157-l 61

Surgical Dncology 1992; 1:

Early results of follow-up after radical resection for colorectal cancer. Preliminary results of a prospective randomized trial J. MAKELii, S. LAITINEN AND M. I. KAIRALUOMA Oulu University Central Hospital, Department of Surgery, 90220 Oulu, Finland

One-hundred intensive

and

six consecutive

monitoring

after

into a conventional (Group

II). After

in Group the

follow-up

a median

I was 24%

those followed corresponding

figures

local

recurrence

perineal

hepatic the

for local

II were

colon

surgery.

in Group

I during

results

encourage

Surgical

Keywords:

II 25%

Oncology

colorectal

(13/52).

36% (10/26)

local, three,

five

and

hepatic

II. Mortality

the

rates among

respectively. extirpation

two

Of

and

the of a

intestinal

resections

re-

for solitary

have been removed

and

trial

group

to date is 13% (7/54)

polyps

surveillance

us to continue

of

recurrence

six distant,

I, whereas

and two

adenomatous

endoscopic

The recurrence

regional

in Group

II. Two

follow-up

and 30% (g/30),

in Group

study

randomized

rate of detection

four and five. One radicai

performed

have been performed

54 being

I) and 52 into an intensified

recurrences

I and 8% (4152) in Group

preliminary

was

has been

anastomotic

metastases

Group

I, one

in Group

in a prospective cancer,

of 2 years the overall

and in Group

in Group

included

for colorectal

group (Group

follow-up

(13/54)

were

resection

up for at least 2 years were

recurrences

resections

patients

radical

seven

in Group

up to 5 years

in

from

II. These

after

primary

1992; 1: 157-161.

neoplasms,

comparative

study,

follow-up,

studies,

random

allocation.

low-up

INTRODUCTION

order In order

to achieve

better

surgery for colorectal

long-term

results

examinations to

detect

We

observed

primary surgery is the most important factor, but the

programme

early detection

too insensitive

resections Because rectal

and

at

the delay cancer

performing grammed

least

can allow reasonable

in diagnosis

greatly

might

the

chances

value

of intensive

resection for colorectal questioned resections recently,

because

after

been conducted

been

specifically

scheme

J.

Mlkeb,

MD,

Oulu

University

and

recurrences

[4]. Thus in 1987 we

with

when

for a median

study to compare a new

intensified

the follow-up

has

period of 2 years, we

of fol-

157

answer

recurrence

so far? (ii) Do the differ (iii) What

been performed?

Hospital Department of Surgery, 90220 Oulu, Finland.

to

(i) What

grammes?

Central

attempts

questions: recurrences

Correspondence:

protocol

with

present the early results of this study. This report

re-

survival [l, 21. More

a more intensive

to

intensive regimen.

curative

cancer has previously

in

and

protocol in order to assess the possible benefit of an

to a

of the low rate of radical

early

comprehensive

patients

prospective

In this communication follow-up

and poor long-term however,

to detect

the old follow-up

of

higher rate of re-resectability. The

recommended

that our old follow-up

was not sufficiently

began a randomized

pro-

lead

previously

suitable for operative treatment

colo-

an intensive,

theoretically

re-

palliation.

of recurrent

reduces

a radical reoperation, follow-up

radical

been

recurrences

improve the chances of a cure by surgery [3].

after

cancer, the radical nature of

of recurrence

has

local

are the between kinds

the

following

rates of detection methods the

of

revealing

follow-up

pro-

of reoperations

have

J.Miikel3 et al.

158 MATERIAL

AND

METHODS

not performed every

One-hundred surgery

and

for

six

patients

colorectal

underwent

cancer

at Oulu

radical

University

Central Hospital during the years 1988-1990. patients were randomized two follow-up

54 patients into Group I

programmes:

(the old follow-up

into

protocol)

and

52 patients

into

Group II (an intensified protocol). There were 27 women 27 women

and 25 men in Group II. The mean age of

the patients from

in Group

I was 69 + 15 years,

33 to 85 years,

and that of Group

ranging II 63 + 15

after

but it was performed

operation

and

resection every year after operation. In the

present

surgical with

study

removal

radical

resection

of all macroscopic

microscopically

evaluated

clearance

surgical margins. The distributions to

the

Turnbull

modification

patient

clinic of the Department

to visit the outof Surgery

third month for the first 2 postoperative

every

years and

then every sixth month for the next 3 years. During each visit, the medical

a clinical examination

complete

blood

cell counts,

was performed

and

Table

metastases

and

D) and those

with

1. All patients

extensive

with

local growth

distant

(Dukes

in

cancer growth in the lymph nodes at the apex of the were

excluded.

