Journal of Surgical Oncology 45177-179 (1990)
Obstructing Carcinoma of the Cecum PETER F. ROVITO, MD, GARY VERAZIN, MD, AND JOSEPH I. PROROK, MD, FACS From the Department of Surgery, lehigh Valley Hospital Center, Allentown, Pennsylvania
Carcinoma of the cecum, the third most common location for malignancy of the large bowel, was examined with attention centered upon cecal cancers producing obstruction. Reviewing 136 patients revealed 11 obstructing lesions (8.1%) presenting as distal small bowel obstructions. The mean age of the patients was 74 years. All but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy. There was no operative mortality or significant morbidity. Bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment. KEYWORDS:obstruction, resection, lesions
INTRODUCTION The cecum is the third most common location for carcinoma of the large bowel [ 11. Malignancy in this area is frequently associated with delayed diagnosis because of the unimpressive nature of its symptoms. Obstructive symptoms from carcinoma of the cecum are an even rarer phenomenon. It is felt that this is due to the large diameter and easy distensibility of the cecum, plus the liquid nature of its contents. We have reviewed the cases of carcinoma of the cecum at the Lehigh Valley Hospital Center with attention centered on obstructing lesions. Management, outcome, and a review of the literature are also analyzed.
patients had no further workup and were taken directly to surgery. Only patients with histologically proved carcinoma of the cecum were included in the study. Also, patients were excluded if the gross description, based on the operative or pathology reports, indicated that most of the tumor was situated above the orifice of the ileocecal valve. Tumors were classified according to the Astler Coller modification of the Dukes system (Table I).
RESULTS Over this 10 year period, there were a total of 136 patients with carcinoma of the cecum. Eleven (8.1%) of these patients had obstructing lesions which fit the criteria previously outlined. The diagnosis of obstructing carcinoma of the cecum was verified at surgery. There were six females and five males. The ages ranged from 69 to 93 years, with a mean age of 74 years. All patients were explored and all but one had resection for cure. A right hemicolectomy and ileotransverse colostomy was performed on all resection-for-cure patients. The remaining patient had a palliative bowel bypass performed at the time of surgery. No operative mortality occurred and all patients were subsequently
MATERIALS AND METHODS The entire experience of carcinoma of the cecum at the Lehigh Valley Hospital Center was reviewed from October 1977 to December 1986. Those cases of malignant obstructing lesions were identified and examined. Obstruction was defined as a patient presenting with clinical signs of small bowel obstruction, i.e., nausea with or without vomiting, abdominal pain and distention, and high-pitched hyperactive bowel sounds with tenderness on physical examination. Also needed was radiologic confirmation on obstructive series consistent with small bowel obstruction, i.e., distended small bowel with Accepted for publication June 1, 1990. air fluid levels and minimal air in the colon (Fig. 1). Address reprint requests to Dr. Peter F. Rovito, 1600 Lehigh Parkway Prior to exploration, six patients underwent barium East, Allentown, PA 18103. enemas, two patients had small bowel series, and one Dr. Gary Verazin is presently at the Department of Surgical Oncology patient had a barium enema and colonoscopy. Two & Endoscopy, Roswell Park Cancer Institute, Buffalo, NY 14263. 0 1990 Wiley-Liss, Inc.
178
Rovito et al.
Fig. 1. Obstructive series consisting of supine (A) and left lateral (B) decubitus films. This is consistent with distal small bowel obstruction with air fluid levels and minimal air in the colon.
discharged from the hospital. All patients had adenocarcinoma of colonic origin. Three of the patients had synchronous pathology including a tubular adenoma of the cecum, a tubulovillous adenoma of the ascending colon, and an adenomatous polyp of the ascending colon. There was one B-1 lesion, five B-2 lesions, two C-2 lesions, and three D lesions. At this writing, there are survivors (one B-1, four B-2, and one C-2; 5 5 % ) , five of which have no evidence of tumor. Three are long-term survivors (beyond five years). One is alive with documented liver metastasis. The mean survival is 35 months with a range of 3 to 108 months. Five patients died of their disease due to distant metastases (45%). Three of these patients had distant metastases at surgery, one had a B-2 lesion, and the other had a C-2 cecal tumor (Table 11).
