Treatment of Carcinoma of the Rectum by Electrocoagulation and Radiation, in Selected Cases

SLIGHTLY more than 5 per cent of all malignant lesions occur in the colon, and the majority of these are located in the terminal four and one-half inches and within reach of the examining finger. This type of carcinoma occurs most often between the ages of 40 and 70 years, but cases have been known to occur as early as at the age of 10 years. The preponderant occurrence of neoplasms at points of fixation in the colon strongly suggests that irritation is a major causative factor. However, no definite predisposition can be proven except in cases arising from multiple polyposis in which it must be assumed that an abnormality previously existed at the site of the polyp formation. As yet no satisfactory evidence has been adduced that carcinoma develops in tissues altered by the presence of hemorrhoids, fistulæ, or cicatrices. Clinically, three types of growth are encountered: 1. The polypoid or protuberant growth, which is movable and ulcerates superficially. 2. The flat crater-like excavated growth with indurated base, and margins which are elevated and nodular. 3. The annular growth with superficially ulcerated surface. Seventy-five per cent of these neoplasms appear on the anterior wall of the colon. The onset of the disease is insidious; the patient commonly complains of increasing constipation, pain in back or bowel, or has noticed the appearance of blood-stained stools. These three symptoms are present in 85 per cent of all cases of carcinoma of the rectum. Occasionally, tenesmus, a slight discharge from the rectum, dysuria, and ribbon-like stools are also present. Secondary symptoms such as emaciation, cachexia, and anemia appear late and usually follow the absorption of toxins, from an associated proctitis present in the region immediately proximal to the site of the tumor. From the time of appearance of the first symptoms, an average of twelve months elapse before patients with carcinoma of the rectum apply for treatment and, although the disease is slow growing, the process is, by that time, usually fairly well advanced. Glandular metastases are present in a large percentage of cases and the colon may be fixed by extension of the process to adjacent tissues. It is such conditions, resulting from delay, which make the treatment of carcinoma of the colon rather difficult. Once the diagnosis is established, the elimination or destruction of the disease process must be next considered. It is the consensus of opinion that if a malignant tumor has remained local, and none of the cells has either infiltrated or metastasized to adjacent or distant structures, then complete surgical extirpation offers the greatest likelihood of cure. Those patients in whom radical surgery can be carried out with reasonable promise of success are classed as operable. Under these conditions, only from 30 to 70 per cent of patients are operable, depending upon the ability and boldness of the surgeon.