There is the increase in colorectal cancer incidence in Japan. The increase in the rate of colon cancer compared with rectal cancer was noticed. The proximal migration of the tumor site from the left colon to right colon is shown in the study. The evident shift toward earlier stage was clearly revealed. According to the extended lymph node resection, the improvement of overall 5-year survival rate from 55% to 69% is important trend.
M. Maruta 1; K. Kotake 2; K. Maeda 3
Sankeikai Hattori Hospital, Japan
1; Tochigi Cancer Center, Japan
2; Fujita Health University Hospital, Japan
Vyšlo v časopise:
Rozhl. Chir., 2007, roč. 86, č. 11, s. 618-621.
Monotematický speciál - Původní práce
Incidence kolorektálního karcinomu v Japonsku stoupá. Bylo zjištěno, že nárůst frekvence výskytu je vyšší u karcinomu tlustého střeva než u karcinomu rekta. Studie ukazuje proximalizaci místa nádoru z levé do pravé části tlustého střeva. Je též zcela zřejmý posun k časnějším stadiím onemocnění. Na základě rozsáhlých resekcí lymfatických uzlin je patrné, že v průběhu doby došlo ke zlepšení frekvence celkového pětiletého přežití z 55 % na 69 %.
Colorectal cancer incidence has been on the increase in
Japan and was estimated in 1996 to be approximately 80,000 with more
than fourfold in crease during the past 20 years. This cancer is the
fourth and the second leading cause of death for males and females
respectively and approximately 36,000 patients died of this cancer in
According to the GLOBOCAN 2002 report by the
International Agency for Research on Cancer, the countries with the
highest incidence of colorectal cancer are shown in figure 1. In
males, the Czech Republic is the highest, and Japan is fifth. In
females, the Czech Republic is tenth and Japan is 22nd
(figure 1) .
We established “Japanese General Rules for Clinical
and Pathological Studies on Cancer of the Colon, Rectum and Anus”
in 1977 . At that time the TNM classification had not been
established and Dukes classification had been prepared. Since 1978 we
have registered all cases of colorectal cancer in whole country. From
this registration database, 84,695 patients who had surgery were
in tumor sites
Changes in tumor sites have been observed over the last
20 years. The number of registered cases of colon and rectal cancer,
colon is light blue line, rectum is pur-pure line, increased in both
males and females.
The rate of colon cancer, compared with rectal cancer,
increased in both males and females, orange colored circle in the
figure 2 and the predominance of colon cancer was especially
noticeable in females (figure 2).
migration of the tumor
migration of the tumor site was noted. While the proportion of rectal
cancer, red colored in the figure 3, was on the decline, the
proportion of right colon cancer, orange colored, and left colon
cancer, blue colored, continued to increase steadily. In females the
number of right colon cancers exceeded that of left colon cancers
during the most recent period (figure 3).
of TNM stage
The distribution of TNM stages is shown in figure 4. The
proportion of stage 3 and 4 decreased as expected. The striking
changes were for stage 1. 12%, 15%, 18% and 21%. The proportion of
stage 1 nearly doubled from 12% to 21%.
colonoscopy with the dye-spray method
Recently, with the progress in colonoscopic diagnosis,
we are able to make fairly accurate diagnosis of T-1 cancer. Using
magnifying colonoscopy with the dye-spray method, we can observe the
surface of the tumor in minute detail . The upper row photographs
show a flat in normal view, but in lower row elevated lesion which is
clearly identified by this dye-spray method (figure 5).
photos in figure 6 show the findings of magnifying colonoscopy. This
is normal view, next dye-spray view. Magnifying slowly to the
surface, we can see fine pits like this, and this is magnifying pits.
And the scope is capable of magnifying 100 times for detailed
pattern of surface structure
structure can be classified into 6 patterns (figure 7) . Type 1,
round pits, is normal or inflammatory. Type 2 papillary pits, is
hyperplasia. Type 3L, large tubular pits, is
adenoma. Type 3S, small tubular pits, is adenoma. Type 4, branch like
pits, is villous tumor. Type 5, non-structure pits, is cancer.
