Indian Journal of Cancer Home 

ORIGINAL ARTICLE
[Download PDF]
Year : 2017  |  Volume : 54  |  Issue : 2  |  Page : 397--400

Clinico-pathological profile of colorectal cancer in first two decades of life: A retrospective analysis from tertiary health center

D Sharma, G Singh 
 Department of Radiotherapy, VMMC and Safdarjung Hospital, New Delhi, India

Correspondence Address:
Dr. D Sharma
Department of Radiotherapy, VMMC and Safdarjung Hospital, New Delhi
India

Abstract

AIM: This retrospective observational study was done to analyze age, gender, site of primary tumor and histological characterstics in patients of colorectal carcinoma in the first two decades of life. MATERIAL AND METHOD: A total of 373 patients of colorectal patients were registered in the Department of Radiation Oncology from January 2010 to December 2015. Patients who were <20 years of age were analyzed for clinicopathological characteristic. RESULTS: In our study, a total of 29 out of 373 patients (7.75%) were ≤20 years. Male to female distribution was 2.2:1. Younger age group presented with advanced Stage III and IV 58.62% and 10.34% patients, respectively. Only 9 (30.5%) patients were of Stage I and II. The most common involved site was rectum in 21 (72.41%) patients, followed by rectosigmoid involvement in 5 (17.24%). CONCLUSIONS: Colorectal carcinoma in young adults is usually locally advanced or metastatic. Therefore, the diagnosis of CRC should be done at early and curable stage. Bleeding per rectum in a younger age group should not be ignored but must be properly evaluated.



How to cite this article:
Sharma D, Singh G. Clinico-pathological profile of colorectal cancer in first two decades of life: A retrospective analysis from tertiary health center.Indian J Cancer 2017;54:397-400


How to cite this URL:
Sharma D, Singh G. Clinico-pathological profile of colorectal cancer in first two decades of life: A retrospective analysis from tertiary health center. Indian J Cancer [serial online] 2017 [cited 2021 Dec 2 ];54:397-400
Available from: https://www.indianjcancer.com/text.asp?2017/54/2/397/225793


Full Text

 Introduction



The third most common cancer both in male and female is colorectal cancer (CRC) worldwide.[1] In India, it is the fourth most common cause of cancer in males and third most common cause of cancer in females.[2] The age-standardized rates of CRC in India have been estimated to be 4.2 and 3.2/100,000 for males and females, respectively, compared to 35.3 and 25.7, respectively, in the USA.[3],[4] CRC is the cancer of old age; mostly occur after the fifth decade of life.[5] However, the incidence of CRC is increasing in young age especially in developing countries, which is mainly contributed by change in lifestyle and food habits.[6],[7],[8],[9]

Aim

The aim of this retrospective observational study was to find out the incidence and clinical characteristics in first two decades of life.

 Materials and Methods



All CRC patients who attended the radiation oncology outpatient department and received either form of treatment (surgery, preoperative neoadjuvant therapy, adjuvant therapy, or palliative chemotherapy/radiotherapy [RT]) in our hospital from 2010 to 2015 were analyzed retrospectively. Out of these patients who are <20 years of age were analyzed for clinicopathological characteristics. Patients with ulcerative colitis and known hereditary cancer syndromes were excluded from the study. The stage-wise analysis was performed according to TNM classification AJCC seventh edition.[10]

 Results



A total of 373 patients of colorectal patients were registered in the Department of Radiation Oncology from January 2010 to December 2015. Out of which, 157 (41.97%) patients were ≤40 years. In the under 40 group, 29 patients were ≤20 years (7.75%) [Table 1].{Table 1}

The average duration of presenting complaints was 9 months; correlating well with established literature that this type of CRC has a short history. The male to female distribution was 2.2:1 with higher male predominance. Below 20 years group, 17 (58.62%) patients were of Stage III, whereas 3 patients (10.34%) were metastatic, of which 2 patients presented with peritoneal metastasis and 1 patient presented with liver metastasis. Only 9 (30.5%) patients were of Stage I and II. The most common involved site was rectum in 21 (72.41%) patients, followed by rectosigmoid involvement in 5 (17.24%) and colon involvement in 3 (10.34%). Anal canal was also involved in 14.28% of patients. The majority of patients presented with bleeding per rectum followed by anorexia and weight loss and altered bowel habits (24, 18, and 11 patients, respectively). Four patients presented with obstruction, among these four patients, three patients had perforation. As per histopathological review, most common type of malignancy was mucinous or mucin secreting adenocarcinoma followed by moderately differentiated adenocarcinoma and signet cell adenocarcinoma (27.6%, 20.7%, and 17.2%, respectively) [Table 2].{Table 2}

