Clinical significance of rectal cancer in young patients

Outcomes of Young Patients With Rectal Cancer From a Tertiary Cancer Care Centre in India

BACKGROUND

Carcinoma of the rectum is the fourth most common cancer in the world. The peak age of diagnosis is around the seventh decade. Rectal cancer presenting in those < 35 years old are very peculiar in that they present with adverse histologic features and more advanced stage compared with rectal cancer presenting in older patients.

MATERIALS AND METHODS

We retrospectively evaluated the patient records of young patients with rectal cancer (aged < 35 years) treated in our unit at the All India Institute from 2007 to 2013.

RESULTS

A total of 60 young patients with rectal cancer were registered in our unit during the study period. A family history of cancer was present in 3 patients. The median age at presentation was 27.5 years (range, 15-34 years). The male-to-female ratio was 1.5:1. Of the 60 patients, 52 (86.6%) presented with advanced-stage disease (stage III and IV). Mucinous, signet, papillary, and other poor-risk histologic features were seen in 33 patients (55%). The treatment intention was radical for 50 patients (83.3%). The median follow-up period was 7.3 months. Eighteen patients had documented disease progression. Distant metastasis was the most common type of failure, seen in 14 of 18 patients (77%). The median progression-free survival (PFS) was 1.4 years. The 1- and 3-year PFS rates were 66.5% and 42.0%, respectively. On univariate analysis, the Karnofsky performance status and histologic type were significant prognostic factors for PFS.

CONCLUSION

A greater proportion of poor histologic subtypes was found among young patients with rectal cancer. The high incidence of poor histologic subtypes confers a poor prognosis in these patients.

Sporadic early-onset colorectal cancer is a specific sub-type of cancer: a morphological, molecular and genetics study

Sporadic early onset colorectal carcinoma (EOCRC) which has by definition no identified hereditary predisposition is a growing problem that remains poorly understood. Molecular analysis could improve identification of distinct sub-types of colorectal cancers (CRC) with therapeutic implications and thus can help establish that sporadic EOCRC is a distinct entity. From 954 patients resected for CRC at our institution, 98 patients were selected. Patients aged 45–60 years were excluded to help define “young” and “old” groups. Thirty-nine cases of sporadic EOCRC (patients≤45 years with microsatellite stable tumors) were compared to both microsatellite stable tumors from older patients (36 cases, patients>60 years) and to groups of patients with microsatellite instability. Each group was tested for TP53, KRAS, BRAF, PIK3CA mutations and the presence of a methylator phenotype. Gene expression profiles were also used for pathway analysis. Compared to microsatellite stable CRC from old patients, sporadic EOCRC were characterized by distal location, frequent synchronous metastases and infrequent synchronous adenomas but did not have specific morphological characteristics. A familial history of CRC was more common in sporadic EOCRC patients despite a lack of identified hereditary conditions (p = 0.013). Genetic studies also showed the absence of BRAF mutations (p = 0.022) and the methylator phenotype (p = 0.005) in sporadic EOCRC compared to older patients. Gene expression analysis implicated key pathways such as Wnt/beta catenin, MAP Kinase, growth factor signaling (EGFR, HGF, PDGF) and the TNFR1 pathway in sporadic EOCRC. Wnt/beta catenin signaling activation was confirmed by aberrant nuclear beta catenin immunostaining (p = 0.01). This study strongly suggests that sporadic EOCRC is a distinct clinico-molecular entity presenting as a distal and aggressive disease associated with chromosome instability. Furthermore, several signaling pathways including the TNFR1 pathway have been identified as potential biomarkers for both the diagnosis and treatment of this disease.

Better long-term survival in young patients with non-metastatic colorectal cancer after surgery, an analysis of 69,835 patients in SEER database

Objective

To compare the long-term survival of colorectal cancer (CRC) in young patients with elderly ones.

