Colorectal Cancer: Colonoscopy and Follow Up

Abstract

Pelvic recurrence is a significant concern following curative resection for rectal cancer, regardless of the tumor’s origin of the rectum. In this retrospective observational study, 219 patients were analyzed, with 213 undergoing surgical treatment for rectal cancer at three surgical centers between 2014 and 2019. Surgical procedures included anterior resection with Hartmann’s procedure (39 patients), anterior resection of rectosigmoid with colorectal anastomosis (130 cases), and abdominoperineal resection (44 cases). After a 2-year follow-up, pelvic recurrence occurred in 19 patients, constituting approximately 8.9% of cases. The recurrence rates varied among surgical procedures, with a 15.38% recurrence rate after the Hartmann procedure, 9% after abdominoperineal resection, and 7% after anterior resection of rectosigmoid with colorectal anastomosis. Emphasize the high recurrence rates associated with advanced stages of rectal cancer. Notably, its follow-up was done clinically, by laboratory tests, colonoscopy (the main test for pelvic recurrence) after 6 months of surgery, 12 months, and 2 years, computed tomography (CT), magnetic resonance imaging (MRI), and pelvic ultrasound at one year and 2 years, a lower recurrence rate being indicative of a successful curative surgical treatment. The Hartmann procedure, often performed as an emergency operation for locally advanced lesions, exhibited the highest recurrence rate.

1. Introduction

A colonoscopy is a medical procedure used to examine the inside of the colon and rectum. It is an essential tool for diagnosing and monitoring various gastrointestinal conditions, including colorectal cancer, inflammatory bowel disease, and polyps.

Space of endoscopy rooms: reception and waiting room, room procedure, (Figure 1), recovery room, postprocedural and consultation room, and the last training room for students and residents. Equipment: endoscope tower – endoscope, monitor, insufflation, light source, and other instruments that are necessary for procedures, storage instruments, accessories, and consumables. The control of infection is carried out by cleaning and sterilization room.

Figure 1.

Colonoscopy position.

Here’s a brief overview of the colonoscopy procedure:

1.1 Preparation

Before the colonoscopy, patients are instructed to follow a specific diet and bowel preparation regimen. This often involves following a clear liquid diet and taking a laxative or bowel-cleansing solution to empty the colon.

1.2 Arrival at the medical facility

Patients typically arrive at a hospital or an outpatient clinic for the procedure. They will be asked to change into a hospital gown.

Consent form and Medical History. You will be asked to sign a consent form, and a nurse or healthcare provider will review medical history, including any allergies, medications you’re currently taking, and any pre-existing medical conditions.

Sedation and monitoring: Most colonoscopies are performed with sedation or anesthesia to ensure the patient’s comfort and minimize discomfort. The patient is closely monitored throughout the procedure, including vital signs like blood pressure, heart rate, and oxygen levels.

Positioning: The patient will be positioned on your left side on an examination table. of the colonoscope: A long, flexible tube colonoscope is inserted through the anus and advanced slowly into the colon until cecum and ileocecal valve. The colonoscope has a light and a camera at the tip, allowing the doctor to view the inner lining of the colon on a monitor.

Examination of the colon: As the colonoscope is advanced, the examiner views the entire length of the colon, looking for abnormalities, such as polyps, inflammation, diverticula, or tumors. Biopsy or polyps removal (if necessary): During the colonoscopy, the endoscopist may take tissue samples (biopsies) if suspicious areas are found. Additionally, small polyps can often be removed during the procedure to prevent them from becoming cancerous [1].

Documentation: After a thorough examination, the colonoscope is slowly withdrawn, and the endoscopist carefully documents any findings. This documentation may include photographs or video recordings.

Recovery: After the colonoscopy, patients are taken to a recovery area where they can rest and recover from the sedation. It’s essential to have a friend or family member available to drive the patient home because the sedation can temporarily impair judgment and coordination. Post-procedure discussion: Once the patient is fully awake and alert, the endoscopist and nurse will discuss the findings of the colonoscopy with the patient. If biopsies were taken, results may not be available immediately and could take a few days.

