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Carcinoma of the Cecum
Gastrointestinal and Hepatohiliary Malignancies
0039-6109/86 $0.00 + .20
Carcinoma of the Cecum
C. W. Broders, M.D.*
A review of 62 patients with cancer of the cecum treated at Scott and White Memorial Hospital and Clinic over an 8-year period is presented. Symptoms and signs of cancer are discussed. In this review, 80 per cent of male patients and 60 per cent of female patients had erythrocyte counts below the minimal normal value, and 22 per cent of the male and 29 per cent of the female patients had below normal total serum proteins. Hemoglobin levels were below minimal normal values in 80 per cent and 70 per cent of the male and female patients, respectively. SCOTT AND WHITE DATA Cancer of the cecum has reported 5-year survival rates of 32.5 per cent,4 35 per cent,3 and as high as 57.7 per centS of those who have survived a "curative" resection. The incidence of cancer of the cecum is quite low compared with cancers of the remainder of the colon and rectum. Foti and Cohn reported an incidence of cecal cancer of 8.2 per cent among 1687 patients with cancer of the colon and rectum. 3 In the Scott and White Cancer Program's annual report of 1984, 15 per cent of all colorectal carcinomas were found to occur in the cecum.7 The sine qua non for improving the cure rate of cancer of the cecum (as well as any colorectal cancer) is early detection of the lesion followed by early surgical treatment. However, the early detection factor remains elusive. It is not that early diagnosis of a cecal cancer is not feasible; the necessary technology to diagnose these enigmatic tumors is readily available. Roentgenographic barium study of the colon has been the chief diagnostic tool for years. Colonoscopy, now well established in its second decade of usage, has proved most worthy in identifying colon lesions (and even in performing biopsies). In some situations, a computed tomography (CT) scan may be helpful in identifying an intra-abdominal lesion (a cecal *Consultant, Department of General Surgery, and Program Director, Surgical Residency Program, Scott and White Memorial Hospital and Clinic; and Professor of Surgery, Texas A&M University College of Medicine, Temple, Texas.
Surgical Clinics of North America-Vol. 66, No.4, August 1986
787
788
C. W.
BRODERS
Table 1. Normal Laboratory Values* PROTEINS (GM PER DL)
Total ERYTHROCYTES
Men Women Both
(106)
HEMOGLOBIN (GM PER DL)
HEMATOCRIT (ML PER DL)
4.7-6.1 4.2-5.4
14-18 12-16
42-52 37-47
(gm per dl)
Albumin (gm per dl)
Globulin (gm per dl)
6.0-8.5
3.0-5.5
1.5-3.0
*Data from Scott and White Memorial Hospital and Clinic, 1977-1984.
mass) in a patient who has a paucity of physical findings and a persistence of obscure abdominal complaints. Interestingly, the use of sonography following the barium enema was reported as helpful in identifYing a cecal mass in five patients in whom barium enema was reported inconclusive. 6 The presence of anemia or hypoproteinemia provokes suspicion, at least among surgeons, of a cecal cancer. The presence of a palpable, right-sided, abdominal mass arouses both the patient's and the physician's alarm. The best means for early detection of carcinoma of the cecum is' a determined physician who views with suspicion the patient's vague abdominal complaints and the presence of slight anemia. Checking the patient's stool for occult blood is a simple office procedure; a positive finding is an indication for follow-up studies of the gastrointestinal tract. When the barium enema study is reported as negative and the physician is unable to explain a patient's anemia or abdominal complaints, repeat studies are indicated. The cecum does not lend itself to demonstrating early symptoms and signs of a tumor. Being the largest part of the colon in diameter and the recipient of liquid stool, it accommodates cancer growth for a longer period of time than do the colon and rectum. The early symptoms may be vague, nondescript, right-sided, or epigastric pain. Sixty-one per cent of the patients in one cecal cancer study described weight loss, weakness, and fatigue. 