F r 6 q u e n c e des adOnomes s y n c h r o n e = m 6 t a c h r o n i q u e s c h e z les m a l a d e s op6r6s pour c a n c e r co lo rec ta l

F.P. ROSSINI , A. F E R R A R I , M. S P A N D R E , M. C A V A L L E R O , C. G E M M E , F.M. DE FILIPPIS, S. C O V E R L I Z Z A *

Servizio di Gastroenterologia-Endoscopia Digestiva. �9 Servizio di Anatomia e Istologia Patologica.

Ospedale S. Giovanni, Istituto di Oncologia, V. Cavour 31, Torino (Italia).

Incidence of synchronous-metachronous adenomas in patients operated for colorectal carcinoma

RI~SUME

Les malades op6r6s pour carcinome colorectal sont expos6s au risque soit d'une r6cidive de la tumeur primitive, soit du d6veloppement de 16sions m6tachroniques (ad6nomes et/ou cancers).

Afin de pr6ciser la fr6quence des ad6nomes chez les patients soumis ~ des r6sections coliques pour carcinome et d'autre part, de d6montrer I'utilit6 et I'efficacit6 de la surveillance endoscopique de tels patients, les auteurs rapportent les r6sultats de la surveillance coloscopique d'un groupe de 208 patients op6r6s pour cancer du c61on.

Des ad6nomes ont 6t6 mis en 6vidence dans le c61on restant chez 23,5 % des patients. Aucune relation n'a 6t6 6tablie entre la pr6sence et le type histologique des ad6nomes, la localisation de la tumeur primitive, le type d'op6ration et le stade de la 16sion primitive selon la classification de Dukes. Le taux de diagnostic des ad6nomes et leur diminution chez les patients soumis ~ une surveillance endoscopique r6guli~re, contraste avec la fr6quence relativement 61ev6e que l'on observe chez les patients soumis h une surveillance endoscopique occasionnelle et irr6guli~re.

S U M M A R Y

Patients operated for colorectal carcinoma are at risk o f either a recurrence o f the primary tumour or the development o f metachronous lesions (adenomas and~or cancer).

In order to assess the frequency o f adenomas in patients given intestinal resection for large bowel carcinoma and to ascertain usefulness and efficacy o f endoscopic follow-up o f a group o f 208 patients operated for large bowel cancer.

Adenomas were detected in the residual colon o f 23.5 % of the patients. No correlation was found among presence and histotype o f adenomas, site o f the primary tumour, type o f operation, Dukes' stage. The rate o f diagnosis o f adenomas and their size decrease in patients regularly fol lowed up endoscopically, while in patients who only occasionally and irregularly attend endoscopic follow-up examinations they remain significantly high.

I N T R O D U C T I O N

Les patients soumis a une r6section pour cancer colorectal const i tuent un groupe expos6 au risque de d6veloppement ult6rieur de tumeurs sur le c61on restant. Ces derni6res peuvent se manifester soit sous forme d 'une r6cidive du cancer primitif au niveau de l ' anas tomose ou sous la forme de 16sions m6tachroniques qui peuvent 8tre b6nignes (ad6nomes) ou malignes [3, 13, 14, 15, 17, 21].

En cas de 16sions n6oplasiques associ6es (ad6- nomes ou cancer) h une tumeur pour laquelle un malade subit une intervent ion, il est bien connu qu 'un grand nombre d 'ad6nomes sont diagnosti-

qu6s en phase pr6-op6ratoire [5, 6, 7, 13, 15, 18]. Par ailleurs, il est 6galement bien connu que de telles tumeurs peuvent 6chapper h la raise en 6vidence radiologique ou endoscopique, en raison des difficult6s rencontr6es lors de la mise au point pr6-op6ratoire de ces tumeurs , en particulier s'il y a st6nose.

De telles tumeurs n6oplasiques sont des 16sions synchrones non diagnostiqu6es, ou de v6ritables 16sions m6tachrones, f r6quentes chez de tels pa- tients.

De plus, l 'ad6nome peut par lui-m6me 6tre le pr6curseur du cancer colique et son ex6r6se endoscopique a une valeur pr6ventive [18, 19, 20].

Tir6s ~ part : D r F.P. ROSSINI, Dept. of Gastroenterology - Digestive Endoscopy, Istituto di Oncologia, Ospedale S. Gio- vanni, Via Cavour 31, 10132 Torino (Italia).

