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Intrinsic lesions of the stomach
INTRINSIC
LESIONS OF THE STOMACH* A REVIEW
ALEX B. RAGINS,
M.D.
OF 458 CASES AND HAROLD
COHEN,
M.D.
Chicago, Illinois ROM 1936 to 1946 a tota of 71 I gastric resections were performed in the surgica1 department of the Cook County Hospital. Of this group, 458 cases were performed for intrinsic Iesions of the stomach. Our anaIysis wiI1 be confined to the Iatter group.
F
TABLE I INTRINSICLESIONS OF
82.1 per cent was encountered. Six cases or 2.8 per cent were found in the second to the third decade, and three cases or 1.4 per cent were
found between the eighth and ninth decades. The youngest patient on which resection for gastric uIcer was performed was twenty-four TABLE
THE
STOMACH
No. of
Type of Lesion
Cases
PerEentage
TotaI..........................
.
’ 214
I’
2 I 1 I I
46.7 48.6 0.65 0.65 0.65 0.43 0.43 0.43 0.43 0.21 0.21 0.21 0.21
458
100.00
223 3 3 3 2
2 2
-__
In this series of 438 cases, 214 or 64.7 per cent were peptic uIcers of the stomach. (Table I.) The race incidence was noted in 192 cases and the distribution was found to be 80 per cent in the white race, 18.2 per cent in the Negro race and 1.04 per cent in the yeIIow race. As to the distribution between men and women, 185 or 86 per cent were found in the former, and twenty-nine or 14 per cent in the latter, a ratio of 6: I. This finding is in keeping with the sex incidence of peptic uIcer when we consider the ratio of essentia1 Iesions as found at autopsy by Portis and Jaffe.l In regard to the distribution of gastric ulcers according to age (TabIe II, Fig. I) the greatest number was found between the fourth and
DISTRIBUTION
Age
(yr.1
_
.-
Benign gastric ulcer.. . . Carcinoma of stomach.. Lymphosarcoma. Polyp with maIignant changes. SyphiIitic gastritis. . Leiomyoma. . Polyps. ReticuIum ceI1 sarcoma. Submucous fibroma. Carcinoma and fibroma. Neurofibroma. . Lipoma.. . Lymphatic Ieukemia..
AGE
2 I-3” 31-40 41-50 5 1-60 61-70 7 I-80 ,,,I:“”
IN
11
CASES
OF
PEPTIC
ULCER
No. of Cases
Percentage
6
2.8
__I_~
1
~
2!
1
!jo
of age and the oIdest was eighty-three years of age. MuItipIe uIcers were encountered in twenty-
years
three cases, eighteen having two uIcers, two havingthree ulcers and three having four uIcers. The Iatter two groups showed uIcers which were subacute in character. The size of the ulcer was found to vary considerably (TabIe III),
ranging in size from 0.2 cm. to 8.0 cm. in diameter. The greatest majority, seventy-four cases or 31 per cent, ranged from 1.0 to 1.9 cm. in their greatest diameter. The gross appearance of the ulcer was uniformIy characteristic, the proxima1 edge showing a gradua1 sloping margin, whereas the dista1 edge was steep and occasionaIIy overhanging. The mucous membrane was slightly reddened and edematous at the edge of the ulcer. The microscopic sections of the gastric ulcers showed the characteristic four Iayers as described by Askanazy,z nameIy, the exudative Iayer, necrotic Iayer, vascuIar granuIation area and the seventh decades in which a tota of I 74 cases or underIying Iayer of dense fibrous connective * From the Departments of Surgery and Surgical Pathology, Cook County HospitaI, Chicago, III. 192
American
Journal
of Surgery
Ragins,
Cohen-Lesions
tissue. In most instances, the Iatter Iayer, except for the few subacute peptic ulcers which we have encountered, had destroyed the muscuIaris propria. The site of 237 ulcers was noted. The greatest number (214) were found aTong the Iesser curvature. (Table IV.)
of Stomach
I93
that muIticentric carcinomatous changes were noted in the mucous membrane at a considerable distance from the ulcer. These malignant changes were noted in two maIes aged seventyfour and sixty-nine, respectively. Two hundred twenty-three patients or 48.6 per cent were re-
TABLE III SIZE
I
Size (cm.)
