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Colorectal cancer: Comparison of clinicopathologic features between Moroccans patients less than 50 years old and older
Pathologie Biologie 61 (2013) 117–119
Available online at
www.sciencedirect.com
Original article
Colorectal cancer: Comparison of clinicopathologic features between Moroccans patients less than 50 years old and older Le cancer colorectal : comparaisons des caracte´ristiques clinicopathologiques des patients aˆge´s de 50 ans et moins avec des patients aˆge´s de plus de 50 ans A. Benmoussa a,*, S. Zamiati b, W. Badre c, A. Wakadi b, N. Bennani b, N. Tahiri Jouti b, S. Nadifi a a
Laboratory of medical genetic, faculty of medicine and pharmacy Casablanca, 19, rue Tarik-Ibnou-Ziad, Casablanca, Morocco Service of anatomy pathologic, centre hospitalier Ibn-Rochd, CHU de Casablanca, 8, rue Lahcen-El-Arjoune, quartier des Hoˆpitaux de Casablanca, Casablanca, Morocco c Service of gastroenterology, centre hospitalier Ibn-Rochd, CHU de Casablanca, 8, rue Lahcen-El-Arjoune, quartier des Hoˆpitaux de Casablanca, Casablanca, Morocco b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 August 2010 Accepted 18 January 2012
Introduction. – Colorectal cancer is a major public health problem. However, this cancer is usually developed on preexisting lesion. This makes this cancer accessible to a prevention strategy. Objective. – The aim of this study was to determine the clinicopathologic characteristics of patients under 50 years. Patients and methods. – This study involved 133 patients with colorectal cancer recruited in CHU IbnRochd, Casablanca. Data relating age, sex, stage at presentation, histological type and tumor location were obtained from the pathological and clinical records of each patient. Statistical analysis was performed to compare clinicopathological data in patients under 50 years and in older patients. Results and discussion. – The average age of patients was 54 years. The frequency of patients aged 50 or under was 40.6% The tumors in the youngest age group were more often mucinous and signet ring cells (18.5%) versus (5.1%) in the oldest age group. The right colon was more often affected in the youngest age group, 38.9% versus 17.7% in the oldest age group (P = 0.008). Conclusion. – The proposition of colorectal cancer in subjects 50 or under was high in Morocco. Colorectal cancers in the youngest age group were more often mucinous or signet ring cells and was more often located in the right colon. We intend to complete this study by a genetic study to help improve prevention and care of young patient. ß 2012 Elsevier Masson SAS. All rights reserved.
Keywords: Colorectal cancer Clinicopathologic features Young Moroccan patients Under 50 years old HNPCC
R E´ S U M E´
Mots cle´s: Cancer colorectal Caracte´ristiques clinicopathologiques Malades jeunes marocains ˆ ge´s de moins de 50 ans A HNPCC
Introduction. – Le cancer colorectal est un proble`me majeur de sante´ publique. Toutefois, ce cancer se de´veloppe ge´ne´ralement sur des le´sions pre´existantes, ce qui rend ce cancer accessible a` une strate´gie de pre´vention. Objectif. – Cette e´tude a pour objectif de de´terminer les caracte´ristiques clinicopathologiques des patients aˆge´s de 50 ans ou moins, afin de de´tecter et de traiter plus efficacement ces patients jeunes. Patients et me´thodes. – Cette e´tude a porte´ sur 133 patients atteints de cancer colorectal, recrute´s au centre hospitalier universitaire Ibn-Rochd a` Casablanca. Les donne´es concernant l’aˆge, le sexe, le stade lors de la pre´sentation, la diffe´renciation de la tumeur, le type histologique et la localisation de la tumeur ont e´te´ tire´es des dossiers pathologiques et cliniques de chaque patient. L’analyse statistique a e´te´ effectue´e pour comparer les donne´es clinicopathologiques des patients de moins de 50 ans et les patients plus aˆge´s. Re´sultats et discussion. – L’aˆge moyen des patients dans notre se´rie e´tait de 54 ans. La proportion des patients de 50 ans et moins e´tait de 40,6 %. Dans ce groupe, 18,5 % des cancers e´taient mucineux ou en bague a` chaton contre 5,1 % chez les plus de 50 ans. Le cancer du coˆlon droit e´tait plus fre´quent chez les patients de 50 ans et moins (38,9 %) que dans le groupe plus aˆge´ (17,7 % ; p = 0,008). Cette e´tude va eˆtre comple´te´e par une e´tude ge´ne´tique pour contribuer a` ame´liorer la pre´vention et la prise en charge des
* Corresponding author. E-mail address: [email protected] (A. Benmoussa). 0369-8114/$ – see front matter ß 2012 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.patbio.2012.01.003
A. Benmoussa et al. / Pathologie Biologie 61 (2013) 117–119
118
patients jeunes. Une proportion e´leve´e des cancers colorectaux affecte des sujets jeunes au Maroc. Ces cancers sont plus souvent de type mucineux ou en bague a` chaton et sie`gent plus souvent dans le coˆlon droit ou le rectum. ß 2012 Elsevier Masson SAS. Tous droits re´serve´s.
