A potentially brighter prognosis for colon carcinoma in the third and fourth decades

Young Patients With Colorectal Cancer Have Higher Early Mortality but Better Long-Term Survival

INTRODUCTION

To define the prognosis of colorectal cancer (CRC) in young patients and to compare their postoperative treatment with that of older patients.

METHODS

This multicenter study enrolled 5,457 patients with primary CRC who underwent surgical resection. The overall survival (OS), clinicopathologic characteristics, and postoperative treatment of 253 young patients aged 18-44 years and 5,204 older patients aged 44-80 years were analyzed.

RESULTS

The OS rate was 77.1% for young and 74.2% for older patients (P = 0.348). Landmark analysis showed a significant difference in survival between young and older patients, with 63.8% of deaths among young patients being within 25 months of surgery compared with 42.4% among older patients (P = 0.002). Among those who survived more than 25 months, young patients had significantly better survival than older patients (P = 0.009). Multivariable analysis of young patients revealed that the tumor location, perineural invasion, and stage were associated with poor survival within 25 months; after this period, stage was the only prognostic marker. Young patients were more likely to receive chemotherapy, particularly multiagent regimens. For young patients, no significant difference in OS was found based on the chemotherapy regimen, regardless of disease stage (II, III, or IV, all P > 0.05). In addition, unlike in older patients, no difference in OS was found in young patients regardless of the drug regimen administered (all P > 0.05).

DISCUSSION

Young-onset CRC may have a unique disease biology that warrants further research and therapy development.

Colorectal cancer in adolescents and young adults: Defining a growing threat

Colorectal cancer (CRC) incidence is rising among adolescents and young adults (AYAs), with the greatest increase occurring in distal colon and rectal cancers. Reasons for this striking trend are not well understood. Genetically linked cases of CRC occur in the context of familial conditions such as Lynch Syndrome, but most AYA cases of CRC are sporadic. Unique biology is suggested, yet limited information is available regarding the molecular underpinnings of CRC in this age group. Young patients are more likely to experience delays in diagnosis and to present with advanced-stage disease; yet, prognosis by stage is comparable between younger and older adults. Treatment paradigms are based on evidence reflecting the older adult population. Given the concerning rise in CRC rates among AYAs, there is urgent need for further research into the role of screening from a younger age, biology of disease, and optimal therapies in this age group.

Colorectal cancer in young adults: a retrospective study of 32 tunisian patients

Young people under the age of 40 with colorectal cancer represent a distinct subgroup with a more aggressive disease behaviour compared to older patients. This study aim to provide an updated overview on clinicopathological features, treatment and outcome of colorectal cancer in young adults under the age of 40. In our retrospective study, we reviewed 32 cases of colorectal cancer in young adults aged less than 40 years that were diagnosed at the pathology department of Mongi Slim hospital over a fifteen-year period (April 2000 - November 2014). Our study group included 13 male and 19 female patients (sex-ratio M/F = 0,68) between 17 and 39 years of age (mean = 31,25 years). The presenting clinical symptoms were dominated by altered bowel habits (n=17), followed by bleeding per rectum (n=16). Histopathological examination of the surgical and biopsy specimens established the diagnosis of mucinous adenocarcinoma in nine cases, well-differentiated adenocarcinoma in 11 cases, moderately differentiated adenocarcinoma in six cases, poorly differentiated adenocarcinoma in four cases and signet ring cell carcinoma in two cases. The tumours were classified after surgery as stage I (n = 2) (6%), stage IIA (n = 7) (22%), stage IIB (n=4) (13%), stage IIC (n=1) (3%), stage IIIB (n=8) (25%), stage IIIC (n= 4) (12%), stage IVA (n=4) (13%) and stage IVB (n=2) (6%). During the follow-up period which ranged between one month and 9 years, local recurrence of the tumour occurred in six cases, seven patients had hepatic metastases and seven patients died after a mean follow-up period of seven months. Molecular genetic studies are increasing the understanding of the pathobiology of colorectal cancer and may ultimately allow at-risk patients to be identified at an earlier stage.

Early onset sporadic colorectal cancer: Worrisome trends and oncogenic features

Early onset colorectal cancers, defined as arising before 50 years of age, are a growing health hazard in western and eastern countries alike. The incidence of colon and rectal cancers in young individuals is projected to increase by as much as 90% and 140%, respectively, by 2030. Although several known cancer risk factors (e.g. smoking, alcohol, dietary habits) have been investigated, there is no single compelling explanation for this epidemiological trend. While some early onset colorectal cancers have been associated with germline mutations in cancer predisposition genes, genetic syndromes are implicated in only a fraction of these cancers (20%) and do not explain the rising incidence. Colorectal neoplasms develop through microsatellite instability or chromosomal instability pathways, with most of the early onset colorectal cancers exhibiting microsatellite stable phenotypes. Genome-wide hypomethylation is a feature of a subgroup of early onset cancers, which appears to be correlated with chromosomal instability and poor prognosis.

