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Cancer of the Colon and Rectum
Cancer of the Colon and Rectum HENRY W. CAVE, M.D., F.A.C.S. * KENNETH M. LEWIS, JR., M.D. ** WALTER T. WICHERN, M.D·t
CARCINOMA of the large bowel and of the rectum is not uncommon. These malignant growths comprise 95 per cent of all tumors of the intestinal tract and 7 per cent of all carcinomas. The differential diagnosis in patients presenting certain vague abdomina('symptoms should always encompass strong suspicion for tumors of the large bowel. Since they are more common after the fourth decade of life, there is an increase of this disease that parallels the gradual rise in the average age of the population. The earlier the diagnosis can be made, the greater the opportunity for cure. It is therefore imperative that physicians be constantly alert td the possibility of cancer of the colon and rectum. POLYPOID LESIONS: TIIEIR REMOVAL IN PROPHYLAXIS OF CANCER
Polypoid lesions of the colon and of the rectum are of immeasurable importance to the practicing surgeon and offer unique opportunity in the prophylaxis of carcinoma. This importance is manifest in the relative frequency with which they occur, the close relationship they bear with carcinoma in the same area, and the relative ease with which they may be recognized and treated. Incidence and Distribution of Polyps
Excluding the first two decades of life the incidence of adenomatous polyps of the large intestine increases with each decade. Swinton! of the Lahey Clinic reported an incidence of 7 per cent in 1843 postmortem From the Department of Surgery, The Roosevelt Hospital, New York City.
* Clinical Professor of Surgery, College of Physicians and Surgeons, Columbia University; Chief of Surgery, The Roosevelt Hospital.
** First Lieutenant, Medical Corps, U. S. Army. t Resident, First Surgical Service, The Roosevelt Hospital.
H. W. Cave, K. M. Lewis, Jr., W. T. Wichern examinations. At the Roosevelt Hospital in a recent ten year period (1940-1950) there were 141 polyps of the colon and of the rectum. In Table 1 it may be seen that 80 per cent of the polyps were benign, 14 per cent demonstrated premalignant change, and 18, or 12 per cent, were associated with carcinoma of the large bowel. Swinton2 also reported that in 828 cases of carcinoma of the large bowel there were associated polyps in 25 per cent and that in 14 per cent the malignancy could be shown to arise from a pre-existing benign polyp. Table 2 presents the distribution of polyps in this series. Most were found in the distal 10 or 12 inches of the large intestine. More than one polyp was demonstrated in 25 per cent and we believe that the incidence of multiple polyps is even higher. This multiplicity of polyps is most Table 1 CHARACTER OF
141
POLYPS NUMBER
Benign. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 114 Premalignant.. . . .. . . . . . . . . . . . . . . . .. 19 Malignant. . . . . . . . . . . . . . . . . . . . . . . . . . 8 Associated with carcinoma.. . . . . . . .. 18
PER CENT
80 14 6 12
Table 2 LOCATION OF POLYPS OF COLON AND RECTUM NUMBER
Rectum. . . . . . . . . . . . . . . . . . . . . . . . . . .. 110 Sigmoid colon. . . . . . . . . . . . . . . . . . . . .. 15 Descending colon. . . . . . . . . . . . . . . . . . . 3 Transverse colon. . . . . . . . . . . . . . . . . . . 5 Ascending colon. . . . . . . . . . . . . . . . . . . . 3 Cecum. ............................ 5
PER CENT
79 11 2 3 2 3
disturbing and the discovery of one polyp in the distal colon should make the observer alert for the discovery of others. Diagnosis of Polyps
As indicated by the incidence of polyps found at autopsy, many patients must either have no symptoms or else minor and vague symptoms that are overlooked. In our series the most frequent symptom was recurrent rectal bleeding, the character of which varied with the location of the polyp. With low-lying polyps the outside of the stool was coated a bright red, while with polyps of the right colon the blood was a dark red and mixed with the stool. Recurrent rectal bleeding occurred in 52 per cent of our series. Other symptoms included change of bowel habits, constipation, bouts of diarrhea, and vague abdominal cramps. The larger polyps may ca.use varying degrees of pa-rtial obstruction and occasion-
Cancer of Colon and Rectum
445
ally form the head of an intussusception. A pedunculated polyp low in the rectum will often protrude from the anus on straining. Careful digital examination of the rectum will demonstrate many rectal polyps. Sixty to 80 per cent may be demonstrated with the use of the sigmoidoscope which is the most important tool in the completion of the diagnosis. Those polyps above the reach of the sigmoidoscope are more difficult to demonstrate. Barium enema and air contrast studies after careful preparation become necessary. The site of the filling defect may vary as much as 6 or 8 inches because of play allowed by the pedicle. However, even when extreme care is utilized in the performance of the roentgenologic studies, many smaller polyps are overlooked. Treatment
