2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Authors SectionEditor DeputyEditors

FinlayAMacrae,MD KennethKTanabe,MD DianeMFSavarese,MD
JohannaBendell,MD ShilpaGrover,MD,MPH

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Feb2016.|Thistopiclastupdated:Mar29,2016.
INTRODUCTIONColorectalcancer(CRC)isacommonandlethaldisease.Itisestimatedthatapproximately134,490newcasesoflargebowelcancerare
diagnosedannuallyintheUnitedStates[1],includingapproximately95,270colonand39,220rectalcancers.Approximately49,190Americansareexpectedtodie
oflargebowelcancereachyear.AlthoughCRCmortalityhasbeenprogressivelydecliningsince1990atarateofapproximately3percentperyear[2],itstill
remainsthethirdmostcommoncauseofcancerdeathintheUnitedStates.Global,countryspecificincidenceandmortalityratesareavailablefromtheWorld
HealthOrganizationGlobocandatabase.

Incontrasttothesedeclines,theincidenceofCRCinmenandwomenundertheageof50hasbeensteadilyincreasingatarateof2.1percentperyearfrom1992
through2012[1].Theseincreasesaredrivenpredominatelybyleftsidedcancersingeneralandrectalcancerinparticular(3.9percentperyear)[3].Current
literaturesuggeststhatover86percentofthosediagnosedundertheageof50aresymptomaticatdiagnosis,andthisisassociatedwithmoreadvancedstageat
diagnosisandpooreroutcomes[4].Atpresent,screeningisnotrecommendedforindividualsundertheageof50unlesstheyhaveapositivefamilyhistoryora
predisposinginheritedsyndrome.(See"Screeningforcolorectalcancer:Strategiesinpatientsataveragerisk"and"Screeningforcolorectalcancerinpatientswitha
familyhistoryofcolorectalcancer"and"Colorectalcancer:Epidemiology,riskfactors,andprotectivefactors",sectionon'Incidence'.)

CRCisdiagnosedaftertheonsetofsymptomsorbecauseofoccultbleedinginthemajorityofpatients.ScreeningofasymptomaticindividualsforCRCis
advocatedbymajorsocietiesandpreventivecareorganizations.Screeninghasbeenshowntodetectasymptomaticearlystagemalignancyandimprovemortality.
However,whilecompliancewithCRCscreeningguidelinesissteadilyimproving,itisstillrelativelylow.(See"Screeningforcolorectalcancer:Strategiesinpatients
ataveragerisk".)

Theclinicalpresentation,diagnosis,andstagingofCRCwillbereviewedhere.Thepathology,prognosticdeterminants,andtreatmentofcolonandrectalcancerare
discussedelsewhere.

(See"Pathologyandprognosticdeterminantsofcolorectalcancer".)
(See"Overviewofthemanagementofprimarycoloncancer".)
(See"Surgicalresectionofprimarycoloncancer".)
(See"AdjuvanttherapyforresectedstageIII(nodepositive)coloncancer".)
(See"AdjuvantchemotherapyforresectedstageIIcoloncancer".)
(See"Adjuvanttherapyforresectedcoloncancerinelderlypatients".)
(See"Overviewofsurgeryforthetreatmentofprimaryrectaladenocarcinoma".)
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(See"Neoadjuvantchemoradiotherapyandradiotherapyforrectaladenocarcinoma".)
(See"Adjuvanttherapyforresectedrectaladenocarcinoma".)

CLINICALPRESENTATIONPatientswithcolorectalcancer(CRC)maypresentinthreeways:

Suspicioussymptomsand/orsigns

Asymptomaticindividualsdiscoveredbyroutinescreening(see"Screeningforcolorectalcancer:Strategiesinpatientsataveragerisk")

Emergencyadmissionwithintestinalobstruction,peritonitis,orrarely,anacutegastrointestinal(GI)bleed

Therearenosymptomsinthemajorityofpatientswithearlystagecoloncancerandthesepatientsarediagnosedasaresultofscreening.Althoughtheincreasing
uptakeofCRCscreeninghasledtomorecasesbeingdiagnosedatanasymptomaticstage,mostCRCs(70to90percentintwocontemporaryseries[5,6])are
diagnosedaftertheonsetofsymptoms.SymptomsofCRCaretypicallyduetogrowthofthetumorintothelumenoradjacentstructures,andasaresult,
symptomaticpresentationusuallyreflectsrelativelyadvancedCRC.(See"Screeningforcolorectalcancer:Strategiesinpatientsataveragerisk"and"Screeningfor
colorectalcancerinpatientswithafamilyhistoryofcolorectalcancer".)

SymptomsfromthelocaltumorTypicalsymptoms/signsassociatedwithCRCincludehematocheziaormelena,abdominalpain,otherwiseunexplainediron
deficiencyanemia,and/orachangeinbowelhabits[712].Lesscommonpresentingsymptomsincludeabdominaldistention,and/ornauseaandvomiting,which
maybeindicatorsofobstruction.Acompilationofthemostfrequentsymptomsandfindingsthatprompteddiagnosticcolonoscopyinaseriesof388consecutive
patientsdiagnosedwithaCRCbetween2011and2014includedthefollowing[5]:

Bloodperrectum(37percent).
Abdominalpain(34percent).
Anemia(23percent).
Sixpatients(1.9percent)hadincidentalcolonichypermetabolicactivitydetectedonapositronemissiontomography/computedtomography(PET/CT)image
doneforanotherreason.
Onlyfourindividuals(1.3percent)underwentdiagnosticcolonoscopybecauseofchangeinbowelhabits(diarrhea).

Ontheotherhand,amongthe28patientswhosediagnosiswasestablishedatthetimeofsurgery,themostcommonindicationsforemergentsurgerywere
obstruction(57percent),apreoperativediagnosisofacuteappendicitisonpreoperativeCTimagingwithacecaladenocarcinomafoundinthesurgicalspecimen(25
percent),andperforation(18percent).

Obstructivesymptomsaremorecommonwithcancersthatencirclethebowel,producingthesocalled"applecore"descriptionseenonradiologicimaging(image
1AB).

Amongsymptomaticpatients,clinicalmanifestationsalsodifferdependingontumorlocation:

AchangeinbowelhabitsisamorecommonpresentingsymptomforleftsidedthanrightsidedCRCsbecausefecalcontentsareliquidintheproximalcolon
andthelumencaliberislarger,andtheyarethereforelesslikelytobeassociatedwithobstructivesymptoms.

Hematocheziaismoreoftencausedbyrectosigmoidthanrightsidedcoloncancer.
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IrondeficiencyanemiafromunrecognizedbloodlossismorecommonwithrightsidedCRCs[13].Cecalandascendingcolontumorshaveafourfoldhigher
meandailybloodloss(approximately9mL/day)thantumorsatothercolonicsites[14].(See"Causesanddiagnosisofirondeficiencyanemiaintheadult",
sectionon'Searchforsourceofbloodandironloss'.)

Abdominalpaincanoccurwithtumorsarisingatallsitesitcanbecausedbyapartialobstruction,peritonealdissemination,orintestinalperforationleadingto
generalizedperitonitis.

Rectalcancercancausetenesmus,rectalpain,anddiminishedcaliberofstools.

Theseconceptscanbeillustratedbythedistributionoffindingsatpresentationinaseriesof253CRCsthatwerediagnosedandtreatedatateaching/national
referralhospitalinKenyabetween1993and2005,whichincluded140rectalcancers,54rightsidedcoloncancers,and59leftsidedcoloncancers(table1)[11].

MetastaticdiseasePatientsmayalsopresentwithsigns/symptomsofmetastaticdisease.Approximately20percentofpatientsintheUnitedStateshave
distantmetastaticdiseaseatthetimeofpresentation[1].CRCcanspreadbylymphaticandhematogenousdissemination,aswellasbycontiguousand
transperitonealroutes.Themostcommonmetastaticsitesaretheregionallymphnodes,liver,lungs,andperitoneum.Patientsmaypresentwithsignsorsymptoms
referabletoanyoftheseareas.Thepresenceofrightupperquadrantpain,abdominaldistention,earlysatiety,supraclavicularadenopathy,orperiumbilicalnodules
usuallysignalsadvanced,oftenmetastaticdisease.

Becausethevenousdrainageoftheintestinaltractisviatheportalsystem,thefirstsiteofhematogenousdisseminationisusuallytheliver,followedbythelungs,
bone,andmanyothersites,includingthebrain.However,tumorsarisinginthedistalrectummaymetastasizeinitiallytothelungsbecausetheinferiorrectalvein
drainsintotheinferiorvenacavaratherthanintotheportalvenoussystem.

UnusualpresentationsThereareavarietyofatypicalpresentationsofCRC.Theseinclude:

Localinvasionoracontainedperforationcausingmalignantfistulaformationintoadjacentorgans,suchasbladder(resultinginpneumaturia)orsmallbowel.
Thisismostcommonwithcecalorsigmoidcarcinomasinthelattercase,theconditioncanmimicdiverticulitis.

Feverofunknownorigin,intraabdominal,retroperitoneal,abdominalwallorintrahepaticabscessesduetoalocalizedperforatedcoloncancer[15,16].
StreptococcusbovisbacteremiaandClostridiumsepticumsepsisareassociatedwithunderlyingcolonicmalignanciesinapproximately10to25percentof
patients[17].Rarely,otherextraabdominalinfectionscausedbycolonicanaerobicorganisms(eg,Bacteroidesfragilis)maybeassociatedwithCRC[18].(See
"Clinicalmanifestations,diagnosis,andtreatmentofinfectionsduetogroupDstreptococci(Streptococcusbovis/Streptococcusequinuscomplex)",sectionon
'Associationwithcolonicneoplasia'.)

CRCultimatelyprovestobethesiteoforiginofapproximately6percentofadenocarcinomasofunknownprimarysites[19].(See"Adenocarcinomaof
unknownprimarysite".)

CRCmaybedetectedonthebasisofdiscoveryoflivermetastasesthataredetectedincidentallyduringstudiessuchasgallbladderorrenalultrasound,orCT
scansforevaluationofothersymptoms(eg,dyspnea).

ImpactofsymptomsonprognosisThepresenceofsymptomsandtheirparticulartypeprovidesomeprognosticimportance:

Patientswhoaresymptomaticatdiagnosistypicallyhavemoreadvanceddiseaseandaworseprognosis[5,20].Inonestudyof1071patientswithnewly

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diagnosedcoloncancer,217ofwhomwerediagnosedthroughscreening,thepatientsnotdiagnosedthroughscreeningwereatsignificantlyhigherriskfora
moreinvasivetumor(T3:relativerisk[RR]1.96),nodalinvolvement(RR1.92),andmetastaticdiseaseonpresentation(RR3.37).Inaddition,patientsnot
diagnosedthroughscreeninghadsignificantlyhigherdeathrates(RR3.02)andrecurrencerates(RR2.19)aswellasshortersurvivalanddiseasefree
intervals[20].(See"Testsforscreeningforcolorectalcancer:Stooltests,radiologicimagingandendoscopy".)

Thetotalnumberofsymptomsmaybeinverselyrelatedtosurvivalforcolonbutnotforrectalcancer[21].Whetherthedurationofsymptomsinfluences
prognosisisuncleartheavailabledataaremixed[2224].