3 A later symptom of cancer of the cecum is a palpable mass in the right lower quadrant. Rarely, cancer of the cecum can present as acute appendicitis because of obstruction of the lumen of the appendix by the encroaching cecal tumor. 2 Cecal cancers are usually exophytic, large, and bulky. Should the tumor growth become large enough to obstruct the ileocecal valve, the symptoms and signs of intestinal obstruction occur (abdominal cramping, distention, pain, nausea, and vomiting). In a review of Scott and White records of all patients treated for cancer of the cecum from the beginning of 1977 to the end of 1984, a total of 62 patients had a histologically confirmed diagnosis of cancer of the cecum. This study included 37 women and 25 men. The average age at the time of diagnosis was 72.2 years for women and 70.9 years for men. Because cancer of the cecum is frequently associated with anemia and hypoproteinemia, particular attention was given to the erythrocyte, hemoglobin, and hematocrit values, as well as to the total proteins and the albumin fraction (Table 1). The erythrocyte count averaged 4.21 million
r 789
CARCINO'vIA OF THE CECUM
Table 2. Laboratory Values: Range and Mean* PROTEINS (GM PER DL)
(106)
HEMOGLOBIN (GM PER DL)
HEMATOCRIT (ML PER DL)
Total (gm per dl)
Number of women Range Mean
32 of 37
37 of 37
37 of 37
34 of 37
34 of 37
34 of 37
3.0-5.47 4.04
6.2-16.3 10.6
23-47 32.03
4.6-7.5 6.22
2.6-4.7 3.65
2.0-3.9 2.57
Number of men Range Mean
24 of 25
25 of 25
25 of 25
22 of 25
22 of 25
22 of 25
3.29-5.66 4.27
6.4-15.5 11.0
20.3-46.0 33.18
4.9-7.5 6.3
2.5-4.5 3.62
2.0-3.2 2.69
ERYTHROCYTES
Albumin (gm per dl)
Globulin (gm per dl)
*Data from Scott and White Memorial Hospital and Clinic, 1977-1984.
red blood cells in 56 of the 62 patients; five women and one man did not have an erythrocyte count performed (Table 2). The 32 female patients had an average red blood count (RBC) value of 4.0, with a range from 3.0 to 5.47. The 24 male patients had slightly higher RBCs than the women, with an average of 4.27 and a range from 3.29 to 5.66. Considering those patients whose erythrocyte count was below the minimum of normal (women 4.2 and men 4.7), the average RBC was 3.88 for both sexes for whom an erythrocyte count was performed. There were 32 women of 37 total and 24 of the 25 men who had erythrocyte counts performed. Twenty women had an RBC lower than 4.2 million, ranging from 3.0 to 4.21 with an average of 3.72. Thus, 60 per cent of the women had RBC below normal. Of the 24 male patients who had RBC determinations, 20 had RBCs below 4.7, with an average of 4.04. Eighty-three per cent of the men tested had low erythrocyte counts. All 37 women had hemoglobin and hematocrit tests, which averaged 10.6 gm per dl and 32.0 ml per dl, respectively. Twenty-six of the thirtyseven women (70 per cent) had lower than minimum normal hemoglobin values, ranging from 6.2 to 11.0 gm per dl, with an average of 9.1 gm per dl. Twenty-eight women (75.6 per cent of those tested) had hematocrit values below normal, averaging 28.5 ml per dl with a range from 19.8 to 36.5 ml per dl (Table 2). For the men, the hemoglobin and hematocrit determinations averaged 11.0 gm per dl and 33.1 ml per dl, ranging in value from 6.4 to 15.5 gm per dl and 23 to 47 ml per dl, respectively. Eight per cent of the male patients had below average hemoglobin values with an average of 10.7 gm per dl. The male hematocrit average was 33.1 ml per dl, with a range of 20.3 to 46 ml per dl. However, 21 of the men (84 per cent) had below normal values, with an average of 31.2 ml per dl. Total protein determinations for 56 of the 62 patients averaged 6.26 gm per dl. The protein range for female patients was 4.6 to 7.7 gm per dl, with an average of 6.22 gm per dl for the 34 female patients whose total proteins had been determined. Ten women (29 per cent) had lower than the normal level of proteins. In 22 of the 25 male patients, total proteins
Ii c.
790
W.
