Staging and Prognosis of Colon Cancer
Section snippets
History
In 1932, Cuthbert Dukes, a pathologist at St. Marks Hospital, introduced a staging system for rectal cancer based on the correlation between worsening patient prognosis and progressive tumor invasion of the bowel wall and regional lymph nodes [3]. Tumors with penetration limited to the bowel wall were classified as stage A, with penetration into the perirectal tissue classified as stage B. Involvement of regional lymph nodes designated the patient as stage C, regardless of the depth of
Current staging
Current staging uses the TNM system. The sixth editions of both the AJCC “Cancer Staging Manual” [9] and the UICC “Classification of Malignant Tumours” [10] went into effect in January 2003 (Table 1, Table 2). The evaluation of outcome data from large patient databases is used to constantly update the TNM system. Notable changes were made between the fifth and sixth iterations, foremost of which were stratifications of stages II and III. Stage II (T3–4 N0 M0 in the fifth edition) was split into
Future changes
The sixth editions of the AJCC-UICC staging systems allow for greater patient stratification and prognostication than previous editions. One assumption inherent in the concept of a staging system is that patients will have a worse prognosis (decreased survival) as their stage progresses. However, a recent analysis of patient survival by TNM staging has unveiled a conundrum in regard to sixth edition staging. Using the Surveillance, Epidemiology, and End Results (SEER) [14] data from January 1,
Sentinel lymph node biopsy
Given the evidence that examining fewer lymph nodes can result in missed nodal disease, it has been suggested that node-negative patients who experience a relapse did in fact have a false-negative nodal evaluation. A more focused examination of a subset of lymph nodes in specimen can be facilitated with the use of sentinel lymph node (SLN) biopsy. Sentinel lymph node biopsy uses blue dye or radiolabeled colloid in conjunction with intraoperative gamma probe localization or both to identify the
Staging of rectal cancer
As is the case for adenocarcinoma of the colon, the treatment of rectal cancer is primarily surgical. Traditionally, mid and high rectal cancer (5–15 cm from the anal verge) were treated with low anterior resection, with abdominoperineal resection used for lower tumors (≤5 cm from the anal verge). Several significant advances have been made in the last 20 years to promote less morbid treatment of rectal cancer. Advancements in surgical technique and neoadjuvant treatment regimens have been used
Prognostic factors in colorectal cancer
A large number of variables are known to be important in predicting tumor recurrence and death from colorectal cancer. The depth of tumor penetration and regional and distant lymph node metastases (ie, the TNM stage) remains the most accurate prognostic tool available [68]. Extensive research has been performed in the search for factors with prognostic significance independent of TNM staging. Particular points of interest include the identification of a subgroup of patients who have stage II
Summary
Significant advances have been made in all aspects of care relating to colorectal cancer. Although surgery will likely remain the mainstay of definitive treatment for the majority of colorectal malignancies, a better understanding of tumor progression and biology will help guide the choice of surgical therapy to best achieve a curative resection. Additionally, advances in the use of neoadjuvant and adjuvant therapies should continue to increase disease-free and overall survival when combined
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