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A retrospective analysis of 2000 cases with colorectal carcinoma

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Colorectal cancer (CRC) is a major cause of death in the western world and a leading cause of cancer-related death. It is one of the most common human malignancies with >300,000 cases both in the United States and in the European Union each year.
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  A retrospective analysis of 2000 cases with colorectal carcinoma G. Basdanis  • A. Mekras  • V. N. Papadopoulos  • E. Karamanlis  • D. Paramythiotis  • D. Mekras  • D. Panagiotou  • S. Panidis  • A. Michalopoulos Published online: 2 September 2011   Springer-Verlag 2011 Abstract Purpose  Colorectal cancer (CRC) is a major cause of death in the western world and a leading cause of cancer-related death. It is one of the most common humanmalignancies with  [ 300,000 cases both in the UnitedStates and in the European Union each year. The presentstudy was conducted to assess differences in various vari-ables of CRC, such as location of the tumor, differentia-tion, Dukes classification, 5-year survival and possiblechanges in these patterns during the examined period.  Methods  We collected data on 2000 patients with colo-rectal cancer, diagnosed and treated from 1960 to 2008 in1st Propedeutic Surgical Clinic of Aristotle’s University,Thessaloniki.  Results  Of 2000 cases reviewed, cancer was almost equalpresented to both sexes, for all groups. Rectum was themost common tumor location in all analyzed groups(40.1%). The most common tumor differentiation was themoderate one (68.5%). Concerning tumor staging, Dukes’B tumors were most common (42.5%), and the cancer-related 5-year survival was increased by the time from 42to 71%. Conclusion  In the past 20 years, considerable improve-ments have been made in colorectal cancer therapy, andpatients had received more sophisticated and multidisci-plinary treatments, resulting in a better 5-year survival rate. Keywords  Colorectal cancer    Dukes stage   Differentiation Introduction Colorectal cancer (CRC) is a major cause of death in thewestern world and a leading cause of cancer-related death.It is one of the most common human malignancies with [ 300,000 cases both in the United States and in theEuropean Union each year. In the past decade, survival of metastatic colorectal cancer patients has approximatelydoubled [1]. This significant improvement is mainly due tothe development of new combinations of standard che-motherapy, radiotherapy, new surgical equipments andtechniques, and also to the introduction of new targetedtherapies, such as monoclonal antibodies [1]. Most colo-rectal cancer arises from adenomatous polyps. Theselesions can be detected and removed during colonoscopy.Studies show this procedure would decrease by [ 80% therisk of cancer death, provided it is started by the age of 50and repeated every 5 or 10 years [2]. Most colorectalcancers should be preventable, through increased surveil-lance, improved lifestyle and, probably, the use of dietarychemopreventative agents. As per current guidelines underNational Comprehensive Cancer Network, in average risk individuals with negative family history of colon cancerand personal history negative for adenomas or inflamma-tory bowel diseases, flexible sigmoidoscopy every 5 yearswith fecal occult blood testing annually or double-contrastbarium enema is another option acceptable for screeningrather than colonoscopy every 10 years (which is currentlythe gold standard of care). Colorectal cancer is very much acancer of the elderly, and with increasing aging of thepopulation, the number of cases in the population may be G. Basdanis    A. Mekras ( & )    V. N. Papadopoulos   E. Karamanlis    D. Paramythiotis    D. Mekras   D. Panagiotou    S. Panidis    A. MichalopoulosFirst Propedeutic Surgical Clinic,Aristotle’s University of Thessaloniki,A.H.E.P.A. Hospital, St. Kyriakidi 1,54636 Thessaloniki, Greecee-mail: almekras@yahoo.gr  1 3 Tech Coloproctol (2011) 15 (Suppl 1):S107–S110DOI 10.1007/s10151-011-0744-y  expected to rise further in spite of decreases in incidenceand mortality rates [3].The present study was conducted to assess differences invarious variables of CRC and possible changes in thesepatterns during the examined period. Patients and methods We collected data on 2000 patients with colorectal cancer,diagnosed