Colorectal cancers under 45 years of age

BACKGROUND/AIMS: The aim of this study was to evaluate patients with colorectal cancer under the age of 45 and compare with colorectal cancer patients over the age of 45 treated in our surgical clinic. METHODOLOGY: At the Surgical Department of the Medical Faculty of Uludag University between 1986-2000 (15 years), 680 cases with colorectal cancer diagnosis were operated on. One hundred and thirty-six (20%) of these cases who were under the age of 45 were retrospectively evaluated and compared with other patients. RESULTS: The family history of ten of those patients was positive. The most common referring symptoms were rectal bleeding (61.7%), and weight loss (29.4%). Tumor was localized at right colon in 19%, at left colon in 6.6%, at the sigmoid and the rectum in 74%. Nine of those cases (6.6%) were operated emergently, the rest (93.3%) were operated electively. One hundred and eighteen of the cases (86.7%) were resectable and 61 cases (44.8%) were showing distant metastases during the operations. CONCLUSIONS: As a conclusion, in Turkey, young age group colorectal cancers are 4-5 times more common than in Western communities. Because of the high probability of colorectal cancers, considering the possibility of colorectal cancer and taking a careful family history will help to catch the case at an earlier stage and will improve the chance of cure.     

Colorectal adenocarcinoma in patients less than 40 years of age

From 1973 to 1985, 105 patients under 40 years of age were treated for colorectal adenocarcinoma at Roswell Park Cancer Institute. There were 51 males and 54 females. The mean age was 32 years. The majority of patients were treated for left colon or rectal carcinomas. Ninety-seven of 105 patients underwent surgical resection of their primary cancer, 70 (67 percent) of which were potentially curative. Twenty-seven patients underwent palliative resections. Dukes' A or B lesions were not seen in patients less than 20 years old, whereas these early lesions were seen in 11 percent of patients 20 to 29 years old and in 26 percent of patients greater than 30 years of age. The mean survival for patients between 20 and 29 years was 39 months and 46 months for patients 30 years and older.     

Colorectal cancer in patients older than 75 years of age

Two hundred and seven hospital records of patients with colon or rectal cancer from 1982 to 1985 were reviewed retrospectively. Ninetysix patients were 75 years of age or older and 111 were younger than 75 years. Comparison of the two groups showed that the elderly group presented with lower hematocrits and serum albumin values despite comparable pathologic stages and tumor location. A higher preanesthetic stage was seen in the elderly group. The total perioperative mortality rates for the young and elderly groups were 3.6 percent and 7.1 percent, respectively, and were not statistically different. Emergency perioperative mortality rates were 5.2 percent and 10 percent, respectively, and also were not statistically different. All nine patients aged 90 and older underwent a major abdominal operation without the occurrence of any perioperative mortality. This study suggests that age need no longer be considered a major risk factor for immediate surgical outcome in colorectal cancer.     

Colorectal cancer in patients under 40 years of age

In a review of 1037 patients with colorectal cancers, there were 32 patients below the age of 40 years (3 percent). Rectal bleeding and abdominal pain were the most common presenting symptoms. The average delay between the onset of symptoms and treatment was 6.5 months. An analysis of tumors according to Dukes' staging revealed no significant difference between young and elderly patients. The younger patients had a greater frequency of mucinous and poorly differentiated carcinoma. When compared by clinical staging, however, the young patient did as well or better than his older counterpart. Clinical staging was the most important prognostic factor, irrespective of age. No inherent difference was found in the virulence of the cancer in the young, and five-year survival rates were not significantly different in young and old patients (59 percent vs. 49 percent).     

Characteristics of patients with lung cancer under the age of 45 years: a case control study

OBJECTIVE: The aim of this study was to define the clinical and pathological features associated with lung cancer diagnosed in persons under the age of 45 compared with lung cancer in an older population of greater than 45 years. METHODOLOGY: A case control study was undertaken. Cases were defined as patients diagnosed with lung cancer under the age of 45 years. Controls were lung cancer patients over 45 years matched only for the date of diagnosis. Up to four controls were selected for each case. A retrospective review was undertaken of the records of a single tertiary respiratory institution which served a population of 1.2 million. RESULTS: Forty-eight cases of lung cancer (< 45 years of age) were identified and were compared to 123 matched controls with lung cancer (> 45 years of age). Of the cases 67% were female compared with 32% female cases in the control group (P < 0.01). The rate of adenocarcinoma was significantly higher among cases (48% vs 27%, P=0.001), while squamous cell carcinoma was more common in the controls (35% vs 17% P =0.001). Smoking was common in both groups although less so among cases (79% vs 95%, P=0.001)). There was no difference in survival rates between the cases (11 months) compared with controls (8 months) (P=0.1). CONCLUSIONS: Young lung cancer patients were predominantly female and adenocarcinoma accounted for a disproportionate number of the histological types. Cigarette smoking appears to be the main aetiological agent but as 21% of the patients under 45 years were non-smokers, other factors (genetic/hormonal) may also contribute. This study has not demonstrated a worse outcome in younger patients.     