Obstructionand/orperforation,althoughuncommon,carryapoorprognosis,independentofstage[8,2528].Amongpatientswithnodenegativecoloncancer,
obstructionorperforationarepoorprognosticfactorsthatmayinfluencethedecisiontopursueadjuvantchemotherapy.(See"Adjuvantchemotherapyfor
resectedstageIIcoloncancer",sectionon'Clinicopathologicvariables'.)

Tumorspresentingwithrectalbleeding(typicallythoseinvolvingthedistalcolonandrectum)havebeenthoughttohaveabetterprognosisbecauseoftheir
tendencytobediagnosedatanearlierstage[29,30]however,bleedingisnotanindependentpredictorofoutcome[26,31].Rectalbleedingismorecommonly
seenwithdistaltumors,andalargerproportionofdistalcoloncancerspresentasearlystagetumorsascomparedwithproximaltumors[30].

Otherdeterminantsofprognosis,includingclinicopathologicandmolecularfeatures,arediscussedelsewhere.(See"Pathologyandprognosticdeterminantsof
colorectalcancer".)

DIAGNOSISColorectalcancer(CRC)maybesuspectedfromoneormoreofthesymptomsandsignsdescribedaboveormaybeasymptomaticand
discoveredbyroutinescreeningofaverageandhighrisksubjects.OnceaCRCissuspected,thenexttestcanbeacolonoscopy,bariumenema,orcomputed
tomographycolonography.However,examinationoftissueisrequiredtoestablishthediagnosisthisisusuallyaccomplishedbycolonoscopy.(See"Screeningfor
colorectalcancer:Strategiesinpatientsataveragerisk"and"Screeningforcolorectalcancerinpatientswithafamilyhistoryofcolorectalcancer"and"Lynch
syndrome(hereditarynonpolyposiscolorectalcancer):Screeningandmanagement"and"Familialadenomatouspolyposis:Screeningandmanagementofpatients
andfamilies"and"Juvenilepolyposissyndrome".)

Histopathologically,themajorityofcancersarisinginthecolonandrectumareadenocarcinomas.ThehistologicdiagnosisofCRCisdiscussedindetailelsewhere.
(See"Pathologyandprognosticdeterminantsofcolorectalcancer",sectionon'Histologyandimmunohistochemistry'.)

ColonoscopyColonoscopyisthemostaccurateandversatilediagnostictestforCRC,sinceitcanlocalizeandbiopsylesionsthroughoutthelargebowel,
detectsynchronousneoplasms,andremovepolyps.SynchronousCRCs,definedastwoormoredistinctprimarytumorsdiagnosedwithinsixmonthsofaninitial
CRC,separatedbynormalbowel,andnotduetodirectextensionormetastasis,occurin3to5percentofpatients[3234].Theincidenceissomewhatlower
(approximately2.5percent)whenpatientswithLynchsyndromeareexcludedthepresenceofsynchronouscancersshouldraisetheclinicalsuspicionforLynch
Syndrome[35].(See"Lynchsyndrome(hereditarynonpolyposiscolorectalcancer):Clinicalmanifestationsanddiagnosis",sectionon'Colonicmanifestations'.)

Thepreparationfor,diagnosticuseof,andcomplicationsassociatedwithcolonoscopyarediscussedelsewhere.(See"Overviewofcolonoscopyinadults".)

Whenviewedthroughtheendoscope,thevastmajorityofcolonandrectalcancersareendoluminalmassesthatarisefromthemucosaandprotrudeintothelumen
(figure1).Themassesmaybeexophyticorpolypoid.Bleeding(oozingorfrankbleeding)maybeseenwithlesionsthatarefriable,necrotic,orulcerated(picture1A
B).Circumferentialornearcircumferentialinvolvementofthebowelwallcorrelateswiththesocalled"applecore"descriptionseenonradiologicimaging(image1A
B).
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Aminorityofneoplasticlesionsinthegastrointestinaltract(bothinasymptomaticandsymptomaticindividuals)arenonpolypoidandrelativelyflatordepressed.In
onestudy,nonpolypoidcolorectalneoplasmshadagreaterassociationwithcarcinomathandidpolypoidneoplasms[36].Cancersthatarisefromnonpolypoid(flat)
adenomasmaybemoredifficulttovisualizecolonoscopicallythanpolypoidlesions,butcolonoscopyisthoughttohavesuperiorsensitivityinthissituationthan
doesbariumenemaorcomputedtomography(CT)colonography.(See"Approachtothepatientwithcolonicpolyps",sectionon'Morphologic/endoscopic
classification'.)

Forendoscopicallyvisiblelesions,methodsfortissuesamplingincludebiopsies,brushings,andpolypectomy.Forlesionsthatarecompletelyremoved
endoscopically(withpolypectomy,endoscopicmucosalresection,orendoscopicsubmucosaldissection),tattooingisimportantforsubsequentlocalizationifan
invasiveneoplasmisfound,andadditionallocaltherapyisneeded.Tattoosaretypicallyplacedadjacenttoorafewcentimetersdistaltothelesion,withthe
locationbeingdocumentedinthecolonoscopyreport.Large,laterallyspreadingcolonicpolypscannowbesafelyremovedendoscopically,providedtheymeet
endoscopiccriteriathatpredicttheirbenignnature(table2).(See"Endoscopicremovaloflargecolonpolyps",sectionon'Patientselection'and"Approachtothe
patientwithcolonicpolyps",sectionon'Management'.)

Amongasymptomaticpatients,colonoscopicmissratesforCRCsinthehandsofexperiencedoperatorsrangefrom2to6percent,andarehighestontherightside
ofthecolon[3739].(See"Testsforscreeningforcolorectalcancer:Stooltests,radiologicimagingandendoscopy",sectionon'Sensitivityofcolonoscopy'.)

TheavailabledataconcerningmissratesforCRCamongsymptomaticpatientsundergoingcolonoscopyareasfollows:

InarandomizedtrialcomparingcolonoscopyversusCTcolonographyforindividualswithsymptomssuggestiveofCRCconductedbySIGGAR(Special
InterestGroupinGastrointestinalandAbdominalRadiology)investigators,noneofthe55cancersthatwerediagnosedinthecohortof1072patientswhowere
randomlyassignedtocolonoscopyweremissed[40].

Inasystematicreviewandmetaanalysisof25diagnosticstudiesprovidingdataon9223patientswithacumulativeCRCprevalenceof3.6percent(414
cancers),thesensitivityofopticalcolonoscopyfordetectionofCRCwas94.7percent(178of188,95%CI9097.2)[41].Thus,themissratewas5.3percent.

LargeretrospectivestudiesfromCanada[4244]andtheUnitedStates[45,46]haveusedadministrativedatabasestoidentifypatientsdiagnosedwithCRC
whohadhadacolonoscopyperformedforanyindication6to60monthspriortoCRCdiagnosis.Theseinterval,missed,orpostcolonoscopyCRCs
accountedfor6to9percentofallCRCsintheirseries.OtherstudiesofpostcolonoscopyCRC(sometimescalledintervalcancers)haveshownaclose
inverserelationshipbetweentheincidenceofthesecancersinacolonoscopist'spracticeandthatcolonoscopist'sadenomadetectionrate.(See"Overviewof
colonoscopyinadults",sectionon'Qualityindicators'.)

Ifamalignantobstructionprecludesafullcolonoscopypreoperatively,theentireresidualcolonshouldbeexaminedsoonafterresection.

Intheabsenceofanobstruction,wherecolonoscopyisincomplete,anotheroptionisPillCamcolon2,awirelesscolonvideoendoscopycapsuleapprovedfor
CRCscreening,althoughitsuseinpatientswithsymptomssuggestiveofCRC(eg,anemia,rectalbleeding,weightloss)iscontroversial.(See"Wirelessvideo
capsuleendoscopy",sectionon'Coloncapsuleendoscopy'and"Testsforscreeningforcolorectalcancer:Stooltests,radiologicimagingandendoscopy",section
on'Capsuleendoscopy'.)

FlexiblesigmoidoscopyOverthelast50years,agradualshifttowardrightsidedorproximalcoloncancershasbeenobservedbothintheUnitedStatesand
internationally,withthegreatestincreaseinincidenceisincecalprimaries(picture2).Becauseofthis,andbecauseofthehighfrequencyofsynchronousCRCs,
flexiblesigmoidoscopyisgenerallynotconsideredtobeanadequatediagnosticstudyforapatientsuspectedofhavingaCRC,unlessapalpablemassisfeltinthe
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rectum.Insuchcases,afullcolonoscopywillstillbeneededtoevaluatetheremainderofthecolonforsynchronouspolypsandcancers(see"Colorectalcancer:
Epidemiology,riskfactors,andprotectivefactors",sectionon'Incidence').Nevertheless,screeningforCRCusingaflexiblesigmoidoscopeisoneofthefew
modalitiesthathavebeenproventhroughrandomizedcontrolledtrialstoreduceCRCmortalityandincidence[40].

BariumenemaBariumenemaiswidelyavailableandmaybeusedtoinvestigatepatientswithsymptomssuggestingofCRC(image1AB)[47,48].However,
thediagnosticyieldofbothdoublecontrastbariumenema(DCBE)aloneandthecombinationofDCBEplusflexiblesigmoidoscopyislessthanthatofcolonoscopy
orCTcolonographyfortheevaluationoflowertractsymptoms[48,49].

TheyieldofDCBEalonewasaddressedinarandomizedtrialcomparingDCBEversusCTcolonographyin3838patientswithsymptomssuggestiveofCRC[48].
Ofthe2527patientsassignedtoDCBE,thedetectionrateforCRCorlargepolypswassignificantlylower(5.6versus7.3percentwithCTcolonography).Ratesof
additionalstudiesaftertheinitialprocedureweresignificantlylowerafterDCBEthanCTcolonography(18versus24percent)withthreeyearsoffollowup.The
needforadditionalstudiesfollowingCTcolonographywasduemostlytothehigherpolypdetectionrateCRCwassubsequentlydiagnosedinmorepatientswho
hadinitiallyundergoneDCBE(missrate14versus7percent).

Ifapolypormassisdetectedbybariumenema,colonoscopyisrecommendedtoestablishthehistology,removethepolyp,andsearchforsynchronouslesions.

CTcolonographyCTcolonography(alsocalledvirtualcolonoscopyorCTcolography)providesacomputersimulatedendoluminalperspectiveoftheairfilled
distendedcolon.ThetechniqueusesconventionalspiralorhelicalCTscanormagneticresonanceimagesacquiredasanuninterruptedvolumeofdata,and
employssophisticatedpostprocessingsoftwaretogenerateimagesthatallowtheoperatortoflythroughandnavigateacleansedcoloninanychosendirection.CT
colonographyrequiresamechanicalbowelprepthatissimilartothatneededforbariumenema,sincestoolcansimulatepolyps.(See"Overviewofcomputed
tomographiccolonography".)

CTcolonographyhasbeenevaluatedinpatientswithincompletecolonoscopyandasaninitialdiagnostictestinpatientswithsymptomssuggestiveofCRC.

