent recurrent disease was 93 percent, 79 percent, and 83 percent, respectively. The sensitivity of CEA for predicting hepatic metastases was 80 percent, with a median lead time of eight (range, 1-30) months, compared with only 46 percent for sites of recurrent disease other than the liver.

CONCLUSIONS

CEA was the first indicator of recurrent disease in 58 percent of all patients and in 80 percent of patients with liver metastases. The diagnosis of recurrent disease may be made several months earlier by investigating the first abnormal CEA level, although any benefit in terms of survival remains to be proven.

Optimal follow-up in colorectal cancer patients: what tests and how often?

Patients' benefit from follow-up examinations after curative surgery for colorectal cancer is unproven in spite of numerous different programs' having been designed for that purpose. Unfortunately, no final results from prospective randomized studies have been published yet and no ideal marker for recurrent cancer is available to identify patients in whom new curative treatment may be possible. So far, screening for metachronous neoplasia with intervals of several years may influence survival, whereas benefit from detecting recurrent colorectal cancer may be claimed only by using historical or other inappropriate controls. The tradition of follow-up is expensive and prospective evidence for any cost benefit is needed to justify continuous use of our limited resources in this area of patient care.

Follow-up of patients with colorectal cancer. A meta-analysis

OBJECTIVE

The authors sought to determine whether intensive follow-up improves 5-year survival rates in patients with colorectal cancer who were operated on for cure.

SUMMARY BACKGROUND DATA

Intensive follow-up of patients with colorectal cancer is still controversial. The present uncertainty in regard to the value of intensive follow-up could be the result of the absence of prospective randomized studies comparing patients with and without follow-up.

METHODS

Studies comparing two follow-up programs of different intensities were identified in the medical literature and were aggregated in a meta-analysis using the "random effects method." Seven nonrandomized studies describing 3283 patients were analyzed.

RESULTS

Patients with intensive follow-up did have 9% better 5-year survival rates than did those with minimal or no follow-up, only when intensive follow-up included carcinoembryonic antigen (CEA) assays. In addition, more asymptomatic recurrences were detected and more recurrences were resected in patients with intensive follow-up.

CONCLUSIONS

This meta-analysis indicated that intensive follow-up using CEA assays can identify treatable recurrences at a relatively early stage. Treatment of these recurrences appears to be associated with improved 5-year survival rates. However, not all intensive follow-up strategies will be equally effective. Follow-up may yield the best results if diagnostic tests are used only to detect those recurrences that can be operated on with curative intent and when follow-up is "individualized," according to patient characteristics.

Early results of follow-up after radical resection for colorectal cancer. Preliminary results of a prospective randomized trial

One-hundred and six consecutive patients were included in a prospective study of intensive monitoring after radical resection for colorectal cancer, 54 being randomized into a conventional follow-up group (Group I) and 52 into an intensified follow-up group (Group II). After a median follow-up of 2 years the overall rate of detection recurrence in Group I was 24% (13/54) and in Group II 25% (13/52). The recurrence rates among those followed up for at least 2 years were 36% (10/28) and 30% (9/30), respectively. Of the recurrences in Group I, one was local, five regional and six distant, and the corresponding figures in Group II were three, four and five. One radical extirpation of a local perineal recurrence has been performed in Group I, whereas two intestinal reresections for local anastomotic recurrences and two hepatic resections for solitary hepatic metastases have been performed in Group II. Mortality to date is 13% (7/54) in Group I and 8% (4/52) in Group II. Two adenomatous polyps have been removed from the colon in Group I during endoscopic surveillance and seven in Group II. These preliminary results encourage us to continue the trial up to 5 years after primary surgery.

Palliative operations for colorectal cancer

A review of 96 consecutive patients who underwent palliative surgery for primary colorectal cancer was undertaken to clarify the value of palliation achieved with surgical treatment. The overall rate of postoperative mortality was 8 percent (8 of 96) and the overall rate of postoperative morbidity was 24 percent (23 of 96). The mortality rate was 5 percent (3 of 66) after resective surgery and 17 percent (5 of 30) after nonresective surgery. Three deaths were related to the malignant disease, three were related to the intra-abdominal infection, and two were related to formation of intestinocutaneous fistulas. Of the 8 patients who died, 1 had a tumor with local visceral involvement only and 7 had a tumor with more distant spread. Median survival was 10 months for all patients, 15 months for patients treated with resective surgery, and 7 months for nonresected patients. Five patients (5 percent) have survived for longer than 5 years. The median relief of preoperative cancer symptoms was 4 months (4 months after resective surgery and 1 month after nonresective surgery). Twenty-five patients have undergone second surgery. It is concluded that palliative resective surgery for colorectal cancer can improve patient comfort with an acceptable postoperative mortality rate when cancer growth is localized and in favorable cases with more distant spread, whereas nonresective surgery fails to achieve symptom relief.

Rectal endosonography for the visualisation of the anastomosis after anterior resection and its relevance to local recurrence

Rectal endosonography can be used to detect and localise recurrent rectal carcinoma. Distal and proximal to a rectal anastomosis the separate layers of the bowel wall as seen by rectal endosonography are well defined but at the precise level of the anastomosis separation of the layers is lost and they appear to merge. By studying histological sections of a normal anastomosis we have demonstrated that this loss of definition seen endosonographically correlates with the histological appearances. These appearances of the normal anastomosis provide a baseline image for the identification of recurrences in the region of the anastomosis.

Metachronous colorectal carcinoma

During the period 1943-67, 903 Danish patients aged less than 40 years had colorectal carcinoma. The patients were followed up for up to 41 years and during this period 44 of 501 (9 per cent) operated on for cure developed a metachronous colorectal carcinoma. The cumulative risk of a metachronous colorectal carcinoma was 30 per cent after up to 41 years of observation. The occurrence of a metachronous colorectal carcinoma was evenly distributed in the observation period. The cumulative survival rate after operation for a metachronous colorectal carcinoma was 41 per cent after 20 years of observation. We propose a lifelong follow-up programme after resection of colorectal carcinoma for cure in this age group, including annual Hemoccult test and colonoscopy at 3-year intervals.