les cancers synchrones du côlon

L e s c a n c e r s s y n c h r o n e s du c61on

J. G R O D O S , J. H A O T

C l i n i q u e s U n i v e r s i t a i r e s S a i n t - L u c , B r u x e l l e s ( B e l g i q u e )

Synchronous cancers of the colon

RI~SUMI~

Analysant une s6rie de 1000 pi~ces de (recto) colectomie contenant au moins un ad6nocarcinome invasif, les auteurs dOnombrent 6 % de l~sions malignes multiples, qu'ils d6membrent en 3 catOgories :

1. Cancers synchrones (3 %). 2. Cancer et polype canc6ris6 superficiellement (2 %). 3. Cancer et m6tastase intracolique (1%). D'autre part, des polypes b6nins sont plus fr6quemment associ6s aux cancers multiples (36 %) qu'aux cancers uniques (18 %). Ces chiffres sont tr~s probablement inf~rieurs ~ la r6alit6, puisqu'une 6tude se basant sur l'analyse de pi&ces op6ratoires ne

peut tenir compte du segment colique non r6s6qu6. Les auteurs comparent leurs donn6es ~ ceiles de la litt6rature ; en accord avec cette derniere, ils confirment l'absolue n6cessit6

d'un examen endoscopique minutieux de tout le gros intestin lors de la d~couverte d'un cancer colique, afin que le chirurgien ne laisse pas en place un second foyer n6oplasique.

S U M M A R Y

Analyzing a series o f 1000 samples from (procto) colectomy operations containing at least one invasive adenocarcinoma, the authors observed 6 % multiple malignant lesions, divided into 3 categories :

1. Synchronous cancer (3 %).

2. Cancer with superficially cancerous polyp (2 %).

3. Cancer with intracolic metastasis (1%).

Moreover, benign polyps are more frequently associated with multiple cancers (36 %) than with single cancers (18 %).

These figures are very probably lower than in reality, since the study is based on samples f rom operations and cannot take into account the colonic segment remaining in place.

The authors compare their data with those o f the literature : in agreement with other studies, they confirm the absolute necessity for a detailed endoscopic examination o f the large intestine when colonic cancer is discovered, to avoid the oversight o f a second neoplastic site.

I N T R O D U C T I O N

L e s p r o b l ~ m e s pos6s p a r les cance r s mu l t i p l e s du cElon, s y n c h r o n e s o u m E t a c h r o n e s , on t fai t l ' o b j e t d ' u n e l i t tE ra tu re r e l a t i v e m e n t a b o n d a n t e au cou r s de ces d e r n i ~ r e s ann6es . L e u r i m p o r t a n c e t i en t h l eur f r 6 q u e n c e , n o n n6g l igeab le , e t au r i sque qu ' i l s f on t c o u r i r a u ch i ru rg i en de la i sser en p l a c e un s e c o n d c a n c e r i g n o r e lors d ' u n e co lec to- m i e p o u r a d E n o c a r c i n o m e .

A u d e p a r t d ' u n e sErie d e p i~ces opEra to i r e s , nous avons ca lcu l6 la f r 6 q u e n c e des 16sions m a l i g n e s m u l t i p l e s s y n c h r o n e s du gros in tes t in et c o m p a r e nos d o n n E e s a ce l l e s de la l i t tEra ture .

M A T E , R I E L E T M E T H O D E S

C e t r ava i l se base su r l ' a n a l y s e a n a t o m o - p a t h o - l o g i q u e d ' u n e s6rie d e 1000 s p 6 c i m e n s o p 6 r a t o i r e s d e c o l e c t o m i e ou d e r e c t o c o l e c t o m i e , requs au Se rv i ce d ' A n a t o m i e P a t h o l o g i q u e de I ' U C L e n t r e fEvr ier 73 et j u in 85.

