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etween 59 and 85 percent. However, there is a subset of patientswith stage II cancers who do benefit from adjuvant chemotherapy.Stage III colorectal cancers exist when cancer is present in one ormore lymph nodes with any level of bowel wall penetration. Colonresection and, in most cases, postoperative chemotherapy yield a fiveyearsurvival rate between 44 and 84 percent depending on the subsetwithin stage III cancers.Stage IV colorectal cancers are present when cancer hasmetastasized to other locations in the body and has a five-year survivalof 10 percent or less. Surgical resection of the primary cancer site isappropriate in almost all cases. When surgical or radiation therapytreatment can be used to eliminate all metastatic disease, the patient’sfive-year survival may approach 25 percent. Radiation therapy is usedin select cases and chemotherapy is recommended for all.With rectal cancer, preoperative radiographic testing is critical todetermine the proper treatment recommendations. Rectal ultrasoundand, more recently, rectal MRI (which is available at St. Anthony’s) areused to identify whether the cancer is stage I, II or III before surgery.Stage I rectal cancers are treated with surgery alone and yield afive-year survival rate of 70-80 percent. Both stage II and stage IIIrectal cancers are treated most often with preoperative radiation andchemotherapy followed by an appropriate rest period before surgicalresection. In nearly all cases, these patients should receive furtherchemotherapy after healing from their surgery. Five-year survival ratesfor stage II is 50-60 percent and stage III is 30-40 percent.Stage IV rectal cancers are treated similarly to stage IV coloncancers.All of the latest treatments for colorectal cancer are available atSt. Anthony’s Medical Center. State-of-the-art surgical treatmentsinclude laparoscopic colectomy and other minimally invasive surgicaltechniques to remove the cancer. Transanal endoscopic microsurgeryis available for select early rectal cancers. This outpatient procedureallows the patient to return to work and a normal lifestyle within afew days. Today, with rare exception, if patients have a rectal cancerthat does not directly invade the anal canal, they can be reassured apermanent colostomy will not be necessary.As described, even when colon and rectal cancers are treatedwith the latest and most sophisticated techniques, some patientswill develop a cancer recurrence. Careful monitoring is critical aftertreatment for a minimum of five years with an appropriate history,physical examination, laboratory evaluations and radiographic testing.When patients have their recurrent cancer detected early, and treatedwith the selective use of surgery, radiation and/or chemotherapy,there is a greater probability for improved quality of life and, in someinstances, cure.10David Schuval M.D. FACS FASCRS
The Pathologist’s Role in the Diagnosis, Staging andTreatment of Colorectal CancerColon and rectal cancers are amongst the most frequent cancersdiagnosed in Americans. These cancers, often considered togetheras colorectal cancer, are one of the most frequent causes of cancerdeaths. Colorectal cancer rates can be decreased, and deaths frommany of these cancers prevented, by screening and surveillanceprograms for early detection and removal of colorectal polyps. Polypsare collections of precancerous cells which represent an overgrowthin abnormal colorectal lining cells. They may be flat or raised abovethe surrounding tissue, and are usually visible via colonoscopy. Smallpolyps may be removed via colonoscopy; larger polyps may requiresurgery for removal. If not removed, over time colorectal polyps mayundergo further changes, including genetic mutations, and becomecancer (carcinoma). Colorectal carcinomas may also be detected bycolonoscopy, and are usually removed (resected) by surgery.Pathologists are physicians who specialize in the diagnosis ofhuman diseases (pathology) by examination of tissue. Pathologistsencounter colorectal polyps and cancers in both endoscopic biopsiesand surgically removed segments of colon and rectum. These tissuesare placed in formalin, a fixative which helps preserve cellular detail,and then examined by the pathologist.Small biopsy specimens are used in their entirety to produce slidesfor microscopic examination. Larger specimens, including colon andrectum removed surgically, are grossly (with the naked eye) examinedand dissected by the pathologist to select the areas of most significancefor microscopic examination. These areas include the tumor or polypitself and its relationship to the edges of surgical resection (margins ofthe specimen). For the polyp or cancer, size, shape, color, consistency,and distance from the margins are noted and documented in thepathology report. The presence or absence of invasion into the bowelwall is also noted. Additional characteristics of any invasion and thestatus of the margins are further classified upon microscopic exam (seebelow).An important feature in the staging of colorectal cancers isthe status of the lymph nodes. These are normal structures in thefat surrounding the colon and rectum, where lymphocytes andinflammatory cells cluster, and where lymphatic channels drain. Theseare typically the sites where colorectal cancers first metastasize, andare therefore important to examine to assess for metastatic colorectalcancer. These lymph nodes must be dissected, or teased out of theirsurrounding fat, by the pathologist. Often lymph nodes are quiteobvious, and may even be enlarged, up to several centimeters (1-2inches), due to inflammation or metastatic cancer. However theselymph nodes may also be quite small or few in number in somecases (eg, smaller specimens, after radiation or chemotherapy, elderly11
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