BRODERS
Table 3. Operative Procedures* TYPE OF SURGERY
MEN
WOMEN
TOTAL
Curative right hemicolectomy alone Palliative right hemicolectomy alone Curative right hemicolectomy and cholecystectomy Palliative right hemicolectomy and cholecystectomy Right hemicoled:omy and sigmoidectomy (for diverticulitis of sigmoid) Right hemicolectomy and sigmoidectomy (concomitant carcinoma of sigmoid) Total colectomy and ileoproctectomy Bypass procedure Exploration and biopsy only Total
15 2
o
21 3 5 3 3
36 5 6 5 3
1
0
1
2 1 1
2 0 0 37
40
1 2
25
1 1 62
*Data from Scott and White Memorial Hospital and Clinic, 1977-1984.
ranged from 4.9 to 5.9 gm per di, with an average of6.31 gm per dl. There were five men (22 per cent) with less than 6 gm per dl total protein for an average of 5.5 gm per dl. The albumin average in 56 patients was 3.63 gm per dl (3.65 in women and 3.62 in men). There were two 79-year-old women, both of whom had elevated (and the same) erythrocyte, hemoglobin, and hematocrit counts (5.47, 16.3 gm per dl, and 47 ml per dl, respectively), which were attributed to hemoconcentration due to associated small bowel obstruction by a large cecal adenocarcinoma in both cases. Both of these female patients had low total proteins of 4.6 gm per dl each. All patients with cecal lesions in this study group had adenocarcinoma of the cecum; two of this total had villous adenocarcinomas (Table 3). A total of 56 patients had right hemicolectomies, of which 11 were considered by the surgeon to be palliative. Eleven of the total number of patients who had a right hemicolectomy also had a cholecystectomy because of cholelithiasis (Table 3). A sigmoid resection for diverticulitis was performed concomitantly with a right hemicolectomy in three female patients and for a synchronous adenocarcinoma of the sigmoid in one male patient.
CONCLUSION Carcinoma of the cecum constitutes a small percentage of all colon and rectal cancers. Because of its large diameter and the flow of liquid small bowel contents into it, the cecum easily accommodates the presence of a tumor, which is thereby easily obscured. Cancer of the cecum presents vague, abdominal complaints early in its course. With time, the patient may experience progressive weakness. A palpable abdominal mass may become more discernible and the patient may be found to be anemic. Total proteins may be lower than normal or at least in the low range of normal. Diagnosis, particularly in the earlier stages, depends on awareness of the examining physician that a carcinoma of the cecUm may be present. The physician's determination to identify the cause of the patient's vague abdominal discomfort and weakness is the key to discovering cecal
791
CARCiNOMA OF THE CECUM
carcinoma. A radical right hemicolectomy is the operative procedure of choice for cancer of the cecum. A palliative right hemicolectomy, if feasible, should be performed, even in the presence of liver metastasis. A hemicolectomy improves the quality of life for the patient by eliminating a nidus for bowel obstruction and for blood and protein loss. Also, there is the possibility that chemotherapists will be better able to treat the metastasis after the primary tumor has been removed.
REFERENCES 1. Abrams, J. S.: A hard look at colonoscopy. Am. J. Surg., 133:111-115, 1977. 2. Fabri, P. J., and Carey, L. D.: Cecal carCinoma presenting as acute appendicitis: A reappraisal. J. Clin. Gastroenterol., 2: 173-174, 1980. 3. Foti, C. E., and Cohn, 1., Jr.: Cancer of the cecum: Review of 139 cases. Am. Surg., 36:129-135, 1970. 4. Gennaro, A. R.: Carcinoma of the cecum. Surg. Gynecol. Obstet., 144:504-506, 1977. 5. Griffin, G. D. J., Judd, E. S., and Gage, R. P.: Carcinoma of the right side of the colon: Operability, resectability, and survival rates. Ann. Surg., 143:330-336, 1956. 6. Owens, A. P., Banerjee, B., and Morewood, D. J. W.: Sonography as an aid to diagnosis of caecal carcinoma in the elderly. Clin. Radiol., 34:669-672, 1983. 7. Scott and White Cancer Program: Annual Report. Temple, Texas, Scott and White Memorial Hospital and Clinic, 1984, p 25. 8. Waldmann, T. A., Wochner, R. D., and Strober W.: The role of the gastrointestinal tract in plasma protein metabolism. Am. J. Med., 46:275-285, 1969. Division of General Surgery Scott and White Memorial Hospital and Clinic 2401 South 31st Street Temple, Texas 76508