Mots-cl~s : cancer colo-rectal, chirurgie, endoscopie, polypes, surveillance.

Key-words : colorectal carcinoma, endoscopy, follow-up, polyps, surgery.

Acta Endoscopica Volume 16 - N ~ 3 - 1986 151

D6s lors, il est 6vident que tous les patients op6r6s pour cancer colorectal doivent 6tre soumis

une surveillance correcte et scrupuleuse.

Selon les auteurs [1, 2, 4, 8, 9, 10, 11, 13, 16, 17, 21], diff6rents intervalles de temps et proto- coles endoscopiques ont 6t6 propos6s ; tous s'ac- cordent sur I ' imp6ratif d 'une surveillance m6thodi- que de ces malades.

La pr6sente 6tude a pour but d'6tablir la fr6- quence des ad6nomes dans un groupe de patients

haut risque et d '6valuer l'efficacit6 diagnostique de la surveillance endoscopique, en particulier dans l ' identification des ad6nomes synchrones et m6tachroniques. Nous avons aussi analys6 les avantages d 'un protocole de surveillance compor- tant un p rogramme d 'examens p6riodiques.

M A TIE, R I E L E T M E T H O D E S

Notre 6tude, ~ la fois r6trospective et prospec- tive, concerne 208 patients soumis h une r6section c61ique pour cancer.

Nous avons exclu de l '6tude les patients soumis une amputat ion abdominop6rin6ale selon Miles

ou h une op6rat ion de Har tman pour cancer rec- tal. Nous avons 6galement exclu les r6sections intestinales pour polypose diffuse e t / ou familiale en raison des diff6rents probl6mes soulev6s par cette pathologie et des protocoles diff6rents dans l 'abord diagnostique et la surveillance.

Notre groupe compor te 110 femmes d 'un ~ge moyen de 56 ans (limites : 29-80) et 98 hommes, d 'un hge moyen de 58 ans (limites : 24-82) (fig. 1).

200.

180.

160.

140.

120.

100.

80.

60.

40.

20.

0

SEXE ET AGE

M = Age moyen 56 ans, limites (24-82)

F = Age moyen 58 ans, limites (29-90)

IIIlIJIJllliJJJ]lllllllllllllllllillllllllllllllllll hornmes femmes

Figure 1

Parmi les 208 patients, 162 (78 %) ont 6t6 sou- mis h une r6section du c61on gauche (h6micolecto- mie, ou r6section segmentaire) , 31 (14,8 %) h une r6section du c61on droit , et 15 (7,2 %) ~t une r6section du c61on transverse pour cancer (fig. 2). Cette s6rie de 208 patients a 6t6 divis6e en 2 groupes.

a9

cL

z

200.

180,

160-

140-

120.

100.

80-

60-

40-

20-

0

TYPE DE Re:SECTION COLIQUE

1 = c61on gauche

2 = c61on transverse

3 = c61on droit

, , , I 1 1 2 3

Figure 2

Le premier groupe de 142 patients a subi une coloscopie totale moins d 'un an apr6s l ' interven- tion. 50 parmi ces patients ont 6t6 investigu6s annuellement pendant 4 ans apr6s I ' intervention. Un autre groupe de 30 patients a 6t6 soumis ~ une surveillance pendant 5 ans et 25 sont encore sou- mis h des investigations annuelles, 8 ans apr6s l 'op6ration.

Le second groupe de 66 patients a 6t6 soumis des explorations endoscopiques irr6guli6res. Ce groupe compor te 20 patients examin6s deux ans apr6s l ' intervention, 12 apr6s 3 ans, 5 apr6s 4 ans, 10 apr6s 5 ans et 25 patients plus de 5 ans apr6s l ' intervention.

T o u s l e s polypes rencontr6s en cours de surveil- lance ont 6t6 r6s6qu6s [18, 19, 20] et l 'examen histologique a 6t6 r6alis6 selon les recommanda- tions de I 'OMS [12].

RE, S UL T A T S

La surveillance endoscopique des 208 patients r6s6qu6s pour cancer coiorectal a r6v616 des ad6- nomes dans 49 cas (23,5 %). Un total de 71 ad6nomes ont 6t6 enlev6s par polypectomie en- doscopique.

