Colorectal cancer: Comparison of clinicopathologic features

Pathologie Biologie 61 (2013) 117–119
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Original article
Colorectal cancer: Comparison of clinicopathologic features between Moroccans
patients less than 50 years old and older
Le cancer colorectal : comparaisons des caractéristiques clinicopathologiques des patients âgés de
50 ans et moins avec des patients âgés de plus de 50 ans
A. Benmoussa a,*, S. Zamiati b, W. Badre c, A. Wakadi b, N. Bennani b, N. Tahiri Jouti b, S. Nadifi a
a
Laboratory of medical genetic, faculty of medicine and pharmacy Casablanca, 19, rue Tarik-Ibnou-Ziad, Casablanca, Morocco
Service of anatomy pathologic, centre hospitalier Ibn-Rochd, CHU de Casablanca, 8, rue Lahcen-El-Arjoune, quartier des Hôpitaux de Casablanca, Casablanca, Morocco
c
Service of gastroenterology, centre hospitalier Ibn-Rochd, CHU de Casablanca, 8, rue Lahcen-El-Arjoune, quartier des Hôpitaux de Casablanca, Casablanca, Morocco
b
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 3 August 2010
Accepted 18 January 2012
Introduction. – Colorectal cancer is a major public health problem. However, this cancer is usually
developed on preexisting lesion. This makes this cancer accessible to a prevention strategy.
Objective. – The aim of this study was to determine the clinicopathologic characteristics of patients
under 50 years.
Patients and methods. – This study involved 133 patients with colorectal cancer recruited in CHU IbnRochd, Casablanca. Data relating age, sex, stage at presentation, histological type and tumor location were
obtained from the pathological and clinical records of each patient. Statistical analysis was performed to
compare clinicopathological data in patients under 50 years and in older patients.
Results and discussion. – The average age of patients was 54 years. The frequency of patients aged 50 or
under was 40.6% The tumors in the youngest age group were more often mucinous and signet ring cells
(18.5%) versus (5.1%) in the oldest age group. The right colon was more often affected in the youngest age
group, 38.9% versus 17.7% in the oldest age group (P = 0.008).
Conclusion. – The proposition of colorectal cancer in subjects 50 or under was high in Morocco.
Colorectal cancers in the youngest age group were more often mucinous or signet ring cells and was more
often located in the right colon. We intend to complete this study by a genetic study to help improve
prevention and care of young patient.
ß 2012 Elsevier Masson SAS. All rights reserved.
Keywords:
Colorectal cancer
Clinicopathologic features
Young Moroccan patients
Under 50 years old
HNPCC
R É S U M É
Mots clés:
Cancer colorectal
Caractéristiques clinicopathologiques
Malades jeunes marocains
Âgés de moins de 50 ans
HNPCC
Introduction. – Le cancer colorectal est un problème majeur de santé publique. Toutefois, ce cancer se
développe généralement sur des lésions préexistantes, ce qui rend ce cancer accessible à une stratégie de
prévention.
Objectif. – Cette étude a pour objectif de déterminer les caractéristiques clinicopathologiques des
patients âgés de 50 ans ou moins, afin de détecter et de traiter plus efficacement ces patients jeunes.
Patients et méthodes. – Cette étude a porté sur 133 patients atteints de cancer colorectal, recrutés au
centre hospitalier universitaire Ibn-Rochd à Casablanca. Les données concernant l’âge, le sexe, le stade
lors de la présentation, la différenciation de la tumeur, le type histologique et la localisation de la tumeur
ont été tirées des dossiers pathologiques et cliniques de chaque patient. L’analyse statistique a été
effectuée pour comparer les données clinicopathologiques des patients de moins de 50 ans et les patients
plus âgés.
Résultats et discussion. – L’âge moyen des patients dans notre série était de 54 ans. La proportion des
patients de 50 ans et moins était de 40,6 %. Dans ce groupe, 18,5 % des cancers étaient mucineux ou en
bague à chaton contre 5,1 % chez les plus de 50 ans. Le cancer du côlon droit était plus fréquent chez les
patients de 50 ans et moins (38,9 %) que dans le groupe plus âgé (17,7 % ; p = 0,008). Cette étude va être
complétée par une étude génétique pour contribuer à améliorer la prévention et la prise en charge des
* Corresponding author.