Methods

Using Surveillance, Epidemiology, and End Results (SEER) population-based data, we identified 69,835 patients with non-metastatic colorectal cancer diagnosed between January 1, 1988 and December 31, 2003 treated with surgery. Patients were divided into young (40 years and under) and elderly groups (over 40 years of age). Five-year cancer specific survival data were obtained. Kaplan-Meier methods were adopted and multivariable Cox regression models were built for the analysis of long-term survival outcomes and risk factors.

Results

Young patients showed significantly higher pathological grading (p<0.001), more cases of mucinous and signet-ring histological type (p<0.001), later AJCC stage (p<0.001), more lymph nodes (≥12 nodes) dissected (p<0.001) and higher metastatic lymph node ratio (p<0.001). The 5-year colorectal cancer specific survival rates were 78.6% in young group and 75.3% in elderly group, which had significant difference in both univariate and multivariate analysis (P<0.001). Further analysis showed this significant difference only existed in stage II and III patients.

Conclusions

Compared with elderly patients, young patients with colorectal cancer treated with surgery appear to have unique characteristics and a higher cancer specific survival rate although they presented with higher proportions of unfavorable biological behavior as well as advanced stage disease.

Colorectal cancer in younger patients - a single centre analysis

Debate surrounds the nature of colorectal cancers in younger patients and whether they are more likely to present with aggressive disease. Pearson's correlation coefficient was used to examine whether a relationship exists between age and variables such as family history, mucinous tumours, metastases and final pathology. 41 patients under the age of 45 were diagnosed and operated for colorectal cancer between September 1998 and December 2010 in our centre. Nineteen patients were under the mean age of 35 years. There was no correlation between younger patients and metastatic disease (r= -0.129, p=0.440) or family history (r= -0.258, p=0.123). There was no correlation between age and Dukes staging (r= -0.052, p=0.756), tumour stage (r= -0.110, p=0.516), nodal status (r= -0.053, p=0.751), mucinous tumours (r=0.104, p=0.569) and cell differentiation (r= 0.046, p=0.787). Overall mortality was 26% and of those who survived 10% have metastatic disease. Median survival was 26 months after surgery. Younger patients under 45 appear to be a homogenous group in relation to colorectal tumour characteristics. Further longitudinal studies to examine the differences between this group and older people are needed.

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.

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.

Two week rule referral for patients with colorectal cancer below the age of 50; are we being ageist?

OBJECTIVES

The TWR system was introduced in July 2000. The purpose of this study was to investigate whether patients below the age of 50 years with colorectal cancer (CRC) are experiencing delays in treatment.

METHODS

The CRC database was searched for all newly diagnosed colorectal cancers between January 2001 and December 2005 in patients who were aged less than 50 years.

RESULTS

There were 911 patients with CRC during the study period. Of these, 41 patients (4.5%) were aged under 50. Thirty-eight case notes were retrieved and reviewed; the median age was 47 years. Fourteen (37%) presented as an emergency, 9 (24%) via the TWR, 8 (21%) were non-TWR referrals to outpatients and the remainder were referred via miscellaneous routes. The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the miscellaneous (direct endoscopy, in-hospital physician's referral) group. The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the outpatient group and 96 days (range 27-270 days) in the miscellaneous group. Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria.

CONCLUSION

Patients with symptoms of CRC below the age of 50 years may face referral and diagnostic delay if not referred via the TWR system; many of these would be eligible if age was not a deciding factor.

Rectal cancer in young adults: a series of 102 patients at a tertiary care centre in India

OBJECTIVE

Rectal cancer in young patients is uncommon. There is little information on rectal cancer in young adults in India. The aim of this study was to determine the relative incidence of rectal cancer in young patients in India and identify any differences in histological grade and pathological stage between younger and older cohorts.

METHOD

All adult patients presenting at a tertiary colorectal unit with primary rectal adenocarcinoma between September 2003 and August 2007 were included. Patients were divided into two groups: 40 years and younger, and older than 40 years. Details regarding patient demographics, preoperative assessment, management and tumour grade and stage were obtained from a prospectively maintained database.

