Spatial Leon
Distribution of Colonic Carcinoma
Morgenstern, MD, Stephen
E.
Lee, MD
\s=b\ During the past several decades, there has been a shift in the distribution of colorectal cancer toward the right side, with an increase in colon lesions on the right side and a marked decrease in rectal lesions. In 1,009 cases studied between 1966 and 1977, this change in distribution pattern is illustrated. A revision of widespread current concepts of colonic cancer detection is indicated.
(Arch Surg 113:1142-1143, 1978)
There
has been a substantial change in the spatial distribution of cancer in the colon during the past two decades. The change has been a shift in the site of growth toward the right side of the colon, most noticeably seen in the lessening comparative incidence of carcinoma in the rectum and rectosigmoid colon. We add our study of 1,009 consecutive cases of colonie carcinoma to others that have also shown this changing pattern of site distribution of human colonie cancer. A small group of experimentally induced carcinomas is also reported with special reference to site of tumor induction. MATERIALS AND METHODS Clinical One thousand and nine consecutive cases of colonie carcinoma, resected at the Cedars-Sinai Medical Center, Los Angeles, between the years 1966 and 1977 inclusive, were studied for location of tumor as well as other pathologic features. Data was obtained from both operative and pathology reports. This study deals only with the distribution of these tumors in the colon.
Experimental Eight Sprague-Dawley rats of both sexes were given 20 mg/kg of 1,2-dimethylhydrazine by weekly subcutaneous injections. The diet was regular rat chow. Animals were killed between 22 and 32 weeks after the beginning of injections. The entire intestine was studied for tumor induction and the sites carefully noted. RESULTS Clinical The results of our clinical study are given in Table 1. The preponderant number of lesions occurred in the left side of the colon, 7% occurring in the descending colon and 38% in the sigmoid and rectosigmoid. The low incidence (15%) of rectal carcinoma is especially notable. Accepted From
Angeles.
publication March 30, 1978. the Department of Surgery, Cedars-Sinai Medical Center,
Transverse colon lesions (16%) included lesions of both flexures. Colon lesions on the right side (24%) included lesions of the cecum as well as ascending colon.
Experimental The distribution of colonie tumors induced in rats with is given in Table 2. A total of 78 tumors were induced in eight animals. Although the series of animals is small, the distribution of tumors was fairly uniform. The majority of lesions (57%) were found in the descending and sigmoid colon. Only 4% were in the rectum. The remainder of lesions occurred in the transverse colon (24%) and in the right side of the colon
1,2-dimethylhydrazine
(15%).
COMMENT In striking contrast to the distribution pattern reported by us, two previous studies may be cited as illustrative examples of the site distributipn of colonie cancer reported two or three decades ago. Welch and Giddings1 reported their findings in 1,876 cases seen at the Massachusetts General Hospital, Boston, between 1937 and 1948. Forty-
three percent of the lesions were in the rectum, 28% in the sigmoid-rectosigmoid, and 14% on the right side of the colon. Similarly, a study of 1,059 patients with carcinoma of the colon seen between 1945 and 1949 at the Lahey Clinic Foundation, Boston was reported by Swinton and Counts.Nearly 78% of the lesions were located in the anus, rectum, and rectosigmoid, with only 7.6% in the right side of the colon. Table 1.—Distribution of Colonie Cancer
by Site
_Site_No._% Total colon
247
24
Transverse colon" Descending colon
163
16
71
Sigmoid Rectum
379 149
7 38 15
Total
1,009
Too
Right
and
rectosigmoid
"Includes both flexures.
Table 2—Distribution
by
Site of 78 Tumors in
Eight
Animals
_Site_No._% Total
for
Los
Read before the annual meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, Calif, Jan 21, 1978. Reprint requests to Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048 (Dr Morgenstern).
