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home - Colon - Colorectal and Anal Cancer - Adenoma Surveillance Written by Dr Sebastian Zeki
Knowledge

Knows the pathology of benign and malignant tumours of the colon
and rectum
Has awareness of the molecular genetics of colorectal
carcinogenesis and the adenoma-carcinoma sequence
Knows the range of predisposing conditions including inherited
syndromes and acquired colonic diseases
Knows the range of clinical presentation and the means of
diagnosis, investigation, management and follow-up
Knows the strategy for prevention including procedures for
screening

Skills
Uses clinical assessment and selects investigations to reach a rapid
conclusion as to whether a patient might have colorectal cancer and
arranges timely investigation.
Refers the patient to the multi-disciplinary team CbD, mini-CEX,

Behaviours
Shows ability to react to possible diagnosis of malignancy in a timely
manner

Communicates with patient and family in a sympathetic and
understanding manner, explains next steps, involves other health
professionals (including the GP) as appropriate

Adenoma Surveillance

Summaryofrecommendationsforcolorectalcancer-screeningandsurveillanceinhighriskgroups Theprojectedbene tofsurveillanceatage55yearsinthis groupissomewhatmoretangiblethaninyoungeragegroups. Theproportionofpeopleaged55yearswithatleastone adenomahasbeenvariouslyreportedas4 e 21%,butonly2 e 6% havesigni cantneoplasia. 227 230234235 Extrapolatingfrom contemporarypopulationincidencedataforthisagegroup andapplyingarelativeriskofabout3duetofamilyhistory, 217 aroundonein180peoplewillharbourahighriskcolorectal neoplasm/canceratscreening,assuminga3-yearneoplasiadwell time. l a v r e t n i d n a e r u d e c o r p g n i n e e r c S n e e r c s l a i t i n i f o e m i T e r u d e c o r p g n i n e e r c S s p u o r g e s a e s i d k s i r h g i H Procedures/ yr/300,000 & s T F L , T C , n o i t a t l u s n o C r e c n a c l a t c e r o l o C Colonoscopy Colonoscopywithin6months ofresection onlyifcolon evaluationpre-op.incomplete CTLiverScanwithin2years post-op.Colonoscopy5yearlyuntil co-morbidityoutweighs 175 Colonic adenomas Lowrisk 1-2adenomas,both < 1cm Colonoscopy5yearsornosurveillanceCeasefollow-upafternegative colonoscopy Intermediaterisk 3 e 4adenomas,ORatleastone adenoma $ 1cm Colonoscopy3years3yearlyuntil2consecutivenegative colonoscopies,thennofurther surveillance Highrisk $ 5adenomasor $ 3withatleast one $ 1cm Colonoscopy1yearAnnualcolonoscopyuntiloutofthis riskgroupthenintervalcolonoscopy asperintermediateriskgroup PiecemealpolypectomyColonoscopyorflexi-sig (dependingonpolyplocation) 3months d consideropen surgicalresectionifincomplete healingofpolypectomyscar Ulcerative colitisand Crohn’s colitis Lowrisk Extensivecolitiswithnoinflammation orleftsidedcolitisorCrohn’scolitis of < 50%colon Pancolonicdyespraywithtargeted biopsy.Ifnodyespraythen2 e 4 randombiopsiesevery10cms. 10yearsfromonsetof symptoms 0 2 s r a e y 5 Intermediaterisk Extensivecolitiswithmildactivediseaseor post-inflammatorypolypsorfamilyhistoryof colorectalcancerinaFDR < 50yrs. 0 1 s r a e y 3 Highrisk Extensiveatleastmoderatecolitisorstricture inpast5yearsordysplasiainpast5years (decliningsurgery)orPSCorOLTforPSC) orcolorectalcancerinaFDR < 50yrs. 6 r a e y 1 3 y l l a u n n a g i S i x e l F y r e g r u s r e t f a s r y 0 1 g i S i x e l F y m o t s o d i o m g i s - o r e t e r U 1 y l r a e y 5 y p o c s o n o l o C . s r y 0 4 t A y p o c s o n o l o C y l a g e m o r c A CT,Computedtomography;LFT’s,liverfunctiontests;OLT,orthopticlivertransplant;PSC,primarysclerosingcholangitis. Table3 Summaryofrecommendationsforcolorectalcancerscreeningandsurveillanceinmoderateriskfamilygroups Moderateriskfamilyhistorycategories Life-timerisk ofCRCdeath (without surveillance) { Screeningprocedure Ageatinitial screen(if olderat presentation instigate forthwith)Screeningprocedureandinterval Procedures/ yr/300000 Colorectalcancerin3FDRinfirst degreekinship*,none < 50yrs w 1in6 e s r y 5 7 e g a o t y p o c s o n o l o c y l r y 5 s r y 0 5 y p o c s o n o l o C 0 1 w 18 Colorectalcancerin2FDRinfirst degreekinship*, meanage < 60yrs w 1in6 e s r y 5 7 e g a o t y p o c s o n o l o c y l r y 5 s r y 0 5 y p o c s o n o l o C 0 1 w 60 Colorectalcancerin2FDR $ 60yrs w . s r y 5 5 e g a t a y p o c s o n o l o c y l n o - e c n O s r y 5 5 y p o c s o n o l o C 2 1 n i 1 Ifnormal d nofollow-up 12 Colorectalcancerin1FDR < 50yrs w . s r y 5 5 e g a t a y p o c s o n o l o c y l n o - e c n O s r y 5 5 y p o c s o n o l o C 2 1 n i 1 Ifnormal d nofollow-up 10 AllotherFHofcolorectalcancer > e n o N A / N A / N e n o N 2 1 n i 1 Incidentcolorectalcancercase(age 50yrs,orMMRprediction > 10%), notfulfillingLynchsyndromecriteria N/ATumourMSIand/orIHCanalysis x Ifnotumourtestingavailableconsider geneticsreferral N/AStandardpost-opfollow-upunless Lynchsyndrome(LS)featureson tumouranalysisoramutationidentified, thenLSsurveillanceapplies. 20 * Affectedrelativeswhoarefirst-degreerelativesofeachotherANDatleastoneisafirstdegreerelativeoftheconsultand.Noaffectedrelative < 50yearsold(otherwisehigh-riskcriteriawould apply).Combinationsof3affectedrelativesinafirst-degreekinshipinclude:parentandaunt/uncleand/orgrandparent;OR2siblings/1parent;OR 2siblings/1offspring.Combinationsof2affected relativesinafirstdegreekinshipincludeaparentandgrandparent,or > 2siblings,or > 2children,orchild+sibling.Wherebothparentsareaffected,thesecountasbeingwithintherst-degree kinship. y ClinicalGeneticsreferralrecommended. z Centresmayvarydependingcapacityandreferralagreements.Ideallyallsuchcasesshouldbeflaggedsystematicallyforfutureauditonanationalsc ale. x RefertoClinicalgeneticsifIHClossorMSI-H. { CancerresearchUK(http://info.cancerresearchuk.org/cancerstats/)andISDScotland(http://www.isdscotland.org/isd/183.html). Gut 2010; 59 :666 e 690.doi:10.1136/gut.2009.179804 Table4 Summaryofrecommendationsforcolorectalcancerscreeningandsurveillanceinhighriskfamilygroups Familyhistorycategories* Life-timeriskof CRCdeath (without surveillance)ScreeningprocedureAgeatinitialscreen Screeningintervaland procedureProcedures/yr/300000 At-riskHNPCC(fulfils modifiedAmsterdam criteria y ,oruntestedFDR ofprovenmutationcarrier) 1in5(male) 1in13(female) MMRgenetestingof affectedrel. Colonoscopy+/ OGD Colonoscopyfromage 25yrs. OGDfromage50yrs 18 e 24monthscolonoscopy (2yrlyOGDfromage50yrs) 50 MMRgenecarrier1in2.5(male) 