0.2 I
.o
2.0
to
to to
0.l) I
()
2.9
3.0 to 3.9 4.0 to 4.9 5.0t05.9 6.0 to 6.9 7.0 to 7.9 8.0 to 8.9 Unknown
OF
GASTRIC
ULCERS
No. of Ulcers
Pcrcrntage
62 76 39 33 15 6
25.3 3, .o ‘5.9 13.4 6. I 2.4 0.4 0.” 1.2
0
3 IO ) ------
Total
~
4.0 --____----
245
100.00
~
TABLE IV SITE OF GAsTRI<: ,,LCERS No. of Ulcers
Site
Lesser curvature Greater curvature.. Anterior wall Posterior wall. Unknown.
.I
Total. ‘I
FIG. centage
2’4 12
87.3 7.8 I .2
t: 8
3.2 3.2
245
1950
sected for gastric carcinoma, and of this group, 184 patients or 82 per cent were males and thirty-nine or 18 per cent were females, a ratio of 4.5: I. The race incidence was noted in 183 cases, 75 per cent occurring in the white race, 24 per cent in the Negro race and I per cent in the yellow race. TABLE v
100.00
In our series of 214 gastric ulcers which we have examined there were only two cases which presented evidence of carcinoma arising from a pre-existing peptic ulcer, giving us an incidence of only 0.9 per cent. This is in keeping with the findings of Portis and Jaffe,’ Crohn3 and Abrahamson and Hinton.” In the two cases of peptic ulcer with carcinom’atous changes which we have observed, these changes occurred along the edge of the uIcer, with extension into the adjacent submucosa and dense stroma of the existing peptic uIcer. Both ulcers were located along the lesser curvature, one having a defect measuring 4.5 by 3.5 cm. and the other a defect measuring 2.8 cm. in diameter. In the Iatter case there was evidence of the carcinoma arising independentIy of the ulcer, in view of the fact
August,
I. Age group eupresscd in ten-year periods.
ACE
DISTRIBUTION
Age b-r.1 21-30 31-40 41-50 51-h 6 I -70 71-80 81-90
IN
CARCINOMA
No. of Casts
2
9 22 101 66 22
OF
STOMACH
THE
Percentage
0
C)
4
0
9.8 45.0 30.0 9.8 0 4
Total
The age distribution is summarized in Table v, the youngest being twenty-eight and the oIdest eighty-five years of age. The greatest incidence was noted in the fifth decade in which IO I or 45 per cent were Iisted. (Fig. I .)
Ragins,
‘94
Cohen-Lesions
HistoIogicaHy, the type of carcinoma encountered was chiefly that of adenocarcinoma. This was noted in 203 cases or gr per cent. Scirrhous carcinoma ranked second in frewith eleven cases or 5.4 per cent. quence, Medullary carcinoma was third with six cases, an incidence of 3 per cent; finaIly, there were three cases of colloid carcinoma or I .4 per cent. The gross appearance of the maIignant tumors of the stomach was unfortunateIy not completely described in forty-nine cases. In 179 cases, however, the diffuse ulcerating infiltrating type was noted in 162 patients and the polypoid form was observed in seventeen cases. Of the remaining twenty-one examined cases of intrinsic Iesions of the stomach, the foIIowing were described (TabIe I): syphilitic gastritis three cases; lymphosarcoma three cases; reticulum cel1 sarcoma two cases; fibroma two cases; adenocarcinoma with fibroma one case; benign gIanduIar polyps of the stomach two cases; polyps of the stomach with malignant changes three cases; leiomyoma two cases; fibrosarcoma one case, and neurofibroma one case. This series of twenty-one cases represents a group of unusual lesions of the stomach which are seldom encountered but which have to be considered in the differentia1 diagnosis of gastric ulcers and malignancy. COMMENTS It is apparent from the above study, that gastric surgery for intrinsic Iesions of the stomach concerns itseIf mainIy with the removal of the gastric ulcers and carcinomas. In our series the number of cases of each type is almost equaI. It is obvious then that the preoperative identification of the nature of the Iesion is not as important as the need of resection for the reIief of persistent symptoms of gastric ulcer or carcinoma. We are in agreement with the opinion of Bockus who believes that the important probIem of clinicians is not how often