D e ce m a t e r i e l , nous n ' a v o n s r e t e n u que les p i ece s m e s u r a n t au m i n i m u m 20 cm de long , e t c o n t e n a n t au m o i n s un c a n c e r invas i f ( c ' e s t -~ -d i re d 6 p a s s a n t le n iveau d e la m u s c u l a r i s m u c o s a e ) . Il s ' ag i t d a n s c h a q u e cas d ' u n e p r e m i e r e i n t e rven - t i o n ; les rEcidives e t les c a n c e r s dEveloppEs sur a n a s t o m o s e n ' o n t p a s 6t6 p r i s en cons id6 ra t i on .

TirEs h part : Prof. J. HAOT, Service d'Anatomie Pathologi- que, Ciiniques Universitaires Saint-Luc, U.C.L., Avenue Hip- pocrate 10, 1200 Bruxelles (Belgique)

Mots-cl~s : Ad6nocarcinome colique, cancer colique, cancers synchrones, colectomie.

Key-words : Colectomy, colonic adenocarcinoma, colonic cancer, synchronous cancer.

Acta Endoscopica Volume 1 7 - N ~ 1 - 1987 11

Nous n 'avons inclus dans notre travail que les ad6nocarcinomes de type ent6roide, en 6cartant les autres formes de tumeurs (carcinome 6pider- moide du rectum, carcino~de, lymphome. . . ) . Nous avons 6galement exclu les cancers d6velopp6s dans un contexte de rectocolite ulc6ro-h6morragique ou de polypose familiale, car ils y sont souvent multi- pies.

Nous avons recherch6 dans quelle propor t ion les cancers rectocoliques de notre s6rie s 'accompa- gnaient d 'autres tumeurs 6pith61iales :

soit b6nignes : polypes ad6nomateux, villeux ou vi l lo-ad6nomateux.

- soit malignes : dans ce cas, nous avons distin- gu6 3 possibilit6s :

1. Cancers synchrones

Deux ou plusieurs ad6nocarcinomes primitifs, infiltrants (c 'est4t-dire d6passant t o u s l e niveau de la muscularis mucosae) confirm6s histologique- ment , s6par6s par des segments coliques normaux (Fig. 1), mont ran t en p6riph6rie une zone dysplasique transitionnelle reliant le cancer h la muqueuse saine, et ne constituant pas une localisation m6tastat ique du ou des autres cancers [15, 18].

2. Cancer + polype cancdrisd

Ad6nocarc inome infiltrant accompagn6 d 'un polype pr6sentant un foyer de canc6risation intramuqueuse sans d6bordement de la Muscularis mucosae (Fig. 2).

Figure 2

Cancer et polype cancerise. L'adenocarcinome infiltrant (==Jl~) est situe 12 cm du polype cancerise en surface (~). Femme de 66 ans.

Cancer and cancerous polyp. The infiltrating carcinoma (=11~) is situated at a distance of 12 cm from the polyp with a cancerized surface (--~).

66 year old woman.

Figure 1

Double adenocarcinome : les 2 tumeurs de taille fort differente (respec- tivement 3,5 et 10 cm de grand axe) sont separees par un segment

colique normal de 15 cm de long. Femme de 54 ans.

Double adenocarcinoma: the two tumors are of very different sizes (large axis 3.5 and 10cm respectively) and separated by a normal

colonic segment of 15 cm length. 54 year old woman.

3. Cancer + m~tastase colique

Ad6nocarc inome infiltrant ayant engendr6 une m6tastase dans la paroi colique. Le foyer m6tasta- tique se caract6rise par un d6veloppement intrapa- ri6tal ; la muqueuse est normale , inflammatoire ou part iel lement ulc6r6e par la m6tastase, mais ne pr6sente pas de zone transitionnelle dysplasique ; f r6quemment , on d6tecte des perm6ations lympha- tiques dans son voisinage surtout au niveau de la sous-muqueuse et de la sous-s6reuse.

