| Abstract|| |
Objective: To report the pattern of presentation of colorectal carcinoma and the outcome of surgical therapy in a tertiary care hospital in Riyadh Saudi Arabia.
Methods: The case reports of all patients diagnosed to have colorectal cancer were retrospectively examined for: age, sex, symptoms and clinical findings, site of primary tumour and extent of metastases, operative management, histopathology results and the outcome of surgical therapy.
Results: There were forty-three (33 male, 10 female) patients, with a mean age of 42.7 years (range, 23-79 years). Sixteen (37.2%) cases presented with rectal bleeding, ten (23.2%) with abdominal pain, eight (18.5%) had altered bowel habits whereas anaemia was found to be the most frequent clinical result reported in twenty (46.4%) patients. Right side tumour was encountered in twentyone (48.8%) cases, left side tumour in twelve (27.9%) and anorectal cancer in ten (23.2%).For these lesions, thirty (69.7%) curative and thirteen (30.3%) palliative procedures were undertaken. All patients were reported to have adenocarcinomas: six (13.9%) patients had Dukes Stage A, eight (18.6%) Dukes B, twenty (46.1%) Dukes C and nine (20.9%) Dukes D. There were two post
operative deaths, and four (9.3%) patients died due to tumour dissemination and cachexia, while twenty nine (67.4%) subjects had disease free survival.
Conclusion: There is a substantial proximal shift of the colorectal carcinoma with more advanced lesions at the time of presentation. Surgical resection should be the mainstay treatment with potentially curable tumours.
Keywords: Anterior resection, bleeding per rectum, colorectal carcinoma, curative resection, right hemicolectomy
|How to cite this article:|
Eltinay OF, Guraya SY. Colorectal carcinoma: Clinico-pathological pattern and outcome of surgical management. Saudi J Gastroenterol 2006;12:83-6
Colorectal carcinoma (CRC) is the second leading cause ofcancer-related deaths in the United States, with about 145,000new cases in 2003 and 57,000 deaths. Despite advances in theadjuvant therapy, surgery remains the only effective treatmentfor carcinoma of the colon and rectum. Surgical resectionof colorectal carcinoma is associated with a 5 year survivalof about 90 percent but unfortunately, about 20 percent ofpatients present with metastatic disease.
The present study was designed to report different patternsof presentations of colorectal carcinoma, various surgicalprocedures performed and the survival. The need forearly detection and the intent towards curative resection isemphasized.
| Patients & Methods|| |
This retrospective study was conducted at King KhalidUniversity Hospital, Riyadh over a 4 year period, 1999 through2003. The medical records of the patients found to havecolorectal carcinoma, emergency and elective admissions,were analyzed for the demographic information, symptomsand physical findings, location of primary cancer and the extentof metastases, operative procedure, tumour characteristics,complications and the final outcome. In addition to thebaseline investigations, serum carcinoembryonic antigen(CEA), abdominal ultrasound, abdominal and pelvic CTscan and colonoscopy were performed in all patients. Anoperation was declared curative when all macroscopic tumourswere considered to be removed with no evidence of residualdisease. Right colon was defined as the large bowel extendingfrom ileocecal valve to splenic flexure as most tumours of distaltransverse colon and splenic flexure were treated by extendedright hemicolectomy. Left sided tumours were labelled asthose found in the descending and sigmoid colon while rectaltumours were defined as those located within 16cm of analverge including rectosigmoid junction. The patients undergoingelective surgery had mechanical bowel preparation while allpatients were given intravenous metronidazole and cefuroximein the peri-operative period.
All colorectal anastomosis were carried out by using variousstapling devices like GIA, TA, CEEA and roticulator staplers.Post operative mortality was considered as death within thirtydays of Surgery. Follow up was planned to review the patientsat two weeks and three months after discharge, and thenevery six month with serum CEA and abdominal ultrasoundexamination. All patients were referred to medical oncology forthe adjuvant chemo-radiation as per protocol. The SPSS 10.0software package (SPSS Inc., Chicago, IL) was used for thedata analysis.