1. Introduction Colorectal cancer (CRC) is a major public health problem. It is frequent and severe. Every year, one million people in the world develop CRC and 50% of them die within 5 years after diagnosis [1– 3]. However, this cancer is usually developed on preexisting lesion, which makes this cancer accessible to a prevention strategy. The study of colorectal cancer carcinogenesis has demonstrated an accumulation of successive mutations, on both oncogenes and tumor suppressor genes [4]. There are two main pathways of carcinogenesis in the colorectal cancer: the chromosomal instability pathway borrowed by 85% of sporadic colorectal cancers and all cancers developed in the context of familial adenomatous polyposis (FAP); and the microsatellites instability pathway, present mainly in colorectal cancers of hereditary non-polyposis colorectal cancer (HNPCC) and in 15% of sporadic CRC. This pathway is characterized by instability of repeated sequences caused by deficient DNA repair. The genes involved are the mismatch repair (MMR) [4–7]. In Morocco, the cancer registry of the Greater Casablanca report that colorectal cancer represents 5% of recorded cancers, with a standardized incidence of 5.3 new cases per 100,000 inhabitants. The average age at diagnosis of CRC, according to the registry, was 56 years [8] versus 68 years in industrialized countries [2]. The low age of patients with colorectal cancer in Morocco and the high incidence of young patients led us to determine the clinicopathologic characteristics of patients younger than 50 years to permit us detecting and treating effectively young people. 2. Patients and methods This is a retrospective study between June 2008 to December 2009; 133 patients with colorectal adenocarcinoma, confirmed by a histological examination in the pathology unit of the University Hospital of Casablanca, were included. Data relating age, sex, stage at presentation, differentiation of the tumor (well, moderate and poor), mucinous and signet ring subtype, and tumor location were obtained from the pathological and clinical records of each patient. The tumor location dividing the large bowel into three sites: the right colon (appendix, cecum, ascending colon, hepatic flexure and transverse colon), the left colon (splenic flexure, descending colon and sigmoid colon), and the rectum (rectosigmoid junction and rectal ampulla). Staging of the tumor was based on TNM classification [9]. Statistical analysis was performed to compare clinicopathological data in patients under 50 years and older patients, by the Chi2 test. A P value of < 0.05 was considered significant.