A local recurrence restricted and

a

was

The locations

defined

to the anastomosis regional

here

of the

as being

and its surroundings,

recurrence

beyond

the

site

of

primary resection without distant metastases.

and

tests of occult faecal

and carcinoembryonic

measured,

[5]

history for the interval was

obtained, bleeding

the

are presented

primary tumours are listed in Table 2. expected

of

grades of histological differentation

mesenterium

were

tissue

into Dukes stages

years, ranging from 33 to 81 years. The age distribuAll the patients

denotes

tumour

tion is presented

in Fig. 1.

computed

(CT) of the liver and the site of primary

according

and 27 men in Group I and

preoperatively,

months

tomography

These

during hospitalization

6

antigen levels were

1. Histological classification

was performed

at each visit for patients who underwent

and Dukes staging

according to the Turnbull modification

of the patients

primary colorectal cancer

and a chest X-ray was performed.

In Group I a rigid sigmoidoscopy

Table

Dukes stages

surgery for

rectal and sigmoid cancers and a barium enema for

Group

I

A

B

Group II

all patients at 12 months and then once per year. In Group

II,

performed

colonoscopy

video-imaging

was

3 months after surgery, if not performed

preoperatively,

and thereafter

patients.

Flexible

imaging

was

patients

with

with

video-

4

7

2

6

4

3

15

13

7

19

12

-

-

24

15

13

24

Ill

operated

on for rectal or

15

Ultrasonography

of the liver was

month

C

I

Total

third

B

II

for

every

A

Differentiation 11 -

had been

sigmoid tumours.

a year for all

fibresigmoidoscopy

performed

who

once

C

2

1

15

Table 2. Site of the primary tumour

25 BRGrow

I

II

GrowII

Follow-up group

Site

Group I Coecum

12

9

5

6

Hepatic flexure

3

0

Transverse

1

2

1

1

Ascending

(40

41-50

51-60

61-70

71-80

>80

Age (years) Figure 1. The age distribution follow-up

of the patients in the old

Group (Group I) and in the intensified follow-up

Group (Group II).

Group II

colon colon

Splenic flexure Descending

colon

1

1

16

17

Rectum

15

16

Total

54

2

Sigmoid colon

Radical resection after colorectal At the time

of this report,

and 30 patients

in Group

at least 2 years, 2 years. pared

and the median

The patients

here with

site of recurrent mortality

groups

to the number,

tumours,

methods

the treatment

so far

and

removed

the

copy

until

Perineal

are com-

case in Group

mode

of recurrences,

the

Four

of synchronous

surveillance.

RESULTS recurrence I and 25%

sponding

figures

being

in Group

rate so far was 24% (13/54) (13/52)

in Group

for those

followed

36% (10128) in Group

II. The distribution

up for

over

II and one in Group

I (Table

Group

II, anastomotic

line recurrences

sitated

one anterior

a Dukes

of recurrences

accord-

A 27% (4/15),

25% (6/24) and C 20% (3/15) in Group Pelvic recurrences (five)

than

stases

were

in Group

were

more

(five)

than

local recurrences

and

one

one

in Group abdominal,

recurrences.

was

regarded

common

I (two)

(Table

in Group and

liver

detected

3). There

regional

five

both

commonest

groups

I II

and and

ultrasound

two

occult

recurrence

recurrences

blood

following

II, but this recurrence

Table

the first

five I, six

Pelvis

sign

and

hemicolectomies

radically.

cases

in Group

II the non-resectability confirmed

at

by colonos-

in two

of regional One

First method showing

in only cases

in

recurrences bypass

and

Follow-up group Group II

Elevation of CEA

8

5

Endoscopy finding

0

3

Positive faecal blood test

1

1

Computed

0

2

0

2

1

0

Ultrasound

tomography

finding

finding

Roentgenography

of the chest

Clinical symptom Total

3

0

13

13

Table 5. Treatment

of recurrences

2

5

3

2

Lung

2

0

Perineum

1

1 2 13 (25%)

during

Group II 1 Radical resection Anterior

4

reresection

Intestinal reresection

Group II 3

detected

follow-up

perineal extirpation

5

0

these

Table 4. Detection of recurrences

Radical resection

Follow-up group

13 (25%)

and

elevated

I and

laparotomy.