0039-6109/86 $0.00 + .20
Carcinoma of the Cecum
C. W. Broders, M.D.*
A review of 62 patients with cancer of the cecum treated at Scott and White Memorial Hospital and Clinic over an 8-year period is presented. Symptoms and signs of cancer are discussed. In this review, 80 per cent of male patients and 60 per cent of female patients had erythrocyte counts below the minimal normal value, and 22 per cent of the male and 29 per cent of the female patients had below normal total serum proteins. Hemoglobin levels were below minimal normal values in 80 per cent and 70 per cent of the male and female patients, respectively. SCOTT AND WHITE DATA Cancer of the cecum has reported 5-year survival rates of 32.5 per cent,4 35 per cent,3 and as high as 57.7 per centS of those who have survived a "curative" resection. The incidence of cancer of the cecum is quite low compared with cancers of the remainder of the colon and rectum. Foti and Cohn reported an incidence of cecal cancer of 8.2 per cent among 1687 patients with cancer of the colon and rectum. 3 In the Scott and White Cancer Program's annual report of 1984, 15 per cent of all colorectal carcinomas were found to occur in the cecum.7 The sine qua non for improving the cure rate of cancer of the cecum (as well as any colorectal cancer) is early detection of the lesion followed by early surgical treatment. However, the early detection factor remains elusive. It is not that early diagnosis of a cecal cancer is not feasible; the necessary technology to diagnose these enigmatic tumors is readily available. Roentgenographic barium study of the colon has been the chief diagnostic tool for years. Colonoscopy, now well established in its second decade of usage, has proved most worthy in identifying colon lesions (and even in performing biopsies). In some situations, a computed tomography (CT) scan may be helpful in identifying an intra-abdominal lesion (a cecal *Consultant, Department of General Surgery, and Program Director, Surgical Residency Program, Scott and White Memorial Hospital and Clinic; and Professor of Surgery, Texas A&M University College of Medicine, Temple, Texas.
Surgical Clinics of North America-Vol. 66, No.4, August 1986
787
788
C. W.
BRODERS
Table 1. Normal Laboratory Values* PROTEINS (GM PER DL)
Total ERYTHROCYTES
Men Women Both
(106)
HEMOGLOBIN (GM PER DL)
HEMATOCRIT (ML PER DL)
4.7-6.1 4.2-5.4
14-18 12-16
42-52 37-47
(gm per dl)
Albumin (gm per dl)
Globulin (gm per dl)
6.0-8.5
3.0-5.5
1.5-3.0
*Data from Scott and White Memorial Hospital and Clinic, 1977-1984.
mass) in a patient who has a paucity of physical findings and a persistence of obscure abdominal complaints. Interestingly, the use of sonography following the barium enema was reported as helpful in identifYing a cecal mass in five patients in whom barium enema was reported inconclusive. 6 The presence of anemia or hypoproteinemia provokes suspicion, at least among surgeons, of a cecal cancer. The presence of a palpable, right-sided, abdominal mass arouses both the patient's and the physician's alarm. The best means for early detection of carcinoma of the cecum is' a determined physician who views with suspicion the patient's vague abdominal complaints and the presence of slight anemia. Checking the patient's stool for occult blood is a simple office procedure; a positive finding is an indication for follow-up studies of the gastrointestinal tract. When the barium enema study is reported as negative and the physician is unable to explain a patient's anemia or abdominal complaints, repeat studies are indicated. The cecum does not lend itself to demonstrating early symptoms and signs of a tumor. Being the largest part of the colon in diameter and the recipient of liquid stool, it accommodates cancer growth for a longer period of time than do the colon and rectum. The early symptoms may be vague, nondescript, right-sided, or epigastric pain. Sixty-one per cent of the patients in one cecal cancer study described weight loss, weakness, and fatigue. 