E-mail address: [email protected] (A. Benmoussa).
0369-8114/$ – see front matter ß 2012 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.patbio.2012.01.003
A. Benmoussa et al. / Pathologie Biologie 61 (2013) 117–119
118
patients jeunes. Une proportion élevée des cancers colorectaux affecte des sujets jeunes au Maroc. Ces
cancers sont plus souvent de type mucineux ou en bague à chaton et siègent plus souvent dans le côlon
droit ou le rectum.
ß 2012 Elsevier Masson SAS. Tous droits réservés.
1. Introduction
Colorectal cancer (CRC) is a major public health problem. It is
frequent and severe. Every year, one million people in the world
develop CRC and 50% of them die within 5 years after diagnosis [1–
3]. However, this cancer is usually developed on preexisting lesion,
which makes this cancer accessible to a prevention strategy. The
study of colorectal cancer carcinogenesis has demonstrated an
accumulation of successive mutations, on both oncogenes and
tumor suppressor genes [4]. There are two main pathways of
carcinogenesis in the colorectal cancer: the chromosomal instability pathway borrowed by 85% of sporadic colorectal cancers and
all cancers developed in the context of familial adenomatous
polyposis (FAP); and the microsatellites instability pathway,
present mainly in colorectal cancers of hereditary non-polyposis
colorectal cancer (HNPCC) and in 15% of sporadic CRC. This
pathway is characterized by instability of repeated sequences
caused by deficient DNA repair. The genes involved are the
mismatch repair (MMR) [4–7].
In Morocco, the cancer registry of the Greater Casablanca report
that colorectal cancer represents 5% of recorded cancers, with a
standardized incidence of 5.3 new cases per 100,000 inhabitants.
The average age at diagnosis of CRC, according to the registry, was
56 years [8] versus 68 years in industrialized countries [2]. The low
age of patients with colorectal cancer in Morocco and the high
incidence of young patients led us to determine the clinicopathologic characteristics of patients younger than 50 years to permit us
detecting and treating effectively young people.
2. Patients and methods
This is a retrospective study between June 2008 to December 2009; 133 patients
with colorectal adenocarcinoma, confirmed by a histological examination in the
pathology unit of the University Hospital of Casablanca, were included. Data
relating age, sex, stage at presentation, differentiation of the tumor (well, moderate
and poor), mucinous and signet ring subtype, and tumor location were obtained
from the pathological and clinical records of each patient. The tumor location
dividing the large bowel into three sites: the right colon (appendix, cecum,
ascending colon, hepatic flexure and transverse colon), the left colon (splenic
flexure, descending colon and sigmoid colon), and the rectum (rectosigmoid
junction and rectal ampulla). Staging of the tumor was based on TNM classification
[9]. Statistical analysis was performed to compare clinicopathological data in
patients under 50 years and older patients, by the Chi2 test. A P value of < 0.05 was
considered significant.
3. Results
Our study involved 133 patients with colorectal cancer. The
average age of these patients was 54 years old, with an age range
from 18 to 89. Among them, 54% of the patients were women. The
mean age of females and males were respectively 53 years and 55
years. We divided the patients into two groups: patients who were
50 years old and less and patients more than 50 years old. The
number of patients in the first group was 54 (40.6% of the all
patients). The proportion of the women in the youngest age group
was 56.6% and in the oldest group 53.2%. In our series, 46.6% of the
cancers were located in the rectum. The proportion of right colon
cancers was higher in patients 50 years old and less than in older
patients (P = 0.008). The proportion of poorly differentiated
adenocarcinomas was higher in the youngest age group than in
the oldest (8.9%; P = 0.10). Mucinous adenocarcinomas and signet
ring cells represented 18.5% of cancers in the youngest age group
versus 5.1% in the oldest age group (P = 0.012) (Table 1).