Comparing Clinical Characteristics and Outcomes of Young-onset and Late-onset Colorectal Cancer: An International Collaborative Study

BACKGROUND

Compared with the general population, the incidence of young-onset (YO) colorectal cancer (CRC) is increasing. However, a significant knowledge gap exists in the clinical characteristics, treatment patterns, and outcomes for these patients.

MATERIALS AND METHODS

Six international tertiary cancer centers conducted a retrospective study. Patients with YO CRC (aged 18-44 years) and LO CRC (aged > 44 years) diagnosed with histologically proven colorectal adenocarcinoma from June 2003 to June 2014 were enrolled. Patients were randomly chosen from each center's database, and the patient demographics and treatment information were collected. The data were then centralized, and the final analysis was performed at a single institution. Cox proportional hazards models were used to estimate the crude and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for progression-free survival and mortality, and YO was compared with LO. Site-specific HRs were pooled using a random-effects meta-analysis.

RESULTS

Overall, 498 patients, including 224 with YO (129 men; mean age, 37 ± 5.5 years) and 274 with LO (167 men; mean age, 64.8 ± 9.5 years) CRC, were included. At the diagnosis, 137 patients (61.2%) and 122 patients (44.5%) with YO and LO CRC had metastatic disease, respectively. For both cohorts, the 3 most common presenting symptoms were pain, hematochezia, and weight loss. Surgery was performed in 141 YO (63.0%) and 219 LO (79.9%) patients. The longitudinal noncurative treatment patterns were similar, but more biologic therapy was used for these YO patients. The pooled progression-free survival analysis results for first-line noncurative treatment favored LO (HR, 1.96; 95% CI, 1.04-3.68). The mortality analysis showed no significant differences between the 2 groups (YO: HR, 1.53; 95% CI, 0.91-2.58).

CONCLUSION

Despite similar treatment patterns and survival outcomes, YO disease might be clinically more aggressive.

Does young age influence the prognosis of colorectal cancer: a population-based analysis

BACKGROUND

Controversy exists whether young patients diagnosed with colorectal cancer have a poorer prognosis. Although younger patients are more likely to have certain poor prognostic factors, prior studies have shown mixed results in terms of overall prognosis, which may be due to lack of adjustment for confounding factors. The primary objective of our study was to determine the effect of age on survival following treatment of colorectal cancer in the Province of Manitoba, Canada, while controlling for important cofactors.

METHODS

This was a population-based analysis of all adult patients (age≥18 years) diagnosed with adenocarcinoma of the colon or rectum between 1 January 2004 and 31 December 2006 in the Province of Manitoba. Patient, tumor, and treatment factors were identified using administrative data. Five-year Kaplan-Meier survival and Cox proportional hazards model were analyzed to determine whether young age (45 years of age or younger) was associated with a poorer prognosis, while controlling for confounding variables.

RESULTS

Of the 2,086 patients identified, 70 (3.36%) were considered young. These patients were more likely to have T4 tumors and node-positive disease. Older patients had more advanced comorbidities. Young age was an independent predictor of better survival. Poorer survival was associated with male gender, increasing stage, higher grade, comorbidity, lower socioeconomic status, and lack of receipt of surgery or chemotherapy.

CONCLUSIONS

Young people make up a small minority of patients with colorectal cancer. Young patients present with more locally advanced colorectal cancer. Despite this, on a population basis, their prognosis may be more favorable than their older counterparts when controlling for disease, patient, and treatment factors.

Overexpression of CK20, MAP3K8 and EIF5A correlates with poor prognosis in early-onset colorectal cancer patients

PURPOSE

Due to ethnic, genetic and environmental factors, the clinical and molecular characteristics of Turkish colorectal cancer (CRC) patients are different from those of Western populations. The aim of this study was to clarify the relevant alterations of gene expression associated with colorectal carcinogenesis in early-onset patients and to identify specific biomarkers that could provide novel therapeutic molecular targets in this population.

METHODS

The expression profiles of 114 different genes were evaluated using mRNA PCR arrays in 39 tumors and 20 surgical margin tissue samples from 39 sporadic CRC patients diagnosed at less than 50 years of age.

