Diseases of the
COLON Vol. 20
RECTUM March, 1977
No. 2
Symposium Looking Ahead* M o d e r a t o r : BARTON HOEXTER, M.D. Great Neck, New York P a n e l i s t s : J. C. B. PENrOLD, F.R.A.C.S., TIMOTHY M. TALBOT-r, M.D.,
A. W. MARTIN MARINO, JR., M.D., ROBERT J. SPENCER, M.D., CLYDE E. CULP, M.D. t
DR. HOEXTER
rectal p r o g r a m . I w o u l d like to i n t r o d u c e Mr. C a m p b e l l Penfold, of M e l b o u r n e , Australia, w h o is g o i n g to talk to us a b o u t the "Early Detection of C o l o n i c Cancer by Colonoscopy."
I consider myself very lucky to be able to m o d e r a t e this panel, because I believe it is one of the most d y n a m i c areas of o u r colo-
Early Detection o[ Colonic Cancer by Colonoscopy J. C. B. PeNVOLD, F.R.A.C.S.,++ J. T . G. RENNEY, F.R.A.C.S. Melbourne, Australia
w h e t h e r the recent new development, colonoscopy, has p r o d u c e d this earlier detection of colonic cancer. T o answer this we have analyzed o u r colonoscopies to determine the frequency with which cancer is detected, the n a t u r e of the cancers detected, a n d w h e t h e r they are detected earlier t h a n expected. Colonoscopy in cancer detection m a y be considered in four m a i n areas: clinical suspicion of colonic cancer where the radio-
WE BELIEVE t h a t earlier detection of coIonic cancer should improve survival of the patients. W h a t we d o n ' t k n o w is * Symposium presented at the meeting of the American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, May 2 to 6, 1976. t Dr. Culp presented the paper for Dr. Spencer who was unable to attend the meeting. For reprints of the symposium please write to the authors of individual presentations. $ Repatriation General Hospital, Heidelberg West, Vic., 3077, Australia. 85 Dis. Col. & Reet. March, 1977
Volume 20 Number 2
Dis. Col. & Rect.
P E N F O L D AND R E N N E Y
86 TABLE 1.
Indications ]or Colonoscopy
Equivocal x-ray findings Unexplained rectal bleeding Polyps Assessment of "'colitis" Miscellaneous
239 203 161 76 8 687
TABLE 2.
Sites of Cancers Detected by Colonoscopy
Rectum Sigmoid Descending colon Transverse colon Right colon
Identified
Clarified
Total
3 29 8 2 2
1 18 2 0 2
4 47 10 2 4
44
23
67
TABLE 3. Sizes of Cancers Detected by Colonoscopy
Identified Clarified ~lcm
Total
2
0
2
1-1.9 cm
12
0
12
24
13
10
23
cm 4 cm
17
13
30
44
23
67
logic appearance is normal, radiologic suspicion where the radiologic appearance is equivocal, high-risk patients such as those who have past histories of cancer or polyps, and population screening. O u r results are drawn from the first two a r e a s - clinical or radiologic suspicion of colonic cancer. T h e y come from the colonoscopy units at the Royal Melbourne, R e p a t r i a t i o n General, and St. Vincent's Hospitals, Melbourne, since their inception in 1973. T h e y account for 80 per cent of colonoscopies p e r f o r m e d in the State of Victoria over this period. Victoria had a population of 3,679,400 in 1w and in that year 940 persons died from
March, 1977
cancers of the large intestine.7 T h i s incidence is similar to the current American figure. Methods Seven different colonoscopes, including all sizes and both O l y m p u s a n d A.C.M.I. makes, have been used. All examinations performed were recorded. T h o s e patients in w h o m cancer was detected h a d their operative specimens e x a m i n e d for site, size, grade, and stage of the tumor. A cancer, in this study, is Considered to be one that has invaded the muscularis m u c o s a e - - i n - s i t u growths are excluded. T o aid in interpretation of results, the cancers are divided into two groups, "identified" a n d "clarified." "Identified" cancers are those that h a d been completely missed on prior clinical a n d radiologic examination. "Clarified" cancers are those that had been d e m o n s t r a t e d by barium-enema examination, b u t their exact natures were equivocal prior to colonoscopy. Results Six h u n d r e d eighty-seven colonoscopies were performed over the period October 1973 to March 1976. Seventeen