Follow-up and recommendations: Depending on the results of the colonoscopy, the doctor may recommend further tests or treatments. Patients may also receive guidance on lifestyle changes, such as dietary adjustments or regular screenings.

2. Types of screening tests

Stool tests: Guaiac-based fecal occult blood test (gFOBT): This test uses the chemical guaiac to detect blood in stool. At home, you could use a stick or brush to obtain a small amount of stool. You then return the test sample to the healthcare provider or a laboratory, where stool samples are checked for blood. Fecal immunochemical test (FIT): This test uses antibodies to detect blood in the stool. You receive a test kit from your healthcare provider. This test is done the same way as gFOBT. FIT-DNA test: (or stool DNA test) This test combines the FIT with a test to detect altered DNA in stool [2]. You collect a test sample to check for an entire bowel movement and send it to a laboratory to be tested for cancer cells.

Flexible sigmoidoscopy (Flex Sig): The healthcare provider puts a short, thin, flexible, lighted tube into your rectum and checks for polyps or cancer inside the rectum and lower third of the colon.

Colonoscopy: Similar to flexible sigmoidoscopy, except the healthcare provider uses a longer, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon. During the test, the healthcare provider can find and remove most polyps and some cancers. Colonoscopy may also be used as a follow-up test if one of the other screening tests finds anything unusual.

CT colonography (virtual colonoscopy): Computed tomography (CT) colonography, also called a virtual colonoscopy, uses X-rays and computers to produce images of the entire colon. The images are displayed on a computer screen for the healthcare provider to analyze.

DNA stool tests, such as Cologuard, detect specific DNA changes associated with colorectal cancer.

Colorectal cancer follow-up colonoscopy: Follow-up colonoscopies are an essential part of monitoring individuals who have previously been diagnosed with colorectal cancer or who have had precancerous polyps removed during a colonoscopy. The specific recommendations for follow-up colonoscopies can vary based on the individual’s medical history, the stage of cancer, and the presence of any risk factors [3].

However, here is a general guideline for follow-up colonoscopies after a colorectal cancer diagnosis:

Posttreatment evaluation: After the initial diagnosis and treatment of colorectal cancer, your healthcare provider will typically recommend a follow-up evaluation to assess the effectiveness of the treatment and to check for any signs of cancer recurrence.

3. Importance of early detection

Improved survival rates: When colorectal cancer is detected at an early stage, the chances of successful treatment and long-term survival are significantly higher. In fact, for localized colorectal cancer (cancer that hasn’t spread beyond the colon or rectum), the 5-year survival rate can exceed 90%. Early detection allows for timely intervention and more effective treatment options. Minimized treatment intensity: Early stage colorectal cancer often requires less aggressive treatment than advanced-stage cancer. Surgery alone may be curative in many cases, sparing patients from the need for extensive chemotherapy or radiation therapy. Early detection can prevent the cancer from progressing to a more advanced stage, which may involve more invasive treatments and potentially debilitating symptoms, and this helps in maintaining a better quality of life for patients [4]. Treating colorectal cancer at an early stage is generally less costly than treating advanced-stage cancer. This can lead to cost savings for patients and healthcare systems.

Prevention of metastasis: Colorectal cancer that is caught early is less likely to metastasize to other organs or lymph nodes. Early detection often allows for the preservation of more of the colon or rectum during surgery, minimizing the need for extensive surgical procedures, such as colostomy or ileostomy [5]. Colorectal cancer often starts as benign growths—polyps. During a colonoscopy, these polyps can be identified and removed, effectively preventing cancer from developing.

The identification of hereditary conditions, such as Lynch syndrome or familial adenomatous polyposis (FAP), which increase the risk of colorectal cancer is important. Identifying these conditions in one family member can lead to early screening and preventive measures for other family members. Screening can detect cancer in its earliest stages or identify precancerous lesions, reducing the overall burden of the disease. Early detection allows for long-term surveillance and monitoring of individuals at higher risk for colorectal cancer. This ensures that any new polyps or cancerous growths are detected promptly.