Right colon Transverse colon Descending and sigmoid Rectum Total
Downloaded From: http://archsurg.jamanetwork.com/ by a DALHOUSIE UNIVERSITY-DAL-11762 User on 06/20/2015
12
15
19
24
44
57
3
4
78
100
The more recent trend, showing an increasing frequency in incidence of lesions toward the right side of the colon and a substantial decrease in rectal cancers, is exemplified by the reports of Cady et al,8 Cutler,' and Rhodes et al.5 Each of these reports gives the findings in thousands of cases, howing the steady progression in incidence of malignant lesions toward the right side. The same phenom¬ enon has been pointed out by a number of other au¬ thors."-'' The results of our experimental studies are in accord with other studies,"1 insofar as the low incidence of induced rectal carcinoma is concerned. Other studies" have shown a higher incidence of right-sided lesions than left-sided lesions, but the infrequency of rectal lesions is consistent. Thus, the experimental model resembles the human distri¬ bution pattern to an extent. Of what importance is this changing pattern of distribu¬ tion of colonie cancer? The authors can deduce no obvious contribution of this observation to the numerous theories of causation described for colonie cancer. The observation does have practical importance, however, in its application to methods of detection and screening for malignant lesions of the colon. The older concept, still taught in our medical schools and still described in modern surgical texts, is that two thirds or three fourths of all colonie cancers are discoverable by digital examination and proctosigmoidoscopy. This concept is no longer valid. Less than 20% of the malignant colonie lesions are present in the rectum. Only a little more than half are located in the sigmoid and rectum. Detection and screening methods must, therefore, be oriented toward the whole colon, rather than concentrating on its most distal segment. The stool guiac test for occult blood (hemoccult test), the well-performed barium enema examination, and colonoscopy must play an increasingly prominent role in colonie cancer detection and screening. For the present, we have no other effective methods, although new means of detection, such as carcinoembrionic antigen in colonie washings and cytologie studies, are under investigation. Carcinoma of the colon has shown a noticeable rise in absolute incidence in the American population,4 in contrast to the declining incidence of carcinoma of the stomach. Its incidence is second only to that of skin cancer and has now exceeded the combined incidence of lung cancer in men and women. Thus, all clinical observations regarding any change in biological behavior of this neoplasm are impor¬ tant. There is increasing demographic evidence that envi¬ ronmental factors, principally dietary, play an important role in the cause of colon cancer. The high rate of ingestion of animal fat in the American diet is frequently mentioned as a possible causative factor, as is the lack of bulk or fiber.1- Experimental evidence has implicated bile acids" and fat " as enhancing factors in carcinogenesis. For these and similar studies, the dimethylhydrazine-induced tumors have provided a valuable experimental tool. The decreasing incidence of human rectal cancer and the low incidence of carcinogen-induced rectal tumors may have some biological common denominator.
reviewing our own material as well as that of others reported in the world literature, it has become obvious that a precise means of localizing the tumor site and the easy retrieval of such information is highly desirable. We have been struck by the difficulty in determining tumor loca¬ tion, size, and other features in standard operative and pathology reports. Moreover, similar difficulties are not only mentioned by other authors, but also demonstrated in the variation in site reporting, both in nomenclature and In
definition of anatomic regions of the colon. There is a high probability that the pattern of colonie carcinoma will continue to change, making precision and standardization in reporting of cases of utmost importance. We propose that a stamp or form be appended to all records involving cases of carcinoma of the colon; that this be standardized not only for the purpose of recording, but also be mandatory in reporting of colonie carcinoma; that it include site (eg, cecum and ascending colon, transverse, descending, sigmoid-rectosigmoid, rectum), size, Duke's classification, and nodal metastasis. Standardization and precision in recording and reporting such information will be of immense help in the accrual of the information necessary in the study of neoplasia. This
Society.
study
was
supported by
a
grant from the American Cancer
Seth Reed aided in the compilation of the data. Pamela Fall technical and secretarial assistance.
