Surveillance after endoscopic and surgical resection of colorectal cancer

Accepted Manuscript Surveillance after endoscopic and surgical resection of colorectal cancer Masau Sekiguchi, Takahisa Matsuda, MD, PhD, Yutaka Saito

PII:

S1521-6918(16)30066-X

DOI:

10.1016/j.bpg.2016.09.002

Reference:

YBEGA 1451

To appear in:

Best Practice & Research Clinical Gastroenterology

Received Date: 24 July 2016 Revised Date:

5 August 2016

Accepted Date: 6 September 2016

Please cite this article as: Sekiguchi M, Matsuda T, Saito Y, Surveillance after endoscopic and surgical resection of colorectal cancer, Best Practice & Research Clinical Gastroenterology (2016), doi: 10.1016/ j.bpg.2016.09.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Masau Sekiguchi 1, 2, 3, Takahisa Matsuda 1, 2, 3, Yutaka Saito 2

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Surveillance after endoscopic and surgical resection of colorectal cancer

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1. Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan

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2. Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan

3. Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan

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Correspondence to: Takahisa Matsuda, MD, PhD Cancer Screening Center/ Endoscopy Division, National Cancer Center Hospital, Tokyo,

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Japan

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Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan

5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan Tel: +81-3-3542-2511, Fax: +81-3-3542-3815 Email: [email protected]

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ABSTRACT With the increase in colorectal cancer burden, surveillance following

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endoscopic and surgical resection is an essential issue. The aim of surveillance programs is improvement of patient survival by early detection of residual tumor tissue

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or local recurrence, metachronous colorectal tumors, and metastases. Appropriate

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surveillance should be determined according to these risk of factors. In current guidelines, only surveillance colonoscopy is recommended after endoscopic resection of polyps with high-grade dysplasia, whereas intensive, multimodality surveillance using colonoscopy, radiological imaging and tumor marker measurements is recommended

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following surgical resection of invasive colorectal cancer. Detailed recommendations, including the timing of surveillance, are described based on high-quality evidence.

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required.

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However, there are still many unresolved issues for which more high-quality evidence is

Key words: Colonoscopy; colorectal cancer; endoscopic resection; surgery; surveillance

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Introduction Colorectal cancer (CRC) is one of the leading causes of cancer-related death in

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many countries, both Western and Asian [1]. In Japan, CRC is now the second most commonly diagnosed cancer and the second leading cause of cancer-related death [2].

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To reduce CRC mortality, the implementation of well-organized, effective CRC

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screening is essential [3-7].

Because the number of endoscopic and surgical resections has been increasing, appropriate surveillance programs after CRC resection need to be considered. Currently, several guidelines on surveillance after surgical resection of CRC are available in

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several regions, including the EU [8], US [9-12], and Japan [13]. In Europe and the United States, polyps with high-grade dysplasia (HGD) are

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issues of polyp surveillance guidelines [14, 15], while in Japan, these lesions are called

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“intramucosal cancer” and are a topic of cancer surveillance guidelines [16, 17]. The adherence to surveillance recommendations is often poor [18, 19]. All

physicians engaged in the management of CRC are required to deepen their knowledge of surveillance. In this article, we review surveillance after endoscopic and surgical resection of polyps with HGD and of invasive CRC.

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Purposes of surveillance following CRC resection There are three purposes of surveillance following CRC resection: (1) detection

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of residual tumor tissue or local recurrence; (2) detection of metachronous colorectal tumors; and (3) detection of metastases. Thus, the appropriate surveillance program

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should be determined according to the risk of these purposes. For the detection of

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residual tumor tissue or local recurrence and metachronous colorectal lesions, colonoscopy is the most established examination method [8-17]. Radiological examinations, such as Computed tomography (CT) of the chest and abdomen, are used to detect metastases [8-11, 13]. In addition, medical history, physical examination and

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carcinoembryonic antigen (CEA) measurement are recommended for surveillance [8-11, 13]. Underuse of these surveillance methods, which may result in the occurrence of

