Is routine use of adjuvant chemotherapy for rectal cancer with complete pathological response justified?

BACKGROUND: Patients with locally advanced rectal cancer (LARC) receiving neoadjuvant chemoradiation (nCRT) can have a complete pathologic response (pCR), and are given postoperative adjuvant chemotherapy (ACT). METHODS: A prospectively maintained outcomes database was queried for patients who had pCR to nCRT for LARC from 2000 to 2012. Local recurrence and survival were analyzed according to whether patients received ACT. RESULTS: We identified 139 patients and excluded 9 due to lack of follow-up. Mean age was 58.9 ± 11.8 years. 83 patients (63.8%) did not receive ACT (Group A) and 47 (36.2%) did (Group B). Mean follow-up was 5.7 ± 3 and 5.6 ± 3.5 years for Groups A and B respectively (p = 0.51). Groups were comparable in age, gender, tumor differentiation, and clinical staging. There were no differences in oncological outcomes. CONCLUSION: Avoiding routine use of ACT in patients with a pCR may be considered. Further justification of this approach warrants prospective randomized studies.

Achieving a complete colonic evaluation in patients with incomplete colonoscopy is worth the effort.

BACKGROUND: Patients with an incomplete colonoscopy are potentially at risk for missed lesions. OBJECTIVE: The purpose of this work was to identify the percentage of patients completing colonic evaluation after incomplete colonoscopy, the manner in which the evaluation was completed, and the incidence of significant pathology. DESIGN: This was a retrospective analysis of prospectively collected data. SETTINGS: The study was conducted in an outpatient colonoscopy clinic in the colorectal surgery department of a tertiary referral center. PATIENTS: Patients included those undergoing incomplete colonoscopy from a database of 25,645 colonoscopies performed from 1982 to 2009. INTERVENTIONS: Procedures aimed at completing colorectal evaluation were included in the study. MAIN OUTCOME MEASURES: Reason for incompletion, secondary study, its success, and findings were measured. RESULTS: A total of 242 patients with incomplete colonoscopies were identified; 166 (69%) were women. The average age of patients was 59 years. Most frequent causes for incomplete colonoscopy were inadequate preparation (34%), pain (30%), and tortuosity (20%). The scope could not pass the splenic flexure in 165 patients (71%). A total of 218 patients (90%) were offered completion studies, and 179 patients (82%) complied. Seventy-three of 82 patients who had a surveillance colonoscopy had a follow-up (89%), compared with 72 (87%) of 83 with symptoms and 40 (74%) of 54 who had a screening. Barium enema (BE) was performed in 74 (41%), repeat colonoscopy in 71 (40%), CT colonography in 17 (9%), and colonoscopy under general anesthesia in 9 patients (5%). Resection with intraoperative/perioperative colonoscopy was required in 8 patients (4%). Repeat colonoscopy found 32 lesions (24 tubular adenomas, 4 tubulovillous adenomas, and 4 sessile serrated polyps) in 17 patients (24%). Radiology demonstrated new abnormalities in 11 (12%) of 91 patients, prompting 7 colonoscopies. In 3 patients, colonoscopy showed an inverted appendix, a tubulovillous adenoma, and a sigmoid stricture. Overall, clinically significant lesions were found in 19 patients (10%). LIMITATIONS: This study was limited by an incomplete colonoscopy subjectively determined at the time of colonoscopy, as well as by a lack of comparison group. CONCLUSIONS: Complete colonic evaluation in patients with an incomplete colonoscopy is important. Repeat colonoscopy may be the most efficient way to achieve this.

Colon cancer screening update and management of the malignant polyp.

Colorectal carcinoma is common, but screening for this cancer has found less acceptance with the public than screening for breast, prostate, and cervical cancer. Available methods include fecal occult blood tests (FOBTs), flexible sigmoidoscopy (FOS), double-contrast barium enema, colonoscopy, computed tomographic colography, and fecal DNA. Evaluation of these options demonstrates that colonoscopy at ages 55 and 65 offers the best combination of reduction in colorectal cancer at the lowest cost. However, when compliance with screening recommendations is very high, costs are high, and the proportion of cancers arising from adenomas is low, the combination of FOS and FOBT is most cost effective. Malignant polyps look friable and irregular and feel hard. Sessile malignant polyps need to be treated by formal resection. Patients with pedunculated polyps with favorable histology (clear margin, well or moderately differentiated, no lymphovascular invasion) can be observed, and those whose polyps show unfavorable histology should have the polyp-bearing segment of colon resected along with its draining lymph nodes.