3. Results Our study involved 133 patients with colorectal cancer. The average age of these patients was 54 years old, with an age range from 18 to 89. Among them, 54% of the patients were women. The
mean age of females and males were respectively 53 years and 55 years. We divided the patients into two groups: patients who were 50 years old and less and patients more than 50 years old. The number of patients in the first group was 54 (40.6% of the all patients). The proportion of the women in the youngest age group was 56.6% and in the oldest group 53.2%. In our series, 46.6% of the cancers were located in the rectum. The proportion of right colon cancers was higher in patients 50 years old and less than in older patients (P = 0.008). The proportion of poorly differentiated adenocarcinomas was higher in the youngest age group than in the oldest (8.9%; P = 0.10). Mucinous adenocarcinomas and signet ring cells represented 18.5% of cancers in the youngest age group versus 5.1% in the oldest age group (P = 0.012) (Table 1). 4. Discussion Our study aimed to explore differences in clinicopathologic characteristics in Moroccan patients with early onset versus later onset colorectal cancer. The mean age of patients was 54 years, and sex ratio was 0.85. Fifty-four patients (40.6%) were 50 years of age or younger. The sex ratio in the first group and the second group were respectively 0.76 and 0.87. Youngest patients had significantly higher proportion of cancers in the right colon (38.9%) compared to the oldest age group (17.7%) and a significantly higher proportion of mucinous and signet ring cells histology. Clinical characteristics from colorectal cancers in Morocco differ from those reported in North America and Europe [1,3]. However, similar frequencies were reported by the countries of North Africa, Tunisia 29.3%, Egypt 31% [10,11]. These data can be explained by risk factors common to these countries. In fact, colorectal cancer is multifactorial. Several risk factors have been studied including food, tobacco, alcohol, physical inactivity and precancerous lesions. Heredity is also a risk factor. It was overestimated initially on the basis of specialized hospital statistics. Population-based statistics indicate that hereditary colorectal cancer represent less than 5% of all colorectal cancers [12–14]. Two autosomal dominant diseases are known: familial adenomatous polyposis (FAP) characterized by the presence of thousands of colorectal polyps [6] and HNPCC or lynch syndrome suspected by the Amsterdam criteria: three or more family members with a confirmed diagnosis of colorectal cancer, one of whom is a first-degree relative (parent, child sibling) of the other two; two successive affected generations (one of the patients is a firstdegree family member of the other patients); one or more colon cancers diagnosed younger than 50 years; FAP has been excluded.
Table 1 Comparison of clinicopathologics parameters between group I and group II. Sex ratio Localisation Parameter Number of Mean patients age of patients Right colon Left colon Group I Group II P value
54 79 –
41.5 67.5 –
0.76 0.87 0.52
21 (38.9%) 14 (17.7%) 0.008
Differentiation Left colon Rectum and rectum
10 (18.5%) 3 (5.6%) 16 (20.3%) 7 (8.9%) 0.8 0.47
Well
Moderately Poorly
20 (37.0%) 26 (48.1%) 18 (33.3%) 42 (53.2%) 46 (58.2%) 26 (32.9%) 0.06 0.25 0.84
Mucinous and ring cells
Tumors stages Stages 1 and 2
Stages 3 and 4
10 (18.5%) 10 (18.5%) 30 (55.5%) 24 (44.7%) 7 (8.9%) 4 (5.1%) 56 (71%) 23 (29%) 0.10 0.012 0.069 0.07
Group I: patients 50 years old or younger; group II: patients more than 50 years old; a P value < 0.05 was considered significant.
A. Benmoussa et al. / Pathologie Biologie 61 (2013) 117–119
These criteria are considered too stringent by the experts; they have been revised several times. But young age seems to be a common trait [15,16]. We think that in Morocco, the lynch syndrome is underestimated and that could be explained by two points: the first one is that colorectal cancer in persons with lynch syndrome occurs at an early age [15]. The second point is that clinicians would not press for complete family medical history of patients. And this may lead to missed diagnosis of lynch syndrome. However, the proportion of colorectal cancer with a genetic predisposition is not high in population-based studies. In a population-based study in France, in patients under 45, 8.9% occurred in the context of familial polyposis and 1.4% within HNPCC syndrome [16]. Ja¨rvinen and Turunen [17] reported 6.8% of colorectal cancer in young patients with ‘‘cancer family syndrome’’. On patients’ gender, most studies found that there are more men than women in the young group, but the difference is not significant [18]. Also, we found that there is no difference in gender distribution of the two groups. The presence of mucinous and signet ring tumors was reported by several articles [18–21]. We confirmed the same results in our series (18.5% versus 5.1% in the group of old). Similar to previous studies, we found that the colorectal cancer in young patients was more localized in the right side. Although, we did not find a significant difference between the two groups about tumor stage classification, and the histology differentiation, in contrast with other studies [18–21]. The small size of our sample may partly explain this mismatch. In this study, we verified that young Moroccan patients with CCR had several distinct clinicopathological characteristics. We thought that genetic study will have a great merit and will contribute to better prevention and adapted coverage of young patients. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
119
References [1] Burkitt DP. Epidemiology of cancer of the colon and rectum. Dis Colon Rectum 1993;36:1071–82. [2] Jemal A, Thomas A, Murray T, Thun M. Cancer statistics. CA Cancer J Clin 2002;52:23–47. [3] Faivre J, Dancourt V, Lejeune C, Tazi MA, Lamour J, Gerard D, et al. Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study. Gastroenterology 2004;126:1674–80. [4] Worthley DL, Whitehall VL, Spring KJ, Leggett BA. Colorectal carcinogenesis: road maps to cancer. World J Gastroenterol 2007;13:3784–91. [5] Grady WM. Genomic instability and colon cancer. Cancer Metastasis Rev 2004;23:11–27. [6] Issa JP. Colon cancer: it’s CIN or CIMP. Clin Cancer Res 2008;14:5939–40. [7] Smith G, Carey FA, Beattie J, Wilkie MJ, Lightfoot TJ, Coxhead J, et al. Mutations in APC, Kirsten-ras and p53 – alternative genetic pathways to colorectal cancer. Proc Natl Acad Sci U S A 2002;99:9433–8. [8] Registre des cancers de la re´gion du grand Casablanca. Donne´es 2004. Ministe`re de la Sante´ publique. [9] Puppa G, Sonzogni A, Colombari R, Pelosi G. TNM staging system of colorectal carcinoma: a critical appraisal of challenging issues. Arch Pathol Lab Med 2010;134:837–52. [10] Missaoui N, Jaidaine L, Ben Abdelkader A, Beizig N, Anjorin A, Yaacoubi MT, et al. Clinicopathological patterns of colorectal cancer in Tunisia. Asian Pac J Cancer Prev 2010;11:1719–22. [11] Soliman AS, Bondy ML, Levin B, Hamza MR, Ismail K, Ismail S, et al. Colorectal cancer in Egyptian patients under 40 years of age. Int J Cancer 1997;71:26–30. [12] Hemminki K, Li X. Familial colorectal adenocarcinoma from the Swedish Family-Cancer Database. Int J Cancer 2001;94:743–8. [13] Katballe N, Christensen M, Wikman FP, Ørntoft TF, Laurberg S. Frequency of hereditary non-polyposis colorectal cancer in Danish colorectal cancer patients. Gut 2002;50(1):43–51. [14] Ponz de Leon M, Sassatelli R, Benatti P, Roncucci L. Identification of hereditary nonpolyposis colorectal cancer in the general population. The 6-year experience of a population-based registry. Cancer 1993;71(11):3493–501. [15] Bonis PA, Trikalinos TA, Chung M, Chew P, Ip S, DeVine DA, Lau J. Hereditary nonpolyposis colorectal cancer: diagnostic strategies and their implications. Evid Rep Technol Assess 2007;150:1–180. [16] Mitry E, Benhamiche AM, Jouve JL, Clinard F, Finn-Faivre C, Faivre J. Colorectal adenocarcinoma in patients under 45 years of age: comparison with older patients in a well-defined French population. Dis Colon Rectum 2001;44: 380–7. [17] Ja¨rvinen HJ, Turunen MJ. Colorectal carcinoma before 40 years of age: prognosis and predisposing conditions. Scand J Gastroenterol 1984;19:634–8. [18] Heys SD, O’ Hanrahan TJ, Brittenden J, Eremin O. Colorectal Cancer in young patients: a review of the literature. Eur J Surgical Oncol 1994;20:225–31. [19] Murphy G, Devesa SS, Cross AJ, Inskip PD, McGlynn KA, Cook MB. Sex disparities in colorectal cancer incidence by anatomic subsite, race and age. Int J Cancer 2011;128(7):1668–75. [20] Kam MH, Eu KW, Barben CP, Seow-Choen F. Colorectal cancer in the young: a 12-year review of patients 30 years or less. Colorectal Dis 2004;6:191–4. [21] Keswani SG, Boyle MJ, Maxwell JPJ4th, Mains L, Hunt JP, O’Leary JP. Colorectal cancer in patients younger than 40 years of age. Am Surg 2002;68:871–6.
