Prospective monitoring trial for carcinoma of colon and rectum after surgical resection.

In 1978, a prospective program was initiated to evaluate postoperative monitoring of patients after resection of carcinoma of the colon and rectum. The program included clinical examination, interval endoscopy, measurement of carcinoembryonic antigen (CEA), selected liver function tests (alkaline phosphatase and gamma glutamyl transferase) and roentgenologic testing: roentgenograms of the chest, barium enema, intravenous pyelogram (IVP) and computerized axial tomographic (CAT) scan. Of the initial 226 patients enrolled, 179 had at least one abnormal elevation of the CEA level, and in 70 (39 per cent), recurrence developed. Of the 70 with recurrence, 62 (89 per cent) had elevated CEA levels (greater than 3.0 nanograms per milliliter) prior to detection of recurrence by other means. Eight patients had normal levels (two were false-negative and the other six were tested at inappropriate times). Although other test results often complemented CEA, they were generally less sensitive for early detection. Selective use of these tests frequently documented site and extent of recurrence. The detection sensitivity of these other tests was highest with CAT scan (83 per cent), followed by barium enema and endoscopy (56 and 46 per cent). Forty-five patients underwent re-exploration. Recurrence was found in 42, of whom 23 had resectable disease (five of 11, liver; 17 of 24, local or pelvis, and one of one, lung). In three patients, nothing abnormal was found at exploration; two of these patients ultimately had metastases develop. The median survival time was 43 months and the estimated five year survival rate was 38 per cent. CEA is the best over-all indicator of early recurrence and frequent testing at short intervals is most important. Periodic clinical examination and selected other studies are also essential for early documentation of recurrence. Second-look surgical procedures appear beneficial for survival time in selected patients.