History

Because of increased emphasis on screening practices, colon cancer is now often detected before it starts to cause symptoms. In more advanced cases, common clinical presentations include iron-deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits, and intestinal obstruction or perforation. Right-sided lesions are associated with younger age, and common presenting signs include bleeding and/or diarrhea. Left-sided tumors are associated with older age, and patients commonly present with bowel obstruction.

In patients younger than 50 years old—an age group that is experiencing rising rates of colorectal cancer (see Overview/Epidemiology)—a study that used data from England's Clinical Practice Research Datalink found that abdominal pain was the most common presenting symptom of colorectal cancer. Compared with other age groups, these younger patients had the lowest percentage of typical ‘red-flag’ signs and symptoms (ie, rectal bleeding, anemia, change in bowel habits, diarrhea, abdominal mass). Instead, these patients were more likely to have presented to their primary care provider, in the year before diagnosis, with nonspecific symptoms.^[45]

Physical Examination

Physical examination findings can be very nonspecific (eg, fatigue, weight loss) or normal early in the course of colon cancer. In more advanced cases, any of the following may be present:

Abdominal tenderness
Macroscopic rectal bleeding
Palpable abdominal mass
Hepatomegaly
Ascites

Differential Diagnoses

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Standard colectomies for adenocarcinoma of the colon.

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Table 1. TNM Classification for Colon Cancer

Primary tumor (T)
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
Tis	Carcinoma in situ: intraepithelial or intramucosal carcinoma (involvement of lamina propria with no extension through the muscularis mucosa)
T1	Tumor invades submucosa (through the muscularis mucosa but not into the muscularis propria)
T2	Tumor invades muscularis propria
T3	Tumor invades through the muscularis propria into the pericolorectal tissues
T4	Tumor invades the visceral peritoneum or invades or adheres to adjacent organ or structure
T4a	Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
T4b	Tumor directly invades or is adherent to other organs or structures
T Suffix	Definition
(m)	Select if synchronous primary tumors are found in a single organ
Definition of Regional lymph nodes (N)
NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Metastasis in 1-3 regional lymph nodes (tumor in lymph nodes measuring ≥0.2 mm) or any number of tumor deposits are present and all identifiable nodes are negative
N1a	Metastasis in 1 regional lymph node
N1b	Metastasis in 2-3 regional lymph nodes
N1c	Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized, pericolic, or perirectal/mesorectal tissues without regional nodal metastasis
N2	Metastasis in 4 or more lymph nodes
N2a	Metastasis in 4-6 regional lymph nodes
N2b	Metastasis in 7 or more regional lymph nodes
N Suffix	Definition
(sn)	Select if regional lymph node metastasis identified by sentinel lymph node biopsy only
(f)	Select if regional lymph node metastasis identified by fine needle aspiration or core needle biopsy
Definition of Distant metastasis (M) The terms pM0 and Mx are not valid categories in the TNM system. Assignment of the M category for clinical classification may be cM0, cM1 or pM1. Any of the categories (cM0, CM1 or pM1) may be used with pathological stage grouping.
M Category	M Criteria
cM0	No distant metastasis by imaging or other studies, no evidence of tumor in distant sites or organs. (This category is not assigned by pathologists.)
cM1	Metastasis to one or more distant sites or organs or peritoneal metastasis is identified
cM1a	Metastasis confined to 1 organ or site is identified without peritoneal metastasis
cM1b	Metastasis to two or more sites or organs is identified without peritoneal metastasis
M1c	Metastasis to the peritoneal surface alone or with other site or organ metastases
pM1	Metastasis to one or more distant sites or organs or peritoneal metastasis is identified and microscopically confirmed
pM1a	Metastasis to one site or organ is identified without peritoneal metastasis and microscopically confirmed
pM1b	Metastasis to two or more sites or organs is identified without peritoneal metastasis and microscopically confirmed.
pM1c	Metastasis to the peritoneal surface is identified alone or with other site or organ metastasis and microscopically confirmed

Table 2. Anatomic stage/prognostic groups

0	Tis	N0	M0
I	T1	N0	M0
	T2	N0	M0
IIA	T3	N0	M0
IIB	T4a	N0	M0
IIC	T4b	N0	M0
IIIA	T1-T2	N1/N1c	M0
	T1	N2a	M0
IIIB	T3-T4a	N1/N1c	M0
	T2-T3	N2a	M0
	T1-T2	N2b	M0
IIIC	T4a	N2a	M0
	T3-T4a	N2b	M0
	T4b	N1-N2	M0
IVA	Any T	Any N	M1a
IVB IVC	Any T Any T	Any N Any T	M1b M1c