Initial follow-up colonoscopy: The first follow-up colonoscopy is usually scheduled within the first year after the completion of your initial treatment. The timing may vary depending on the stage and aggressiveness of the cancer (Figures 2 and 3).

Figure 2.

Recovery room.

Figure 3.

Room procedure.

Frequency of follow-up colonoscopies: The frequency of follow-up colonoscopies after the initial posttreatment evaluation will depend on several factors, including the stage of cancer, the completeness of initial treatment, and individual risk factors. Common recommendations are as follows: High-risk situations (e.g., advanced cancer, positive lymph nodes, or incomplete resection): Colonoscopy every 3–6 months for the first 2–3 years. Intermediate-risk situations: Colonoscopy every 6–12 months for the first 2–3 years. Low-risk situations: Colonoscopy every 1–3 years after the initial follow-up.

Long-term surveillance:

After several years of regular follow-up colonoscopies with no signs of cancer recurrence, the interval between colonoscopies may be extended, typically to every 3–5 years. However, the specific schedule should be determined by your healthcare provider based on your individual case.

4. Lifelong surveillance

In some cases, individuals with a history of colorectal cancer may require lifelong surveillance to monitor for cancer recurrence or the development of new polyps.

Additional testing: In addition to colonoscopy, other tests may be recommended as part of your follow-up, such as blood tests to monitor tumor markers, CT scans, or other imaging studies to check for metastasis (spread of cancer), and regular physical examinations [6].

Adherence to recommendations: It’s crucial to adhere to your healthcare provider’s recommended follow-up schedule and undergo any additional testing as advised. Regular follow-up is essential for early detection of any cancer recurrence or new polyps, as early intervention can lead to better outcomes.

Lifestyle and health maintenance: In addition to medical follow-up, maintaining a healthy lifestyle, including a balanced diet, regular exercise, and avoidance of tobacco and excessive alcohol consumption, can help reduce the risk of cancer recurrence and other health problems. Follow-up for rectal cancer typically involves a combination of medical evaluations, imaging studies, and endoscopic procedures to monitor for cancer recurrence and assess the effectiveness of treatment. The specific follow-up plan may vary depending on the stage of cancer, the type of treatment received, and individual patient factors [7].

Here’s a general guideline for follow-up after rectal cancer treatment, including endoscopic procedures:

Initial posttreatment evaluation: After completing treatment for rectal cancer, you will undergo an initial evaluation to assess the response to treatment and ensure there is no immediate evidence of cancer recurrence.

This evaluation may include physical examinations, blood tests, and imaging studies such as CT scans.

Endoscopic follow-up procedures: Endoscopic procedures like sigmoidoscopy or colonoscopy are essential for monitoring the rectal area and the rest of the colon for any signs of cancer recurrence or new polyps. The frequency and timing of these procedures depend on various factors, including the stage of the initial cancer, the type of treatment received, and individual risk factors [8]. In some cases, the first follow-up endoscopy may be scheduled within a few months after completing treatment. Subsequent endoscopies may then be performed at regular intervals. The specific schedule should be determined by your healthcare provider based on your individual case (Figure 4).

Figure 4.

Local recurrence at enterocolic anastomosis end-side.

In addition to endoscopy, imaging studies such as CT scans may be recommended periodically to check for any signs of cancer recurrence or metastasis to nearby lymph nodes or distant organs. Tumor marker testing: Blood tests to monitor tumor markers (e.g., CEA—carcinoembryonic antigen) may be part of your follow-up plan. Elevated levels of these markers can sometimes indicate cancer recurrence. Stool testing: Periodic stool testing for blood or other markers may be recommended to check for any signs of rectal cancer recurrence or new growths. Long-term surveillance: The frequency of follow-up examinations and tests may decrease over time if there are no signs of cancer recurrence. After several years of surveillance with no issues, follow-up intervals may be extended [9]. Adherence to recommendations: It’s crucial to adhere to your healthcare provider’s recommended follow-up schedule and undergo any necessary tests and procedures. Regular follow-up is essential for early detection of any cancer recurrence or new growths. Lifestyle and health maintenance: Maintaining a healthy lifestyle, including a balanced diet, regular exercise, and avoiding tobacco and excessive alcohol consumption, can help reduce the risk of cancer recurrence and improve overall health.

