Screening, surveillance and endoscopic therapy for colon cancer - - PowerPoint PPT Presentation

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Screening, surveillance and endoscopic therapy for colon cancer - - PowerPoint PPT Presentation

Mar 07, 2023 164 likes •317 views

Screening, surveillance and endoscopic therapy for colon cancer Moderators: Steven Fern, DO & David Cort, MD Panelists Steven H. Itzkowitz, MD David Lieberman, MD Professor of Medicine Professor of Medicine Associate Director, The Dr.

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Screening, surveillance and endoscopic therapy for colon cancer

Moderators: Steven Fern, DO & David Cort, MD

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Panelists

David Lieberman, MD Professor of Medicine Chief, Division of Gastroenterology & Hepatology Oregon Health & Science University Portland, OR Joel V. Brill, MD Chief Medical Officer of Predictive Health, LLC Assistant Clinical Professor of Medicine University of Arizona School of Medicine Phoenix, AZ Steven H. Itzkowitz, MD Professor of Medicine Associate Director, The Dr. Henry D. Janowitz Division of Gastroenterology Mount Sinai School of Medicine New York, NY Douglas K. Rex, MD Professor of Medicine Director of Endoscopy Indiana University Indianapolis, IN

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Case 1

8 mm polyp in the sigmoid colon is removed with biopsy

  • forceps. Biopsy shows adenocarcinoma

AQ 1. Further management should include

1.

Immediately go back and tattoo

2.

Colonoscopy in 3 months

3.

Sigmoid resection

4.

CT scan

5.

EUS for evaluation of the site and possible EMR

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Case 2

3 cm sessile polyp (villous adenoma) in the rectosigmoid

removed piecemeal with saline assisted polypectomy.

Pathology:

multiple areas of high-grade dysplasia and

  • ne small focus of invasive adenoCa invading the lamina propria

AQ 2. Appropriate further management of this patient would be

1.

Repeat colonoscopy in 3 months

2.

Low anterior resection

3.

Transanal endoscopic Microdissection (TEM)

4.

EUS evaluation for residual tumor/regional lymph nodes

5.

CT abdomen and pelvis

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Case 3

3 cm pedunculated polyp in the transverse colon

is removed with snare resection

Pathology: invasive adenocarcinoma not reaching the stalk

AQ 3. Appropriate further management of this patient would be

1.

Observation

2.

Repeat colonoscopy in 3 months

3.

Repeat colonoscopy in 1 year

4.

Surgical resection

5.

CT scan

6.

Tattoo the polypectomy site

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Case 4

A 10 mm sessile polyp is noted in the cecum on a CTC performed after a failed colonoscopy. AQ 4. What to do next?

1.

Attempt colonoscopy by a “better” endoscopist

2.

Review of CTC by a “better” radiologist

3.

Repeat CTC in 3 months

4.

Laparoscopic right colon resection

5.

Repeat CTC in 1 year

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Case 5

65 year old woman with multiple medical problems

but no family history of colon cancer

undergoes screening colonoscopy after split dose colonic prep.

Normal colonoscopy

but has lot of liquid stool that cannot be entirely suctioned off

AQ 5. Appropriate further management of this patient would be

1.

Repeat colonoscopy in 1-2 weeks

2.

Repeat colonoscopy in 6 months

3.

Repeat colonoscopy in 5 years

4.

Repeat colonoscopy in 10 years

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Case 6

 A 61 year old woman consults you about colon cancer screening.  She avoided getting her screening colonoscopy at age 50

 colonoscopy 20 years ago for LLQ pain (by another gastroenterologist)

 Difficult and painful colonoscopy due to sigmoid diverticulosis and adhesions

from prior GYN surgery.

 She is not sure whether he reached the cecum,  She thinks that he removed a "polyp".

 A repeat colonoscopy 5 years later

 again very difficult and associated with a fair amount of pain.  She does not recall if any polyps were removed.

 She hates taking "that awful gallon of yucky liquid".

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Case 6 (contd.)

Her grandmother had CRC at age 82,

 but no other family history.

She has put off any screening,

 but after the recent death of her closest friend to CRC, she became concerned.

She has no GI symptoms.

AQ 6. Which of the following would you advise?

  • A. Colonoscopy with an easier prep and better sedation
  • B. CT colonography
  • C. Fecal immunochemical test
  • D. Stool DNA test
  • E. Flexible sigmoidoscopy plus FOBT
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Question to Panel

 What are the issues with nurse administered

propafol sedation for colonoscopy

 Do you foresee a significant future role for this

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Question to Panel

 What is the added cancer risk due to radiation

exposure with CTC

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Question to Panel

 What is the CTC positivity rate in real world situations  Conflict of interest in over-interpreting CT findings–

 Since radiologist are penalized for missing “lesions” but not

for over-diagnosing

 How about the liability for missed extra-colonic lesions

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Question to panel

 In clinical practice, what is the most appropriate

way to use the commercially available molecular markers?

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Goals and achievements of colon cancer screening program

Potential benefits

Prevention of colon cancer

Reduction of colon cancer incidence noted in last 10 years

Early diagnosis of colon cancer

Stage migration noted in last 10 years

Potential costs

Economic cost

Colonoscopy cost

use of anesthesia

follow up colonoscopies for benign polyps

Use of newer improved technology endoscopes and devices

Pathology cost

Biopsying more and more polyps

Use of special stains

Cost of newer markers

Cost of lost work

Cost of managing complications

Patient suffering

Preparing for colonoscopy

due to complications

Anxiety in those found to have benign polyps

Question to Panel

  • Is there a risk that the recent advances and developments in colon cancer

screening will increase the costs to the point of making it cost-prohibitive?

  • Is there anything that can be done or is being done to prevent that situation?