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advanced CRC, must be avoided. Overuse should also be avoided because it is

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necessary to reduce the number of unnecessary surveillance examinations and save them for screening and other purposes. The final goal of surveillance is to improve survival of patients following CRC

resection. Several systematic reviews have demonstrated improved overall survival of patients undergoing intensive surveillance following CRC resection [20-24]. On the other hand, no significant improvement in cancer-related survival by the surveillance

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has been reported yet. although mMore investigation is necessary to obtain evidence on the effect of surveillance in reducing cancer-specific mortality [20-24]. Based on the

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evidence for improvement of survival, intensive surveillance is strongly recommended in every guideline [8-17]. However, the content of the intensive surveillance in the

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studies included in the systematic reviews was heterogeneous, and the recommended

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surveillance programs differ according to the guidelines [8-17]. Thus, we need to understand the differences among the guidelines to implement appropriate surveillance in daily practice and to establish more appropriate surveillance programs in the future.

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Surveillance following endoscopic resection of HGD Currently, with development of endoscopic resection, most HGD lesions (i.e.

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intramucosal cancers) can be treated endoscopically. Several endoscopic resection

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techniques can be utilized, from polypectomy and conventional endoscopic mucosal resection to endoscopic submucosal dissection [25-34]. After endoscopic resection of HGD, surveillance with colonoscopy, targeting residual tumor tissue or local recurrence and metachronous colorectal lesions, is recommended in the US, EU and Japanese guidelines (Table 1) [13-17]. If a HGD is resected en bloc with negative margins (complete resection), the risk of residual tumor or local recurrence is negligible;

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whereas, the risk is higher with piecemeal resection [35-40]. A Japanese retrospective study analyzing 572 endoscopically resected colorectal tumors ≥10 mm in size showed

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Surveillance after piecemeal resection

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resection were 18.4%, 23.1%, and 30.7%, respectively [35].

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that the 6-, 12- and 24-month cumulative rates of local recurrence after piecemeal

Many residual tumor tissue or local recurrence following endoscopic piecemeal resection of HGD are detected within 6–12 months after resection. Thus, it is recommended in the US, EU, and Japanese guidelines that first surveillance

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colonoscopy should be performed within a short interval after endoscopic piecemeal resection of HGD (Table 1) [14-17]. However, no consensus has been reached with

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regard to how to continue surveillance after the first surveillance colonoscopy following

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piecemeal resection of HGD. Regarding this issue, we have to remember that recurrence can occur long after the piecemeal resection. Several Japanese papers have reported recurrent cases occurring over three years, over five years and even over 10 years after piecemeal resection of HGD [41-43]. From the finding, long-term surveillance targeting recurrence is believed to be necessary after piecemeal resection. In addition, the finding that late recurrent cases included not only intramucosal recurrence but also invasive

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recurrence is noteworthy [41-43]. Considering the risk of invasive recurrence, Because invasive recurrence can develop with a submucosal tumor-like appearance and it is

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difficult to detect with colonoscopy, surveillance with such modalities as CT and endoscopic ultrasonography may be necessary following piecemeal resection of HGD.

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Furthermore, the validity effectiveness and indications of piecemeal endoscopic

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mucosal resection require more discussion. Although the usefulness effectiveness of the piecemeal procedure has been examined, still longer follow-up data are warranted for further discussion [44].

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Surveillance after complete resection (en bloc resection with negative margins) After complete endoscopic resection of HGD, the risk of local recurrence and

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metastases is considered negligible. However, surveillance is still necessary. In this

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case, the target of the surveillance is metachronous colorectal tumors, and surveillance colonoscopy is recommended. Several studies have shown that HGD at initial colonoscopy is a risk factor for subsequent advanced neoplasms [45-53]. In the current US and EU guidelines on post-polypectomy surveillance, the colonoscopy interval is based on risk stratification according polyp features at initial colonoscopy, such as number, size and histopathological findings [14, 15]. In both guidelines, patients who

