Early Stage Colon Cancer

Case History:
Our patient, 42-year-old gentleman, has history of recurrent abdominal pain for a duration of around one year, on initial evaluation he was found to have duodenal ulcer and H pylori infection is stomach. He was treated for same by gastro physician. However, the pain continued intermittently, and he also developed constipation, so he was again investigated thoroughly and was found to have colon carcinoma involving hepatic flexure. Further staging workup showed non metastatic tumor and so he underwent curative colon cancer surgery i.e. Right hemicolectomy with ileostomy under our gastro surgical team. He had post-operative complication of anastomotic hemorrhage, which was managed with re-exploration and blood transfusion with good response. His post-operative recovery was overall slow and he had significant weight loss for which dietary changes and nutritional supplements were added. Diagnosis: His final histopathology report of surgery confirms the ulcerative poorly differentiated adenocarcinoma of hepatic flexure along with mucinous component and signet ring cells, involving pericolic fat, margins were negative, all 71 lymph nodes were negative for metastasis, no lymph vascular or perineural invasion. So final stage comes to be pT3N0M0, Gr3 (AJCC stage IIA). He was than counseled for further treatment options and their benefits.
 
Discussion:
The aim of adjuvant therapy is to eradicate residual micro metastasis thus improving the cure rate in early stage. Adjuvant chemotherapy has become standard for stage III colon cancer and most for the centers uses 6 months of FOLFOX or CAPOX regimens, However the decision to treat a patient with stage II colon cancer with adjuvant chemotherapy can be challenging. Although the benefit of treatment is clear in most patients with stage III disease, the decision to provide chemotherapy after surgical resection in stage II disease, must be made on an individual basis. Several trails have demonstrated the small but absolute benefits of receiving adjuvant chemotherapy for stage II colon cancer for disease-free survival and overall survival (2 to 5% absolute benefit). In an attempt to better understand the role of chemotherapy, several studies were performed that identifies high risk characteristic that can be used prognostically and predictively to aid in the clinical decision-making process, ASCO, the National Comprehensive Cancer Network, and the European Society of Medical Oncology have published guidelines describing these high-risk characteristics.
 
Risk Stratification in the Stage II Colon Cancer Population:
The NCCN clinical practice guidelines define high-risk stage II disease as being characterized by at least one of the following factors: T4 tumors; poor histologic grade (undifferentiated or poorly differentiated); lymph vascular involvement; bowel obstruction at presentation; T3 lesion with localized perforation or close, indeterminate, or positive margins; MSI (Microsatellite Instability) – Low and Inadequately sampled lymph nodes (defies as fewer than 12 nodes analyzed). According to these guidelines, patients with high-risk disease should be considered for adjuvant chemotherapy. The presence of MSI has been associated with better outcomes in stages II and III  patient. So as per guidelines if patient of stage II colon cancer has MSI high result and there are no other high-risk factors present. We can safely avoid adjuvant chemotherapy.
 
Summary:
For patients with low-risk stage II cancer, the small-interval benefit from treatment is balanced by the fixed risks of severe toxicity from chemotherapy. Although the decision regarding adjuvant treatment needs to be individualized, observation only is an acceptable option for these patients. For the patient with high-risk stage II disease, the benefit from chemotherapy is greater and outweighs the risks associated with chemotherapy in most situations. Guidelines recommend options of either observation alone or combination chemotherapy alone or combination chemotherapy regimens for high risk stage II disease. In our patient it was decided to give adjuvant chemotherapy with either CAPOX or capecitabine alone depending on the post-operative recovery. This decision was made based on high risk features of poorly differentiated tumor morphology. Also, additional poor prognostic factors were considered like young age of diagnosis and presence of signet ring morphology in overall decision making. Our patient finally decided to go for MSI testing to decide between chemotherapy versus observation option. The result of test is pending by this time.

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