IncompletecolonoscopyNoncompletionratesfordiagnosticcolonoscopyinsymptomaticpatientsareapproximately11to12percent[40,50].Reasonsfor
incompletenessincludetheinabilityofthecolonoscopetoreachthetumorortovisualizethemucosaproximaltothetumorfortechnicalreasons(eg,partiallyor
completelyobstructingcancer,tortuouscolon,poorpreparation)andpatientintoleranceoftheexamination.Inthissetting,CTcolonographyishighlysensitivefor
thedetectionofCRCandcanprovidearadiographicdiagnosis,althoughitcanovercallstoolasmassesinpoorlydistendedorpoorlypreparedcolonsitalsolacks
thecapabilityforbiopsyorremovalofpolyps[41,5154].

CTcolonographyshouldberestrictedtopatientswhoareabletopassflatusandcapableoftoleratingtheoralpreparation.Forclinicallyobstructedpatients,a
gastrointestinal(GI)protocolabdominalCTscanisagoodalternativetoCTcolonography.

InitialdiagnostictestSystematicreviewsofscreeningstudiesconductedinasymptomaticpatientssuggestthatCTcolonographyandcolonoscopyhave
similardiagnosticyieldfordetectingCRCandlargepolyps.Comparisonofthebenefitsandcostsofthetwoproceduresdependsonotherfactors,oneofthemost
importantofwhichistheneedforadditionalinvestigationafterCTcolonographyandtheexposuretoradiation,whichisparticularlyimportantwhererecurrent
scanningovertimemaybecontemplatedsuchasinscreening.(See"Radiationrelatedrisksofimagingstudies".)

Abnormalresultsshouldbefollowedupbycolonoscopyforexcisionandtissuediagnosis,orforsmallerlesions,additionalsurveillancewithCTcolonography.There
iscontroversyastothethresholdsizeofapolypthatwouldindicatetheneedfor(interventional)colonoscopyandpolypectomy.CTcolonographyalsohasthe
abilitytodetectextracoloniclesions,whichmightexplainsymptomsandprovideinformationastothetumorstage,butalsocouldgenerateanxietyandcostfor
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unnecessaryinvestigationandmayhavealowyieldofclinicallyimportantpathology[55].(See"Testsforscreeningforcolorectalcancer:Stooltests,radiologic
imagingandendoscopy",sectionon'Computedtomographiccolonography'.)

TheperformanceofdiagnosticCTcolonographyascomparedwithcolonoscopyinpatientswithsymptomssuggestiveofCRChasbeenaddressedinthefollowing
studies:

Asystematicreviewandmetaanalysisincluded49studies(11,551patients)inwhichpatientsunderwentCTcolonographyforthediagnosisofcolorectal
polypsandcancerwithsubsequentcolonoscopyforverificationofthefindings43studies(6668patients)examinedasymptomaticordiseaseenriched
population[41].Therewere394cancersinthesymptomaticpopulation(prevalence6percent)andatotalof414cancersintheentirecohort.CTcolonography
detected96.1percentofthehistologicallyprovencancers(95%CI93.997.7percent).Inasubsetof25studies(9223patients)inwhichthesensitivityof
colonoscopycouldbeassessedindependently(ie,whenthecolonoscopywasperformedwithoutknowledgeofthepriorCTcolonographyresult,ananalysis
whichincludedpredominantlydatafromasymptomaticindividuals),thesensitivityofcolonoscopywas94.7percent(178of188cancers,95%CI90.497.2
percent).

ThediagnosticperformanceofCTcolonographywasdirectlycomparedwithcolonoscopyintheSIGGARtrialinwhich1610patientswithsymptoms
suggestiveofCRCwererandomlyassignedtocolonoscopy(n=1072)orCTcolonography(n=538)[40].Theprimaryendpointwastherateofadditional
colonicinvestigationaftertheprimaryprocedurefordetectionofCRCorlarge(>10mm)polyps.DetectionratesforCRCandlargepolypswere11percentfor
bothprocedures.CTcolonographymissed1of29CRCsandcolonoscopymissednoneof55.However,patientsundergoingCTcolonographyweremorethan
threetimesmorelikelytogetadditionalcolonicinvestigations(30versus8percent).OnlyonethirdofthesepatientswerefoundtohaveCRCoralargepolyp.

Atleastonepreviouslyunknownextracolonicfindingwasreportedin60percentofthe475patientswhohadCTcolonographyandnodiagnosisofCRC.Most
werejudgedtobeclinicallyunimportant.Amongthe48patientswhowereinvestigatedfurtherforextracolonicfindings,onlyapproximatelyonethirdreceiveda
diagnosisthatexplainedatleastoneoftheirpresentingsymptomsandonlyninepatientswerefoundtohaveanextracolonicmalignancy.

Overall,CTcolonographyhadsuperiorpatientacceptabilitycomparedwithcolonoscopyintheshortterm(immediatelyafterthetest)butthebenefitsof
colonoscopy(beingmoresatisfiedwithhowresultswerereceivedandlesslikelytorequirefollowupcolonicinvestigations)becameapparentafterlongerterm
followup(threemonths)[56].

TheavailabledatasuggestthatCTcolonographyprovidesasimilarlysensitive,lessinvasivealternativetocolonoscopyinpatientspresentingwithsymptoms
suggestiveofCRC.However,giventhatcolonoscopypermitsremoval/biopsyofthelesionandanysynchronouscancersorpolypsthatareseenduringthesame
procedure,inourview,colonoscopyremainsthegoldstandardforinvestigationofsymptomssuggestiveofCRC.CTcolonographyispreferredoverbariumenema
whereaccesstocolonoscopyislimited.

PILLCAM2AcoloncapsuleforCRCscreeninghasbeenapprovedbytheEMAinEuropeandbytheUSFoodandDrugAdministration.IntheUnitedStates,it
isapprovedforuseinpatientswhohavehadanincompletecolonoscopy.WhileitsroleinscreeningforCRCisstilluncertain,itcouldbeconsideredinapatient
withanincompletecolonoscopywholacksobstruction.

LaboratorytestsAlthoughCRCisoftenassociatedwithirondeficiencyanemia,itsabsencedoesnotreliablyexcludethedisease.Thereisnodiagnosticrole
forotherroutinelaboratorytest,includingliverfunctiontests,whichlacksensitivityfordetectionoflivermetastases.

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TumormarkersAvarietyofserummarkershavebeenassociatedwithCRC,particularlycarcinoembryonicantigen(CEA).However,allthesemarkers,
includingCEA,havealowdiagnosticabilitytodetectprimaryCRCduetosignificantoverlapwithbenigndiseaseandlowsensitivityforearlystagedisease[57
60].AmetaanalysisconcludedthatthepooledsensitivityofCEAfordiagnosisofCRCwasonly46percent(95%CI0.450.47)[61].Nootherconventionaltumor
markerhadahigherdiagnosticsensitivity,includingcarbohydrateantigen199(CA199,pooledsensitivity0.30,95%CI0.280.32).

Furthermore,specificityofCEAisalsolimited.Inthepreviouslymentionedmetaanalysis,thespecificityofCEAfordiagnosisofCRCwas89percent(95%CI
0.880.92).NoncancerrelatedcausesofanelevatedCEAincludegastritis,pepticulcerdisease,diverticulitis,liverdisease,chronicobstructivepulmonarydisease,
diabetes,andanyacuteorchronicinflammatorystate.Inaddition,CEAlevelsaresignificantlyhigherincigarettesmokersthaninnonsmokers[62,63].

AnexpertpanelontumormarkersinbreastandcolorectalcancerconvenedbytheAmericanSocietyofClinicalOncology(ASCO)recommendedthatneitherserum
CEAnoranyothermarker,includingCA199,shouldbeusedasascreeningordiagnostictestforCRC[58].Asimilarrecommendationhasbeenmadebythe
EuropeanGrouponTumorMarkers[64].

However,CEAlevelsdohavevalueinthefollowupofpatientswithdiagnosedCRC.ASCOguidelinesrecommendthatserumCEAlevelsbeobtained
preoperativelyinmostpatientswithdemonstratedCRCtoaidinsurgicaltreatmentplanning,posttreatmentfollowup,andintheassessmentofprognosis[58]:

SerumlevelsofCEAhaveprognosticutilityinpatientswithnewlydiagnosedCRC.PatientswithpreoperativeserumCEA>5ng/mLhaveaworseprognosis,
stageforstage,thanthosewithlowerlevels.(See"Pathologyandprognosticdeterminantsofcolorectalcancer",sectionon'PreoperativeserumCEA'.)

ElevatedpreoperativeCEAlevelsthatdonotnormalizefollowingsurgicalresectionimplythepresenceofpersistentdiseaseandtheneedforfurther
evaluation.(See"Surveillanceaftercolorectalcancerresection",sectionon'Carcinoembryonicantigen'.)

FurthermoreserialassayofpostoperativeCEAlevelsshouldbeperformedforfiveyearsforpatientswithstageIIandIIIdiseaseiftheymaybeapotential
candidateforsurgeryorchemotherapyifmetastaticdiseaseisdiscovered.ArisingCEAlevelaftersurgicalresectionimpliesrecurrentdiseaseandshouldprompt
followupradiologicimaging.(See"Surveillanceaftercolorectalcancerresection".)

BloodbasedtestsforearlydetectionofCRC,ortomonitorforpostoperativerecurrence,areunderactivedevelopmentatpresent.Amongstthecontendersare
Sept9[65]andtheGeminitest[66,67].

DIFFERENTIALDIAGNOSISThesignsandsymptomsassociatedwithcolorectalcancer(CRC)arenonspecific,andthedifferentialdiagnosis,particularly
amongpatientspresentingwithofabdominalpainandrectalbleeding,isbroad.(See"Causesofabdominalpaininadults"and"Etiologyoflowergastrointestinal
bleedinginadults"and"Evaluationofoccultgastrointestinalbleeding"and"Approachtoacutelowergastrointestinalbleedinginadults".)

Manyconditionscausesignsorsymptomsthataresimilartocolorectaladenocarcinomasincludingothermalignanciesaswellasbenignlesionssuchas
hemorrhoids,diverticulitis,infection,orinflammatoryboweldisease.TheriskofCRCposedbyparticularsymptomshasbeenaddressedinthefollowingstudies:

Ametaanalysisof15studiesconcludedthatthesensitivityofindividualsymptoms(changeinbowelhabits,anemia,weightloss,diarrhea,abdominalmass)
forthediagnosisofCRCwaspoor(rangingfrom5to64percent),andspecificitywaslimited,aswouldbeexpectedforalowprevalencedisease[68].
However,thespecificitywas>95percentfordarkredrectalbleedingandforthepresenceofapalpableabdominalmassonexamination,indicatingthat
patientswithoutCRCrarelyhavethesefindingsandsuggestingthatthepresenceofeithermakesthediagnosisofaCRClikely.

TheassociationbetweenconstipationandCRCwasaddressedinametaanalysisof28crosssectionalsurveysandcohortstudies,whichdemonstratedno
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increaseintheprevalenceofCRCamongindividualswithconstipationastheprimaryindicationforcolonoscopy[69].

