Evaluation of a pre-operative staging protocol in the management of colorectal carcinoma

The optimum strategy for pre-operative staging of colorectal carcinoma (CRC) has yet to be defined. A protocol for staging CRC patients was set up in this hospital in 1998. The protocol included complete colonic visualization together with assessment of the liver and lung for potential metastatic disease. Pelvic imaging was required to assess the local spread of rectal tumours. Our aim was to evaluate prospectively this protocol.

Data from all patients diagnosed with primary CRC between January 1999 and December 2002 were prospectively collected and analysed.

There were 295 patients; 56 (19%) patients presented as an emergency and were excluded. The study group consisted of 239 patients (206 had elective surgery and 33 had no resectional surgery). In the patients who presented electively; 88% had complete colonic imaging; 87% chest imaging; 90% had liver imaging; 91% of rectal tumours had pelvic imaging. Overall 75% of the elective patients completed the staging protocol. Reasons for incomplete staging were numerous and most were justifiable. Findings which influenced clinical management included alteration in surgical approach (14), lung metastases (7), primary lung cancers (2), definite liver metastases (25), possible liver metastases (8), neo-adjuvant radiotherapy required (27), advanced local disease (9) and other incidental findings (12).

Our protocol influenced further management decisions in 39% of patients. Better stratification of patient care is possible, with the ultimate aim to avoid unnecessary surgery. However, complete staging is not always possible to perform.