RESULTS

One hundred and two of 287 patients (35.5%) were 40 or younger at presentation. Younger patients were more likely to present with less favourable histological features (52.0% vs 20.5% (P < 0.001)) and low rectal tumours (63.0% vs 50.0%) (P = 0.043), but were equally likely to undergo curative surgery compared to the older group (P = 0.629). Younger patients undergoing surgery had a higher pathological T stage (T0-2 18.9%, T3 62.3%, T4 19.7% vs 34.5%, 56.0%, 9.5%) (P = 0.027) and more advanced pathological N stage (N0 31.1%, N1 41.0%, N2 27.9% vs 53.4%, 26.7%, 17.2%) (P = 0.014).

CONCLUSION

The relative number of young patients with rectal cancer in this Indian series is higher than figures reported in western populations. The reasons for this are not clear. The histopathological features of rectal tumours in young patients in this study are consistent with similar studies in Western populations.

Young-onset colorectal cancer in patients with no known genetic predisposition: can we increase early recognition and improve outcome?

Early recognition of colorectal cancer (CRC) in young patients without known genetic predisposition is a challenge, and clinicopathologic features at time of presentation are not well described. We conducted the current study to review these features in a large population of patients with young-onset CRC (initial diagnosis at age <or=50 yr without established risk factors). We reviewed the records of all patients aged 50 years or younger diagnosed with a primary CRC at our institution between 1976 and 2002. Patients with inflammatory bowel disease, polyposis syndromes, or a known genetic predisposition for CRC were excluded. Data regarding clinical and pathologic features at time of initial presentation were abstracted by trained personnel. We identified 1025 patients, 585 male. Mean age at presentation was 42.4 years (standard deviation 6.4). Eight hundred eighty-six (86%) patients were symptomatic at time of diagnosis. Clinical features in symptomatic patients included rectal bleeding (51%), change in bowel habits (18%), abdominal pain (32%), weight loss (13%), nausea/vomiting (7%), melena (2%), and other (26%). Evaluation of asymptomatic patients was pursued with findings of anemia (14%), positive fecal occult blood test (7%), abdominal mass (2%), mass on digital rectal exam (2%), and other (80%). Site of primary tumor was colonic in 51% and rectal in 49%. Synchronous malignant lesions were noted in 1%. Mucinous and signet cell histology was seen in 11% and 2%, respectively. Tumor grade distribution was grade 1 (2%), grade 2 (54%), grade 3 (34%), and grade 4 (7%). The stage distribution was stage I (13%), stage II (21%), stage III (32%), and stage IV (34%). To our knowledge, the current study is the largest cohort of young-onset CRC patients with no known genetic predisposition for disease. Most patients were symptomatic, had left-colon or rectal cancers and presented with more advanced stage disease. Our findings should promote increased awareness and the aggressive pursuit of symptoms in otherwise young, low-risk patients, as these symptoms may represent an underlying colorectal malignancy.

Cohen CR. Colorectal Cancer in the Young Patient

Colorectal cancer is the second most common cause of death from cancer in the UK. It is estimated that between 2 to 3 per cent of colorectal cancer occurs in patients younger than the age of 40 years. It remains unclear from the literature whether this group of patients has a worse prognosis from colorectal cancer than the population as a whole. There are no large series that report a 10-year survival in young patients diagnosed with colorectal cancer. The authors’ objective was to assess patients diagnosed with colorectal cancer younger than the age of 40 years to determine whether the 5- and 10-year survival rates in a tertiary referral center compares favorably with survival rates obtained at other centers and the population as a whole. A retrospective observational study was conducted and an analysis of the patient's notes was made, specifically looking at age at diagnosis, nature and duration of symptoms, predisposing risk factors for colorectal cancer, the site within the bowel of the colorectal cancer, the type of curative resection performed, Dukes’ stage, and details of 5- and 10-year follow-up to assess survival. Forty-nine patients age 40 years or younger received treatment for colorectal cancer at St. Mark's Hospital from 1982 to 1992. The overall 5- and 10-year survival was 58 per cent and 46 per cent respectively. The study provides more evidence to support the fact that young patients with colorectal cancer seem to present with more advanced disease. Despite this, the overall 5-year relative survival rate is comparable if not better than other studies, supporting recent evidence that the prognosis in this group of patients is no worse than for colorectal cancer in the population as a whole.