RESULTS

The expression levels of IMPDH2, CK20, MAP3K8 and EIF5A were strongly up-regulated in CRC tissues compared with normal colorectal tissues (p < 0.05). The highly significant expression ratios of CK20, MAP3K8 and EIF5A observed in the colorectal tumors of patients predicted recurrence (p < 0.05). The expression of IMPDH2, CK20, MAP3K8 and EIF5A was significantly higher in the tumors of patients with short median survival (log-rank p value < 0.05). Progression-free survival was also significantly increased in patients with low expression of the EIF5A gene compared with those who exhibited high expression of this gene (log-rank p value < 0.05).

CONCLUSION

We demonstrated that high CK20, MAP3K8 and EIF5A expression levels were significant prognostic factors for poor overall survival in CRC patients. Further studies and validations are required; these genes may provide novel therapeutic molecular targets for CRC treatment, as well as new directions for the development of anticancer drugs.

Colorectal carcinoma in different age groups : a histopathological analysis

PURPOSE

Although colorectal cancer is typical in the older population, tumor onset before age 40 is not infrequent. However, the behavior, characteristics, and prognosis of this disease in young patients are unclear when compared to the older population. It is believed that young patients have a poor prognosis. We hypothesized that young patients have a poor prognosis because they have advanced-stage cancer with more aggressive pathologic features.

METHODS

Using a university hospital database, we analyzed the histopathological features of three groups of patients with a diagnosis of colorectal cancer: young age group (patients 40 years and younger), intermediate age group (patients 41-80 years old), and old age group (patients 81 years and older).

RESULTS

A total of 653 cases of colorectal cancer were analyzed. The young age group comprised 48 patients (7.4%), the intermediate age group comprised 538 patients (82.4%) and the old age group consisted of 67 patients (10.3%).The gender distribution was similar between the groups. The mean age of the young, intermediate, and old age groups were 34.5 (±5.0), 61.7 (±11.1) and 85.1 (±4.6) years old, respectively. The pathological features analyzed such as lymph node involvement, tumor histological classification and grade, venous, neural and lymphatic invasion, T and N classification of the TNM System, and Astler-Coller classification were similar between the age groups.

CONCLUSIONS

The colorectal histopathological features in young patients are similar to older patients. More aggressive characteristics or more advanced stage are not seen in younger patients.

Colorectal cancer in the young: trends, characteristics and outcome

BACKGROUND

Colorectal cancer (CRC) in young patients is associated with a poor outcome due to advanced stage at diagnosis and poor differentiation.

AIM

The aim of this study is to compare clinicopathological characteristics, overall survival (OS) and disease-free survival (DFS) of young (≤40 years) and older patients with CRC.

METHODS

A total of 2,538 patients including 59 young patients (age ≤40 years) with CRC were identified over 20 years. The clinicopathological variables of young patients were compared with a group of consecutive older patients (n = 416) spanning both decades. Survival analysis was done using Kaplan-Meier, log-rank and Cox regression models.

RESULTS

The frequency in young patients increased from 1.4% to 3.0% from first to second decade (overall -2.3%, p = 0.006). There was a higher frequency of tumours with poor differentiation (43% vs. 16%, p = < 0.001), T4 stage (47% vs. 30%, p = 0.005) and vascular invasion (VI; 38% vs. 29%, p = 0.13) in younger group. There was no significant difference in OS (p = 0.116) and DFS (p = 0.261) between the two groups. Node-negative young patients had a significantly better OS (p = 0.046). Young patients with VI had significantly reduced OS (p = 0.043), whereas young patients without VI had significantly better OS (p = 0.012). Multivariate analysis showed T4 status (p = 0.001) and vascular invasion (p = 0.002) as independent prognostic factors for OS and T4 status (p = 0.004) as independent factor influencing DFS.

CONCLUSION

The frequency of CRC in young patients increased significantly. Vascular invasion is the single most important prognostic factor in young CRC. Along with vascular invasion, high proportion of T4 status in young patients increases the chances of recurrence and negates any survival advantage in young patients.

Do young patients with colorectal cancer have a poorer prognosis than old patients?

BACKGROUND

Colorectal cancer (CRC) is generally a disease of the older population. The prognosis and clinicopathologic features of CRC in the young, compared with those in older patients, continue to be debated. The aim of this study was to compare the survival, clinicopathologic features, and tumor markers of CRC in patients aged 40 y or younger and older patients.

METHODS

A total of 230 patients with CRC of stage I-III were assessed retrospectively, with an endpoint of recurrence or metastasis after curative operation. The markers CEA, MMP-2, and p27(kip1) were studied by immunohistochemistry in all patients.