ApopulationbasedcasecontrolstudyofclinicalfeaturesbeforediagnosisofCRCconductedin21primarycarepracticesinExeter,DevonintheUnited
Kingdomincluded349patientsovertheageof40whowerediagnosedwithCRCoverafouryearperiodand1744controlswithoutCRCwhowerematched
byage,sex,andgeneralpractice[9].Primarycarerecordsfortwoyearsbeforediagnosiswerereviewedtoascertainsymptoms.Ofthe349casesstudied,
210(60percent)hadtumorsatordistaltothesplenicflexure,and126(36percent)wereproximaltoit,withtheremainderhavingmultipleorunknownsites.
TenfeatureswereassociatedwithCRCbeforediagnosisinunivariateanalysis,thelikelihoodratiosforCRCaccordingtosymptomswere:rectalbleeding10,
weightloss5.1,abdominalpain4.5,diarrhea3.9,constipation1.8,abnormalrectalexamination18,abdominaltenderness4.6,hemoglobin<10g/dL9.5,and
positivefecaloccultblood31.Thepositivepredictivevalues(PPVs)forabdominalpain,constipation,diarrhea,weightloss,andrectalbleedingwerehigherfor
olderpatients(70andover),especiallyrectalbleeding.Whensymptomswerecombined,thePPVwashighest(>10)forhemoglobin<10g/dLcombinedwith
abdominaltenderness.TheveryhighPPVforapositivefecaloccultbloodtestvalidatesthepolicyofpromptinvestigationofpatientswithpositivefecaloccult
bloodtests,particularlyifsymptomatic.(See"Testsforscreeningforcolorectalcancer:Stooltests,radiologicimagingandendoscopy",sectionon'Stool
basedtests'.)

Anothersystematicreviewof62studiesassessingtherelationshipbetweensymptomsandCRCusedestimatesofsensitivityandspecificitytocalculatea
diagnosticoddsratio(DOR=[sensitivity/(1sensitivity)]/[(1specificity)/specificity]),whichprovidedasinglesummarymeasureofaccuracyforeachsymptom
ahighDORindicatesahighcorrelationbetweenthesymptomandthedisease,whileaDORofonemeansthatthesymptompresenceisnobetterthan
chanceindiscriminatingbetweendiseaseandnondiseasedpatients[70].TheDORs,sensitivity,likelihoodratioofhavingthediseaseifthesymptomwas
present,andlikelihoodofhavingCRCintheabsenceofthesymptomforavarietyofsymptomsareoutlinedinthetable(table3).Theauthorsconcludedthat
onlyrectalbleedingandweightlosswereassociatedwiththepresenceofaCRCandeventhesehadrelativelylowDORs.

Thedifferentialdiagnosisofacolonicmassasseenonradiographicorendoscopicstudiesincludesanumberofbenignandmalignantdisorders,thedifferentiation
ofwhichcangenerallyrequiresbiopsyandhistologicevaluation(table4).Inparticular,raremalignanciesotherthanadenocarcinomasthatareprimarytothelarge
bowelincludeKaposisarcoma(KS),lymphomas,carcinoid(welldifferentiatedneuroendocrine)tumors,andmetastasesfromotherprimarycancers.(See
"Pathologyandprognosticdeterminantsofcolorectalcancer",sectionon'Histologyandimmunohistochemistry'.)

DisseminatedKScaninvolvethecolon,particularlyinpatientswithAIDS,manifestedascharacteristicviolaceousmaculesornodules[71].(See"AIDS
relatedKaposisarcoma:Clinicalmanifestationsanddiagnosis",sectionon'Gastrointestinaltract'.)

PrimarynonHodgkinlymphomaofthelargebowelmostcommonlyarisesinthececum,rightcolon,orrectumandusuallypresentsatanadvancedstagein
adults.Coloniclymphomatypicallyappearsasalargesolitarymass,althoughmultiplepolypoidlesionsordiffuseinvolvementcanoccur[72].(See"Clinical
presentationanddiagnosisofprimarygastrointestinallymphomas".)

Coloniccarcinoidtumorsarefoundmostcommonlyintheappendix,rectum,andcecum,andtheytendtodevelopatayoungeragethanadenocarcinomasof
thecolon.Appendicealandrectalcarcinoids,mostofwhicharelessthan2cm,appearassubmucosalnodulesandtendtobeindolent.Incontrast,primary
coloniccarcinoidtumorscanpresentaslargeapplecorelesions,whichcanbeclinicallyaggressiveandmaymetastasize.(See"Clinicalcharacteristicsof
carcinoidtumors".)

Metastasesfromotherprimarycancers,mostoftenovariancancer,canmimicaprimarylargebowelmalignancy.(See"Epithelialcarcinomaoftheovary,
fallopiantube,andperitoneum:Clinicalfeaturesanddiagnosis",sectionon'Differentialdiagnosis'.)

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STAGINGOncethediagnosisofcolorectalcancer(CRC)isestablished,thelocalanddistantextentofdiseaseisdeterminedtoprovideaframeworkfor
discussingtherapyandprognosis.Areviewofthebiopsyspecimenisimportantpriortomakingadecisionabouttheneedforclinicalstagingstudiesandsurgical
resection,especiallyforacancerouspolyp.Polypswithanareaofinvasivemalignancythathavebeencompletelyremovedandlackassociatedadversehistologic
features(positivemargin,poordifferentiation,lymphovascularinvasion)havealowriskoflymphaticanddistantmetastasesinsuchpatients,polypectomyalone
maybeadequate.Thisismoreeasilydeterminedifthepolypispedunculated.(See"Approachtothepatientwithcolonicpolyps".)

TNMstagingsystemTheTumorNodeMetastases(TNM)stagingsystemoftheAmericanJointCommitteeonCancer/UnionforInternationalCancerControl
(table5)isthepreferredstagingsystemforCRC[73].UseoftheolderAstlerCollermodificationoftheDuke'sclassificationisdiscouraged.

Themostrecent2010TNMstagingclassificationincludesanumberofchangescomparedwiththeolder2002classification[73]:

SubdivisionofT4lesionsintoT4a(tumorperforatesthesurfaceofthevisceralperitoneum)andT4b(directinvasionorhistologicadherencetootherorgans
and/orstructures).

FurthersubstagingofstageIIintoIIA(T3N0),IIB(T4aN0),andIIC(T4bN0)disease.

N1andN2categoriesaresubdividedaccordingtothenumberofinvolvednodes.

SatellitedepositsthatarediscontinuousfromtheleadingedgeofthecancerandlackevidenceofaresiduallymphnodeareclassifiedasN1cdisease.

SeveralstagegroupingsofstageIIIdiseasehavebeenrevisedbaseduponrefinementinprognosticstratification.

M1issubdividedintoM1aforsinglemetastaticsiteandM1bformultiplemetastaticsites.

ThesechangesweresupportedbyanalysisofdataonbothcolonandrectumcancerfromthepopulationbasedSurveillance,EpidemiologyandEndResults
(SEER)registry[74,75].However,therevisededitionoftheTNMstagingclassificationisnotusedinallcountries.Asexamples,insomeareasoftheNetherlands,
thefiftheditionoftheTNMstagingclassificationisstillusedpurposelyforrectalcanceraslatermodificationswerenotconsideredtorepresentanimprovement,
whereasinJapan,noneoftherevisedcriteriaonsatellitedepositsthatlackevidenceofaresiduallymphnodewereadoptedintheseventheditionoftheNational
CancerStagingManualeditedbytheJapaneseSocietyforCanceroftheColonandRectumbecauseofthelackofsufficientjustificationforthischange[76].

Radiographic,endoscopic,andintraoperativefindingscanbeusedtoassignaclinicalstage,whileassessmentofthepathologicstage(termedpT,pN,pM)requires
histologicexaminationoftheresectionspecimen.Preoperativeradiationandchemotherapycansignificantlyalterclinicalstaging[77]asaresult,posttherapy
pathologicstagingisdesignatedwithaypprefix(ie,ypT,ypN).(See"Pathologyandprognosticdeterminantsofcolorectalcancer".)

ClinicalstagingevaluationPreoperativeclinicalstagingisbestaccomplishedbyphysicalexamination(withparticularattentiontoascites,hepatomegaly,and
lymphadenopathy,andpotentialfixationofrectalcancers),computedtomography(CT)scanoftheabdomenandpelvis,andchestimaging.Althoughfrequently
obtainedpreoperatively,liverenzymesmaybenormalinthesettingofsmallhepaticmetastasesandarenotareliablemarkerforexclusionofliverinvolvement
(picture3).Thesinglemostcommonlivertestabnormalityassociatedwithlivermetastasesisanelevationintheserumalkalinephosphataselevel[78].

CTscanIntheUnitedStatesandelsewhere,thestandardpracticeatmostinstitutionsisthatallpatientswithstageII,III,orIVCRCundergochest,
abdomen,andpelvicCT,eitherpriortoorfollowingresection,anapproachendorsedbytheNationalComprehensiveCancerNetwork.Ingeneral,itispreferable
toobtainthesescanspriorto,ratherthanaftersurgery,asthescanresultswilloccasionallychangesurgicalplanning.

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AbdomenandpelvisInpatientswithnewlydiagnosedCRC,preoperativeabdominalandpelvicCTscanscandemonstrateregionaltumorextension,
regionallymphaticanddistantmetastases,andtumorrelatedcomplications(eg,obstruction,perforation,fistulaformation)[79,80].ThesensitivityofCTfor
detectingdistantmetastasisishigher(75to87percent)thanfordetectingnodalinvolvement(45to73percent)orthedepthoftransmuralinvasion(approximately
50percent)[79,8185].ThesensitivityofCTfordetectionofmalignantlymphnodesishigherforrectalthanforcoloncancersperirectaladenopathyispresumedto
bemalignantsincebenignadenopathyistypicallynotseeninthisareaintheabsenceofdemonstrableinflammatoryprocess(eg,proctitis,fistula,perirectal
abscess)[86].

CTscanisnotareliablediagnostictestforlowvolumetumoronperitonealsurfaces[87].ThesensitivityofCTfordetectingperitonealimplantsdependsonthe
locationandsizeoftheimplants.Inonestudy,thesensitivityofCTfornodules<0.5cmwas11percentanditwasonly37percentforimplants0.5to5cm[88].

Althoughcommonlyobtained,thenecessityofpreoperativeabdominal/pelvicCTforallpatientswithCRCisdebated.Inaretrospectivereviewof180resected
patients,only3of67patientshadincidentalfindingsonCTthatalteredthesurgicalapproach[84].Assessmentofhepaticmetastasesbyintraoperativeultrasound
andmanualpalpationofthelivermayprovideabetteryieldthanpreoperativeCT,particularlyforpatientswhoarefoundtohavetransmuralinvolvement(T3/4)atthe
timeofexploration[8991].However,theincreasinguseoflaparoscopiccolonicresectionsprecludesmanualpalpation,andevenwithopenproceduressurgeons
maynothaveadequateaccesstotheliverdependinguponthelocationoftheincisionandtheextentofadhesionsfrompriorsurgery.

Thefindingoflivermetastasesonpreoperativestudiesmaynotnecessarilyalterthesurgicalapproachtotheprimarytumor,particularlyinpatientswhoare
symptomaticfromtheirprimarytumor(eg,bleeding,impendingobstruction).Inpatientswithfourorfewerhepaticlesions,resectionmaybecurative,withfiveyear
relapsefreesurvivalratesof24to38percent.Althoughmostsurgeonsadvocateresectionoftheprimarytumorandsynchronoushepaticmetastasesattwo
differentoperations,someapproachbothsitesatthesametime.(See"Managementofpotentiallyresectablecolorectalcancerlivermetastases".)