Table 2. Surveillance recommendations for stage II and III colon cancer

Parameter	Organization
Parameter	ESMO [JSMO](2013)	ASCO (2013)	NCCN (2016)
History and physical exam	Every 3-6 mo for 3 y, then every 6 -12 mo at 4 and 5 y	Every 3-6 mo for 3 y, then every 6 mo to 5 y	Every 3-6 mo for 2 y, then every 6 mo to 5 y
CEA	Every 3-6 mo for 3 y, then every 6 -12 mo at 4 and 5 y	Every 3 mo for 3 y*	Every 3-6 mo for 2 y, then every 6 mo to 5 y
Chest CT*	Every 6-12 mo for first 3 y	Every 1 y for 3 y	Every 1 y for 5 y
Colonoscopy**	At y 1 after surgery, and every 3-5 y thereafter	At 1 y, then every 5 y, dictated by the findings on the previous colonoscopy	At 1 y, 3 y, then every 5 y if negative
Abdominal CT*	Every 6-12 mo for first 3 y	Every 1 y for 3 y	Every 6-12 mo for up to 5 y; scans to include chest and pelvis
ESMO = European Society of Medical Oncology; JSMO = Japanese Society of Medical Oncology; ASCO = American Society of Clinical Oncology; NCCN = National Comprehensive Cancer Network; CEA = carcinoembryonic antigen; CT = computed tomography * For patients at high risk for recurrence (eg, lymphatic or venous invasion, or poorly differentiated tumors). **Colonoscopy should be performed 3-6 mo postoperatively if preoperative colonoscopy was not done, due to an obstructing lesion; otherwise, colonoscopy in 1 y; if abnormal, repeat in 1 year; if no advanced adenoma (ie, villous polyp, polyp > 1 cm, or high-grade dysplasia), repeat in 3 y, then every 5 y.

Table 1.

Parameter	Organization
Parameter	ESMO (2013)^[141]	ASCO (2013)^[140]	NCCN (2022)^[96]	ASCRS (2015)^[169]
History and physical exam	Every 3-6 mo for 3 y, then every 6 -12 mo at 4 and 5 y	Every 3-6 mo for 3 y, then every 6 mo to 5 y	Every 3-6 mo for 2 y, then every 6 mo to 5 y	Every 3-6 mo for 2 y, then every 6 mo to 5 y
CEA	Every 3-6 mo for 3 y, then every 6 -12 mo at 4 and 5 y	Every 3 mo for 3 y*	Every 3-6 mo for 2 y, then every 6 mo to 5 y	Every 3-6 mo for 2 y, then every 6 mo to 5 y
Chest CT*	Every 6-12 mo for first 3 y	Every 1 y for 3 y	Every 6-12 mo for 5 y	Every 1 y for 5 y
Colonoscopy**	At y 1 after surgery, and every 3-5 y thereafter	At 1 y, then every 5 y, dictated by the findings on the previous colonoscopy	At 1 y; if advanced adenoma, repeat in 1 y; if no advanced adenoma, repeat in 3 y, then every 5 y	At y 1 after surgery, and every 3-5 y dictated by the findings on the first postoperative examination
Abdominal CT*	Every 6-12 mo for first 3 y	Every 1 y for 3 y	Every 6-12 mo for 5 y; scans to include pelvis	Every 1 y for 5 y
ESMO = European Society of Medical Oncology; ASCO = American Society of Clinical Oncology; NCCN = National Comprehensive Cancer Network; American Society of Colon and Rectal Surgeons = ASCRS CEA = carcinoembryonic antigen; CT = computed tomography * For patients at high risk for recurrence (eg, lymphatic or venous invasion, or poorly differentiated tumors). **Colonoscopy should be performed 3-6 mo postoperatively if preoperative colonoscopy was not done, due to an obstructing lesion; otherwise, colonoscopy in 1 y; if abnormal, repeat in 1 year; if no advanced adenoma (ie, villous polyp, polyp >1 cm, or high-grade dysplasia), repeat in 3 y, then every 5 y.

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