Carcinoma of the cecum in association with acute appendicitis

CARCINOMA

OF THE CECUM IN ASSOCIATION ACUTE

WITH

APPENDICITIS

LIEUT. COL. EDWARD F. MCLAUGHLIN MEDICAL CORPS, ARMY OF THE UNITED STATES

T

HE finding of cecal malignancy in conjunction with acute appendicitis is unusua1. It is true that cancer of the cecum often gives rise to symptoms and less suggesting “chronic appendicitis” often simulates the picture of acute appendicitis, but the definite association of the two conditions in an intimate pathoIogica1 reIationship has been demonstrated very infrequentIy. On the other hand, considering simpIy the mechanics which are involved, one would not expect the association of these two conditions to be so rare. Yet, it is, and in four representative studieslm4 of malignancies of the cecum and ascending coIon, no instances of the coexistence of mahgnancy and acute appendicitis are recorded. Erdman and CIarkr studied forty-eight cases of ceca1 maIignancy and do not mention the hnding of acute appendicitis at ah. LaheyZ reviewed the cases at his cIinic in rg3g and mentions no such association. Chamberlain3 studied forty-one cases of cecal carcinoma with no accompanying appendicea1 inff ammation and Mayo and LoveIace4 went over the 883 case histories of a11 the ceca1 and ascending coIon maIignancies at the Mayo CIinic for the period rgo7 and 1938, and described no instance of intimate reIationship between the growths and infIammation of the vermiform appendix. RepeatedIy, CharIes W. Mayo has stressed in talks and in articIes the necessity for examining the cecum at the time of appendectomy. He lays particuIar stress upon those cases in which the appendix is removed in an “interval stage” or where

it is found to be not acutely inflamed. A certain number of patients having had such operations show up with carcinoma of the cecum within a reIativeIy short time afterwards, and the concIusion is obvious that the operator at the time of the appendectomy faiIed to evaIuate carefuIIy the cecum and ascending colon. It is our beIief that a simiIar checkup should be made when one finds acute appendicitis especiaIIy if there be any suggestion of a m&s present in the Iower cecum. It is not advocated that the patient be subjected to an intra-abdomina1 expIoration which would tend to spread contamination from the obviousIy inflamed appendix but. it is urged that the avaiIabIe portion of the cecum be carefuIIy scrutinized and paIpated and the biopsies be taken as indicated. With the belief that more maIignancies of the cecum couId be found even in association with acute appendicitis, it is considered worth whiIe airing this genera1 subject at the present time. The association of cecal maIignancy and acute appendicitis has appeared as a subject entity in the literature but the writings on this association of pathoIogies is scant and spotty and seems worthy of review and correlation. One more case is reported here and added to the smaI1 total. A discussion of the subject is included covering the associated pathologies, the possibility of preoperative suspicion and the probIem of diagnosis at operation. The question of what is proper treatment and when it should be instituted is aIso covered. While Beran; reported a case of cancer of the cecum associated with appendicea1