ChestTheclinicalbenefitofroutineclinicalstagingwithchestCTisalsocontroversial.Atleastintheory,imagingofthechestmightbeofmorevaluefor
rectalcancersincevenousdrainageofthelowerrectumisthroughthehemorrhoidalveinstothevenacava,bypassingtheliver,andlungmetastasesmightbe
morecommon[92].

Themajorissueisthefrequentfindingofindeterminatelesions(10to30percent),whichaddtotheclinicalcomplexity(ie,shouldfurtherpreoperativediagnostic
workupbeundertaken)butareseldommalignant(7to20percent).Asystematicreviewof12studiesincluding5873patientsundergoingstagingforanewly
diagnosedCRC[93]foundthat732(9percent)hadindeterminatepulmonarynodulesonpreoperativechestCT.Ofthese,80(11percent)turnedouttobecolorectal
metastasesatfollowup.Generally,thepresenceofregionalnodalmetastasesatthetimeofresection,multiplenumbersofindeterminatepulmonarynodules,size
5mm,rectalascomparedwithcoloncancer,parenchymalversussubpleurallocationofthenodule,anddistantmetastaseselsewhereweresignificantly
associatedwithmalignancy,whilecalcificationwasassociatedwithabenignetiology.Overall,theriskofmalignancyformostpatientswithindeterminate
pulmonarynodules(approximately1percent)seemssufficientlylowthatfurtherpreoperativediagnosticworkupisunnecessary.

LiverMRIContrastenhancedmagneticresonanceimaging(MRI)ofthelivercanidentifymorehepaticlesionsthanarevisualizedbyCT,andisparticularly
valuableinpatientswithbackgroundfattyliverchanges[94].AmetaanalysisconcludedthatMRIisthepreferredfirstlineimagingstudyforevaluatingCRCliver
metastasesinpatientswhohavenotpreviouslyundergonetherapy[95].However,newergenerationCTscannersandtheuseoftriplephaseimagingduring
contrastadministrationhasimprovedsensitivityofCTfordetectionoflivermetastases.Incurrentpractice,liverMRIisgenerallyreservedforpatientswhohave
suspiciousbutnotdefinitivefindingsonCTscan,particularlyifbetterdefinitionofhepaticdiseaseburdenisneededinordertomakedecisionsaboutpotential
hepaticresection.(See"Managementofpotentiallyresectablecolorectalcancerlivermetastases",sectionon'Patientselection'.)

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PETscansPositronemissiontomography(PET)scansdonotappeartoaddsignificantinformationtoCTscansforroutinepreoperativestagingofCRC
[96,97].TheestablishedroleofPETscanninginpatientswithCRCasanadjuncttootherimagingmodalitiesisdescribedinthefollowingsettings:

Localizingsite(s)ofdiseaserecurrenceinpatientswhohavearisingserumcarcinoembryonicantigen(CEA)levelandnondiagnosticconventionalimaging
evaluationfollowingprimarytreatment.Inthissetting,PETscanningcanpotentiallylocalizeoccultdisease,permittingtheselectionofpatientswhomay
benefitfromexploratorylaparotomy[98101].(See"Surveillanceaftercolorectalcancerresection".)

Inanillustrativeseries,105suchpatientsunderwentPETscanningandsubsequentabdominopelvicCTscans[98].ComparedwithCTandotherconventional
diagnosticstudies,PETscanninghadahighersensitivity(87versus66percent)andspecificity(68versus59percent)forthedetectionofclinicallyrelevant
tumor.Inasecondreport,PETscanfindingsledtoapotentiallycurativeresectionin14of50patients(28percent)withelevatedserumCEAlevelsanda
completelynormalorequivocalconventionaldiagnosticworkup[99].

EvaluationofpatientswhoarethoughttobepresentorfuturecandidatesforresectionofisolatedCRClivermetastases.TheroutineuseofPETpriorto
attemptedresectionreducesthenumberofnontherapeuticlaparotomies.(See"Managementofpotentiallyresectablecolorectalcancerlivermetastases",
sectionon'PETscans'.)

RecentchemotherapymayalterthesensitivityofPETforthedetectionofcolorectallivermetastases,aneffectthoughtrelatedtodecreasedcellularmetabolic
activityofthetumor.However,generally,thebenefitofaPETscanistodetectextrahepaticmetastasesinpatientsconsideredliverresectioncandidates,andin
thissituation,itisappropriatetoobtainaPETpriortoinitiationofchemotherapy.Thissubjectisaddressedindetailelsewhere.(See"Managementofpotentially
resectablecolorectalcancerlivermetastases",sectionon'PETscans'.)

LocoregionalstagingforrectalcancerAnaccuratedeterminationoftumorlocationwithintherectumanddiseaseextentisnecessarypriortotreatmentin
ordertoselectthesurgicalapproachandtoidentifythosepatientswhoarecandidatesforinitialchemoradiotherapypriortosurgery.(See"Neoadjuvant
chemoradiotherapyandradiotherapyforrectaladenocarcinoma",sectionon'Indicationsforneoadjuvanttreatment'.)

Digitalrectalexamination(DRE),rigidsigmoidoscopy,transrectalultrasound,transrectalendoscopicultrasound,andpelvicMRIcanallassistindeterminingthe
needforradicalresectionversuslocalexcision,andwhetherthepatientisacandidateforpreoperativetherapy.Thissubjectisdiscussedelsewhere.(See
"Pretreatmentlocalstagingevaluationforrectalcancer".)

INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and"BeyondtheBasics."TheBasicspatient
educationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatienteducation
piecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantin
depthinformationandarecomfortablewithsomemedicaljargon.

Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicstoyourpatients.(Youcanalsolocatepatient
educationarticlesonavarietyofsubjectsbysearchingon"patientinfo"andthekeyword(s)ofinterest.)

Basicstopics(see"Patientinformation:Colonandrectalcancer(TheBasics)")

BeyondtheBasicstopics(see"Patientinformation:Colonandrectalcancer(BeyondtheBasics)"and"Patientinformation:Colorectalcancertreatment
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metastaticcancer(BeyondtheBasics)")

SUMMARY

Patientswithcolorectalcancer(CRC)maypresentinthreeways(see'Clinicalpresentation'above):

Patientswithsuspicioussymptomsand/orsigns

Asymptomaticindividualsdiscoveredbyroutinescreening(see"Screeningforcolorectalcancer:Strategiesinpatientsataveragerisk")

Emergencyadmissionwithintestinalobstruction,peritonitis,orrarely,anacutegastrointestinal(GI)bleed

AlthoughtheincreasinguptakeofCRCscreeninghasledtomorecasesbeingdiagnosedatanasymptomaticstage,mostCRCsarediagnosedafterthe
onsetofsymptoms(mostcommonlyrectalbleeding,abdominalpain,otherwiseunexplainedirondeficiencyanemiaand/orachangeinbowelhabits).Achange
inbowelhabitsisamorecommonpresentingsymptomforleftsidedascomparedwithrightsidedcancers.Hematocheziaismorelikelywithrectalthancolon
cancers,andoccultcolonicbleedingismorecommonwithcecalandascendingcoloncancers.(See'Symptomsfromthelocaltumor'above.)

OneinfivepatientswithCRCpresentswithmetastaticdisease.Themostcommonmetastaticsitesaretheregionallymphnodes,liver,lungs,and
peritoneum.(See'Metastaticdisease'above.)

UnusualpresentationsofCRCincludemalignantfistulaformation,feverofunknownorigin,sepsisfromStreptococcusbovisandClostridiumsepticum,and
adenocarcinomaofunknownprimary.(See'Unusualpresentations'above.)

ApositivefecaloccultbloodtesthasamuchhigherpredictivevalueforCRCthananysingleorcombinationofsymptoms,warrantinghighpriorityfor
colonoscopicfollowup.(See'Differentialdiagnosis'above.)

Thevastmajorityofcolonandrectalcancersareendoluminaladenocarcinomasthatarisefromthemucosa.Colonoscopyisthemostversatilediagnostictest
insymptomaticindividuals(see'Colonoscopy'above).Computedtomography(CT)colonographyprovidesasimilarlysensitive,lessinvasivealternativeto
colonoscopyinpatientspresentingwithsymptomssuggestiveofCRC.However,giventhatcolonoscopypermitsremoval/biopsyofthelesionandany
synchronouscancersorpolypsthatareseenduringthesameprocedure,colonoscopyremainsthegoldstandardforinvestigationofsymptomssuggestiveof
CRC.CTcolonographyispreferredoverbariumenemawhereaccesstocolonoscopyislimited.(See'Initialdiagnostictest'aboveand'Bariumenema'
above.)

Inpatientsinwhomfortechnicalreasonsthetumorcannotbereachedbycolonoscopy(eg,partiallyobstructingcancer,tortuouscolon,poorprep)orbecause
ofpatientintolerance,CTcolonographycanprovidearadiographicdiagnosis.

Oncethediagnosisisestablished,thelocalanddistantextentofdiseasespreadisdeterminedtoprovideaframeworkfordiscussingtherapyandprognosis.
Preoperativeclinicalstagingisbestaccomplishedbyphysicalexamination,CTscanoftheabdomenandpelvis,andchestimaging.(See'Clinicalstaging
evaluation'above.)

Positronemissiontomography(PET)scansdonotappeartoaddsignificantinformationtoCTscansforroutinepreoperativestagingofanewlydiagnosed
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CRCexceptfortheevaluationofpatientswhoarethoughttobecandidatesforresectionofisolatedCRClivermetastases.(See'PETscans'above.)

Additionalprocedures(digitalrectalexamination[DRE],rigidsigmoidoscopy,transrectalendoscopicultrasound,and/ormagneticresonanceimaging[MRI])are
indicatedforlocoregionalstagingofpatientswithrectalcancertoselectthesurgicalapproachandtoidentifythosepatientswhoarecandidatesforinitial
radiotherapyorchemoradiotherapyratherthansurgery.(See'Locoregionalstagingforrectalcancer'above.)

ThereisnodiagnosticroleforroutinelaboratorytestinginscreeningorstagingCRC.However,serumcarcinoembryonicantigen(CEA)levelsshouldbe
obtainedpreoperativelyandpostoperativelyinpatientswithdemonstratedCRCtoaidsurgicaltreatmentplanningandassessmentofprognosis.(See'Tumor
markers'above.)

ACKNOWLEDGMENTTheeditorialstaffatUpToDatewouldliketoacknowledgeDennisJAhnen,MD,whocontributedtoanearlierversionofthistopic
review.

