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Endoscopy Versus double-Contrast barium enema in the evaluation of patients with symptoms suggestive of colorectal carcinoma
SCIENTIFIC PAPERS
Endoscopy Versus Double-Contrast Barium Enema in the Evaluation of Patients With Symptoms Suggestive of Colorectal Carcinoma Mary Jane W a r d e n , M D , Nicholas J, Petrel, M D , F A C S , L e m u e l Herrera, M D , F A C S , and A m o l d Mittelman, M D , Buffalo, New York
The annual incidence of colorectal cancer in the United States for 1986 is estimated to be 140,000 cases, second only to lung cancer as the leading cause of carcinoma-related deaths [1]. Survival rates of patients with adenocarcinoma of the colon and rectum vary with the stage of disease at diagnosis. Although the overall 5 year survival rate of all patients with colorectal malignancy is 40 percent, the survival rate of patients with early lesions is over 90 percent [2,3]. Screening programs to detect colorectal lesions early in their natural history, and thus contribute to improving survival rates, have been developed [4-7]; however, in the present cost-conscious medical climate, screening examinations must be both sensitive and cost-effective. This report describes our experience in comparing the negative findings of the 65 cm flexible sigmoidoscope, with those on double-contrast barium enema and colonoscopy in the screening of patients with symptoms characteristic of colorectal cancer.
followed by sigmoidoscopy with the Pentax 65 cm flexible scope. Patients with normal findings on flexible sigmoidoscopic examination underwent a double-contrast barium enema. If an abnormality was found by barium enema, the patient subsequently underwent colonoscopy. Patients found to have adenomatous polyps on flexible sigmoidoscopy were referred for colonoscopy and will be the subject of a future report. There were 276 patients referred from the screening clinic to the colorectal clinic who form the basis of this study. There were 105 men and 171 women. All patients underwent examination with the 65 cm flexible sigmoidoscope. The median distance from the anal verge examined by the flexible scope was 55 cm. The patients were prepared for the sigmoidoscopic exam with one to two Fleet| enemas 1 hour before endoscopy. The endoscopy was performed in the left lateral decubitus position by a surgical fellow under the supervision of a staff surgeon fully trained in endoscopy. Results
Material and Methods
At Roswell Park Memorial Institute, patients with positive findings on a stool guaiac test, hematochezia, a change in bowel habits, or a family history of colorectal carcinoma were referred from the screening clinic to the colorectal clinic for further investigation. All patients underwent a thorough history and physical examination From the Department of Surgical Onoology,Roswell Park Memorial Institute, Buffalo, New York. Requests for reprints shouldbe addressedto Nicholas J. Petrelli, MD, Department of Surgical Oncology, Roswell Park Memorial Institute, 666 Elm Street, Buffalo, New York 14263.
224
The findings on flexible sigmoidoscopic and double-contrast barium enema examinations were in agreement in 258 patients. In 178 of these examinations, findings of both flexible sigmoidoscopy and barium enema were completely negative. In the remaining 80 cases, both flexible endoscopy and barium enema revealed minor positive findings such as diverticulosis. In an additional 18 patients, negative findings on flexible sigmoidoscopy were followed by positive findings on barium enema (Figure 1). Five of the barium examinations were interpreted as showing
The American Journal of Surgery
EndoscopyVersusBariumEnema polyps in the colon or rectum, three reported descending colon polyps, three reported filling defects in the cecum, one a filling defect in the sigmoid, and one a narrowing in the ascending colon. Colonoscopy discovered no abnormalities in all 13 of these patients; therefore, the barium enema findings were considered false-positive (72 percent). The remaining five patients were found to have significant findings on barium enema after normal findings on flexible sigmoidoscopy (Table I). One patient had a defect in the cecum on barium enema. On colonoscopy, a cecal polyp 3 mm by 5 mm was discovered together with a transverse colon polyp 2 by 3 mm in size. A second barium enema demonstrated a polyp in the ascending colon, and colonoscopy confirmed two adenomatous polyps in the ascending colon. The third barium enema revealed a polyp in the transverse colon, and colonoscopy yielded an adenomatous polyp in the transverse colon and one in the cecum. A polyp in the splenic flexure noted on barium enema in the fourth patient was not found on colonoscopy. However, an adenomatous polyp 8 cm from the anal verge, missed on both flexible sigmoidoscopy as well as barium enema, was found. In the fifth patient, a polyp 50 cm within the descending colon found on barium enema was confirmed on coionoscopy and contained a focus of carcinoma in situ. This patient had a redundaut sigmoid colon, and it is possible that the flexible scope was unable to reach the polyp. It is noteworthy that all polyps found on colonoscopy were less than 1 cm in diameter. In this subset of 18 patients with positive findings on barium enema after no abnormalities were found on flexible sigmoidoscopy, 5 (28 percent) were found to be significant, 4 with adenomatous polyps and 1 with a carcinoma in situ. Also, in four of these five patients colonoscopy found additional polyps that were not seen on barium enema. Therefore, 5 of 276 patients (1.8 percent) had abnormalities found on barium enema after none were discovered by flexible sigmoidoscopy, 1.4 percent harbored premalignant polyps, and 0.4 percent had an unsuspected colonic carcinoma in situ.