Primary myelodysplasia: management and outcome at 3 years in 45 patients age 65 and older

OBJECTIVES: To study myelodysplasia in patients age 65 and older. SETTING: A French university hospital. PARTICIPANTS: Forty-five patients age 65 and older with a diagnosis of myelodysplasia made in the hospital between January 1993 and December 1998. MEASUREMENTS: Clinical presentation, initial hematological features, type of myelodysplasia (French American British classification), treatment, and evolution at 36 months were studied. RESULTS: The mean age of the group was 78. Anemia was the initial hematological feature in 30 patients out of 45 and was symptomatic in 24 patients. Refractory anemia was diagnosed in 20 patients; 11 patients presented with refractory anemia with excess blast cells, eight with chronic myelomonocytic leukemia. Thirty-one patients received erythrocyte transfusions, no patient received chemotherapy. At 36 months, 68.8% of the patients were dead. The median survival (22 months) was lower than in other reported series even in types of myelodysplasia with a classically better prognosis. CONCLUSION: Myelodysplasia is probably underdiagnosed in older people and has a poor prognosis (median survival 22 months), and no effective treatment is available in older patients.     

Colorectal cancer screening in HIV-infected patients 50 years of age and older: missed opportunities for prevention

OBJECTIVES: Although human immunodeficiency virus (HIV)-infected patients are now living longer, there are no published data on colorectal cancer (CRC) screening in this population. We hypothesized that HIV-infected patients were less likely to be screened for CRC compared to patients without HIV. METHODS: Consecutive HIV-infected patients > or =50 yr old seen in our outpatient clinic from 1/1/01 to 6/30/02 were identified. For each HIV-infected patient, we selected one age- and gender-matched control subject without HIV infection who was seen during the same time period. The electronic medical records were reviewed to determine the proportion of patients that had a fecal occult blood test (FOBT), flexible sigmoidoscopy, air-contrast barium enema (ACBE), or colonoscopy. RESULTS: During the 18-month study period, 538 HIV-infected outpatients were seen and 302 (56.1%) were > or =50 yr old. Despite significantly more visits with their primary care provider, HIV-infected patients were less likely to have ever had at least one CRC screening test (55.6%vs 77.8%, p < 0.001). The proportion of HIV-infected patients who ever had a FOBT (43.0%vs 66.6%, p < 0.001), flexible sigmoidoscopy (5.3%vs 17.5%, p < 0.001), ACBE (2.6%vs 7.9%, p= 0.004), or colonoscopy (17.2%vs 27.5%, p= 0.002) was significantly lower than in control subjects. In addition, HIV-infected patients were significantly less likely to be up-to-date with at least one CRC screening test according to current guidelines (49.3%vs 65.6%, p < 0.001). CONCLUSIONS: A substantial number of HIV-infected patients are > or =50 yr of age and CRC screening is underutilized in this population. Public health strategies to improve CRC screening in HIV-infected patients are needed.     

Characteristics of patients less than 45 years of age compared with older patients undergoing coronary artery bypass grafting