of Stomach
the gastric ulcer becomes maIignant but whether an ulcerating lesion of the stomach is benign or maIignant. In our series only 0.9 per cent of the uIcers resected reveaIed evidence of carcinomatous tissue at the edge of the ulcer, and of the two cases one suggests a dual lesion, that of peptic ulcer of the stomach and primary carcinoma of the stomach starting from multrcentric foci. It is interesting to note that in our series ol five cases of polyps of the stomach, three showed evidence of malignant changes. One can say, therefore, that polyps of the stomach are a more serious lesion since they more readily develop malignant changes. Of the remaining twenty-one cases described here the incidence is too Iow for any interpretive value, except to say that they are to be considered in the differentia1 diagnosis of intrinsic gastric lesions. CONCLUSION
A survey of 458 intrinsic lesions of the stomach was made, the majority of which were either carcinoma or gastric uIcer. The pathologic differentiation of these Iesions was noted. The incidence of the changes of a carcinoma developing in a gastric uIcer was 0.9 per cent and does not indicate a reason, in our opinion, for radical gastric surgery, for fear of malignant changes in a chronic ulcer but for the indications of gastric uIcer per se. REFERENCES
I. PORTS, A. S. and JAFFE, R. H. A study of peptic uIcer. J. A. M. A., IIO: 6-13, 1938. 2. ASKANAZY, M. Ueber Bau und Entstehung dcs chronischen Magengeschwurs, sowie Soorpilzenbefunde in ihm. Vircbows Arch. f. path. Amt., 234: III, i921,2~0:370, 1924. 3. CROHN, B. B. Affections of the Stomach. Philadelphia, 1927. W. B. Saunders & Co. 4. ABRAHAMSON, R. H. and HINTON, J. W. Gastric carcinoma. Surg., Gynec. Ed Obst., 84: 48 I, 1947. 5. BOCKUS, H. L. Gastroenterology. Vol. I, pp. 416, 43~. Philadelphia, ,943. W. B. Saunders & Co.
American Journal of Surgery
LESIONS OF THE STOMACH* A REVIEW
ALEX B. RAGINS,
M.D.
OF 458 CASES AND HAROLD
COHEN,
M.D.
Chicago, Illinois ROM 1936 to 1946 a tota of 71 I gastric resections were performed in the surgica1 department of the Cook County Hospital. Of this group, 458 cases were performed for intrinsic Iesions of the stomach. Our anaIysis wiI1 be confined to the Iatter group.
F
TABLE I INTRINSICLESIONS OF
82.1 per cent was encountered. Six cases or 2.8 per cent were found in the second to the third decade, and three cases or 1.4 per cent were
found between the eighth and ninth decades. The youngest patient on which resection for gastric uIcer was performed was twenty-four TABLE
THE
STOMACH
No. of
Type of Lesion
Cases
PerEentage
TotaI..........................
.
’ 214
I’
2 I 1 I I
46.7 48.6 0.65 0.65 0.65 0.43 0.43 0.43 0.43 0.21 0.21 0.21 0.21
458
100.00
223 3 3 3 2
2 2
-__
In this series of 438 cases, 214 or 64.7 per cent were peptic uIcers of the stomach. (Table I.) The race incidence was noted in 192 cases and the distribution was found to be 80 per cent in the white race, 18.2 per cent in the Negro race and 1.04 per cent in the yeIIow race. As to the distribution between men and women, 185 or 86 per cent were found in the former, and twenty-nine or 14 per cent in the latter, a ratio of 6: I. This finding is in keeping with the sex incidence of peptic uIcer when we consider the ratio of essentia1 Iesions as found at autopsy by Portis and Jaffe.l In regard to the distribution of gastric ulcers according to age (TabIe II, Fig. I) the greatest number was found between the fourth and
DISTRIBUTION
Age
(yr.1
_
.-
Benign gastric ulcer.. . . Carcinoma of stomach.. Lymphosarcoma. Polyp with maIignant changes. SyphiIitic gastritis. . Leiomyoma. . Polyps. ReticuIum ceI1 sarcoma. Submucous fibroma. Carcinoma and fibroma. Neurofibroma. . Lipoma.. . Lymphatic Ieukemia..
