Carcinoma of the rectum

CARCINOMA CONSERVATIVE

OF THE RECTUM

SURGERY IN CERTAIN

COMMANDER

DONALD

R. KELLER

MEDICAL CORPS, UNITED STATES NAVAL

T

HE treatment of malignant and of potentiaIly maIignant diseases today is based on principles that have reached a high degree of standardization. At the present time more attention is given to the potentiaIIy maIignant disease in an effort to eradicate this condition before deep-seated infiItration and secondary metastasis have occurred. This is most appIicabIe to earIy Iesions of the rectum and Iower coIon. PoIypoid disease of the rectum and colon faI1 under two definite but not cIearIy differentiated types, mainIy muItipIe and soIitary. The Iatter type is more commonIy found Iocated in the rectum and Iower sigmoid. StaemmIer, from a series of eighty cases, reported 58 per cent in the rectum and 13.2 per cent in the sigmoid. MaIignant change in the base of poIypoid growths of chiIdren is not infrequent. Bacon found eight cases of patients under the age of twenty years out of a series of 1,995. One patient, four years and seven months of age, showed earIy maIignant change in a poIyp removed from the rectum. Phifer, in a series of forty-nine cases, found twenty-two patients with malignancy under fifteen years of age; twentyseven patients were between the ages of fifteen and twenty years. Schmeiden and Westhue’s cIassification of polyps described three histoIogica1 forms: The first benign type is usuaIIy a solitary Iesion made up of an abundant tissue stroma, covered by a normal mucous membrane Iayer of epitheIium identica1 with sigmoid or recta1 Iining. A second group is composed of a simiIar stroma covered with a more atypical ceIIuIar undifferentiated showing some mucosa

INSTANCES

RESERVE

areas. The third precancerous type exhibits an irregularly arranged epitheIia1 covering and shows a definite lack of differentiation of the epitheIia1 ceIIs. The portion of the tumor undergoing maIignant change is the base and may be suspected cIinicaIIy by its raised and indurated appearance. To this classification a fourth group can be added, nameIy, that type of solitary poIyp which shows definite maIignant changes at the base and not showing any evidence in the stalk. EarIy diagnosis of this Iatter type before invasion of the submucosa1 layer is extremeIy important. As aIready stated above the greatest percentage of polyps is located in the rectum and the sigmoid, and they are associated with precancerous and actua1 cancerous changes. The author believes that more emphasis shouId be put on the routine examination of patients especiaIIy in reference to the study of the rectum and colon. This can be carried out readiIy by routine proctoscopy and sigmoidoscopy at six-month intervals. Barium enema with ffuoroscopy and x-ray may be added for study of the higher coIon if desired. In carrying out this procedure once a poIyp is found in the earIy It can be treated constage of change. servativeIy and with IittIe Ioss of time and expense to the patient. The surgeon, having found the soIitary polyp in the rectum or sigmoid, should immediateIy ascertain the degree of the disorder. This is best obtained by taking two or three biopsy sections from separate areas of the tumor base. StrictIy benign Iesions and those cIassified by Schmeiden and Westhue as showing precancerous changes can be treated according to their Iocation: Lesions of the sigmoid and recta1 sigmoid are best treated by the abdomina1 336

NEW Senr~s VOL.LXIV, No. 3

KeIIer-Rectal

Carcinoma

route; lesions of the upper rectum and especiaIIy those of the anterior waI1 are satisfactorily treated by the Bevan opera-

FIG.

tion; for those Iesions invoIving the Iower five inches of the rectum, but onIy those Iocated on the posterior and posteroIatera1 waIIs, the technic described by the author is best suited. However, for those cases showing malignant changes which extend from the base through the submucous Iayer of the rectum, the radica1 combined abdominaI-perinea1 resection, either as a one- or two-stage procedure is recom-

American

Journal

of Surgery

347

mended. In certain of these cases, the surgeon may encounter a patient who does not present a satisfactory risk for the

I.