Les pi~ces op6ratoi res ont 6t6 fix6es au formol. Pour chaque cas, nous disposions d 'une description macroscopique et histologique d6taill6e, accompa- gn6e le plus souvent de diapositives. Les pr616ve- ments effectu6s ont 6t6 inclus en paraff ine, puis ont 6t6 coup6s ~ 6Ix et color6s ~ l 'h6matoxyline- 6osine-safran, et , au besoin, suivant ies m6thodes du PAS et du Bleu Alcian.

12 V o l u m e 1 7 - N ~ 1 - 1 9 8 7 A c t a E n d o s c o p i c a

RES UL TA TS

La moyenne d'~ge de nos patients est de 65 ans, avec, comme extr6mes 38 et 93 ans.

506 sont des hommes et 494 sont des femmes ( rapport H / F de 1,02).

C o m m e signal6 ci-haut, les pi~ces op6ratoires s61ectionn6es mesurent au moins 20 cm et les plus longues cor respondent h des proctocolectomies totales. La longueur moyenne des sp6cimens est de 34 cm.

Le tableau I mont re que la fr6quence des 16sions malignes multiples est d 'environ 6 % du total des cas.

TABLEAU I

A N A L Y S E D E 1 000 P I~CES D'EXI~RI~SE ( R E C T O ) C O L I Q U E P O U R A D I ~ N O C A R C I N O M E

Cancer solitaire . . . . . . . . . . . . . . . .

Cancer + polype b6nin * . . . . . . . . . .

Cancers synchrones . . . . . . . . . . . . .

Cancer + polype canc6ris6 ** . . . . . . .

Cancer + m6tastase colique . . . . . . . .

776

167

3~ 1 18

9

5,7 %

* Ad6nomateux, villeux ou villo-ad6nomateux, sans dysplasie significa- tive, ~ l'exclusion des polypes hyperplasiques. ** Canc6risation intramuqueuse.

Les cancers synchrones au sens strict du terme [15,18] repr6sentent 3 %, les cancers associ6s h u n polype canc6ris6 forment un groupe de 2 % et les cancers ayant engendr6 une localisation m6tasta- t ique at teignent quasi 1 % .

Qua t re sp6cimens sont por teurs de 16sions multiples :

- - quadruple cancer infiltrant,

- - triple cancer infiltrant + 1 polype canc6ris6,

- - double cancer infiltrant + 1 polype canc6ris6 (Fig. 3),

- - c a n c e r infiltrant unique + 3 polypes canc6- ris6s.

L 'analyse du groupe des 16sions malignes multiples ne mont re pas de pr6dominance d 'un sexe par rappor t ~ l 'autre (Tableau II).

TABLEAU II

Extr6mes Age moyen

Cancers synchrones (n = 30)

Cancer + polype canc6ris6 * (n = 18)

Cancer + m6tastase colique (n = 9)

Rappor t H / F

. . 16/14

8/10

4/5

67 (52-89)

66,5 (45-84)

57 (40-80)

Canc6risation intramuqueuse.

A c t a E n d o s c o p i c a

Figure 3 Double cancer infiltrant (,=~) et polype canceris6 (-~) dans le m6me

segment colique. Homme de 68 ans. Double infiltrating cancer (=lb=) and cancerous polyp (--~) in the same

colonic segment. 68 year old man.

La moyenne d'~ge des patients atteints de cancers synchrones ou de cancer accompagn6 de polype canc6ris6 est pra t iquement identique (67 ans et 66,5 ans), et ne t tement sup6rieure celle des malades pr6sentant un cancer avec m6ta- stase intracolique (moyenne 57 ans).

Le tableau III donne la distance mesur6e entre ces tumeurs multiples : elle est la plus 61ev6e pour les cancers synchrones (moyenne 1 7 c m avec comme extr6mes 2 et 120 cm), interm6diaire pour les cancers accompagn6s de polype canc6ris6 (moyenne 11 c m ; extr6mes 3-39 cm) et la plus faible pour les cancers avec m6tastase (moyenne 3 cm ; extr6mes 1 et 7 cm).

