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Ileocolic intussusception due to metastasis from embryonal carcinoma of the testis
KEOCOLIC INT’CISSUSCEPTION DUE TO METASTASIS EMBRYONAL CARCINOMA OF THE TESTIS JOSEPH M.
FROM
MILLER, M.D., CAPT. GABRIEL F. CUCOLO, M.C. AND LIEUT. COL. J. WILLIAM HEARN, M.C. Fort Howard, hlaryland
I
in ad&s is a reIativeIy infrequent cause of intraabdomina1 surgica1 emergency. Tumors of the smaI1 bowel are the most common cause of this accident with benign neoplasms being more frequentIy seen than the maIignant variety. Metastatic neoplasms are a rare cause of intussusception. Metastasis of an embryona1 carcinoma of the testis to the iIeum producing intussusception is a medica curiosity. EmbryonaI carcinoma of the testis may pursue a reIativeIy benign course for a protracted period and its presence then heraIded by rapid, progressive deveIopment in distant portions of the body. The most frequent presenting symptom in carcinoma of the testicle is painIess enIargement of the organ ; in many cases only a smaI1 tumor is noted. As pointed out by Auerbach, Brines and Yoguda,’ metastases foIIow a fairIy consistent pattern. A Iarge, paIpabIe mass is CharacteristicaIIy present in the upper portion of the abdomina1 cavity straddIing the vertebrae. The Iungs, mediastina1 Iymph nodes and the Iiver aIso a;e frequent sites of secondary tumors. Late symptoms and signs may sometimes appear in a catastrophic manner with no indication that the testicuIar tumor is the underIying cause. NTUSSUSCEPTION
CASE REPORT Such a sequence of events was found in a nineteen year old, white soIdier who stated that he had been iII for approximateIy six days prior to admission. The iIIness was initiated by paraumbilical pain of moderate degree, nausea and vomiting. The patient was seen by his battaIion surgeon who noted no great change in the condition of the patient in the subsequent five
days. The patient stated that he continued to eat but that the meaIs frequentIy were fohowed by emesis. He had had a watery stoo1 the day before admission but bIood had not been noted in the feca1 materia1. A mass was found in the right Iower quadrant of his abdomen by his battaIion surgeon on the day of admission to our instaIIation. Treatment prior to this time included the administration of fluids by the intravenous route, peniciIIin and morphine. The patient stated that about ten months before admission he had been struck in the Ieft testicIe by a box. The organ became quite tender and was swoIIen on the foIIowing day but returned to normal size subsequentIy. There had been no change in the size of the testis since that period. Physical examination reveaIed an acuteIy iI1, drowsy, dehydrated, white maIe whose pupiIs were miotic and whose throat was diffuseIy red. VisibIe abdomina1 peristaIsis was not present. A Iarge, tender mass was paIpabIe in the right Iower quadrant of the abdomen and rebound tenderness was referred to this sector from a11 of the other quadrants. A moderate degree of tenderness was found on the right side of the rectum but bIood was not found on the examining finger. A smaI1 discrete noduIe measuring about z cm. in diameter was paIpabIe in the Ieft testicIe. The differentia1 diagnosis presented by this patient was extremely interesting. He had been iI for a period of approximately six days with no great progression of symptoms. Physical signs during this period had remained about the same except for the presence of a mass in the abdomen which was first noted on the day of transfer. RecapituIation of the history reveaIed that the patient had had paraumbiIica1 pain with nausea, vomiting and the presence of a mass which had appeared rather Iate in the course. The history and physica findings as revealed upon admission suggested that the patient might have had acute appendicitis
270
American
Journal
of Surgery
Milter
et al.-Ileocolic
with perforation and abscess formation. Support was given to this diagnosis by .the relatively benign course which the indrvrdual had pursued for six days. However, the presence oi some of the characteristic symptoms and signs of intussusception were noted. The exact role of the nodule in the left testis which was suspected of malignancy was not well understood at this time. However, it was apparent that this individual had suffered some acute intraabdominal catastrophe. After suitable preparation a right muscle-splitting McBurney type of incision was made; the mass was approached in a retroperitoneal manner with the idea that if purulent materia1 were encountered in an abscess from a perforated appendix, drainage and perhaps