1in6.5(female) Colonoscopy+/ OGD At-riskFAP (memberofFAPfamilywith nomutationidentified) 1in4APCgenetestingof affectedrel. Colonoscopyoralternating colonoscopy/flexsig. Puberty Flexibleapproachimportant makingallowancefor variationinmaturity Annualcolonoscopyor alternatingcolonoscopy/ flexsig.untilaged30yrs Thereafter3 e 5yearlyuntil 60yrs. Procto-colectomyor colectomyif+’ve. 2 FulfilsclinicalFAPcriteria, orprovenAPCmutation carrieroptingfordeferred surgery d prophylactic surgerynormallystrongly recommended 1in2Colonoscopyoralternating Colonoscopy/flexsig. OGDwithforward& side-viewingscope. Usuallyatdiagnosis Otherwisepuberty. Flexibleapproachimportant makingallowancefor variationinmaturity Recommendationfor procto-colectomy&pouch/ colectomybeforeage30yrs. Cancerriskincreases dramaticallyage > 30yrs Twiceyrlycolonoscopyor alternatingcolonoscopy/ flexsig. 1 FAPpostcolectomy andIRA 1in15 (rectalcancer) Flex.rectoscopy Forward&side-viewing OGD Aftersurgery OGDfromage30yrs Annualflexrectoscopy 3yrlyforward&side-viewing OGD 3(dependenton surgicalpractice) FAPpostprocto-colectomy andpouch NegligibleDREandpouchendoscopy Forward&side-viewing OGD Aftersurgery OGDfromage30yrs Annualexamsalternating flex/rigidpouchendoscopy 3yrlyforward&side-viewing OGD 3(dependenton surgicalpractice) MUTYH-associated polyposis(MAP) 1in2 e 2.5Genetictesting Colonoscopy +/ OGD Colonoscopyfromage 25yrs.OGDfromage 30yrs Mutationcarriersshould becounselledaboutthe availablelimitedevidence Optionsincludeprophylactic colectomyandileorectal anastomosis;orbiennial colonoscopysurveillance. 3-5yrlygastro-duodenono- scopy. 4 1FDRwithMSI-Hcolorectal cancer AND IHCshows lossofMSH2,MSH6 orPMS2expression. MLH1lossandMSI specificallyexcluded(MLH1 lossinelderlypatientwith rightsidedtumourisusually somaticepigeneticevent) 1in5(male) 1in13(female) (likelyover-esti- mate) Colonoscopy +/ OGD Colonoscopyfromage 25yrs. OGDfromage50yrs 2yrlycolonoscopy (withOGDaged > 50yrs) < 5butvariable,dependingon extentofuseofMSIandIHC tumouranalysis Peutz-JeghersSyndrome1in6Genetictestingofaffected rel. Colonoscopy+/ OGD Colonoscopyfromage 25yrs. OGDfromage25yrs SmallbowelMRI/ enteroclysis 2yrlyColonoscopy Considercolectomy andIRAforcoloniccancer SmallBowelVCEorMRI/enter- oclysis2 e 4yrly OGD2yrly 3 Juvenilepolyposis1in6Genetictestingofaffected rel. Colonoscopy+/ OGD Colonoscopyfromage 15yrs. OGDfromage25yrs 2yrlycolonoscopyand OGD.Extendintervalaged > 35yrs. 3 * TheAmsterdamcriteriaforidentifyingHNPCCare:threeormorerelativeswithcolorectalcancer;onepatientafirstdegreerelativeofanother;twog enerationswithcancer;andonecancer diagnosedbelowtheageof50orotherHNPCC-relatedcancerse.g.endometrial,ovarian,gastric,upperurethelialandbiliarytree. y ClinicalGeneticsreferralandfamilyassessmentrequired,ifnotalreadyinplaceorreferralwasnotinitiatedbyClinicalGenetics. FAP,familialadenomatosispolyposis;FDR,firstdegreerelative(sibling,parentorchild)withcolorectalcancer;HNPCC,hereditarynon-polypos iscolorectalcancer;IHC,immunohistochemistryof tumourmaterialfromaffectedproband;MSI-H,micro-satelliteinstability e high(twoormoreMSImarkersshowinstability);OGD,oesophagogastroduodenoscopy;VCE,videocapsule endoscopy.

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