The basic principle in the treatment of polyps of the colon and of the rectum is their thorough removal by the simplest and safest means, followed by repeated endoscopic and roentgenologic examinations. The simple pedunculated polyp of the rectum may be ligated well down on its stalk and excised. If situated higher in the rectum, but still visible through the proctoscope, its pedicle may be fulgurated with a snare and so removed, but this has the disadvantage of preventing adequate microscopic examination of the specimen. When the polyp is located above the peritoneal reflection it must be removed by exploratory celiotomy and colotomy. Whether resection is required for grossly benign polyps is difficult to decide at the operating table. If invasion is demonstrated by immediate pathologic examination, resection of the bowel should be immediately performed. If histologic evidence of cancer without invasion is found on pathologic examination (which may be difficult or impossible to demonstrate by frozen section), complete removal of the polyp is probably sufficient. If invasion, missed at operation, is found on final pathologic examination then reoperation and resection are advisable. Because of the practical difficulties involved in persuading the patient and his family of the necessity of a second operative procedure so soon after the first, and because of the comparable mortality of resection of the large bowel for polyp and colotomy for the removal of a polyp, one might very well consider resection the procedure of choice in instances of the slightest doubt. The experience of McLanahan and associates,3 who found 10 recurrences of polyps (5 of which were malignant) out of a group of 38 patients having local removals of malignant adenomas, would tend to substantiate this conclusion. The sessile polyp and the papilloma are best excised with a rim of normal mucous membrane. In the rectum this often necessitates proctotomy with splitting of the anal sphincter and sometimes excision of the coccyx to obtain adequate exposure. Should an invasive lesion be found, then, of course, abdominoperineal resection is indicated.
H. W. Cave, K. M. Lewis, Jr., W. T. Wichern 'The treatment of choice in polyposis of the colon is complete colectomy, leaving the patient with a permanent ileostomy. However, a compromise procedure has been brought forward by Rankin and others. This is a three stage procedure in which all the polyps in the rectum and sigmoid are first excised or fulgurated. After healing, this is followed by ileosigmoidostomy and later by resection of the terminal ileum and colon. These patients must be followed carefully at least at six month intervals for recurrence of polyps in the rectum. Polyps of the rectum and of the colon, because of their frequency, location, relationship to carcinoma in the same areas, and because of their relatively easy recognition with proctoscopic and roentgenologic techniques, offer a unique opportunity to the surgeon for the prophylaxis of carcinoma of the large intestine. Table 3 LOCATION OF CARCINOMA OF COLON AND RECTUM NUMBER
Cecum, , , .......... , ..... , . . . . . .. Ascending colon ...... , . . . . . . . . . .. Hepatic flexure., ..... " .... , ... ,. Transverse colon ..... , , . . . . . . . . .. Splenic flexure ................... , Descending colon ...... , ..... ' , . .. Sigmoid colon ...... , .... , ........ Rectosigmoid, . , .. , . . . . . . . . . . . . . .. Rectum ................ , ... , ..... Anus ... , , ... ' .. , ..... , . . . . . . . . . . .
55 29 12 28 10 22 144 56 147 7
PER CENT
10.8 [5.7 [2.4 5.5 2.1 4.3 28.0 10.9 28.8 1.4
CARCINOMA: DISTRIBUTION, TYPES, METASTASIS
Although carcinoma may develop in any portion of the colon, it is more frequently found in the areas where stasis is most common and in areas where polyps have been found most prevalent. In a recent survey of the colon carcinomas at Roosevelt Hospital (1940-1950), comprising 510 cases, 68 per cent were located in the sigmoid, rectosigmoid and the rectal areas. Table 3 indicates the distribution of remaining tumors. It is not uncommon to find two separate areas of carcinoma and frequently adenomatous polyps, as indicated previously, are found elsewhere in the bowel in addition to the malignant lesions. Malignant lesions of the colon and rectum vary considerably in size and appearance. Large, soft, polypoid lesions are often less malignant than small ulcerative growths. Colloid carcinoma usually is associated with a large tumor which may be radically.removed without leaving any obvious cancer, but cure of this type is unusual. The small scirrhous encircling tumor often described as the "napkin ring" type produces early obstruction and is quite amenable to "cure." The ulcerative lesions
Cancer of Colon and Rectum
447
may be small, but are more often large at the time of discovery and entirely encircle the lumen of the bowel. There is great variation in the spread of cancer of the colon. Modes of extension include: (1) local spread to adjacent organs which can often be sacrificed with the main tumor. (2) Lymphatic spread. This represents the most common mode of extension of the disease and for this reason the lymph node area draining the tumor region should be generously excised in the block resection of the tumor. (3) Spread through blood vessels. This often occurs even in the absence of demonstrable lymph node involvement. In this variety metastases are found early in the liver. Distal spread is unusual, although the lung, the skeleton and the brain may occasionally be the seat of metastatic disease. Usually, however, this is a very late manifestation. In this respect, cancer of the intestinal tract is different from certain cancers arising elsewhere, particularly of the breast and of the prostate. EARLY DIAGNOSIS