L 'examen histologique a montr6 63 ad6nomes tubulaires (88,7 %) (36 avec une dysplasie 16g~re et 27 avec une dysplasie mod6r6e) , 8 ad6nomes tubulovilleux (11,3 %) (7 avec une dysplasie mod6r6e et 1 avec une dysplasie s6v6re) (fig. 3).

Les ad6nomes ont 6t6 diagnostiqu6s chez 38 (23,4 %) des 162 patients soumis h une r6section du c61on gauche. Ceux-ci 6taient porteurs de 59 ad6nomes (52 tubulaires, 29 avec dysplasie 16g6re, 23 avec dysplasie mod6r6e, et 7 polypes tubulovil- leux, 6 avec dysplasie mod6r6e, 1 avec dysplasie s6v~re) ; 45 polypes se t rouvaient en amont de l 'anastomose chirurgicale et 14 en aval. 8 ad6- nomes (7 tubulaires - - 4 avec dysplasie 16g6re - - 3 avec dysplasie mod6r6e et 1 tubulovilleux avec dysplasie mod6r6e) , tous localis6s en aval de l 'anastomose, ont 6t6 observ6s chez 7 (22,5 %)

152 V o l u m e 16 - N " 3 - 1 9 8 6 A c t a E n d o s c o p i c a

des 31 pat ients an t6r ieurement op6r6s de r6section colique droite. 4 ad6nomes , tous tubulaires (3 avec dysplasie 16g6re, 1 avec dysplasie mod6r6e) , tous Iocalis6s en aval de l ' anas tomose , ont 6t6 observ6s chez 4 (26,5 %) des 15 pat ients soumis 3̀ une r6section du c61on transverse.

C L A S S E M E N T H I S T O P A T H O L O G I Q U E DES A D E N O M E S

70

Dans ce groupe , 3 patients pr6sentaient un ad6- nome 3̀ la fois au p remie r contr61e et "3 l 'un des examens de contr61e ult6rieurs.

Dans le second groupe de 66 pat ients soumis 3̀ des examens irr6guliers, un total de 25 ad6nomes ont 6t6 mis en" 6vidence chez 14 pat ients ( 2 1 % ) . Les d imensions des ad6nomes diagnost iqu6s /~ dif- f6rents intervalles de t emps sont illustr6s par la figure 5.

60 laire

Iovi l leux 50

40

30

20

10

0 1 2

1 - - Faible degr~ de dysp las ie

2 - - Dysplasie mode ree

Figure 3

- - Moder6e - - Sev6re

Parmi les 142 pat ients du p remier groupe, examin6s un mois apr6s l ' in tervent ion et ensuite 3̀ intervalles annuels , des ad6nomes ont 6t6 diagnos- tiqu6s chez 35 malades (24,6 %) , totalisant un n o m b r e de 46 ad6nomes . La figure 4 illustre les dimensions des ad6nomes diagnostiqu6s ~ diff6- rents intervalles de t emps s6parant la r6section et l ' in tervent ion initiale.

EXAMEN A N N U E L - TAILLE DES A D E N O M E S

l i . . . . . .

ooo~, 1 8 ~ 4 0 3 0 3 , ,

. . , ~ . . . . . . . ~ . . . . . . . i . . . . . . . i . . . . . . . �9 . . . . . . . �9 . . . . . . . . .

o o o o

TOT. " " ! " 34 ' 6 ' 0 " 3 " 0 ' 3 "

. . ~ 1 7 6 . . . . . . . �9 . . . . . . . i . . . . . . . i . . . . . . . �9 . . . . . . . �9 . . . . . . . . .

i i i i i i

< 1 C M . . .

> 1 C M . - .

ann6es 1 2 3 4 5 > 5

Interval le pos t -ope ra to i re en annees

Figure 4

Si nous consid6rons la f r6quence des ad6nomes en fonction de la surveil lance au cours du temps, nous voyons qu 'un an apr~s l ' in tervent ion, 30 ad6- nomes ont 6t6 trouv6s chez 142 pat ients ( 2 1 % ) . A 2 ans, 4 cas ont 6t6 observ6s sur 50 (8 %) ; ~ 3 ans, aucun sur 50 ; h 4 ans, 2 sur 50 (4 %) ; h 5 ans, aucun sur 3 0 ; 3̀ 6 ans, 1 sur 25 (4 % ) ; et enfin ~ 8 ans, 1 sur 25 (4 %) .