| Results|| |
Forty-three patients were included in this group; thirtythreemen and ten women with a mean age of 42.7 years andrange of 23-79 years [Table - 1]. Rectal bleeding was the mostfrequent presentation encountered in fourteen (32.5%) patientsfollowed by abdominal pain recorded in eight (18.6%) cases[Table - 2]. Seventeen (39.5%) subjects were found to haveanaemia at the time of admission while eleven (25.5%) patientsdemonstrated occult blood in faeces. Right sided colonic cancerswere demonstrated in twenty-one (48.8%) cases, left sidedcarcinomas in twelve (27.9%) patients, whereas ten (23.3%)had anorectal tumours. Various surgical procedures performedare outlined in [Table - 3], which also illustrates that thirty (69.7%)curative and thirteen (30.3%) palliative operations wereundertaken in this series. Histologically, all tumours werefound to be adenocarcinomas: 39% well differentiated, 40%moderately differentiated and 21% poorly differentiated. Therewere fourteen (32.5%) patients with Duke A, B and 29 (67.5%)with Duke C, D stages. Post operatively, five (11.6%) casesdeveloped wound infection, two cases (4.6%) anastomoticleakage and two cases (4.6%) had deep vein thrombosis despiteanticoagulation. Follow up of all treated patients has so farrevealed twenty (67.4%) patients in disease free state whileeight (18.6%) cases presented with recurrence within a meanperiod of nine months: four patients with liver metastases, onewith peritoneal seedling and one with pleural effusion. Therewere four (9.3%) deaths during the follow up primarily due torespiratory, cardiovascular events and tumour dissemination.
| Discussion|| |
The estimated number of diagnosed cases of CRC world widein the year 2000 was 944,717 with 64.4% occuring in the moredeveloped countries, accounting for 10% of cancer deaths inthe Western world. A total of 753 cases were diagnosed tohave CRC between January 1999 and December 2000 with anoverall age standardized rate (ASR) of 4.9/100,000 which was5.0/100,000 for men and 4.7/100,000 for women. Amongthe Asian population, Singaporeans have higher incidence ofcolorectal carcinoma than the Malays and Indians. In thisseries, the male to female ratio was 3.3:1 which is in accordancewith male preponderance reported in the literature. The meanage was 42.7 years, which is a much younger age group thanthe published figures (≥ 50 years) though Nadir et al havereported a mean age of 23 years. This study demonstrated thatmore patients with left sided lesions presented as an emergencyas compared to the right sided tumours (6 versus 2) and fewerpatients who presented as an emergency underwent potentiallycurative resection (4 curative versus 5 palliative). Thesefindings are in accordance with McArdle et al, who reportedthat the overall survival at five years was 57.5% after electiveand 39.1% after emergency curative surgery (p < 0.001) forCRC.
The current recommendations for screening include thefollowing for an asymptomatic individual with an average riskfor colorectal cancer: annual digital examination starting at theage of 40 years, faecal occult blood testing every year staringat the age of 50, and flexible sigmoidoscopy every 3 to 5 yearsfrom 50 years onwards(15). Colonoscopy is generally reservedfor patients with positive findings on these screening tests orthose with higher than average risk for colorectal cancer.The analysis of our study implies that patients may not beadequately screened by these recommendations (21 right sidedversus 12 left sided lesions). The findings of the present studyare supported by other published reports indicating a significantpredominance of right sided lesions in African and whiteAmericans,,,. Some authors found that the proximal migrationof the colon cancer was more pronounced in females, whileothers reported this trend in the elderly patients,. A dietarychange in the past decades has been held responsible for therightward shift of colon cancer: a high-protein diet increases therisk of left sided colon carcinoma while a high fat diet increasesthe risk of proximal neoplasms. Therefore, we advocatecolonoscopy rather than sigmoidoscopy to be the appropriatescreening modality, although multi-institutional prospectivestudies are required to validate such observations.
Our study showed that thirteen (30.2%t) patients presentedwith advanced disease (Duke C and D) and out of those, ten(76.9%) were in a younger age group (±50 years). At the sametime, these tumours were more poorly differentiated, whichcould be attributed to the higher growth rate of colorectalcancer in younger patients. A higher rate of curative resections(69.7%) in this series reflects the author's policy to supportthe premise that surgical resection not only provides theopportunity for cure but also results in excellent palliation.We had eight (18.6%) cases with recurrences within ninemonths of the primary surgery reaffirming the belief that 80%of the recurrences appear in the first two years after resection,while overall recurrence rate remains steady at 50%.
One of the challenging issues is to determine which patientwith metastatic liver disease should have palliative resection.Hepatic resection is generally indicated when there is a unilobarliver metastasis or hepatic replacement by metastatictumour that is <25% to <50% of the liver volume."Extensive liver disease" has been reported to be associatedwith short survival times by various authors., No hepaticresection was undertaken in this study as all the patients withliver metastasis had bi-lobar involvement.
To conclude, there is tendency for colorectal carcinoma toinvolve proximal colon with aggressive lesions in the youngerage group. Refinements in surgical techniques have produceda major impact on the resectability rate, and surgery shouldbe offered to all patients with potentially resectable colorectalcarcinomas.
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Omar F Eltinay
Assistant Professor & Consultant Surgeon King Khalid University Hospital, P.O. Box 7805 Riyadh 11472
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3]