Symptoms
As in malignant growths in other parts of the body the one essential and important feature is early diagnosis. In the majority of instances the malignancy does not become obviou~ until it is well established, which emphasizes the importance of tracking down even the slightest symptoms. In our series of 510 patients with carcinoma of the large intestine a change in bowel habits, the passage of gross blood by rectum, and pain, including colicky, local quadrant and rectal pain, were the earliest arM most prominent symptoms. Irregularity of more than a few days' duration must be taken seriously. There may be a period of feeling of abdominal fullness with a need for increasing the usual catharsis, if any is regularly used, or there may be repeated bouts of loose bowels. A feeling of increased flatulence with a tendency to let out the belt or girdle is significant. Blood from the right colon was usually changed, being black when passed by rectum; lesions of the distal colon usually demonstrated bright red blood by rectum. Pain was a most common symptom in both right and left sided lesions. On the right it usually presented as intermittent and dull aching pain in the appropriate quadrant without reference to food intake or defecation. On the left side it was more commonly intermittent and colicky in nature. There were also symptoms of anorexia, weight loss and weakness associated with all lesions regardless of location. In our series three females and two males had lesions proximal to the rectum and the reverse was true for lesions of the colon. The average. age was 60 years-ol~est 91, youngest 26.
#8
H. W. Cave, K. M. Lewis, Jr., W. T. Wichern
Physical Diagnosis
A patient presenting the symptoms that lead to the suspicion of carcinoma should have a careful physical examination to include the following: 1. Special attention to the abdomen to evaluate the presence and character of a mass; to evaluate the liver edge for possible metastases. 2. Careful digital rectal examination. Many of the tumors of the rectum and lower sigmoid and in some cases of the upper sigmoid may be palpated on digital examination. It is of some aid to perform the examination in the Sims' position and to follow this with examination with the patient in the squatting position and straining. In the female bimanual examinations should be done of the vagina and rectum, for a mass in the sigmoid is occasionally palpable or ballotable between the examiner's hands. 3. Sigmoidoscopic examination which is preferably done in the kneechest position. Usually the entire lower 26 cm. of bowel may be visualized and occasionally a higher placed tumor will intussuscept to this level. The importance of the sigmoidoscope is clearly demonstrated in that 68 per cent of the 510 lesions of this report were visualized in this manner. 4. Roentgen examination of the colon. If the lesion is an obstructing one, flat films of the abdomen may reveal the location of the tumor. The barium enema should be used with caution in instances of obstruction, for with barium proximal to the lesion in any amount the hazards of surgery will be significantly increased. If the lesion is small and there is no obstruction, it is wise to study the remaining colon as well as possible by barium enema and contrast techniques. Multiple carcinomas are sometimes found, 8 per cent in this series, and adenomatous polyps are often visualized elsewhere in the bowel. SURGICAL TREATMENT
At the present time surgery offers the only opportunity for cure of carcinoma of the colon and rectum. The earlier the lesion ill discovered the greater will be the opportunity for cure. Once the diagnosis of a malignant lesion has been made no unnecessary delay should be permitted; a curable process may change in one day to an incurable one. In the series discussed here the patients had symptoms for an average of 6.5 months prior to surgery. This delay is most regrettable. In many of the cases there were apathy and procrastination on the part of the patient, but too often a history of one or more consultations with physicians during that period was obtained. Preoperative treatment should be carefully planned. Patients are often in need of fluid and electrolyte and blood replacement. The bowel should
Cancer of Colon and Rectum be cleansed mechanically as well as possible. In the absence of obstruction, this may be done with saline cathartics and enemas. Sulfasuxidine will reduce materially the coliform count and neomycin introduced twenty-four hours prior to the operative procedure will significantly reduce the total count for a period of several days. During this period of preparation, which consumes four or five days, the diet should be high in protein and in calories and as nearly as possible nonresidue. In the presence of obstruction, the situation is often a surgical emergency. Usually this is best dealt with by proximal drainage. In the presence of an incompetent ileocecal valve the small bowel may be greatly dilated, in which case it is best deflated with a Miller-Abbott or Harris tube. When the ileocecal valve is competent there may be tremendous distention of the large bowel proximal to the