AGE
2 I-3” 31-40 41-50 5 1-60 61-70 7 I-80 ,,,I:“”
IN
11
CASES
OF
PEPTIC
ULCER
No. of Cases
Percentage
6
2.8
__I_~
1
~
2!
1
!jo
of age and the oIdest was eighty-three years of age. MuItipIe uIcers were encountered in twenty-
years
three cases, eighteen having two uIcers, two havingthree ulcers and three having four uIcers. The Iatter two groups showed uIcers which were subacute in character. The size of the ulcer was found to vary considerably (TabIe III),
ranging in size from 0.2 cm. to 8.0 cm. in diameter. The greatest majority, seventy-four cases or 31 per cent, ranged from 1.0 to 1.9 cm. in their greatest diameter. The gross appearance of the ulcer was uniformIy characteristic, the proxima1 edge showing a gradua1 sloping margin, whereas the dista1 edge was steep and occasionaIIy overhanging. The mucous membrane was slightly reddened and edematous at the edge of the ulcer. The microscopic sections of the gastric ulcers showed the characteristic four Iayers as described by Askanazy,z nameIy, the exudative Iayer, necrotic Iayer, vascuIar granuIation area and the seventh decades in which a tota of I 74 cases or underIying Iayer of dense fibrous connective * From the Departments of Surgery and Surgical Pathology, Cook County HospitaI, Chicago, III. 192
American
Journal
of Surgery
Ragins,
Cohen-Lesions
tissue. In most instances, the Iatter Iayer, except for the few subacute peptic ulcers which we have encountered, had destroyed the muscuIaris propria. The site of 237 ulcers was noted. The greatest number (214) were found aTong the Iesser curvature. (Table IV.)
of Stomach
I93
that muIticentric carcinomatous changes were noted in the mucous membrane at a considerable distance from the ulcer. These malignant changes were noted in two maIes aged seventyfour and sixty-nine, respectively. Two hundred twenty-three patients or 48.6 per cent were re-
TABLE III SIZE
I
Size (cm.)
0.2 I
.o
2.0
to
to to
0.l) I
()
2.9
3.0 to 3.9 4.0 to 4.9 5.0t05.9 6.0 to 6.9 7.0 to 7.9 8.0 to 8.9 Unknown
OF
GASTRIC
ULCERS
No. of Ulcers
Pcrcrntage
62 76 39 33 15 6
25.3 3, .o ‘5.9 13.4 6. I 2.4 0.4 0.” 1.2
0
3 IO ) ------
Total
~
4.0 --____----
245
100.00
~
TABLE IV SITE OF GAsTRI<: ,,LCERS No. of Ulcers
Site
Lesser curvature Greater curvature.. Anterior wall Posterior wall. Unknown.
.I
Total. ‘I
FIG. centage
2’4 12
87.3 7.8 I .2
t: 8
3.2 3.2
245
1950
sected for gastric carcinoma, and of this group, 184 patients or 82 per cent were males and thirty-nine or 18 per cent were females, a ratio of 4.5: I. The race incidence was noted in 183 cases, 75 per cent occurring in the white race, 24 per cent in the Negro race and I per cent in the yellow race. TABLE v
100.00
In our series of 214 gastric ulcers which we have examined there were only two cases which presented evidence of carcinoma arising from a pre-existing peptic ulcer, giving us an incidence of only 0.9 per cent. This is in keeping with the findings of Portis and Jaffe,’ Crohn3 and Abrahamson and Hinton.” In the two cases of peptic ulcer with carcinom’atous changes which we have observed, these changes occurred along the edge of the uIcer, with extension into the adjacent submucosa and dense stroma of the existing peptic uIcer. Both ulcers were located along the lesser curvature, one having a defect measuring 4.5 by 3.5 cm. and the other a defect measuring 2.8 cm. in diameter. In the Iatter case there was evidence of the carcinoma arising independentIy of the ulcer, in view of the fact
August,
I. Age group eupresscd in ten-year periods.
ACE
DISTRIBUTION
Age b-r.1 21-30 31-40 41-50 51-h 6 I -70 71-80 81-90
IN
CARCINOMA
No. of Casts
2
9 22 101 66 22
OF
STOMACH
THE
Percentage
0
C)
4
0
9.8 45.0 30.0 9.8 0 4
Total
The age distribution is summarized in Table v, the youngest being twenty-eight and the oIdest eighty-five years of age. The greatest incidence was noted in the fifth decade in which IO I or 45 per cent were Iisted. (Fig. I .)