Comments In the present study, we compared the use of the 65 cm flexible sigmoidoscope and double-contrast barium enema in the screening of patients with symptoms suggestive of colorectal cancer. The benefit gained in screening for colorectal cancer is due to the prevalence of the disease in the population and the improved chance for cure if diagnosed early in the natural history of the disease. Colorectal adenomatous polyps are known to be precursors of the development of adenocarcinoma. Thus, a program which detects and eliminates these premalignant lesions should improve the survival
Volume 155, February 1988
j 13 Patie
18 Patients
~
~ ~ 5 Patients (28%)
~
False-positive BE via colonoscopy
True-positive BE via colonoscopy (Table I)
Figure 1. Patients with negative findings on 65 cm flexible endoscopy with abnormalities found on barium enema. BE = barium enema.
TABLE I Patient No. 1 2 3 4 5
Patients with True-Positive Findings on Barium Enema (BE) and on Colonoscopy Findings on BE
Findings on Colonoscopy
Defect in cecum
Cecal polyp; transverse polyp Ascending polyp 2 ascending polyps Transverse polyp Transverse polyp; cecal polyp Splenic flexure polyp Rectal polyp; no splenic flexure polyp Descending polyp Descending polyp (carcinoma in situ)
rate of colorectal carcinoma. According to Gilbertsen [8], in a group of patients in whom adenomas were removed by endoscopic polypectomy, the actual incidence of rectosigmoid carcinoma was only 15 percent of the expected incidence. Although there is agreement that screening for colorectal carcinoma can improve survival rates, there is no agreement on the best methods of accomplishing that screening. For example, the problems associated with the fecal occult blood test have been reviewed b y Simon [9] previously. In the present study, findings 0 n b a r i u m enema and flexible sigmoidoscopic examination were in agreement in 93 percent of cases. Of the 18 patients in whom there were major discrepancies between barium enema findings and flexible sigmoidoscopy findings, 13 (72 percent) were confirmed to be falsepos!tive barium studies b y colonoscopy. Of greater significance is the fact that of the 276 patients referred for workup of colorectal malignancy, only 1.8 percent of patients had significant findings beyond the reach of the 65 cm flexible sigmoidoscope after an unremarkable examination, whereas 1 patient had a colonic carcinoma in situ. This becomes important when the cost-benefit ratio of screening for colorectal cancer is taken into account. Although colonoscopy is the definitive examination to rule ou t a colonic tumor, this is not practical as a screening tool, and a less expensive and time-consuming procedure that does not significantly diminish sensitivity must be employed. Flexible sigmoidoscopy appears to fulfill these requirements.