obstructing lesion. When the lesion is in the left colon it is preferable to do a transverse colostomy but the distention may be so great as to necessitate cecostomy. When the lesion is in the ascending colon, cecum or hepatic flexure an ileotransverse colostomy is the procedure of choice. It is rarely justifiable to attack the primary lesion in the presence of obstruction. Regardless of the procedure employed in the resection of a malignant tumor of the large intestine, a good margin of normal bowel on both sides of the tumor should be taken to insure the removal of all the lymph node spread. Since the lymph node area follows the blood supply, it may be necessary to remove long segments of normal bowel. In lesions of the right colon, resection of the terminal ileum and entire right colon is carried out with primary end-to-end anastomosis of the ileum to the distal transverse colon. Discrepancies in diameter between the two segments of bowel may be obviated by resecting the ileum at an angle so as to resect more of the antimesenteric border. Primary anastomosis, we feel, makes for a stronger anastomosis and one in which there is less chance for subsequent leakage. In lesions of the left colon, except in the presence of obstruction, we also believe that the procedure of choice is adequate resection with primary end-to-end anastomosis, although previously we preferred some form of obstructive resection. In those lesions just above the peritoneal reflection we are of the opinion that resection and primary end-to-end anastomosis is the most desirable procedure. Lesions existing at the peritoneal resection or below in the rectum are most adequately treated by abdominoperineal resection. Whether exteriorization or primary suture methods are used, it is necessary that the remaining normal segments of the bowel have an adequate blood supply. Successful anastomosis depends further on the lack of tension at the suture line, closure of traps in the mesentery, and avoidance of gross contamination. Postoperatively, patients should be supported by blood transfusions and intravenous therapy until normal peristalsis with the passage of
450
H. W. Cave, K. M. Lewis, Jr., W. T. Wichern
flatus has become established. Penicillin should be given and the neomycin continued for four or five days. Oral feedings may be started cautiously on the third day and progress as indicated. Results
All of the malignant lesions of the large intestine in our series of 510 cases were operated upon. One hundred and twelve lesions (22 per cent) were found inoperable and some form of proximal decompression was carried out. It was possible to resect the primary lesion in 398 instances (78 per cent) but there was evidence of gross involvement of the liver in 27 and of the peritoneum in 17 instances. The hospital mortality for the entire group was 10.5 per cent, 55 deaths in 510 operative procedures. There were 26 deaths (6.5 per cent) in 398 resections of the primary tumor, and 29 deaths (25.9 per cent) in 112 patients in whom the priTable 4 CAUSES OF DEATH IN RESECTIONS FOR CARCINOMA OF THE LARGE BOWEL
Peritonitis... . Cardiovascular insufficiency. Pulmonary embolism. Pneumonia. . . . . . Renal insufficiency. . . . Hepatic insufficiency. . Anesthetic death.
7 15 4 3 3 2 1
mary tumor could not be removed and some form of palliation was carried out. Table 4 indicates the causes of death definitely attributable to the operative procedure. In 20 deaths which occurred during convalescence from the operative procedure, but before the patient left the hospital, coronary thrombosis, cerebrovascular accident, cirrhosis, pulmonary tuberculosis, primary carcinoma outside of the colon and the rectum, and suicide were responsible. Of the 510 patients, 55 were lost to follow-up. Twenty-four patients alive and well at the end of five years without evidence of recurrence of their disease subsequently died of carcinoma. In 17 instances it was a recurrence of the colon carcinoma; in 8 it was from carcinoma other than in the colon. This points up once again the well known but occasionally forgotten fact that the term "five year cure" is little more than a convenient yardstick when used in connection with patients suffering from malignant disease. It gives an approximate idea of the end results in a group of patients with malignant disease in one site or another, but it cannot be applied to the individual patient. Surgical resection of the malignant lesion of the large intestine car-
Cancer of Colon and Rectum
451
ried out before there is extension to subtending lymph nodes or adjacent or distant viscera offers greater opportunity for survival than surgery for carcinoma in any other portion of the gastrointestinal tract. Every symptom, however vague, should be evaluated in this light and all diagnostic procedures exhausted. Polypoid lesions of the colen and of the rectum are of immeasurable importance and when recognized should be promptly and completely removed because of the close relationship they bear with carcinoma in the same area. REFERENCES 1. Swinton, N. W.: Significance and Frequency of Benign Polyps of the Colon and Rectum, Am. Pract. 2: 603, 1948. 2. Swinton, N. W.: Surgical Practice of the Lahey Clinic. Philadelphia, W. B. Saunders Co., 1951, p. 391. 3. McLanahan, S., Grove, G. P. and Kieffer, R. F.: J.A.M.A. 141: 822,1949.