provided
References CE, Giddings WP: Carcinoma of colon and rectum: Observations Massachusetts General Hospital cases, 1937-1948. N Engl J Med 244:859\x=req-\ 867, 1951. 2. Swinton NW, Counts RL: Cancer of the colon and rectum: Statistical study, with end-results. JAMA 161:1139-1142, 1956. 3. Cady B, Persson AV, Monson DO, et al: Changing patterns of colorectal carcinoma. Cancer 33:422-426, 1974. 4. Cutler SJ: Colon and rectum, in Schottenfeld D (ed): Cancer Epidemiology and Prevention. Springfield, Ill, Charles C Thomas Publisher, pp 375-385, 1975. 5. Rhodes JB, Holmes FF, Clark GM: Changing distribution of primary cancers in the large bowel. JAMA 238:1641-1643, 1977. 6. Moss NH, Extel LM: Cancers of the gastrointestinal tract: Trends in method of treatment and patient survival. Proceedings of the sixth National Cancer Conference. Philadelphia, JB Lippincott Co, 1970, pp 459-467. 7. Franklin R, McSwain B: Carcinoma of the colon, rectum and anus. Ann 1. Welch
on
Surg 171:811-818, 1970. 8. Liechty RD, Ziffren SE, Miller FE, et al: Adenocarcinoma of the colon and rectum: Review of 2,261 cases over a 20-year period. Dis Colon Rectum 11:201-208, 1968. 9. Axtell LM, Chiazze L: Changing relative frequency of cancers of the
colon and rectum in the United States. Cancer 19:750-754, 1966. 10. Martin MS, Martin F, Michiels R, et al: An experimental model for cancer of the colon and rectum: Intestinal carcinoma induced in the rat by 1,2 dimethylhydrazine. Digestion 8:22-34, 1973. 11. Nigro ND, Bhadrachari N, Chomchai C: A rat model for studying colonic cancer: Effect of cholestyramine on induced tumors. Dis Colon Rectum 16:438-443, 1973. 12. Weisburger JH, Reddy BS, Wynder EL: Colon cancer: Its epidemiology and experimental production. Cancer 40:2414-2420, 1977. 13. Chomchai C, Bhadrachari N, Nigro ND: The effect of bile on the induction of experimental intestinal tumors in rats. Dis Colon Rectum 17:310-312, 1974. 14. Broitman SA, Vitale JJ, Vavrousek-Jakuba E, et al: Polyunsaturated fat, cholesterol and large bowel tumorigenesis. Cancer 40:2455-2463, 1977.
Downloaded From: http://archsurg.jamanetwork.com/ by a DALHOUSIE UNIVERSITY-DAL-11762 User on 06/20/2015
Distribution of Colonic Carcinoma
Morgenstern, MD, Stephen
E.
Lee, MD
\s=b\ During the past several decades, there has been a shift in the distribution of colorectal cancer toward the right side, with an increase in colon lesions on the right side and a marked decrease in rectal lesions. In 1,009 cases studied between 1966 and 1977, this change in distribution pattern is illustrated. A revision of widespread current concepts of colonic cancer detection is indicated.
(Arch Surg 113:1142-1143, 1978)
There
has been a substantial change in the spatial distribution of cancer in the colon during the past two decades. The change has been a shift in the site of growth toward the right side of the colon, most noticeably seen in the lessening comparative incidence of carcinoma in the rectum and rectosigmoid colon. We add our study of 1,009 consecutive cases of colonie carcinoma to others that have also shown this changing pattern of site distribution of human colonie cancer. A small group of experimentally induced carcinomas is also reported with special reference to site of tumor induction. MATERIALS AND METHODS Clinical One thousand and nine consecutive cases of colonie carcinoma, resected at the Cedars-Sinai Medical Center, Los Angeles, between the years 1966 and 1977 inclusive, were studied for location of tumor as well as other pathologic features. Data was obtained from both operative and pathology reports. This study deals only with the distribution of these tumors in the colon.
Experimental Eight Sprague-Dawley rats of both sexes were given 20 mg/kg of 1,2-dimethylhydrazine by weekly subcutaneous injections. The diet was regular rat chow. Animals were killed between 22 and 32 weeks after the beginning of injections. The entire intestine was studied for tumor induction and the sites carefully noted. RESULTS Clinical The results of our clinical study are given in Table 1. The preponderant number of lesions occurred in the left side of the colon, 7% occurring in the descending colon and 38% in the sigmoid and rectosigmoid. The low incidence (15%) of rectal carcinoma is especially notable. Accepted From
Angeles.
publication March 30, 1978. the Department of Surgery, Cedars-Sinai Medical Center,
Transverse colon lesions (16%) included lesions of both flexures. Colon lesions on the right side (24%) included lesions of the cecum as well as ascending colon.
