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Overview of CRC (3/3)

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Tumor Staging and Treatment

Tumor staging is used by investigators and clinicians to group patients who have tumors with like characteristics into subgroups. Generally, grouping is according to

  • Tumor size
  • Extent of disease to the lymph nodes
  • Evidence of spread to distant organs-metastasis

There are many different staging systems; however, the system most commonly used in describing CRC is the Tumor, Nodes, Metastasis (TNM) system of the American Joint Committee on Cancer. Clinical trials testing the efficacy and safety of new agents, combinations of drugs, and multimodal therapies analyze study findings according to subgroups of patients with CRC, because there are differences in response, depending on extent of disease and various host factors. This approach helps physicians to base their recommendations on scientific evidence and to customize their treatment recommendations to the individual, thus ensuring that the patient will receive the best evidence-based therapy available given his or her particular clinical situation.

The following is a summary of evidence-based National Comprehensive Cancer Network (NCCN) guidelines for the formulation of treatment recommendations for CRC1 along with an illustration of each stage of the disease.11

  • Stage 0: surgery with clear margins. Referred to as carcinoma in situ, cancer cells found in the superficial tissues of the colon.
  • Stage I: surgery alone usually wide resection. Tumor is located in the inner most lining and tissues of the colon.
  • Stage II: surgery + consider 6 months of adjuvant chemotherapy or entry into clinical trial or observation alone; consideration of adjuvant chemotherapy is more strongly recommended for patients with high risk factors.
    Stage II is further defined as
    • IIA: confirmed in the middle layers of the colon and/or tissues around the colon.
    • IIB: located beyond the colon wall into nearby organs and/or through the peritoneum.
  • Stage III: surgery + 6 months of adjuvant chemotherapy; if patient had resectable liver metastasis then add radiation therapy.
    Stage III is divided into 3 substages
    • IIIA: The innermost tissue layer of the colon wall through the middle layers and detected in as many as 3 lymph nodes.
    • IIIB: Detected in as many as 3 nearby lymph nodes and spread to
      • beyond the middle tissue layers
      • or nearby tissues around the colon
      • or into nearby organs and/or through the peritoneum
    • IIIC: Cancer confirmed in 4 or more nearby lymph nodes and spread to
      • beyond the middle tissue layers
      • or nearby tissues around the colon
      • or into nearby organs and/or through the peritoneum.
    • Stage IV: surgery + chemotherapy with any of numerous regimens containing tested combinations of agents (5-FU/leucovorin, oxaliplatin, irinotecan, capecitabine, bevacizumab, cetuximab). Cancer has spread to adjacent lymph nodes and liver or lungs.

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Table 1. American Joint Commission on Cancer (AJCC) Staging for Colorectal Cancer: Tumor (T), Node (N), Metastases (M)

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Classification Description
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into the subserosa or into nonperitonealized pericolic or perirectal tissues
T4 Tumor perforates the visceral peritoneum or directly invades other organs or structures
NX Regional lymph nodes cannot be assessed
N0 No regional lymph mode metastases
N1 Metastasis in 1-3 pericolic or perirectal lymph nodes
N2 Metastases in > 4 pericolic or perirectal lymph nodes
MX Presence of distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis

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Stage Primary Tumor (T) Regional Lymph Nodes (N) Distant Metastases (M) Dukes
0 Tis N0 M0 —
I T1 N0 M0 A
  T2 N0 M0 B1
IIA T3 N0 M0 B2
IIB T4 N1 M0 B3
IIIA T1-T2 N1 M0 C1
IIIB T3-T4 N1 M0 C2/C3
IIIC Any T N2 M0 C1/C2/C3
IV Any T Any N M1 D

*From American Joint Committee on Cancer,9 with permission.Rule

 

References

  1. American Cancer Society. Cancers facts and figures 2007. Available at: http://caonline.amcancersoc.org/cgi/content/full/57/1/43. Accessed January 18, 2007.
  2. Surveillance, Epidemiology, and End Results (SEER). Cancer stat fact sheets: cancer of the colon and rectum. Available at: http://www.seer.cancer.gov/statfacts/html/colorect.html. Accessed February 6, 2007.
  3. Vasen, HFA. Clinical diagnosis and management of hereditary colorectal cancer syndromes. J Clin Oncol. 2000(21 suppl);18:81s-92s.
  4. Laken, SJ, Petersen,GM, Gruber, SB, et al. Familial colorectal cancer in Ashkenazim due to a hypermutable tract in APC. Nat Genet. 1997;17:79-83.
  5. Giovannucci E. Modifiable risk factors for colon cancer. Gastroenterol Clin North Am. 2002;31:925-943.
  6. Danaei G, Vander Hoom S, Lopez AD, et al and the Comparative Risk Assessment collaborating group (Cancers). Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet. 2005; 366:1784-1793. Also available at: http://www.thelancet.com/journals/lancet/full?volume=366&issue=9499. Accessed January 19, 2007.
  7. American Cancer Society. Colorectal cancer facts and figures special edition 2006. Available at: http://www.cancer.org/docroot/STT/stt_0_2006.asp?sitearea=STT&level=1. Accessed January 19, 2007.
  8. Francois F, Park J, Bini E. Colon pathology detected after a positive screening flexible sigmoidoscopy: a prospective study in an ethnically diverse cohort. Am J Gastroenterol. 2006;101:823-830.
  9. American Joint Committee on Cancer. AJCC Cancer Staging Manual, 6th ed. New York: Springer-Verlag; 2002.
  10. American Society for Gastrointestinal Endoscopy. Truth and misconceptions concerning colon cancer. Available at: http://www.askasge.org/pages/tentruths.cfm. Accessed January 19, 2007.
  11. National Comprehensive Cancer Network. Practice guidelines in oncology: colon cancer, v1.2007. Available at: http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf. Accessed January 19, 2007.

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This page was last modified on 2/15/2007, at 10:11:11 am ET.