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undergo polypectomy for HGD are considered to be high-risk, and intensive surveillance is recommended, with colonoscopy at 3-year intervals. In contrast, in

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Japan, the surveillance recommendation is not based on risk stratification, although some studies on the Japanese population have indicated that HGD is a risk factor for

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subsequent advanced neoplasms [16, 17, 45, 49]. At present, the Japanese guidelines

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simply recommend that post-polypectomy surveillance colonoscopy should be performed within 3 years, regardless of the outcome of polypectomy the nature of resected polyps. The results of the Japan Polyp Study, a Japanese multicenter randomized control trial focusing on surveillance colonoscopy, are emerging, and

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further improvement in Japanese surveillance guidelines can be expected [16, 17, 54].

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Quality factors of the initial colonoscopy

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The above-mentioned surveillance recommendations should only be applied after complete, high-quality baseline colonoscopy is performed. Several studies have clarified and emphasized the importance of endoscopist- and center-related quality factors that are associated with the risk of interval CRC [55-58]. Quality factors of CS colonoscopy are now reviewed and described in other US and EU guidelines, and endoscopists should be aware of them [59, 60]. Related to this issue, good bowel

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preparation is also important for the achievement of high-quality colonoscopy. An inadequate level of bowel preparation is related to low detection of neoplastic lesions

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and a higher risk of missed lesions, resulting in a higher risk of advanced neoplasm at surveillance [61-64]. In the US and EU guidelines, early repetition of colonoscopy is

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recommended in patients with inadequate bowel preparation [14, 15].

Subsequent surveillance after the first follow-up colonoscopy Recommendations

on

subsequent

surveillance

colonoscopy

targeting

metachronous colorectal tumors after the first initial follow-up colonoscopy are also

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described in the US and EU guidelines, based on the results of several cohort studies [14, 15, 65-67]. If the first surveillance colonoscopy following endoscopic resection of

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HGD detects high-risk adenomas, including HGD, a 3-year interval before a second

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surveillance colonoscopy is recommended. When only low-risk or no adenomas are detected at the first surveillance colonoscopy, a 5-year interval is recommended. However, the evidence is weak about this issue, thus, more investigation and discussion is necessary.

Surveillance following surgical resection of CRC

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Following surgical resection of CRC, intensive multimodality surveillance using colonoscopy, radiological imaging and tumor maker measurements is

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recommended, considering the risk of metastases, local recurrence and/or metachronous colorectal tumors [8-13]. Several systematic reviews have shown that intensive

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surveillance using CT scanning and CEA measurement improves survival of patients

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who have undergone surgical resection of CRC [20-24], and CT and measurement of CEA are recommended in several current surveillance guidelines [8-13]. Table 2 summarizes the recommendations on surveillance following curative surgical resection of CRC in the US [National Comprehensive Cancer Network

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(NCCN), American Society of Clinical Oncology (ASCO), and US Multi-Society Task Force (USMSTF)], EU [European Society for Medical Oncology (ESMO)], and Japan

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[Japanese Society for Cancer of the Colon and Rectum (JSCCR)] [8-13]. In all

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guidelines, medical history, physical examination, CEA measurement, CT of the chest and abdomen, and colonoscopy are recommended after surgery for colon cancer. After surgery for rectal cancer, CT of the pelvis (all guidelines) and digital rectal examination (Japanese guidelines only) are additionally recommended. In the Japanese guidelines, measurement of carbohydrate antigen 19-9 is also recommended. Except for colonoscopy for detection of metachronous colorectal tumors, the surveillance period is

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determined to be 5 years in every guideline. This is based on previous studies showing

[13, 20, 68].

