Postoperative screening of patients with carcinoma of the colon

Outcome of Follow-Up Programs in Patients Previously Resected for Colorectal Cancer

The survival of a group of 115 patients (group A) who entered a follow-up program after apparently « curative » surgery for colorectal cancer was compared with that of 62 similar patients (group B) who did not join such a program. No significant difference was found. Clinical benefits to single patients in group A, in terms of anticipated diagnosis and effective treatment of recurrences and of metachronous neoplasias, appeared to be, if any, extremely limited. In light of the high costs of intensive follow-up programs, it is concluded that their use can be justified only within controlled perspective trials aimed to evaluate their usefulness.

Limitations of CEA Monitoring as a Guide to Second-Look Surgery in Colorectal Cancer Follow-Up

Forty-two patients with localized colorectal cancer (Dukes’ A, B, C stages) were treated with potentially curative surgery and controlled with a follow-up program, which included CEA monitoring, for a period ranging from 12 to 48 months (median 33 months). During this period, we observed recurrent neoplastic disease in 14 patients. A retrospective analysis of the results showed that: 1. patients with a preoperative CEA value > 20 ng/ml have a significantly higher risk of recurrence than the patients with CEA < 20 ng/ml; 2. sensitivity of the CEA test was good for metastatic recurrent disease, fairly good for residual neoplastic disease, but insufficient for local recurrence; 3. test-specificity was poor, as demonstrated by the negative results of four exploratory laparotomies performed exclusively on the basis of increased CEA levels. Since the principal aim of a second-look operation is the cure of local recurrence, this type of surgery cannot be proposed only on the basis of increased CEA levels.

Blood CEA levels for detecting recurrent colorectal cancer

BACKGROUND

Testing for carcino-embryonic antigen (CEA) in the blood is a recommended part of follow-up to detect recurrence of colorectal cancer following primary curative treatment. There is substantial clinical variation in the cut-off level applied to trigger further investigation.

OBJECTIVES

To determine the diagnostic performance of different blood CEA levels in identifying people with colorectal cancer recurrence in order to inform clinical practice.

SEARCH METHODS

We conducted all searches to January 29 2014. We applied no language limits to the searches, and translated non-English manuscripts. We searched for relevant reviews in the MEDLINE, EMBASE, MEDION and DARE databases. We searched for primary studies (including conference abstracts) in the Cochrane Central Register of Controlled Trials (CENTRAL), in MEDLINE, EMBASE, and the Science Citation Index & Conference Proceedings Citation Index - Science. We identified ongoing studies by searching WHO ICTRP and the ASCO meeting library.

SELECTION CRITERIA

We included cross-sectional diagnostic test accuracy studies, cohort studies, and randomised controlled trials (RCTs) of post-resection colorectal cancer follow-up that compared CEA to a reference standard. We included studies only if we could extract 2 x 2 accuracy data. We excluded case-control studies, as the ratio of cases to controls is determined by the study design, making the data unsuitable for assessing test accuracy.

DATA COLLECTION AND ANALYSIS

Two review authors (BDN, IP) assessed the quality of all articles independently, discussing any disagreements. Where we could not reach consensus, a third author (BS) acted as moderator. We assessed methodological quality against QUADAS-2 criteria. We extracted binary diagnostic accuracy data from all included studies as 2 x 2 tables. We conducted a bivariate meta-analysis. We used the xtmelogit command in Stata to produce the pooled estimates of sensitivity and specificity and we also produced hierarchical summary ROC plots.

MAIN RESULTS

In the 52 included studies, sensitivity ranged from 41% to 97% and specificity from 52% to 100%. In the seven studies reporting the impact of applying a threshold of 2.5 µg/L, pooled sensitivity was 82% (95% confidence interval (CI) 78% to 86%) and pooled specificity 80% (95% CI 59% to 92%). In the 23 studies reporting the impact of applying a threshold of 5 µg/L, pooled sensitivity was 71% (95% CI 64% to 76%) and pooled specificity 88% (95% CI 84% to 92%). In the seven studies reporting the impact of applying a threshold of 10 µg/L, pooled sensitivity was 68% (95% CI 53% to 79%) and pooled specificity 97% (95% CI 90% to 99%).

AUTHORS' CONCLUSIONS

CEA is insufficiently sensitive to be used alone, even with a low threshold. It is therefore essential to augment CEA monitoring with another diagnostic modality in order to avoid missed cases. Trying to improve sensitivity by adopting a low threshold is a poor strategy because of the high numbers of false alarms generated. We therefore recommend monitoring for colorectal cancer recurrence with more than one diagnostic modality but applying the highest CEA cut-off assessed (10 µg/L).

Carcinoembryonic Antigen in the Staging and Follow-up of Patients with Colorectal Cancer

CEA is a complex glycoprotein produced by 90% of colorectal cancers and contributes to the malignant characteristics of a tumor. It can be measured in serum quantitatively, and its level in plasma can be useful as a marker of disease. Because of its lack of sensitivity in the early stages of colorectal cancer, CEA measurement is an unsuitable modality for population screening. An elevated preoperative CEA is a poor prognostic sign and correlates with reduced overall survival after surgical resection of colorectal carcinoma. A failure of the CEA to return to normal levels after surgical resection is indicative of inadequate resection of occult systemic disease. Frequent monitoring of CEA postoperatively may allow identification of patients with metastatic disease for whom surgical resection or other localized therapy might be potentially beneficial. To identify this group, serial CEA measurement appears to be more effective than clinical evaluation or any other diagnostic modality, although its sensitivity for detecting recurrent disease is not as high for locoregional or pulmonary metastases as it is for liver metastases. Several studies have shown that a small percentage of patients followed postoperatively with CEA monitoring and who undergo CEA-directed salvage surgery for metastatic disease will be alive and disease-free 5 years after surgery. Furthermore, CEA levels after salvage surgery do appear to predict survival in patients undergoing resection of liver or pulmonary metastases. However, several authors argue that CEA surveillance is not cost-effective in terms of lives saved. In support of this argument, there is no clear difference in survival after resection of metastatic disease with curative intent between patients in whom the second-look surgery was performed on the basis of elevated CEA levels and those with other laboratory or imaging abnormalities. There is also no clear consensus on the frequency or duration of CEA monitoring, although the ASCO guidelines currently recommend every 2-3 months for at least 2 years after diagnosis. In the follow-up of patients undergoing palliative therapy, the CEA level correlates well with response, and CEA is indicative of not only response but may also identify patients with stable disease for whom there is also a demonstrated benefit in survival and symptom relief with combination chemotherapy. More recently, scintigraphic imaging after administration of radiolabeled antibodies afforded an important radionuclide technique that adds clinically significant information in assessing the extent and location of disease in patients with colorectal cancer above and beyond or complementary to conventional imaging modalities. Immunotherapy based on CEA is a rapidly advancing area of clinical research demonstrating antibody and T-cell responses.