appendectomy could be performed. No abscess was found. Therefore, the peritoneum was opened wideIy and the mass was found to be an ileocoIic intussusception. Reduction was impossible. The 20 cm. of ileum just proximai to the area where the small intestine entered the ~ntussusception was moderately cyanotic and the proximal portion of the smali bowel was slightly dilated. With delivery of the mass from the peritoneal cavity, the cyanosis of this area of smali intestine disappeared and a normal color returned. The areas of the involved ileum, cecum and appendix in the mass were resected between Payr clamps. The free edge of the mesentery of the resected portion of ireurn was sutured to the lateral peritoneal wall and the free ends of the iIeum and cecum brought out of the abdomen together with the two portions of the bowe1 sutured in an approximated position. The peritoneum, muscIe, fascia and skin were closed about the protruding ends of the boweI. Measurement of the specimen after operation when the ileum was cut and the intussusception reduced revealed that about 34 cm. of gangrenous ileum had been removed. A small tumor measuring about I .$ cm. in diameter was present at the head of the intussusception and the serosa1 surface of the ileum opposite the tumor showed a definite umbiIication. The patient did well in the immediate postoperative period. Intubation with a MiIlerAbbott tube was done and the patient was given titrated whole blood and plasma intravenousIy. Sulfadiazine was the chemotherapeutic agent used. Thirty-six hours after operation a catheter was placed into the lumen of Au,qst,
‘949
Intussusception
the ileum and secured with a purse-string suture. Immediate passage of gas and fecal material through the tube was noted. Complirations relative to the operative procedure itseIf did not appear. On the fifth postoperative day the patient complained of a severe headache which was reIieved by caffeine sodium benzoate. Later he again suffered from a severe occipitofrontal headache. Examination of the fundi revealed a shght distention of the retinal veins. With the suspicion that the patient might be suffering from a virus encephalitis of which isolated cases were being seen in the area, a spinal tap was done and an initial pressure of 430 mm. was found. This was reduced but subsequent taps revealed the pressure to be still elevated. Headache was a constant complaint from this time unti1 time of death aithough some relief was obtained by the repeated removal of spinal fluid. The cause of death was increased intracrania1 pressure due to an unknown cause with suspicion that metastasis from a tumor either of the ileum or the testis might be the responsible agent. Post-mortem examination was done with the outstanding findings being widespread tumor masses in the retroperitoneal area. hlultiple areas of metastasis were found in the lungs and the right cerebra1 hemisphere. A single metastasis in the spleen was found. A smah tumor was found in the left testis. Microscopic examination of these tissues revealed that the tumor in the testicle was primary and that the remaining tumors were metastatic. The testicuIar tumor was carcinomatous in nature with large, pale ceIIs with vesicuIar nuclei. Marked pleomorphism and occasiona mitoses were seen. In one section tumor tissue was seen to be invading a blood vessel Examination of the tumor in the ileum which had been removed surgieaIIy showed an identical appearance with the testicular neoplasm. it is noteworthy that the lymph nodes in the immediate area of the tumor in the ileum did not show invasion by tumor cells.
The case reported herein is that of a patient whose presenting compIaint of an embryonal carcinoma of the left testis was the appearance of an iIeocolic intussusception due to an isoIated metastasis
272
MiIIer
et aI.-IIeocoIic
to the iIeum. IIeocoIic resection was done successfuIIy. The patient subsequentIy died of muItipIe metastases wideIy spread throughout the body with the immediate cause of death being respiratory faiIure secondary to increased intracrania1 pres-
Intussusception sure due to a Iarge metastatic right cerebrum.
Iesion in the
REFERENCE
I. AUERBACH, OSCAR, BRINES, OSBORNE 0. and YoGUDA, OSBER. NeopIasms of the testis. J. Ural., 56: 368-374. 1946.
WITH the exception of cases due to gas bacillus infection, acute gangrene of the scrotum is aImost invariably due to the hemolytic streptococcus and, in the opinion of R. C. Robinson, ought to be treated primariIy with peniciIIin rather than surgery. Surgery prematureIy performed may be very detrimental in these acute cases. (Richard A. Leonardo, M.D.)