Background: Coronary artery disease (CAD) was not recognized as common among young patients until the study by Yater in 1948. Subsequent studies further elucidated the nature of the disease, which had become more apparent in the younger groups. Hypothesis: The study was undertaken to determine the prevalence of risk factors and severity of coronary disease among young patients aged ≤ 45 years undergoing coronary artery bypass grafting (CABG) compared with older patients. Methods: in all, 112 young patients aged ≥ 45 years (Group 1) and 798 older patients aged > 45 years (Group 2) were analyzed for trends to hypertension, smoking, diabetes, family history of heart disease, hypercholesterolemia, obesity, and history of previous myocardial infarction (MI). The severity of disease was examined in terms of number of diseased vessels, vessel size, number of grafts performed, performance of endarterectomies, and left ventricular function. Results: Group 1 had a higher incidence of positive family history (68.5 vs. 51.2%, p < 0.05), and lower incidences of hypertension (62.7 vs. 81.5%, p < 0.05), obesity (42.9 vs. 83.9%, p<0.05), and history of previous MI (54.5 vs. 94.6%, p < 0.05). Group 2 had a higher incidence of left main disease (22.6 vs. 11.4%, p < 0.05). The distribution of the affected vessels of the young patients was most commonly the left anterior descending (90.4%) followed by the right coronary (79.8%) and circumflex arteries (69.2%). Group 2 had more grafts per patient (3.82 vs. 3.37, p< 0.05). The size of the diseased vessels measured intraoperatively was similar (1.56 vs. 1.58 mm, p = NS) in both groups. Endarterectomy was performed almost three times more often in Group 1 patients (8.2 vs. 3.0%, p>0.05). Operative mortality was less in Group 1 mean (1.8 vs. 6.3%, p < 0.05). Group 2 had a greater mean left ventricular ejection fraction (53.8 vs. 49.7%, p< 0.05). Conclusion: Compared with the older population, patients < 45 years of age who underwent CABG had (1) a higher incidence of positive family history of CAD, (2) a higher likelihood of requiring an endarterectomy, and (3) lower operative mortality rate despite a slightly poorer ventricular function.     

Colorectal adenocarcinoma in patients less than 40 years old

Summary Carcinoma of the colorectum knows no age barrier. To date, more than 1,400 cases have been reported to occur in persons less than 40 years old. Our experience with 70 patients treated over a tenyear interval is reviewed. Signs and symptoms in the young are not distinctive. Diagnosis depends on a high index of suspicion and appropriate investigative procedures. Survival times are shorter in the patients who have mucinous and anaplastic tumors, and their incidences seem to be increased in this age segment. Overall survival does not significantly differ from our general experience (41 per cent, 5-year survival). Early diagnosis and prompt institution of aggressive surgical treatment can be expected to produce survival equivalent to that in patients of other ages. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Francisco, California, May 4 to 8, 1975.     

Colorectal cancer screening from 45 years of age: Thesis,antithesis and synthesis

Colorectal cancer incidence and mortality in patients younger than 50 years are increasing, but screening before the age of 50 is not offered in Europe. Advancedstage diagnosis and mortality from colorectal cancer before 50 years of age are increasing. This is not a detection-bias effect; it is a real issue affecting the entire population. Three independent computational models indicate that screening from 45 years of age would yield a better balance of benefits and risks than the current start at 50 years of age. Experimental data support these predictions in a sex-and race-independent manner. Earlier screening is seemingly affordable,with minimal impediments to providing younger adults with colonoscopy.Indeed, the American Cancer Society has already started to recommend screening from 45 years of age in the United States. Implementing early screening is a societal and public health problem. The three independent computational models that suggested earlier screening were criticized for assuming perfect compliance.Guidelines and recommendations should be derived from well-collected and reproducible data, and not from mathematical predictions. In the era of personalized medicine, screening decisions might not be based solely on age, and sophisticated prediction software may better guide screening. Moreover, early screening might divert resources away from older individuals with greater biological risks. Finally, it is still unknown whether early colorectal cancer is part of a continuum of disease or a biologically distinct disease and, as such, it might not benefit from screening at all. The increase in early-onset colorectal cancer incidence and mortality demonstrates an obligation to take actions. Earlier screening would save lives, and starting at the age of 45 years may be a robust screening option.     

Diagnosis of silent ischemia in patients with previous myocardial infarct, under 45 years of age