225
Warden et al
Summary Two hundred seventy-six patients with positive findings on a stool guaiac test, hematochezia, a Change in bowel habits, or a family history of colorectal carcinoma were referred to the colorectal clinic for further investigation. There were 105 men and 171 women. All patients underwent examination with the 65 cm flexible sigmoidoscope. Patients with no abnormalities on endoscopy underwent a double-contrast barium enema. If the barium enema revealed a polyp or other suspicious pathologic process, the patient was referred for colonoscopy. In 258 patients, findings of barium enema and flexible sigmoidoscopy were in agreement. The findings in 178 of these examinations were completely negative, and in the remaining 80 cases flexible endoscopy and barium enema revealed diverticulosis. In an additional 18 patients, negative findings on flexible sigmoidoscopy were followed by positive findings on barium enema. Thirteen of these 18 patients (72 percent) had negative findings oncolonoscopies and therefore had false-positive findings on barium enema. In the remaining five patients (28 percent), an unsuspected colonic carcinoma or premalignant polyp was discovered on barium enema and docu-
226
mented by colonoscopy. Also, in four of these five patients, colonoscopy found additional polyps that were not seen on barium enema.
References 1. Silverberg E, Lubera J. Cancer statistics. CA 1985; 36: 9-25. 2. MetUin C,Natarajan N, Mittelman A, et al. Management and survival of adenocarcinoma of the rectum in the United States: results of a nationalsurvey by the American College of Surgeons. Oncology 1982; 39: 265-73. 3. Evans J, Vana J, Aronoff B, et al. Management and survival of carcinoma of the colon: results of a national survey by the American College of Surgeons. Ann Surg 1978; 188: 71621, 4. Cummings M, Michalek A, MetUin C, Mittelman A. Screening for colorectal cancer using the Hemoccult II stool guaiac slide test. Cancer 1984; 53: 10: 2201-5. 5. Greegor D: A progress report: detection of colorectal cancer using guaiac slides. CA 1972; 22: 360-3. 6. Miller S, Knight A. The early detection of colorectal cancer. Cancer i977; 40: 945-9. 7. Gilbertsen V, McHugh R, Schuman L, et al. The earlier detection of Colorectal cancers: a preliminary report of the results of the occult blood study. Cancer 1980; 45: 2899901. 8. Gilbertsen VA. Proctosigmoidoscopy and polypectomy in reducing the incidence of recta! cancer. Cancer 1974; 34: 936-59. 9. Simon JB. Occult blood screening for colorectal carcinoma: a critical review. Gastroenterology 1985; 88: 820-37.
The American Journal of Surgery
Endoscopy Versus Double-Contrast Barium Enema in the Evaluation of Patients With Symptoms Suggestive of Colorectal Carcinoma Mary Jane W a r d e n , M D , Nicholas J, Petrel, M D , F A C S , L e m u e l Herrera, M D , F A C S , and A m o l d Mittelman, M D , Buffalo, New York
The annual incidence of colorectal cancer in the United States for 1986 is estimated to be 140,000 cases, second only to lung cancer as the leading cause of carcinoma-related deaths [1]. Survival rates of patients with adenocarcinoma of the colon and rectum vary with the stage of disease at diagnosis. Although the overall 5 year survival rate of all patients with colorectal malignancy is 40 percent, the survival rate of patients with early lesions is over 90 percent [2,3]. Screening programs to detect colorectal lesions early in their natural history, and thus contribute to improving survival rates, have been developed [4-7]; however, in the present cost-conscious medical climate, screening examinations must be both sensitive and cost-effective. This report describes our experience in comparing the negative findings of the 65 cm flexible sigmoidoscope, with those on double-contrast barium enema and colonoscopy in the screening of patients with symptoms characteristic of colorectal cancer.
followed by sigmoidoscopy with the Pentax 65 cm flexible scope. Patients with normal findings on flexible sigmoidoscopic examination underwent a double-contrast barium enema. If an abnormality was found by barium enema, the patient subsequently underwent colonoscopy. Patients found to have adenomatous polyps on flexible sigmoidoscopy were referred for colonoscopy and will be the subject of a future report. There were 276 patients referred from the screening clinic to the colorectal clinic who form the basis of this study. There were 105 men and 171 women. All patients underwent examination with the 65 cm flexible sigmoidoscope. The median distance from the anal verge examined by the flexible scope was 55 cm. The patients were prepared for the sigmoidoscopic exam with one to two Fleet| enemas 1 hour before endoscopy. The endoscopy was performed in the left lateral decubitus position by a surgical fellow under the supervision of a staff surgeon fully trained in endoscopy. Results
Material and Methods
At Roswell Park Memorial Institute, patients with positive findings on a stool guaiac test, hematochezia, a change in bowel habits, or a family history of colorectal carcinoma were referred from the screening clinic to the colorectal clinic for further investigation. All patients underwent a thorough history and physical examination From the Department of Surgical Onoology,Roswell Park Memorial Institute, Buffalo, New York. Requests for reprints shouldbe addressedto Nicholas J. Petrelli, MD, Department of Surgical Oncology, Roswell Park Memorial Institute, 666 Elm Street, Buffalo, New York 14263.