per cent of these examinations were unsatisfactory for a variety of reasons, but m a i n l y because of inadequate bowel p r e p a r a t i o n a n d anatomic difficulties. T h e indications for colonoscopy are shown in T a b l e 1. U n e x p l a i n e d rectal bleeding includes bleeding observed by the patient or clinician and also that detected chemically in the stools, "occult blood." Many of the 161 patients referred because of suspected polyps h a d their polyps excluded at colonoscopy. T h u s , the indications are examples of clinical or radiologic suspicion of cancer of the bowel. Sixty-seven cancers were f o u n d at colonoscopy. Fifty-eight were p r i m a r y tumors and nine were recurrences. T h i s is a cancer yield of 10 per cent. Forty-four were in the "identified" cancer group, that is, the can-
Volume 20 Number 2
EARLY COLONOSCOP1C CANCER D E T E C T I O N
cers had been missed clinically and radiologically. This is the group in which we believe colonoscopy produces the most benefit in cancer detection. I n many instances, as the findings were so unexpected, it is likely that further delays in diagnosis would have followed had colonoscopy not been available. T h e sites of the cancers detected are shown in Table 2. Note the predominance of cancers in the signoid colon and the paucity of findings in the right colon despite total colonoscopy. T h e endoscopic sizes of the tumors detected are shown in Table 3. T h e striking feature is the 14 tumors less than 2 cm in diameter in the "identified" group. No tumor as small as this was found in the "clarified" group. T h e endoscopic finding of small cancers like these 14 has been reported by other colonoscopists as wellA. 6 We believe, as has been suggested by others, 2 that smaller size, especially less than 2 cm in diameter, is an indication of earlier cancer. When examining operative colonic cancer specimens it is u n c o m m o n to find tumors this small, so it is not surprising that Dukes 3 was unable to find any relationship between tumor size and stage. On the other hand, most polyps are smaller than 2 c m , so any program aimed at eradicating polyps s should pick up these small cancers as well. I n our 161 patients referred for suspected polyps, we found a number of small cancers. Some of the small cancers had residual adenomatous tissue in the lesions, supporting the polyp-cancer sequence 4 and illustrating that cancer detection and polyp detection are inseparable. Further, regular ablation of all rectal polyps has been shownS to reduce the incidence of rectal cancer significantly. Lesions this small are readily detected at colonoscopy, yet are commonly missed on barium-enema examination. I n summary, the thrust of our colonoscopy is to detect the small cancers and also to detect and remove benignappearing polyps, which may be pre-
TABLE 4.
87
Histological Identified
Low
11
Average
Grades (Dukes) Clarified
Total
9
20
20
9
29
High
8
4
12
No biopsy
5
1
6
44
23
67
TABLE 5.
Dukes" Classification Identified
Clarified
Total
A
18
2
20
B
9
12
21
C No operation
6
7
13
11
2
13
44
23
67
cancerous. Both are readily achieved at colonoscopy. T h e grades of the tumors detected are shown in T a b l e ~t. T h e r e was no striking difference similar to that seen with size, although overall, more low-grade tumors were found. Finally, and most. importantly, when the stages of the tumors detected were examined (Table 5), a predominance of Dukes' A cases was found. T h e 18 A cases make up 56 per cent of the operative specimens in the "identified" group, and clearly demonstrate that these cancers have been detected much earlier than expected. It is hoped that this is the result of colonoscopy. No such feature was found in the "clarified" group, nor do we feel that colonoscopy has been so helpful in this group, as most of these patients would have undergone surgical treatment in any event. Conclusions
Colonscopy resulted in detection of cancers in I0 per cent of patients examined. These cancers were at an earlier stage than expected, possibly due to colonoscopy.