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Surveillance for pStage I cancer patients

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that most recurrences and metastases are detected within 5 years after initial treatment

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The recommendations summarized in Table 2 can be applied to patients with pStage II and III CRC. However, surveillance after surgical resection of cancers in pStage I (pT1 or pT2 pN0 pM0) requires more discussion because of the low possibility of recurrence, particularly for node-negative pT1 cancer. Data from a cohort study

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involving 14 Japanese institutions of the JSCCR showed that the recurrence rate (local recurrence or metastases) of node-negative pT1 was 1.3% for colon cancer and 1.1% for

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rectal cancer during a median follow-up of 7.8 years [13, 69]. Despite this low risk of

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recurrence, the Japanese guidelines recommend the intensive surveillance shown in Table 2, even for node-negative pT1 cancer, reasoning that recurrent cases can be detected early by surveillance and then cured [13]. In contrast, the surveillance recommendations for pStage I cancer is not described in the ASCO guidelines because of minimal data to provide guidance [9]. In the NCCN guidelines, only colonoscopy is recommended for surveillance of pT1 cancers patients [10, 11].the recommendations of

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the ASCO and NCCN guidelines do not target pStage I cancers [9-11]. Further

cancer.

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Surveillance colonoscopy after surgical resection of CRC

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investigation is necessary to establish more efficient programs for surveillance of pT1

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Colonoscopy surveillance targeting metachronous colorectal lesions is essential after surgical resection of CRC as well as endoscopic resection of HGD. It is reported that past history of CRC is a risk factor for metachronous CRC, and that the estimated cumulative incidence of metachronous CRC is 0.3%–0.35% per year following CRC

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resection [12, 70-72]. It is also reported that metachronous CRC can be found at any time, even long after the index case of CRC [12, 72-84]. Thus, postoperative

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surveillance colonoscopy is recommended in the long term [8-13]. An interval of 1 year

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between CRC resection and the first surveillance colonoscopy is recommended in every guideline [8-13]. This is based on previous studies showing that the incidence of metachronous CRC, which actually includes overlooked lesions at the time of the initial colonoscopy, is high within the first few years after surgery [73, 85-90]. Another study using a decision analysis model has indicated that 1-year surveillance colonoscopy is efficient and cost-effective [91]. The schedule of subsequent surveillance colonoscopy

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after the first investigation is also described in the guidelines; however, there is only

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weak evidence available at present, and more investigation is necessary [8-13, 92].

Additional consideration in surveillance after the resection of rectal cancer

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Following resection of rectal cancer, additional consideration is necessary for

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surveillance colonoscopy because of the possible higher risk of higher propensity for local recurrence [77, 87, 93, 94]. The recurrence rate of localized rectal cancer is reportedly higher particularly when surgery did not include total mesorectal excision, including transanal excision [95-101]. For patients undergoing such surgery, therefore,

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more-intensive local surveillance using flexible sigmoidoscopy or endoscopic

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ultrasound is recommended in the 2012 USMSTF guidelines [12].

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Additional consideration in surveillance after the resection of obstructive CRC The prevalence of synchronous CRC is reportedly 0.7%–7% in patients with

CRC, and thus it is advisable to perform complete high-quality colonoscopy preoperatively [12, 102]. However, sometimes, incomplete colonoscopy cannot be avoided because of malignant obstruction. In this situation, surveillance colonoscopy soon after postoperative recovery is recommended, which usually means 3–6 months

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after surgery [8-13]. In addition, As an alternative to colonoscopy in the situation of malignant obstruction, CT colonography (CTC) is recommended can be used

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preoperatively to examine the colon proximal to the malignant obstruction preoperatively in the USMSTF guidelines [12]. A recent case series including 284

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patients with obstructing CRC showed that sensitivity of CTC for synchronous

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advanced neoplasia (including high-risk polyps and CRC) is 80.0% (per-lesion) and 88.6% (per-person), and 100% for CRC (both per-lesion and per-person) [103].

