Staging Paradox and recurrence pattern among stage IIB, IIC, and IIIA Colon cancers - a retrospective cohort study

Sep 21, 2026

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Survival outcomes for stage IIB and IIC colon cancer are paradoxically worse than for stage IIIA in real-world TNM comparisons. This retrospective cohort study evaluated oncological outcomes and sought factors influencing the staging paradox using a prospectively maintained 9-year cancer database. Patients with stage IIB (pT4aN0M0), IIC (pT4bN0M0), or IIIA (pT1-2N1M0) were analyzed for tumor features, radicality, harvested lymph nodes, and chemotherapy.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages11

Reading Time28 min

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Abstract

Purpose

Methods

Results

Conclusions

Introduction

TNM system and nodal status

Discrepancy: staging paradox

Proposed explanations

Chemotherapy considerations

Methods

Patient selection

International Journal of Colorectal Disease (2024) 39:161 [https://doi.org/10.1007/s00384-024-04737-1](https://doi.org/10.1007/s00384-024-04737-1) Staging Paradox and recurrence pattern among stage IIB, IIC, and IIIA Colon cancers: a retrospective cohort study Yu‑Tso Liao1,2 · John Huang3 · Ji‑Shiang Hung3 · Kai‑Wen Huang1,3 · Jin‑Tung Liang3 Accepted: 6 October 2024 / Published online: 14 October 2024 © The Author(s) 2024 Abstract Purpose The survival rates of patients with stage IIB and IIC colon cancer are paradoxically inferior to that of patients with stage IIIA colon cancer. This study aimed to examine the oncological outcomes and investigate the factors that could affect the staging paradox among stage IIB, IIC, and IIIA colon cancers based on a 9-year cancer database. Methods Patients with stage IIB (pT4aN0M0), IIC (pT4bN0M0), or IIIA (pT1-2N1M0) colon cancer were retrospectively selected from a prospectively maintained medical database from January 2011 to December 2019. Factors that might influence the staging paradox, including radicality, harvested lymph nodes, and chemotherapy administration, were examined. Results A total of 282 patients (stage IIB, n = 59; stage IIC, n = 46; and stage IIIA, n = 177) were enrolled. Patients with stage IIB/C cancer demonstrated higher carcinoembryonic antigen levels, larger tumor size, more frequent tumor obstruction, and higher locoregional recurrence than those with stage IIIA cancer. With respect to 10-year locoregional recurrence-free survival and cancer-specific survival, patients with stage IIB and IIC cancers had significantly lower survival rates than did those with stage IIIA cancer (73.7% vs. 66.3% vs. 91.2%, P = 0.0003; 5.4% vs. 10.9% vs. 11.2%, P = 0.0023) . The staging paradox persisted in patients who underwent R0 resection, had harvested lymph nodes ≥ 12, and received chemotherapy, as confirmed by multivariate regression analysis. Conclusions Based on the inferior oncological outcomes and higher locoregional recurrence rate, this study highlighted the need for intensified cytotoxic chemotherapy specific to this recurrence pattern for patients with stage IIB/C colon cancer. Keywords Colon cancer · Staging paradox · Locoregional recurrence · Stage IIB/C · Stage IIIA · Chemotherapy Introduction In the tumor-node-metastasis (TNM) system for colorectal cancer, nodal status is a significantly more important indicator of prognosis than the depth of invasion. A positive nodal status is considered a systemic disease status, having a worse oncological outcome and requiring systemic chemotherapy to prolong survival. In contrast, a negative nodal status is * Jin-Tung Liang [jintung@ntu.edu.tw](jintung@ntu.edu.tw) 1 Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan 2 Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan 3 Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan considered a local disease status, mainly relying on R0 surgical resection. Conventionally, systemic chemotherapy for negative nodal status is unnecessary, unless high-risk features, such as pT4, are present [1, 2] . Nevertheless, patients with stage IIB/C colon cancer (T4aN0M0 and T4bN0M0) have worse oncological outcomes than do those with stage IIIA colon cancer (T1-2N1 and T1N2a) [3, 4]. The discrepancy in survival between the TNM system and real-world data is referred to as the “staging paradox,” implying a mis match between TNM staging and its relevant survival. Possible explanations to reconcile the staging paradox and TNM system include staging migration due to inadequate lymph node harvest, a higher positive surgical margin for T4N0, lack of chemotherapy for stage IIB/C, and the aggressive biological characteristics of stage IIB/C [4] . Multivisceral resection is re

FAQs

What is the staging paradox discussed in the study?

The study describes a mismatch where TNM staging predicts outcomes that differ from real-world survival, with stage IIB/IIC performing worse than stage IIIA.

How were patients selected for the retrospective cohort analysis?

Patients with stage IIB (pT4aN0M0), IIC (pT4bN0M0), or IIIA (pT1-2N1M0) colon cancer were retrospectively drawn from a prospectively maintained medical database covering January 2011 to December 2019.

Which factors were examined as potential contributors to the staging paradox?

The analysis assessed factors including radicality, harvested lymph nodes, and chemotherapy administration, alongside tumor and outcome measures such as locoregional recurrence.

Sep 21, 2026

Uploaded by Rowan