EXAMEN O C C A S l O N N E L - TAILLE DES ADI~NOMES

t . " . ~

< 1 CM . . . . . . 2 3 7 6 . . . . . . . .

> 1 CM . . . . . . 2 1 0 4 . . . . . . .

�9 . . . . ; ; . . . . . . .

i i i

annees 2 3 5 > 5

Interval le pos t -ope ra to i re en annees

Figure 5

Si nous consid6rons l 'analyse s6quentiel le des polypes au cours du temps , h 2 ans d ' in terval le pos t -op6ra to i re , 2 cas ont 6t6 diagnost iqu6s sur 12 pat ients (16 %) . A 3 ans, 3 cas sur 12 (25 % ) ; 4 ans, aucun sur 5 ; h 5 ans, 3 sur 10 (30 % ) ; et ensuite 6 sur 25 (24 %) .

Les diff6rents pourcen tages de f r6quence des ad6nomes mis en 6vidence par les endoscopies successives dans les deux groupes sont confront6s dans la figure 6.

% 30"

FREQUENCE DES A D E N O M E S

20.

10.

1 2 3 4 5 > 5 a n s

Figure 6

A c t a E n d o s c o p i c a V o l u m e 16 - N " 3 - 1 9 8 6 153

DISCUSSION

Les ad6nomes s 'observent avec une fr6quence 61ev6e chez ies malades soumis "~ des examens de surveillance apr6s r6section colique pour cancer.

Les ad6nomes ont 6t6 mis en 6vidence sur le c61on restant c h e z 2 3 , 5 % des 208 patients investi- gu6s dans la pr6sente 6tude.

Ii n 'existe pas de corr61ation entre ia pr6sence de ces ad6nomes et ie type d ' in tervent ion ant6- rieur ni par cons6quent , la Iocalisation de la tumeur primitive. En r6alit6, la surveillance r6v61e des ad6nomes chez 23,4 % des patients soumis une r6section du c61on gauche, 22,5 % dans les cas op6r6s d 'une colectomie droi te , et 26,5 % chez ceux ayant subi une r6section du c61on transverse (fig. 7).

FREQUENCE DES ADI~NOMES EN FONCTION DU TYPE DE RESECTION COLIQUE

% 30

% 20

%10

gauche transverse droit

Figure 7

En outre , il n 'existe pas de relation entre le type histologique des ad6nomes diagnostiqu6s iors de la surveillance endoscopique et la localisation de la tumeur primitive, donc le type d ' intervention r6alis6e, puisque la fr6quence des ad6nomes tubu- laires se r6partit de faqon ident ique chez les malades soumis h une r6section du c61on gauche ( 8 8 , 1 % ) , du c61on droit (87,5 %) et du c61on transverse (100 %).

Par ailleurs, aucune corr61ation n'a 6t6 d6mon- tr6e entre la fr6quence des ad6nomes, le type histologique de la 16sion primitive ou son stade selon la classification de Dukes (dans la mesure oO il 6tait connu) .

Quant ~ savoir si les ad6nomes mis en 6vidence par la surveillance endoscopique des patients op6r6s 6taient des 16sions f ranchement m6tachroni- ques ou des tumeurs synchrones non reconnues lors du diagnostic initial, la r6ponse ne peut 6tre qu 'approximat ive et tout h fait sp6culative.

Au cours des deux premi6res ann6es post-op6ra- toires, la f r6quence des ad6nomes est 61ev6e (16- 2 1 % lors du premier contr61e endoscopique) , que l 'examen de contr61e ait 6t6 effectu6 un an ou deux apr6s la r6section colique (fig. 6).

I! est tr~s vraisemblable que la majori t6 des ad6nomes sont synchrones de la 16sion primitive mais n 'ont pas 6t6 reconnus lors de la mise au point pr6-op6ratoire.

Dans le groupe des patients qui ont subi une surveillance endoscopique annuelle, la fr6quence des ad6nomes diminue avec le temps et semble se situer h 4 % apr6s 4 ans. Lh, il pourrai t s'agir de 16sions m6tachrones, du fait qu'il est peu vraisem- blable que chez chaque malade examin6, des 16sions aient 6chapp6 au d6pistage lors d 'endoscopies r6p6t6es. La taille plus r6duite des ad6nomes diagnostiqu6s apr6s 2 ans (moins d ' l cm de diam6tre) constitue 6galement un argument dans ce sens.