224
The findings on flexible sigmoidoscopic and double-contrast barium enema examinations were in agreement in 258 patients. In 178 of these examinations, findings of both flexible sigmoidoscopy and barium enema were completely negative. In the remaining 80 cases, both flexible endoscopy and barium enema revealed minor positive findings such as diverticulosis. In an additional 18 patients, negative findings on flexible sigmoidoscopy were followed by positive findings on barium enema (Figure 1). Five of the barium examinations were interpreted as showing
The American Journal of Surgery
EndoscopyVersusBariumEnema polyps in the colon or rectum, three reported descending colon polyps, three reported filling defects in the cecum, one a filling defect in the sigmoid, and one a narrowing in the ascending colon. Colonoscopy discovered no abnormalities in all 13 of these patients; therefore, the barium enema findings were considered false-positive (72 percent). The remaining five patients were found to have significant findings on barium enema after normal findings on flexible sigmoidoscopy (Table I). One patient had a defect in the cecum on barium enema. On colonoscopy, a cecal polyp 3 mm by 5 mm was discovered together with a transverse colon polyp 2 by 3 mm in size. A second barium enema demonstrated a polyp in the ascending colon, and colonoscopy confirmed two adenomatous polyps in the ascending colon. The third barium enema revealed a polyp in the transverse colon, and colonoscopy yielded an adenomatous polyp in the transverse colon and one in the cecum. A polyp in the splenic flexure noted on barium enema in the fourth patient was not found on colonoscopy. However, an adenomatous polyp 8 cm from the anal verge, missed on both flexible sigmoidoscopy as well as barium enema, was found. In the fifth patient, a polyp 50 cm within the descending colon found on barium enema was confirmed on coionoscopy and contained a focus of carcinoma in situ. This patient had a redundaut sigmoid colon, and it is possible that the flexible scope was unable to reach the polyp. It is noteworthy that all polyps found on colonoscopy were less than 1 cm in diameter. In this subset of 18 patients with positive findings on barium enema after no abnormalities were found on flexible sigmoidoscopy, 5 (28 percent) were found to be significant, 4 with adenomatous polyps and 1 with a carcinoma in situ. Also, in four of these five patients colonoscopy found additional polyps that were not seen on barium enema. Therefore, 5 of 276 patients (1.8 percent) had abnormalities found on barium enema after none were discovered by flexible sigmoidoscopy, 1.4 percent harbored premalignant polyps, and 0.4 percent had an unsuspected colonic carcinoma in situ.
Comments In the present study, we compared the use of the 65 cm flexible sigmoidoscope and double-contrast barium enema in the screening of patients with symptoms suggestive of colorectal cancer. The benefit gained in screening for colorectal cancer is due to the prevalence of the disease in the population and the improved chance for cure if diagnosed early in the natural history of the disease. Colorectal adenomatous polyps are known to be precursors of the development of adenocarcinoma. Thus, a program which detects and eliminates these premalignant lesions should improve the survival
Volume 155, February 1988
j 13 Patie
18 Patients
~
~ ~ 5 Patients (28%)
~
False-positive BE via colonoscopy
True-positive BE via colonoscopy (Table I)
Figure 1. Patients with negative findings on 65 cm flexible endoscopy with abnormalities found on barium enema. BE = barium enema.