4. Discussion
Our study aimed to explore differences in clinicopathologic
characteristics in Moroccan patients with early onset versus later
onset colorectal cancer. The mean age of patients was 54 years, and
sex ratio was 0.85. Fifty-four patients (40.6%) were 50 years of age
or younger. The sex ratio in the first group and the second group
were respectively 0.76 and 0.87. Youngest patients had significantly higher proportion of cancers in the right colon (38.9%)
compared to the oldest age group (17.7%) and a significantly higher
proportion of mucinous and signet ring cells histology. Clinical
characteristics from colorectal cancers in Morocco differ from
those reported in North America and Europe [1,3].
However, similar frequencies were reported by the countries of
North Africa, Tunisia 29.3%, Egypt 31% [10,11]. These data can be
explained by risk factors common to these countries. In fact,
colorectal cancer is multifactorial. Several risk factors have been
studied including food, tobacco, alcohol, physical inactivity and
precancerous lesions. Heredity is also a risk factor. It was
overestimated initially on the basis of specialized hospital
statistics. Population-based statistics indicate that hereditary
colorectal cancer represent less than 5% of all colorectal cancers
[12–14]. Two autosomal dominant diseases are known: familial
adenomatous polyposis (FAP) characterized by the presence of
thousands of colorectal polyps [6] and HNPCC or lynch syndrome
suspected by the Amsterdam criteria:
three or more family members with a confirmed diagnosis of
colorectal cancer, one of whom is a first-degree relative (parent,
child sibling) of the other two;
two successive affected generations (one of the patients is a firstdegree family member of the other patients);
one or more colon cancers diagnosed younger than 50 years;
FAP has been excluded.
Table 1
Comparison of clinicopathologics parameters between group I and group II.
Sex ratio Localisation
Parameter Number of Mean
patients
age of
patients
Right colon Left colon
Group I
Group II
P value
54
79
–
41.5
67.5
–
0.76
0.87
0.52
21 (38.9%)
14 (17.7%)
0.008
Differentiation
Left colon
Rectum
and rectum
10 (18.5%) 3 (5.6%)
16 (20.3%) 7 (8.9%)
0.8
0.47
Well
Moderately Poorly
20 (37.0%) 26 (48.1%) 18 (33.3%)
42 (53.2%) 46 (58.2%) 26 (32.9%)
0.06
0.25
0.84
Mucinous
and ring
cells
Tumors stages
Stages 1
and 2
Stages 3
and 4
10 (18.5%) 10 (18.5%) 30 (55.5%) 24 (44.7%)
7 (8.9%)
4 (5.1%) 56 (71%)
23 (29%)
0.10
0.012
0.069
0.07
Group I: patients 50 years old or younger; group II: patients more than 50 years old; a P value < 0.05 was considered significant.
A. Benmoussa et al. / Pathologie Biologie 61 (2013) 117–119
These criteria are considered too stringent by the experts; they
have been revised several times. But young age seems to be a
common trait [15,16].
We think that in Morocco, the lynch syndrome is underestimated and that could be explained by two points: the
first one is that colorectal cancer in persons with lynch
syndrome occurs at an early age [15]. The second point is that
clinicians would not press for complete family medical history
of patients. And this may lead to missed diagnosis of lynch
syndrome.
However, the proportion of colorectal cancer with a genetic
predisposition is not high in population-based studies. In a
population-based study in France, in patients under 45, 8.9%
occurred in the context of familial polyposis and 1.4% within
HNPCC syndrome [16]. Järvinen and Turunen [17] reported 6.8% of
colorectal cancer in young patients with ‘‘cancer family syndrome’’.
On patients’ gender, most studies found that there are more
men than women in the young group, but the difference is not
significant [18]. Also, we found that there is no difference in gender
distribution of the two groups.
The presence of mucinous and signet ring tumors was reported
by several articles [18–21]. We confirmed the same results in our
series (18.5% versus 5.1% in the group of old). Similar to previous
studies, we found that the colorectal cancer in young patients was
more localized in the right side. Although, we did not find a
significant difference between the two groups about tumor stage
classification, and the histology differentiation, in contrast with
other studies [18–21]. The small size of our sample may partly
explain this mismatch.
In this study, we verified that young Moroccan patients with
CCR had several distinct clinicopathological characteristics. We
thought that genetic study will have a great merit and will
contribute to better prevention and adapted coverage of young
patients.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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