American
Journal of Surgery
FROM
MILLER, M.D., CAPT. GABRIEL F. CUCOLO, M.C. AND LIEUT. COL. J. WILLIAM HEARN, M.C. Fort Howard, hlaryland
I
in ad&s is a reIativeIy infrequent cause of intraabdomina1 surgica1 emergency. Tumors of the smaI1 bowel are the most common cause of this accident with benign neoplasms being more frequentIy seen than the maIignant variety. Metastatic neoplasms are a rare cause of intussusception. Metastasis of an embryona1 carcinoma of the testis to the iIeum producing intussusception is a medica curiosity. EmbryonaI carcinoma of the testis may pursue a reIativeIy benign course for a protracted period and its presence then heraIded by rapid, progressive deveIopment in distant portions of the body. The most frequent presenting symptom in carcinoma of the testicle is painIess enIargement of the organ ; in many cases only a smaI1 tumor is noted. As pointed out by Auerbach, Brines and Yoguda,’ metastases foIIow a fairIy consistent pattern. A Iarge, paIpabIe mass is CharacteristicaIIy present in the upper portion of the abdomina1 cavity straddIing the vertebrae. The Iungs, mediastina1 Iymph nodes and the Iiver aIso a;e frequent sites of secondary tumors. Late symptoms and signs may sometimes appear in a catastrophic manner with no indication that the testicuIar tumor is the underIying cause. NTUSSUSCEPTION
CASE REPORT Such a sequence of events was found in a nineteen year old, white soIdier who stated that he had been iII for approximateIy six days prior to admission. The iIIness was initiated by paraumbilical pain of moderate degree, nausea and vomiting. The patient was seen by his battaIion surgeon who noted no great change in the condition of the patient in the subsequent five
days. The patient stated that he continued to eat but that the meaIs frequentIy were fohowed by emesis. He had had a watery stoo1 the day before admission but bIood had not been noted in the feca1 materia1. A mass was found in the right Iower quadrant of his abdomen by his battaIion surgeon on the day of admission to our instaIIation. Treatment prior to this time included the administration of fluids by the intravenous route, peniciIIin and morphine. The patient stated that about ten months before admission he had been struck in the Ieft testicIe by a box. The organ became quite tender and was swoIIen on the foIIowing day but returned to normal size subsequentIy. There had been no change in the size of the testis since that period. Physical examination reveaIed an acuteIy iI1, drowsy, dehydrated, white maIe whose pupiIs were miotic and whose throat was diffuseIy red. VisibIe abdomina1 peristaIsis was not present. A Iarge, tender mass was paIpabIe in the right Iower quadrant of the abdomen and rebound tenderness was referred to this sector from a11 of the other quadrants. A moderate degree of tenderness was found on the right side of the rectum but bIood was not found on the examining finger. A smaI1 discrete noduIe measuring about z cm. in diameter was paIpabIe in the Ieft testicIe. The differentia1 diagnosis presented by this patient was extremely interesting. He had been iI for a period of approximately six days with no great progression of symptoms. Physical signs during this period had remained about the same except for the presence of a mass in the abdomen which was first noted on the day of transfer. RecapituIation of the history reveaIed that the patient had had paraumbiIica1 pain with nausea, vomiting and the presence of a mass which had appeared rather Iate in the course. The history and physica findings as revealed upon admission suggested that the patient might have had acute appendicitis
270
American
Journal
of Surgery
Milter
et al.-Ileocolic
with perforation and abscess formation. Support was given to this diagnosis by .the relatively benign course which the indrvrdual had pursued for six days. However, the presence oi some of the characteristic symptoms and signs of intussusception were noted. The exact role of the nodule in the left testis which was suspected of malignancy was not well understood at this time. However, it was apparent that this individual had suffered some acute intraabdominal catastrophe. After suitable preparation a right muscle-splitting McBurney type of incision was made; the mass was approached in a retroperitoneal manner with the idea that if purulent materia1 were encountered in an abscess from a perforated appendix, drainage and perhaps appendectomy could be performed. No abscess was found. Therefore, the peritoneum was opened wideIy and the mass