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.

Colorectal cancer follow-up: perspectives for future studies

This paper reviews some of the issues involved in the planning and execution of studies to assess the effect of different follow-up strategies for colorectal cancer patients. Mathematical models and many previous studies have failed to indicate strong support for the hypothesis that extensive follow-up leads to an increase in survival rates. In order to assess the best follow-up strategies, at present, within the different Dukes' stages, extremely large trials are required and none of the previous studies have satisfied this criterion, though recently planned studies will, if recruitment targets are met. The large number of patients required, the length of time the study must run, existing accepted follow-up practices in different countries, and the difficulty of managing patients on different follow-up strategies within the same centre all pose problems for the design of a randomized trial. These are not insurmountable, but do contribute to a possible downfall of a large multicentre randomized trial of follow-up strategies. Although such a trial will require considerable international cooperation it will have enormous benefits and implications if it is managed and completed successfully.

Value of postoperative surveillance after radical surgery for colorectal cancer: results of a cohort study

PURPOSE

Early detection of recurrence after curative resection for primary colorectal cancer should improve patients' prognosis. However, the usefulness of postoperative surveillance programs has not been clarified yet. The present cohort study was aimed at assessing the effectiveness of systematic follow-up in patients with colorectal cancer who were operated on for cure, regarding both rate of tumor recurrence amenable to curative-intent surgery and rate of survival.

METHODS

One hundred ninety-nine colorectal cancer patients who underwent radical primary surgery were followed according a well-defined postoperative surveillance program, which consisted of laboratory studies (including serum carcinoembryonic antigen assay) every three months, physical examination and abdominal ultrasound or computed tomography every six months, and chest radiograph and total colonoscopy once per year. Cohorts were defined according to patients' compliance with the proposed follow-up program. A multivariate regression model was constructed to predict survival.

RESULTS

One hundred forty patients were considered to be compliant with the surveillance program, whereas the remaining 59 patients occasionally attended follow-up investigations or did not comply at all. Although there were no differences in the overall recurrence rate (38 vs. 41 percent; P = 0.52), curative-intent reoperation was possible in 18 patients (34 percent) of those with tumor recurrence in the compliant cohort but in only 3 patients (12 percent) in the noncompliant cohort (P = 0.05). Similarly, the probability of survival was higher in the compliant cohort, both regarding overall (63 vs. 37 percent at 5 years; P < 0.001) and cancer-related (69 vs. 49 percent at 5 years; P < 0.02) rates. Cox regression analysis disclosed that only a more advanced TNM stage (odds ratio, 8.17; 95 percent confidence interval, 1.13-59.29) and noncompliance with the postoperative surveillance program (odds ratio, 2.32; 95 percent confidence interval, 1.50-3.60) had an independent negative impact on survival.

CONCLUSION

Systematic postoperative surveillance in patients with colorectal cancer who were operated on for cure increases both the rate of tumor recurrence amenable to curative-intent surgery and rate of survival.

Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients

BACKGROUND & AIMS

Guidelines on the type and frequency of follow-up of patients after curative surgery for colorectal cancer are unclear. The aim of this study was to determine the survival benefit of a planned follow-up program.

METHODS

Three hundred twenty-five patients who underwent curative resection of colorectal cancer were prospectively randomized to either intensive or standard follow-up. After stratification according to Dukes' stage and site in the colon or rectum, patients were randomized to intensive follow-up of yearly colonoscopy, computerized tomography (CT) of the liver, and chest radiography and clinical review and simple screening vs. structured clinical review and simple screening tests only.

RESULTS

On completion of 5-year follow-up, there was no significant difference in survival between the two groups. Yearly colonoscopy failed to detect any asymptomatic local recurrences. Only one asymptomatic curable metachronous colon tumor was detected. Liver CT resulted in earlier detection of hepatic metastases but did not increase the number of curative hepatectomies. Only 1 patient had an asymptomatic CT-detected liver metastasis, and another had an asymptomatic chest radiography-detected lung metastasis. Both had curative resections.

CONCLUSIONS

Yearly colonoscopy, liver CT, and chest radiography will not improve survival from colorectal cancer when added to symptom and simple screening review.

Value of carcinoembryonic antigen monitoring in curative surgery for recurrent colorectal carcinoma

PURPOSE

This study is designed to review a carcinoembryonic antigen (CEA)-driven postoperative protocol designed to identify patients suitable for curative reresection when recurrent colorectal cancer is identified.

METHODS

A total of 285 patients who were operated on for colon or rectal carcinoma between 1981 and 1985 were evaluated (with CEA levels) every two months for the first two years, every three months for the third year, every six months for years 4 and 5, and annually thereafter. CEA levels above 5 microg were considered abnormal and were evaluated with diagnostic imaging and/or endoscopy.