DISCUSSION Fifteen percent of the patients with colorectal carcinoma presented with obstruction [2]. When carcinoma proceeds to obstruction, it is a well-accepted fact that the results of treatment are poorer when compared to nonobstructed malignant disease [ 1-31, The reasons for this are felt to be numerous. The tumor burden is greater as obstructing cancers are usually larger, although this is not universally accepted [4]. This is especially true of the cecum and right colon where the tumors tend to grow as large polypoid, fungating masses. In comparison, left-
sided cancers grow in an annular fashion, producing a “napkin-ring”constriction [3,5-71. With obstruction, the proximal bowel is in a more pathological state, being distended, atonic, and with greater bacterial and toxin load. Also, with obstruction, there is increased pressure in the lumen which is transmitted to the bowel wall. This causes increased pressure in the venous and lymphatic vascular channels, which is felt by many to make the patient prone to microembolization of tumor and, hence, more advanced disease [7]. These factors are coupled with the patient population, which consists of elderly patients who are all in varying degrees of anemia, malnutrition, and chronic disease. Review of the literature reveals a paucity of information on carcinoma of the cecum and even less on cecal carcinoma presenting as obstruction. Gennaro [8], in 1977, reviewed carcinoma of the cecum over a 10 year period. In his series of 66 patients, there was one obstruction, an incidence of only 1.5%. Foti and Cohn [9] examined a 16 year period which included 139 cases of cecal cancer. They found six obstructions, a 4.3% incidence. In Broders’ [lo] report in 1986 on 62 patients over an eight year period, there was no mention of obstructing carcinoma of the cecum. This study revealed an incidence of obstruction of 8.1%, almost double the highest incidence previously reported. Although a small series, the five year survival at this writing of 27% compares to the 29% reported by
Obstructing Carcinoma of the Cecum TABLE I. Astler Coller Modification of the Dukes Classification of Colon Carcinoma Dukes’ A-Carcinoma confined to the mucosa Dukes’ BI -Tumor extending to but not through the muscularis propria Dukes’ B2-Tumor extending through the muscularis propria Dukes’ C 1-B 1 with lymph node involvment Dukes’ C2-B2 with lymph node involvement Dukes’ D-Distant metastasis
TABLE 11. Demographics and Survival of Patients With Obstructing Carcinoma of the Cecum Name
Age
Sex
Stage
Su rviva 1
1. G.L.
72
F
D
2. M.L.
77
M
B2
3. E.M.
92
F
B2
4. R.S.
81
F
B2
5. O.W.
72
M
B2
6. C.P.
69
F
c2
7. C.H.
73
M
D
8. B.C.
69
F
c2
9. J.Y.
71
M
BI
10. E.M.
93
F
B2
11. S.C.
79
M
D
Died 3 months post diagnosis of disseminated disease Alive-no evidence of tumor 9 years post diagnosis Alive-no evidence of tumor 9 years post diagnosis Died 1 1/2 years post diagnosis of disseminated disease Alive-no evidence of tumor 7 years post diagnosis Died 1 1/2 years post diagnosis of disseminated disease Died 4 months post diagnosis of disseminated disease Alive-liver metastasis 1 year post diagnosis of primary lesion Alive-no evidence of tumor 1 year post diagnosis Alive-no evidence of tumor 1 year post diagnosis Died 3 months post diagnosis of disseminated disease
Welch and Donaldson on obstructing right colon lesions [ 1I]. Of the 11 patients in the series, the one B-1 and four of the five B-2 patients are alive beyond five years giving a 100% and an 80% survival respectively. One of the two C-2 lesions and all three of the patients with D lesions succumbed to their disease less than a year and a half from the time of diagnosis. This yielded a 50% and 0% survival respectively. Although a radical right hemicolectomy was the procedure of choice advocated by Broders [lo], we performed a conventional right hemicolectomy with primary anastomosis. We feel this is a more than adequate resection with comparable five year survival rates to other obstructing right colon lesions. Also, there was no operative mortality and no major morbidity.
179
It may be concluded from this study that the diagnosis of obstructing carcinoma of the cecum should be considered in elderly patients presenting with signs and symptoms of distal small bowel obstruction. As is the case for obstructing tumors in other parts of the large bowel, obstructing cecal cancers carry a poor survival rate primarily due to advanced disease at the time of diagnosis and treatment.