Group I

I

for coe-

C tumours)

CEA was

C

of local in Group

Liver

Suture line

right

B and

Dukes

metastases

II. A positive

Abdomen

Total

in

cancer

Group

for

Group I

(Table

CT two

hemicolectomy

was not confirmed

3. Locations of recurrent

Location of recurrence

three,

in Group

test was right

recurrence

of the CEA value

revealed

intestinal

one

recurrence

were

in Group

regional

indicating

was elevation

4). Fibresigmoidoscopy faecal

sign

resection

and hepatic

two

in

neces-

following

hemicolectomy

II, two anastomotic

three

5). Of those

Solitary

(Dukes

resected

Group was

distant. The

after

in

meta-

in Group

Of the recurrences as local,

right

cancer

performed

II.

in Group

whereas

frequently

three distant

more

II (three),

after cancer.

In three B

I, and A 23%

(3/13), B 17% (4/24) and 40% (6/15) in Group

re-resection

C sigmoid

cancers

were

suture

the

biopsy.

two of these four cases.

I and 30% (9130)

ing to Dukes stages was as follows:

by fine needle

once

Group

developed 2

of rectal

removed were

cal

II, the corre-

in CEA in one

recurrence

radically

fibre-

anastomosis.

reoperations

resection

in Group

was

radical

routine

the

the elevation

was confirmed

caecal The overall

reach

I and this perineal

C cancer

diagnosis

the first

because

not

pain preceded

Dukes

and

later

did

time was

of

years

6 months

sigmoidoscopy

up for

showing

number

during

I

in Group

follow-up

in the two

respect

sign of recurrence, adenomas

28 patients

II had been followed

159

cancer

Left hepatic lobectomy Palliative lung resection

Left hemihepatectomy 1 -

Laparotomy

3

Laparotomy

2

Palliative radiotherapy

2

Palliative radiotherapy

2

Cytotoxic chemotherapy

1 Cytotoxic chemotherapy 5 Conservative treatment

3

Conservative Total

treatment

13

2

13

J.Mike/i

160 enterostomy

procedure

impending with

a

local

refused

for

hepatic

palliative

pelvic

alive

and

metastases

per cent 92%

4 and

who

Dukes

patients

in Group

I

in Group

II (48/52)

of primary

C 1 in Group

infarction

II. One patient

without

Our

intention

cancer

patients,

are

tumours

in

Although differ

not

definitive

undertaken intensive tive

with

mild tubular

dysplasia,

one moderate adenoma

were

adenomas,

removed

in Group

one with

and three

both

severe

I, and

dysplasia,

mild, and one tubulovillous

with mild dysplasia

in Group

al.

measuring

the primary adjuvant been

cancer, follow-up

suggested

allows

disease

of

time

achievement intensive

intensive,

and

should better

be

results

the existence stage could of a regimen

So far none follow-up

group

in the

followed

has

whereas

was

endoscopic

died during complete incomplete separately.

P-year follow-up

2-year follow-up

and during

(others) are presented

fibresigmoidoscopy, the recommenda-

1 I]

that

after

second-look

confirmation

following

metastases

to exclude or possible

add

endoscopy

as all three

resection

longer

to

Colonoscopy

because

non-investigative

of the limited

units to accommodate

capacity

the has

part of the followof colorectal

fibresigmoidoscopies, in

as

of our local recur-

in this way.

an important

can, of course,

at laparotomy,

113, 141, and we agree with this. The future between

or

clinical,

in CEA. The irresecta-

recurrence

to

after curative

first

or CT,

as an anastomotic

certainty

worthwhile detected

II. The

ultrasound

investigation

distant

[12].

been considered

Figure 2. Survival figures in Groups I and II. The patients

[IO,

elsewhere programme,

in CEA

was possible.

bility of a local or regional

were

and

recurrence,

and the second

time

recurrence,

with

led to surgical

Group

us to favour

growth,

diagnostic

elevations

by

the

may lead to

lung resection

in

be considered of

during

seven

before

detected

in the

et a/. confirm

I, two

causes of an elevation

It seems

Group II

increase

follow-up

diagnostic

authors

be determinated

regimen

be obtained

of a perineal

or radiological

unresectable

rences

reopera-

27 to 60% when

Of the

surgery

incline

should

documented

Group I

rate.