Surveillance for Lynch syndrome patients

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When we consider the surveillance after resection of CRC, Lynch syndrome (LS) should be paid more attention [104-109]. It is known that LS accounts for about

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3% of newly diagnosed CRC cases, and there may be LS patients among those

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undergoing a usual surveillance program after CRC resection [104-109]. Patients with LS require a different surveillance approach targeting multiple organs, thus, it is essential to detect them precisely among CRC cases [110-112]. For the detection of LS, clinical criteria such as the Amsterdam II criteria and Revised Bethesda guidelines have been used [113, 114]. However, it is reported that some LS cases among CRC patients have been overlooked by those criteria [115-118]. The recent current US guidelines on

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LS recommend testing the tumors in all CRC patients with immunohistochemistry or for microsatellite instability to identify potential LS cases [111, 112]. However, this

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approach is currently adopted only in the US and further worldwide discussion is necessary regarding the detection of LS. Furthermore, colonoscopy surveillance

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programs for LS patients also require further investigation. It is suggested by recent the

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US guidelines that surveillance colonoscopy should be performed every 1–2 years; however, the level of evidence is still low.

Future perspectives of surveillance after resection of HGD and CRC

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There are still unresolved issues, including appropriate surveillance after resection of pT1 cancer and optimal timing of second surveillance colonoscopy;

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therefore, more evidence is necessary to establish efficient surveillance programs. It is

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also important to consider the cost-effectiveness of surveillance and the resource capacity of available examination methods, particularly for colonoscopy. Colonoscopy resources are limited and colonoscopy is used not only for surveillance, but also for other purposes such as screening, therefore, it is essential to distribute the resources efficiently to each purpose. Related to this issue, it is also important to explore other methods that can be used for surveillance. For instance, CTC is expected to become a

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new surveillance method because it may be used for intraluminal and extraluminal surveillance; however, there is only limited evidence to support its usefulness [103-105,

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119, 120]. Also, evidence on the usefulness of fecal immunochemical and DNA tests for surveillance is still insufficient [106-109 121-124]. More evidence is needed for these

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methods, and at the same time, we hope for development of new modalities for

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surveillance.

In the future, a more personalized surveillance approach considering both genetic and environmental backgrounds may become necessary, although such an approach is not practiced at present because of a lack of evidence.

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Regarding the issue of genetics, Lynch syndrome (LS) should be paid more attention [110-115]. It is known that LS accounts for about 3% of newly diagnosed CRC

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cases, and there may be LS patients among those undergoing a usual surveillance

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program after CRC resection [110-115]. Patients with LS require a different surveillance approach targeting multiple organs, thus, it is essential to detect them precisely among CRC cases [116, 117]. For the detection of LS, clinical criteria such as the Amsterdam II criteria and Revised Bethesda guidelines have been used [118, 119]. However, it is reported that some LS cases among CRC patients have been overlooked by those criteria [120-123]. The recent US guidelines on LS recommend testing the tumors in all

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CRC patients with immunohistochemistry or for microsatellite instability to identify potential LS cases [116, 117]. However, this approach is currently adopted only in the

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US and further worldwide discussion is necessary regarding the detection of LS. Furthermore, colonoscopy surveillance programs for LS patients also require further

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investigation. It is suggested by recent US guidelines that surveillance colonoscopy

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should be performed every 1–2 years; however, the level of evidence is still low.

Conclusions

Periodic surveillance colonoscopy is recommended following endoscopic

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resection of HGD. After surgical resection of CRC, intensive multimodality surveillance using colonoscopy, CT and CEA measurement is recommended. The importance of

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surveillance is undoubted, but there is still much room to improve surveillance

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programs, and gathering more evidence is warranted.

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Practice points


Surveillance following endoscopic and surgical resection of HGD and CRC is

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important to detect residual tumor tissue or local recurrence, metachronous colorectal tumors, and metastases, followed by improving survival of patients.

Periodic surveillance colonoscopy is necessary following endoscopic resection of

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HGD.

Intensive multimodality surveillance using colonoscopy, CT and CEA measurement is required following surgical resection of CRC.

Several guidelines on surveillance are available.

Research agenda

More high quality evidence is required regarding the schedule for second

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subsequent surveillance colonoscopies after the first one following endoscopic and surgical resection of HGD and CRC.




It requires more data and discussion to establish appropriate follow-up after

piecemeal resection of HGD.