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a cancer of the cecum abscess in IgIg, it was reaIIy Morton, of second operation; was present, however. The invoIved tissue EngIand, who first entered into a discussion of the whoIe probIem.6 In a case report by was removed and an iIeotransverse colosMuir,’ obstruction by a ceca1 cancer caused tomy done. A IocaI recurrence was noted appendicea1 inffammation and m’ucoceIe a year and one-quarter Iater in the abformation. Quoting from what may have domina1 waI1 at the site of the sinus tract. been a persona1 communication (since the In 1938, Skegers13 reported three cases of reference could not be traced), Muir writes carcinoma of the cecum, their cIinica1 as foIIows: “WiIkie has pointed out that course resembIing that of appendicitis and in the same year Speese and Bothe14 reacute appendicitis may be the first indication of this disease (carcinoma of the ported two cases; the one case showed a association of acute appencecum).” Mayer8 reported three cases of rather typica acute appendicitis in association with bowe1 dicitis pIus ceca1 carcinoma but in the maIignancy, one of which foIIowed the other, no acute appendicitis was found, course more typica of those in other re- although there was every preoperative indiports. Parker and RosenthaI,g cite one cation that it was present. The subject was typica case of ceca1 carcinoma and acute again discussed in an articIe by BartIett appendicitis in which the carcinoma of the and MiIIer15 in which acute appendicitis is cecum invaded and obstructed the base of regarded as a “ compIication ” of carcinoma of the cecum. the appendix, giving an obstructive gangreThree exceIIent references which have nous appendicitis with rupture for which operation was performed and drainage in- a bearing on one aspect of the subject, nameIy, the question as to whether carstituted. The draining sinus persisted and cinoma at the base of the appendix is ceca1 the maIignancy spread to and invoIved the or appendicea1, are given as foIIows: Young iIeoceca1 vaIve giving rise to a subsequent and Wyman,“j UihIein and McDonaId,” obstruction. Secondary operation reveaIed and Chomet.‘s the true status of the conditions present. Throughout the scant Iiterature on this Another case is aIso reported which was subject, there appears to be a few common aImost identi;aI with one of those reported denominators: (I ) An acute attack suggestby Mayer. It was one in which acute appening appendicitis in an individua1 in whom dicitis was found in conjunction with an no suspicion of maIignancy exists; (2) abobstructing maIignancy of the transverse scess formation in the appendiceal region; coIon. As Iate as 1935, Banks and GreenlO (3) faiIure to identify the presence of a made the statement that in the Iiterature (4) a they were abIe to find but three papers on neopIasm at the primary operation; persistence of the draining sinus beyond this subject, the one by Mayer, the one by and (5) the feeling of Parker and RosenthaI and another by a norma expectancy, a mass near the Iower cecum. French author named Shear?’ whose Sifting out of the case reports those in articIe is not avaiIabIe to this writer. The immediate authors add another case of which the maIignancy was further aIong in the Iarge bowe1 than the cecum or in which their own. AIso in x936, Cooke12 reports there was some other reason to doubt that one more case which is a rather typica one. the intimate association of ceca1 cancer The patient had an acute episode of abdomina1 pain and was found to have an and acute appendicitis existed there remain eIeven instances of this association. The abscess in the appendicea1 area. This was articIes by WiIkie (as quoted by Muir’) and drained and continued to drain for a period Shears” were not avaiIabIe . of eight months. At this time a mass was paIpabIe and the patient was re-operated CASE REPORT upon. The appendix was apparentIy comA twenty-three-year oId, white maIe first pIeteIy digested for it was not found at the noticed abdominal pain June IO, x944. This

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FIG. I. X-ray taken September I, 1944, showing what appears to be extrinsic pressure upon the lower portion of the cecum and adjacent small bowel, giving a distorted outline of these parts. In the center of the infringing mass is a small calcified area.

centered at first in the Iower abdomen just beIow the umbihcus but moved very promptly to the right lower quadrant and remained as a sharp, steady, moderately severe pain unti1 the night of June 12, 1944, when the pain was so severe it interferred with sIeep. On the next day the patient was hospitaIized. The pain did not radiate aIthough the patient occasionally feIt an isoIated sharp twinge in the region of the heart on deep breathing. There had been Ioss of appetite and slight nausea since the onset of pain but no vomiting. The boweIs moved daiIy and stooIs were we11 formed. There was no dysuria. The patient enjoyed good health previously except for an aIIeged attack of appendicitis in childhood. The famiIy and socia1 history contributed nothing. PhysicaI findings on abdomina1 examination were described by the examiner as foIIows: “There is moderate tenderness in the right Iower quadrant about at McBurney’s point and there is a smooth, rounded, tender mass