radicaI abdominaI-perinea1 procedure. The author wishes to report a case of a seventyyear oId maIe, who cIinicaIIy did not present a good risk and was treated with the operative technic described beIow : CASE

REPORT

The patient, Mr. L. D. S., first came to the cIinic June, 1939, for a usua1 yearIy check-up. Examination reveaIed a smaI1 thrombosed

348

American

Journal

of Surgery

KeIIer-Recta1

Carcinoma

externa1 hemorrhoid. DigitaI examination discIosed a Iarge movabIe mass 8 cm. up on the posterior waI1 of the rectum. Proctoscopic

FIG.

examination showed a norma recta1 sigmoid junction and an entireIy norma rectum, except for the presence of a polypoid mass in the posterior waI1. It .measured exactIy 3.5 cm. in Iength. The base of the tumor was eIevated and indurated and appeared somewhat congested. Two biopsy specimens taken from separate parts of the indurated base reveaIed the foIlowing pathoIogica1 changes : Microscopic section showed a moderate number of poIyp-like pieces of tissue, covered by atypica1 tubuIar gIands. Many of the glands

showed secondary budding lined by papilIated epitheIium. The lining epithelia1 ceIIs were Iarge, coIumnar in type and had moderateIy

2.

Iarge

hyperchromatic

nucIei.

The

connective

tissue core of the Iargest polyp showed sIight infihration of atypica1 epitheIia1 glands. There was aIso fibrobIastic proIiferation and Iymphoinfiltration. Another section showed cytic gigantic atypical tubuIar gIands lined by papiIIated corumnar ceI1 epitheIium. A moderate number of mitotic figures were seen throughout. Diagnosis: Recta1 tissue: Adenocarcinoma

(adenoma

Iar and productive

destruens) infiftration.

; chronic,

cellu-

NEW SERIES VOL. LXIV, No. 3

KeIIer-Rectal

Carcinoma

Physicat examination reveaIed the head and respiratory systems to be normaI. Pulse : The puke was reguIar with good

American Journa.1 of Surgery

349

hemogIohin,

60 per cent; erythrocyte count, Ieucocyte count, 8,000; there were 64 per cent poIymorphonucIears, 18 per cent

3,100,000;

FIG. 3.

volume. The bIood pressure was 140/60. There was sIight enIargement of the heart on percussion and flouroscopy. There were no organic murmurs. The abdomen was retracted. There were no visible or palpable masses or paIpabIe inguina1 nodes. The external genitaIia were normaI. The prostate gIand felt irreguIar in shape, considerably enIarged, and had moderateIy firm consistency. Urinalysis was essentiaIIy negative. The blood picture revealed the foIIowing:

smaI1 lymphocytes, and 8 per cent large lymphocytes; eosinophils were negative. Morphine suIfate, 35 gr. hypodermicaIIy, was given one hour before the operation. The patient was pIaced in the Iithotomy position and 50 mg. of metycaine were given intraspinaIIy. Twenty minutes after the administration of the spinal anesthesia, the anal sphincters were gradually dilated by digita means. MaIIeabIe retractors were then inserted at the upper and Iateral angIes of the diIated ana orifice. A

350

American Journal of Surgery

KeIIer-Recta1

heavier similar retractor was then inserted along the posterior and anal-rectal waI1 up to the base of the mass which bulged forn-arcl into

Frc.

Carcinoma

JUNE. 1914

Eight days folIowing operation, a large one an d one-eighth inch bore proctoscope was inserted and the raw puckered margins of rectal

4.

