What information do I need to make an informed decion regarding
treatment options for a 19 year old male with Colorectal signet-ring
cell carcinoma (SRCC), Stage 3-4.

Hi, 

 First, as the little disclaimer down at the bottom of these pages
says, I'm not a doctor and even if I was, Researchers are sources of
general information. Finding a good, and qualified doctor is sometimes
difficult, and I am assuming this is the basis for your question, to
become more informed so that you can make better decisions regarding
who will treat. Okay, with that said and out of the way, let's do some
digging.

First of all you are going to need to know something about the
disorder itself. This is "thick" reading, so grab your glasses and a
fresh cup of coffee.

Signet-ring tumours have mucus inside the cells. The mucus pushes the
nucleus (control centre) of the cell over to one side, making the
tumour cell look the shape of a signet ring under the microscope. Only
about 1-2% of all colorectal cancers are signet-ring type. They are
treated the same way as other adenocarcinomas of the colon or rectum.

Stage III (Dukes' C) - cancer has spread outside the colon into lymph
nodes nearby.

Stage IV (Dukes' D) - cancer has spread beyond colon to distant organs
(such as the liver, lungs, or bones)

Types of Colorectal Cancer
http://www.cancerhelp.org.uk/help/default.asp?page=4020

Primary colorectal signet-ring cell carcinoma in Singapore
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11906382&dopt=Abstract

Primary signet-ring cell carcinoma of the colon and rectum.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8790846&dopt=Abstract

Colorectal cancer in a patient younger than 20 years of age: report of
a case and a review of the Japanese literature.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8897681&dopt=Abstract

Radiation-associated rectal cancer: report of four cases.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10436374&dopt=Abstract


Annals of Internal Medicine
http://www.annals.org/issues/v137n7/full/200210010-00012.html

Medical Oncology: A Comprehensive Review
http://www.cancernetwork.com/textbook/morev17.htm

Medical Care The management of colorectal cancer
www.york.ac.uk/inst/crd/ehc36.pdf

Royal College of Pathologists
http://www.rcpath.org/activities/publications/ccancer.html


Next we will move into types of treatments commonly used for this
disorder.

Ordinary colorectal adenocarcinoma vs. primary colorectal signet-ring
cell carcinoma: study matched for age, gender, grade, and stage.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10613484&dopt=Abstract

Peritonectomy and intraperitoneal chemotherapy in appendiceal and
colorectal cancer.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10527351&dopt=Abstract


Abstract
Studies using the anti-idiotypic monoclonal antibody 105AD7 in
patients with primary and advanced colorectal cancer.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12398121&dopt=Abstract

Follow up information
105AD7 - a cancer vaccine for the future ?
http://www.klinik.uni-frankfurt.de/surgery-online/vol1_art1_MAxwell.html

Abstract
DCR3 locus is a predictive marker for 5-fluorouracil-based adjuvant
chemotherapy in colorectal cancer
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12397645&dopt=Abstract

University of Minnesota Cancer Center
http://www.cancer.umn.edu/page/clinical/colon.html

Efficacy and tolerability of irinotecan in patients with advanced
colorectal cancer in Singapore.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12395655&dopt=Abstract

Phase II study of dolastatin-10 as first-line treatment for advanced
colorectal cancer.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12393982&dopt=Abstract

The role of F-18 FDG positron emission tomography in preoperative
assessment of the liver in patients being considered for curative
resection of hepatic metastases from colorectal cancer.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12169999&dopt=Abstract

Downstaging of hepatocellular carcinoma and liver metastases from
colorectal cancer by selective intra-arterial chemotherapy.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11935134&dopt=Abstract

Clinical significance of vascular endothelial growth factor C
expression and angiogenesis at the deepest invasive site of advanced
colorectal carcinoma.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11914602&dopt=Abstract

COLO-RECTAL CANCER
http://www.hsc.wvu.edu/radrx/rectum.htm

NMJ
http://www.med.nagoya-cu.ac.jp/NMJ/45-171.html


Latest News (Various Articles and Procedures )

Cancer Hope News
http://www.cancerhope.com/site/editorial/news_gi.shtml

And lastly you, keeping yourself healthy, mentally and spiritually. 

COLORECTAL CANCER SURVIVORS UNITE TO HELP OTHERS 
http://www.cancer.umn.edu/page/mcccrelease3.html

There is an email and phone number to get in touch with that group. I
couldn't find a web page for them, they may not have one yet. I
recommend getting in touch with this group as soon as possible as they
may have information which is not published to the web, or in a
"public" area.