STUDY OBJECTIVE: Diagnostic methods validation and incidence estimation of silent myocardial ischemia in patients with previous myocardial infarction under 45 years. DESIGN: Prospective in comparison with a healthy group. SETTING: Cardiac outpatients follow-up at Faro's District Hospital. PATIENTS AND PARTICIPANTS: A random group of 23 outpatients (GI) under 45 years, with previous myocardial infarction. A second group of healthy volunteers (GII) similar in age and sex. INTERVENTIONS: After discontinuing therapy, a maximal treadmill exercise test (E.T.) was performed in both groups, using the Bruce protocol. A ST segment depression greater than or equal to 1 mm, measured 80 ms after J point was the positive criteria. Simultaneously a 24 h Holter recording was obtained using a two channel real time recorder. ST segment depression greater than or equal to 1 mm, measured 80 ms after J point and lasting over 60 s., was the positive criteria. Patients with left bundle branch block or left ventricular hypertrophy criteria were excluded. Concerning ventricular arrhythmias only repetitive forms were considered. MEASUREMENTS AND RESULTS: Ten E.T. (43.5%) resulted positive in GI. Simultaneous Holter recording was positive in nine patients (one false negative). From the 13 patients with negative E.T., 12 had negative Holter recordings (one false positive). Every E.T. and simultaneous Holter resulted negative in GII. Silent ischemia was detected in eight GI patients (34.8%) all of them belonging to the subgroup with positive E.T. In four patients the silent ischemia was detected by asymptomatic E.T., and simultaneous Holter. The remaining four patients had silent ischemia diagnosed on the subsequent Holter. Silent ischemia episodes were not detected in the subgroup of 13 patients with negative E.T. Between those two subgroups it is highly significant (p less than 0.001) the difference in the incidence of silent ischemia. The patients with silent ischemia recorded an average of 6.5 episodes/patient/day mainly in day time (p less than 0.001). Episodes of silent ischemia were more frequent in the subgroup of patients with asymptomatic positive E.T. than in the subgroup of positive E.T. with pain (p less than 0.004). It was not confirmed any significant difference in the incidence of ventricular arrhythmias among patients with or without silent ischemia. CONCLUSIONS: We have verified an high incidence of silent ischemia in a group of patients with previous myocardial infarction. Holter's electrocardiographic monitoring has a high concordance with E.T. results, when performed simultaneously. In fact, it does not provide any significant additional information since every patient with silent ischemia had positive E.T., but can be complementary in the evaluation of the total ischemic burden. It has been checked that episodes of silent ischemia have a major incidence at day time, appearing more often in patients with asymptomatic positive E.T.     

Colorectal cancer in patients over 80 years of age

Between January 1, 1973, and December 31, 1986, 1,734 patients underwent colorectal resections for carcinoma. Patients were divided into two groups: Group I included 163 patients aged 80 years on first presentation; Group II comprised 1,571 patients aged <80 years. The total perioperative mortality rates for the elderly and young group were 15.3 percent and 5 percent, respectively (P <0.001). The surgical mortality rates after elective operations in Groups I and II were 7.4 and 4.5 percent, respectively, and were not statistically different. Emergency surgery was associated with a significantly higher incidence of perioperative deaths at any age (P <0.001). In the elderly group, most deaths (88 percent) resulted from complications of coexisting medical disorders or thromboembolic complications. The 5-year survival for the young and elderly group were 46.2 percent and 35 percent, respectively (P <0.05). However, excluding patients dying from nonmalignant disease, the 5-year survival rate did not differ significantly between the two groups of patients (49.5 percent vs. 41.2 percent).     

Trends in incidence and management of esophageal adenocarcinoma in a well-defined population

OBJECTIVES: Little epidemiological data is available concerning esophageal adenocarcinomas in France. The aim of this study was to study epidemiological characteristics and management of esophageal adenocarcinoma in a well-defined population. METHODS: Data were collected by the Burgundy Digestive Cancer Registry covering a population of 1 052 000, over a 28-year period (1976-2001). Incidence, treatment and stage at diagnosis were noted. Univariate and multivariate analysis of survival was performed. RESULTS: Age standardized incidence rates were 1.60/100,000 in men and 0.15/100,000 in women. The mean increase in incidence rates by 5-year periods were respectively + 68.1% (P<0.001) and + 97.4% (P<0.001). Overall, 69.9% of the cancers were located in the lower third of the esophagus. Surgical resection was performed in 32.1% of patients. Among the surgical patients, the tumor was limited to the esophageal wall in 11.4%, lymph node metastases were present in 18.1% and non-resectable distant metastases in 70.5%. There was no improvement of stage at diagnosis over time. Survival rates were 14.4% at 3 years and 9.2% at 5 years. Five-year survival rates varied from 38.4% for cases limited to the esophageal wall to 1.8% for metastatic and non resectable cases. Stage at diagnosis was the only significant prognostic factor in the multivariate analysis. CONCLUSION: Esophageal adenocarcinomas are rare cancers characterized by a sharp rise in incidence over the past years in France. Stage at diagnosis and prognosis are worse than reported in hospital statistics.     

