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Prognostic Impact of pT Stage and Peritoneal Invasion in Locally Advanced Colon Cancer

Baguena, Gloria, M.D., Ph.D.1; Pellino, Gianluca, Ph.D., E.B.S.Q.-c, M.D.1; Frasson, Matteo, Ph.D., E.B.S.Q-c., M.D.1; Roselló, Susana, M.D., Ph.D.2; Cervantes, Andres, M.D., Ph.D.2; García-Granero, Alvaro, M.D., Ph.D.1; Giner, Francisco, M.D., Ph.D.3; García-Granero, Eduardo, Ph.D., E.B.S.Q.-c, M.D.1

Diseases of the Colon & Rectum: June 2019 - Volume 62 - Issue 6 - p 684–693
doi: 10.1097/DCR.0000000000001367
Original Contributions: Colorectal Cancer
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BACKGROUND: TNM stage has been identified as an independent variable for local recurrence and survival after colon cancer resection. It is still unclear whether peritoneal invasion (pT4a) is a risk factor for adverse oncologic outcome or whether these patients have better results compared with contiguous organs infiltration (pT4b), independent from nodal status (pN).

OBJECTIVE: The purpose of this study was to analyze whether peritoneal invasion is an independent risk factor for worse oncologic outcome after curative colon cancer resection.

DESIGN: This was a retrospective analysis with multivariate regression of a prospective database, according to Strengthening the Reporting of Observational Studies in Epidemiology Statement.

SETTINGS: The study was conducted in a specialized colorectal unit of a tertiary hospital.

PATIENTS: A consecutive series of pT3-pT4a-pT4b patients with colon cancer who underwent curative surgery (1993–2010) were included, and patients with metastasis were excluded.

MAIN OUTCOME MEASURES: A multivariate Cox regression analysis was performed to assess independent risk factors for 5-year local recurrence, peritoneal carcinomatosis-like recurrence, disease-free survival, and cancer-specific survival.

RESULTS: A total of 1010 patients were analyzed (79.3% pT3, 9.9% pT4a, and 10.8% pT4b). At diagnosis, 22.0% had obstructive symptoms, and 10.5% had bowel perforation. A total of 72.2% of the surgeries were elective, and in 15.6% en bloc resection of contiguous organs was performed. Median follow-up was 62 months (38–100 mo). For the whole group, 5-year actuarial rates were 8.8% for local recurrence, 2.5% for peritoneal carcinomatosis, 75.5% for disease-free survival, and 81.8% for cancer-specific survival. At multivariate analysis, pT4a stage was an independent risk factor for local recurrence (p = 0.002; HR = 3.1), peritoneal carcinomatosis (p = 0.02; HR = 4.9), worse disease-free survival (p = 0.002; HR = 1.9), and cancer-specific survival (p = 0.001; HR = 2.2). When considering only the 566 patients with ≥12 nodes identified, T stage was still associated with higher local recurrence (p = 0.04) and carcinomatosis rate (p = 0.04), as well as worse disease-free (p = 0.009) and cancer-specific survival (p = 0.014).

LIMITATIONS: This was a retrospective, single-center study.

CONCLUSIONS: pT4a stage is an independent risk factor for worse oncologic outcome after curative colon cancer resection compared with pT3 and pT4b stages. The current pT4a-pT4b classification should be reconsidered. Of note, even in pT4a patients, 5-year carcinomatosis rate does not exceed 6%. See Video Abstract at

1 Digestive Surgery Unit, Department of General Surgery, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain

2 Department of Haematology and Medical Oncology, Hospital Clinico Universitario, University of Valencia, Valencia, Spain

3 Department of Pathology, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia, Spain

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Funding/Support: None reported.

Financial Disclosure: None reported.

Gloria Baguena and Gianluca Pellino contributed equally to this article.

Correspondence: Matteo Frasson, Ph.D., E.B.S.Q-c., M.D., Hospital Universitario y Politecnico La Fe, Avda de Fernando Abril Martorell, n. 106, Piso 5, Torre G 46026 Valencia, Spain. E-mail: Twitter: @frasson_matt

© 2019 The American Society of Colon and Rectal Surgeons