PENFOLD AND RENNEY
88
Many were small, suggesting that the most f r u i t f u l a p p r o a c h to e r a d i c a t i n g c a n c e r is t h r o u g h t h e m a n a g e m e n t of p o l y p s . T h e i n d i c a t i o n s for c o l o n o s c o p y s h o u l d r e m a i n t h e c l i n i c a l o r r a d i o l o g i c s u s p i c i o n of col o n i c cancer. T h e s e e n c o u r a g i n g r e s u l t s suggest t h a t c o l o n o s c o p y offers a s i g n i f i c a n t a d v a n c e in cancer detection. Further results from much l a r g e r series a r e e a g e r l y a w a i t e d to see whether they confirm these preliminary findings. References 1. Barrett PJ, Nagy GS: Gastrointestinal endoscopic polypectomy. Med J Aust 1:5, 1976
Dis. Col. & Rect. Niarch, 1977
2. Cady B, Persson AV, Monson DO, et al: Changing patterns of colorectal carcinoma. Cancer 33: 422, 1974 3. Dukes CE: The surgical pathology of rectal cancer. Proc R Soc Med 37: 131, 1943 4. Fenoglio CM, Lane N: The anatomical precursor of colorectal carcinoma. Cancer 34: 819, 1974 5. Gilbertsen VA: Proctosi~noidoscopy and polypectomy in reducing the incidence of rectal cancer. Cancer 34: 936, 1974 6. Nagasako K, Nagai K, Suzuki H. et al: Fiberscopic diagnosis of early cancer of the colon. Endoscopy 4: 1, 1972 7. Victorian Government Statist (1976): Unpublished data 8. Wolff WI, Shinya H: Endoscopic polypectomy: Therapeutic and clinicopathologic aspects. Cancer 36: 683, 1975
Announcements I n t e r n a t i o n a l Conference on Gastrointestinal Cancer
This Meeting, organized by the Israel Gastroenterological Society and Cancer Association, in collaboration with the American Cancer Society, College of Gastroenterology, Gastrointestinal Endoscopy Society, and the European Organization for Research on Treatment of Cancer, will be held in Israel, November 6-11, 1977. The Conference will comprise papers and discussions on advances in basic research, diagnosis, detection and prognosis, prevention, therapy and rehabilitation, and will also include areas of agreement and controversy. Numerous workshops will be held during the Conference. Further details can be had from the Organizing Secretary, Dr. P. Rozen, c/o Secretariat, P.O.B. 16271, Tel Aviv, Israel. The deadline for papers is June 30, 1977.
X l I I A r g e n t i n e Congress of Gastroenterology The XIII Argentine Congress of Gastroenterology will be held in Buenos Aires, Argentina, September 18-23, 1977. The General San Martin Cultural Center will be the headquarters for sessions and exhibitions. Themes of the Congress wiI1 be Early Diagnosis of Digestive Cancer, Gastroduodenal Ulcers, Physiopathic Consequences of Digestive-tract Resections, Viral Hepatitis, and Intrahepatic Cholestasis. In addition to the presentations of invited contributors, symposia will be held, and two courses will be presented: Progress in Diagnostic Methodology Involving the Digestive Apparatus; Treatment, Extensive Therapy of the Digestive Apparatus. Further information may be obtained by contacting the General Secretary, Dr. Julio N. Cosen, Secretaria: Ceni S.A., Ave. Roque S. Pefia 1110-2 o Piso, 1035 Buenos Aires, Argentina.
COLON Vol. 20
RECTUM March, 1977
No. 2
Symposium Looking Ahead* M o d e r a t o r : BARTON HOEXTER, M.D. Great Neck, New York P a n e l i s t s : J. C. B. PENrOLD, F.R.A.C.S., TIMOTHY M. TALBOT-r, M.D.,
A. W. MARTIN MARINO, JR., M.D., ROBERT J. SPENCER, M.D., CLYDE E. CULP, M.D. t
DR. HOEXTER
rectal p r o g r a m . I w o u l d like to i n t r o d u c e Mr. C a m p b e l l Penfold, of M e l b o u r n e , Australia, w h o is g o i n g to talk to us a b o u t the "Early Detection of C o l o n i c Cancer by Colonoscopy."
I consider myself very lucky to be able to m o d e r a t e this panel, because I believe it is one of the most d y n a m i c areas of o u r colo-
Early Detection o[ Colonic Cancer by Colonoscopy J. C. B. PeNVOLD, F.R.A.C.S.,++ J. T . G. RENNEY, F.R.A.C.S. Melbourne, Australia
w h e t h e r the recent new development, colonoscopy, has p r o d u c e d this earlier detection of colonic cancer. T o answer this we have analyzed o u r colonoscopies to determine the frequency with which cancer is detected, the n a t u r e of the cancers detected, a n d w h e t h e r they are detected earlier t h a n expected. Colonoscopy in cancer detection m a y be considered in four m a i n areas: clinical suspicion of colonic cancer where the radio-
WE BELIEVE t h a t earlier detection of coIonic cancer should improve survival of the patients. W h a t we d o n ' t k n o w is * Symposium presented at the meeting of the American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, May 2 to 6, 1976. t Dr. Culp presented the paper for Dr. Spencer who was unable to attend the meeting. For reprints of the symposium please write to the authors of individual presentations. $ Repatriation General Hospital, Heidelberg West, Vic., 3077, Australia. 85 Dis. Col. & Reet. March, 1977
Volume 20 Number 2
Dis. Col. & Rect.
P E N F O L D AND R E N N E Y
86 TABLE 1.
Indications ]or Colonoscopy
Equivocal x-ray findings Unexplained rectal bleeding Polyps Assessment of "'colitis" Miscellaneous
239 203 161 76 8 687
TABLE 2.