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

REFERENCES

1.SiegelRL,MillerKD,JemalA.Cancerstatistics,2016.CACancerJClin201666:7.
2.RyersonAB,EhemanCR,AltekruseSF,etal.AnnualReporttotheNationontheStatusofCancer,19752012,featuringtheincreasingincidenceofliver
cancer.Cancer2016.
3.AhnenDJ,WadeSW,JonesWF,etal.Theincreasingincidenceofyoungonsetcolorectalcancer:acalltoaction.MayoClinProc201489:216.
4.DozoisEJ,BoardmanLA,SuwanthanmaW,etal.Youngonsetcolorectalcancerinpatientswithnoknowngeneticpredisposition:canweincreaseearly
recognitionandimproveoutcome?Medicine(Baltimore)200887:259.
5.MorenoCC,MittalPK,SullivanPS,etal.ColorectalCancerInitialDiagnosis:ScreeningColonoscopy,DiagnosticColonoscopy,orEmergentSurgery,and
TumorStageandSizeatInitialPresentation.ClinColorectalCancer201615:67.
6.MoielD,ThompsonJ.Earlydetectionofcoloncancerthekaiserpermanentenorthwest30yearhistory:howdowemeasuresuccess?Isitthetest,the
numberoftests,thestage,orthepercentageofscreendetectedpatients?PermJ201115:30.
7.SpeightsVO,JohnsonMW,StoltenbergPH,etal.Colorectalcancer:currenttrendsininitialclinicalmanifestations.SouthMedJ199184:575.
8.SteinbergSM,BarkinJS,KaplanRS,StableinDM.Prognosticindicatorsofcolontumors.TheGastrointestinalTumorStudyGroupexperience.Cancer1986
57:1866.
9.HamiltonW,RoundA,SharpD,PetersTJ.Clinicalfeaturesofcolorectalcancerbeforediagnosis:apopulationbasedcasecontrolstudy.BrJCancer2005
93:399.
10.RizkSN,RyanJJ.Clinicopathologicreviewof92casesofcoloncancer.SDJMed199447:89.
11.SaidiHS,KaruriD,NyaimEO.Correlationofclinicaldata,anatomicalsiteanddiseasestageincolorectalcancer.EastAfrMedJ200885:259.
12.MajumdarSR,FletcherRH,EvansAT.Howdoescolorectalcancerpresent?Symptoms,duration,andcluestolocation.AmJGastroenterol199994:3039.
13.GoodmanD,IrvinTT.Delayinthediagnosisandprognosisofcarcinomaoftherightcolon.BrJSurg199380:1327.
14.MacraeFA,StJohnDJ.RelationshipbetweenpatternsofbleedingandHemoccultsensitivityinpatientswithcolorectalcancersoradenomas.
http://www.uptodate.com/contents/clinicalpresentationdiagnosisandstagingofcolorectalcancer?topicKey=ONC%2F2496&elapsedTimeMs=1&source=search_result&searchTerm=cancer+de+colon&selectedTitle=1%7E15 14/36
2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Gastroenterology198282:891.
15.TsaiHL,HsiehJS,YuFJ,etal.Perforatedcoloniccancerpresentingasintraabdominalabscess.IntJColorectalDis200722:15.
16.AlvarezJA,BaldonedoRF,BearIG,etal.Anaerobicliverabscessesasinitialpresentationofsilentcoloniccancer.HPB(Oxford)20046:41.
17.PanwalkerAP.Unusualinfectionsassociatedwithcolorectalcancer.RevInfectDis198810:347.
18.LamS,GreenbergR,BankS.Anunusualpresentationofcoloncancer:purulentpericarditisandcardiactamponadeduetoBacteroidesfragilis.AmJ
Gastroenterol199590:1518.
19.AbbruzzeseJL,AbbruzzeseMC,LenziR,etal.Analysisofadiagnosticstrategyforpatientswithsuspectedtumorsofunknownorigin.JClinOncol1995
13:2094.
20.AmriR,BordeianouLG,SyllaP,BergerDL.Impactofscreeningcolonoscopyonoutcomesincoloncancersurgery.JAMASurg2013148:747.
21.PolissarL,SimD,FrancisA.Survivalofcolorectalcancerpatientsinrelationtodurationofsymptomsandotherprognosticfactors.DisColonRectum1981
24:364.
22.RamosM,EstevaM,CabezaE,etal.Relationshipofdiagnosticandtherapeuticdelaywithsurvivalincolorectalcancer:areview.EurJCancer2007
43:2467.
23.RamosM,EstevaM,CabezaE,etal.Lackofassociationbetweendiagnosticandtherapeuticdelayandstageofcolorectalcancer.EurJCancer2008
44:510.
24.TrringML,FrydenbergM,HansenRP,etal.Timetodiagnosisandmortalityincolorectalcancer:acohortstudyinprimarycare.BrJCancer2011104:934.
25.GriffinMR,BergstralhEJ,CoffeyRJ,etal.Predictorsofsurvivalaftercurativeresectionofcarcinomaofthecolonandrectum.Cancer198760:2318.
26.WolmarkN,WieandHS,RocketteHE,etal.TheprognosticsignificanceoftumorlocationandbowelobstructioninDukesBandCcolorectalcancer.
FindingsfromtheNSABPclinicaltrials.AnnSurg1983198:743.
27.CarraroPG,SegalaM,CesanaBM,TiberioG.Obstructingcoloniccancer:failureandsurvivalpatternsoveratenyearfollowupafteronestagecurative
surgery.DisColonRectum200144:243.
28.CrucittiF,SofoL,DogliettoGB,etal.Prognosticfactorsincolorectalcancer:currentstatusandnewtrends.JSurgOncolSuppl19912:76.
29.StapleyS,PetersTJ,SharpD,HamiltonW.Themortalityofcolorectalcancerinrelationtotheinitialsymptomatpresentationtoprimarycareandtothe
durationofsymptoms:acohortstudyusingmedicalrecords.BrJCancer200695:1321.
30.CaldarellaA,CrocettiE,MesseriniL,PaciE.Trendsincolorectalincidencebyanatomicsubsitefrom1985to2005:apopulationbasedstudy.IntJ
ColorectalDis201328:637.
31.ChapuisPH,DentOF,FisherR,etal.Amultivariateanalysisofclinicalandpathologicalvariablesinprognosisafterresectionoflargebowelcancer.BrJ
Surg198572:698.
32.LangevinJM,NivatvongsS.Thetrueincidenceofsynchronouscancerofthelargebowel.Aprospectivestudy.AmJSurg1984147:330.
33.PassmanMA,PommierRF,VettoJT.Synchronouscolonprimarieshavethesameprognosisassolitarycoloncancers.DisColonRectum199639:329.
34.MulderSA,KranseR,DamhuisRA,etal.Prevalenceandprognosisofsynchronouscolorectalcancer:aDutchpopulationbasedstudy.CancerEpidemiol
201135:442.
35.FanteR,RoncucciL,TamassiaMG,etal.Frequencyandclinicalfeaturesofmultipletumorsofthelargebowelinthegeneralpopulationandinpatientswith
hereditarycolorectalcarcinoma.Cancer199677:2013.
36.SoetiknoRM,KaltenbachT,RouseRV,etal.Prevalenceofnonpolypoid(flatanddepressed)colorectalneoplasmsinasymptomaticandsymptomaticadults.
JAMA2008299:1027.
http://www.uptodate.com/contents/clinicalpresentationdiagnosisandstagingofcolorectalcancer?topicKey=ONC%2F2496&elapsedTimeMs=1&source=search_result&searchTerm=cancer+de+colon&selectedTitle=1%7E15 15/36
2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

37.RexDK,RahmaniEY,HasemanJH,etal.Relativesensitivityofcolonoscopyandbariumenemafordetectionofcolorectalcancerinclinicalpractice.
Gastroenterology1997112:17.
38.BresslerB,PaszatLF,ChenZ,etal.Ratesofnewormissedcolorectalcancersaftercolonoscopyandtheirriskfactors:apopulationbasedanalysis.
Gastroenterology2007132:96.
39.SinghS,SinghPP,MuradMH,etal.Prevalence,riskfactors,andoutcomesofintervalcolorectalcancers:asystematicreviewandmetaanalysis.AmJ
Gastroenterol2014109:1375.
40.AtkinW,DadswellE,WooldrageK,etal.Computedtomographiccolonographyversuscolonoscopyforinvestigationofpatientswithsymptomssuggestiveof
colorectalcancer(SIGGAR):amulticentrerandomisedtrial.Lancet2013381:1194.
41.PickhardtPJ,HassanC,HalliganS,MarmoR.Colorectalcancer:CTcolonographyandcolonoscopyfordetectionsystematicreviewandmetaanalysis.
Radiology2011259:393.
42.BaxterNN,SutradharR,ForbesSS,etal.Analysisofadministrativedatafindsendoscopistqualitymeasuresassociatedwithpostcolonoscopycolorectal
cancer.Gastroenterology2011140:65.
43.SinghH,NugentZ,DemersAA,BernsteinCN.Rateandpredictorsofearly/missedcolorectalcancersaftercolonoscopyinManitoba:apopulationbased
study.AmJGastroenterol2010105:2588.
44.SinghH,NugentZ,MahmudSM,etal.Predictorsofcolorectalcancerafternegativecolonoscopy:apopulationbasedstudy.AmJGastroenterol2010
105:663.
45.CooperGS,XuF,BarnholtzSloanJS,etal.Prevalenceandpredictorsofintervalcolorectalcancersinmedicarebeneficiaries.Cancer2012118:3044.
46.SamadderNJ,CurtinK,TuohyTM,etal.Characteristicsofmissedorintervalcolorectalcancerandpatientsurvival:apopulationbasedstudy.
Gastroenterology2014146:950.
47.CheongY,FarrowR,FrankCS,StevensonGW.Utilityofflexiblesigmoidoscopyasanadjuncttodoublecontrastbariumenemaexamination.Abdom
Imaging199823:138.
48.HalliganS,WooldrageK,DadswellE,etal.Computedtomographiccolonographyversusbariumenemafordiagnosisofcolorectalcancerorlargepolypsin
symptomaticpatients(SIGGAR):amulticentrerandomisedtrial.Lancet2013381:1185.
49.IrvineEJ,O'ConnorJ,FrostRA,etal.Prospectivecomparisonofdoublecontrastbariumenemaplusflexiblesigmoidoscopyvcolonoscopyinrectal
bleeding:bariumenemavcolonoscopyinrectalbleeding.Gut198829:1188.
50.http://fg.bmj.com/content/3/3/124.full.pdf+html(AccessedonMarch22,2013).
51.MorrinMM,FarrellRJ,RaptopoulosV,etal.Roleofvirtualcomputedtomographiccolonographyinpatientswithcolorectalcancersandobstructingcolorectal
lesions.DisColonRectum200043:303.
52.MacariM,BermanP,DickerM,etal.UsefulnessofCTcolonographyinpatientswithincompletecolonoscopy.AJRAmJRoentgenol1999173:561.
53.NeriE,GiustiP,BattollaL,etal.Colorectalcancer:roleofCTcolonographyinpreoperativeevaluationafterincompletecolonoscopy.Radiology2002
223:615.
54.PullensHJ,vanLeeuwenMS,LaheijRJ,etal.CTcolonographyafterincompletecolonoscopy:whatisthediagnosticyield?DisColonRectum201356:593.
55.U.S.PreventiveServicesTaskForce.Screeningforcolorectalcancer:U.S.PreventiveServicesTaskForcerecommendationstatement.AnnInternMed
2008149:627.
56.vonWagnerC,GhanouniA,HalliganS,etal.PatientacceptabilityandpsychologicconsequencesofCTcolonographycomparedwiththoseofcolonoscopy:
resultsfromamulticenterrandomizedcontrolledtrialofsymptomaticpatients.Radiology2012263:723.

http://www.uptodate.com/contents/clinicalpresentationdiagnosisandstagingofcolorectalcancer?topicKey=ONC%2F2496&elapsedTimeMs=1&source=search_result&searchTerm=cancer+de+colon&selectedTitle=1%7E15 16/36
2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