3 A later symptom of cancer of the cecum is a palpable mass in the right lower quadrant. Rarely, cancer of the cecum can present as acute appendicitis because of obstruction of the lumen of the appendix by the encroaching cecal tumor. 2 Cecal cancers are usually exophytic, large, and bulky. Should the tumor growth become large enough to obstruct the ileocecal valve, the symptoms and signs of intestinal obstruction occur (abdominal cramping, distention, pain, nausea, and vomiting). In a review of Scott and White records of all patients treated for cancer of the cecum from the beginning of 1977 to the end of 1984, a total of 62 patients had a histologically confirmed diagnosis of cancer of the cecum. This study included 37 women and 25 men. The average age at the time of diagnosis was 72.2 years for women and 70.9 years for men. Because cancer of the cecum is frequently associated with anemia and hypoproteinemia, particular attention was given to the erythrocyte, hemoglobin, and hematocrit values, as well as to the total proteins and the albumin fraction (Table 1). The erythrocyte count averaged 4.21 million
r 789
CARCINO'vIA OF THE CECUM
Table 2. Laboratory Values: Range and Mean* PROTEINS (GM PER DL)
(106)
HEMOGLOBIN (GM PER DL)
HEMATOCRIT (ML PER DL)
Total (gm per dl)
Number of women Range Mean
32 of 37
37 of 37
37 of 37
34 of 37
34 of 37
34 of 37
3.0-5.47 4.04
6.2-16.3 10.6
23-47 32.03
4.6-7.5 6.22
2.6-4.7 3.65
2.0-3.9 2.57
Number of men Range Mean
24 of 25
25 of 25
25 of 25
22 of 25
22 of 25
22 of 25
3.29-5.66 4.27
6.4-15.5 11.0
20.3-46.0 33.18
4.9-7.5 6.3
2.5-4.5 3.62
2.0-3.2 2.69
ERYTHROCYTES
Albumin (gm per dl)
Globulin (gm per dl)
*Data from Scott and White Memorial Hospital and Clinic, 1977-1984.
red blood cells in 56 of the 62 patients; five women and one man did not have an erythrocyte count performed (Table 2). The 32 female patients had an average red blood count (RBC) value of 4.0, with a range from 3.0 to 5.47. The 24 male patients had slightly higher RBCs than the women, with an average of 4.27 and a range from 3.29 to 5.66. Considering those patients whose erythrocyte count was below the minimum of normal (women 4.2 and men 4.7), the average RBC was 3.88 for both sexes for whom an erythrocyte count was performed. There were 32 women of 37 total and 24 of the 25 men who had erythrocyte counts performed. Twenty women had an RBC lower than 4.2 million, ranging from 3.0 to 4.21 with an average of 3.72. Thus, 60 per cent of the women had RBC below normal. Of the 24 male patients who had RBC determinations, 20 had RBCs below 4.7, with an average of 4.04. Eighty-three per cent of the men tested had low erythrocyte counts. All 37 women had hemoglobin and hematocrit tests, which averaged 10.6 gm per dl and 32.0 ml per dl, respectively. Twenty-six of the thirtyseven women (70 per cent) had lower than minimum normal hemoglobin values, ranging from 6.2 to 11.0 gm per dl, with an average of 9.1 gm per dl. Twenty-eight women (75.6 per cent of those tested) had hematocrit values below normal, averaging 28.5 ml per dl with a range from 19.8 to 36.5 ml per dl (Table 2). For the men, the hemoglobin and hematocrit determinations averaged 11.0 gm per dl and 33.1 ml per dl, ranging in value from 6.4 to 15.5 gm per dl and 23 to 47 ml per dl, respectively. Eight per cent of the male patients had below average hemoglobin values with an average of 10.7 gm per dl. The male hematocrit average was 33.1 ml per dl, with a range of 20.3 to 46 ml per dl. However, 21 of the men (84 per cent) had below normal values, with an average of 31.2 ml per dl. Total protein determinations for 56 of the 62 patients averaged 6.26 gm per dl. The protein range for female patients was 4.6 to 7.7 gm per dl, with an average of 6.22 gm per dl for the 34 female patients whose total proteins had been determined. Ten women (29 per cent) had lower than the normal level of proteins. In 22 of the 25 male patients, total proteins
Ii c.
790
W.