CARCINOMA of the large bowel and of the rectum is not uncommon. These malignant growths comprise 95 per cent of all tumors of the intestinal tract and 7 per cent of all carcinomas. The differential diagnosis in patients presenting certain vague abdomina('symptoms should always encompass strong suspicion for tumors of the large bowel. Since they are more common after the fourth decade of life, there is an increase of this disease that parallels the gradual rise in the average age of the population. The earlier the diagnosis can be made, the greater the opportunity for cure. It is therefore imperative that physicians be constantly alert td the possibility of cancer of the colon and rectum. POLYPOID LESIONS: TIIEIR REMOVAL IN PROPHYLAXIS OF CANCER
Polypoid lesions of the colon and of the rectum are of immeasurable importance to the practicing surgeon and offer unique opportunity in the prophylaxis of carcinoma. This importance is manifest in the relative frequency with which they occur, the close relationship they bear with carcinoma in the same area, and the relative ease with which they may be recognized and treated. Incidence and Distribution of Polyps
Excluding the first two decades of life the incidence of adenomatous polyps of the large intestine increases with each decade. Swinton! of the Lahey Clinic reported an incidence of 7 per cent in 1843 postmortem From the Department of Surgery, The Roosevelt Hospital, New York City.
* Clinical Professor of Surgery, College of Physicians and Surgeons, Columbia University; Chief of Surgery, The Roosevelt Hospital.
** First Lieutenant, Medical Corps, U. S. Army. t Resident, First Surgical Service, The Roosevelt Hospital.
H. W. Cave, K. M. Lewis, Jr., W. T. Wichern examinations. At the Roosevelt Hospital in a recent ten year period (1940-1950) there were 141 polyps of the colon and of the rectum. In Table 1 it may be seen that 80 per cent of the polyps were benign, 14 per cent demonstrated premalignant change, and 18, or 12 per cent, were associated with carcinoma of the large bowel. Swinton2 also reported that in 828 cases of carcinoma of the large bowel there were associated polyps in 25 per cent and that in 14 per cent the malignancy could be shown to arise from a pre-existing benign polyp. Table 2 presents the distribution of polyps in this series. Most were found in the distal 10 or 12 inches of the large intestine. More than one polyp was demonstrated in 25 per cent and we believe that the incidence of multiple polyps is even higher. This multiplicity of polyps is most Table 1 CHARACTER OF
141
POLYPS NUMBER
Benign. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 114 Premalignant.. . . .. . . . . . . . . . . . . . . . .. 19 Malignant. . . . . . . . . . . . . . . . . . . . . . . . . . 8 Associated with carcinoma.. . . . . . . .. 18
PER CENT
80 14 6 12
Table 2 LOCATION OF POLYPS OF COLON AND RECTUM NUMBER
Rectum. . . . . . . . . . . . . . . . . . . . . . . . . . .. 110 Sigmoid colon. . . . . . . . . . . . . . . . . . . . .. 15 Descending colon. . . . . . . . . . . . . . . . . . . 3 Transverse colon. . . . . . . . . . . . . . . . . . . 5 Ascending colon. . . . . . . . . . . . . . . . . . . . 3 Cecum. ............................ 5
PER CENT
79 11 2 3 2 3
disturbing and the discovery of one polyp in the distal colon should make the observer alert for the discovery of others. Diagnosis of Polyps
As indicated by the incidence of polyps found at autopsy, many patients must either have no symptoms or else minor and vague symptoms that are overlooked. In our series the most frequent symptom was recurrent rectal bleeding, the character of which varied with the location of the polyp. With low-lying polyps the outside of the stool was coated a bright red, while with polyps of the right colon the blood was a dark red and mixed with the stool. Recurrent rectal bleeding occurred in 52 per cent of our series. Other symptoms included change of bowel habits, constipation, bouts of diarrhea, and vague abdominal cramps. The larger polyps may ca.use varying degrees of pa-rtial obstruction and occasion-
Cancer of Colon and Rectum
445
ally form the head of an intussusception. A pedunculated polyp low in the rectum will often protrude from the anus on straining. Careful digital examination of the rectum will demonstrate many rectal polyps. Sixty to 80 per cent may be demonstrated with the use of the sigmoidoscope which is the most important tool in the completion of the diagnosis. Those polyps above the reach of the sigmoidoscope are more difficult to demonstrate. Barium enema and air contrast studies after careful preparation become necessary. The site of the filling defect may vary as much as 6 or 8 inches because of play allowed by the pedicle. However, even when extreme care is utilized in the performance of the roentgenologic studies, many smaller polyps are overlooked. Treatment