Available online at
www.sciencedirect.com
Original article
Colorectal cancer: Comparison of clinicopathologic features between Moroccans patients less than 50 years old and older Le cancer colorectal : comparaisons des caracte´ristiques clinicopathologiques des patients aˆge´s de 50 ans et moins avec des patients aˆge´s de plus de 50 ans A. Benmoussa a,*, S. Zamiati b, W. Badre c, A. Wakadi b, N. Bennani b, N. Tahiri Jouti b, S. Nadifi a a
Laboratory of medical genetic, faculty of medicine and pharmacy Casablanca, 19, rue Tarik-Ibnou-Ziad, Casablanca, Morocco Service of anatomy pathologic, centre hospitalier Ibn-Rochd, CHU de Casablanca, 8, rue Lahcen-El-Arjoune, quartier des Hoˆpitaux de Casablanca, Casablanca, Morocco c Service of gastroenterology, centre hospitalier Ibn-Rochd, CHU de Casablanca, 8, rue Lahcen-El-Arjoune, quartier des Hoˆpitaux de Casablanca, Casablanca, Morocco b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 August 2010 Accepted 18 January 2012
Introduction. – Colorectal cancer is a major public health problem. However, this cancer is usually developed on preexisting lesion. This makes this cancer accessible to a prevention strategy. Objective. – The aim of this study was to determine the clinicopathologic characteristics of patients under 50 years. Patients and methods. – This study involved 133 patients with colorectal cancer recruited in CHU IbnRochd, Casablanca. Data relating age, sex, stage at presentation, histological type and tumor location were obtained from the pathological and clinical records of each patient. Statistical analysis was performed to compare clinicopathological data in patients under 50 years and in older patients. Results and discussion. – The average age of patients was 54 years. The frequency of patients aged 50 or under was 40.6% The tumors in the youngest age group were more often mucinous and signet ring cells (18.5%) versus (5.1%) in the oldest age group. The right colon was more often affected in the youngest age group, 38.9% versus 17.7% in the oldest age group (P = 0.008). Conclusion. – The proposition of colorectal cancer in subjects 50 or under was high in Morocco. Colorectal cancers in the youngest age group were more often mucinous or signet ring cells and was more often located in the right colon. We intend to complete this study by a genetic study to help improve prevention and care of young patient. ß 2012 Elsevier Masson SAS. All rights reserved.
Keywords: Colorectal cancer Clinicopathologic features Young Moroccan patients Under 50 years old HNPCC
R E´ S U M E´
Mots cle´s: Cancer colorectal Caracte´ristiques clinicopathologiques Malades jeunes marocains ˆ ge´s de moins de 50 ans A HNPCC
Introduction. – Le cancer colorectal est un proble`me majeur de sante´ publique. Toutefois, ce cancer se de´veloppe ge´ne´ralement sur des le´sions pre´existantes, ce qui rend ce cancer accessible a` une strate´gie de pre´vention. Objectif. – Cette e´tude a pour objectif de de´terminer les caracte´ristiques clinicopathologiques des patients aˆge´s de 50 ans ou moins, afin de de´tecter et de traiter plus efficacement ces patients jeunes. Patients et me´thodes. – Cette e´tude a porte´ sur 133 patients atteints de cancer colorectal, recrute´s au centre hospitalier universitaire Ibn-Rochd a` Casablanca. Les donne´es concernant l’aˆge, le sexe, le stade lors de la pre´sentation, la diffe´renciation de la tumeur, le type histologique et la localisation de la tumeur ont e´te´ tire´es des dossiers pathologiques et cliniques de chaque patient. L’analyse statistique a e´te´ effectue´e pour comparer les donne´es clinicopathologiques des patients de moins de 50 ans et les patients plus aˆge´s. Re´sultats et discussion. – L’aˆge moyen des patients dans notre se´rie e´tait de 54 ans. La proportion des patients de 50 ans et moins e´tait de 40,6 %. Dans ce groupe, 18,5 % des cancers e´taient mucineux ou en bague a` chaton contre 5,1 % chez les plus de 50 ans. Le cancer du coˆlon droit e´tait plus fre´quent chez les patients de 50 ans et moins (38,9 %) que dans le groupe plus aˆge´ (17,7 % ; p = 0,008). Cette e´tude va eˆtre comple´te´e par une e´tude ge´ne´tique pour contribuer a` ame´liorer la pre´vention et la prise en charge des
* Corresponding author. E-mail address: [email protected] (A. Benmoussa). 0369-8114/$ – see front matter ß 2012 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.patbio.2012.01.003
A. Benmoussa et al. / Pathologie Biologie 61 (2013) 117–119
118
patients jeunes. Une proportion e´leve´e des cancers colorectaux affecte des sujets jeunes au Maroc. Ces cancers sont plus souvent de type mucineux ou en bague a` chaton et sie`gent plus souvent dans le coˆlon droit ou le rectum. ß 2012 Elsevier Masson SAS. Tous droits re´serve´s.
