Tech Coloproctol (2004) 8:S177–S179 DOI 10.1007/s10151-004-0149-2
N. Nikoloudis • K. Saliangas • A. Economou • E. Andreadis • S. Siminou • I. Manna • K. Georgakis T. Chrissidis
Synchronous colorectal cancer
Abstract Synchronous carcinomas of the colon and rectum are of considerable clinical significance because of their frequency, the number of extra tumours missed and the difficulty of preoperative diagnosis. A retrospective evaluation of 283 patients with primary colorectal adenocarcinomas was performed. There were 6 patients with 12 synchronous adenocarcinomas (2.12%). Colonoscopy and double-contrast barium enema revealed the synchronous cancer in 66.6% of the cases. In two cases the second cancer was found intraoperatively. In one patient an urgent laparotomy was performed because of acute abdomen caused by perforation of the ascending colon. Typical colectomies, depending upon the segment of the location of the lesion, were performed. Second cancers had a significantly more favourable stage than index colorectal adenocarcinomas. The index and the secondary cancers of synchronous colorectal adenocarcinomas showed a better histologic grade (well differentiated type) than the single cancers. Full clinical and radiological investigation is essential, before any operation is undertaken for colorectal cancer.
Introduction The incidence of two or more primary colorectal carcinomas has been estimated to be 2–9% [1] of all carcinomas in the colon and rectum. In up to 75% there are associated benign neoplasms [2–4]. Preoperative examination for colorectal carcinoma includes various methods, including barium enema and colonoscopy. There is still some controversy about which examination is better for complete surveillance of the whole colon and rectum. The significance of synchronous adenoma is not fully understood, but its presence is associated with an increased risk of metachronous colorectal cancer. In the general population people with an adenomamatous polyp might have a six-fold increased risk of developing colorectal cancer. If the synchronous cancers are recognised and treated promptly they do not often affect prognosis, but if ignored they present later as an early metachronous cancer, which might be at a more advanced stage.
Key words Synchronous colorectal cancer • Barium enema examination • Colonoscopy Patients and methods
N. Nikoloudis • K. Saliagas • A. Economou • E. Andreadis S. Siminou • I. Manna • K. Georgakis • T. Chrissidis Department of Surgery General Hospital of Edessa, Greece N. Nikoloudis () 61 Nikomidias str., 58200 Edessa, Greece E-mail:
[email protected]
From January 1990 to December 2003, 283 patients with primary adenocarcinomas were operated on in our department. There were 6 patients (5 male, 1 female), aged 59–83 (mean age 71.3 years) with synchronous adenocarcinomas (2.12%). The criteria we used for multiple colorectal carcinomas were: each tumour had to have a definite histological picture of malignancy, be distinctly separated by at least 2 cm from an intact bowel wall, and clearly have no metastatic origin from another colorectal tumour. Tumour locations were divided into four groups: (1) right colon, (2) transverse colon, (3) left colon and (4) rectum. A follow-up was pursued to be performed in all the patients. A case was considered cancer-free if no evidence was found of cancer recurrence or metastasis by clinical examination, physical examination, X-ray examination or tumour marker (CEA, Ca 19-9) during the follow-up time. The
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acute abdomen, caused by perforation of the ascending colon. In one patient the synchronous adenocarcinoma was found intraoperatively, by palpation of the colon. The sex and the age of the patients, as well as the tumour locations of index and secondary colorectal adenocarcinomas and the operations performed, are shown in Table 2. In synchronous colorectal adenocarcinoma, index cancer location was not significantly different from that of single cancers, but second cancers differed significantly from single cancers in location. Typical colectomies, depending upon the segment of the location of the lesion, were performed. In the case of the ascending colon perforation, local resection of the tumour and temporary colostomy was performed combined with sigmoidectomy. Histological staging of the index and second cancers and also the survival rate, are shown in Table 3. There were no significant differences in stage between the index cancer of synchronous and single colorectal adenocarcinomas. Second cancers had a significantly more favourable stage (33.3% stage 0, 16.6% stage I, 33.3%
staging system used was the TNM/UICC classification. After surgery, colonoscopy was performed twice annually or annually if there was, or was not, an associated lesion (polyp), respectively. CT of the abdomen was also performed annually.