Allogeneic BMT in patients above 45 years of age: a single center experience

Increasing age has been reported to be associated with worse outcome and higher occurrence of complication after allogeneic bone marrow transplantation. We analysed a cohort of 39 patients between the ages of 45 and 57 (median 49 years) with different hematologic malignancies who had undergone BMT in our institution over the preceding 4 years. Pretransplant conditioning consisted of Bu/CY2, GVHD prophylaxis of a combination of cyclosporine and "short" methotrexate. At present 54% of patients remain alive (with a median follow-up 44 months), the probability of survival at 5 years is 53% (5-year DFS 78%). The 5-year survival probability in the control group of younger patients is 53% (P = 0.8003). Main causes of death were GVHD (4 patients, 10%), relapse (5 patients, 13%) and infection (6 patients, 15%). The incidence of acute GVHD grade II-IV was 51% (grade III-IV 0% patients), the incidence of chronic GVHD 49% (limited 18% and extensive 31% patients). Our results suggest that allogeneic BMT can be performed in patients above the age of 45 years with acceptable morbidity and mortality, especially if a family HLA matched donor is available.     

Colorectal carcinoma in patients less than 40 years of age

The mean incidence of colorectal carcinoma in persons under age 40 in Sweden is 1.74/100,000/year. Over a 30-year period, 1950 through 1979, 1061 patients with colorectal carcinoma were seen, 48 of whom were under age 40 (21 to 39 years) and in this study were compared with older patients. Carcinoma was superimposed upon ulcerative colitis in 18 patients. All patients treated for palliation died within two years. Curability rate, 67 per cent, and the proportion of Dukes' A lesions were the same as in older patients, whereas young patients had fewer B and more C lesions. Five-year survival was 33 per cent overall and 50 per cent in curable cases, not different from the rates in older patients (33 and 47 per cent). Five-year survival was 100 per cent in stage A, 50 per cent in stage B, and 33 per cent in stage C. The age factor had no impact upon survival, and colitic origin of a carcinoma did not decrease survival more than did carcinoma itself. It is concluded that colorectal carcinoma in patients under age 40 differs in no respect from the disease in older patients.     

Colorectal cancer in patients younger than 40 years of age

To assess prognostic factors in patients who develop colorectal cancer before the age of 40 years, a 30-year experience from 1956 through 1985 was reviewed. There were 50 patients ranging in age from 7 to 39 years. Five cases were associated with either ulcerative colitis (2) or familial polyposis (3). The most common presenting symptoms were abdominal pain (66 percent), hermatochezia (60 percent), change in bowel habit (41 percent) and weight loss (30 percent). On pathologic staging (N=44), only 14 of 44 (31 percent) had a Dukes' stage A on B lesion, 20 (45 percent) had Dukes' stage C, and the remaining 10 (23 percent) had distant metastases at the time of surgery. Fiveyear survival rate was 28 percent with a disease-free survival rate of 18 percent. Median survival was only 28 months. Negative prognostic tactors were Dukes' stage C/D (P<0.01), symptom duration of longer than 3 months (P=01), noncaucasian ancestry (P=0.1), and poorly differentiated histology (P=06). In contrast to older patients with colorectal cancer, only 1 of 30 (3 percent) patients with stage C/D disease was disease-free at 5 years. In view of the poor survival rate associated with both delay in diagnosis and the presence of advanced disease, it was concluded that young patients presenting with the symptoms listed above need early, aggressive evabuation for possible colorectal cancer     

Colorectal carcinoma in patients less than 40 years of age

Between 1960 and 1979, 37 patients, ranging in age from 18 to 40 years, were treated for colorectal cancer. Symptoms typical of colorectal malignancy had been present for an average of 10.4 months; a positive family history, previous colonic disease, or immunosuppression was present in 22 patients (59 per cent). Distribution of lesions was unusual in that only 40 per cent were within reach of the sigmoidoscope, and only 7.5 per cent could be palpated on rectal examination. Dukes' staging at diagnosis was improved in distribution to that reported in the adult population (51 per cent localized vs. 40.1 per cent). Histologic characteristics of the tumors were not unusual; however, incidence of poorly differentiated (18.9 per cent) and mucin-producing (10.8 per cent) cancers was increased. Perineural invasion was associated with disseminated disease. Vascular invasion was associated with disseminated disease and poor prognosis. Overall fiver-year survival was 56.8 per cent. Five-year survival in 24 patients undergoing potentially curative resection increased to 70.8 per cent. Colorectal carcinoma in patients under 40 years of age is unusual, and delay in diagnosis is common. The distribution of lesions is more homogeneous than that seen in older patients, and high-grade malignancies are more frequent. Survival data in this series are more favorable than those generally reported. Improved five-year survival following potentially curative resection (70.8 per cent) stresses the need for early diagnosis and treatment Read at the meeting of the American Society of Colon and Rectal Surgeons, Hollywood, Florida, May 11 to 16, 1980. Supported in part by the Roessler Foundation and the American Cancer Society.