TABLE I Patient No. 1 2 3 4 5
Patients with True-Positive Findings on Barium Enema (BE) and on Colonoscopy Findings on BE
Findings on Colonoscopy
Defect in cecum
Cecal polyp; transverse polyp Ascending polyp 2 ascending polyps Transverse polyp Transverse polyp; cecal polyp Splenic flexure polyp Rectal polyp; no splenic flexure polyp Descending polyp Descending polyp (carcinoma in situ)
rate of colorectal carcinoma. According to Gilbertsen [8], in a group of patients in whom adenomas were removed by endoscopic polypectomy, the actual incidence of rectosigmoid carcinoma was only 15 percent of the expected incidence. Although there is agreement that screening for colorectal carcinoma can improve survival rates, there is no agreement on the best methods of accomplishing that screening. For example, the problems associated with the fecal occult blood test have been reviewed b y Simon [9] previously. In the present study, findings 0 n b a r i u m enema and flexible sigmoidoscopic examination were in agreement in 93 percent of cases. Of the 18 patients in whom there were major discrepancies between barium enema findings and flexible sigmoidoscopy findings, 13 (72 percent) were confirmed to be falsepos!tive barium studies b y colonoscopy. Of greater significance is the fact that of the 276 patients referred for workup of colorectal malignancy, only 1.8 percent of patients had significant findings beyond the reach of the 65 cm flexible sigmoidoscope after an unremarkable examination, whereas 1 patient had a colonic carcinoma in situ. This becomes important when the cost-benefit ratio of screening for colorectal cancer is taken into account. Although colonoscopy is the definitive examination to rule ou t a colonic tumor, this is not practical as a screening tool, and a less expensive and time-consuming procedure that does not significantly diminish sensitivity must be employed. Flexible sigmoidoscopy appears to fulfill these requirements.
225
Warden et al
Summary Two hundred seventy-six patients with positive findings on a stool guaiac test, hematochezia, a Change in bowel habits, or a family history of colorectal carcinoma were referred to the colorectal clinic for further investigation. There were 105 men and 171 women. All patients underwent examination with the 65 cm flexible sigmoidoscope. Patients with no abnormalities on endoscopy underwent a double-contrast barium enema. If the barium enema revealed a polyp or other suspicious pathologic process, the patient was referred for colonoscopy. In 258 patients, findings of barium enema and flexible sigmoidoscopy were in agreement. The findings in 178 of these examinations were completely negative, and in the remaining 80 cases flexible endoscopy and barium enema revealed diverticulosis. In an additional 18 patients, negative findings on flexible sigmoidoscopy were followed by positive findings on barium enema. Thirteen of these 18 patients (72 percent) had negative findings oncolonoscopies and therefore had false-positive findings on barium enema. In the remaining five patients (28 percent), an unsuspected colonic carcinoma or premalignant polyp was discovered on barium enema and docu-
226
mented by colonoscopy. Also, in four of these five patients, colonoscopy found additional polyps that were not seen on barium enema.
References 1. Silverberg E, Lubera J. Cancer statistics. CA 1985; 36: 9-25. 2. MetUin C,Natarajan N, Mittelman A, et al. Management and survival of adenocarcinoma of the rectum in the United States: results of a nationalsurvey by the American College of Surgeons. Oncology 1982; 39: 265-73. 3. Evans J, Vana J, Aronoff B, et al. Management and survival of carcinoma of the colon: results of a national survey by the American College of Surgeons. Ann Surg 1978; 188: 71621, 4. Cummings M, Michalek A, MetUin C, Mittelman A. Screening for colorectal cancer using the Hemoccult II stool guaiac slide test. Cancer 1984; 53: 10: 2201-5. 5. Greegor D: A progress report: detection of colorectal cancer using guaiac slides. CA 1972; 22: 360-3. 6. Miller S, Knight A. The early detection of colorectal cancer. Cancer i977; 40: 945-9. 7. Gilbertsen V, McHugh R, Schuman L, et al. The earlier detection of Colorectal cancers: a preliminary report of the results of the occult blood study. Cancer 1980; 45: 2899901. 8. Gilbertsen VA. Proctosigmoidoscopy and polypectomy in reducing the incidence of recta! cancer. Cancer 1974; 34: 936-59. 9. Simon JB. Occult blood screening for colorectal carcinoma: a critical review. Gastroenterology 1985; 88: 820-37.
The American Journal of Surgery