Ragins,
‘94
Cohen-Lesions
HistoIogicaHy, the type of carcinoma encountered was chiefly that of adenocarcinoma. This was noted in 203 cases or gr per cent. Scirrhous carcinoma ranked second in frewith eleven cases or 5.4 per cent. quence, Medullary carcinoma was third with six cases, an incidence of 3 per cent; finaIly, there were three cases of colloid carcinoma or I .4 per cent. The gross appearance of the maIignant tumors of the stomach was unfortunateIy not completely described in forty-nine cases. In 179 cases, however, the diffuse ulcerating infiltrating type was noted in 162 patients and the polypoid form was observed in seventeen cases. Of the remaining twenty-one examined cases of intrinsic Iesions of the stomach, the foIIowing were described (TabIe I): syphilitic gastritis three cases; lymphosarcoma three cases; reticulum cel1 sarcoma two cases; fibroma two cases; adenocarcinoma with fibroma one case; benign gIanduIar polyps of the stomach two cases; polyps of the stomach with malignant changes three cases; leiomyoma two cases; fibrosarcoma one case, and neurofibroma one case. This series of twenty-one cases represents a group of unusual lesions of the stomach which are seldom encountered but which have to be considered in the differentia1 diagnosis of gastric ulcers and malignancy. COMMENTS It is apparent from the above study, that gastric surgery for intrinsic Iesions of the stomach concerns itseIf mainIy with the removal of the gastric ulcers and carcinomas. In our series the number of cases of each type is almost equaI. It is obvious then that the preoperative identification of the nature of the Iesion is not as important as the need of resection for the reIief of persistent symptoms of gastric ulcer or carcinoma. We are in agreement with the opinion of Bockus who believes that the important probIem of clinicians is not how often
of Stomach
the gastric ulcer becomes maIignant but whether an ulcerating lesion of the stomach is benign or maIignant. In our series only 0.9 per cent of the uIcers resected reveaIed evidence of carcinomatous tissue at the edge of the ulcer, and of the two cases one suggests a dual lesion, that of peptic ulcer of the stomach and primary carcinoma of the stomach starting from multrcentric foci. It is interesting to note that in our series ol five cases of polyps of the stomach, three showed evidence of malignant changes. One can say, therefore, that polyps of the stomach are a more serious lesion since they more readily develop malignant changes. Of the remaining twenty-one cases described here the incidence is too Iow for any interpretive value, except to say that they are to be considered in the differentia1 diagnosis of intrinsic gastric lesions. CONCLUSION
A survey of 458 intrinsic lesions of the stomach was made, the majority of which were either carcinoma or gastric uIcer. The pathologic differentiation of these Iesions was noted. The incidence of the changes of a carcinoma developing in a gastric uIcer was 0.9 per cent and does not indicate a reason, in our opinion, for radical gastric surgery, for fear of malignant changes in a chronic ulcer but for the indications of gastric uIcer per se. REFERENCES
I. PORTS, A. S. and JAFFE, R. H. A study of peptic uIcer. J. A. M. A., IIO: 6-13, 1938. 2. ASKANAZY, M. Ueber Bau und Entstehung dcs chronischen Magengeschwurs, sowie Soorpilzenbefunde in ihm. Vircbows Arch. f. path. Amt., 234: III, i921,2~0:370, 1924. 3. CROHN, B. B. Affections of the Stomach. Philadelphia, 1927. W. B. Saunders & Co. 4. ABRAHAMSON, R. H. and HINTON, J. W. Gastric carcinoma. Surg., Gynec. Ed Obst., 84: 48 I, 1947. 5. BOCKUS, H. L. Gastroenterology. Vol. I, pp. 416, 43~. Philadelphia, ,943. W. B. Saunders & Co.
American Journal of Surgery