Tumors of the 1)Igestive Tract Benign Tumors

TUMORS OF THE 1)IGESTIVE TRACT CHARLES F. GERCHICKTER, M.D. (lhai the Burgiccil Pathologiccil Lciborcitory, Uepnrtrrirnt of S?rryer?j Johns Ilopk~nsLlo c1711l zl7liVersif?J) The digestive tract is continuous with the mucous membranes of ectodermal origin in the mouth and at the anus. The pharynx, although of entodermal origin is lined by epidermal tissue, and tumors of this portion of the tract are more conveniently considered with other epidermal tumors of the oral and intra-oral membranes. Neoplasms of the remainder of the digestive tract will be considered together. The most frequent tumors in this region, except for those in the esophagus, which loses its digestive epithelium during embryonic life, are adenoma mid adenocarcinoma. These growths arise from the glandular portion of the mucosa throughout the digestive tract.. The incidence of benign adenomas is approximately one-sixteenth that of cancer. Adenocarcinoma and its mucoid, fibrous, and anaplastic vari- ants are more common in the stomach, large bowel, and rectum, and relatively rare in the esophagus and small intestine. Primary mucoid mrcinoma is uncommon, but is similar in distribution to adenocar- cainoma. Squamous-cell caiicer is the predominating form in the esophagus and may invade the cardiac end of the stomach. It is also found in the rectum and anal margin, but is exceedingly unusual elsewhere in the gastro-intestinal tract. Sarcoma is not common in the alimentary canal. Lympliosarcoma, myosarcoma, and sarcoma of the nerve sheath are the leading forms. These growths comprise approximately 4 per cerit of the malignimt tumors in the present series. BENIGNTUMORS With the exception of polypoid adenomas and so-called carciiioids, 1)criign tumors are relatively rare in the gastro-intestinal tract. My- omas, angiomas, and other new growths of the supporting wall of the digestive tube occur. They are not peculiar to this region, however, aiitl are omitt ed from the present discussion. The distribution and calassification of benign tumors in this series are as shown in Table I. Adcizomatous Polyps Adc.nomiltons polyps arc single or multiple. The multiple type may rarely give a familial history, several mcmbers of a single family being aflcctcd. Tho distribution of these growths in the digestive tmct in the present study was as shown in Table I and Fig. 1. 130 TUMORS OF THE DIGESTIVE TRACT 131 While reduplication of the epithelial layers of the mucosa at the margin of traction diverticula may occur, benign papillomas are rarely observed in the esophagus. Ginsburg has reported a case of multiple ptipillomas of the esophagus which the patient related to swallowing of ammonia twenty years previously. Patterson, in a review of 61 cases of benign tnmors of the esophagus iii the literature between the years I71 7 and 1932, found only 3 adenomas. Recently Moersch and Broders have reported the fourth case. In geiieral, the incidence of these be- itign growths in the digestive tract increases from above downwvud, approximately 60 per cent occurriiig in the rectum. The tumors are often multiple. Stewart reports 56 cases of gastric polyps ancl 127 oc- curring in the large bowel; 23 of the gastric cases were multiple, arid 57 T4nm I: Rrnigrb Titmors of tliP Di,yr,\tave Tract (178 Cases) ..............NOlW .......... 10 ............................... 36 cases ......................... 10 ................... 5 ........................ 1 Small iritc+t int1 .......... Itectiun ................. s tomac~ll ............ .................. of the coloiiic cases. He estimated that 5 per cent of carcinomas of the stomach are related to pre-existing benign polyps, whereas 36 per cent of eancei's in tlir large bowel have such an origin. Some observers, in- c*lutiing Fitzgihhon ancl Rankiii, believe that practically all cai.cinomas of the large bowel originate iii polypoid adenomas. These tumors project into the lumcii of the digestive tube causing o1,structioii or 1)lcccling. Young adults are usnally affected. With qowths iii the iwtnm or stomach fraiik hemorrhage may occur, whereas those ill thci lwrgc bowel tiiitl intestiiie are manifested by tarry stools or anemia. (Figs. '3, 1ant1 6.) tut.y 111 dfiplr polyposis occurred twice in the preseiit series. ln one of these cases malignant change occurred. This patient, a male 132 CHAHLES F. GESCHICKTEB aged fifty-two, was admitted for acute diarrhea, distention, aiid a,- dominal tenderness. Examination showed multiple polyps in the rectum and failure of the rectum aiid sigmoid region to fill by barium enema. A firm abdominal mass was palpated in the region of the left colori which at operation proved to be an inoperable carcinoma. The patient stated that a fatal form of intestinal trouble had affected his family. A brother had died, supposedly from intestinal tuberculosis. Rchilliiig has reviewed the literature on this phase of the disease. Males are usually affected. The entire tract from the stomach to the FIG.1. CIIAET SHOWINGTHE DISTR~BUTIONOF BENIGN ADENOMAS IN THE DIGESTIVETRACT rectum is involved, and in 50 per cent of the cases malignaricy