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Chapter 13: Colorectal Cancer

Jennifer M. Duff; Jason Starr; Carmen Joseph Allegra

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INTRODUCTION

Epidemiology

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Epidemiology
Incidence
Colorectal (CRC) cancer: 145,600 estimated new cases in 2019: 101,420 colon cancer and 44,180 rectal cancer
Deaths: 51,020 estimated in 2019
Median age at diagnosis: 67 years
Lifetime risk of developing CRC: 4.2 percent of men and women will be diagnosed in their lifetime. CRC is more common in men compared with women, and in those of African-American descent

Surveillance, Epidemiology and End Results (SEER) Program, available from http://seer.cancer.gov [accessed 2019]

https://www.cancer.net/cancer-types/colorectal-cancer/statistics [accessed 2019]
Colorectal Cancer Subsites
Proximal colon: 41%
Distal Colon: 22%
Rectum: 28%
Other: 8%
Staging Distribution: Colon
Local: 38%
Regional: 35%
Distant: 23%
Staging Distribution: Rectum
Local: 41%
Regional: 34%
Distant: 19%

Howlader N et al, editors. SEER Cancer Statistics Review, 1975–2016. Bethesda, MD: National Cancer Institute; 2019

Siegel RL et al. Colorectal Cancer Statistics, 2017. CA Cancer J Clin 2017;67:177–193

Five-year Survival

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Five-year Survival
Colorectal Cancer: Five-year Relative Survival by Stage at Diagnosis
Localized (cancer confined to primarysite) 90%
Regional (cancer spread to regional lymph nodes) 72%
Distant (cancer metastasized) 14%

https://seer.cancer.gov/statfacts/html/colorect.html#survival [accessed 2020]

Amin MB et al, editors. AJCC Cancer Staging Manual 8th Ed. New York: Springer; 2017

Work-up

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Work-up
Colon and Rectal Cancer Appropriate for Resection

H&P, CBC, serum electrolytes, LFTs, serum creatinine, BUN, and CEA. Full colonoscopy, CT scan of thorax and abdomen, and pelvis with IV and oral contrast, pathology review

Rectal lesions: pelvic MRI with contrast or endoscopic ultrasound

PET scans are not routinely performed, used to clarify findings from a contrasted CT scan or if the patient has a contraindication to receiving contrast

MSI or MMR testing should be performed in all patients with a personal history of colon cancer to evaluate for the risk of Lynch syndrome and provide prognostic value in stage II CRC
Stage IV As above plus extended RAS analysis and BRAF V600E mutation testing
https://www.nccn.org/professionals/physician_gls/pdf/rectal_blocks.pdf [accessed March 2017]

Pathology

World Health Organization Classification

  1. Adenocarcinoma (>90%)

  2. Mucinous adenocarcinoma

  3. Adenosquamous carcinoma

  4. Small cell carcinoma

  5. Medullary carcinoma

  6. Signet ring adenocarcinoma

  7. Squamous cell carcinoma

  8. Undifferentiated

 

Skibber JM et al. Cancer of the colon. In: DeVita VT Jr et al. editors. Cancer: Principles & Practice of Oncology, 10th ed. Philadelphia: Wolters Kluwer; 2015:1216–1270

Staging

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Staging
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ: intraepithelial or invasion of lamina propria✫
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into pericolorectal tissues
T4a Tumor penetrates to the surface of the visceral peritoneum
T4b Tumor directly invades or is adherent to other organs or structures†

✫Tis includes cancer cells confined within the glandular basement membrane (intraepithelial) or mucosal lamina propria ...

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