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FIG. 2. A Iater appearance of the bowe1 on the same day, September I, 1944, showing the persistence of the deformity in the lower cecum and adjacent bowel, apparently from extrinsic pressure. One shadow in the small bowel seems to demonstrate the Meckel’s diverticulum unsuspected at this time but Iater found at operation.

paIpabIe in the right Iower quadrant. Rebound tenderness is referred to the right Iower quadrant.” The diagnosis of an acute appendicitis was made and on June 13, 1944, the day of admission, and the patient was operated upon. The operative note is as foIIows: “Abdomen was prepared with Tincture of Merthiolate, opened through McBurney incision. There was a smaI1 amount of clear fluid present. The cecum couId not be delivered. The appendix could be palpated Iying retrocecaIIy and feIt to be z cm. in diameter by about 7 cm. in Iength. The organ was entirely retroperitoneal, not even a trace being visibIe. An attempt was made to mobiIize the cecum and expose the appendix but the tissues were so acuteIy infected and so friable that it was feIt to be better judgment simply to drain the appendicea1 region. Drainage was established with cigarette drains, one in the pelvis, one in the IateraI gutter, one in the retroceca1 portion, where mobiIization had

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FIG. 3. Photograph of specimen unopened showing mostIy the numerous adhesions of the small bowel to the cecum, the fulIness of the lower end of the cecum and the absence of any remains of the appendix. Meckel’s diverticulum is cIearIy shown.

been started. Wound closed about the drain in layers.” The operation lasted one hour nine minutes. Anesthesia was a spinal, ISO mg. of procaine hydrochloride being administered. The patient’s recovery after operation was prompt and his general condition was good. Drains were removed on the fifth day. As his convalescence progressed, he complained of continued pain in the lower right quadrant and a palpable mass was still extant there. The draining sinus persisted. This status continued for approximately two and one-half months when he was transferred to this hospital. Upon examination here, the patient was found to be in excellent general condition and the only positive findings were the scar of his previous operation, a draining sinus within it and a palpable mass deep in the lower right quadrant beneath the scar. This mass was firm and seemed to be fixed to the undersurface of the abdominal wall Laboratory examinations gave findings within norma limits including hemoglobin vaIues, ethrocyte counts and urinalyses. X-ray of the gastrointestinal tract (Figs. I and z) was reported as follows: “ . . . Subse-

quent observation at 2, 3, and 4 hours shows a filling defect from what appears to be an extrinsic lesion in the right lower quadrant. This displaces the cecum and terminal ileum upward and 2 or 3 other’ loops of iIeum medialward. In the center of this defect is a small irregular oval shadow about I .3 cm. having the density of calcium. This may possibly represent a foreign body reaction. Impression: Chronic granuloma in the region of the cecum.” It was believed that the patient had an ample opportunity to heal his sinus tract. The possibility that it was being perpetuated by some foreign body at the base of the tract was taken into consideration and a decision was made to open the abdomen and investigate. This was done on September 4, 1944. The operative report of this procedure reads as folright rectus incision was lows : “A four-inch made, centered I $4 inches beIow the umbilicus and 135 inches to the right of it. On opening the peritoneal cavity, the cecum was found to be tightly bound to the lateral and posterolateral abdominal wall. Loops of small bowel were attached to the cecum by recent but well established adhesions. These adhesions were severed and the small bowel separated from

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FIG. 4. Cecum

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open shows the matignant mass to be at the lower portion near where the appendix presumably joined it.