1. Introduction Colorectal cancer (CRC) is a major public health problem. It is frequent and severe. Every year, one million people in the world develop CRC and 50% of them die within 5 years after diagnosis [1– 3]. However, this cancer is usually developed on preexisting lesion, which makes this cancer accessible to a prevention strategy. The study of colorectal cancer carcinogenesis has demonstrated an accumulation of successive mutations, on both oncogenes and tumor suppressor genes [4]. There are two main pathways of carcinogenesis in the colorectal cancer: the chromosomal instability pathway borrowed by 85% of sporadic colorectal cancers and all cancers developed in the context of familial adenomatous polyposis (FAP); and the microsatellites instability pathway, present mainly in colorectal cancers of hereditary non-polyposis colorectal cancer (HNPCC) and in 15% of sporadic CRC. This pathway is characterized by instability of repeated sequences caused by deficient DNA repair. The genes involved are the mismatch repair (MMR) [4–7]. In Morocco, the cancer registry of the Greater Casablanca report that colorectal cancer represents 5% of recorded cancers, with a standardized incidence of 5.3 new cases per 100,000 inhabitants. The average age at diagnosis of CRC, according to the registry, was 56 years [8] versus 68 years in industrialized countries [2]. The low age of patients with colorectal cancer in Morocco and the high incidence of young patients led us to determine the clinicopathologic characteristics of patients younger than 50 years to permit us detecting and treating effectively young people. 2. Patients and methods This is a retrospective study between June 2008 to December 2009; 133 patients with colorectal adenocarcinoma, confirmed by a histological examination in the pathology unit of the University Hospital of Casablanca, were included. Data relating age, sex, stage at presentation, differentiation of the tumor (well, moderate and poor), mucinous and signet ring subtype, and tumor location were obtained from the pathological and clinical records of each patient. The tumor location dividing the large bowel into three sites: the right colon (appendix, cecum, ascending colon, hepatic flexure and transverse colon), the left colon (splenic flexure, descending colon and sigmoid colon), and the rectum (rectosigmoid junction and rectal ampulla). Staging of the tumor was based on TNM classification [9]. Statistical analysis was performed to compare clinicopathological data in patients under 50 years and older patients, by the Chi2 test. A P value of < 0.05 was considered significant.