RESULTS

The young group comprised 28 (12.2%) patients aged 40 y or younger with a median age of 36 y. The remaining 202 patients (87.8%) comprised the old group, with a median age of 61 y. There were no statistical differences in gender distribution, tumor sites, tumor size, or gross type between the young and old groups. The young group had a higher incidence of mucinous adenocarcinoma (17.9%) than the old group (6.4%) (P = 0.035). The distribution of stage, differentiation grade, and extent of venous invasion were similar. The median disease-free survival time was 60 mo for the young group and 49 mo for the old. Univariate analysis revealed that this difference was not significant (P = 0.1158). Multivariate Cox regression analysis also demonstrated that the age of the patient was not an independent factor for the prognosis of CRC. There were no statistical differences between the young and old groups in the expression of CEA, MMP-2, or p27(kip1).

CONCLUSIONS

The results of this study indicated that there was a subtle difference in the incidence of mucinous adenocarcinoma between young and old patients with CRC. However, stage I-III young patients had a similar disease-free survival period as the older patients. Other clinicopathologic characteristics, and tumor markers such as CEA, MMP-2, and p27(kip1), were also similar between young and old CRC patients.

Colorectal carcinoma in young adults: a retrospective study on Indian patients: 2000-2008

AIM

To highlight an increased incidence of colorectal cancer (CRC) amongst young Indian adults.

METHOD

A retrospective study of 305 cases of CRC admitted to SSKM Hospital, Kolkata, India during 2000-2008 was carried out.

RESULTS

The ratio (0.64) of under-40 to above-40 CRC patients reported in this study is comparable to those from premier Oncology Centers in India (∼0.52) and is higher than those in the Indian National Cancer Registry (∼0.20) and international average (0.07). Distinctive tumour characteristics in younger patients including left-sided lesion (69.7%), presentation at an advanced (III/IV) stage (60%), poor histological differentiation (50%) and predominance of mucin-secreting adenocarcinoma (80%) are similar to those reported in the international literature. Some features are suggestive of hereditary non polyposis colorectal cancer syndrome, which may be a possible reason for the high proportion of young CRC patients.

CONCLUSION

A high index of suspicion for CRC among young Indian adults is necessary.

Node yield and node involvement in young colon cancer patients: is there a difference in cancer survival based on age?

BACKGROUND

The effect on cancer-specific survival (CSS) from the number of resected nodes (node yield) and the number of nodes involved with colon cancer has not been studied with respect to age.

PATIENT AND METHODS

Data from 1992 to 2006 from the Surveillance, Epidemiology and End Results (SEER) registry were analyzed for colon cancer patients undergoing curative resection, comparing younger (< 40; n = 2,642) and older (> or = 40; n = 138,769) patients.

RESULTS

The mean number of positive nodes and mean node yield was higher for the younger group. Younger patients were more likely to have metastatic disease and to have a nodal yield of > or = 12 nodes, and were less likely to have node-negative colon cancers (all p < 0.0001). Younger age was associated with a lower risk of death from colon cancer (HR = 0.65; p < 0.0001). No CSS effect was noted with the interaction of age with either node yield or node involvement. Node yield < 12 created a higher risk of cancer-specific death (HR = 1.22; p < 0.0001) regardless of stage. KM plots by stage demonstrated a CSS advantage (p < 0.0001) for younger patients.

CONCLUSIONS

Younger patients with colon cancers do not have a worse CSS simply because of their young age, so long as proper oncologic surgical principles are adhered to.

Improved survival in an Asian cohort of young colorectal cancer patients: an analysis of 523 patients from a single institution

BACKGROUND

Colorectal cancer (CRC) in the young is rare. Outcomes remain varied compared to older populations. The study reviews characteristics and overall survival (OS) of CRC in patients < or =50 years old.

MATERIALS AND METHODS

Five hundred and twenty-three (14%) of 3,796 sporadic CRCs were identified. Patients were compared for demographics, tumour characteristics, treatment, and 5-year overall specific survival. Independent prognostic factors were evaluated.

RESULTS

The majority were males (54%) with a median age of 45 years (range 19-50 years). Sixty-three percent of the patients presented with advanced stage disease (stage III and IV), and tumours were predominantly left-sided (83%). A higher frequency of mucinous or signet ring cell histological subtypes (16% vs 9%, p = 0.028) as well as poorly differentiated tumours (30% vs 12%, p = 0.0001) were present in younger patients < or =40 years. With a median follow-up of 41 months, the 5-year OS is 58% (95% confidence interval 53-64%). Younger patients < or =40 years had significantly superior 5-year OS of 62% vs 58% in the age group 41-50 years old (p = 0.004). Multivariate analysis identified five independent prognostic features: age group of 41-50 years, poorly differentiated tumour grade, presence of perineural infiltration, high tumour stage, and carcinoembryonic antigen values > or =5 ng/ml.