Un point m6rite d '6tre soulign6 : la fr6quence des ad6nomes diagnostiqu6s reste 61ev6e (24- 30 %), m6me apr6s 5 ans, chez les patients soumis irr6guli6rement ou de fa~on occasionnelle h des examens de surveillance endoscopique. Ceci ne nous permet pas d 'aff i rmer que nous sommes en pr6sence de 16sions m6tachroniques ; de plus ces ad6nomes pourra ient tr6s bien 6tre des petites 16sions synchrones qui auraient 6chapp6 au d6pis- tage et n 'auraient 6t6 reconnues qu'h une 6tape ult6rieure. Cet te derni6re hypoth6se est appuy6e par les plus grandes variations de taille des ad6- nomes et l 'existence d 'ad6nomes de diam6tre sup6- rieur h 1 cm apr6s 5 ans. Cet te observat ion con- firme de fa~on indubitable, la valeur et l'efficacit6 diagnostique d 'une surveillance endoscopique r6gu- li6re et programm6e.

D6s lors il est essentiel d 'assurer une prise en charge p6riodique avec examens coloscopiques intervalles r6guliers (annuels, ou au moins t o u s l e s deux ans) chez les patients qui ont subi une r6sec- tion colique pour cancer. Une telle prise en charge nous permet d 'assurer la surveillance de l 'anasto- mose chirurgicale et de reconna~tre une r6cidive de la 16sion primitive.

Elle pe rmet avant tout un diagnostic pr6coce, l 'ex6r~se par polypectomie endoscopique des ad6- nomes de diff6rents types histologiques (syn- chrones ou m6tachrones) f r6quemment observ6s t o u s l e s niveaux du c61on restant. Cette att i tude constitue la seule strat6gie conforme h une pr6ven- tion efficace des cancers m6tachroniques du c61on et du rectum.

154 V o l u m e 16 - N " 3 - 1986 A c t a E n d o s c o p i c a

R~FERENCES

5.

6.

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8 .

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1. B A C O N H . E . , B E R K E L E Y I . L . - - The rationale of resection for recurrent cancer of the colon and rectum. Dis. col. Rectum 2, 1959, 549-554.

2. BARBERANI F., B U Z Z I F., DI COSTANZO F., DELLA SPOLENTINA A., FATALE G., ROSSI P. - - Incidenza di recidive sulla linea anastomotica in pazienti operati per carcinoma del colon-retto. Giorn. Ital. End. Dig., 1983, 6, 233-238.

3. BUSSEY H.J.R. - - Clinical experience at Saint Mark's Hospital with multiple synchronous cancers of the colon and the rectum. Dis. Colon Rectum.

4. COCHRANE J.P.S., WILLIAMS J.P., FABER R.G. , SLACK W.W. - - Value of out patient follow-up after curative surgery for carcinoma of the large bowel. Brit. Med. Jour., 1980, 3, 593-595.

ENTERLINE H . T . - - Management of polypoid lesions. J.A.M.A., 1975, 231, 967-968.

EKELUNG G., PIHL B . - - Multiple carcinomas of the colon and rectum. Cancer, 1974, 33, 1630-1634.

EKELUNG G., LINDSTROM C. - - Histopathological analysis of benign polyps in patients with carcinoma of the colon and rectum. Gut 1974, 15, 654-663.

EKMANN C., GUSTAVSON J., HENNING D. - - Value of a follow-up study of recurrent carcinoma of the colon and rectum. Surg. Ginecol. Ostet., 1977, 45, 859-897.

HEALD R., L O C K H A R T MUMMERY H.E. - - The lesions of the second cancer of the large bowel. Brit. Surg., 1972, 59, 16-19.

HERMANEK P . - - Colorectal polyps and polyposis. Proctology 2, 1979, sept., 8-16.

MORSON B.C., MUTO T., BUSSEY H.J.R. - - The evolution of cancer of the colon and rectum. Cancer, 1975, 36, 2251-2270.

12. MORSON B.C., SOBIN L.H. - - Histological typing of intestinal tumours. W.H.O., Geneva, 1979.

13. MORSON B.C., DAWSON I.N.P. - - Gastrointestinal pathology. Blackwell Scientific Publications Sec. Edit., 1979, 653.

14. NAVA H.R., P A G A N A T.J. - - Postoperative monitoring of colorectal carcinoma. Cancer, 1982, 49, 1043-1047.

15. P A G A N A T.J. - - The use of colonoscopy in the study of synchronous colorectal neoplasms. Cancer, 1984, 53, 356- 359.