Experimental The distribution of colonie tumors induced in rats with is given in Table 2. A total of 78 tumors were induced in eight animals. Although the series of animals is small, the distribution of tumors was fairly uniform. The majority of lesions (57%) were found in the descending and sigmoid colon. Only 4% were in the rectum. The remainder of lesions occurred in the transverse colon (24%) and in the right side of the colon
1,2-dimethylhydrazine
(15%).
COMMENT In striking contrast to the distribution pattern reported by us, two previous studies may be cited as illustrative examples of the site distributipn of colonie cancer reported two or three decades ago. Welch and Giddings1 reported their findings in 1,876 cases seen at the Massachusetts General Hospital, Boston, between 1937 and 1948. Forty-
three percent of the lesions were in the rectum, 28% in the sigmoid-rectosigmoid, and 14% on the right side of the colon. Similarly, a study of 1,059 patients with carcinoma of the colon seen between 1945 and 1949 at the Lahey Clinic Foundation, Boston was reported by Swinton and Counts.Nearly 78% of the lesions were located in the anus, rectum, and rectosigmoid, with only 7.6% in the right side of the colon. Table 1.—Distribution of Colonie Cancer
by Site
_Site_No._% Total colon
247
24
Transverse colon" Descending colon
163
16
71
Sigmoid Rectum
379 149
7 38 15
Total
1,009
Too
Right
and
rectosigmoid
"Includes both flexures.
Table 2—Distribution
by
Site of 78 Tumors in
Eight
Animals
_Site_No._% Total
for
Los
Read before the annual meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, Calif, Jan 21, 1978. Reprint requests to Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048 (Dr Morgenstern).
Right colon Transverse colon Descending and sigmoid Rectum Total
Downloaded From: http://archsurg.jamanetwork.com/ by a DALHOUSIE UNIVERSITY-DAL-11762 User on 06/20/2015
12
15
19
24
44
57
3
4
78
100
The more recent trend, showing an increasing frequency in incidence of lesions toward the right side of the colon and a substantial decrease in rectal cancers, is exemplified by the reports of Cady et al,8 Cutler,' and Rhodes et al.5 Each of these reports gives the findings in thousands of cases, howing the steady progression in incidence of malignant lesions toward the right side. The same phenom¬ enon has been pointed out by a number of other au¬ thors."-'' The results of our experimental studies are in accord with other studies,"1 insofar as the low incidence of induced rectal carcinoma is concerned. Other studies" have shown a higher incidence of right-sided lesions than left-sided lesions, but the infrequency of rectal lesions is consistent. Thus, the experimental model resembles the human distri¬ bution pattern to an extent. Of what importance is this changing pattern of distribu¬ tion of colonie cancer? The authors can deduce no obvious contribution of this observation to the numerous theories of causation described for colonie cancer. The observation does have practical importance, however, in its application to methods of detection and screening for malignant lesions of the colon. The older concept, still taught in our medical schools and still described in modern surgical texts, is that two thirds or three fourths of all colonie cancers are discoverable by digital examination and proctosigmoidoscopy. This concept is no longer valid. Less than 20% of the malignant colonie lesions are present in the rectum. Only a little more than half are located in the sigmoid and rectum. Detection and screening methods must, therefore, be oriented toward the whole colon, rather than concentrating on its most distal segment. The stool guiac test for occult blood (hemoccult test), the well-performed barium enema examination, and colonoscopy must play an increasingly prominent role in colonie cancer detection and screening. For the present, we have no other effective methods, although new means of detection, such as carcinoembrionic antigen in colonie washings and cytologie studies, are under investigation. Carcinoma of the colon has shown a noticeable rise in absolute incidence in the American population,4 in contrast to the declining incidence of carcinoma of the stomach. Its incidence is second only to that of skin cancer and has now exceeded the combined incidence of lung cancer in men and women. Thus, all clinical observations regarding any change in biological behavior of this neoplasm are impor¬ tant. There is increasing demographic evidence that envi¬ ronmental factors, principally dietary, play an important role in the cause of colon cancer. The high rate of ingestion of animal fat in the American diet is frequently mentioned as a possible causative factor, as is the lack of bulk or fiber.1- Experimental evidence has implicated bile acids" and fat " as enhancing factors in carcinogenesis. For these and similar studies, the dimethylhydrazine-induced tumors have provided a valuable experimental tool. The decreasing incidence of human rectal cancer and the low incidence of carcinogen-induced rectal tumors may have some biological common denominator.
