Abstract

Colorectal cancer (CRC) is the third most common cancer in the world and considered mainly as a disease of the elderly. Almost 60% of cases are encountered in developed countries. In India, colon cancer ranks 8th and rectal cancer ranks 9th among men. For women, rectal cancer does not figure in the top 10 cancers, whereas colon cancer ranks 9th.[1] An alarming proportion of adenocarcinoma has been noted in adults aged <50>50 years.[2,3] We review the presentation, treatment, and outcomes of patients with carcinoma colon who were aged <40>

Tumor registry at our hospital was analyzed for cases of CRC. Of the 320 patients studied, those diagnosed with CRC aged <40>

An total of 89 patients diagnosed with CRC and aged <40 href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5759066/table/T1/" target="table" class="fig-table-link figpopup" rid-figpopup="T1" rid-ob="ob-T1" co-legend-rid="" xss=removed>Table 1. The median age of the study cohort was 33 years (12–40). Majority of the patients belonged to the age group of 30–39 years (n = 49; 55%). There was a male preponderance (56.2%) with the ratio of male to female being 50:39. The most common symptoms at presentation were lower gastrointestinal bleed (n = 43; 48.3%) followed by abdominal pain (n = 41; 46.1%). The other common presenting complaints were change in bowel habits (n = 37; 41.5%), weight loss (n = 24; 26.9%), obstructive symptoms (n = 13; 14.6%), and tenesmus (n = 3;3.4%). The most common sites of disease were the rectum (n = 45; 50.6%) followed by the following sites in the colon namely - unspecified site (n = 12; 13.5%), caecum (n = 7; 7.9%), ascending colon (n = 7; 7.9%), and the rectosigmoid junction (n = 7; 7.9%). There was only one case of a synchronous primary – involving both the rectum and hepatic flexure (each staged separately). The histology in all the cases was adenocarcinoma. Most tumors were either moderately (n = 48; 54%) or poorly differentiated (n = 35; 39.3%). Most tumors presented in higher stage, with stage 3/metastatic disease. The most common sites of metastases were liver (n = 15; 46.9%) followed by metastases in the peritoneum (n = 11; 34.3%) and ovaries (n = 9; 28.1%). The other sites with metastatic involvement were omentum, and uncommon sites were mesentery, anterior abdominal wall, bones, supraclavicular lymph nodes, lung, and pleura.

Table 1

There was no family history of colon cancer in any of our patients. This is unlike some studies that have documented an incidence of >10%.[6,9]

The most common sites involved were the rectum, followed by right-sided colonic cancers. This is similar to various studies where rectum or the proximal colon has been the dominant sites of involvement in young patients.[2,3,6,7,8] Whether the propensity for tumors to occur more in the right colon than left in young patients is indicative of the presence of familial syndromes which are uninvestigated needs to be looked into. We had one case of synchronous primaries – rectum with hepatic flexure. Studies have not documented synchronous primaries, except the study by Gado et al.[8] which had one such case.

The stage of malignancy in our patients was mostly of advanced stage. There were a considerable number of patients with higher T and N status. This is in concordance with other studies which have documented higher stages in younger patients.[2,9] The delay in diagnosis, higher grade of tumor, and lower suspicion of malignancy in younger people due to assumed lack of incidence could be causative factors for an advanced presentation.

The grade of tumor in our series was mostly moderately or poorly differentiated carcinoma, suggesting a more aggressive tumor biology in this subset of patients, which translates to poorer outcomes. A higher grade of tumor has been documented in all studies that have analyzed this subset of patients.[3,6,9]

The most common sites of metastases in our study were liver, followed by intraabdominal sites such as peritoneum, ovary, and mesentery which concur with the fact that the most common presenting site is hepatic in CRC. Three cases had metastases in their appendicular skeleton – the humerus and radius and ulna, which are unusual sites of metastases in carcinoma colon.

Most patients were treated with curative intent, with most receiving the standard multimodality treatment. The most common practiced regimen in our center is FOLFOX-4 which was administered to 88.6% of the patients receiving chemotherapy, followed by 5-fluorouracil/leucovorin which is the regimen in those receiving concurrent chemoradiation. Other regimens commonly used include capecitabine/oxaliplatin and single agent capecitabine, which have not been used in any of the patients in the present study. Although the patients with metastatic disease received palliative chemotherapy, none could be administered targeted therapies.

The OS of the cohort was a median of 23 months, with patients in the early stages (34 months) doing significantly better than those in the advanced stage (19 months), i.e., patients who are node positive, locally advanced disease and metastatic disease. A study has documented a low 5-year survival of 23% in their patients of carcinoma colon in young.[10] Furthermore, those with metastatic disease upfront had a significantly inferior survival (14 months) compared to those without metastatic disease (26 months) (P = 0.00196). The median OS between those aged <40>40 years in our analysis revealed a significantly inferior outcomes for those with CRC in young, 35 versus 23 months (P = 0.0029). The lower survival noted could be due to higher grade and mere number of patients presenting with advanced stage of disease.

Analysis revealed that there were no variables that significantly affected survival such as age, grade, and site of metastases – hepatic versus extrahepatic. However, univariate analysis for gender revealed a significantly better outcome for females than males.

Conclusions

Colorectal carcinoma seems to be emerging as a major health problem even in developing countries like India. Changing lifestyle, dietary habits, obesity, and lesser physical activity would only become additive risk factors to this subset of patients. Our study revealed that carcinoma colon in young was aggressive and associated with high mortality. There should be a high index of suspicion in any young patient presenting with symptoms suggestive of a colonic malignancy and should be evaluated promptly and treated aggressively.

Acknowledgment