5. Colonoscopy in colorectal cancer diagnosis

The colonoscope is inserted via anus to rectum and advanced through all of the colon until the cecum, and terminal ileum. The colonoscope inspects the entire mucosa of any lesions—tumors, polyps, ulcerations, or diverticula. Suspicion of any lesion observed may take the specimen for histopathology analyses, which is an important step to confirm the diagnosis. Assess the size, type, and location of the lesions from the anal orifice and this is an important information for the treatment.

The diagnosis of neoplasm after colorectal treatment as local recurrence and new polyps or tumors is used by colonoscopy follow-up for surveillance and monitoring. The screening for tumors and other lesions like inflammatory bowel disease, diverticulosis and diverticulitis, and bleeding is carried out [10].

Staging of colorectal cancer by endoscopy, CT scan, and MRI: The staging of colorectal cancer follows TNM conform to American Joint committee on Cancer (AJCC): (T) tumor size and extent of the primary tumor, (N) lymph nodes that contain malignant cells, and (M) metastasis to distant organs or tissues. The overview of stages of colorectal cancer is given as follows:

Stage 0: (Tis, N0, M0): carcinoma in situ. Cancer is confined to the innermost layer of the colon or rectum and has not invaded deeper layers. It has not spread to lymph nodes or distant sites.

Stage I (T1-T2, N0, M0): Cancer has grown through the mucosa and into the submucosa (T1) or muscularis propria (T2) of the colon or rectum. It has not spread to lymph nodes or distant sites.

Stage II Stage IIA (T3, N0, M0): Cancer has penetrated the submucosa and has grown into the muscularis propria (T3) of the colon or rectum. It has not spread to lymph nodes or distant sites. Stage IIB (T4a, N0, M0): Cancer has invaded through the serosa (the outermost layer) of the colon or rectum (T4a). It has not spread to lymph nodes or distant sites. Stage IIC (T4b, N0, M0): Cancer has invaded nearby structures or organs (T4b). It has not spread to lymph nodes or distant sites.

Stage III (Any T, N1/N2, M0): Cancer has invaded lymph nodes (N1/N2) but has not spread to distant sites. This stage is further subdivided into IIIA, IIIB, and IIIC based on the extent of lymph node involvement.

Stage IV (Any T, Any N, M1): Cancer has spread to distant organs or tissues, such as the liver, lungs, and peritoneum. This stage is considered advanced or metastatic colorectal cancer [11].

6. Treatment options for colorectal cancer

Surgery:

Surgical treatment is the most important treatment for colorectal cancer for stage 0 to stage III by endoscopic, laparoscopic, or open approach.

Polypectomy: Removal of small, benign polyps and tumors involved just mucosa during a colonoscopy. Local excision: Removal of small, early stage cancers without affecting a significant portion of the colon or rectum.

Segmental colectomy: Removal of the portion of the colon with lymphadenectomy in V shape the tip of V is to mesentery. The remaining healthy sections are anastomosed.

Right or left hemicolectomy with lymphadenectomy and anastomosis with or without protection.

Anterior resection with primary anastomosis, anterior resection with Hartmann procedure, with end left-sided colostomy.

Abdominoperineal resection with end colostomy for rectal cancer low situation below 4 cm from the anal orifice.

Total colectomy: Removal of the entire colon with enterorectal or anal anastomosis with ileostomy protection of synchronous multiple tumors in the rectum and colon [12].

Surgery may also be used to remove metastatic lesions in other organs, such as the liver (atypical lobectomy) or lungs.