Enfin le tableau IV montre que les cancers multiples s 'accompagnent deux lois plus fr6quem- ment de polypes b6nins (ad6nomateux, villeux ou mixtes) que les cancers uniques.

DISCUSSION

La d6terminat ion de la fr6quence des cancers coliques synchrones a fait l 'objet de nombreuses 6tudes : suivant la plupart des auteurs, cette fr6- quence varie entre 2 et 9 % de l 'ensemble des

V o l u m e 1 7 - N ~ 1 - 1 9 8 7 13

TABLEAU III

D I S T A N C E E N T R E LES C A N C E R S S Y N C H R O N E S

Distance en cm N o m b r e de cas %

Ent re l e t 1 0 c m 16 (53 %)

Ent re 11 et 20 cm 10 (33 %)

Plus de 2 0 c m 4 (14 %)

D I S T A N C E E N T R E C A N C E R E T P O L Y P E CANCI~RISI~


Ent re 1 et 1 0 c m 12 (67 %)

Ent re 1 1 e t 2 0 c m 4 (22 %)

Plus de 2 0 c m 2 ( 1 1 % )

D I S T A N C E E N T R E C A N C E R E T MI~TASTASES


Ent re 1 et 1 0 c m 9 ( 1 0 0 % )

Plus de 10 cm 0 (0 %)

TABLEAU IV

% DE C A N C E R S C O L I Q U E S A C C O M P A G N I ~ S D E P O L Y P E S BI~NINS *

Cancer un ique . . . . . . . . . . . . . . . . . . . 18 %

Cancers synchrones Cancer + polype canc6ris6 . . . . . . . . . . . 36 %

Ad6nomateux, villeux ou villo-ad6nomateux sans dysplasie significa- tive.

cancers coliques [1-7, 9-17, 19-22, 24] ; certains avencent mrme la proportion de 12 % [23], voire de 15 h 20 % [8]. Cette discordance relative dans les chiffres peut s'expliquer de 3 faqons :

1. Certaines 6tudes, comme la n6tre, ne se basent que sur l'examen anatomo-pathologique de pieces oprratoires, ce qui ne permet pas de prrju- ger de l'6tat du segment colique laiss6 en place [13, 14, 20].

2. D'autres s6ries prennent en compte la totalit6 du gros intestin et fondent leur calcul sur l'examen baryt6 et l'endoscopie [17, 21] voire sur l'autopsie [22].

3. Enfin, certains auteurs ne considerent pas un polype siege d'un foyer superficiel de cancdrisation (ne d6bordant pas le niveau de la muscularis mucosae) comme un second cancer [4, 6, 13, 14, 24] ; par contre d'autres s6ries les incluent [3, 7, 12, 15, 19] ; d'autres encore ne font pas mention de cette distinction.

Notre s6rie de 1000 pieces de r6section colique comporte une proportion de 6 % de 16sions malignes synchrones (Tableau I). Si l'on exclut

comme la plupart des auteurs [5], les cas de mrtastases intracoliques, il reste 5 % de cancers primitifs multiples, ce qui se situe dans la moyenne des chiffres citrs ci-haut. On peut en outre logiquement supposer que cette proportion de 5 % est infrrieure ~ la rralitr, puisque nous ne pouvons avec ce type de mat6riel, tenir compte du segment colique non rrsrqur.

Les cancers synchrones sont 2 h 3 lois plus souvent accompagnrs de polypes brnins que les cancers uniques: ces derniers s'associent h des polypes dans une proportion qui, dans la littrra- ture, varie de 17 h 62 % des cas, la majorit6 des chiffres publirs se situant entre 20 et 30 % [1, 3, 4, 9, 13, 19, 20, 21] ; par contre, les cancers synchrones s'associent ~ des polypes dans 38 86 % des cas suivant les srries [3, 4, 7, 8, 10, 11, 13, 14, 19, 20, 21, 23, 24].

Cette constatation prrsente un grand int6rrt cli- n ique: le risque qu'un patient drveloppe un second adrnocarcinome est plus grand si son cancer colique est associ6 h des polypes [4, 8] et d'autant plus que les polypes sont nombreux [3].