Thanks, 

webadept-ga

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Request for Answer Clarification by greatview-ga on 29 Oct 2002 14:13 PST

I am looking for information that will direct me toward the best
postitioned hospital/research center that can give me a
thorough,additional diagnoisis/treatment plan.
The background information you supplied is very helpful

---

Clarification of Answer by webadept-ga on 29 Oct 2002 14:47 PST

What area of the world are you in, or does this matter to you?

webadept-ga

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Request for Answer Clarification by greatview-ga on 29 Oct 2002 17:52 PST

Denver Colorado, although am intertested in any expertise

---

Clarification of Answer by webadept-ga on 30 Oct 2002 00:15 PST

Okay, here is a list of hospitals and centers, and articles which
should help you out.

Best hospitals perform in high volumes
http://www.usatoday.com/news/comment/2001-08-07-ncguest1.htm

Johns Hopkins Kimmel Cancer Center
http://www.hopkinskimmelcancercenter.org/CANCERTYPES/colon-rectal-cancer.cfm?CANCERID=78

usnews.com Health: Best Hospitals : Digestive disorders including
colon cancer
http://www.usnews.com/usnews/nycu/health/hosptl/rankings/specihqgast.htm

That last is a list of 50 hostpitals which are rated top in colon
cancer treatment.

If that doesn't cover it for you, just post a Clarification and I'll
look around for more.

webadept-ga

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Request for Answer Clarification by greatview-ga on 06 Nov 2002 14:35 PST

I am very satisfied with your research. This particular cancer has an
"EGFR" receptor. What is that and are there any clinical trials that
address it.
Thanks

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Clarification of Answer by webadept-ga on 06 Nov 2002 20:43 PST

epidermal growth factor receptor 

Colorectal Carcinoma
http://www.thedoctorsdoctor.com/diseases/colon_ca.htm

Cancer 2001 Sep 1;92(5):1331-46 Abstract quote

BACKGROUND: An epidermal growth factor receptor (EGFR)
immunohistochemical detection system currently is being developed. The
current study attempts to address background EGFR reactivity issues
before determining the optimum EGFR scoring system.

METHODS: Tissue sections from 102 patients with T3N1-2M1 colon
adenocarcinoma were stained with a prototype EGFR detection system.
The number of cases, location, percentage, and intensity of reactive
cells (0+ [none] to 3+ [strong]) were scored and compared with the
length of survival.

RESULTS: Approximately 75.5% of the adenocarcinoma cases had EGFR
reactivity; 31.4% of the tumors had 3+ reactivity in 10-50% of the
neoplastic cells and 3.9% had 3+ reactivity in > 50% of cells.
Increased numbers of reactive cells per case predominantly resulted
from increased 3+ reactivity. The mean percentage of 2+ (moderate) and
3+ reactive cells per case increased in the regions of deepest
invasion. The mean percentage of 3+ reactivity per case was
significantly greater in the deepest tumor region compared with the
superficial region (16.9% vs. 7.9%; P = 0.004). EGFR reactivity in
metastases appeared to have the strongest correlation with reactivity
in the deep regions of colon adenocarcinoma. An increasing percentage
of 2+ and 3+ or 3+ only reactivity in the deep region was found to
have the strongest correlation with decreased survival (P = 0.0252).

CONCLUSIONS: EGFR reactivity of 2+ and 3+ may provide a framework for
a scoring system. It may be important to evaluate EGFR reactivity in
the deepest region of tumor invasion because this region appears to
contain the largest percentage of 3+ reactive cells and appears to
have the strongest correlation with survival length and EGFR
reactivity in lymph node and liver metastases.


EGFR
http://www.egfr-info.com/

Role of epidermal growth factor receptor  (doesn't really apply to
cancer but has some good information)
http://www.biomedcentral.com/1465-9921/2/85/

EGFR 
http://www.cancerindex.org/geneweb/EGFR.htm

You can see much more information on Google regarding this by using
this query
://www.google.com/search?num=100&hl=en&lr=&ie=UTF-8&oe=UTF-8&safe=off&q=epidermal+growth+factor+receptor+%2Bcancer

Thanks, 

webadept-ga

Very helpful; Research was presented in an organized, thoughtful way.

Hi,

I would also add some comments:

Primary colorectal signet-ring cell carcinoma is a rare but
distinctive tumour of the colon and rectum. In different series, it
represents arounf 1% of all colorectal carcinomas. The
clinicopathological features are still controversial. It use to be
diagnosed by rectal bleeding or bowel obstruction, and unfortunalety
at a very late stage of disease. (57.1 percent Stage IV and 35.7
percent Stage III, in one study). The stage III means metastases in 1
to 4 regional lymph nodes, while stage IV means distant metastases.