and treated from 1960 to 2008 in 1st PropedeuticSurgical Clinic of Aristotle’s University, Thessaloniki. Thediagnosis was based in combination of clinical examinationand laboratory results. Pathologic confirmation of diagno-sis was also available. For our analyses, the followingvariables were assessed: age, sex, location of the tumor(right, left colon and rectum), grade of differentiation(well, moderate and poor) and stage (Dukes classification).Five patient’s groups were created according to the decadeof presentation as follows: Group A, from 1960 to 1969;Group B, from 1970 to 1979; Group C, from 1980 to 1989;Group D, from 1990 to 1999; and Group E, from 2000 to2008. CRC-specific survival was computed since the dateof cancer diagnosis up to the date of death or end of follow-up (December 31, 2004). Patients who died due to causesunrelated to colorectal cancer were censored at the time of death, whereas patients who died within 1 month fromsurgical intervention were excluded from the analyses.Cancer-related 5-year survival and stage-related survivalwere analyzed. Univariate analysis was performed usingthe chi-squared test, with statistical significance attributesto  P \ 0.05. Results Of 2000 cases reviewed, 130 patients were allocated toGroup A, 170 to Group B, 301 to Group C, 559 to Group Dand 800 to Group E. The patient’s mean age was60.72 years for Group A, 62.90 years for Group B,63.10 years for Group C, 64.70 years for Group D and62.30 years for Group E. The main clinical symptomsaccording to the prevalence were in 57% of patients changein frequency or character of stool (bowel movements),abdominal pain in 32%, rectal bleeding in 29%, iron defi-ciency anemia in 27% and other symptoms (fatigue, per-sistent nausea or vomiting, unexplained weight loss, rectalpain and abdominal distension) in 18%. Cancer was almostequal presented to both sexes, for all groups (Table 1).The rectal location of tumors constituted more than 40%of total cases. Rectum was the most common tumor loca-tion in all analyzed groups, except Group D, in which theleft-side tumors outbalanced. The right-side carcinomaswere the less common primary tumor location in all fivegroups. The tumor location distributions are presented inTable 2.The most common tumor differentiation was the mod-erate one for all groups (Table 2). Good differentiationtumors showed a continuous decrease from Group A (38%)to Group E (15%). Low tumor differentiation decreasedalso during the recent years.Concerning tumor staging (Table 3), Dukes’ B tumorswere more common in Groups A, B, D and E (48 and 42%in Groups A and B, and 43 and 47% in Groups D and E,respectively). Dukes’ C stage was the second most commonin all groups, except Group C. Metastasis (Dukes’ ‘‘D’’) was Table 1  Patient’s sex distribution in the five analyzed groupsGroup A Group B Group C Group D Group EMale  n  (%) 66 (50.7) 88 (51.7) 151 (50.2) 285 (51) 411 (51.3)Female  n  (%) 64 (49.3) 82 (48.3) 150 (49.8) 274 (49) 389 (48.7)Total  n  130 170 301 559 800 Table 2  The tumor location distributions and differentiation in the five analyzed groupsColon DifferentiationRight  n  (%) Left  n  (%) Rectum  n  (%) Good  n  (%) Moderate  n  (%) Low  n  (%)Group A 37 (28.5) 45 (34.6) 48 (36.9) 49 (38) 65 (50) 48 (36.9)Group B 49 (28.8) 54 (31.7) 67 (39.5) 62 (36) 83 (49) 67 (39.5)Group C 83 (27.6) 101 (33.6) 117 (38.8) 92 (31) 185 (61) 117 (38.8)Group D 115 (20.5) 233 (41.6) 211 (37.5) 101 (18) 420 (75) 211 (37.5)Group E 213 (26.7) 268 (33.5) 319 (39.8) 120 (15) 616 (77) 319 (39.8)Total 497 (24.8) 701 (35) 802 (40.1) 424 (21.2) 1,369 (68.5) 802 (40.1)S108 Tech Coloproctol (2011) 15 (Suppl 1):S107–S110  1 3  more common (17%) in Group C, in contrast to 2% in theGroup B patients, in the second period.The stage-related survival was increased for eachpatient’s decade group (Fig. 1). Cancer-related 5-yearsurvival (CRS) was also increased in every group (Fig. 2).The patients in Group E (2000–2008) showed the highestCRS (71% with more than 5 years). The CRS was almostdoubled from Group A to Group E. Discussion In the past 20 years, considerable improvements have beenmade in colon cancer therapy, with overall survival ratesincreasing from 45 to 75%. It is important to note that thepatients had received better treatment after 1985. Colo-rectal cancer treatments continually evolve, and survivalrates have likely improved since the late 1980s. Recent Table 3  The Dukes