RESULTS

Follow-up was available for 280 patients (98.2 percent). Distribution of patients by Astler-Coller was: A, 14 percent; B1, 20 percent; B2, 39 percent; C1, 5 percent; C2, 21 percent. There were 62 of 280 patients (22 percent) who developed elevated CEA levels, with 44 patients who demonstrated clinical or radiographic evidence of recurrence. Eleven patients were selected for surgery with curative intent (4 hepatic resections, 1 pulmonary wedge resection, 2 abdominoperineal resections, 2 segmental bowel resections, and 2 cranial metastasectomies). Three of 11 patients (27 percent) benefited and have disease-free survivals greater than 60 months. Of the 223 patients without elevated CEA, 22 (9.9 percent) had recurrent cancer without any survivors. Overall, 3 of 285 patients (1.1 percent) were cured as a result of CEA follow-up.

CONCLUSION

CEA-driven surgery is useful in selected patients and can produce long-term survivors.

Routine compared with nonscheduled follow-up of patients with "curative" surgery for colorectal cancer

BACKGROUND

The main rationale for follow-up of colorectal cancer patients resected for "cure" is that early detection and treatment of recurrence and metachronous disease should result in improved survival. Our purpose was to assess in a prospective fashion the impact on survival of a follow-up program versus that of undergoing nonscheduled visits.

METHODS

Within the 14-year period from 1975 through 1988, a prospective study was carried out on 800 patients with colorectal adenocarcinoma radically resected with no evidence of synchronous cancers of the colon and rectum or in other organs, of whom 322 patients were to attend a 5-year follow-up, and 478 patients were free to make nonscheduled visits on account of symptoms.

RESULTS

Asymptomatic recurrence was found at follow-up in 92 (28%) of 322 patients, whereas 175 (36%) of 478 patients had a symptomatic recurrence detected at a nonscheduled visit. Diagnosis of resectable recurrence was established within a median time of 21.5 months. Surgical resection of recurrence was performed in 30 (32%) of 92 and in 13 (7%) of 175 patients (32 vs. 7%; p < 0.001). Resection was curative in 13 (14%) of 92 and in two (1%) of 175. Five-year survival of resected recurrence was 10% in 30 of 92 patients and 0.8% in 13 of 175 (10 vs. 0.8%; p < 0.01). Two patients are alive with no evidence of disease or two (2%) of 92. Metachronous colorectal lesions were treated for cure in 63 (19.5%) of 322 patients. The effectiveness of scheduled follow-up was 4% (13 of 322 patients).

CONCLUSIONS

These results underline the rationale for a follow-up program in early detection and surgical treatment of recurrent disease in patients operated on for colorectal cancer.

Surgical management of locally recurrent rectal cancer

The surgical management of locally recurrent rectal cancer may involve major procedures and is not for the faint-hearted. Nevertheless, such treatment is preferable to chemotherapy and radiotherapy; the latter will fail over a period of months during which the patient is likely to experience intractable pain. Radical surgery offers good palliation and a better quality of life. Survival is prolonged by such operations which may be curative in up to one-third of patients. Nevertheless, surgeons must be realistic in their assessment of and discussions with patients.

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 of patients resected for gastric cancer

In this study we used a cost-outcome analysis to evaluate our follow-up protocol for patients who had been resected for gastric cancer. We designed a descriptive cross-sectional trial through consecutive sampling of patients who had undergone resection of gastric carcinoma and were followed in our outpatient department during 1991. Serological (CEA) and or imaging procedures were pathologic at least two months prior to the onset of symptoms in 33% of recurrences. No significant correlation was found between serum CEA levels and CEA tumor tissue staining in patients who recurred. Only 17% of patients who relapsed underwent further treatment (surgery and chemotherapy) with no improvement found in terms of survival. The overall cost per year has been estimated at US$ 6118. Our results show that serological levels of CEA and available imaging techniques for routine follow-up provide little advantage in diagnosing gastric cancer recurrence over clinical surveillance alone.

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.

Benefits of colonoscopic surveillance after curative resection of colorectal cancer

OBJECTIVE

The authors determined the usefulness of routine colonoscopy after colorectal cancer surgery.

SUMMARY BACKGROUND DATA

Some studies suggest benefit to colonoscopy in the routine follow-up of patients with colorectal cancer who are resected for cure, whereas other studies show no benefit.

METHODS

Chart review was conducted for 290 patients who underwent curative resection for colorectal cancer between 1967 and 1991 at a colorectal surgeon's practice. Colonoscopy was performed every 6 months during the first year, then every 1 to 2 years, or when intercurrent symptoms appeared.

RESULTS

Overall, 31 patients (10.7%) developed recurrent disease, which increased as a function of stage (C2 > B2 > A), with a median time to diagnosis of 20 months. Of these 31 recurrences, 14 (45.2%) were solely local (of whom 12 were asymptomatic); 17 (54.8%) involved distant disease. Nine locally recurrent patients were able to undergo curative resection. Of 19 symptomatic patients, only 3 (15.8%) were amenable to curative resection. Six patients (2.1%) developed a metachronous second primary colorectal cancer, of whom four (66.7%) were asymptomatic, and five (83.3%) were able to undergo curative resection. Overall, because of surveillance colonoscopies, 13 asymptomatic patients (4.5%) had curative resection for localized recurrent disease or a metachronous second primary cancer.

CONCLUSIONS

Colonoscopy is a useful modality in the early detection of recurrent and metachronous disease after colorectal cancer, increasing the potential for curative resection and improved survival.

Current follow-up strategies after resection of colon cancer. Results of a survey of members of the American Society of Colon and Rectal Surgeons

The follow-up of patients after potentially curative resection of colon cancer has important clinical and financial implications for patients and society, yet the ideal surveillance strategy is unknown.