L 'r tude de notre srrie confirme ce fait (Tableau IV): nos cancers multiples sont 2 lois plus souvent (36 % de cas) accompagnrs de polypes brnins que les cancers uniques (18 % des cas).

Notons que dans notre travail, la proportion de polypes d'accompagnement, relativement modeste par rapport aux chiffres cit6s ci-haut, s'explique par la nature de notre matrriel, qui ne tient pas compte du segment colique laiss6 en place [13].

D'autre part, nous n'avons retenu, comme certains [11, 14] que les polypes "nroplasiques" (adrnomateux, villeux ou villo-adrnomateux) c'est-~- dire les polypes ~t potentialit6 maligne. La relative dispersion des chiffres de la litt6rature cit6s ci-haut pourrait s'expliquer par le fait que d'autres incluent en plus, les polypes hyperplasiques (mrta- plasiques), voire les formations polypoides non 6pithrliales (lymphoides...) [7]. Nous n'avons pas tenu compte de ces 16sions -pourtant nombreuses dans notre srrie car leur importance canc6rologi- que est nulle.

Enfin, il apparait que les patients porteurs de cancers coliques synchrones, sont plus exposrs, de mrme que leurs families h des cancers coliques mrtachrones voire h des cancers d'autres organes [10, 11, 22].

Ces faits confirment l'absolue nrcessit6 d'une exploration endoscopique minutieuse de tout le gros intestin lors de la drcouverte d'un cancer colique, afin de ne pas laisser en place une 16sion maligne ignorre, et de modifier 6ventuellement la tactique oprratoire [20].

Rappelons ~ cet 6gard que la palpation per- oprratoire du c61on n'est pas liable [1, 11, 20] et, que la coloscopie totale est mieux adapt6e h la recherche d'un second foyer n6oplasique que le lavement baryt6 [1, 4, 13, 17, 19, 20, 21].


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INTRODUCTION

The problems posed by multiple colonic cancers, synchronous or metachronous, have been discussed in the literature, relatively abundant these last years. Their importance is linked to their frequency, which is not negligible, and the risk that the sur- geon might overlook a second cancer when perfor- ming a colectomy for an adenocarcinoma.

Based on a series of surgical specimens, we have calculated the frequency of multiple malignant synchronous lesions o f the large intestine, and compa- red our data with those found in the literature.

M AT E RIAL A N D METHODS

This study is based on the pathological analysis of a series of specimens collected from colectomy and proctocolectomy operations. This analysis was done by the Pathology Department of the U.C.L. between February 1973 and June 1985. Of these

specimens, only those measuring more than 20 cm in length and containing at least one invasive cancer (i.e. beyond the muscularis mucosae level) were retained. In each case it was the first surgical intervention : neither cases of recurrence nor cancers developed on anastomoses were taken into consideration. Only intestinal type adenocarcinomas have been included in our study, to the exclusion of other forms of tumors (epidermoid rectal carcinoma, carcinoid, lymphoma...). We also excluded cancers which developed in the context of ulcerative colitis or familial polyposis, because they are often multiple.

We have investigated in what proportion the proctocolonic cancers of our series were accompanied by other epithelial tumors that were either :

�9 benign : adenomatoas, villous, or villo-adenomatoas polyps ; or

�9 malignant: in this case, we distinguished three possibilities :

1. Synchronous cancers

Two or more primary adenocarcinomas, infiltrating (i.e. penetrating beyond the mascularis muco-

Acta Endoscopica Volume 17- N ~ 1 - 1987 15

sae level), with histological confirmation, separated by normal colonic segments (fig. 1), showing a peripheral transitional dysplasic zone connecting the cancer to the healthy mucosa, and which does not constitute a metastatic localization [15, 18].

2. Cancer + cancerous polyp

Infiltrating adenocarcinomas accompanied by a polyp presenting a site of intra-mucosa cancerisation without overflowing into the sub-mucosa (Fig. 2).