Of the 29 patients, 4 patients were either lost to follow up or refused treatment. A total of 25 patients underwent surgery, of which radical surgery was performed in 15 cases and palliative colostomies was done in 10 patients. Radical surgery included radical colectomies in three patient, abdominoperineal resection in eight patients and low anterior resection in 4 cases. RT was used in 17 cases. In 3 cases, palliative RT was used. Seven cases received preoperative RT, five cases received postoperative RT, and three patients received radical RT. The dose in preoperative setting as well as postoperative setting was 50.4 Gy in 28 fractions. Radical RT was given in dose of 54–59.4 Gy in 5–6 weeks. Chemotherapy was used in 22 patients, as neoadjuvant in 7 cases, adjuvant in 11 cases, and as palliative in 4 patients. 5-fluorouracil (5 FU) and leucovorin were used in case of concurrent and neoadjuvant setting whereas in adjuvant as well in palliative setting oxaliplatin and 5 FU-based chemotherapy was used [Table 3].{Table 3}

 Discussions



CRC is a cancer of old age, mostly occur after fifth decade of life. However, the incidence of CRC is increasing in young age, especially in developing countries. Studies have shown that about 5%–15% of CRCs belong to young age.[11] In the present study, (41.97%) patients were ≤40 years and in the under 40 group, 29 patients were ≤20 years (7.75%). Studies have shown that CRCs in young age are often associated with underlying predisposing conditions such as inflammatory bowel disease or hereditary polyposis syndromes.[12] Such patients are also at an increased risk of developing a second gastrointestinal or extraintestinal malignancies.[13] In a study, Gafanovich et al. reported a high frequency of microsatellite instability and germline mismatch mutations in pediatric CRC patients who developed second malignancies.[14] Chan et al. demonstrated that 84% of patients below 31 years of age carried a germline mutation in one of the mismatch repair genes.[15] Bhatia et al. demonstrated a six-fold increase in the number of cases among relatives of patients diagnosed with CRC before 15 years of age.[16] Various studies had shown that colorectal carcinoma in young age are often associated with mucinous carcinoma and signet cell carcinoma when compared to older age group [9],[17],[18],[19],[20] Endreseth et al. had shown that signet ring tumor has a higher propensity for early bowel wall invasion and involvement of peritoneal surface.[20] In the present study, the most common histopathology was mucinous carcinoma (27.6%). The combined mucinous and signet ring and poorly differentiated adenocarcinoma accounted for 58.6%. It has been found both from western and Indian literature that colorectal carcinoma in young adults is usually locally advanced or metastatic. Studies have shown that a total of 75%–80% of the cases either present with Stage III and Stage IV.[9],[19],[21],[25] In the present study, 58.6% of patients present with nodal involvement and 10.3% cases present with metastatic disease, accounting a total of 69% cases of Stage III and Stage IV. In the present study, the most commonly involved organ is rectum (73%), followed by the involvement of colon (23.4%) and rectosigmoid (3.5%). The percentage of involvement of rectum/colon is different in different decades. Various studies from Indian subcontinent also demonstrated the most commonly involved site is rectum [8],[9],[17],[19] in contrast to western literature in which colon was more frequently involved.[22],[23]

The treatment of CRC in either age group is curative surgical resection with or without chemotherapy and or RT. However, the majority of patients in young age group either presents with locally advanced (inoperable) or with poor general condition. Different modalities such as preoperative RT, chemo-RT, or the use of chemotherapy (Leucovorin/5 FU) may be considered to increase resectability rates.[17],[24],[25] Pratt et al. also demonstrated favorable response of fluorouracil and leucovorin in young patients with CRC.[21] In the present study only 51.72% of patients underwent curative surgery, because at presentation disease was either inoperable or because of poor general condition.

 Conclusions



The incidence of colorectal carcinoma is increasing in the young age group and is often associated with advanced stage, poor general condition at presentation, mainly involving rectum with mucinous, signet cell histopathology all contributing to poor outcome. Therefore, diagnosis of CRC should be done at the early and curable stage. Bleeding per rectum in a younger age group should not be ignored but must be evaluated with at least a digital rectal examination and sigmoidoscopy/colonoscopy.