PURPOSE

The aim of this study was to determine the current follow-up practice pattern of a large, diverse group of experts.

METHODS

The 1,663 members of The American Society of Colon and Rectal Surgeons were asked, via a detailed questionnaire, how often they request nine discrete follow-up evaluations in their patients treated for cure with TNM Stage I, II, or III colon cancer over the first five posttreatment years. These evaluations were clinic visit, complete blood count, liver function tests, serum carcinoembryonic antigen (CEA) level, chest x-ray, bone scan, computerized tomographic scan, colonoscopy, and sigmoidoscopy.

RESULTS

Forty-six percent (757/1663) completed the survey and 39 percent (646/1663) provided evaluable data. The results indicate that members of The American Society of Colon and Rectal Surgeons generally conduct follow-up on their patients personally after performing colon cancer surgery (rather than sending them back to their referral source). Routine clinic visits and CEA levels are the most frequently performed items for each of the five years. The large majority (> 75 percent) of surgeons see their patients every 3 to 6 months for years 1 and 2, then every 6 to 12 months for years 3, 4, and 5. Approximately 80 percent of respondents obtain CEA levels every 3 to 6 months for years 1, 2, and 3, and every 6 to 12 months for years 4 and 5. Colonoscopy is performed annually by 46 to 70 percent of respondents, depending on year. A chest x-ray is obtained yearly by 46 to 56 percent, depending on year. The majority of the members of The American Society of Colon and Rectal Surgeons do not routinely request computerized tomographic scan or bone scan at any time. There is great variation in the pattern of use of complete blood count and liver function tests. Members of The American Society of Colon and Rectal Surgeons from the United States tend to follow their patients more closely than do those living in other countries. The intensity of follow-up does not markedly vary across TNM Stages I to III.

CONCLUSION

The surveillance strategies reported here rely most heavily on clinic visits and CEA level determinations, generally reflecting guidelines previously proposed in the current literature.

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.

Is follow-up of colorectal cancer patients worthwhile?

Between 1978 and 1989, 1,045 of 1,399 patients (580 male and 474 female) underwent curative surgery for colorectal carcinoma. Of these patients, 350 (33 percent) had recurrences, another 16 (1.5 percent) developed a metachronous colorectal cancer, and 23 (2 percent) had cancers of other organs. An isolated locoregional recurrence was found in 75/350 (21 percent). The remaining 275/350 patients (79 percent) showed systemic dissemination of the carcinoma. Reoperations with curative intent were performed on 56/350 patients (16 percent). Only 21 of the 56 resected patients (38 percent), i.e., 21/350 (6 percent), were without recurrence at the end of the follow-up period on December 31, 1990. Despite a curative reoperation, 62 percent of the patients again developed recurrent growths. There is an imbalance between the efforts invested in tumor follow-up and the benefits gained. Further follow-up programs should be investigated in a controlled, prospective fashion.

Does methodic long-term follow-up affect survival after curative resection of colorectal carcinoma?

Records of 487 patients in long-term follow-up after Ro resection of colorectal carcinomas between January 1, 1980 and December 31, 1989 were analyzed. Every patient underwent regular examinations according to a defined schedule after curative resection of colorectal carcinoma. The date of evaluation was June 31, 1991. During a median observation time of 48 months (range, 15-132 months), tumor recurrence was observed in 149 patients (30.6 percent), with 56.4 percent of these suffering from tumor-associated symptoms. As the primary manifestation of tumor recurrence, only distant metastases (DM) were found in 76 patients (51 percent), only local recurrence (LR) in 46 patients (30.9 percent), and both DM and LR in 27 patients (18.1 percent). Patients with rectal carcinoma developed LR more frequently (P < 0.05) (19.5 percent) than patients with colon carcinoma (11.8 percent). The probability of developing distant metastases was not different (P < 0.05) for colon or rectal carcinoma but depended on primary tumor stage (P < 0.05). Only 36 patients (24.2 percent) with recurrence could undergo further curative resection. Fifty patients (33.5 percent) were given palliative therapy, and 63 patients (42.3 percent) were given no oncologic treatment. Only 9 of the 36 patients (6 percent of all recurrence patients) undergoing Ro resection were free of tumor for more than two years. In no case was a third Ro resection possible. The survival time of these patients was increased significantly after Ro resection of tumor recurrence (P = 0.03). Our study suggests that only a very few patients may live longer as a result of regular follow-up programs after curative resection for colorectal carcinoma.

Biochemical markers for colorectal cancer. Diagnostic and therapeutic implications

The development of the understanding of oncogenes, tumor suppressor genes, and signal transduction has provided a significant advance in the concepts of the mechanisms of carcinogenesis in the colon and rectum. The tools provided by the molecular geneticist and the immunobiologist may yield powerful new techniques for screening individuals at risk, for identifying those patients with biologically more aggressive tumors, for developing novel therapies targeted directly at tumor cells, and for providing the means for more sensitive and specific detection of recurrence of disease.