was found to be an ileocoIic intussusception. Reduction was impossible. The 20 cm. of ileum just proximai to the area where the small intestine entered the ~ntussusception was moderately cyanotic and the proximal portion of the smali bowel was slightly dilated. With delivery of the mass from the peritoneal cavity, the cyanosis of this area of smali intestine disappeared and a normal color returned. The areas of the involved ileum, cecum and appendix in the mass were resected between Payr clamps. The free edge of the mesentery of the resected portion of ireurn was sutured to the lateral peritoneal wall and the free ends of the iIeum and cecum brought out of the abdomen together with the two portions of the bowe1 sutured in an approximated position. The peritoneum, muscIe, fascia and skin were closed about the protruding ends of the boweI. Measurement of the specimen after operation when the ileum was cut and the intussusception reduced revealed that about 34 cm. of gangrenous ileum had been removed. A small tumor measuring about I .$ cm. in diameter was present at the head of the intussusception and the serosa1 surface of the ileum opposite the tumor showed a definite umbiIication. The patient did well in the immediate postoperative period. Intubation with a MiIlerAbbott tube was done and the patient was given titrated whole blood and plasma intravenousIy. Sulfadiazine was the chemotherapeutic agent used. Thirty-six hours after operation a catheter was placed into the lumen of Au,qst,
‘949
Intussusception
the ileum and secured with a purse-string suture. Immediate passage of gas and fecal material through the tube was noted. Complirations relative to the operative procedure itseIf did not appear. On the fifth postoperative day the patient complained of a severe headache which was reIieved by caffeine sodium benzoate. Later he again suffered from a severe occipitofrontal headache. Examination of the fundi revealed a shght distention of the retinal veins. With the suspicion that the patient might be suffering from a virus encephalitis of which isolated cases were being seen in the area, a spinal tap was done and an initial pressure of 430 mm. was found. This was reduced but subsequent taps revealed the pressure to be still elevated. Headache was a constant complaint from this time unti1 time of death aithough some relief was obtained by the repeated removal of spinal fluid. The cause of death was increased intracrania1 pressure due to an unknown cause with suspicion that metastasis from a tumor either of the ileum or the testis might be the responsible agent. Post-mortem examination was done with the outstanding findings being widespread tumor masses in the retroperitoneal area. hlultiple areas of metastasis were found in the lungs and the right cerebra1 hemisphere. A single metastasis in the spleen was found. A smah tumor was found in the left testis. Microscopic examination of these tissues revealed that the tumor in the testicle was primary and that the remaining tumors were metastatic. The testicuIar tumor was carcinomatous in nature with large, pale ceIIs with vesicuIar nuclei. Marked pleomorphism and occasiona mitoses were seen. In one section tumor tissue was seen to be invading a blood vessel Examination of the tumor in the ileum which had been removed surgieaIIy showed an identical appearance with the testicular neoplasm. it is noteworthy that the lymph nodes in the immediate area of the tumor in the ileum did not show invasion by tumor cells.
The case reported herein is that of a patient whose presenting compIaint of an embryonal carcinoma of the left testis was the appearance of an iIeocolic intussusception due to an isoIated metastasis
272
MiIIer
et aI.-IIeocoIic
to the iIeum. IIeocoIic resection was done successfuIIy. The patient subsequentIy died of muItipIe metastases wideIy spread throughout the body with the immediate cause of death being respiratory faiIure secondary to increased intracrania1 pres-
Intussusception sure due to a Iarge metastatic right cerebrum.
Iesion in the
REFERENCE
I. AUERBACH, OSCAR, BRINES, OSBORNE 0. and YoGUDA, OSBER. NeopIasms of the testis. J. Ural., 56: 368-374. 1946.
WITH the exception of cases due to gas bacillus infection, acute gangrene of the scrotum is aImost invariably due to the hemolytic streptococcus and, in the opinion of R. C. Robinson, ought to be treated primariIy with peniciIIin rather than surgery. Surgery prematureIy performed may be very detrimental in these acute cases. (Richard A. Leonardo, M.D.)
American
Journal of Surgery