- The first action, must be confirmation of the Histological type. The
biological behavior of signet-ring cell carcinomas tends to be worse
than that of mucinous carcinomas. For example, immunohistochemical
staining expression of E-cadherin is a well defined method for
confirming the diagnosis. Other techniques are K-ras gene mutation,
p53 immunostaining and microsatellite instability. Usually only
palliative surgery is possible, and oftenly oriented to management of
complications. In contrast to non-signet colorectal carcinoma,
signet-ring cell cancer is characterized by a significantly higher
incidence of peritoneal tumor spread (6o to 35%, according to the
series vs 12.5% for the ordinary adenocarcinoma) and a lower incidence
of hepatic metastases (14.3 percent, vs 32%). The curative resection
rate is also lower (64.2 vs 80.4%, p < 0.005) and a higher local or
distant metastasis rate (61.1 vs 17.8%, p < 0.05). Survival with
signet ring cell carcinoma is lower than that of ordinary
adenocarcinoma. "Stage-on-diagnosis" and "presence of subsequent
distant metastasis" are the major factors influencing survival of
signet ring cell carcinoma patients.

Talking about some treatment alternatives, there is a small study made
with only 8 patients with criteria for peritoneal carcinomatosis. In
this case, after removing all macroscopic evidence of disease, this
was followed by early postoperative intraperitoneal chemotherapy. This
treatment doesn't seem to be already stablished for this type of
cancer.

Surgery options are based on the localization of the tumor. According
to clinical series, there is a nearly equal distribution of primary
signet-ring cell carcinoma between the right colon and left
colon/rectum. In a serie of 29 patients, most cases the tumors were >
6 cm, ulcerated, and involved the full thickness of the bowel wall.
Other relevant fact is the presence the presence of synchronous
colorectal adenocarcinomas (higher that 13% in this study)

In young patients, the statistics about survival and incidence are
similar.

If the stage III is confirmed and sugery is available, the Cancer Care
Ontario Practice Guidelines recommend adjuvant therapy (Chemotherapy
before surgery) with the combination of radiotherapy and chemotherapy.
If the goal of adjuvant therapy is to improve survival, there is no
evidence to support the use of radiotherapy alone. There is also
evidence that chemotherapy should include 5-fluorouracil (5-FU; 2000).

Bibliography:

ANZ J Surg  2001 Dec;71(12):703-6 

J Korean Med Sci  2002 Feb;17(1):23-8 

Dis Colon Rectum  1999 Dec;42(12):1618-25 

Aust N Z J Surg  1999 Oct;69(10):729-32 

Surg Today  1999;29(3):226-32 

Int J Cancer  1999 Feb 19;84(1):33-8 

Am J Gastroenterol  1996 Oct;91(10):2195-9 

J Am Coll Surg  1996 Aug;183(2):105-12 

Ann Surg Oncol  1996 Jul;3(4):344-8 

Surg Today  1996;26(10):810-3 

Curr Oncol 2000;7(1):37-51

I have a friend at the UCSF Cancer Center who is an oncologist
specializing in GI related cancers. Let me know if you are interested
and I will forward his contact information to you.

Dear GreatView:

All of the above information is excellent and may be helpful to you in
making an informed decision.  Yes, there are numerous treatment
centers in the US and all strive to give their patients the very best
of care.

Since you are located in the Colorado area, I assume that the
diagnosis was made in that area.  I'm not familar with treatment
centers in that part of the country.  I am very familar, however with
several others.  My suggestions for referral and information would
include the following:

University of Chicago Hospital (Chicago, Ill)
Mayo Clinic ( Minnesota)
Childrens Hospital ( Boston, Ma)
Dana Farber ( Boston, Ma)
Sloan-Kettering ( NYCity)

A source of information about colorecal cancer, which you might find
useful may be found at oncolink.com.

Another link, which I found that might be useful concerning clinical
studies is the following:

http://www.upenn.edu/almanac/v48/n19/OncoLink.html

One additional comment:

Since the patient is 19 years old, it is likely that he may be treated
in a hospital that specializes in pediatric medicine.

I realize that by now, you feel completely saturated with medical and
scientific information and perhaps you even feel overwhelmed by the
all of this.
Please let us know if there is anymore we can help you with.  We are
here for you.

My prayers go out to you in the sad time.