Recent advances in surgery for colon and rectal cancer

Surgery is the mainstay of therapy for colon and rectal cancer. Over the past several decades, there have been important advances both in the understanding of the biology of colon and rectal cancer and in the preoperative and operative techniques for treating this disease. Although it appears in some studies that we have made a difference in the survival rates in the treatment of colon and rectal cancer, in actual fact, this phenomenon may only be secondary to better staging and, therefore, a greater ability to prognosticate a particular patient's chance of cure. What has been learned in the past 20 to 30 years is that most colon and rectal carcinomas start as polyps of the colon and rectum. Most often, polyps are sporadic, but there are certain high-risk groups that produce polyps and, consequently, colon and rectal cancer at a much higher rate. The goal of a practicing physician is to identify these high-risk individuals and to recommend frequent screenings so as to intervene before a polyp has had a chance to become a deeply invasive cancer. These high-risk groups are best typified by familial adenomatous polyposis, which if left untreated will, in 100% of cases, lead to the death of a patient from colon or rectal cancer. Other diseases that lead to an increase in colon and rectal cancer but may not go through the usual adenoma-to-carcinoma sequence include inflammatory bowel disease such as Crohn's colitis and ulcerative colitis. Most patients with colorectal carcinoma are asymptomatic at the time of diagnosis. This phenomenon has led to efforts to screen the general population for polyps and for cancer. Screening techniques such as the detection of occult blood in the stool and endoscopic procedures are currently the most popular. It is unclear at this time exactly what the efficacy of these techniques is in improving the survival of the general population from colorectal carcinoma. The surgical techniques to remove colon and rectal carcinomas have recently expanded to include a more aggressive local excision policy for small tumors of the rectum and the application of laparoscopic techniques, new stapling techniques, and new anastomosing techniques for tumors of the colon and rectum. These techniques have become possible in part through advances in surgical instrumentation and also in part from our increasing understanding of the biology of the disease. Both have allowed for more creative approaches to diagnosing and treating colon and rectal cancer.(ABSTRACT TRUNCATED AT 400 WORDS)

Investigation, follow-up and recurrence after resection of colorectal cancer

A study was undertaken to determine the patterns of management in the 2 years following resection of colorectal cancer by Victorian surgeons. Patients were identified by the Victorian Cancer Register as having colorectal cancer diagnosed between July 1 and December 31 1987. The surgeon of each of the 947 eligible patients who underwent surgery was sent a questionnaire seeking information about the pre-operative investigation, type of surgery and subsequent line of referral. Only 16% of colonic cancers and 39% of rectal cancers were biopsied pre-operatively and colonoscopy was undertaken in one-half and one-third respectively. Of the 737 responses, 555 patients were considered to have had curative surgery, and details of their follow-up during the four 6-month periods following surgery was analysed; this includes the effect of tumour stage and surgeon activity on the use and frequency of each test. Most patients had a clinical examination in each of the 6 month periods, but almost half did not have a colonoscopy and two-thirds did not have the serum CEA level measured at all. Only one in eight had a chest X-ray and fewer had the liver scanned during this 2 year period. Eighty-two patients (20% of those satisfactorily followed) suffered a recurrence during this period. Twenty-six were asymptomatic at the time of recurrence and were diagnosed by a routine test and of these, eight were diagnosed by tests used infrequently. Sixteen (20%) were considered surgically curable.

Role of CEA, TPA, and Ca 19-9 in the early detection of localized and diffuse recurrent rectal cancer

Sixty-six consecutive patients who underwent curative resection for rectal cancer were studied prospectively to evaluate the roles of sequential carcinoembryonic antigen (CEA), tissue plasminogen activator (TPA), and carcinomatous antigen 19-9 (Ca 19-9) determinations in the early diagnosis of resectable recurrences. Thirty-three recurrences were detected between 6 and 42 months. CEA, TPA, and Ca 19-9 showed a sensitivity of 72.7 percent, 78.8 percent, and 60.1 percent, respectively, and a specificity of 60.6 percent, 60.6 percent, and 87.9 percent, respectively. In 23 cases the rise in the value of CEA and/or TPA and/or Ca 19-9 was the first sign of recurrences, and the diagnosis was established later by clinical methods. In this group, the lead time was two months for liver metastases and four months for disseminated metastases. As far as the relationship between localization of recurrence and marker level increase is concerned, of 16 hepatic metastases CEA, TPA, and Ca 19-9 showed a sensitivity of 94 percent (P less than 0.05), 69 percent, and 62 percent, respectively. Of six patients with local recurrences, CEA, TPA, and Ca 19-9 showed a sensitivity of 50 percent, 100 percent (P less than 0.05), and 83.3 percent, respectively. Of three patients with peritoneal carcinomatosis, CEA, TPA (P less than 0.05), and Ca 19-9 showed a sensitivity of 0 percent, 100 percent, and 0 percent, respectively. No significant differences were reported among the three markers according to multiple metastases and metachronous polyps. Fourteen patients (42.4 percent) underwent surgical treatment for recurrent disease, and eight of them (57 percent) showed a resectable disease, for a total resectability rate of 24.2 percent. The findings of our study indicate that a follow-up program based on CEA, TPA, and Ca 19-9 assays is related to an early diagnosis and a good resectability rate for both local and metastatic recurrences from rectal cancer.

Prevention and management of recurrent rectal cancer

Increased attention to surgical indications and technique can minimize the risks of recurrent rectal cancer. In addition, the use of adjuvant chemoradiation therapy has been shown to further decrease the risks of recurrent rectal cancer. In the event a recurrence develops, surgical therapy, combined with radiation therapy, can result in local control in as many as 75% of patients and long term survival in 25% to 40% of patients.

Follow-up plans after treatment of primary colon and rectum cancer

Although some would argue about the value of routine follow-up of patients with colon and rectal cancer, well designed programs of testing have been shown to identify treatable recurrence at its earliest detectable stage. Treatment of these recurrences appears to be associated with improved survival. Newer applications of radiolabeled antibodies that are directed to specific or nonspecific cell surface epitopes may increase the value of serologic tumor markers. Ultimately, the application of progressively more stringent cost controls in our medical care delivery systems will demand that follow-up tests be proven of value either in a curative or palliative sense to the patient with recurrent disease.