The basic principle in the treatment of polyps of the colon and of the rectum is their thorough removal by the simplest and safest means, followed by repeated endoscopic and roentgenologic examinations. The simple pedunculated polyp of the rectum may be ligated well down on its stalk and excised. If situated higher in the rectum, but still visible through the proctoscope, its pedicle may be fulgurated with a snare and so removed, but this has the disadvantage of preventing adequate microscopic examination of the specimen. When the polyp is located above the peritoneal reflection it must be removed by exploratory celiotomy and colotomy. Whether resection is required for grossly benign polyps is difficult to decide at the operating table. If invasion is demonstrated by immediate pathologic examination, resection of the bowel should be immediately performed. If histologic evidence of cancer without invasion is found on pathologic examination (which may be difficult or impossible to demonstrate by frozen section), complete removal of the polyp is probably sufficient. If invasion, missed at operation, is found on final pathologic examination then reoperation and resection are advisable. Because of the practical difficulties involved in persuading the patient and his family of the necessity of a second operative procedure so soon after the first, and because of the comparable mortality of resection of the large bowel for polyp and colotomy for the removal of a polyp, one might very well consider resection the procedure of choice in instances of the slightest doubt. The experience of McLanahan and associates,3 who found 10 recurrences of polyps (5 of which were malignant) out of a group of 38 patients having local removals of malignant adenomas, would tend to substantiate this conclusion. The sessile polyp and the papilloma are best excised with a rim of normal mucous membrane. In the rectum this often necessitates proctotomy with splitting of the anal sphincter and sometimes excision of the coccyx to obtain adequate exposure. Should an invasive lesion be found, then, of course, abdominoperineal resection is indicated.
H. W. Cave, K. M. Lewis, Jr., W. T. Wichern 'The treatment of choice in polyposis of the colon is complete colectomy, leaving the patient with a permanent ileostomy. However, a compromise procedure has been brought forward by Rankin and others. This is a three stage procedure in which all the polyps in the rectum and sigmoid are first excised or fulgurated. After healing, this is followed by ileosigmoidostomy and later by resection of the terminal ileum and colon. These patients must be followed carefully at least at six month intervals for recurrence of polyps in the rectum. Polyps of the rectum and of the colon, because of their frequency, location, relationship to carcinoma in the same areas, and because of their relatively easy recognition with proctoscopic and roentgenologic techniques, offer a unique opportunity to the surgeon for the prophylaxis of carcinoma of the large intestine. Table 3 LOCATION OF CARCINOMA OF COLON AND RECTUM NUMBER
Cecum, , , .......... , ..... , . . . . . .. Ascending colon ...... , . . . . . . . . . .. Hepatic flexure., ..... " .... , ... ,. Transverse colon ..... , , . . . . . . . . .. Splenic flexure ................... , Descending colon ...... , ..... ' , . .. Sigmoid colon ...... , .... , ........ Rectosigmoid, . , .. , . . . . . . . . . . . . . .. Rectum ................ , ... , ..... Anus ... , , ... ' .. , ..... , . . . . . . . . . . .
55 29 12 28 10 22 144 56 147 7
PER CENT
10.8 [5.7 [2.4 5.5 2.1 4.3 28.0 10.9 28.8 1.4
CARCINOMA: DISTRIBUTION, TYPES, METASTASIS
Although carcinoma may develop in any portion of the colon, it is more frequently found in the areas where stasis is most common and in areas where polyps have been found most prevalent. In a recent survey of the colon carcinomas at Roosevelt Hospital (1940-1950), comprising 510 cases, 68 per cent were located in the sigmoid, rectosigmoid and the rectal areas. Table 3 indicates the distribution of remaining tumors. It is not uncommon to find two separate areas of carcinoma and frequently adenomatous polyps, as indicated previously, are found elsewhere in the bowel in addition to the malignant lesions. Malignant lesions of the colon and rectum vary considerably in size and appearance. Large, soft, polypoid lesions are often less malignant than small ulcerative growths. Colloid carcinoma usually is associated with a large tumor which may be radically.removed without leaving any obvious cancer, but cure of this type is unusual. The small scirrhous encircling tumor often described as the "napkin ring" type produces early obstruction and is quite amenable to "cure." The ulcerative lesions
Cancer of Colon and Rectum
447
may be small, but are more often large at the time of discovery and entirely encircle the lumen of the bowel. There is great variation in the spread of cancer of the colon. Modes of extension include: (1) local spread to adjacent organs which can often be sacrificed with the main tumor. (2) Lymphatic spread. This represents the most common mode of extension of the disease and for this reason the lymph node area draining the tumor region should be generously excised in the block resection of the tumor. (3) Spread through blood vessels. This often occurs even in the absence of demonstrable lymph node involvement. In this variety metastases are found early in the liver. Distal spread is unusual, although the lung, the skeleton and the brain may occasionally be the seat of metastatic disease. Usually, however, this is a very late manifestation. In this respect, cancer of the intestinal tract is different from certain cancers arising elsewhere, particularly of the breast and of the prostate. EARLY DIAGNOSIS