CONCLUSIONS Carcinoma of the cecum, the third most common location for malignancy of the large bowel, was examined with attention centered upon cecal cancers producing obstruction. Reviewing 136 patients revealed 11 obstructing lesions (8.1%) presenting as distal small bowel obstructions. The ages ranged from 69 to 93 years, mean age of 74 years. All but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy. The remaining patient had a palliative bypass. There was no operative mortality or significant morbidity, and all patients were discharged from the hospital. Bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment. ACKNOWLEDGMENTS Supported by a grant from the Dorothy Rider Pool Trust. REFERENCES 1. Ragland JR, Londe AM, Spratt JS: Correlation of the prognosis of obstructing colorectal carcinoma with clinical and pathologic variables. Am J Surg 121552-556, 1971. 2. Ohman U: Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 143:742-747, 1982. 3. Fitchett CW, Hoffman GC: Obstructing malignant lesions of the colon. Surg Clin North Am 66(4):807 820, 1986. 4. Hoth DF, Petrucci PE: Natural history and staging of colon cancer. Semin Oncol 3(4):331-336, 1976. 5. Greenlee HB, Aranha GV, DeOrio AJ: Neoplastic obstruction of the small and large intestine. Curr Prob Surg 49:18-21, 1979. 6. Floyd CE, Cohni: Obstruction in cancer of The colon. Ann Surg 1651721-73 1. 1969. 7. Wilder TC, Dockerty MB, Waugh JM: A clinicopathologic study of obstructing carcinomas of the right portion of the colon. Surg Gynecol Obstet 113:353-359, 1961. 8. Gennaro AR: Carcinoma of the cecum. Surg Gynecol Obstet 144:504-506, 1977. 9. Foti CE, Cohn I: Cancer of the cecum: review of 139 cases. Am Sure 36:129-135. 1970. 10. BroAers CW: Carcinoma of the cecum. Surg Clin North Am 66(4):787-791, 1986. 11. Welch JP, Donaldson GA: Management of severe obstruction of the large bowel due to malignant disease. Am J Surg 127:492499, 1974.
Obstructing Carcinoma of the Cecum PETER F. ROVITO, MD, GARY VERAZIN, MD, AND JOSEPH I. PROROK, MD, FACS From the Department of Surgery, lehigh Valley Hospital Center, Allentown, Pennsylvania
Carcinoma of the cecum, the third most common location for malignancy of the large bowel, was examined with attention centered upon cecal cancers producing obstruction. Reviewing 136 patients revealed 11 obstructing lesions (8.1%) presenting as distal small bowel obstructions. The mean age of the patients was 74 years. All but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy. There was no operative mortality or significant morbidity. Bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment. KEYWORDS:obstruction, resection, lesions
INTRODUCTION The cecum is the third most common location for carcinoma of the large bowel [ 11. Malignancy in this area is frequently associated with delayed diagnosis because of the unimpressive nature of its symptoms. Obstructive symptoms from carcinoma of the cecum are an even rarer phenomenon. It is felt that this is due to the large diameter and easy distensibility of the cecum, plus the liquid nature of its contents. We have reviewed the cases of carcinoma of the cecum at the Lehigh Valley Hospital Center with attention centered on obstructing lesions. Management, outcome, and a review of the literature are also analyzed.
patients had no further workup and were taken directly to surgery. Only patients with histologically proved carcinoma of the cecum were included in the study. Also, patients were excluded if the gross description, based on the operative or pathology reports, indicated that most of the tumor was situated above the orifice of the ileocecal valve. Tumors were classified according to the Astler Coller modification of the Dukes system (Table I).