Gastrointestinal cancer follow-up: the effectiveness of sequential CEA, TPA and Ca 19-9 evaluation in the early diagnosis of recurrences

One-hundred and seventy-four consecutive patients who underwent curative resection for gastric and colorectal cancer between 1983 and 1985 were studied prospectively to evaluate the roles of sequential carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and Ca 19-9 determinations and independent clinical examinations, in the early diagnosis of resectable recurrences. Sixty-six recurrences (33 from gastric and 33 from colorectal cancer) were detected between 6 and 42 months after primary surgery. In gastric cancer CEA, TPA and Ca 19-9 showed a sensitivity of 64%, 73% and 60% respectively and a specificity of 67%, 65% and 54% respectively. Nine patients (27%) underwent surgical treatment for recurrent disease, and four of these (44.4%) had resectable recurrence, for a total resectability rate of 12%. Of these four patients, three are still living after 12, 36 and 44 months respectively from re-operation without evidence of neoplastic disease. In one of these patients, re-operation was performed on the basis of the elevation of the three markers, without any other clinical sign of disease. This patient had a resectable solitary hepatic recurrence. In colorectal cancer. CEA, TPA and Ca 19-9 showed a sensitivity of 73%, 73% and 49% respectively, and a specificity of 77%, 87% and 97% respectively. Fourteen patients (42.4%) underwent surgical treatment for recurrent disease and eight of these (57%) showed resectable recurrence, for a total resectability rate of 24.2%. Six patients are still living after 9, 16, 21, 31, 41 and 53 months respectively from re-operation without evidence of neoplastic disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of a patient prior to second-look surgery

The evaluation of a patient with a suspected colorectal malignancy is well defined; however, the preoperative work-up of a patient who is a candidate for second-look surgery is controversial and based less on scientific evidence than on empiric or anecdotal grounds. The preoperative assessment of these patients can be divided into two phases. Phase I consists of a thorough history, physical examination, and routine laboratory tests as the most logical and traditional starting point. Phase II consists of specific tests aimed at evaluating the extent of the recurrence and the resectability of the tumor. Of the various modalities available, the enhanced computerized tomogram is currently the method most likely to provide significant information prior to carcinoembryonic antigen (CEA) -directed second-look surgery. The results of the preoperative evaluation together with a thorough understanding of the natural history of the disease will offer a clear perspective as to the most likely outcome.

Second-look surgery for recurrent colorectal carcinoma: is it worthwhile?

Second-look surgery for recurrent colorectal carcinoma has been advocated for over four decades. Routine follow-up procedures gave way to clinically directed or carcinoembryonic (CEA)-directed procedures in the mid-1970's. In this paper, we review the results of second-look surgery for recurrent colorectal carcinoma and ask the question, "Is it worthwhile?" Excluding surgery for symptomatic patients, we conclude that second-look surgery should only be performed for recurrent colorectal carcinoma with the intent of rendering the patient disease-free. Without effective systemic therapy, "palliative" or "debulking" procedures probably do not increase survival. The most likely candidates for such a curative approach with second-look surgery are those with isolated liver, pulmonary, and, less frequently, regional recurrences.

[Individual risk-related after-care in colorectal cancer?]

Efficacy of the regular follow-up program and influence on survival rate following treatment of recurrence were evaluated. 556 follow-up records of patients after resection of colorectal cancer were analysed. The primary drop-out rate was 12.4%. Recurrences were found in 26.6% (n = 128). 53.1% of recurrences were symptomatic at diagnosis of recurrence. Curative resection of recurrence was only performed in 19.5%. 46.1% were given palliative and 34.4 no specific oncologic treatment. We define efficacy as the rate of curative asymptomatic recurrence. This was 3.5% of all patients. From the curative resection of recurrence only 6 patients were free of recurrence longer than 2 years. No second resection of recurrence was possible. Different treatment of recurrence did influence the survival rate (p = 0.09). There was no difference in prognosis for asymptomatic and symptomatic recurrences (p greater than 0.8). In order to increase the efficacy of follow-up for colorectal cancer we are introducing a new concept based on individual risk factors.

A prospective study of local recurrence after resection and low stapled anastomosis in 183 patients with rectal cancer

Local recurrence is the most serious complication of anterior resection for rectal cancer, usually occurring during the first two years after surgery. Over a five-year period, from 1981 to 1986, 183 patients underwent anterior resection for rectal carcinoma at the Surgery Ward of the University of Ferrara. Patients were followed for two years postoperatively. All operations were performed with staplers and classified according to Dukes, with 43 cases of Dukes' A; 83 cases of Dukes' B; and 57 cases of Dukes' C. In the first 24 months after surgery, the tumor recurred locally in 44 of the 183 patients (24 percent). Dukes' stage, grading distal resection margin, and histopathologic differentiation of the distal rectal ring left in the stapler after anastomosis were assessed to determine a prognostic indicator for the recurrence of the tumor. The stage:recurrence ratio was as follows: A, 1 (2 percent); B, 21 (25 percent); and C, 22 (39 percent). The grading:recurrence ratio was: G1, 13:51 (25 percent); G2, 24:110 (22 percent); and G3, 7:22 (32 percent). The ratio between distal rectal resection margin and recurrence was: 0 to 2 cm, 15:27 (56 percent); 2 to 4 cm, 16:74 (22 percent); and over 4 cm, 13:82 (15 percent). Histopathologic examination of the distal rectal ring was negative for all patients. These data confirm the direct relationship between class and local recurrence and indicate histologic grade and distal resection margin as significant prognostic parameters only when interpreted in the light of staging.

The role of CEA, TPA and CA 19-9 in the early detection of recurrent colorectal cancer

Eighty-eight consecutive patients who underwent curative resection for colorectal cancer between 1983 and 1985 were studied prospectively to evaluate the roles of sequential CEA, TPA and CA 19-9 determinations and independent clinical examination in the early diagnosis of resectable recurrences. Twenty nine recurrences were detected between 8 and 38 months after primary surgery. CEA, TPA and CA 19-9 showed a sensitivity of 72%, 62% and 38%, and a specificity of 78%, 86% and 97%, respectively. Of eight recurrences in which CEA was not raised, five induced a rise in TPA and two a rise in CA 19-9. The rise in the serum concentration of one of the three markers was the first sign of relapse in 23 (79%) patients. Two second-look laparotomies based solely on a rise in serum markers were performed. In one case diffuse recurrent disease was found, and in the other a resectable solitary hepatic metastasis was found.