57.MacdonaldJS.Carcinoembryonicantigenscreening:prosandcons.SeminOncol199926:556.
58.LockerGY,HamiltonS,HarrisJ,etal.ASCO2006updateofrecommendationsfortheuseoftumormarkersingastrointestinalcancer.JClinOncol2006
24:5313.
59.PalmqvistR,EngarsB,LindmarkG,etal.PrediagnosticlevelsofcarcinoembryonicantigenandCA242incolorectalcancer:amatchedcasecontrolstudy.
DisColonRectum200346:1538.
60.vanderSchouwYT,VerbeekAL,WobbesT,etal.Comparisonoffourserumtumourmarkersinthediagnosisofcolorectalcarcinoma.BrJCancer1992
66:148.
61.LiuZ,ZhangY,NiuY,etal.Asystematicreviewandmetaanalysisofdiagnosticandprognosticserumbiomarkersofcolorectalcancer.PLoSOne2014
9:e103910.
62.AlexanderJC,SilvermanNA,ChretienPB.Effectofageandcigarettesmokingoncarcinoembryonicantigenlevels.JAMA1976235:1975.
63.SajidKM,ParveenR,ChaouachiK,etal.Carcinoembryonicantigen(CEA)levelsinhookahsmokers,cigarettesmokersandnonsmokers.JPakMedAssoc
200757:595.
64.DuffyMJ,vanDalenA,HaglundC,etal.Clinicalutilityofbiochemicalmarkersincolorectalcancer:EuropeanGrouponTumourMarkers(EGTM)guidelines.
EurJCancer200339:718.
65.SongL,LiY.SEPT9:ASpecificCirculatingBiomarkerforColorectalCancer.AdvClinChem201572:171.
66.SymondsEL,PedersenSK,BakerRT,etal.ABloodTestforMethylatedBCAT1andIKZF1vs.aFecalImmunochemicalTestforDetectionofColorectal
Neoplasia.ClinTranslGastroenterol20167:e137.
67.PedersenSK,SymondsEL,BakerRT,etal.EvaluationofanassayformethylatedBCAT1andIKZF1inplasmafordetectionofcolorectalneoplasia.BMC
Cancer201515:654.
68.FordAC,VeldhuyzenvanZantenSJ,RodgersCC,etal.Diagnosticutilityofalarmfeaturesforcolorectalcancer:systematicreviewandmetaanalysis.Gut
200857:1545.
69.PowerAM,TalleyNJ,FordAC.Associationbetweenconstipationandcolorectalcancer:systematicreviewandmetaanalysisofobservationalstudies.AmJ
Gastroenterol2013108:894.
70.AdelsteinBA,MacaskillP,ChanSF,etal.Mostbowelcancersymptomsdonotindicatecolorectalcancerandpolyps:asystematicreview.BMC
Gastroenterol201111:65.
71.FriedmanSL,WrightTL,AltmanDF.GastrointestinalKaposi'ssarcomainpatientswithacquiredimmunodeficiencysyndrome.Endoscopicandautopsy
findings.Gastroenterology198589:102.
72.BuschE,RodriguezBigasM,MamounasE,etal.PrimarycolorectalnonHodgkin'slymphoma.AnnSurgOncol19941:222.
73.AJCC(AmericanJointCommitteeonCancer)CancerStagingManual,7thedition,Edge,SB,Byrd,DR,Compton,CC,etal(Eds)(Eds),Springer,NewYork
2010.p.143.
74.GundersonLL,JessupJM,SargentDJ,etal.Revisedtumorandnodecategorizationforrectalcancerbasedonsurveillance,epidemiology,andendresults
andrectalpooledanalysisoutcomes.JClinOncol201028:256.
75.GundersonLL,JessupJM,SargentDJ,etal.RevisedTNcategorizationforcoloncancerbasedonnationalsurvivaloutcomesdata.JClinOncol2010
28:264.
76.http://www.kaneharashuppan.co.jp/catalog/detail.html?isbn=9784307202442(AccessedonMay03,2012).
77.SongJS,ChangHJ,KimDY,etal.IstheN1ccategoryofthenewAmericanJointCommitteeoncancerstagingsystemapplicabletopatientswithrectal

http://www.uptodate.com/contents/clinicalpresentationdiagnosisandstagingofcolorectalcancer?topicKey=ONC%2F2496&elapsedTimeMs=1&source=search_result&searchTerm=cancer+de+colon&selectedTitle=1%7E15 17/36
2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

cancerwhoreceivepreoperativechemoradiotherapy?Cancer2011117:3917.
78.NiederhuberJE.Colonandrectumcancer.Patternsofspreadandimplicationsforworkup.Cancer199371:4187.
79.TaylorAJ,YoukerJE.Imagingincolorectalcarcinoma.SeminOncol199118:99.
80.HortonKM,AbramsRA,FishmanEK.SpiralCTofcoloncancer:imagingfeaturesandroleinmanagement.Radiographics200020:419.
81.HundtW,BraunschweigR,ReiserM.EvaluationofspiralCTinstagingofcolonandrectumcarcinoma.EurRadiol19999:78.
82.IsbisterWH,alSaneaO.Theutilityofpreoperativeabdominalcomputerizedtomographyscanningincolorectalsurgery.JRCollSurgEdinb199641:232.
83.BalthazarEJ,MegibowAJ,HulnickD,NaidichDP.Carcinomaofthecolon:detectionandpreoperativestagingbyCT.AJRAmJRoentgenol1988150:301.
84.McAndrewMR,SabaAK.Efficacyofroutinepreoperativecomputedtomographyscansincoloncancer.AmSurg199965:205.
85.VallsC,LopezE,GumA,etal.HelicalCTversusCTarterialportographyinthedetectionofhepaticmetastasisofcolorectalcarcinoma.AJRAmJ
Roentgenol1998170:1341.
86.ThoeniRF.Colorectalcancer.Radiologicstaging.RadiolClinNorthAm199735:457.
87.JacquetP,JelinekJS,StevesMA,SugarbakerPH.Evaluationofcomputedtomographyinpatientswithperitonealcarcinomatosis.Cancer199372:1631.
88.KohJL,YanTD,GlennD,MorrisDL.Evaluationofpreoperativecomputedtomographyinestimatingperitonealcancerindexincolorectalperitoneal
carcinomatosis.AnnSurgOncol200916:327.
89.MilsomJW,JerbyBL,KesslerH,etal.Prospective,blindedcomparisonoflaparoscopicultrasonographyvs.contrastenhancedcomputerizedtomographyfor
liverassessmentinpatientsundergoingcolorectalcarcinomasurgery.DisColonRectum200043:44.
90.StoneMD,KaneR,BotheAJr,etal.Intraoperativeultrasoundimagingoftheliveratthetimeofcolorectalcancerresection.ArchSurg1994129:431.
91.MachiJ,IsomotoH,YamashitaY,etal.Intraoperativeultrasonographyinscreeningforlivermetastasesfromcolorectalcancer:comparativeaccuracywith
traditionalprocedures.Surgery1987101:678.
92.KirkeR,RajeshA,VermaR,BankartMJ.Rectalcancer:incidenceofpulmonarymetastasesonthoracicCTandcorrelationwithTstaging.JComputAssist
Tomogr200731:569.
93.NordholmCarstensenA,WilleJrgensenPA,JorgensenLN,HarlingH.Indeterminatepulmonarynodulesatcolorectalcancerstaging:asystematicreviewof
predictiveparametersformalignancy.AnnSurgOncol201320:4022.
94.SahaniDV,BajwaMA,AndrabiY,etal.Currentstatusofimagingandemergingtechniquestoevaluatelivermetastasesfromcolorectalcarcinoma.AnnSurg
2014259:861.
95.NiekelMC,BipatS,StokerJ.DiagnosticimagingofcolorectallivermetastaseswithCT,MRimaging,FDGPET,and/orFDGPET/CT:ametaanalysisof
prospectivestudiesincludingpatientswhohavenotpreviouslyundergonetreatment.Radiology2010257:674.
96.FurukawaH,IkumaH,SekiA,etal.Positronemissiontomographyscanningisnotsuperiortowholebodymultidetectorhelicalcomputedtomographyinthe
preoperativestagingofcolorectalcancer.Gut200655:1007.
97.NahasCS,AkhurstT,YeungH,etal.Positronemissiontomographydetectionofdistantmetastaticorsynchronousdiseaseinpatientswithlocallyadvanced
rectalcancerreceivingpreoperativechemoradiation.AnnSurgOncol200815:704.
98.WhitefordMH,WhitefordHM,YeeLF,etal.UsefulnessofFDGPETscanintheassessmentofsuspectedmetastaticorrecurrentadenocarcinomaofthe
colonandrectum.DisColonRectum200043:759.
99.FlamenP,HoekstraOS,HomansF,etal.Unexplainedrisingcarcinoembryonicantigen(CEA)inthepostoperativesurveillanceofcolorectalcancer:theutility
ofpositronemissiontomography(PET).EurJCancer200137:862.

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

100.LibuttiSK,AlexanderHRJr,ChoykeP,etal.Aprospectivestudyof2[18F]fluoro2deoxyDglucose/positronemissiontomographyscan,99mTclabeled
arcitumomab(CEAscan),andblindsecondlooklaparotomyfordetectingcoloncancerrecurrenceinpatientswithincreasingcarcinoembryonicantigenlevels.
AnnSurgOncol20018:779.
101.FlanaganFL,DehdashtiF,OgunbiyiOA,etal.UtilityofFDGPETforinvestigatingunexplainedplasmaCEAelevationinpatientswithcolorectalcancer.Ann
Surg1998227:319.

Topic2496Version51.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

GRAPHICS

Rectalcancerasseenonbariumenema

Doublecontrastbariumenemashowsaneccentricmassarisingfrom
theanteriorwalloftherectum(arrow).

CourtesyofJonathanKruskal,MD,PhD.

Graphic82202Version3.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Cancerofthecolonasseenonbariumenema

Doublecontrastbariumenemashowsanapplecorelesionsurrounding
thelumenofthedescendingcolon.

CourtesyofJonathanKruskal,MD.

Graphic75818Version3.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Symptomatologyofcolorectalcancersbaseduponanatomicsite

Rightcolon Leftcolon Rectum

Numberofpatients 54 59 140

Meanhemoglobinatpresentation 10.5g/dL 11.6g/dL 11.4g/dL

Symptomsatdiagnosis(percent)

Rectalbleeding 21 44 79

Tenesmus 12 16 31

Abdominalpain 77 84 60

Intestinalobstruction 15 27 44

Mucusdischarge 0 7 24

Changedbowelhabit 64 86 66

Datafrom:SaidiHS,KaruriD,NyaimEO.Correlationofclinicaldata,anatomicalsiteanddiseasestageincolorectalcancer.EastAfrMedJ200885:259.

Graphic88705Version1.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

ColoncancerseenonCTscanandcolonoscopy

(A)Computedtomographic(CT)scanshowingafillingdefectintheascending
colon(redarrow)alongwithaninvolvedlymphnode(yellowarrow).
(B)Coloncanceridentifiedintheascendingcolononsubsequentcolonoscopy.

Graphic83618Version1.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Adenocarcinomaofthecolon

Adenocarcinomaofthecolonmayhaveavarietyofappearancesonendoscopy.Panel
A:atypicalexophyticmassPanelB:afriablepolypoidmassPanelC:
circumferentialadenocarcinoma.