the cecum. It was impossibIe to bring the cecum up without breaking into the chronic inflammatory hbrous tissue which bound it to the abdominal waI1. Separation of the cecum from the parietes was begun and carried on graduahy. Very firm and even calcareous fibrous and chronic infIammatory tissue was encountered. Pieces of this very firm tissue were taken for microscopic examination. The cecum was not opened during the freeing process but its undersurface was quite raw when it was IinaIIy dislodged. No remains of the appendix could be identified despite the fact that the area where it might be expected was we11 exposed. The raw surface of the ceca1 pIain catgut waI1 was closed over with ‘00’ sutures. A cigarette drain was pIaced in the operative area and brought out through the lower angIe of the wound. The abdomen was then cIosed in layers.” FoIlowing this operation the patient had a somewhat stormy convaIescence with drainage from the new wound. He graduaIIy improved, however, and after approximately four weeks, the draining sinus had heaIed over as had aIso the origina sinus. The report from the pathoIogist on the sections submitted was most interesting. “Histology: HistoIogicaI examination of wal1 of specimen sent in from the operation reveals an infiltration in aI1 of aIveoIar gland composed of a singIe Iayer of coIumnar epitheIium resembhng intestina1 mucosa. They are grow-

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of the cecum

ing without a definite pattern in a connective tissue stroma which is infiItrated with Iymphocytes. Although this represents a definite maIignancy, it is of Iow grade pathologically since the aIveoIar structure is we11 maintained throughout. Some of the gIands secrete mucous. Diagnosis: Adenocarcinoma of intestine, probabIy coIon .” On the basis of these findings another operation was unquestionabIy necessary. Some time was aIIowed for further convaIescence and genera1 up-buiIding and incIuded a furIough home since the man’s morale was somewhat low. This deIayed the direct action upon the malignant growth but it was time we11 spent for when the patient returned he was in good spirits, had gained weight and the abdomina1 wall was free of any residual infection. The preoperative checkup reveaIed norma hndings for bIood count, hemogIobin, plasma protein IeveI and blood chemistry. The bowels moved normaIIy every day and he never had any indication of change in bowe1 habit nor had bIood ever been detected in the stools. On November 16, 1944, (five months after the first admission for “acute appendicitis”) a third operation was performed. The descripthe patient under anestion follows: “With thesia, palpation of the abdomina1 wall and through it the abdomen itseIf reveaIed a mass in the Iower right quadrant approximateIy 2” x 3” in measurement. This was firm and fixed. The abdomen was opened through the

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FIG. 5. Microphotograph (X 125) represents the more adenoid portion of the tumor showing irregular Iarge mucus secreting glands with some loss of polarity of nucIeii and piling of cyIindrica1 epithelial ceIIs. Some of the tubules show cystic distention.

FIG. 6. Microphotograph (X 600) shows typica secreting cyIindrica1 ceIIs that line some spaces; the dark band-like nucleus (indicated by arrow) is a mitotic Iigure removed from normal position against the basement membrane. Other space Wed with thin mucin has lost its epithelia1 lining.

previous right rectus incision and after omental adhesions were freed, the bowe1 in the Iower right quadrant was seen to be tightIy bound down. Hard tissue was paIpated in the region of the Iower cecum and in the mesentery nearby, nodules were feIt. SmaII Ioops of boviiel bound in the mass were freed and the mass seemed to invoIve the cecum. This was fixed to the adjacent structures and separateIy to the anteroIatera1 abdomina1 waI1. The Iiver was examined and found to be normaI; there were no noduIes in it. Firm and hard glands were present in the mesentery, both adjacent to the mass and beyond the immediate vicinity of the same. The cecum with its contained mass was graduaIIy freed from the tissues in contact with it. The process of freeing was a tedious one and it was impossible to separate the mass compIeteIy from the posteroIatera1 peritoneum and abdomina1 waI1. In order to mobiIize the cecum, the peritoneum and part of the muscIe tissue of the abdominal waI1 was incised in an encircring manner and brought away with-the mass. EIevating the Iower portion of the cecum, the iIiac vesseIs and ureter were separated from it. The smaI1 bowe1 proxima1 to the cecum was traced backward and a Meckle’s diverticulum found bound deep in the pelvis. Going distahy from the mass, the ascending coIon seemed free of invoIvement in