Impact of the barium enema on patient management

The medical records of 214 consecutive inpatients who had a barium enema examination were reviewed, and the clinical indications, efficacy of the barium enema, and patient outcome were correlated to determine the impact of the barium enema on patient management. The most frequent indications were rectal bleeding (33%), abdominal pain (31%), anemia (17%), weight loss (12%), and previous lesions needing reevaluation (12%). Diverticular disease (30%), colonic polyps (10%), and primary or secondary malignancies (12%) were the most common abnormalities detected radiographically. The sensitivity of the barium enema for colonic neoplasms was 89%, with only 1 small cecal polyp being undetected. The effects of barium enema on patient management were serious pathology excluded (64%), diagnosis made that changed therapy (24%), existing therapy continued (10%), and a further study ordered (2%). No serious or life-threatening lesion was missed by barium enema.

Colorectal cancer. The bases for a comprehensive follow-up

The purpose of this article was to review the effectiveness of follow-up in patients with colorectal cancer submitted to curative treatment. A comprehensive follow-up involves rational initial management of the primary tumor, knowledge of prognostic factors, selection of the patient to be followed, determination of the time for follow-up, use of the most appropriate tests for early diagnosis of recurrence, and eventual curative treatment. The updated answers to all these questions are given through an extensive review of the world literature and confronted with the authors' experience of eight years of follow-up in a series of 170 colorectal cancer patients treated for cure. Although the future might be more promising, past world experience suggests only a few patients could be saved. It is concluded that there is no place for incomplete and disperse screening tests, and only comprehensive, intensive, and very well-coordinated follow-up programs should be undertaken if better results are hoped to be achieved.

Detection and treatment of local recurrence

The chance of a curative reoperation is better in patients with an asymptomatic recurrence than in those with a symptomatic one. Pelvic recurrences are often detected by thorough physical examination. In general, however, the sensitivity of the clinical examination is low, so that about 75% of the patients have symptomatic recurrence when it is detected clinically. Serial examinations of CEA, however, seem at present time to be the best indication of recurrence. Thus, elevated serum CEA concentration seems to predict cancer recurrence correctly in 80-90%.

Tumour markers in colorectal cancer

Carcinoembryonic antigen (CEA) is still the best marker both for primary diagnosis and post-treatment monitoring of patients with colorectal cancer. Monoclonal antibodies, especially CA 19-9 and CA 50 may give additional information whereas CA 125 seems to be of no value in patients with colorectal cancer. The sensitivity of CEA determination for Dukes' A carcinomas is as low as 30%, but increases to 85% for Dukes' D carcinomas. The best clinical benefit of CEA is in postoperative monitoring of surgically treated patients with colorectal cancer. The sensitivity and specificity for distant metastases are 85%. The sensitivity in the detection of local recurrence is low (40%) but the specificity is still high (80%). A high CEA level postoperatively strongly suggests either local recurrence or disseminated disease, but a negative value does not exclude their presence. If CEA is negative both preoperatively and one month postoperatively, CA 19-9 or CA 50 may be used in the monitoring of these patients.

Pelvic recurrence of rectal cancer. Options for curative resection

Pelvic recurrence is an ominous event after curative resection of rectal cancer and is rarely amenable to re-resection by conventional methods. A method to permit a composite resection of these using the abdominal sacral approach has been described previously. This report updates that experience with resection of pelvic recurrence of rectal cancer in 28 patients. Of these, 24 were done with curative intent, and four were done for palliation (mainly for infected or fungating tumor). All patients had extensive preoperative evaluation by clinical and radiologic tests, and most patients had a long free interval period of approximately 18 months, after their primary resection. Although 47 patients had exploratory surgery, only 29 had local disease amenable to resection and four had palliative resections. About half the patients had had an abdominoperineal resection, half had had an anterior resection, and one third had had previous efforts to resect the recurrence. All but one patient had been irradiated with 3000-11,000 cGy. All but two patients (of the 24 curative efforts) required a formal abdominosacral resection (through S1-2 in 12, S2-3 in 9, and S4-5 in 1). Over half the patients also required a bladder resection. There were three operative deaths (12%); one patient had a cardiac death immediately after operation and two were septic deaths at 35 and 60 days. The survivors generally had relief of sacral root pain and good motor function; most of those previously employed could return to work. The actuarial 5-year survival rate is 25% and median survival is 36 months. Long-term survival over 48 months was recorded in five of 21 surgical survivors (23.8%). Survival in a historic comparative group of 30 patients treated for local recurrence only (mainly by radiation) was 15 months median, and at 5 years the survival rate was 3% (p less than 0.001). In conclusion, selected patients with pelvic recurrence of rectal cancer may be retrieved by and returned to functional life with the composite abdominosacral resection.

Follow-up of colorectal cancer resected for cure. An experience with CEA, TPA, Ca 19-9 analysis and second-look surgery

Sixty-four consecutive patients who had undergone curative resection for colorectal carcinoma were studied prospectively to evaluate the roles of sequential CEA determinations and independent instrumental follow-up in the early detection of resectable recurrences. Fifty-two of these patients also were submitted to sequential determinations of other tumor antigens: TPA (tissue polypeptide antigen) and Ca 19-9 (colon cancer antigen detected with a monoclonal antibody), for a retrospective evaluation of their utility as markers of recurrent tumors. Twenty-two recurrences were detected in a period ranging from 12 to 72 months (median, 47 months). CEA was the best predictor of recurrence (sensitivity, 90 percent) when compared with the other two markers (TPA sensitivity, 60 percent; Ca 19-9 sensitivity, 20 percent). When compared with the instrumental or biochemical examinations of the follow-up, CEA was still the most sensitive indicator of relapse although the specificity was quite low (78 percent) if minimal significative increases were considered. History and physical examination were more useful than CEA in detecting local recurrences in rectal cancer where the preoperative CEA level was low. A few second-look explorations based solely on small CEA increases failed to demonstrate recurrence or revealed peritoneal carcinomatosis. Selected second-look surgery based on demonstrated recurrences resulted in a resectability rate of 57 percent. A follow-up program based on frequent CEA assays, history, and physical examinations, including rectal, vaginal, and perineal exploration, is proposed. Extensive instrumental investigations should follow when a minimal significative CEA rise is observed, or when history and physical examinations suggest a possible recurrence. Second-look surgery should be evaluated after confirmed or highly suspected diagnosis of recurrence, on the basis of instrumental or clinical examinations.