RESULTS Over this 10 year period, there were a total of 136 patients with carcinoma of the cecum. Eleven (8.1%) of these patients had obstructing lesions which fit the criteria previously outlined. The diagnosis of obstructing carcinoma of the cecum was verified at surgery. There were six females and five males. The ages ranged from 69 to 93 years, with a mean age of 74 years. All patients were explored and all but one had resection for cure. A right hemicolectomy and ileotransverse colostomy was performed on all resection-for-cure patients. The remaining patient had a palliative bowel bypass performed at the time of surgery. No operative mortality occurred and all patients were subsequently
MATERIALS AND METHODS The entire experience of carcinoma of the cecum at the Lehigh Valley Hospital Center was reviewed from October 1977 to December 1986. Those cases of malignant obstructing lesions were identified and examined. Obstruction was defined as a patient presenting with clinical signs of small bowel obstruction, i.e., nausea with or without vomiting, abdominal pain and distention, and high-pitched hyperactive bowel sounds with tenderness on physical examination. Also needed was radiologic confirmation on obstructive series consistent with small bowel obstruction, i.e., distended small bowel with Accepted for publication June 1, 1990. air fluid levels and minimal air in the colon (Fig. 1). Address reprint requests to Dr. Peter F. Rovito, 1600 Lehigh Parkway Prior to exploration, six patients underwent barium East, Allentown, PA 18103. enemas, two patients had small bowel series, and one Dr. Gary Verazin is presently at the Department of Surgical Oncology patient had a barium enema and colonoscopy. Two & Endoscopy, Roswell Park Cancer Institute, Buffalo, NY 14263. 0 1990 Wiley-Liss, Inc.
178
Rovito et al.
Fig. 1. Obstructive series consisting of supine (A) and left lateral (B) decubitus films. This is consistent with distal small bowel obstruction with air fluid levels and minimal air in the colon.
discharged from the hospital. All patients had adenocarcinoma of colonic origin. Three of the patients had synchronous pathology including a tubular adenoma of the cecum, a tubulovillous adenoma of the ascending colon, and an adenomatous polyp of the ascending colon. There was one B-1 lesion, five B-2 lesions, two C-2 lesions, and three D lesions. At this writing, there are survivors (one B-1, four B-2, and one C-2; 5 5 % ) , five of which have no evidence of tumor. Three are long-term survivors (beyond five years). One is alive with documented liver metastasis. The mean survival is 35 months with a range of 3 to 108 months. Five patients died of their disease due to distant metastases (45%). Three of these patients had distant metastases at surgery, one had a B-2 lesion, and the other had a C-2 cecal tumor (Table 11).
DISCUSSION Fifteen percent of the patients with colorectal carcinoma presented with obstruction [2]. When carcinoma proceeds to obstruction, it is a well-accepted fact that the results of treatment are poorer when compared to nonobstructed malignant disease [ 1-31, The reasons for this are felt to be numerous. The tumor burden is greater as obstructing cancers are usually larger, although this is not universally accepted [4]. This is especially true of the cecum and right colon where the tumors tend to grow as large polypoid, fungating masses. In comparison, left-
sided cancers grow in an annular fashion, producing a “napkin-ring”constriction [3,5-71. With obstruction, the proximal bowel is in a more pathological state, being distended, atonic, and with greater bacterial and toxin load. Also, with obstruction, there is increased pressure in the lumen which is transmitted to the bowel wall. This causes increased pressure in the venous and lymphatic vascular channels, which is felt by many to make the patient prone to microembolization of tumor and, hence, more advanced disease [7]. These factors are coupled with the patient population, which consists of elderly patients who are all in varying degrees of anemia, malnutrition, and chronic disease. Review of the literature reveals a paucity of information on carcinoma of the cecum and even less on cecal carcinoma presenting as obstruction. Gennaro [8], in 1977, reviewed carcinoma of the cecum over a 10 year period. In his series of 66 patients, there was one obstruction, an incidence of only 1.5%. Foti and Cohn [9] examined a 16 year period which included 139 cases of cecal cancer. They found six obstructions, a 4.3% incidence. In Broders’ [lo] report in 1986 on 62 patients over an eight year period, there was no mention of obstructing carcinoma of the cecum. This study revealed an incidence of obstruction of 8.1%, almost double the highest incidence previously reported. Although a small series, the five year survival at this writing of 27% compares to the 29% reported by
Obstructing Carcinoma of the Cecum TABLE I. Astler Coller Modification of the Dukes Classification of Colon Carcinoma Dukes’ A-Carcinoma confined to the mucosa Dukes’ BI -Tumor extending to but not through the muscularis propria Dukes’ B2-Tumor extending through the muscularis propria Dukes’ C 1-B 1 with lymph node involvment Dukes’ C2-B2 with lymph node involvement Dukes’ D-Distant metastasis
TABLE 11. Demographics and Survival of Patients With Obstructing Carcinoma of the Cecum Name