Sites of Cancers Detected by Colonoscopy
Rectum Sigmoid Descending colon Transverse colon Right colon
Identified
Clarified
Total
3 29 8 2 2
1 18 2 0 2
4 47 10 2 4
44
23
67
TABLE 3. Sizes of Cancers Detected by Colonoscopy
Identified Clarified ~lcm
Total
2
0
2
1-1.9 cm
12
0
12
24
13
10
23
cm 4 cm
17
13
30
44
23
67
logic appearance is normal, radiologic suspicion where the radiologic appearance is equivocal, high-risk patients such as those who have past histories of cancer or polyps, and population screening. O u r results are drawn from the first two a r e a s - clinical or radiologic suspicion of colonic cancer. T h e y come from the colonoscopy units at the Royal Melbourne, R e p a t r i a t i o n General, and St. Vincent's Hospitals, Melbourne, since their inception in 1973. T h e y account for 80 per cent of colonoscopies p e r f o r m e d in the State of Victoria over this period. Victoria had a population of 3,679,400 in 1w and in that year 940 persons died from
March, 1977
cancers of the large intestine.7 T h i s incidence is similar to the current American figure. Methods Seven different colonoscopes, including all sizes and both O l y m p u s a n d A.C.M.I. makes, have been used. All examinations performed were recorded. T h o s e patients in w h o m cancer was detected h a d their operative specimens e x a m i n e d for site, size, grade, and stage of the tumor. A cancer, in this study, is Considered to be one that has invaded the muscularis m u c o s a e - - i n - s i t u growths are excluded. T o aid in interpretation of results, the cancers are divided into two groups, "identified" a n d "clarified." "Identified" cancers are those that h a d been completely missed on prior clinical a n d radiologic examination. "Clarified" cancers are those that had been d e m o n s t r a t e d by barium-enema examination, b u t their exact natures were equivocal prior to colonoscopy. Results Six h u n d r e d eighty-seven colonoscopies were performed over the period October 1973 to March 1976. Seventeen per cent of these examinations were unsatisfactory for a variety of reasons, but m a i n l y because of inadequate bowel p r e p a r a t i o n a n d anatomic difficulties. T h e indications for colonoscopy are shown in T a b l e 1. U n e x p l a i n e d rectal bleeding includes bleeding observed by the patient or clinician and also that detected chemically in the stools, "occult blood." Many of the 161 patients referred because of suspected polyps h a d their polyps excluded at colonoscopy. T h u s , the indications are examples of clinical or radiologic suspicion of cancer of the bowel. Sixty-seven cancers were f o u n d at colonoscopy. Fifty-eight were p r i m a r y tumors and nine were recurrences. T h i s is a cancer yield of 10 per cent. Forty-four were in the "identified" cancer group, that is, the can-
Volume 20 Number 2
EARLY COLONOSCOP1C CANCER D E T E C T I O N
cers had been missed clinically and radiologically. This is the group in which we believe colonoscopy produces the most benefit in cancer detection. I n many instances, as the findings were so unexpected, it is likely that further delays in diagnosis would have followed had colonoscopy not been available. T h e sites of the cancers detected are shown in Table 2. Note the predominance of cancers in the signoid colon and the paucity of findings in the right colon despite total colonoscopy. T h e endoscopic sizes of the tumors detected are shown in Table 3. T h e striking feature is the 14 tumors less than 2 cm in diameter in the "identified" group. No tumor as small as this was found in the "clarified" group. T h e endoscopic finding of small cancers like these 14 has been reported by other colonoscopists as wellA. 6 We believe, as has been suggested by others, 2 that smaller size, especially less than 2 cm in diameter, is an indication of earlier cancer. When examining operative colonic cancer specimens it is u n c o m m o n to find tumors this small, so it is not surprising that Dukes 3 was unable to find any relationship between tumor size and stage. On the other hand, most polyps are smaller than 2 c m , so any program aimed at eradicating polyps s should pick up these small cancers as well. I n our 161 patients referred for suspected polyps, we found a number of small cancers. Some of the small cancers had residual adenomatous tissue in the lesions, supporting the polyp-cancer sequence 4 and illustrating that cancer detection and polyp detection are inseparable. Further, regular ablation of all rectal polyps has been shownS to reduce the incidence of rectal cancer significantly. Lesions this small are readily detected at colonoscopy, yet are commonly missed on barium-enema examination. I n summary, the thrust of our colonoscopy is to detect the small cancers and also to detect and remove benignappearing polyps, which may be pre-
TABLE 4.