CONCLUSION

This study has revealed significantly improved 5-year survival in young CRC compared to those reported in the literature.

Are survival rates different for young and older patients with rectal cancer?

PURPOSE

Although it is generally believed that young patients with rectal cancer have worse survival rates, no comprehensive analysis has been reported. This study uses a national-level, population-based cancer registry to compare rectal cancer outcomes between young vs. older populations.

METHODS

All patients with rectal carcinoma in the Surveillance, Epidemiology, and End Results cancer database from 1991 to 1999 were evaluated. Young (range, 20-40 years; n = 466) and older groups (range, 60-80 years; n = 11,312) were compared for patient and tumor characteristics, treatment patterns, and five-year overall and stage-specific survival. Cox multivariate regression analysis was performed to identify predictors of survival.

RESULTS

Mean ages for the groups were 34.1 and 70 years. The young group was comprised of more black and Hispanic patients compared with the older group (P < 0.001). Young patients were more likely to present with late-stage disease (young vs. older: Stage III, 27 vs. 20 percent respectively, P < 0.001; Stage IV, 17.4 vs. 13.6 percent respectively, P < 0.02). The younger group also had worse grade tumors (poorly differentiated 24.3 vs. 14 percent respectively, P < 0.001). Although the majority of both groups received surgery (85 percent for each), significantly more young patients received radiation (P < 0.001). Importantly, overall and stage-specific, five-year survival rates were similar for both groups (P = not significant).

CONCLUSIONS

Although previous studies have found young rectal cancer patients to have poorer survival compared with older patients, this population-based study shows that young rectal cancer patients seem to have equivalent overall and stage-specific survival.

Do Young Colon Cancer Patients Have Worse Outcomes?

Previous studies on colon cancer have noted rising incidence rates among young individuals and suggest that they may have more aggressive disease and worse 5-year survivals than their older counterparts. Our study uses a nationwide population-based cancer registry to analyze colon cancer presentations and outcomes in a young versus an older population. The records of patients with colon carcinoma were obtained from the Surveillance, Epidemiology, and End Results (SEER) national cancer database (1991-1999). Two cohorts based on age at diagnosis (20-40 years, n = 1334 vs. 60-80 years, n = 46,457) were compared for patient and tumor characteristics, treatment, and 5-year cancer-specific survival. A multivariate Cox regression was performed to identify predictors of survival. The young group had a higher proportion of black and Hispanic patients than did the older group (p < 0.001). Young patients had less stage I or II disease, more stage III or IV disease (p < 0.001), and worse-grade (poorly differentiated or anaplastic) tumors (p < 0.001). The 5-year stage-specific survival was similar for stage I and III disease (p = NS) but was significantly better for young patients with stage II and IV disease (p < 0.01). Using a nationally representative cancer registry, we found that young colon cancer patients tend to have later-stage and higher-grade tumors. However, they have equivalent or better 5-year cancer-specific survival compared to older patients. This population-based finding contradicts prior single-institution reports.

Colorectal cancer in the young

BACKGROUND

Colorectal cancer (CRC) is generally thought of as a disease of older persons; however a significant proportion of patients <40 years present with this disease. Many investigators have published single-institution series on CRC in the young, yet the data vary markedly. We performed a structured review of the current literature aiming to (1) characterize CRC in the young population and (2) determine how CRC in this population should be further addressed regarding detection and treatment.

DATA SOURCES

A Medline literature search was completed. Articles were chosen to include those studies that examined patients <40 years old. A total of 55 articles were chosen from the search and review of the bibliographies.

CONCLUSIONS

We found that CRC in the young population appears to be more aggressive, to present with later stage, and to have poorer pathologic findings. However, if detected early, young patients with Dukes' stage A or B lesions have better overall 5-year survival rates. These findings emphasize the need for health care providers to have a heightened awareness when caring for this young population, particularly because excellent modalities exist to diagnose and treat colorectal cancer.

Clinicopathological and molecular biological features of colorectal cancer in patients less than 40 years of age

BACKGROUND

The aim of the present study was to identify the clinicopathological and molecular biological characteristics of early-onset colorectal cancers.

METHODS

The clinicopathological and molecular biological parameters of 138 consecutive patients with colorectal cancer aged less than 40 years were compared with those of 339 patients aged 60 years or more.