its upper portion. The bowel was divided through the transverse colon near the hepatic 4’ proximal to ffexure and again approximateIy the ileocecal junction. The portion between, intruding the mass, was removed. Both ends of the bowe1 were cIosed in and a side-to-side ileotransverse colostomy done. Prior to the anastomosis all suspicious gIands were dissected out and that portion of the abdomina1 waI1 which was about the oId sinus tract Ieading down to the mass was excised in toto. SuIfaniIamide powder was dusted onto the bowe1. A cigarette drain was pIaced in the area and ‘brought out through the opening made by the excision of the sinus tract. The abdomina1 wounds were cIosed by through-and-through sutures of #IO crochet cotton.” For a day or two there was some drainage of serum and bIood from the wound but the patient’s recovery was rapid and most satisfactory. He was passing gas within five days and had ‘a bowel movement on the seventh day. Both abdomina1 wounds were completely heaIed within two weeks. A report on the tissue examination dated 30, 1944, reads as foIIows: “There November is a Iarge MeckIe’s diverticuIum 6 cm. in Iength and z cm. in diameter. This shows no inffammation or uIceration. A portion of the iIeum is adherent to the cecum by oId adhesions and in

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intimate contact with a Iarge tumor mass the size of a smaI1 appIe. (Fig. 3.) On the serosai side it is covered by a fibrous tissue adhesion. On the mucosa side it shows two fungating protrusions into the Iumen measuring each approximateIy 3 cm. in diameter. (Fig. 4.) The section through the tumor mass reveals it to lie in the mucosa and submucosa. However, section into the mass of fibrous tissues by which the ileum is bound to the cecum reveals an infiltration of malignant tissue throughout this area. Tumor is somewhat geIatinous on sect:on suggesting coIIoid type of malignancy. There are four regional Iymph nodes included with. the specimen. Only one of these is enIarged and is found to contain a dense white indurated tissue resembIing maIignant tissue. The others also show this same type of tissue. There are no implants of carcinomatous tissue visibIe on the free portions of the ileum or its mesentery. HistoIogy: Histologica examination of the mass and the regional Iymph nodes reveals a similar picture in each. In a fibrous stroma infiltrated with lymphocytes, there is a growth of atypical glands Iined by columnar epitheIiaI ceIIs. These show pIeomorphism and mitotic figures. AtypicaI Iarge round cells with rounded eccentric nuclei characteristic of coIloid type of adenocarcinoma are also seen and atypical gland spaces are fiIIing with stringy basophilic mucus. Diagnosis: CoIIoid adenocarcinoma of the cecum with metastasis to regional Iymphnodes.” (Figs. 5 and 6.) The soldier made a compIete recovery from this operation and was soon abIe to eat a reguIar house mea1. His bowels moved daiIy and he gained weight, X-ray examination of the bones and chest showed no evidence of any spread of the malignancy and after a two months’ convaIescence, he was discharged. COMMENT

The discussion may be introduced by quoting from the articIe by UihIein and McDonaId17 in which they describe three types of carcinoma of the appendix, the Iast of which is that type “which resembIes both grossIy and microscopicaIIy those found in the colon and which will be referred to as the colonic type.” Speaking further of this coIonic type of appendicea1 carcinoma they state, “Because of their

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Frc. 7. This microphotograph shows tumor infiltrating the skin. Skin is to the right; tubules of tumor ~11s seen invading dermal papilla via lymphatics. In derma and subcutaneous area to the left are spaces fiIIed with mucin; occasionaIIy, a tubule of tumor was seen and in some of the smaIIer spaces are Ioosened isIands of secreting tumor rpithelial cells.