CourtesyofJamesBMcGee,MD.

Graphic74346Version1.0

Normalsigmoidcolon

Endoscopicappearanceofthenormalsigmoidcolonicmucosa.The
finevasculatureiseasilyvisible,andthesurfaceisshinyand

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

smooth.Thefoldsareofnormalthickness.

CourtesyofJamesBMcGee,MD.

Graphic55563Version1.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Necroticadenocarcinomaofthecolon

Endoscopyshowingnecroticcoloniclesionsthatusuallysuggestan
advancedstageofmalignancy.PanelA:severetissuedestructionhas
ledtonecrosisandbleedingPanelB:thelongstandingtumorhas
extendeddeeplyintothemucosaandbecomenecrotic.

CourtesyofJamesBMcGee,MD.

Graphic54234Version1.0

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Endoscopiccriteriasuggestingmalignancyofapolyp
Firmconsistency

Adherence

Ulceration

Friability

Graphic68868Version1.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Familialcoloncancer

Theseimagesarefroma38yearoldmanwhowasfoundtohave
hemepositivestool.Hisfatherandtwounclesdiedofcoloncancer
beforetheageoffifty.PanelA:Theinitialstudywasabariumenema
(althoughacolonoscopyismorecommonlyusedastheinitial
diagnosticstudyforhemepositivestools).Thebariumenemareveals
afillingdefectinthececum(arrow).PanelsBandC:ACTscanofthe
abdomenshowsalargeexophyticmass(coloredinpinkinpanelC)
involvingthececum(arrows).PanelD:Colonoscopyrevealsthatthe
largeexophyticlesionoccupiesmostofthececum.Adenocarcinoma
wasconfirmedbybiopsy.Despitethesizeofthelesion,thetumor
hadnotspreadbeyondthecolonicwall.

CourtesyofJamesBMcGee,MD.

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Symptomsassociatedwithcolorectalcancer

DOR* Sensitivity 1specificity LR+ LR

Symptom AUC
(95%CI*) (95%CI) (95%CI) (95%CI) (95%CI)
Rectalbleeding 2.6 0.66 0.46 0.25 1.9 0.7
(1.93.6) (0.380.55) (0.190.31) (1.52.3) (0.60.8)
p<0.001
Bloodmixedwith 3.1 0.68 0.49 0.24 2.1 0.7
stool (2.04.8) (0.300.69) (0.130.40) (1.52.8) (0.50.9)

p<0.001
Blood:darkred 3.9 0.71 0.29 0.10 3.1 0.8
(1.79.2) (0.090.65) (0.030.28) (1.66.0) (0.61.1)
p=0.004

Changeinbowel 1.5 0.57 0.32 0.24 1.4 0.9

habit (0.82.8) (0.210.46) (0.150.35) (0.92.1) (0.71.1)
p=0.16
Constipation 1.1 0.52 0.12 0.11 1.1 1.0
(0.81.5) (0.080.18) (0.070.16) (0.81.5) (1.01.0)
p=0.48
Diarrhea 0.9 0.47 0.15 0.17 0.9 1.0
(0.41.7) (0.070.28) (0.090.29) (0.51.6) (0.91.1)
p=0.65

Abdominalpain 0.7 0.45 0.19 0.24 0.8 1.1

(0.51.1) (0.130.28) (0.170.33) (0.61.1) (1.01.2)
p=0.12
Weightloss 2.9 0.67 0.20 0.08 2.5 0.9
(1.65.0) (0.120.31) (0.050.13) (1.54.0) (0.81.0)
p=0.001

LR+:thelikelihoodratioofhavingcolorectalcancerinthepresenceofthesymptomLR:thelikelihoodratioofhavingcolorectalcancerintheabsence

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ofthesymptom.
*DOR:diagnosticoddsratio.NoassociationbetweensymptomandcancerifDOR=1.
AUC:AreaUnderthereceiveroperatingcharacteristicCurve.NoassociationbetweensymptomandcancerifAUC=0.5.
Bleedingofanytype.

Reproducedfrom:AdelsteinB,MacaskillP,ChanSF,etal.Mostbowelcancersymptomsdonotindicatecolorectalcancerandpolyps:asystematicreview.
BMCGastroenterology201111:65.Copyright2011Adelsteinetal.

Graphic88734Version4.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

Causesofacolonicmass

Malignantlesions
Adenocarcinoma

Lymphoma

Carcinoidtumor

Kaposisarcoma

Prostatecancer

Benignlesions
Crohn'scolitis

Diverticulitis

Endometriosis

Solitaryrectalulcer

Lipoma

Tuberculosis

Amebiasis

Cytomegalovirus

Fungalinfection

Extrinsiclesion

Graphic66850Version3.0

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2/4/2016 Clinicalpresentation,diagnosis,andstagingofcolorectalcancer

TNMstagingforcolorectalcancer,7thedition

Primarytumor(T)
TX Primarytumorcannotbeassessed

T0 Noevidenceofprimarytumor

Tis Carcinomainsitu:intraepithelialorinvasionoflaminapropria*

T1 Tumorinvadessubmucosa

T2 Tumorinvadesmuscularispropria

T3 Tumorinvadesthroughthemuscularispropriaintopericolorectaltissues

T4a Tumorpenetratestothesurfaceofthevisceralperitoneum

T4b Tumordirectlyinvadesorisadherenttootherorgansorstructures

Regionallymphnode(N)
NX Regionallymphnodescannotbeassessed

N0 Noregionallymphnodemetastasis

N1 Metastasisin13regionallymphnodes
N1a Metastasisinoneregionallymphnode

N1b Metastasisin23regionallymphnodes

N1c Tumordeposit(s)inthesubserosa,mesentery,ornonperitonealizedpericolicorperirectaltissueswithoutregionalnodalmetastasis

N2 Metastasisinfourormoreregionallymphnodes
N2a Metastasisin46regionallymphnodes

N2b Metastasisinsevenormoreregionallymphnodes

Distantmetastasis(M)
M0 Nodistantmetastasis

M1 Distantmetastasis

M1a Metastasisconfinedtooneorganorsite(eg,liver,lung,ovary,nonregionalnode)

M1b Metastasesinmorethanoneorgan/siteortheperitoneum

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Anatomicstage/prognosticgroups
Stage T N M Dukes MAC

0 Tis N0 M0

I T1 N0 M0 A A

T2 N0 M0 A B1

IIA T3 N0 M0 B B2

IIB T4a N0 M0 B B2

IIC T4b N0 M0 B B3

IIIA T12 N1/N1c M0 C C1

T1 N2a M0 C C1

IIIB T3T4a N1/N1c M0 C C2

T2T3 N2a M0 C C1/C2

T1T2 N2b M0 C C1

IIIC T4a N2a M0 C C2

T3T4a N2b M0 C C2

T4b N1N2 M0 C C3

IVA AnyT AnyN M1a

IVB AnyT AnyN M1b

*Tisincludescancercellsconfinedwithintheglandularbasementmembrane(intraepithelial)ormucosallaminapropria(intramucosal)withnoextension
throughthemuscularismucosaeintothesubmucosa.
DirectinvasioninT4includesinvasionofotherorgansorothersegmentsofthecolorectumasaresultofdirectextensionthroughtheserosa,as
confirmedonmicroscopicexamination(forexample,invasionofthesigmoidcolonbyacarcinomaofthececum)or,forcancersinaretroperitonealor
subperitoneallocation,directinvasionofotherorgansorstructuresbyvirtueofextensionbeyondthemuscularispropria(ie,respectively,atumoronthe
posteriorwallofthedescendingcoloninvadingtheleftkidneyorlateralabdominalwalloramidordistalrectalcancerwithinvasionofprostate,seminal
vesicles,cervix,orvagina).
Tumorthatisadherenttootherorgansorstructures,grossly,isclassifiedcT4b.However,ifnotumorispresentintheadhesion,microscopically,the
classificationshouldbepT14adependingontheanatomicaldepthofwallinvasion.TheVandLclassificationsshouldbeusedtoidentifythepresenceor
absenceofvascularorlymphaticinvasionwhereasthePNsitespecificfactorshouldbeusedforperineuralinvasion.
Asatelliteperitumoralnoduleinthepericolorectaladiposetissueofaprimarycarcinomawithouthistologicevidenceofresiduallymphnodeinthe

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nodulemayrepresentdiscontinuousspread,venousinvasionwithextravascularspread(V1/2),oratotallyreplacedlymphnode(N1/2).Replacednodes
shouldbecountedseparatelyaspositivenodesintheNcategory,whereasdiscontinuousspreadorvenousinvasionshouldbeclassifiedandcountedin
theSiteSpecificFactorcategoryTumorDeposits(TD).
cTNMistheclinicalclassification,pTNMisthepathologicclassification.Theyprefixisusedforthosecancersthatareclassifiedafterneoadjuvant
pretreatment(eg,ypTNM).PatientswhohaveacompletepathologicresponseareypT0N0cM0thatmaybesimilartoStageGroup0orI.Therprefixisto
beusedforthosecancersthathaverecurredafteradiseasefreeinterval(rTNM).
DukesBisacompositeofbetter(T3N0M0)andworse(T4N0M0)prognosticgroups,asisDukesC(AnyTN1M0andAnyTN2M0).MACisthe
modifiedAstlerCollerclassification.

UsedwiththepermissionoftheAmericanJointCommitteeonCancer(AJCC),Chicago,Illinois.TheoriginalsourceforthismaterialistheAJCCCancer
StagingManual,SeventhEdition(2010)publishedbySpringerNewYork,Inc.

Graphic72913Version13.0

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Metastaticcoloncancer

Multiplelivermetastasesseenduringlaparotomyinapatientwith
coloncancer.

CourtesyofRichardBFreeman,Jr,MD.

Graphic81255Version1.0

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ContributorDisclosures
FinlayAMacrae,MDGrant/ResearchSupport:CSIRO[BowelCancer(butyrate)]Actelion[CDiff(cadazolidversusvancomycin)]Glutagen[CoeliacDisease]
CancerAustralia(resveratrol)Medtronics(capsuleendscopes).Consultant/AdvisoryBoards:CommonwealthScientificandIndustrialResearchOrganization
(CSIRO,Australia)InternationalSocietyforGastrointestinalHereditaryTumoursGastroenterologicalSocietyofAustraliaNIHColonFamilyRegisterAustralian
NationalBowelCancerScreeningProgramAustralianNationalBowelCancerScreeningProgram.JohannaBendell,MDNothingtodisclose.KennethKTanabe,
MDGrant/Research/ClinicalTrialSupport:NimbusTherapeutics[hepatocellularcarcinoma(ND654,AcetylCoACarboxylaseallostericinhibitor)].
Consultant/AdvisoryBoards:BestDoctors[GIcancersmelanoma(medicalcare)]PatentHolder,noroyaltieslicensingfeespaidtoauthor:EGFSNPtodetermine
riskforHCC(cirrhosis,hepatocellularcarcinoma)UseofEGFRinhibitorstopreventHCC(cirrhosis,hepatocellularcarcinoma).DianeMFSavarese,MDNothing
todisclose.ShilpaGrover,MD,MPHNothingtodisclose.

Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,
andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconformto
UpToDatestandardsofevidence.

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