Rectal cancer in the young patient

PURPOSE

The purpose of this national study was to evaluate the results of treatment for young rectal cancer patients.

METHODS

This prospective study from the Norwegian Rectal Cancer Project includes all 2,283 patients younger than aged 70 years with adenocarcinoma of the rectum from November 1993 to December 1999. Patients younger than aged 40 years (n = 45), 40 to 44 years (n = 87), 45 to 49 years (n = 153), and 50 to 69 years (n = 1998) were compared for patient and tumor characteristics and five-year overall survival. Patients treated for cure (n = 1,354) were evaluated for local recurrence, distant metastasis, and disease-free survival.

RESULTS

Patients younger than aged 40 years had significantly higher frequencies of poorly differentiated tumors (27 vs. 12-16 percent; P = 0.014), N2-stage (37 vs. 13-18 percent; P = 0.001), and distant metastases (38 vs. 19-24 percent; P = 0.019) compared with older patients. Among those treated for cure, 56 percent of the patients younger than aged 40 years developed distant metastases compared with 20 to 26 percent of the older patients (P = 0.003). Overall five-year survival was 54 percent for patients younger than aged 40 years compared with 71 to 88 percent for the older patients (P = 0.029). Age younger than 40 years was a significant independent prognostic factor and increased the risk for metastasis and death.

CONCLUSIONS

Patients younger than aged 40 years had a more advanced stage at the time of diagnosis and poor prognosis compared with older patients. Young patients treated for cure more often developed distant metastases and had inferior survival.

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.

ras and c-myc protein expression in colorectal carcinoma. Study of cancer-prone patients

This study was performed to determine the correlation of tumor ras and c-myc oncogene expression with clinical and prognostic variables in patients prone to develop colorectal cancer. One hundred eighteen patients with colorectal cancer were studied; mean age was 40 years. Fifty-three were young patients (age 40 or less), 49 had ulcerative colitis, and 16 had multiple polyposis coli. Immunoperoxidase stains of paraffin-embedded cancer sections were performed for the c-myc and ras proteins. ras staining was found to correlate with Dukes stage and prognosis. Patients with tumors negative for ras protein stain had an actuarial five-year survival of 61 percent versus 44 percent for those tumors with a positive stain (P less than 0.05). This correlation was not seen with the c-myc stain. Positive ras oncogene stain appears to be a useful indicator of advanced stage and poor prognosis in colorectal cancer occurring in cancer-prone patients.

Clinical and pathologic prognostic indicators in colorectal cancer. A population-based study

The institution of a colorectal Cancer Register in a health care district of Northern Italy gave the authors the opportunity to evaluate the prognostic relevance of several morphologic and clinical variables by univariate and multivariate analyses. Of the 134 patients registered in 1984, 132 were followed up until the end of 1989. Overall 5-year survival was 37%, but the figure increased to 43% when only colorectal cancer-related deaths were considered. Univariate analysis for clinical variables showed that TNM staging and age at diagnosis were significantly related to prognosis, whereas none of the other parameters were indicative of the clinical outcome. With a similar analysis, among the various morphologic variables, pattern of growth (infiltrating versus expanding) and extent of fibrosis (extensive versus little or absent) appeared to be indicators of prognosis. When the variables that were significant (stage, age, pattern of growth, and fibrosis) in the univariate analysis were entered into the Cox model of multivariate analysis, TNM staging was the only parameter that maintained an independent prognostic importance. The authors state that their results confirm the importance of stage in predicting survival for cancer of the large bowel and suggest that the possible prognostic value of clinical and morphologic variables should be investigated within each of the major TNM or Dukes' classes.