tumor stage in the five analyzed groupsDukes A  n  (%) Dukes B  n  (%) Dukes C  n  (%) Dukes D  n  (%) TotalGroup A (1960–1969) 21 (16.2) 63 (48.5) 29 (22.3) 17 (13) 130Group B (1970–1979) 26 (15.3) 72 (42.3) 67 (39.4) 5 (3) 170Group C (1980–1989) 39 (13) 95 (31.6) 115 (38.2) 52 (17.2) 301Group D (1990–1999) 104 (18.7) 241 (43) 147 (26.3) 67 (12) 559Group E (2000–2008) 107 (13.4) 379 (47.3) 235 (29.4) 79 (9.8) 800Total 297 (15) 850 (42.5) 593 (29.5) 260 (13) 2,000 Group AGroup BGroup CGroup DGroup EA8183859091B6567717983C4751535859D3455.360102030405060708090100    %   o   f   C  a  s  e  s Fig. 1  The stage-related survival in the five analyzed groups GROUP AGROUP BGROUP CGROUP DGROUP E<5 years5856523829>5 years424448627101020304050607080 % Fig. 2  Cancer-related 5-year survival in the analyzed groupsTech Coloproctol (2011) 15 (Suppl 1):S107–S110 S109  1 3  data show that the 5-year survival rates according to thetumor localization are raised (rectum: 59%, right colon:59%, left colon: 65%) [4]. Rectal cancer is considered tohave a higher recurrence rate than colon cancer, because of the extensive lymphatic drainage of the pelvis [5].The sex ratios for colon and rectal cancer differ, rectalcancer being distinctly more common among males in mostcountries, whereas colon cancer affecting both sexes atrather similar rates [6]. In the present study, we did not findstatistically significant differences between the male andfemale patients. We did not find any significant differencesin the incidence of tumor localization. The left colon andrectal tumors constituted more than 75% of total cases. Ourresults are similar with previous reports [7, 8], and in contrast to the results of Gao et al. [9], that both males andfemales show increases in rates of right colon cancer.Our data analysis revealed that the almost 2/3 of thetumors were histologically classified to the moderate dif-ferentiated group, which is comparable with the recentliterature data [10]. The stage-related survival wasincreased for each patient’s decade group. The most sta-tistically significant difference was observed in stage Dtumors. The largest survival improvement was seen duringthe later group of the period observed. Cancer-related5-year survival (CRS) was also increased in every group,with the major improvement in patient’s Group E(2000–2008), which showed the highest CRS (71% withmore than 5 years). The survival improvement is probablya result of the implementation of new combinations of standard chemotherapy, radiotherapy, new surgical equip-ments and techniques, and also to the introduction of newtargeted therapies. Conflict of interest  The authors certify that there is no actual orpotential conflict of interest in relation to this article. References 1. Lie`vre A, Bachet JB, Boige V et al (2008) KRAS mutations as anindependent prognostic factor in patients with advanced colo-rectal cancer treated with cetuximab. J Clin Oncol 26:374–3792. Winawer SJ, Zauber AG, Ho MN et al (1993) The National PolypStudy Workgroup. Prevention of colorectal cancer by colono-scopic polypectomy. N Engl J Med 329:1977–19813. Gibbons L, Waters C, Mao Y et al (2001) Trends in colorectalcancer incidence and mortality. Health Rep 12:41–554. Gatta G, Ciccolallo L, Capocaccia R et al (2003) EUROCAREWorking Group. Differences in colorectal cancer survivalbetween European and US populations: the importance of sub-site and morphology. Eur J Cancer 39:2214–22225. Papadopoulos VN, Michalopoulos A, Netta S et al (2004) Prog-nostic significance of mucinous component in colorectal carci-noma. Tech Coloproctol 1(Suppl):s123–s1256. La Rosa F, Tozzi P, Saltalamacchia G, Vitali R (1989)Descriptive epidemiology of malignant tumors of the colon andrectum. Ann Ig 1(5):899–9227. Wong MT, Eu KW (2007) Rise of colorectal cancer in Singapore:an epidemiological review. ANZ J Surg 77:446–4698. Malila N, Hakulinen T (2003) Epidemiological trends of colo-rectal cancer in the Nordic countries. Scand J Surg 92:5–99. Gao RN, Neutel CI, Wai E (2008) Gender differences in colo-rectal cancer incidence, mortality, hospitalizations and surgicalprocedures in Canada. J Public Health (Oxf) 30:194–20110. Fenoglio-Preiser CM, Noffsinger AE, Stemmermann GN, LantzPE, Isaacson PG (2007) Gastrointestinal pathology: an atlas andtext. Wolters Kluwer, PhiladelphiaS110 Tech Coloproctol (2011) 15 (Suppl 1):S107–S110  1 3
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