RESULTS

The younger patients with colorectal cancer had more mucin-producing (14.5 versus 4.7 per cent; P < 0.001) and poorly differentiated (7.2 versus 3.3 per cent; P = 0.015) tumours, a higher incidence of synchronous (5.8 versus 1.2 per cent; P = 0.007) and metachronous (4.0 versus 0.6 per cent; P = 0.023) colorectal cancers, and more advanced tumour stage (P < 0.001) than older patients. The operative mortality rate was lower (0.7 versus 5.0 per cent; P = 0.026), and cancer-specific survival was similar (in stage I, II and III disease; P > 0.05) or better (in stage IV disease; 95 per cent confidence interval 22.50 to 28.41 versus 12.61 to 17.05 months; P < 0.001). There was a higher percentage of normal p53 expression (61.1 versus 46.8 per cent; P = 0.023) and high-frequency microsatellite instability (MSI-H) (29.4 versus 6.3 per cent; P < 0.001), and a similar family history of cancer (17.5 versus 14.2 per cent; P > 0.05), compared with older patients.

CONCLUSION

Young patients with colorectal cancer have several distinct clinicopathological and molecular biological features. The mechanisms underlying the inconsistency between the presence of MSI-H and a family history of cancer in these early-onset colorectal cancers deserve further investigation.

Colorectal cancer before the age of 40: a case-control study

PURPOSE

Colorectal adenocarcinoma before the age of 40 is uncommon, and its prognosis is controversial, with many studies reporting a worse prognosis than in older patients and others showing no difference. The current study compared two groups of patients who had surgical resection for colorectal adenocarcinoma.

METHODS

The case group was composed of 34 patients younger than 40 (34 +/- 4) years. Detailed pathologic prognosis factors, tumor cell proliferation measured by proliferating cell nuclear antigen, survival, family history, and predisposing conditions were analyzed. Results were compared with a control group constituted of 34 patients older than 65 (75 +/- 6) years matched by gender, cancer site, and Dukes stage.

RESULTS

Tumor differentiation, presence of vascular and perineural neoplastic invasion, tumor growth pattern, tumor cell proliferation measured by proliferating cell nuclear antigen count, and survival according to the Kaplan-Meier method were not significantly different between younger and older patients. The only difference between the two groups was a higher prevalence of family history and predisposing conditions for colorectal cancer in younger patients (23 vs. 3 percent; P = 0.03).

CONCLUSION

This case-control study documents that pathologic features and prognosis of colorectal adenocarcinoma are comparable in patients younger than 40 years compared with older patients for identical stages. The higher prevalence of positive family history in younger patients suggests a different genetic background compared with older patients.

Colorectal carcinoma in young patients: CT detection of an atypical pattern of recurrence

Colonic adenocarcinoma is an uncommon but aggressive neoplasm in patients under the age of 40. The goals of this study were to evaluate the utility of computed tomography (CT) in preoperative staging and detection of postoperative recurrences in young patients with colon cancer and to evaluate the pattern of recurrent disease. We reviewed 51 cases of adenocarcinoma in patients aged 40 years and younger. CT preoperatively staged 21 (72%) of 29 patients correctly and had a 100% positive predictive value for metastatic disease. Recurrent disease occurred in 23 (76%) of 30 nonstage D patients with at least 2 years of disease-free follow-up. CT accurately detected 21 (91%) of 23 cases of recurrent disease. Local recurrences were detected in 20 (87%) of 23 patients. Isolated local disease was the most frequent pattern of recurrence, seen in 17 (74%) of 23 patients. Hepatic metastases were rare and occurred in nine (13%) of 51 patients. Young patients with colon cancer have an increased prevalence of isolated local recurrences and decreased rate of hepatic metastases than the older population. In order to detect early, and therefore resectable recurrent disease, CT examinations should be obtained early and often in the postoperative period.

Colorectal cancer in patients under 30 years of age. Contributors to the Southwestern Surgical Congress Unusual Case Registry

The Southwestern Surgical Congress (SWSC) recently initiated a registry of unusual cases. The registry was created to collect information on patients with uncommon conditions treated by members of the Congress. The registry is intended to be a source of clinical information for the members, as well as a tool for the conduct of retrospective and prospective clinical and epidemiologic studies. As the first project, we collected data on patients with colorectal cancer who were 30 years of age or less at the time of diagnosis. Letters were sent to all members of the SWSC soliciting information about such patients. Data collection sheets were subsequently mailed to those who responded to the letter. The data sheets asked for demographic data, as well as pertinent anamnestic, clinical, and staging information. Operative reports, pathology reports, and paraffin-embedded tissue blocks were also requested. Twenty-four members contributed a total of 55 patients to the registry. There were 23 males (age range: 14 to 30 years) and 32 females (age range: 16 to 30 years). In 37 patients, factors assumed to predispose to colorectal cancer were identified. The most common predisposing factor was smoking. There were 12 right colon tumors, 24 left colon tumors, and 11 rectal tumors. According to the TNM classification, 6 patients had stage I disease, 15 patients had stage II disease, 17 patients had stage III disease, and 17 patients had stage IV disease. Tissue blocks from tumor and adjacent bowel will be examined to address the issue of a possible genetic predisposition for cancer at the molecular level, in these young patients. We will also assess the independent influence of age on prognosis by comparing the actuarial survival and recurrence rates in patients from the registry with data from older patients who are matched for the presence of other known prognostic factors. The Unusual Case Registry will provide the members of the Congress with a valuable database of clinical information. Furthermore, this method of compilation will facilitate the collection of relatively large patient samples over a short period of time. This will greatly facilitate the conduct of original and relevant collaborative prospective studies of uncommon diseases within the framework of the SWSC.

