What is the recommended follow-up plan for a patient with a T3N0M0 classification post sigmoidectomy?

Follow-up Plan Post Sigmoidectomy for T3N0M0 Sigmoid Colon Cancer

For a patient with T3N0M0 sigmoid colon cancer after curative sigmoidectomy, implement intensive surveillance with clinical examination and CEA every 3-6 months for 3 years then every 6-12 months through year 5, CT chest/abdomen/pelvis every 6-12 months for 3 years, and colonoscopy at 1 year then every 3-5 years. 1

Surveillance Schedule: Years 0-3 (Intensive Phase)

Clinical Assessment

• History and physical examination every 3-6 months to detect symptomatic recurrences early 1
• Focus on new abdominal pain, change in bowel habits, weight loss, or symptoms suggesting metastatic disease 2

Laboratory Monitoring

• CEA measurement every 3-6 months if it was elevated preoperatively 1
• CEA elevation may precede clinical or radiographic evidence of recurrence by months, allowing earlier intervention 2

Imaging Surveillance

• CT scan of chest, abdomen, and pelvis every 6-12 months for patients at higher risk of recurrence (T3 qualifies as higher risk) 1
• This intensive imaging is justified because T3N0M0 represents Stage IIA disease with >20% risk of recurrence 3
• Most recurrences (90%) occur within 5 years, with peak incidence in the first 2 years 2

Endoscopic Surveillance

• Colonoscopy at 1 year post-surgery to detect metachronous adenomas or cancers 1
• If complete preoperative colonoscopy was not performed due to obstructing tumor, perform colonoscopy within 3-6 months postoperatively 1

Surveillance Schedule: Years 3-5 (Transition Phase)

• Clinical examination and CEA every 6-12 months 1
• CT imaging annually can be considered, though evidence is weaker after 3 years 1
• Colonoscopy every 3-5 years if no adenomas found at year 1 1

Surveillance Schedule: After Year 5

• Colonoscopy every 3-5 years indefinitely to detect metachronous lesions 1
• Routine CEA and imaging are not recommended beyond 5 years in asymptomatic patients 1

Critical Considerations for T3N0M0 Disease

Adjuvant Chemotherapy Decision

While this question focuses on follow-up, consider adjuvant chemotherapy if high-risk features are present in this T3N0M0 patient 1, 3:

• T4 lesions (not applicable here)
• Poorly differentiated histology
• Vascular or lymphatic invasion
• Perineural invasion
• <12 lymph nodes examined
• Obstruction or perforation at presentation

The presence of these features would warrant discussion of fluoropyrimidine-based chemotherapy, potentially with oxaliplatin 1, 3

Lymph Node Adequacy

• Verify that ≥12 lymph nodes were examined in the surgical specimen 1, 3
• Inadequate lymph node sampling (<12 nodes) represents a high-risk feature and may indicate need for more intensive surveillance or consideration of adjuvant therapy 3

Common Pitfalls to Avoid

• Do not use chest X-ray alone—it has low sensitivity compared to CT chest for detecting pulmonary metastases 1
• Do not perform surveillance in patients unfit for intervention—surveillance is only justified if the patient could tolerate repeat surgery or systemic therapy for detected recurrences 2
• Do not order routine PET scans—these are not recommended for routine surveillance and should be reserved for specific clinical scenarios 1
• Do not neglect colonoscopy—approximately 44% of patients develop metachronous adenomas, with higher rates after right-sided resections 4

Quality of Life Considerations

• Assess for persistent bowel dysfunction including diarrhea, constipation, or fecal urgency—common after sigmoid resection 1
• Screen for psychological distress and sexual dysfunction, which occur at higher rates in colorectal cancer survivors 1
• Encourage healthy lifestyle modifications including regular exercise, smoking cessation, moderate alcohol intake, and diet rich in vegetables and fruits 1

Evidence Quality Note

The most recent high-quality guideline is the 2020 ESMO Clinical Practice Guidelines 1, which provides Level II, Grade B evidence for this intensive surveillance approach. The 2007 ESMO guidelines 1 provide similar recommendations with consistent evidence levels. The rationale for intensive surveillance is that 15-25% of recurrences are potentially curable if detected early, particularly isolated liver or lung metastases amenable to resection 2.