J I Bedah Indonesia

Volume 43 September 2014 Artikel Asli Wahyu, dkk

Management of Sigmoid Cancer

In dr Cipto Mangunkusumo Hospital during 2008–2011

Wahyu Sriningsih, Ibrahim Basir, Benny Philippi

Abstract
A retrospective anal sis as per or ed to si oid cancer cases in the di estive sur er division o ipto
an unkusu o ospital durin the period o i t t o cases ere anal ed or etastases
sta es and histopatholo ortalit and or idit ere calculated or anasto otic leaka e ear survival
and incidence o local recurrence Three ear survival anal sis as per or ed usin aplan eier ased on
sta in and histopatholo The overall operative ortalit as and the anasto otic leaka e incidence
as The incidence o local recurrence as The ear survival rates ased on ukes ta in
ere as ollo s survival or ukes A or ukes B and or ukes and or ukes
The ear survival rates in si oid cancer accordin to histopatholo ere or ell di erentiated
or oderatel di erentiated and or poorl di erentiated sa ple si e as one patient could
not e assessed ith survival or ucinous histopatholo The overall survival in this si oid cancer
stud as I Bedah Indones

Introduction Methods
The incidence of colorectal cancer is increasing every In a four year period of 2008–2011, a retrospective
year.1,2 Colorectal cancer is the third most prevalent evaluation was conducted to patients who seek treat-
malignancies in women and the fourth most prevalent ment to Cipto Mangunkusumo Hospital with the
in men worldwide.3,4 With 5–year mortality rate of working diagnosis of sigmoid cancer and underwent
40%, the American Cancer Society (ACS) estimated surgical management by sigmoidectomy or colosto-
that, approximately 141,210 people will be affected my, either by elective or emergency surgery. Sigmoid
by colorectal cancer and 49,380 people will die from l n an r i d fin d y l n um r l a d m
it in United States in 2011.5,6 During the period of or more from the anocutaneous line based on rigid
2000–2010, there were 662 cases of colorectal cancer sigmoidescopy to the descending colon. Cases with
reported in Cipto Mangunkusumo Hospital.7 anterior resection surgery or pathologic specimen
Sigmoid colon is the most common location of can- from the rectum were excluded from the study.
cer lesion compared to other segments of the colon.3
Two–thirds of colon cancers arise from the left colon Results
and one–third from the right colon. 5,6,8 The distribu- Durin h ri d f fif y nin a-
tion of colon cancer include sigmoid colon (40%) and tients with sigmoid cancer were reported in the di-
caecum or colon (25–35%). Generally, the incidence gestive surgery division of dr Cipto Mangunkusumo
of sigmoid colon cancer increases by 1.2% each year Hospital. Seven patients were excluded because they
in females and 2.5% in males since 2003.3 This in- underwent anterior resection surgery and pathologic
crease is caused by the increased availability of sup- findin h d r al i u h r mainin a-
porting diagnostic measures, including endoscopy tients were followed until they die or at least until 3
and imaging. years since the surgery. The data was analyzed using
Kaplan–Meier to assess patient’s survival.
Table 1. Sigmoid cancer in Digestive Surgery Divi-
Alamat Korespondensi
dr Wahyu Sriningsih SpB
sion during 2008–2011
Divisi Bedah Digestif, Departemen Medik Ilmu Bedah The 3–year survival rates of sigmoid colon can-
RS Ciptomangunkusumo, Jakarta
Email: why_sriningsih@yahoo.com cer based on Duke staging were as follows:

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 22. McArdle CS, Hole D, Hansell D, Blumgart LH, Wood CB. Prospective study of colorectal
J I Bedah Indonesia
Volume 43 September 2014
Wahyu, dkk
cancer in the west of scotland :10 years follow up. Br J Surg. 1990;77:280–2

100% survival for Dukes A, 95.5% for Dukes B and 61.1% for Dukes C and 0% for Dukes C.
Lampiran

Table 1. Sigmoid cancer in Digestive Surgery Division during 2008–2011

Characteristics Number of subjects Total %
Gender
Male 30 52 57,7
Female 22 52 42,3
Age :
Range: 24 – 78 th
Median: 55,5 th
Mean: 52,9 th
Chief complain:
Hematoschezia 32 52 61,5
Mass 9 52 17,3
Obstruction 9 52 17,3
Sigmoid–vesical fistula 2 52 3,9
Surgical procedure:
Sigmoidectomy 49 52 94,2
Colostomy 3 52 5,8
Timing of surgery:
Elective 43 52 82,7
Emergency 9 52 17,3
Type of surgery:
Curative 44 52 84,6
Paliative 8 52 15,4
Duke Staging:
A 4 52 7,7
B 22 52 42,3
C 18 52 34,6
D 8 52 15,4
Histopathology :
Adeno Ca 46 52 88,5
Well 34
Moderately 11
Poor 1
Mucinous 6 52 11,5
Local reccurence 4 44 9,1
Anastomotic leakage 4 49 8,1
Mortality 1 52 1,9