Symptoms
As in malignant growths in other parts of the body the one essential and important feature is early diagnosis. In the majority of instances the malignancy does not become obviou~ until it is well established, which emphasizes the importance of tracking down even the slightest symptoms. In our series of 510 patients with carcinoma of the large intestine a change in bowel habits, the passage of gross blood by rectum, and pain, including colicky, local quadrant and rectal pain, were the earliest arM most prominent symptoms. Irregularity of more than a few days' duration must be taken seriously. There may be a period of feeling of abdominal fullness with a need for increasing the usual catharsis, if any is regularly used, or there may be repeated bouts of loose bowels. A feeling of increased flatulence with a tendency to let out the belt or girdle is significant. Blood from the right colon was usually changed, being black when passed by rectum; lesions of the distal colon usually demonstrated bright red blood by rectum. Pain was a most common symptom in both right and left sided lesions. On the right it usually presented as intermittent and dull aching pain in the appropriate quadrant without reference to food intake or defecation. On the left side it was more commonly intermittent and colicky in nature. There were also symptoms of anorexia, weight loss and weakness associated with all lesions regardless of location. In our series three females and two males had lesions proximal to the rectum and the reverse was true for lesions of the colon. The average. age was 60 years-ol~est 91, youngest 26.
#8
H. W. Cave, K. M. Lewis, Jr., W. T. Wichern
Physical Diagnosis
A patient presenting the symptoms that lead to the suspicion of carcinoma should have a careful physical examination to include the following: 1. Special attention to the abdomen to evaluate the presence and character of a mass; to evaluate the liver edge for possible metastases. 2. Careful digital rectal examination. Many of the tumors of the rectum and lower sigmoid and in some cases of the upper sigmoid may be palpated on digital examination. It is of some aid to perform the examination in the Sims' position and to follow this with examination with the patient in the squatting position and straining. In the female bimanual examinations should be done of the vagina and rectum, for a mass in the sigmoid is occasionally palpable or ballotable between the examiner's hands. 3. Sigmoidoscopic examination which is preferably done in the kneechest position. Usually the entire lower 26 cm. of bowel may be visualized and occasionally a higher placed tumor will intussuscept to this level. The importance of the sigmoidoscope is clearly demonstrated in that 68 per cent of the 510 lesions of this report were visualized in this manner. 4. Roentgen examination of the colon. If the lesion is an obstructing one, flat films of the abdomen may reveal the location of the tumor. The barium enema should be used with caution in instances of obstruction, for with barium proximal to the lesion in any amount the hazards of surgery will be significantly increased. If the lesion is small and there is no obstruction, it is wise to study the remaining colon as well as possible by barium enema and contrast techniques. Multiple carcinomas are sometimes found, 8 per cent in this series, and adenomatous polyps are often visualized elsewhere in the bowel. SURGICAL TREATMENT
At the present time surgery offers the only opportunity for cure of carcinoma of the colon and rectum. The earlier the lesion ill discovered the greater will be the opportunity for cure. Once the diagnosis of a malignant lesion has been made no unnecessary delay should be permitted; a curable process may change in one day to an incurable one. In the series discussed here the patients had symptoms for an average of 6.5 months prior to surgery. This delay is most regrettable. In many of the cases there were apathy and procrastination on the part of the patient, but too often a history of one or more consultations with physicians during that period was obtained. Preoperative treatment should be carefully planned. Patients are often in need of fluid and electrolyte and blood replacement. The bowel should
Cancer of Colon and Rectum be cleansed mechanically as well as possible. In the absence of obstruction, this may be done with saline cathartics and enemas. Sulfasuxidine will reduce materially the coliform count and neomycin introduced twenty-four hours prior to the operative procedure will significantly reduce the total count for a period of several days. During this period of preparation, which consumes four or five days, the diet should be high in protein and in calories and as nearly as possible nonresidue. In the presence of obstruction, the situation is often a surgical emergency. Usually this is best dealt with by proximal drainage. In the presence of an incompetent ileocecal valve the small bowel may be greatly dilated, in which case it is best deflated with a Miller-Abbott or Harris tube. When the ileocecal valve is competent there may be tremendous distention of the large bowel proximal to the obstructing lesion. When the lesion is in the left colon it is preferable