Surveillance following resection of pT1 cancer needs more investigation.




The cost-effectiveness and capacity of surveillance examinations should be

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considered. Exploration of new Ssurveillance methods other than those currently used, such as colonoscopy and CT, should be explored is warranted.


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Identification and management of LS is a related important issue, which requires

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more discussion and evidence.

Conflict of interest

Acknowledgement

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No conflict of interest has been declared by the authors.

This study was supported in part by the National Cancer Center Research and

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Development Fund (27-A-5).

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Rubenstein

JH,

Enns

R,

Heidelbaugh

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et

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American

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syndrome. J Pathol. 2012; 226: 764–74. 117.

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between universal molecular screening for Lynch syndrome and revised

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extracolonic surveillance after curative resection of colorectal cancer. Radiology 2010; 257: 697–704.

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colonoscopic surveillance program speeds detection of colorectal neoplasia.

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Gastroenterology 2010; 139: 1918–26. 107. Lieberman D, Imperiale TF. Interval fecal immunochemical testing in colonoscopic surveillance program. Gastroenterology 2011; 140: 1359–1360. 108. Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med 2014; 370: 1287–97. 109. Kisiel JB, Yab TC, Taylor WR, et al. Stool methylated DNA markers decrease

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following colorectal cancer resection—implications for surveillance. Dig Dis Sci 2014; 59: 1764–7.

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110. Lynch HT, Shaw MW, Magnuson CW et al. Hereditary factors in cancer. Study of two large midwestern kindreds. Arch Intern Med 1966; 117: 206–12.

SC

111. Salovaara R, Loukkola A, Kristo P et al. Population-based molecular detection of

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hereditary nonpolyposis colorectal cancer. J Clin Oncol 2000; 182: 193–200. 112. Aaltonen LA, Salovaara R, Kristo P et al. Incidence of hereditary nonpolyposis colorectal cancer and the feasibility of molecular screening of the disease. N Engl J Med 1998; 338: 1481–7.

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113. Barnetson RA, Tenesa A, Farrington SM et al. Identification and survival of carriers of mutations in DNA mismatch-repair genes in colon cancer. N Engl J Med

EP

2006; 354: 2751–63.

AC C

114. Hampel H, Frankel WL, Martin E et al. Screening for the Lynch syndrome (hereditary nonpolyposis colorectal cancer. N Engl J Med 2005; 352: 1851–60. 115. Pinol V, Castells A, Andreu M et al. Gastrointestinal Oncology Group of the Spanish Gastroenterology Association, accuracy of revised Bethesda guidelines, microsatellite instability, and immunohistochemistry for the identification of patients with hereditary nonpolyposis colorectal cancer. JAMA 2005; 293: 1986–94.

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116. Giardiello FM, Allen JI, Axilbund JE, et al. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-society Task

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Force on colorectal cancer. Am J Gastroenterol. 2014; 109: 1159–79.

117. Rubenstein JH, Enns R, Heidelbaugh J, et al. American Gastroenterological

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Gastroenterology. 2015; 149: 777–82.

SC

Association Institute Guideline on the Diagnosis and Management of Lynch Syndrome.

118. Vasen HF. Clinical diagnosis and management of hereditary colorectal cancer syndromes. J Clin Oncol. 2000; 18: 81S–92S.

119. Umar A, Boland CR, Terdiman JP, et al. Revised Bethesda Guidelines for

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hereditary nonpolyposis colorectal cancer (Lynch syndrome) and microsatellite instability. J Natl Cancer Inst. 2004; 96: 261–8.

EP

120. Juli C, Trésallet C, Brouquet A et al. Identification in daily practice of patients with

AC C

Lynch syndrome (hereditary nonpolyposis colorectal cancer): revised Bethesda guidelines-based approach versus molecular screening. Am J Gastroenterol. 2008; 103: 2825–35.

121. van Lier MG, Leenen CH, Wagner A et al. Yield of routine molecular analyses in colorectal cancer patients ≤70 years to detect underlying Lynch syndrome. J Pathol. 2012; 226: 764–74.