Chemotherapy:

Chemotherapy involves the use of drugs to destroy malignant cells or inhibit their growth and division. Neoadjuvant treatment can be used before surgery, adjuvant after surgery, or as the primary treatment for advanced colorectal cancer (Stage III or IV).

Combination chemotherapy regimens are often used, including drugs like 5-fluorouracil (5-FU), capecitabine, oxaliplatin, and irinotecan [13].

Targeted therapies, such as cetuximab and bevacizumab, may be added to chemotherapy for specific cases.

Radiation therapy:

Radiation therapy uses high-energy X-rays and it may be used in combination with chemotherapy (chemoradiation) to shrink tumors before surgery to treat rectal cancer.

Radiation therapy can also relieve symptoms in advanced cases by shrinking tumors that are causing obstruction or bleeding.

Targeted therapy: Targeted therapies are drugs that specifically target certain molecules or pathways involved in cancer growth. These therapies may be used in combination with chemotherapy for advanced colorectal cancer. Examples include cetuximab, panitumumab, and regorafenib.

Immunotherapy: Immunotherapy, given with drugs such as pembrolizumab or nivolumab, is used in some advanced colorectal cancers with specific biomarkers (e.g., microsatellite instability-high or mismatch repair deficiency). Immunotherapy helps the immune system recognize and attack malignant cells [14].

Palliative care: Palliative care focuses on providing relief from symptoms and improving the quality of life for patients with advanced or metastatic colorectal cancer. It includes pain management, symptom control, and emotional support [15].

6.1 Follow-up colonoscopy

The first follow-up colonoscopy is usually scheduled within the first year after the completion of your initial treatment. The timing may vary depending on the stage and aggressiveness of the cancer.

Common recommendations are as follows: High-risk situations (e.g., advanced cancer, positive lymph nodes, or incomplete resection): Colonoscopy every 3–6 months for the first 2–3 years. Intermediate risk: Colonoscopy every 6–12 months for the first 2–3 years. Low risk: Colonoscopy every 1–3 years after the initial follow-up.

7. Advances in colonoscopy technology

High-definition (HD) and high-resolution imaging: Modern colonoscopes are equipped with high-definition and high-resolution imaging systems. These systems provide clearer and more detailed images of the colon’s lining, making it easier to detect abnormalities, such as polyps or early stage cancers.

Narrow-band imaging (NBI): NBI is an optical enhancement technology that uses narrow-bandwidth light to enhance the visualization of blood vessels and mucosal patterns in the colon. This can help differentiate between benign and potentially malignant lesions.

Chromoendoscopy: Chromoendoscopy involves spraying a special dye or contrast agent onto the colon’s lining to highlight abnormalities. This technique can improve the detection of small or flat polyps and early stage cancers.

Cap-assisted colonoscopy: A soft, flexible cap can be attached to the tip of the colonoscope to help improve the view of the colon’s inner lining. This can be especially helpful in navigating through difficult or tortuous sections of the colon.

Third-eye retroscope: This additional, miniaturized camera at the tip of the colonoscope provides a backward view, enhancing the ability to detect lesions hidden behind folds in the colon.

Wide-angle colonoscopes: Some colonoscopes have a wider field of view, which can help healthcare providers see more of the colon’s surface in a single view, reducing the need for excessive maneuvering.

Disposable colonoscopes: Disposable colonoscopes are emerging as an option for reducing the risk of cross-contamination of infection in healthcare settings.

Improved bowel preparation: Innovations in bowel preparation solutions and techniques are making the cleansing process more patient-friendly and effective, ensuring a clearer view during the procedure.

Patient comfort enhancements: Advances in colonoscopy equipment and techniques aim to improve patient comfort. Smaller-diameter scopes, more flexible instruments, and improved sedation options can lead to a more comfortable experience.

Wireless capsule colonoscopy: While not a replacement for traditional colonoscopy, wireless capsule endoscopy allows for the visualization of the colon using a small, ingestible camera capsule. This technology is still evolving and primarily used in specific clinical situations [16].

