EuropeanJournalof Surgical Oncology 1997; 23:522-525 Surveillance after colorectal cancer surgery Luigi De Salvo, Francesco Razzetta, Alberto Arezzo, Umberto Tassone, Giuseppe Bogliolo*, Deborah Bruzzone and Francescopaolo Mattioli Department of Surgery, and *Department of Internal Medicine, University of Genova, Genot,a, Italy Early diagnosis of local and distant recurrences of colorectal cancer remains difficult and there is no agreement on the effectiveness of follow-up in these patients. The aim of this study is to assess the value of our method of follow-up. We consider.239 patients with coiorectal cancer and at least 2 years follow-up following radical resection. A local recurrence appeared in 26 patients (10.9%), a distant metastasis in 41 (17.1%), while in seven (2.9%) local and distant recurrences appeared simultaneously. Local recurrence was detected because of an increase in carcinoembryonic antigen (CEA) level in' 15 patients (57.7%), during a scheduled endoscopy in four (15.4%) and because of symptoms in seven (26.9%). in seven patients (26.9%) a radical resection was possible. Distant metastases were detected by CEA levels in 20 patients (48.8%), by ultrasonography (U.S.) in 12 (29.3%) and by chest X-ray in five (12.2%). In 13 of 26 patients with liver metastases a resection was performed. This study shows that few patients benefit from follow-up and only CEA levels and liver U.S. performed intensively between 15 and 36 months after surgery are useful in early detection of recurrences. A modification of the follow-up to the single patient, according to the stage, location and grading of cancer, could improve the results, so lowering the costs of this expensive practice. Key words: colorectal cancer; cancer recurrence; post-operative follow-up. Introduction Mortality from colorectal cancer has not decreased in recent years, t 3due to the poor effectiveness of both early diagnosis and adjuvant therapies. Local or distant recurrences of the disease appear in 40-50% of patients following surgical therapy. Many tests have been considered as effective indicators of recurrence,4-7but there is no agreement on their value and the schema in which they should be performed. Recently, the survey by members of the American Society of Colon and Rectal Surgeons reflected general uncertainty and recommended prospective trials to evaluate intensive vs non-intensive follow-up strategies. 4 The aim of this study is to assess the value of our follow-up schedule, the usefulness of the single tests in detecting local or remote recurrence and to screen groups of patients at high risk of recurrence. Materials and methods From June 1986 to September 1995, 374 patients were operated on for colorectal cancer. Among them 257 patients underwent a radical resection, 18 patients (7.5%) were lost to the follow-up, while 239 had a complete follow-up of at least 2 years, and so were considered suitable for this study. Correspondence to: Prof 'Luigi De Salvo, Istituto di Clinica Chirurgica, Universir~ di Genova, V.le Benedetto XV, 8, 16132 Genova, Italy. 0748-7983/97/060522 + 04 $12.00/0 The mean age of these patients was 65 years (range: 35-94) and male:female ratio was 133:106. The operative mortality among patients undergoing radical surgery, amounted to five cases (3.5%). Table I reports the staging of tumours in this group of patients according to UICC classification. The follow-up schedule consisted of clinical and instrumental checks every 3 months during the first year, every 6 months until the fifth year and once a year thereafter (Table 2). Biochemical parameters considered were erythrocyte sedimentation rate, carcinoembryonic antigen (CEA levels), liver function tests, fecal occult blood and blood count. The imaging consisted of liver ultrasonography (U.S.), chest X- ray, endoscopy and/or barium enema of the residual colon. CT or NMR scans were reserved for patients with other symptoms or signs of possible relapse. PET studies could not be performed because they are not available in our town. The patients with stages lI (T4) and Ill disease underwent adjuvant chemotherapy with 5-FU and levamisole within 1 month of surgery. No patient underwent pre-operative radiotherapy, and only patients with advanced rectal cancer underwent radiotherapy after surgery. Statistical analysis was carried out using the Student's t-test for ordinal parameters, and the chi-squared test was used for proportions. Results I The disease recurred in 74 of the 239 patients (31%). Recurrence appeared as local relapse in 26 patients (10.9% © 1997W.B.SaundersCompanyLimited