3. Cancer + colonic metastasis

Infiltrating adenocarcinoma with a metastasis in the colonic wall. The metastatic site is characterized by intra-parietal development ; the mucosa is normal, inflamed, or partially ulcerated by the metastasis, but the dysplastic transitional zone is not pre- sent. Frequently, lymphatic permeations are detec- ted in the surrounding region, especially at the sub- mucosal ans sub-serous levels.

The samples were fixed in formaldehyde. In each case, detailed macroscopic and histological descrip- tions are available, usually accompanied by photo- graphic slides. The samples taken were embedded in paraffin, cut at 6~x and stained with hematoxylin- eosin-saffron, and, if necessary, with PAS methods and Alcian blue.

R E S U L T S

The average age of patients was 65 years with extreme values of 38 and 93 years.

506 were men and 494 were women (M/F ratio of 1.02). As mentioned above, the samples from the operations selected were at least 20 cm long, and the longest samples corresponded to total proctocolectomies. The average length was 34 cm.

Table 1 shows that the frequency of multiple malignant lesions is around 6 % of all cases.

TABLE I

A N A L Y S I S O F 1 000 ( P R O C T O ) C O L O N I C R E S E C T I O N S A M P L E S F O R A D E N O C A R C I N O M A

D e s c r i p t i o n N u m b e r

So l i t a ry c a n c e r

C a n c e r + b e n i g n p o l y p *

S y n c h r o n o u s cance r s

C a n c e r + c a n c e r o u s p o l y p **

C a n c e r + co lon ic m e t a s t a s i s

776

167

3~ 1 18

9

5.7 %

* Adenomatous, villous, or villo-adenomatous polyps, without significant dysplasia, excluding hyperplastic polyps. ** Intra-mucosal cancerisation.

The synchronous cancers, strictly speaking [15, 18] represent 3 %, cancers associated with a cancerous polyp form a group of 2 % and the cancers spawning metastatic extensions attain almost 1 % .

Four specimens had multiple lesions :

- - quadruple infiltrating cancer,

- - triple infiltrating cancer + 1 cancerous polyp,

- - double infiltrating cancer + 1 cancerous polyp (Fig. 3),

- -s ingle infiltrating cancer + 3 cancerous polyps.

The analysis of multiple malignant lesions does not show a predominance of one sex over the other (Table II).

TABLE I I

S y n c h r o n o u s cance r s (n = 30) . .

C a n c e r + c a n c e r o u s p o l y p * (n = 18) . . . . . . . . . . . . . . . .

C a n c e r + co lon ic m e t a s t a s i s (n = 9) . . . . . . . . . . . . . . . . .

M / F r a t i o a v e r a g e age

16/14

8 / 1 0

4 / 5

( e x t r e m e s )

67 (52-89)

66,5 (45-84)

57 (40-80)

Intra-mucosal cancerisation.

The average age of patients with synchronous cancer or cancer accompanied by cancerous polyps is practically the same (67 and 66.5 years old, respectively), clearly higher than that of patients with intra-colonic metastasis (average 57 years).

Table III shows the distance measured between multiple tumors : the highest value is noted for synchronous cancers (average 17 cm, extremes 2 and 120 cm), an intermediate value for cancers accompanied by cancerous polyps (average 11 cm, extremes 3 and 39 cm), while the lowest value was observed for cancers with metastases (average 3 cm, extremes 1 and 7 cm).

Finally, table IV shows that multiple cancers are accompanied by benign polyps (adenomatous, villous, or mixed) twice as often as single cancers.

D I S C U S S I O N

The determination of synchronous colonic cancer frequencies has been studied by a number of authors. According to most of these studies, this frequency varies between 2 % and 9 % of all colonic cancers [1-7, 9-17, 19-22, 24]. However, figures ranging from 12 % [23] up to 15-20 % [8] have been cited.