8. Future directions and research

Personalized medicine and precision oncology: Research is exploring ways to tailor colorectal cancer treatment to the individual patient’s specific genetic and molecular profile. Identifying specific mutations and biomarkers in tumors can help determine the most effective targeted therapies and immunotherapies.

Immunotherapy advances: Immunotherapy advances have shown promise in treating some colorectal cancers, particularly those with specific genetic features like microsatellite instability-high or mismatch repair deficiency. Future research aims to expand the use of immunotherapy and identify additional patient subgroups that may benefit.

Early detection and screening: Ongoing research is focused on developing more accurate and less invasive methods for early detection of colorectal cancer and precancerous lesions. This includes blood-based biomarkers, liquid biopsies, and advanced imaging techniques [17, 18].

Artificial intelligence (AI) and machine learning: AI and machine learning algorithms are being developed to assist in the early detection and characterization of colorectal cancer lesions from medical imaging, such as colonoscopy and CT scans.

Minimally invasive surgery: Advances in surgical techniques, including robotics and laparoscopy, are aimed at reducing the invasiveness of colorectal cancer surgery, shortening recovery times, and improving outcomes.

Biomarker discovery: Research continues to identify new biomarkers in blood, tissue, and stool samples that can aid in early diagnosis, prognosis, and treatment selection.

Genetic counseling and testing: Research into genetic risk factors and hereditary syndromes is ongoing. Identifying at-risk individuals and providing appropriate genetic counseling and testing can help with early intervention and risk reduction.

Targeted therapies: Investigational targeted therapies are being developed to target specific signaling pathways involved in colorectal cancer growth. Research is ongoing to identify novel therapeutic targets.

Chemotherapy and radiation advances: Studies are exploring new combinations of chemotherapy drugs, radiation therapy techniques, and treatment schedules to improve the effectiveness of these treatments while minimizing side effects.

Prevention strategies: Research into lifestyle modifications, dietary interventions, and chemoprevention agents aims to identify strategies for reducing the risk of colorectal cancer.

Health disparities: Efforts are being made to address health disparities in colorectal cancer outcomes, including disparities related to race, ethnicity, socioeconomic status, and geographic location.

Survivorship and quality of life: Research is focusing on improving the long-term quality of life for colorectal cancer survivors through survivorship care plans, psychosocial support, and interventions to manage treatment-related side effects.

Clinical trials: Participation in clinical trials is essential for advancing colorectal cancer research and testing new treatments. Ongoing efforts aim to increase awareness of and access to clinical trials.

Patient-centered care: Future research will continue to emphasize patient-centered care, including shared decision-making, supportive care, and addressing the physical and emotional needs of patients and their families.

My retrospective observational study for 5 years between 2014 and 2019 about pelvic recurrence after surgical treatment of rectal cancer is as follows: 219 patients from three surgical centers in Romania, among which 213 of them were treated surgically in three surgical centers in Romania and three of them underwent procedures for treatment of rectal cancer: 39 patients—anterior resection with Hartmann’s procedure, 130 patients—anterior resection of rectosigmoid with colorectal anastomosis, and 44 patients—abdominoperineal resection, follow-up for 2 years and pelvic recurrence reported in 19 patients, of whom two patients were shown to have anastomosis recurrence and the highest recurrence rate was reported after Hartmann’s procedure. Patients underwent postoperative follow-up for at least 2 years (at 1 month, 3 months, 6 months, 1 year, and 2 years), consisting of anamnesis,;clinical examination; abdominal and pelvic ultrasound; chest radiography; colonoscopy, ultrasound (U/S), CT scan, and MRI (Table 1).

Surgical procedure	No. of patients	% of patients
Abdominoperineal resection	44	20.65%
Rectosigmoidian resection with ileostomy	34	15.96%
Rectosigmoidian resection without ileostomy	96	45.07%
Hartmann procedure	39	18.30%

Table 1.

Surgical procedure and number of patient.