frequent location in the base of the appendix, obstruction to the appendicea1 Iumen usuaIIy resuIts earIy in the course of the disease. As a consequence, acute appendicitis usuaIIy with perforation is a common WhiIe the cases which are occurrence.” under discussion in this paper are not carcinomas of the appendix, stiI1 the Iocation of a carcinoma in the cecum in many instances wiII resuIt in the same mechanica bIockage of the Iumen of the appendix, either by direct impingement or by the impingement of secondary infIammatory sweIIing. One other point shouId be mentioned in the possibIe etioIogy of acute appendicitis and that is the rBIe of infection. ShouId the surface of the carcinoma become eroded, certainIy an entrance is furnished for bacteria which may make their way to the tissues in the waIIs of the adjacent appendix and thus contribute to if not precipitate the attack of acute appendicitis. In any event the most IikeIy possibiIity as far as the carcinoma precipitating an attack of acute appendicitis goes, is the one of obstruction of the appendicea1 lu-

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men. It is not entireIy out of the reaIm of possibility, however, that a certain number of these patients simpIy deveIop simuItaneously an attack of acute appendicitis in the presence of a carcinoma in the adjoining cecum. An interesting sidelight and again possibIy expIained by bIockage of the appendicea Iumen by the growth or its attendant inflammation, is, the fact that certainIy in one case as described by Speese and Bothe,14 a carcinoma of the cecum may give convincing signs and symptoms of acute appendicitis when none is actualIy present. The convincing picture in a case Iike this could undoubtedIy be due to a temporary distention of the appendicea1 Iumen with retained gas without the organ actuaIIy going on to a state of inflammation. In our own case, the proximity of the growth to the appendicea1 Iumen certainly suggested obstruction as the underIying etiologica1 factor. As to diagnosis, it is aImost impossibIe to diagnose the presence of the two lesions preoperatively. If the .attack were to come on in a patient with preceding cIassica1 signs and symptoms of a maIignancy in the cecum, it might be possibIe to arrive at an accurate diagnosis. UsuaIIy these co-Iesions have occurred in rather young individuaIs in. whom the presence of a maIignancy has not been suspected. Diagnosis with the abdomen opened is d$cuIt enough in the presence of the acute infIammation in and about a gangrenous appendix. In the case here cited the appendix was apparentIy thick, acuteIy inffamed and compIeteIy retrocecal and the picture very confusing. It is very dif5cuIt to teI1 whether the sweIIing and firmness in the adjacent structure of the cecum is due to a neopIasm or whether it is simpIy a continuity of an inflammatory reaction. If the presence of malignancy is suspected, certainIy a biopsy of nodes, appendages or even possibIy of the bowe1 waII itseIf is indicated. Should an abscess be present, the diagnosis is even more diffIcuIt, for the operator feels restricted in his investiga-

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tions within the abdomen. In cases of Ionger standing, the clue is the persistence of the drainage and the chronicity of the sinus tract; also as in our own case, the presence of a mass may be detected Iater deep within the abdomen usuaIIy at the base of the sinus tract. Even with this picture it must be recognized that sinuses foIIowing appendicea1 abscesses in which the appendix or part of it is aIIowed to remain in the beIIy, persist for a Iong, Iong time whether a cancer be there or not. One is faced with the decision as to whether he shouId or should not open the abdomen to investigate the situation and again when such investigation is most desirabIe. CertainIy, a period of time shouId be aIIowed to eIapse in order to permit what infection is present to become as inocuous as possibIe. Upon this secondary investigation one may not be abIe to teIl grossIy that he is dealing with a maIignant mass, as was true here. Again, in this present case the presence of a caIcification suggested very strongIy a marked chronic inflammatory reaction which undoubtedly was aIso present, but in addition, the patient had a maIignancy of the cecum. Frozen sections wouId be of great heIp in such contingencies. As far as the operative treatment goes, two fundamenta1 things need to be done: First, the invoIved bowe1 and adjacent Iymph nodes shouId be removed as compIeteIy as possibIe and bowe1 continuity restored. In the second pIace, the contact portion of the abdomina1 waI1 pIus the tissue surrounding the sinus tract shouId be removed en bloc. The need for this is we11 demonstrated in our present case in which sections taken from aIong the sinus tract showed a creeping towards the surface of the maIignant epithelium. (Fig. 7.) UnIess one is dealing with a badIy infected area, the one-stage iIeotran?verse coIostomy, foIIowing the remova of the invoIved portion of the boweI, is desirable. SUMMARY

The Iiterature on the subject of carcinoma of the cecum in association with I.