Non-structural type is an indicator of massive invasion of the
submucosal layer. By these techniques we can find small cancers of
rules of dissection of extent lymph nodes
Concerning surgery, we surgeons, have to dissect the
radical extent lymph nodes according to “The
general rules for clinical and pathological on cancer of the colon
and rectum”. Regional lymph nodes are
classified into three categories such as paracolic node, intermediate
nodes, and main nodes. The extent of D-2 resection is to the
paracolic (n 1) and intermediate nodes (n 2), and that of D-3
resection is to all three nodes categories (n 1, n 2, n 3) in figure
percentage of nodal involvement and survival
According to the registered data, the percentage of
nodal involvement is shown in the figure 9. In T3 and T4 cancer, the
positive rate for para-colic nodes (n 1) was 29%, intermediate nodes
(n 2) was 15.3% and main nodes (n 3) was 4.2%.
As you see survival of colon cancer according to nodal
dissection, survival analysis comparing D3 and D2 resection shows
that survival rates of patients who had D3 resection were
significantly better than those who had D2 resection (figure 10).
Based on these results, D3 resection should be the standard surgery
for stage 2 or stage 3.
rates of colorectal cancer patients
The most important trend of these data was the
improvement in survival rates of patients with rectal cancer and
colon cancer. The over all survival rates of the four time periods
were compared. All survival curves were separated from each
subsequent period by statistically significant differences (figure
11). The 5-year survival rate increased from 55% to 69%.
Proximal migration of colon and rectum cancer already
has been noted not only in western countries but also in non-white
population. In our database of the Japan Society for cancer of the
Colon and Rectum (JSCCR) registry, the rate of colon cancer compared
with rectal cancer, increased in both males and females. The
migration of colon cancer from the left side colon to right side
colon was noted . The impact of newer diagnostic techniques
including total colonoscopy and real increase are proposed in
possibilities. The prevalence of proximal colon cancer was
significantly higher in females than males. No body knows the reason
why right side colon cancer is shown higher in females than males.
Using magnifying colonoscope with dye-spray method, we
can find the earlier stage cancer of the colon and rectum. According
to this progress, the distribution of TNM stage has changed and as
for stage 1, the proportion of stage 1 nearly doubled in 2000.
Especially by magnifying colonoscope, pits patterns of the surface of
tumors are classified into 6 patterns, non-structured type pits is
cancer. By this technique very small cancer of the colon can be
Concerning surgery for colon and rectal cancer, we,
Japanese surgeons do lymphadenectomy according to “the
general rules for clinical and pathological on cancer of the colon
and rectum”. As the survival curve showed,
D3 resection should be standard surgery for cancer of the colon in
stage 2 or stage 3.
Morito Maruta M.D., Ph.D.
Hattori Hospital 1–3–20 Sawakami
1. International Agency for Research on Cancer: GLOBOCAN 2002. http://www.dep.iarc.fr/.
2. Japanese Society for Cancer of the Colon and Rectum. Japanese Society Classification of colorectal carcinoma. Tokyo: Kanehara & Co. 1997.
3. Registry Committee. Japanese Society for Cancer of the Colon and Rectum. Multi-institutional Registry of large bowel cancer in Japan. Vol. 1–23 (1–6 in Japanese and 7–23 in English). Utsunomiya: Registry Committee, 1985–2002.
4. Beart R. W., Melton J., Maruta M., et al. Trends in Right and Left –sided Colon Cancer. Disease of Colon &Rectum. 26: 393–398. 1983.
5. Kudo, S., Tamura, S., Nakajima, T., et al. Diagnosis of colorectal tumors lesions by magnifying endoscopy. Gastrointest. Endosc., 44: 8–14. 1996.
6. Kudo, S., Hirota, S., Nakajima, T., et al. Colorectal tumors and pit pattern. J. Clin Pathol., 47: 880–885. 1994.