Age
Sex
Stage
Su rviva 1
1. G.L.
72
F
D
2. M.L.
77
M
B2
3. E.M.
92
F
B2
4. R.S.
81
F
B2
5. O.W.
72
M
B2
6. C.P.
69
F
c2
7. C.H.
73
M
D
8. B.C.
69
F
c2
9. J.Y.
71
M
BI
10. E.M.
93
F
B2
11. S.C.
79
M
D
Died 3 months post diagnosis of disseminated disease Alive-no evidence of tumor 9 years post diagnosis Alive-no evidence of tumor 9 years post diagnosis Died 1 1/2 years post diagnosis of disseminated disease Alive-no evidence of tumor 7 years post diagnosis Died 1 1/2 years post diagnosis of disseminated disease Died 4 months post diagnosis of disseminated disease Alive-liver metastasis 1 year post diagnosis of primary lesion Alive-no evidence of tumor 1 year post diagnosis Alive-no evidence of tumor 1 year post diagnosis Died 3 months post diagnosis of disseminated disease
Welch and Donaldson on obstructing right colon lesions [ 1I]. Of the 11 patients in the series, the one B-1 and four of the five B-2 patients are alive beyond five years giving a 100% and an 80% survival respectively. One of the two C-2 lesions and all three of the patients with D lesions succumbed to their disease less than a year and a half from the time of diagnosis. This yielded a 50% and 0% survival respectively. Although a radical right hemicolectomy was the procedure of choice advocated by Broders [lo], we performed a conventional right hemicolectomy with primary anastomosis. We feel this is a more than adequate resection with comparable five year survival rates to other obstructing right colon lesions. Also, there was no operative mortality and no major morbidity.
179
It may be concluded from this study that the diagnosis of obstructing carcinoma of the cecum should be considered in elderly patients presenting with signs and symptoms of distal small bowel obstruction. As is the case for obstructing tumors in other parts of the large bowel, obstructing cecal cancers carry a poor survival rate primarily due to advanced disease at the time of diagnosis and treatment.
CONCLUSIONS Carcinoma of the cecum, the third most common location for malignancy of the large bowel, was examined with attention centered upon cecal cancers producing obstruction. Reviewing 136 patients revealed 11 obstructing lesions (8.1%) presenting as distal small bowel obstructions. The ages ranged from 69 to 93 years, mean age of 74 years. All but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy. The remaining patient had a palliative bypass. There was no operative mortality or significant morbidity, and all patients were discharged from the hospital. Bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment. ACKNOWLEDGMENTS Supported by a grant from the Dorothy Rider Pool Trust. REFERENCES 1. Ragland JR, Londe AM, Spratt JS: Correlation of the prognosis of obstructing colorectal carcinoma with clinical and pathologic variables. Am J Surg 121552-556, 1971. 2. Ohman U: Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 143:742-747, 1982. 3. Fitchett CW, Hoffman GC: Obstructing malignant lesions of the colon. Surg Clin North Am 66(4):807 820, 1986. 4. Hoth DF, Petrucci PE: Natural history and staging of colon cancer. Semin Oncol 3(4):331-336, 1976. 5. Greenlee HB, Aranha GV, DeOrio AJ: Neoplastic obstruction of the small and large intestine. Curr Prob Surg 49:18-21, 1979. 6. Floyd CE, Cohni: Obstruction in cancer of The colon. Ann Surg 1651721-73 1. 1969. 7. Wilder TC, Dockerty MB, Waugh JM: A clinicopathologic study of obstructing carcinomas of the right portion of the colon. Surg Gynecol Obstet 113:353-359, 1961. 8. Gennaro AR: Carcinoma of the cecum. Surg Gynecol Obstet 144:504-506, 1977. 9. Foti CE, Cohn I: Cancer of the cecum: review of 139 cases. Am Sure 36:129-135. 1970. 10. BroAers CW: Carcinoma of the cecum. Surg Clin North Am 66(4):787-791, 1986. 11. Welch JP, Donaldson GA: Management of severe obstruction of the large bowel due to malignant disease. Am J Surg 127:492499, 1974.