16. POLK M.C., SPRATF J.S. - - Recurrent colorectal carci- noma : detection treatment and other considerations. Sur- gery, 1971, 69, 9-23.

17. ROSSINI F.P., F E R R A R I A . - - La coioscopia nella valutazione delle lesioni ad alto rischio del grosso intesti- no. Giorn. di Gastroenterologia ed Endoscopia vol. I n ~ 1 Gen. 1978.

18. ROSSINI F.P., F E R R A R I A . - - La polipectomia endoscopica del grosso intestino. Acta Oncologica, 1980, vol. 1, 51-55.

19. ROSSINI F.P., F E R R A R I A., SPANDRE M., COVER- LIZZA S . - - Coioscopic polypectomy in diagnosis and management of cancerous adenomas : an individual and multicentric experience. Endoscopy, 1982, 14, 124-127.

20. ROSSINI F.P., F E R R A R I A., CAVALLERO M. SPAN- DRE M., SCEVOLA F., G E M M E C. - - Chirurgia en- doscopica del grosso intestino. Arch. e Atti della Soc. ltal. di Chir. 86 m~ Congr. ROMA Ott., 1984.

21. WINAWER S.J., SHERLOCK P. - - Surveillance for colorectal cancer in average-risk patients, familial high risk groups and patients with adenomas. Cancer, 1982, 50, 2609-2614.

I N T R O D U C T I O N

Patients given intestinal resection for ~:olorectal carcinoma are a group at risk of further neoplasias in the large intestine remaining to them. The new outbreak may be either a recurrence of the primary carcinoma occurring at the site o f the anastomosis or the development o f metachronous lesions that may be benign (adenomas) or malignant [3, 13, 14, 15, 17, 21] .

In the" case of neoplasias (adenomas or cancer) coexisting with the tumour for which patients were operated, it is well known that one or more adeno- mas may be diagnosed preoperatively [5, 6 , 7 , 13, 15, 18]. However, it is equally well know that such tumours may escape identification by radiology or endoscopy, given the difficulty of accurately sur- veying the entire large intestine preoperatively in the presence o f a tumour, especially if stenosizing.

Such neoplasias, whether undiagnosed synchro- nous lesions or true metachronous events are fre~ quent in such patients.

Moreover, in most cases, the adenoma is the morphological precursor o f carcinoma of the large intestine, which can be prevented by endoscopic

removal of the adenoma [18, 19, 20] . It is therefore clear that all patients operated for colorectal carci- noma require a correct and scrupulous follow-up.

Though the various authors [1, 2 , 4 , 8 , 9 , 10 , 11, 13, 16, 17, 21] propose a variety of times and protocols for follow-up, all agree that methodical surveillance is absolutely essential for such patients.

The present study aims to assess the frequency o f adenomas in this group o f patients at risk and to ascertain the diagnostic efficacy of endoscopic fol- low-up, in particular for the identification o f syn- chronous or metachronous adenomas. We also con- sider the advantages o f a follow-up protocol inclu- ding programmed periodic examinations.

M A T E R I A L S A N D M E T H O D S

The present study, which is both retrospective and prospective, was conducted on 208 patient given colonic resections for carcinoma of the large intestine.

We excluded patients subjected to Miles' abdomi- noperineal amputation or to the Hartmann opera- tion for rectal carcinoma. We also excluded cases

Acta Endoscopica Volume 16 - N ~ 3 - 1986 155

of intestinal resection for diffuse and~or familial polyposis since these involve such diverse problems and hence a diversity of appropriate diagnostic approaches and follow-up protocols.

Our group included 110 females with an average age of 56 years (range 29-80) and 98 males, ave- rage age 58 (range 24-82) (fig. 1).

The second group of 60 patients attended endoscopic follow-ups on an irregular basis. This group included 20 seen two years after surgery, 12 after 3 years, 5 after 4 years, 10 after 5 years and 25 patients more than 5 years after operation.

All polyps encountered at follow-up were remo- ved [18, 19, 20] and histologically typed according to the WHO recommendations [12].