re-resection

other

follow-up

the

that intensive

4 to 6 weeks

at the same

suspicion

benign

pallia-

of three

and Minton

CEA-based

by

Our results

high

every

years,

an from

a liver metastasis

and radical

surgery

in the

to radical

to a right hemihepatectomy,

of

was

two

may only

reported

out of four

recurrence

tion

answer

cure

was observed

be 13

conventional

were

of that

of the

at the time of discovery,

13 recurrences

it has

only

at two

in relation

to extirpation

two

indicated

follow-up intent

six laparotomies

the first to palliative

while

leading

and more

programmes to achieve

of

operations,

same

at an asymtomatic

in our the

At the

re-treatment.

been symptomatic three

surgery

of recognizing

important

radical

recurrences

[6].

hopes

[7]. The possibility the most

radical

can be

diagnosis

and chemotherapy

follow-up

if one

recurrent

cancer

that comprehensive,

co-ordinated

undertaken

of colorectal

pre-symptomatic more

radiotherapy

meticulous well

of treatment

recurrence

curative

in CEA in our Group

the second

by earlier

recurrent to benefit

two

I. This suggests

CEA levels

postoperative

a considerable

DISCUSSION

the

possible

[8]

that an aggressive

II.

all

observed

whereas

of recurrences

re-treatment,

improved

recur-

follow-up. et

elevations

The results

were

but a definitive

resectability first

on

with

of the

in Group

after longer

the

group,

is of benefit

Martin

five

their

be expected

between

at four follow-up

laparotomies tions,

adenoma,

from

operate

surgery

procedures

II died of

and one tubulovillous

to

might

did

in Group

of recurrent

was who

surgery.

follow-up

disease. One tubular

symptoms

rates

B 2 and

any evidence

had

from

Dukes

I, and

group

groups,

recurrences.

have died was Dukes A 2, Dukes 6

Dukes C 2 in Group cardiac

II

patients

and four

follow-up

rence by that time.

Mitomycin

of the patients

(Fig. 2). The distribution

the patients

Three

for pelvic

of those

of

patient

Group

intra-arterial

radiotherapy

Eighty-seven (47/54)

in

treatment.

selective

infusions

because

II, but the

recurrence

additional

received

performed

in Group

abdominal

any

have

was

obstruction

et al.

may of most

the numbers

intervals

have

follow-up

up

cancer to

be

regimens, endoscopy

required

and the

Radical resection

low

cost-benefit

Endoluminal

ratio

of frequent

ultrasound

early detection

has been recommended

confirmation

after longer follow-up One single

the

examinations.

of local recurrence

but this requires

after colorectal

for

of rectal cancer

in larger studies and

metastasis

this series after detection

was

removed

by ultrasound,

in

but CT find-

ings have not led to any radical surgery. The problem

with

CT

is the

postoperative although

difficulty

scar from

in distiguishing

a recurrent

a percutaneous [16].

biopsy

tumour

can

a

mass,

be used to

confirm

recurrence

seemed

to detect only pelvic recurrences

In the present

completeness intensive recurrence

will also improve.

the

no-touch

JC. What can be done to improve

in colorectal

cancer?

Stand

isolation

the results

J Gastroenterol

1988;

23

148: 190-4.

7. Devesa

JM,

Morales

cancer.

The

bases

V, Enrique for

JM,

et al. Colorectal

comprehensive

follow-up.

Dis

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RA, Thompson

the hollow

organs

and follow-up. 9. Martin

WM.

Primary

neoplasms

of the gastrointestinal

tract.

of

Staging

Cancer 1991; 67: 1188-991.

EW Jr, Cooperman

serial carcinoembryonal

does

and an increase

rates as such, but we antici-

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of

rates. Ann Surg 1967; 166: 420-7.

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regimen

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influence

second-look

M, Carey

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LC, Minton

indicated

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rise

in

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colon:

technic

(suppl.)

[I 51.

hepatic

cancer

through

radical re-

The primary results of

this survey seem to support such a view and encou-

10. Minton

JP, Hoehn

400-patient colorectal 11. Fucini

cancer

cancer

CEA,

surgery.

DM, et a/. Results

TPA,

antigen

of a

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Rosi

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PJ, Mojzisik

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LC, Martin

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period.

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C, Tommasi

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JL, Gerber

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