Results Within the 13-year period, 277 patients presented with a single malignant colorectal adenocarcinoma, and 6 patients (5 male, 1 female) had two (2.12%) synchronous adenocarcinomas. The incidence of adenomatous polyps in patients with single CRC was 11.3% (32 patients), while the incidence of adenomatous polyps associated to synchronous adenocarcinomas was 33.3% (in two patients), all resected by the main operation or endoscopically later (Table 1). Colonoscopy and double-contrast barium enema revealed the synchronous cancer in four patients (66.6%). In one case an urgent laparotomy was performed because of
Table 1 Percentage of adenomatous polyps in single and synchronous CRC Patients
Percentage (%)
277 32 6 2
97.88 11.3 2.12 33.3
Single CRC Synchronous adenomatous polyps Synchronous CRC Synchronous adenomatous polyps CRC, colorectal cancer
Table 2 Sex, age, tumour location and operation performed in synchronous CRC Sex
Male Male Female Male Male Male
Age
75 59 66 83 63 82
Tumour location Index cancer
Second cancer
Ascending colon Rectum Sigmoid colon Sigmoid colon Caecum Sigmoid colon
Sigmoid colon Sigmoid colon Transverse colon Rectum Sigmoid colon Ascending colon
Operation
Right colectomy – sigmoidectomy Low anterior resection Sigmoidectomy – transverse colon resection Low anterior resection Right colectomy – sigmoidectomy Sigmoidectomy – local resection, colostomy
Table 3 Staging and survival rate in synchronous CRC Sex/age
Male/75 Male/59 Female/66 Male/83 Male/63 Male/82
TNM/UICC staging Index cancer
Second cancer
T3N0M0 (II) T4N3M0 (III) T4N2M0 (III) T2N1M0 (III) T4N1M0 (III) T4N3M1 (IV)
T4N0M0 (II) TisN2M0 (III) T2N0M0 (II) TisN0M0 (0) T2N0M0 (I) TisN0M0 (0)
Survival
12 months (alive) – no adjuvant therapy 13 months (alive) – chemotherapy 54 months 84 months 36 months 8 months
N. Nikoloudis et al.: Synchronous colorectal cancer
stage II and 16.6% stage III) than index colorectal adenocarcinomas. The index and the secondary cancers of synchronous colorectal adenocarcinomas showed a better histologic grade (well differentiated type) than the single cancers.
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Extensive use of preoperative colonoscopy, as well as intraoperative palpation of the whole colorectum, is recommended.
References Discussion The incidence rate of synchronous CRC in our study, among 277 patients, was 2.12%. Although this incidence is in agreement with other studies [1, 5], several authors believe that the true incidence is higher (7–9%) [6]. The importance of knowing the existence of these synchronous lesions at the time of operation is essential, because as has been proved, 50% of the second cancers were in stage 0, I (early cancers). This observation is confirmed by other authors [7]. Colonoscopy and double-contrast barium enema do not seem to be enough to detect all the synchronous lesions [7–10]. In our study this was achieved in 4 cases (66.6%). Palpation of the whole colorectum intraoperatively is recommended. Most authors agree that benign tumours are associated to CRC. The incidence of adenomatous polyps ranges from 12 to 62% of patients with a single CRC [9], and from 40 to 75% of patients with synchronous cancer [9]. The corresponding percentages in our study were 11.3% and 33.3%. We did not find any difference in the five-year survival between synchronous and single CRC, although there is a great controversy among the editors. In conclusion, full clinical and radiological investigation is essential before any operation is undertaken for colorectal cancer.
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