BRODERS
Table 3. Operative Procedures* TYPE OF SURGERY
MEN
WOMEN
TOTAL
Curative right hemicolectomy alone Palliative right hemicolectomy alone Curative right hemicolectomy and cholecystectomy Palliative right hemicolectomy and cholecystectomy Right hemicoled:omy and sigmoidectomy (for diverticulitis of sigmoid) Right hemicolectomy and sigmoidectomy (concomitant carcinoma of sigmoid) Total colectomy and ileoproctectomy Bypass procedure Exploration and biopsy only Total
15 2
o
21 3 5 3 3
36 5 6 5 3
1
0
1
2 1 1
2 0 0 37
40
1 2
25
1 1 62
*Data from Scott and White Memorial Hospital and Clinic, 1977-1984.
ranged from 4.9 to 5.9 gm per di, with an average of6.31 gm per dl. There were five men (22 per cent) with less than 6 gm per dl total protein for an average of 5.5 gm per dl. The albumin average in 56 patients was 3.63 gm per dl (3.65 in women and 3.62 in men). There were two 79-year-old women, both of whom had elevated (and the same) erythrocyte, hemoglobin, and hematocrit counts (5.47, 16.3 gm per dl, and 47 ml per dl, respectively), which were attributed to hemoconcentration due to associated small bowel obstruction by a large cecal adenocarcinoma in both cases. Both of these female patients had low total proteins of 4.6 gm per dl each. All patients with cecal lesions in this study group had adenocarcinoma of the cecum; two of this total had villous adenocarcinomas (Table 3). A total of 56 patients had right hemicolectomies, of which 11 were considered by the surgeon to be palliative. Eleven of the total number of patients who had a right hemicolectomy also had a cholecystectomy because of cholelithiasis (Table 3). A sigmoid resection for diverticulitis was performed concomitantly with a right hemicolectomy in three female patients and for a synchronous adenocarcinoma of the sigmoid in one male patient.
CONCLUSION Carcinoma of the cecum constitutes a small percentage of all colon and rectal cancers. Because of its large diameter and the flow of liquid small bowel contents into it, the cecum easily accommodates the presence of a tumor, which is thereby easily obscured. Cancer of the cecum presents vague, abdominal complaints early in its course. With time, the patient may experience progressive weakness. A palpable abdominal mass may become more discernible and the patient may be found to be anemic. Total proteins may be lower than normal or at least in the low range of normal. Diagnosis, particularly in the earlier stages, depends on awareness of the examining physician that a carcinoma of the cecUm may be present. The physician's determination to identify the cause of the patient's vague abdominal discomfort and weakness is the key to discovering cecal
791
CARCiNOMA OF THE CECUM
carcinoma. A radical right hemicolectomy is the operative procedure of choice for cancer of the cecum. A palliative right hemicolectomy, if feasible, should be performed, even in the presence of liver metastasis. A hemicolectomy improves the quality of life for the patient by eliminating a nidus for bowel obstruction and for blood and protein loss. Also, there is the possibility that chemotherapists will be better able to treat the metastasis after the primary tumor has been removed.
REFERENCES 1. Abrams, J. S.: A hard look at colonoscopy. Am. J. Surg., 133:111-115, 1977. 2. Fabri, P. J., and Carey, L. D.: Cecal carCinoma presenting as acute appendicitis: A reappraisal. J. Clin. Gastroenterol., 2: 173-174, 1980. 3. Foti, C. E., and Cohn, 1., Jr.: Cancer of the cecum: Review of 139 cases. Am. Surg., 36:129-135, 1970. 4. Gennaro, A. R.: Carcinoma of the cecum. Surg. Gynecol. Obstet., 144:504-506, 1977. 5. Griffin, G. D. J., Judd, E. S., and Gage, R. P.: Carcinoma of the right side of the colon: Operability, resectability, and survival rates. Ann. Surg., 143:330-336, 1956. 6. Owens, A. P., Banerjee, B., and Morewood, D. J. W.: Sonography as an aid to diagnosis of caecal carcinoma in the elderly. Clin. Radiol., 34:669-672, 1983. 7. Scott and White Cancer Program: Annual Report. Temple, Texas, Scott and White Memorial Hospital and Clinic, 1984, p 25. 8. Waldmann, T. A., Wochner, R. D., and Strober W.: The role of the gastrointestinal tract in plasma protein metabolism. Am. J. Med., 46:275-285, 1969. Division of General Surgery Scott and White Memorial Hospital and Clinic 2401 South 31st Street Temple, Texas 76508