super- venes in one or more of the polyps. As many as six members in one family have been affected. Although the disease is hereditary, it is usually not seen until after the twentieth year. lIistologically polypoid adenomas, whether solitary, multiple, or hereditary, are composed of single or reduplicated layers of columnar epithelium, lying on delicate stalks of connective tissue (Figs. 3 and 5). The presence of secretory epithelium varies with the portion of the howti1 tiffectetl. The smaller growths show an orderly arrangement of epithelium, while the larger growths exhihit marlied hyperplasia, vari- ation in the nuclei, and a tendency to invade the surrounding mucosa FIG.2. POLYPOID ADENONAOF THE STODZACH This tunior showed early malignant change. Path. No. 19901. FIG. 3. LOW-POWERPIIOTOMICROGRAPH OF ONE OF SEVERAL BENIGN POLYPOID ADENOMASOF TIIE STOMACH. PATH. NO. 45290 FIQ.4. POLYPOID ADENOMAOF THE DUODENUM Microscopically this tumor showed evidences of early malignant change. Path. No. 46597. From Raiford, T. S.: Arch. Surg. 25: 140, 1933. 133 134 CHARLES I?. GESCHICKTEE and sti-oma. With such invasion it is difficult to distinguish benign adenomns from early adciiocnrcinoma. Solitary polyps in the rectum may hc treated hy excision 01’ fulg~ux- tioii. Elsewhere in the tract resection is the treatmeiit of choice. The possi1)ility of multiplicity cziid of malignant change must bc borne in mind wlieii treatmeiit is undertaken. FIG.5. PHOTOMICROGRAPHOF TYPICAL BENION POLYPOID ADENOMA OF THE ILEUM Thc tumor ocrurrcd in a child of seven months and produced intussusccption. Path. No. 38963. Prom Haiford, T. 8.: Arch. Surg. 25: 157, 1932. 8ince the studies of Huebscliamm and Masson, which related the car- cinoids of the appendix to the chromaffin system, over 400 such tumors have been described in the literature. Thc older term carciiioid ~vas used because of the histologic resemblaiice of these relatively benign growths to cancer. Approximately 300 of these nrgeiitaffiiie tumors have occurred in the appendix and 100 in the small intestine, with scatteretl instaiices in the stomach, largc bowel, and rectum. In the present TUMORS OF THE DIGESTIVE TRACT 135 series 2% of these tumors occurred in the appendix, 10 in the small intestine, 2 in the large bowel, aid one iii the stomach. Adults are iisiially affeded, the age limits hing twelve and sixty-six years in this series. Symptoms appear early in the appendix hecause of the small size of the lumen, aiid suggest appendicitis. At operation a bulbous en- largement is found near the tip of the organ. When the tumor occurs FIG.6. POLYPOIDADENONA OF THE RYWTVX. PATH.No. 29916 in the intestine, diarrhea. without melena (produced by incomplete ob- strnction) is the major symptom. Although the majority of these growths are henigii and run a chronic course, some 20 per cent undergo malignant change. Eight of the cases studied showed secondary deposits in the lymph nodes. Even where such secondary deposits occur a cure may he affected. On microscopic study the tumor cells are found growing in islands or strands surrountled by dense bands of connective tissue. The cells are epithelial in nature, of moderate size, and tend to form a syncytium. The small, more deeply staining cells may show rosette formation. These epithelial cells may be impregnated by silver, hence the term argentaffiiie tumor (Fig. 7). Aberrant Pancreatic Rests These tumors are glandular misplacements which form small sub- mucous grayish white nodules in the wall of the bowel, rarely exceed- ing a centimeter in diameter. They are usually asymptomatic and are discovered only at autopsy. One of the 6 cases in the present series produced an intussusception of the ileum. Microscopically, character- istic paiicreatic tissue is present. The cells are arranged in acini and have a granular basophilic cytoplasm (Fig. 8). In addition, there are islaiids of Langerhaiis and small numbers of pancreatic ducts. ac- cording to Warthin these growths arise from the lateral buds of the pancreatic ducts as they pass through the intestinal wall of the embryo. They are thus segregated and carried up or clown the digestive tract tlnring the process of fetal growth. 136 CHARLES F. GESCHICKTER niucrtirula mid Ederic Cysts I>ivei*ticulilill the gasti.o-iiitcstiiia1 tritcat of the embryo are observed most commonly between the tluodenum aiid the terminal ileum but may occur also in other portions of the tract (Lewis and Thyrig). These knob-like protrusions may disappear or they may persist and give rise to diverticulosis (multiple outpouchings of the intestine), single diverticnla, or enteric cysts. The enteric cysts are formed from diverticnla FIG. 7. PHOTOMICROGRAPH OF A CARCINOID OR ARGENTAFFINETuiaon OF THE ILEUM Path. No. 6739. From Raiford, T. S.: Arch. Surg. 25: 166, 1938. which have lost their communication with the intestinal lumen. Ves- tiges of the so-called post-anal gut, which in the embryo connects tlie central canal of the spinal cord with the invaginating portion of the primitive anus, may also form cysts of this character.

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