87
Histological Identified
Low
11
Average
Grades (Dukes) Clarified
Total
9
20
20
9
29
High
8
4
12
No biopsy
5
1
6
44
23
67
TABLE 5.
Dukes" Classification Identified
Clarified
Total
A
18
2
20
B
9
12
21
C No operation
6
7
13
11
2
13
44
23
67
cancerous. Both are readily achieved at colonoscopy. T h e grades of the tumors detected are shown in T a b l e ~t. T h e r e was no striking difference similar to that seen with size, although overall, more low-grade tumors were found. Finally, and most. importantly, when the stages of the tumors detected were examined (Table 5), a predominance of Dukes' A cases was found. T h e 18 A cases make up 56 per cent of the operative specimens in the "identified" group, and clearly demonstrate that these cancers have been detected much earlier than expected. It is hoped that this is the result of colonoscopy. No such feature was found in the "clarified" group, nor do we feel that colonoscopy has been so helpful in this group, as most of these patients would have undergone surgical treatment in any event. Conclusions
Colonscopy resulted in detection of cancers in I0 per cent of patients examined. These cancers were at an earlier stage than expected, possibly due to colonoscopy.
PENFOLD AND RENNEY
88
Many were small, suggesting that the most f r u i t f u l a p p r o a c h to e r a d i c a t i n g c a n c e r is t h r o u g h t h e m a n a g e m e n t of p o l y p s . T h e i n d i c a t i o n s for c o l o n o s c o p y s h o u l d r e m a i n t h e c l i n i c a l o r r a d i o l o g i c s u s p i c i o n of col o n i c cancer. T h e s e e n c o u r a g i n g r e s u l t s suggest t h a t c o l o n o s c o p y offers a s i g n i f i c a n t a d v a n c e in cancer detection. Further results from much l a r g e r series a r e e a g e r l y a w a i t e d to see whether they confirm these preliminary findings. References 1. Barrett PJ, Nagy GS: Gastrointestinal endoscopic polypectomy. Med J Aust 1:5, 1976
Dis. Col. & Rect. Niarch, 1977
2. Cady B, Persson AV, Monson DO, et al: Changing patterns of colorectal carcinoma. Cancer 33: 422, 1974 3. Dukes CE: The surgical pathology of rectal cancer. Proc R Soc Med 37: 131, 1943 4. Fenoglio CM, Lane N: The anatomical precursor of colorectal carcinoma. Cancer 34: 819, 1974 5. Gilbertsen VA: Proctosi~noidoscopy and polypectomy in reducing the incidence of rectal cancer. Cancer 34: 936, 1974 6. Nagasako K, Nagai K, Suzuki H. et al: Fiberscopic diagnosis of early cancer of the colon. Endoscopy 4: 1, 1972 7. Victorian Government Statist (1976): Unpublished data 8. Wolff WI, Shinya H: Endoscopic polypectomy: Therapeutic and clinicopathologic aspects. Cancer 36: 683, 1975
Announcements I n t e r n a t i o n a l Conference on Gastrointestinal Cancer
This Meeting, organized by the Israel Gastroenterological Society and Cancer Association, in collaboration with the American Cancer Society, College of Gastroenterology, Gastrointestinal Endoscopy Society, and the European Organization for Research on Treatment of Cancer, will be held in Israel, November 6-11, 1977. The Conference will comprise papers and discussions on advances in basic research, diagnosis, detection and prognosis, prevention, therapy and rehabilitation, and will also include areas of agreement and controversy. Numerous workshops will be held during the Conference. Further details can be had from the Organizing Secretary, Dr. P. Rozen, c/o Secretariat, P.O.B. 16271, Tel Aviv, Israel. The deadline for papers is June 30, 1977.
X l I I A r g e n t i n e Congress of Gastroenterology The XIII Argentine Congress of Gastroenterology will be held in Buenos Aires, Argentina, September 18-23, 1977. The General San Martin Cultural Center will be the headquarters for sessions and exhibitions. Themes of the Congress wiI1 be Early Diagnosis of Digestive Cancer, Gastroduodenal Ulcers, Physiopathic Consequences of Digestive-tract Resections, Viral Hepatitis, and Intrahepatic Cholestasis. In addition to the presentations of invited contributors, symposia will be held, and two courses will be presented: Progress in Diagnostic Methodology Involving the Digestive Apparatus; Treatment, Extensive Therapy of the Digestive Apparatus. Further information may be obtained by contacting the General Secretary, Dr. Julio N. Cosen, Secretaria: Ceni S.A., Ave. Roque S. Pefia 1110-2 o Piso, 1035 Buenos Aires, Argentina.