42

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122. Pérez-Carbonell L, Ruiz-Ponte C, Guarinos C et al. Comparison between universal molecular screening for Lynch syndrome and revised Bethesda guidelines in a large

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population-based cohort of patients with colorectal cancer. Gut. 2012; 61: 865–72.

123. Moreira L, Balaguer F, Lindor N et al. Identification of Lynch syndrome among

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patients with colorectal cancer. JAMA. 2012; 308: 1555–65.

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Table 1. Schedule of surveillance following surgical resection of colorectal cancer

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recommended in the US, EU and Japanese guidelines

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HGD, high-grade dysplasia

Table 2. Schedule of surveillance following surgical resection of colorectal cancer recommended in the US, EU and Japanese guidelines

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ASCO, American Society of Clinical Oncology; CEA, Carcinoembryonic antigen; CT, computed tomography; ESMO, European Society for Medical Oncology; NCCN,

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National Comprehensive Cancer Network; USMSTF, US Multi-Society Task Force

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EU (ref. 14)

Japan (ref.16, 17)

3 years after initial colonoscopy

3 years after initial colonoscopy

Within 3 years after initial colonoscopy

Within a short interval (< 1 year) after initial colonoscopy

Within 6 months after initial colonoscopy

Around 6 months after initial colonoscopy

Surveillance colonoscopy following first surveillance colonoscopy

Interval between first and second surveillance colonoscopy is 3 years if high-risk adenoma is detected in the first surveillance and 5 years if low-risk or no adenoma is detected

Same as US guidelines

-

Additional consideration if bowel preparation of initial examination is inadequate

Colonoscopy within 1 year after initial colonoscopy

Early repetition of colonoscopy or a shorter surveillance interval

-

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First surveillance colonoscopy following complete endoscopic resection of HGD First surveillance colonoscopy following endoscopic piecemeal resection of HGD

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ASCO (US) (ref. 9)

NCCN (US) (ref. 10, 11)

USMSTF (US) (ref. 12)

ESMO (EU) (ref. 8)

JSCCR (Japan) (ref. 13)

History and physical examination

Every 3–6 months for 5 years after surgery

Every 3–6 months for the first 2 years, then every 6 months for a total of 5 years after surgery

-

Every 3–6 months for 3 years and every 6–12 months at years 4 and 5 after surgery

Every 3 months for 3 years and every 6 months at years 4 and 5 after surgery

CEA measurement

Every 3–6 months for 5 years after surgery

Every 3–6 months for the first 2 years, then every 6 months for a total of 5 years after surgery

-

Every 3–6 months for 3 years and every 6–12 months at years 4 and 5 after surgery

Every 3 months for 3 years and every 6 months at years 4 and 5 after surgery. CA19-9 measurement is also recommended

Every 12 months for 3 years/every Annually for up to 5 years for 6-12 months for first 3 years for patients patients at high risk of recurrence at high risk of recurrence

-

Every 6–12 months for the first 3 years for patients at high risk of recurrence

Every 6 months for the first 3 years, then every 6-12 months for 2 years

CT scan of chest and abdomen

At year 1 and every 5 years if the findings of the previous examination are normal

At years 1 and 3, then every 5 years if the findings of the previous examination are normal

At years 1 and 4 and every 5 years thereafter if the findings of the previous examination are normal

At year 1 and every 3–5 years thereafter

At years 1 and 3

Colonosccopy (if initial examination is incomplete because of malignant obstruction)

As soon as reasonable after surgery

3-6 months after surgery

Within 3-6-months after surgery

-

Within 6 months

Pelvic CT

Rectosigmoid colonoscopy or endoscopic ultrasonography (for patients at high risk of recurrence)

Pelvic CT, rectosigmoidoscopy (for patients at high risk of recurrence)

-

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Additional consideration following resection of rectal cancer

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Colonoscopy (if initial examination is complete)

Pelvic CT, colonoscopy at 2 years after surgery, and digital rectal examination