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Wahyu, dkk
Volume 43 September 2014

Discussion
Sigmoid colon is the most common site of malignancy
compared to other colon segments.3 The distribution
of cancer in the sigmoid between males and females
is comparable. During 2005–2009, the incidences of
sigmoid cancer in Europe were 166 cases, consisted
of 63 (38%) females and 103 (62%) males. In Ja-
pan, the management of patients with sigmoid cancer
was performed to 133 patients during the period of
2007–2010, including 78 (56.6%) female patients and
55 (41.4%) male patients. In this study, 52 cases of
sigmoid cancer were observed, including 30(57.5%)
female patients and 22(42.3%) male patients.
Sigmoid cancer most commonly affects people aged
> 40 years old, although the tendency of its occur-
rence in younger ages has also began to be reported.
The mean age of occurrence is 70–75 years old. In
this study, the most common age of presentation was
Figure 1. Kaplan Meier, Stage–based
old age (>60 years old), which represented 42.3% of
the cases. Cases in younger age (<40 years old) also
The 3–year survival rates in sigmoid cancer accord-
h d in r a in in id n f hi findin i
ing to histopathology were 73.5% for well differenti-
in agreement with the tendency that colorectal cancer
ated, 63.6% for moderately differentiated and 100%
is starting to be observed in younger age.9
for poorly differentiated (sample size was one patient,
In his study in Cipto Mangunkusumo Hospital during
could not be assessed), with 50% survival for muci-
the period of 2000–2010, Yusak observed the follow-
nous histopathology.
ing staging distribution of colon cancer: 2.6% in stage
I, 18.7% in stage II, 39.1% in stage III, and 30.36% in
stage IV. In Ireland, 31% patients with sigmoid can-
cer who seek medical treatment to the hospital pre-
sented in stages I–II, while 50% presented in stages
III–IV. As a comparison, the distribution of colorec-
tal cancer based on its staging in Singapore showed
that Dukes A,B,C and D stages represent 10% 22%,
32% and 36% of the patients, respectively.10 In this
study, patients with sigmoid cancer who seek treat-
ment in Cipto Mangunkusumo Hospital comprised of
22 (42.3%) patients in Dukes B, 18 (34.6%) in Dukes
C, 8 (15.4%) in Dukes D and 4 (7.7%) in Dukes A
stages.
The use of Dukes staging in this study was considered
due to its applicability compared to AJCC 7th edition
a in n f h diffi ul i f h a li a i n f
Figure 2. Kaplan–Meier, Survival based on histopathology
AJCC 7th edition is the counting of lymph nodes in
the excised tumor mass tissues , where lymph nodes
counting should be performed by a surgeon and

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 J I Bedah Indonesia
Wahyu, dkk
Volume 43 September 2014

pathologist. 4,10,11,12,13,14 techniques, utilized materials, vascularization and