2oo ]-

180 1- 160 y

140 t

120 T

100 1"

I 60

40

20

0

SEX AND AGE

M = mean age 56 YS. range (24-82)

F = mean age 58 YS. range (29-90)

JIJJIJJJIJJlJJJJlJIIIIIr[tllllllll Illllllllllllllll males females

Figure 1

Of the 208 patients, 162 (78 %) were given resec- tions of the left colon (hemicolectomy, or segmen- tary resection), 31 (14.8 %) resection of the right colon and 15 (7.2 %) resection of the transverse colon for carcinoma (fig. 2). Our 208 patients were divided into 2 groups.

o~

,5 k~

"6 (5

Z

200

180

160,

14o

120

100

80

60

40-

20-

0 ! 1

TYPE OF RESECTION

1 = left-colon (78 %)

2 = transv, colon (7.2 %)

3 = right-colon (14.8 %)

, , ,I , i 2 3

Figure 2

The first group o f 142 cases was examined by total coloscopy no more than 1 year after surgery. Fifty of these patients were then subjected to annual follow-up examinations for 4 years after surgery. A further 30 were subjected to a 5 year follow-up and 25 are still attending annual check-ups, 8 years after their operation.

RESULTS

Endoscopic follow-up o f 208 patients given intes- tinal resections for colorectal cancer revealed ade- nomas in 49 (23.5 %). A total of 71 adenomas were removed by endoscopic polypectomy.

Histological typing revealed 63 tubular adenomas (88. 7 %) (36 with mild and 27 with moderate dys- plasia) and 8 tubulovillous adenomas (11.3 %) (7 with moderate and 1 with severe dysplasia) (fig. 3).

HISTOLOGY OF ADENOMAS

70

60

50

40

30

20

10

0 1 2

1 - - Displasia-low (57.1%) - - mod (42.9)

2 - - Displasia-mod (87.5 %) - - sev (12.5 %)

Figure 3

lar (88.7 %)

Io-villous (11.3 %)

Adenomas were diagnosed in 38 (23.4 %) o f the 162 patients given resections o f the left colon. These included 59 adenomas (52 tubular, 29 with mild, 23 with moderate dysplasia, and 7 tubulovillous - - 6 with moderate, 1 with severe dysplasia) ; 45 polyps were located upstream o f the surgical anastomosis and 14 downstream. Eight adenomas (7 tubular - - 4 with mild, 3 with moderate dysplasia and 1 tubulovillous with moderate displasia) all downs- tream of the anastomosis, were encountered in 7 (22.5 %) of the 31 patients given resection of the right colon. Four adenomas, all tubular (3 with mild, 1 with moderate dysplasia) all downstream o f the anastomosis, were encountered in 4 (26.5 %) of the 15 patients given resection of the transverse colon.

Among the first group o f 142 patients examined one year after operation and at yearly intervals

156 V o l u m e 16 - N ~ 3 - 1 9 8 6 A c t a E n d o s c o p i c a

thereafter, adenomas were diagnosed in 35 (24.6 %) making a total of 46 adenomas. Fig. 4 shows the dimension of the adenomas diagnosed at varying distance from the original operation.

ANNUAL EXAMIN. - SIZE OF ADENOMAS

[ .... i . . . . . . . i . . . . . . . . . . . . . . . . . . . . . :; . . . . . . . . . . . . . . . . .

< 1 CM . . . . . . . . 1 8 4 0 3 0 3 . . .

> 1 C M . . . . . . . . 16 2 0 0 0 0 ..

t . . . . T O T . �9 . . . . ? 3 4 6 0 3 0 3 " ' "

. . i . . . . . . . i . . . . . . . . . .

i i i i i i

Years 1 2 3 4 5 > 5

YEARS AFTER SURGERY

Figure 4

I f we also analyse the polyps found in this group during follow-up on a time basis we find that adenomas were diagnosed at two years distance from the operation in 2 out of 12 patients (16 %). A t 3 years there were 3 cases out o f 12 (25 %) ; at 4 years none out of 5 ; at 5 years 3 out of 10 (30 %) ; thereafter 6 out of 25 (24 %).

The different percentage frequency of adenomas identified in successive endoscopic examinations in both groups is shown graphically in fig. 6.

RATE OF A D E N O M A S

% 30

20

l O .