3. Results Our study involved 133 patients with colorectal cancer. The average age of these patients was 54 years old, with an age range from 18 to 89. Among them, 54% of the patients were women. The
mean age of females and males were respectively 53 years and 55 years. We divided the patients into two groups: patients who were 50 years old and less and patients more than 50 years old. The number of patients in the first group was 54 (40.6% of the all patients). The proportion of the women in the youngest age group was 56.6% and in the oldest group 53.2%. In our series, 46.6% of the cancers were located in the rectum. The proportion of right colon cancers was higher in patients 50 years old and less than in older patients (P = 0.008). The proportion of poorly differentiated adenocarcinomas was higher in the youngest age group than in the oldest (8.9%; P = 0.10). Mucinous adenocarcinomas and signet ring cells represented 18.5% of cancers in the youngest age group versus 5.1% in the oldest age group (P = 0.012) (Table 1). 4. Discussion Our study aimed to explore differences in clinicopathologic characteristics in Moroccan patients with early onset versus later onset colorectal cancer. The mean age of patients was 54 years, and sex ratio was 0.85. Fifty-four patients (40.6%) were 50 years of age or younger. The sex ratio in the first group and the second group were respectively 0.76 and 0.87. Youngest patients had significantly higher proportion of cancers in the right colon (38.9%) compared to the oldest age group (17.7%) and a significantly higher proportion of mucinous and signet ring cells histology. Clinical characteristics from colorectal cancers in Morocco differ from those reported in North America and Europe [1,3]. However, similar frequencies were reported by the countries of North Africa, Tunisia 29.3%, Egypt 31% [10,11]. These data can be explained by risk factors common to these countries. In fact, colorectal cancer is multifactorial. Several risk factors have been studied including food, tobacco, alcohol, physical inactivity and precancerous lesions. Heredity is also a risk factor. It was overestimated initially on the basis of specialized hospital statistics. Population-based statistics indicate that hereditary colorectal cancer represent less than 5% of all colorectal cancers [12–14]. Two autosomal dominant diseases are known: familial adenomatous polyposis (FAP) characterized by the presence of thousands of colorectal polyps [6] and HNPCC or lynch syndrome suspected by the Amsterdam criteria: three or more family members with a confirmed diagnosis of colorectal cancer, one of whom is a first-degree relative (parent, child sibling) of the other two; two successive affected generations (one of the patients is a firstdegree family member of the other patients); one or more colon cancers diagnosed younger than 50 years; FAP has been excluded.
Table 1 Comparison of clinicopathologics parameters between group I and group II. Sex ratio Localisation Parameter Number of Mean patients age of patients Right colon Left colon Group I Group II P value
54 79 –
41.5 67.5 –
0.76 0.87 0.52
21 (38.9%) 14 (17.7%) 0.008
Differentiation Left colon Rectum and rectum
10 (18.5%) 3 (5.6%) 16 (20.3%) 7 (8.9%) 0.8 0.47
Well
Moderately Poorly
20 (37.0%) 26 (48.1%) 18 (33.3%) 42 (53.2%) 46 (58.2%) 26 (32.9%) 0.06 0.25 0.84
Mucinous and ring cells
Tumors stages Stages 1 and 2
Stages 3 and 4
10 (18.5%) 10 (18.5%) 30 (55.5%) 24 (44.7%) 7 (8.9%) 4 (5.1%) 56 (71%) 23 (29%) 0.10 0.012 0.069 0.07
Group I: patients 50 years old or younger; group II: patients more than 50 years old; a P value < 0.05 was considered significant.
A. Benmoussa et al. / Pathologie Biologie 61 (2013) 117–119
These criteria are considered too stringent by the experts; they have been revised several times. But young age seems to be a common trait [15,16]. We think that in Morocco, the lynch syndrome is underestimated and that could be explained by two points: the first one is that colorectal cancer in persons with lynch syndrome occurs at an early age [15]. The second point is that clinicians would not press for complete family medical history of patients. And this may lead to missed diagnosis of lynch syndrome. However, the proportion of colorectal cancer with a genetic predisposition is not high in population-based studies. In a population-based study in France, in patients under 45, 8.9% occurred in the context of familial polyposis and 1.4% within HNPCC syndrome [16]. Ja¨rvinen and Turunen [17] reported 6.8% of colorectal cancer in young patients with ‘‘cancer family syndrome’’. On patients’ gender, most studies found that there are more men than women in the young group, but the difference is not significant [18]. Also, we found that there is no difference in gender distribution of the two groups. The presence of mucinous and signet ring tumors was reported by several articles [18–21]. We confirmed the same results in our series (18.5% versus 5.1% in the group of old). Similar to previous studies, we found that the colorectal cancer in young patients was more localized in the right side. Although, we did not find a significant difference between the two groups about tumor stage classification, and the histology differentiation, in contrast with other studies [18–21]. The small size of our sample may partly explain this mismatch. In this study, we verified that young Moroccan patients with CCR had several distinct clinicopathological characteristics. We thought that genetic study will have a great merit and will contribute to better prevention and adapted coverage of young patients. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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