Assessment of clinicopathologic features of colorectal mucinous adenocarcinoma

The purpose of this report is to analyze the clinicopathologic features of colorectal mucinous adenocarcinoma (MC), which is generally believed to have a poor prognosis, in an attempt to assess ways in which the surgical outcome can be improved. Clinicopathologic features of 44 patients with MC (6.6%), from among 662 patients with primary colorectal cancers, were compared with those of 545 patients with nonmucinous (non-MC) adenocarcinoma. MC is more likely to invade the adjacent viscera (29% versus 10%, p < 0.005) and show more extensive lymph node involvement beyond the pericolonic region (50% versus 26%, p < 0.005) than non-MC. Based on these findings, a more aggressive attitude toward surgical intervention is recommended, including extensive lymph node dissection and the resection of adjacent organs that seems to be affected macroscopically, to improve the surgical outcome of this clinical entity.

Adenocarcinomas of the colon and rectum in persons under 40 years old. A population-based study

Data collected by nine population-based tumor registries participating in the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute were analyzed to characterize the epidemiology of noncarcinoid adenocarcinomas of the colon and rectum in young adults. Tumors diagnosed in persons under 40 years old between 1973 and 1984 (n = 1736) were compared with those in persons 40 years and older (n = 106,760). This first large U.S. population-based study of colorectal adenocarcinomas in the young shows a higher incidence in blacks than whites and later detection in black males. It also shows a higher proportion of tumors of mucinous and signet ring histological type than in older age groups. Among the younger group, the average annual age-adjusted incidence rate was 34% higher in black males than in white males (12.6 vs. 9.4 per million persons) and 46% higher in black females than in white females (13.0 vs 8.9 per million persons). The proportion of tumors that were right-sided varied by age: 0-29 years, 30%; 30-39 years, 26%; 40-49 years, 22%; 50-59 years, 21%; 60-69 years, 24%; 70-79 years, 30%; and 80+ years, 35%. Males under age 40 were less likely to present with localized disease (whites, 27%; blacks, 21%) than were those aged 40 and older (whites, 39%; blacks, 36%). The proportion of tumors classified as mucinous decreased with age, from 28% among those aged 0-19 years to 5% among those 40 years and older. A similar trend was observed for signet ring tumors. Although this latter type accounted for 10% of large-bowel tumors among subjects aged 0-19 years, this proportion decreased with age to 0.2% in those 40 years and older.

Relationship between age and survival in cancer of the colon and rectum with special reference to patients less than 40 years of age

The relative survival of all patients (n = 61,769) in the entire Swedish population reported to have a malignant tumour of the colon and rectum between 1960 and 1981 was analysed with special reference to patients under 40 years of age. The 5-year relative survival rate of patients with a tumour of the colon, irrespective of histopathological diagnosis, was 62.0 per cent below the age of 40 years and 44.4 per cent in those 40 years of age or older (P less than 0.05). The corresponding figures for patients with a tumour of the rectum were 46.6 per cent and 39.1 per cent, respectively. When the relative survival was analysed separately for patients with a histopathologically demonstrated adenocarcinoma, the 5-year survival rate among patients with a cancer of the colon was 50.9 per cent in patients below 40 years of age and 48.6 per cent in those 40 years of age or older. In patients with adenocarcinoma of the rectum, the 5-year relative survival rate was 41.1 per cent in patients younger than 40 years of age and 40.7 per cent in patients 40 years of age or older. Thus, patients below the age of 40 years with an adenocarcinoma of the colon and rectum as a group appear to have the same or even a better prognosis than older patients if all tumours are considered, irrespective of histopathological diagnosis.