reviewing our own material as well as that of others reported in the world literature, it has become obvious that a precise means of localizing the tumor site and the easy retrieval of such information is highly desirable. We have been struck by the difficulty in determining tumor loca¬ tion, size, and other features in standard operative and pathology reports. Moreover, similar difficulties are not only mentioned by other authors, but also demonstrated in the variation in site reporting, both in nomenclature and In
definition of anatomic regions of the colon. There is a high probability that the pattern of colonie carcinoma will continue to change, making precision and standardization in reporting of cases of utmost importance. We propose that a stamp or form be appended to all records involving cases of carcinoma of the colon; that this be standardized not only for the purpose of recording, but also be mandatory in reporting of colonie carcinoma; that it include site (eg, cecum and ascending colon, transverse, descending, sigmoid-rectosigmoid, rectum), size, Duke's classification, and nodal metastasis. Standardization and precision in recording and reporting such information will be of immense help in the accrual of the information necessary in the study of neoplasia. This
Society.
study
was
supported by
a
grant from the American Cancer
Seth Reed aided in the compilation of the data. Pamela Fall technical and secretarial assistance.
provided
References CE, Giddings WP: Carcinoma of colon and rectum: Observations Massachusetts General Hospital cases, 1937-1948. N Engl J Med 244:859\x=req-\ 867, 1951. 2. Swinton NW, Counts RL: Cancer of the colon and rectum: Statistical study, with end-results. JAMA 161:1139-1142, 1956. 3. Cady B, Persson AV, Monson DO, et al: Changing patterns of colorectal carcinoma. Cancer 33:422-426, 1974. 4. Cutler SJ: Colon and rectum, in Schottenfeld D (ed): Cancer Epidemiology and Prevention. Springfield, Ill, Charles C Thomas Publisher, pp 375-385, 1975. 5. Rhodes JB, Holmes FF, Clark GM: Changing distribution of primary cancers in the large bowel. JAMA 238:1641-1643, 1977. 6. Moss NH, Extel LM: Cancers of the gastrointestinal tract: Trends in method of treatment and patient survival. Proceedings of the sixth National Cancer Conference. Philadelphia, JB Lippincott Co, 1970, pp 459-467. 7. Franklin R, McSwain B: Carcinoma of the colon, rectum and anus. Ann 1. Welch
on
Surg 171:811-818, 1970. 8. Liechty RD, Ziffren SE, Miller FE, et al: Adenocarcinoma of the colon and rectum: Review of 2,261 cases over a 20-year period. Dis Colon Rectum 11:201-208, 1968. 9. Axtell LM, Chiazze L: Changing relative frequency of cancers of the
colon and rectum in the United States. Cancer 19:750-754, 1966. 10. Martin MS, Martin F, Michiels R, et al: An experimental model for cancer of the colon and rectum: Intestinal carcinoma induced in the rat by 1,2 dimethylhydrazine. Digestion 8:22-34, 1973. 11. Nigro ND, Bhadrachari N, Chomchai C: A rat model for studying colonic cancer: Effect of cholestyramine on induced tumors. Dis Colon Rectum 16:438-443, 1973. 12. Weisburger JH, Reddy BS, Wynder EL: Colon cancer: Its epidemiology and experimental production. Cancer 40:2414-2420, 1977. 13. Chomchai C, Bhadrachari N, Nigro ND: The effect of bile on the induction of experimental intestinal tumors in rats. Dis Colon Rectum 17:310-312, 1974. 14. Broitman SA, Vitale JJ, Vavrousek-Jakuba E, et al: Polyunsaturated fat, cholesterol and large bowel tumorigenesis. Cancer 40:2455-2463, 1977.
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