Three facts account for the relative disagreement in these figures :

1. Some of the studies, such our own, are based only on the examination of surgical samples. This


TABLE II I

DISTANCE B E T W E E N S Y N C H R O N O U S CANCERS

I Distance in cm !Number of cases %

Between 1 and 10 cm 16 (53 %)


More than 20cm 4 (14 %)

D I S T A N C E B E T W E E N C A N C E R A N D C A N C E R O U S POLYP

Distance in cm Number of cases %



More than 20 cm 2 ( 1 1 % )

DISTANCE B E T W E E N C A N C E R A N D METASTASES

Distance in cm Number of cases %


More than 10 cm 0 (0 %)

TABLE IV

% O F C O L O N I C C A N C E R S A C C O M P A N I E D BY B E N I G N POLYPS *

Single cancers . . . . . . . . . . . . . . . . . . . .

Synchronous cancer Cancer + cancerous polyp . . . . . . . . . . .

18 %

36 %

* Adenomatous, villous, or villo-adenomatous polyps, without significant dysplasia.

does not allow any conclusions about the condition of the colonic segment left in place to be drawn [13, 14, 20].

2. Other studies include the whole large intestine, and are based on endoscopies and barium contrast examinations [17, 21], or even on autopsies [22].

3. Finally, some authors do not consider that polyps which are the site o f superficial cancers O.e. not attaining the muscularis mucosae level) are a second cancer [4, 5, 13, 14, 24], while other series include them [3, 7, 12, 15, 19]. Some studies do not even mention this distinction.

Our series o f 1000 colonic resection samples included a 6 % proportion o f malignant synchronous lesions (Table 1). I f we exclude, as do most authors, intracolic metastasis cases, 5 % of primary

multiple cancers remain. This figure is within the average of the figures cited above. We can logically suppose that this 5 % figure is lower than in reality, since we cannot, with this type of material, take into account the colonic segment remaining in place.

Synchronous cancers are accompanied by benign polyps two or three times more often than single cases. The latter are associated with polyps with a frequency of 17 to 62 %, according to the literature, with the majority o f published figures ranging between 20 and 30 % [1, 3, 4, 9, 13, 19, 20, 21]. In contrast, 38 to 86 % o f synchronous cancers are associated with polyps, depending on the series [3, 4, 7, 8, 10, 11, 13, 14, 19, 20, 21, 23, 24].

This observation is o f great clinical interest : the risk that a patient develops a second adenocarcinoma is higher if his colonic cancer is associated with polyps [4, 8], proportionally to the number of polyps observed [3].

The study of our series confirms this fact. (Table I V ) : our multiple cancers are accompanied by benign polyps twice (36 % o f cases) as often as single cancers (18 %).

It should be noted that the proportion of accom- panying polyps is relatively modest in comparison with the figures cited above. This is due to the type o f material we used, which takes into consideration only the excised colonic segment [13].

Moreover, as did others [11, 14] we kept only the "neoplastic" (adenomatous, villous, villo-adenomatous) polyps, i.e. those polyps with malignant potential. The relative dispersion of the figures found in the literature could very well result from the fact that some authors also include hyperplastic (metaplastic) polyps and even non-epithelial poly- poid formations (lymphoid...) [7]. We did not count these lesions while they were very numerous in our study because their cancerological importance is null.

Finally, it would appear that patients with synchronous colonic cancer, as well as their families, have a higher risk of developing metachronic colonic cancers or even cancers in other organs [10, 11, 22].

These facts confirm the absolute necessity for careful endoscopic exploration of the whole large intestine when a colonic cancer is discovered, to avoid missing an unsuspected malignant lesion. Eventually, the operating technique could be modi- fied [20]. It should be recalled that pre-operative palpation of the colon is not reliable [1, 11, 20] and that a total coloscopy is better for detecting a second neoplastic site than barium enema X-ray examination [1, 4, 13, 17, 19, 20, 21).

Acta Endoscopica Volume 17 - N ~ 1 - 1987 17

les cancers synchrones du côlon

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