FIG. 5. FIGS. 4 AND 5, hficroscopic

a clearer view. (Figs. I, 2 and 3.) FolIowing this, a long eight-inch cIamp was Ioosely inserted into the base and with mild traction a transverse eIIiptica1 incision was carried out above and beIow the base of the polyp, so as to meet on each IateraI side. These incisions were carried down to the IongitudinaI muscuIar coat. The poIyp and base were removed intact. Considerable bIeeding was encountered and immediateIy controIIed by applying a narrow gaIIbIadder clamp to the upper and lower severed recta1 margins on each side. The space did not permit suturing, so a slip knot tie of siIk was inserted over the handles of each cIamp on one side and when properly pIaced beneath the clamp ends, was firmIy drawn together and the cIamps sIowIy removed. Similar ligation was carried out on the opposite side. This afforded exceIIent hemostasis. FoIIowing this, a dry gauze pack was carefuIIy inserted we11 above the operation site and one end aIIowed to protrude from the anus. The patient was kept in bed for four days, during which the routine, postoperative hemorrhoida diet was carried out.

sections.

mucosa were carefully cauterized down to a IeveI of the adjacent mucosa. Very IittIe bIeeding was encoimtered. The patient was proctoscoped six weeks later and a very satisfactory Iinear scar was present with no evidence of stricture. Following this, it has been routine to proctoscope the patient at four-month intervals, and up to the present date, which is a tota 6f fifty months, there is no evidence of recurrence at the site of operation, or impairment of genera1 heaIth. Sixteen months Iater, the patient entered the New York Hospital on the Brady UroIogicaI Service, where a transurethra1 resection and biIatera1 partia1 vasectomy was carried out. The patient was discharged at the end of two weeks much improved. The pathoIogica1 diagnosis was as foIIows: Benign hypertrophy of the prostate; chronic prostatitis. CONCLUSIONS

PoIypoid tumqrs of the rectum and coIon are a11to be regarded as precancerous

NEW%n~rz:sVOL LXIV, No. 3

Keller

Rectal

or cancerous in nature. Many cases of solitary polyp have undergone maIignant change before the main objective sign of bleeding has appeared. Many radica1 surgical procedures and fataIities may be avoided by the early diagnosis and eradication of the potentiaIIy maIignant polyp. This can best be accompIished by the including of proctoscopy and sigmoidoscopy as a part of routine physica examinations every six months. Because of the malignant change first appearing in the base of the polyp, the operative procedure of choice for those cases Iocated on the posterior wall of the Iower rectum is described above. The present tendency toward the electrosurgical treatment of these Iesions as an offke procedure is far from being adequate. SurgicaI excisions under spina anesthesia as a hospital procedure is strongly advised. It is we11 to remember that malignant changes aIso occur in poIypoid growths found in the rectum of chiIdren. A case showing early maIignant change

Carcinoma in the mucosal base of a recta1 poIyp is reported with a fifty-month apparent cure to date foIlowing surgica1 removaL REFERENCES 1. SWINTON, N. W. and WARREN, S. PoIyps of coIon and rectum and their relation to malignancy. J. A. M. A., 113: 1927-1933, 1939. 2. SAWYER, H. F. Polyps of the rectum. Am. J. Surg., 3: 657-660, 1940. 3. GREEN, W. W. PoIyps of the lower sigmoid and rectum. Obio State M. J., 37: 38-40, 1941. 4. PHILLIPS, R. B. PoIyps of colon and rectum; association with cancer. ML Surgeon, 88: 258-264, 1941. 5. KLEINER, S. B. ProphyIactic remova of rectal poIyps. Connecticut M. J., 4: 269, 1940. 6. PAGE, R. C. Carcinoma and adenoma of rectum. New York State J. Med., 38: 917-920, 1938. 7. BACON, H. E. and SEALY, W. B. Malignancy of the anus, rectum and sigmoid coIon in the young. Am. J. Sw., 45: 339-347, 1939. 8. MARTIN, W. J., JR. Polypoid versus carcinomatous lesions of colon and rectum. South. M. J., 33: 428-432, 1940. 9. BARNETT, T. N. PoIyps of colon and rectum. Soutb. M. J., 33: 242-245, 1940. IO. CATTELL, R. B. and SWINTON, N. W. Significance and treatment of colonic and rectal polyps. .%rg. Clin. Nortb America, 17: 857-863, 1937. I I. BEVAN, A. D. Carcinoma of the rectum: treatment by IocaI excision. Surg. C/in. Nortb America, I: 1233, 1917.