Limitations

The present study is a retrospective study, and the number of cases is very less (29 cases), and survival analysis is not done in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Wingo PA, Bolden S, Tong T, Parker SL, Martin LM, Heath CW Jr. Cancer statistics for African Americans, 1996. CA Cancer J Clin 1996;46:113-25.
2Ferlay J, Soerjomataram I, Ervik M. Globacon 2012 v1.0. Cancer Incidence and Mortality Woridwide: IARC No. 11. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://www.globacon.iarc.fr. [Last accessed on 2013 Dec 23].
3National Cancer Registry Programme. Population Based Cancer Registries 2004-2005. New Delhi: Indian Council of Medical Research; 2008.
4Parkin DM, Whelan SL, Ferlay L, Young RJ. Cancer Incidence in Five Continents. Series. IARC Scientific Publication No. 143. Vol. 143. Lyon: International Agency for Research on Cancer; 1997. p. 566-7.
5Kenneth R, McQuaid MD. Current Medical Diagnosis and Treatment. In: Tierney LM, McPhee SJ, Papadakis MA, editors. Lange Medical Books. 43rd ed. New York: McGraw-Hill; 2004. p. 613.
6Shahrudin MD, Noori SM. Cancer of the colon and rectum in the first three decades of life. Hepatogastroenterology 1997;44:441-4.
7Pandey A, Gangopadhyay A, Sharma S, Kumar V, Gupta D, Gopal S, et al. Pediatric carcinoma of rectum – Varanasi experience. Indian J Cancer 2008;45:119-22.
8Gupta S, Bhattacharya D, Acharya AN, Majumdar S, Ranjan P, Das S. Colorectal carcinoma in young adults: A retrospective study on Indian patients: 2000-2008. Colorectal Dis 2010;12:e182-9.
9Gupta RK, Ali S, Sakhuja P, Mukherjee D, Agarwal AK, Puri AS. Colorectal carcinoma up to the second decade of life: An 8-year experience in a tertiary care center. Indian J Cancer 2014;51:557-9.
10Edge SB, Byrd DR, Compton CC. American Joint Committee on Cancer, AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010. p. 113-23.
11Mukherji A, Rathi AK, Sharma K, Kumar V, Singh K, Bahadur AK. A study on presentation and behavior of colo-rectal carcinoma in young Indian patients. Trop Gastroenterol 2011;32:122-7.
12Vasen HF, Wijnen JT, Menko FH, Kleibeuker JH, Taal BG, Griffioen G, et al. Cancer risk in families with hereditary nonpolyposis colorectal cancer diagnosed by mutation analysis. Gastroenterology 1996;110:1020-7.
13Aarnio M, Sankila R, Pukkala E, Salovaara R, Aaltonen LA, de la Chapelle A, et al. Cancer risk in mutation carriers of DNA-mismatch-repair genes. Int J Cancer 1999;81:214-8.
14Gafanovich A, Ramu N, Krichevsky S, Pe'er J, Amir G, Ben-Yehuda D. Microsatellite instability and p53 mutations in paediatric secondary malignant neoplasms. Cancer 1999;85:504-10.
15Chan TL, Yuen ST, Chung LP, Ho JW, Kwan KY, Chan AS, et al. Frequent microsatellite instability and mismatch repair gene mutations in young Chinese patients with colorectal cancer. J Natl Cancer Inst 1999;91:1221-6.
16Bhatia S, Pratt CB, Sharp GB, Robison LL. Family history of cancer in children and young adults with colorectal cancer. Med Pediatr Oncol 1999;33:470-5.
17Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Kryj M. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg 2006;93:1215-23.
18Sessions RT, Riddell DH, Kaplan HJ, Foster JH. Carcinoma of the colon in the first two decades of life. Ann Surg 1965;162:279-84.
19Kravarusic D, Feigin E, Dlugy E, Steinberg R, Baazov A, Erez I, et al. Colorectal carcinoma in childhood: A retrospective multicenter study. J Pediatr Gastroenterol Nutr 2007;44:209-11.
20Endreseth BH, Romundstad P, Myrvold HE, Hestvik UE, Bjerkeset T, Wibe A; Norwegian Rectal Cancer Group. Rectal cancer in the young patient. Dis Colon Rectum 2006;49:993-1001.
21Pratt CB, Meyer WH, Howlett N, Douglass EC, Bowman LC, Poe D, et al. Phase II study of 5-fluorouracil/leucovorin for pediatric patients with malignant solid tumors. Cancer 1994;74:2593-8.
22Dozois EJ, Boardman LA, Suwanthanma W, Limburg PJ, Cima RR, Bakken JL, et al. Young-onset colorectal cancer in patients with no known genetic predisposition: Can we increase early recognition and improve outcome? Medicine (Baltimore) 2008;87:259-63.
23Karnak I, Ciftci AO, Senocak ME, Büyükpamukçu N. Colorectal carcinoma in children. J Pediatr Surg 1999;34:1499-504.
24Bosset JF, Collette L, Calais G, Mineur L, Maingon P, Radosevic-Jelic L, et al. Chemotherapy with preoperative radiotherapy in rectal cancer. N Engl J Med 2006;355:1114-23.
25Gérard JP, Conroy T, Bonnetain F, Bouché O, Chapet O, Closon-Dejardin MT, et al. Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: Results of FFCD 9203. J Clin Oncol 2006;24:4620-5.