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acute appendicitis has been reviewed and a tota of eIeven cases found therein. One more case is added. 2. The common succession of events IS: (I) Signs and symptoms of acute appendicitis in an individua1 unsuspected of harboring a maIignancy; (2) appendicea1 rupture and abscess formation; (3) drainage of the abscess without recognition of the presence of ceca1 cancer; (4) faiiure of the resulting sinus to close, and (3) the feeling of a mass in reIation to the lower end of the cecum. 3. Diagnosis preoperativeIy is aImost impossibIe. Diagnosis at operation rests on suspecting the possibility of the presence of a growth, carefuIIy examining and evaIuating the avaiIabIe portion of cecum and finaIly taking tissue for microscopic examination when indicated. 4. Resection of the affected portion of bowe1, the tissue in the “contact” part of the abdominal wal1 and the tissue -surrounding the sinus tract shouId be done. A primary- ileotransverse coIostomy restores bowel continuity. KEFEKENCES J. ERDMAN, J. F. and CLARK, H. E. Tumors of the cecum, discussion and report of 48 cases. Amn. .%rg., 85: 722-31, 1927. 2. LAHEY, F. II. NeopIasms of cecum and ascending colon. Am. J. Surg., 46: 3-1 r, rg3g.

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CHAMBERLAIK, D. T. Cancer of the cecum. S. Clin. North America, 21: 837-49, 1941. 4. MAYO, C. u’. and LOVELACE, W. R., JR. Cancer of the cecum. Surg., Gynec. I?* Obst., 72: 698-706,

3.

194’. BERAN, A. D. Cancer of the cecum and appendiceai abscess. S. Chin., Chicago, 3: 331, Igrg. 6. MORTON, C. A. DifferentiaI diagnosis of maIignant disease of cecum from chronic and subacute appendicitis. Bristol M. C. J., 39: 82-90, Igzz. 7. ~~LJR, J. B. G. A’Iucocele of appendix caused by early carcinoma of cecum. Lancet, 1: 13I, r93 1. 8. MAYER, F. 0. Zentralb1.j. Cbir., 54: 261, rg3.z. g. PARKER, G. E. and ROSENTHAL, D. B. Cancer of the cecum as direct cause of acute appendicitis and simultaneous acute intestina1 obstruction. Lancet, 2: ro8g-logo, 1933. JO. BASKS, A. G. and GREEN, R. D. Cancer of the appendicitis. cecum associated with acute Brit. M. J., J: 926, 1933. ~1. SHEARS, G. F. Ciinique, 27: 7Ig, 1906. 12. COOK, J. Cancer of the cecum with acute appendicitis. Brit. ,M. J., 2: 1083, 1936. ~3. SEEGERS, W. Cancer of cecum resembling appendicitis. Zentralbl. f. Cbir., 65 : 744-48. 1938. 14. SPL~XSE,J. and BOTHE, F. A. Tumors of cecum simulating acute appendicitis. S. Clin. North America, 8: 917-21, 1938. r5. BARTLETT, hl. K. and MILLER, R. H. Cancer of the cecum-acute appendicitis as a complication. New England J. Med., 222: 783-784, 1940. ~6. YOUNG, E. L. and \~YMAN, s. Primary carcinoma of the appendix associated with acute appendicitis. Report of a case. New England J. Med., 227: 703-70 j. 1942. 17. UJIILErv, A. and ~ICDONALD, J. R. Primary carcinoma of the appendix resembling carcinoma of the colon. Surg., Gynec. c?’ Oba., 76: -rr-714,

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“943. 18. CHOMET, B. Carcinoma of appendix. Pa& I4: 447-451, 1944.

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