If we analyse the polyps found during follow-up on a time basis we find that at one year's distance from the operation adenomas were found in 30 out of 142 patients (21%). A t 2 years there were 4 cases out of 50 (8 %) ; at 3 years none out of 50 ; at 4 years 2 out of 50 (4 %) ; at 5 years none out of 30; at 6 years 1 out of 25 (4 % ) ; and at 8 years 1 out of 25 (4 %).

Note that three of the patients in this group presented adenomas both at the first and at one of the subsequent follow-up examinations.

Among the second group of 66 patients who attended follow-ups on an irregular basis, a total of 25 adenomas were identified in 14 (21%). The dimensions of the adenomas diagnosed at various time intervals are shown in fig. 5.

OCCASIONAL EXAMIN - SIZE OF ADENOMAS

t . . . < 1 CM . . . . . . 2 3 7 6 . . . . . . . .

> 1 C M . - . . . . 2 1 0 4 . . . . . . .

TOT . . . . , i 4 i . . . . . . .

i i i

Years 2 3 5 > 5

YEARS AFTER SURGERY

Figure 5

1 2 3 4 5 > 5 years

Figure 6

D I S C U S S I O N

Adenomas were encountered with considerable frequency in the endoscopic follow-up examinations of patients given colonic resections for carcinoma.

Adenomas were diagnosed in the residual colon of 23.5 % of the 208 patients investigated.

There appears to be no correlation between the type of operation and therefore the site of the primary tumour and the presence of such adeno- mas. In fact follow-up revealed adenomas in 23.4 % of the patients given resections of the left colon, in 22.5 % of right colon cases and in 26.5 % of those given resection of the transverse colon (fig. 7).

RATE OF ADENOMAS PER TYPE OF RESECT.

% 30

% 20

% 1 0

left trans, right

Figure 7

Acta Endoscopica Volume 16 - N ~ 3 - 1986 157

Nor is there any apparent connection between the histotype o f the adenomas diagnosed during follow- up and the site o f the primary tumour and hence the type o f operation performed, since the incidence o f tubular adenomas was almost identical in patients given resections of the left (88 .1%) , right (87.5 %) and transverse (100 %) colon.

Similarly no correlation was found between the frequency o f adenomas, their histotype and the Dukes' classification of the primary lesion (where this was known).

When it comes to the question of deciding whe- ther the adenomas identified in the follow-up of patients operated for carcinoma o f the large intes- tine were genuinely metachronous lesions or syn- chronous tumours not identified in the original dia- gnosis, any answer must be speculative and no more than a rough guess. In the first two years after operation the incidence o f adenomas is high (16-21% of the cases at the first endoscopic check- up) whether the initial check-up occured one or two years after the colonic resection (See fig. 6).

It does seem likely that most o f these adenomas are synchronous with the primary tumour but not identified during preoperative diagnostic work-up.

In the group of patients attending annual endoscopic follow-up examinations, the incidence of adenomas decreased over time and seemed to settle at around 4 % after 4 years. These may well be metachronous tumours, partly since it is hardly likely that any individual lesion would escape detec- tion after repeated endoscopies. It is probably also

significant that the adenomas diagnosed after 2 years' fol low-up-were smaller (less than 1 cm in diameter).

One point worth emphasising is the fact that the incidence o f adenomas diagnosed remained high (24 %-30 %) even after 5 years in those patients who only occasionally and irregularly attented endoscopic follow-up examinations. This does not permit us to state that we were dealing with meta- chronous tumours ; moreover these adenomas could equally well be small synchronous lesions that escaped detection and were not identified until a later stage. The latter hypothesis is supported by the greater variation in adenoma dimensions and the presence o f adenomas measuring over 1 cm in diameter after 5 years. What it does indubitably confirm is the value an diagnostic efficacy o f regu- lar programmed endoscopic follow-up.

Periodic monitoring of patients operated for car- cinoma of the large intestine and taking the form of regular colonoscopies at pre-established intervals (yearly, or at most once every 2 years) is therefore essential. Such monitoring not only enables us to study and accurately assess the surgical anastomosis and any local recurrences of the primary tumours. It also and above all provides for the early diagno- sis, removal by endoscopic polypectomy and histo- logical typing o f the adenomas (synchronous or metachronous) that so frequently occur in all parts o f the residual colon. This indeed is the only stra- tegy that provides for effective secondary prevention of metachronous carcinomas of the colon and rectum.

158 Volume 16 - N" 3 - 1986 Acta Endoscopica