to do a transverse colostomy but the distention may be so great as to necessitate cecostomy. When the lesion is in the ascending colon, cecum or hepatic flexure an ileotransverse colostomy is the procedure of choice. It is rarely justifiable to attack the primary lesion in the presence of obstruction. Regardless of the procedure employed in the resection of a malignant tumor of the large intestine, a good margin of normal bowel on both sides of the tumor should be taken to insure the removal of all the lymph node spread. Since the lymph node area follows the blood supply, it may be necessary to remove long segments of normal bowel. In lesions of the right colon, resection of the terminal ileum and entire right colon is carried out with primary end-to-end anastomosis of the ileum to the distal transverse colon. Discrepancies in diameter between the two segments of bowel may be obviated by resecting the ileum at an angle so as to resect more of the antimesenteric border. Primary anastomosis, we feel, makes for a stronger anastomosis and one in which there is less chance for subsequent leakage. In lesions of the left colon, except in the presence of obstruction, we also believe that the procedure of choice is adequate resection with primary end-to-end anastomosis, although previously we preferred some form of obstructive resection. In those lesions just above the peritoneal reflection we are of the opinion that resection and primary end-to-end anastomosis is the most desirable procedure. Lesions existing at the peritoneal resection or below in the rectum are most adequately treated by abdominoperineal resection. Whether exteriorization or primary suture methods are used, it is necessary that the remaining normal segments of the bowel have an adequate blood supply. Successful anastomosis depends further on the lack of tension at the suture line, closure of traps in the mesentery, and avoidance of gross contamination. Postoperatively, patients should be supported by blood transfusions and intravenous therapy until normal peristalsis with the passage of
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flatus has become established. Penicillin should be given and the neomycin continued for four or five days. Oral feedings may be started cautiously on the third day and progress as indicated. Results
All of the malignant lesions of the large intestine in our series of 510 cases were operated upon. One hundred and twelve lesions (22 per cent) were found inoperable and some form of proximal decompression was carried out. It was possible to resect the primary lesion in 398 instances (78 per cent) but there was evidence of gross involvement of the liver in 27 and of the peritoneum in 17 instances. The hospital mortality for the entire group was 10.5 per cent, 55 deaths in 510 operative procedures. There were 26 deaths (6.5 per cent) in 398 resections of the primary tumor, and 29 deaths (25.9 per cent) in 112 patients in whom the priTable 4 CAUSES OF DEATH IN RESECTIONS FOR CARCINOMA OF THE LARGE BOWEL
Peritonitis... . Cardiovascular insufficiency. Pulmonary embolism. Pneumonia. . . . . . Renal insufficiency. . . . Hepatic insufficiency. . Anesthetic death.
7 15 4 3 3 2 1
mary tumor could not be removed and some form of palliation was carried out. Table 4 indicates the causes of death definitely attributable to the operative procedure. In 20 deaths which occurred during convalescence from the operative procedure, but before the patient left the hospital, coronary thrombosis, cerebrovascular accident, cirrhosis, pulmonary tuberculosis, primary carcinoma outside of the colon and the rectum, and suicide were responsible. Of the 510 patients, 55 were lost to follow-up. Twenty-four patients alive and well at the end of five years without evidence of recurrence of their disease subsequently died of carcinoma. In 17 instances it was a recurrence of the colon carcinoma; in 8 it was from carcinoma other than in the colon. This points up once again the well known but occasionally forgotten fact that the term "five year cure" is little more than a convenient yardstick when used in connection with patients suffering from malignant disease. It gives an approximate idea of the end results in a group of patients with malignant disease in one site or another, but it cannot be applied to the individual patient. Surgical resection of the malignant lesion of the large intestine car-
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ried out before there is extension to subtending lymph nodes or adjacent or distant viscera offers greater opportunity for survival than surgery for carcinoma in any other portion of the gastrointestinal tract. Every symptom, however vague, should be evaluated in this light and all diagnostic procedures exhausted. Polypoid lesions of the colen and of the rectum are of immeasurable importance and when recognized should be promptly and completely removed because of the close relationship they bear with carcinoma in the same area. REFERENCES 1. Swinton, N. W.: Significance and Frequency of Benign Polyps of the Colon and Rectum, Am. Pract. 2: 603, 1948. 2. Swinton, N. W.: Surgical Practice of the Lahey Clinic. Philadelphia, W. B. Saunders Co., 1951, p. 391. 3. McLanahan, S., Grove, G. P. and Kieffer, R. F.: J.A.M.A. 141: 822,1949.