Colorectal cancer in patients younger than 40 years of age

To assess prognostic factors in patients who develop colorectal cancer before the age of 40 years, a 30-year experience from 1956 through 1985 was reviewed. There were 50 patients ranging in age from 7 to 39 years. Five cases were associated with either ulcerative colitis (2) or familial polyposis (3). The most common presenting symptoms were abdominal pain (66 percent), hematochezia (60 percent), change in bowel habit (41 percent) and weight loss (30 percent). On pathologic staging (N = 44), only 14 of 44 (31 percent) had a Dukes' stage A or B lesion, 20 (45 percent) had Dukes' stage C, and the remaining 10 (23 percent) had distant metastases at the time of surgery. Five-year survival rate was 28 percent with a disease-free survival rate of 18 percent. Median survival was only 28 months. Negative prognostic factors were Dukes' stage C/D (P less than .001), symptom duration of longer than 3 months (P = .01), noncaucasian ancestry (P = .01), and poorly differentiated histology (P = .06). In contrast to older patients with colorectal cancer, only 1 of 30 (3 percent) patients with stage C D disease was disease-free at 5 years. In view of the poor survival rate associated with both delay in diagnosis and the presence of advanced disease, it was concluded that young patients presenting with the symptoms listed above need early, aggressive evaluation for possible colorectal cancer.

The influence of age upon the survival after curative operation for colorectal cancer

From 1962 to 1982 1,623 consecutive patients were curatively operated for colorectal adenocarcinoma. For all patients cancer specific mortality rates were registered and the influence of the following prognostic factors was evaluated: tumour stage and grade, adenomas, age, sex and tumour site. In a multivariate Cox analysis, with backward elimination of non-significant factors at a 10% level, Dukes' C stage, poor differentiation, and age between 40 and 60 years at onset of carcinoma reached independent prognostic significance.

Prognostic significance of hereditary predisposition on the outcome of colorectal cancer as expressed by increased in vitro tetraploidy

Seventy colorectal cancer patients operated on in the period 1981-1984 were consecutively investigated for in vitro tetraploidy in dermal fibroblasts, as an increased number of tetraploids is considered a marker of genetic predisposition for colorectal cancer. The difference in disease-free survival rates of increased (IVT+) and normal (IVT-) in vitro tetraploidy was not statistically significant (0.1 less than p less than 0.2), but the decrease in the disease-free survival rate of IVT+ was 1.6 times that of IVT-. To exclude the influence of other prognostic factors, a Cox multivariate regression analysis was used, with Dukes C carcinoma and poor differentiation as co-variables for IVT+. In this analysis IVT+ did not show any independent prognostic significance. A genetic predisposition for colorectal cancer, as expressed by the presence of IVT+ in skin fibroblasts, does not seem to influence the survival of patients with colorectal cancer.

Colorectal carcinoma in patients younger than 40 years of age. Montpellier Cancer Institute experience with 78 patients

During an 18-year period, 2600 patients were treated for colorectal carcinoma in the Montpellier Cancer Institute. Of the 93 patients younger than 40 years of age (3.6%), 78 records were retrospectively studied. The overall 5-year survival rate was 30%. Their survival was not significantly affected by the site of the primary tumor, the degree of tumor differentiation, or sex. The only significant parameter was Dukes' staging at presentation (P less than 0.0001). An analysis of sites of recurrence revealed the frequency of liver metastasis, ovarian metastasis in women, and local recurrence of rectal cancer. Although the high failure rate in these areas clearly justifies aggressive combined therapy, the high frequency of inaugural Stage D patients (27%) and their short mean survival time (5 months), underline the crucial importance of early detection. However, it is unfortunate that colorectal cancer screening in young patients is difficult because of the low rates of precancerous states (4%).

Colorectal adenocarcinoma in young Lebanese adults. The American University of Beirut-Medical Center experience with 32 patients

Colorectal adenocarcinoma is uncommon in Lebanon. The low frequency and the low average age at the time of diagnosis, 53.7 years, is similar to that observed in other developing countries. Over a period of 40 years (1945-1985), 32 patients (5.8%) developed colorectal adenocarcinoma before age 30 years. Seventeen and 15 patients were males and females, respectively (age range, 14-29 years). The most common presenting symptoms were blood per rectum (27 patients) and abdominal pain (23 patients). The average interval from the first symptom to histologic diagnosis was 5.7 months. The only significant predisposing factors were the presence of a positive family history for colorectal carcinoma in one patient and bladder exstrophy with ureteral diversion in another. Twenty-four patients had surgery with curative intent. Colloid and signet ring adenocarcinoma were present in 22 patients (68.7%). Classification by Duke's staging system demonstrated Stage C in 15 and Stage D in 5 patients. These findings show a definite increase in carcinoma with high histologic grade and advanced stage at presentation in young Lebanese patients.