Comparing predictive decision rules in postoperative CEA monitoring

To evaluate the usefulness of serial postoperative carcinoembryonic antigen (CEA) assays, seven previously published decision rules for predicting tumor recurrence were compared retrospectively using CEA values from 214 patients followed 36 to 120 months after surgery for colorectal carcinoma. Decision rules employing cutoff values to predict tumor recurrence were found inadequate for the asymptomatic patient. This attenuation of prognostic usefulness appeared attributable to inadequacies of CEA assays for predicting late recurrences. From these analyses, elevated CEA results without other objective evidence might be insufficient to justify second-look surgery. In addition, late recurring tumors tended not to cause elevated CEA levels.

CEA-directed second-look surgery in the asymptomatic patient after primary resection of colorectal carcinoma

Since 1971, serial carcinoembryonic antigen (CEA) levels have been measured to monitor patients after primary resection of colorectal cancer. Based solely on a rise in CEA level above the baseline established after primary resection, 146 patients were readmitted to the hospital. Chest films, liver-spleen scan, colonoscopy, bone scan, abdominal and pelvic CAT scan, and hepatic arteriograms were performed, and elevated CEA levels were confirmed before reexploration was undertaken. In the 146 patients, 139 (95%) had recurrences, and 81 (58%) of these were resectable for potential cure. Two of the first 22 patients re-explored between 1971 and 1975 are still living 11 and 14 years after second look; of 45 patients reoperated upon from 1976 through 1979 and followed for at least 5 years, 14 (31%) are still living. A rise in CEA above the baseline established after primary resection proved to be a sensitive indicator of recurrence and prompted reexploration before symptoms developed. Early alternative therapy was begun in patients with unresectable recurrences.

Detection of recurrent cancer of the colon and rectum

Outpatient follow-up in patients operated upon due to carcinoma of the colon and rectum is usually performed, due to a high rate of recurrence and with the aim of finding a curable recurrence. Due to the enormous cost of an extended follow-up system, a careful evaluation of the benefit is needed. The aim of the present investigation was to study the efficacy of the different tools in an extended follow-up. One hundred ninety patients with carcinoma of the colon and rectum were--apart from traditional clinical follow-up--followed with an extensive laboratory battery including carcinoembryonic antigen (CEA), erythrocyte sedimentation rate (ESR), hemoglobin (Hb), electrophoresis, ALP, and GT. Forty-seven recurrences were found. Thirty-one of these recurrences were first detected by a rise in CEA. Seven cases were detected at clinical follow-up and six cases due to symptoms suggestive of recurrence. The predictive value of a positive test was 79.4% for CEA but very low for the other tests studied. A negative value for any of the tests in the battery was usually accurate. Follow-up after colorectal carcinoma should include CEA as the only laboratory parameter. Postoperative colonoscopy for removal of missed synchronous lesions, chest X-ray, and endoscopic investigations of the anastomotic region also seem to be of value.

Follow-up of patients with colorectal cancer

In our follow-up study of 65 patients after curative surgery for colorectal cancer, tests other than history and physical examination detected only two cases of potentially curable recurrent colorectal cancer. As a routine follow-up test, carcinoembryonic antigen determination is preferable to computerized tomographic scanning, since the sensitivity and specificity of carcinoembryonic antigen and computerized tomographic scanning were found to be equivalent and carcinoembryonic antigen is much less expensive. There was no benefit to the routine use of liver function tests or chest roentgenograms during follow-up. Since barium enema contributed little to what colonoscopy accomplished with greater comfort to the patient, barium enemas should be used only when colonoscopy is not totally successful in reaching the cecum. The most beneficial aspect of the follow-up of these patients is probably the elimination of future metachronous lesions by removal of small, benign polyps.

The significance of DNA distribution pattern in rectal carcinoma. A preliminary study

The DNA distribution pattern was determined retrospectively in 25 rectal carcinomas and the possible correlation to clinical outcome evaluated. The DNA content in individual cells was measured according to a cytophotometric method based on light transmission measurement of Feulgen-stained nuclei. Tumor cells with DNA content exceeding an upper limit, i.e., the 90 percentile of the control cells, were considered to be nondiploid (aneuploid). Virtually all long-term survivors had less than 50 per cent of the tumor cells exceeding the upper diploid level, whereas those developing only a local recurrence had 50 to 70 per cent. Patients with disseminated disease and short survival time had all of their tumor cells exceeding the upper diploid level. There was a highly significant correlation between Dukes' stage and aneuploidy and probably a significant correlation between histologic grading and aneuploidy. The clinical significance of these results lies in the fact that DNA can be measured in biopsy specimens. It might thus be possible to "tailor" the operation according to the future clinical course to be expected. It could be hypothetically argued that patients with a DNA profile heralding disseminated disease and short life expectancy should have surgery that preserves quality of life, whereas those tending to develop a local recurrence should have more aggressive surgery. It may also be possible to define groups of patients thought to prosper from a more intense postoperative surveillance. The scientific basis for these suggestions is still lacking, and further studies on a prospective basis are currently in progress.