The most common histopathology type in sigmoid certainly the skill of the surgeon. According to litera-
cancer is adenocarcinoma.4,12,13 In the literature, it was ture, the rate of leakage ranges from 2 to 19%. Ogiso–
reported that adenocarcinoma represents 93% of sig- Satoso reported 0% rate of leakage in laparoscopic
moid cancer , while the rest is represented by muci- sigmoid resection. This number is possibly caused by
nous and neuro–endocrine tumors. In a study regard- a good pre–operative patient selection.16 Rudinskaite
ing histological characteristics of colorectal cancer in Giedre17 reported 7.4% rate of anastomotic leakage
1998–2001 in United States, which included 522,630 in sigmoid resection, which is in agreement with our
cases of colorectal cancer cases, adenocarcinoma was study with 4 (7.7%) patients reported to have anasto-
reported as the histopathology characteristic in 96% motic leakage as post–operative complication.
of the cases, while 2% was other carcinomas (includ- Staging is the most important prognostic factor to
ing carcinoid tumor), 0.4% was epidermoid carcino- predict the 5–year survival. The 5–year–survival for
ma, an 0.08% was sarcomas. In a study performed in colorectal cancer if diagnosed in its early stages and
dr Cipto Mangunkusumo Hospital in 2000–2010, Yu- the lesion is localized is 90%. However, only 39% of
sak reported colorectal cancer to consist of adenocar- the patients were diagnosed in early stages.13 If the
cinoma (71.6%), adenocarsinoma musinosum (9.1%) tumor has spread to other organs and lymph nodes,
, other types (5.7%), while in the remaining 13.6% the 5–year survival rate is decreased to 70%; and if
of the cases, histopathology results could not be ob- distant metastases are present, the rate decrease even
tained. In our study, the most common type of sigmoid more to 12%.12 According to staging, the 5–year sur-
cancer was adenocarcinoma, which was found in 46 vival rates for colon cancer are 85 – 95% (stage I), 60
(88.5%) patients, and mucinous adenocarcinoma in 6 – 80% (stage II), 30 – 60% (stage III) and 6% (stage
patients (11.5%). IV).
The surgical management of sigmoid cancer is en In Scotland, the 5–year survival rates for Dukes A,B,C
bloc sigmoid resection for curative therapy. In the and D are 81%, 50%, 33% and 0%, respectively.22
past, literatures also reported left hemicolectomy as TKTi showed the 5–year survival rates for colorec-
the management of sigmoid colon cancer. However, tal cancers for Dukes A,B, C, and D are 100%, 50%,
Cataldo et al. reported in their study that left hemi- 33% and 0%, respectively. The 3–year survival rates
colectomy was the ideal therapy for sigmoid cancer, for Dukes A,B, C, and D for sigmoid cancer in this
hil i m id my a r r d uffi i n ly study are 100%, 95.5%, 61.1% and 0%, respectively.
safe.8 In spite of staging, the histological grading also sig-
Meanwhile, Ouchi A et al reported that sigmoid colon nifi an ly in u n h ur i al ra ai n ih
resection in sigmoid cancer should be accompanied well differentiated carcinoma (grades 1 and 2) have a
with lymph node dissection.15,19,20,21 The standard op- better 5–year survival than those with poorly differ-
erating procedure (SOP) of digestive surgery division entiated carcinoma (grades 3 and 4). Based on tumor
for the surgical management of sigmoid cancer is en– grading, the 5–year survival rates of colon cancer are
bloc sigmoid resection, either by open or laparoscopic 59– 93% (grade I), 33–75% (grade II) and 11–56%
surgery. In this study, 49 (94.2%) patients underwent (grade III).
sigmoid resection and 3 (5.8%) patients only under- The 3–year survival rates in sigmoid cancer accord-
went colostomy. ing to histopathology were 73.5% for well differenti-
The initial post–operative complication of sigmoid ated, 63.6% for moderately differentiated and 100%
r i n i l a a ral fa r ha in u n for poorly differentiated (sample size was one patient,
the occurrence of leakage include the general con- could not be assessed), with 50% survival for muci-
ditions of the patient and local factors. The general nous histopathology.
conditions include age, nutritional status and coexist- The morbidity and mortality in surgeries performed
ing diseases; while local factors include anastomosis during emergency situations are higher than the ones

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Volume 43 September 2014

performed in elective basis. The mortality rate of elec- 12. Zinner J Michael, Ashley Stanley W. Tumors of the colon. In
tive surgery is less than 2%, while for emergency sur- Maingot’s abdominal operations 11th ed
gery the number reaches 20%.12,13 The perioperative 13. Gordon Philip H, Nivatuongs Sanhat. Principles and practice
mortality observed in our study was 1.9% in elective of surgery for the colon, rectum and anus. 3rd ed, New York,
2007.
surgery and no mortality was observed in emergency
14. NCCN Clinical Practice guidelines in Oncology Colon Can-
surgeries.
cer version I. 2013
The overall survival of patients with sigmoid cancer in
15. Ouchi A, Sakuma A, Sugawara T, Kawakami K, Shiiba K,
this study is 69.2%. The number found in this study is Ebina N, Shimizu F, Ito H, Sato T. Studies on the result of
far from perfect, taking into account the small number operations for carsinoma of the sigmoid colon. Gan No Rin-
of samples, the short evaluation time of only 3 years sho, 1984;30(10):1274–9
and the use of different staging system. Improvements 16. Ogigo S, Yamaguchi T, Fukuda M, Murakami T, Okuchi Y.
in the number of cases included in the study, period Laparoscopic resection for sigmoid and rectosigmoid colon
of evaluation and staging based on the 7th edition of cancer performed by trainee: impact on short–term outcomes
AJCC should be pursued in future studies. and selection of suitble patients. Int J Colorectal dis; 2012
17. Rudinskaite G, Tamelis A, Saladzinskas Z, Pavalkis D. Risk
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