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LEIOMYOSARCOMA OF THE STOMACH WITH INTRAPERITONEAL PERFORATION
1305
LEIOMYOSARCOMA OF THE STOMACH WITH INTRAPERITONEAL PERFORATION
J. F. HORLEY M.B. Lond. PATHOLOGIST,
ROYAL
SUSSEX COUNTY SUSSEX
HOSPITAL, BRIGHTON,
REPORTS of leiomyosarcoma of the stomach are sufficiently uncommon for individual examples to deserve
this account alone. Moreover, because the with suitable treatment may be excellent, the prognosis importance of distinguishing this neoplasm from carcinoma of the stomach makes its recognition especially
attention
on
important. The incidence is difficult to compute accurately, for reports have been concerned with single examples. Watson (1950) states that most authorities accept an incidence of 1 case in every 1000 malignant gastric neoplasms. However, Marvin and Walters (1948) found, in the records of the Mayo Clinic for 1907-47, 16 cases among 10,000 surgically verified cases of gastric carcinoma, an incidence of 1 in 625 ; but 10 of these had Marshall and Meissner (1950) occurred in 1940-47. found 9 cases of leiomyosarcoma in 1171 operations for malignant growths of the stomach ; and Cowdell (1950) described 5 examples found among 370 gastric neoplasms. These figures suggest that the present incidence may be about 1 in every 100 gastric malignant growths. Whatever the true incidence may be, its importance can never be judged by weight of numbers alone ; for, if it is recognised, there may be a chance of cure in a patient who would be considered hopelessly inoperable had he a gastric carcinoma of similar extent. many
Case-report aged 49, was admitted to the Royal Sussex County Hospital complaining of severe pain on the left side of the abdomen of sudden onset; for the past 6 months he had had discomfort in his epigastrium. On examination he was restless, sweating, and in pain, with blood-pressure 105/70 mm. Hg. His abdomen was distended and tender, with guarding, and some rigidity of the left side. Bowel sounds were diminished. Clinically a perforated viscus was suspected. Laparotomy was done by Mr. W. R. Forrester-Wood. A large cystic swelling was found adherent to the stomach and transverse colon and had perforated into the lesser sac. It was considered impossible to remove the tumour at that A man,
time ; instead
it
was
incised and drained of
some
30
oz.
of
dark fluid. The abdomen was closed with drainage of the neoplasm and lesser sac. Postoperatively the haemoglobin was 92% ( 100 % = 14.8g.). Subsequently, in spite of intravenous therapy, the blood-urea level rose to 178 mg. per 100 ml. on the tenth postoperative day, and twenty-four hours later the patient died. Necropsy twenty-four hours later showed no evidence of recent loss of weight. In the abdomen was found a tumour with irregular contours but roughly spherical (see figure) and measuring 21 X 16 X 10 cm. Its centre had degenerated and been discharged, leaving a wall which varied in thickness from 3 cm. to paper thinness and was firm and rubbery in consistence. Two perforations of this cystic neoplasm led into the peritoneal cavity : one opened into the lesser sac, and the other was the aperture through which the tumour had been drained to the surface at operation. The neoplasm was adherent to the transverse colon and the spleen, but the adhesions could be broken down easily. It was blended intimately with the tail and body of the pancreas, and one segment of the growth formed part of the wall of the stomach. A perforation of the gastric mucosa, measuring 2 X1 cm., opened into the centre of the neoplasm and thus communicated with the two perforations already mentioned. All the remaining organs of the body were normal, in particular no metastasis was found. Microscopty.—Sections, taken from many parts of the neoplasm, were stained with hæmatoxylin and eosin, Van Gieson, phosphotungstic acid hsematoxylm, and Mallory’s trichrome stains. The tumour consisted chiefly of fusiform cells which stained like smooth muscle. The morphology and arrangement of the cells varied considerably in different parts of the neoplasm : in some there was a very regular pattern of interlacing fibres with few mitotic figures ; in others the cells were plumper and pleomorphic, with 2-3 mitotic figures per high-power field. The tumour had broken through the muscularis mucosa of the gastric wall and was nowhere completely encapsulated. It was growing well into the substance of the pancreas but, except in a few places, the growing edge was tipped with a layer of fibroblasts and round cells. The appearances were those of a leiomyosarcoma of the stomach. Discussion
Leiomyosarcoma of the stomach is described as endogastric when the main bulk of the tumour, usually sessile, lies within the lumen of the stomach, and
gastric when
exo-
expands outside it. According to Golden and Stout (1941) these tumours occur with equal frequency in either sex, and may be found at any age. To the naked eye the tumours are usually irregularly lobulated, and to the touch they are firm and rubbery, quite unlike stony hard and friable carcinoma. Pedunculation, with cyst formation from central degeneration of the neoplasm, is not uncommon in the exogastric type. Extension of growth takes place by slow expansion, and the tumour’s invasive powers are usually slight ; hence it
metastases are slow to develop and were seen in less than 20% of the reported examples. However, a few cases, such as that of Lyons and Schneider (1943), have been described in which widespread metastases were found in the presence of a relatively small primary growth. Microscopically, increased mitotic activity and invasion of neighbouring organs may be found, but parts of the tumour, especially in isolation, may be difficult to distinguish from simple leiomyomas. For this reason, and because the term leiomyosarcoma, although histologically correct, may suggest erroneously a highly malignant neoplasm, Golden and Stout (1941) prefer to describe them as malignant leiomyomas. Clinically, leiomyosarcoma of the stomach, especially the exogastric type, may be completely silent until somE
of stomach : be seen emerging from led into lesser sac.
Leiomyosarcoma can
complete specimen. Tail of pancreas right border. Uppermost perforation -
complication arises. Intestinal blood-loss from ulceration of the overlying gastric mucosa may lead to severe and progressive ansemia, and this, combined with the para doxical coupling of a large epigastric tumour with slight loss of weight, may enable the diagnosis to be mad( preoperatively. The present case is unusual in several ways. Anaemia was not a feature, and the tumour, although large, wa, not palpable, possibly because of cystic degeneration
1306 Perforation into the peritoneal cavity, causing an acute abdominal emergency, has been reported previously only 5 times: in 4 (Fritzsche 1918, Baumgartner 1939, Mass and Kirshbaum 1940, Golden and Stout 1941) it was fatal ; but in 1 (Shepherd 1950) resection was followed by recovery. lu 3 of these 5 cases the tumour was mistaken before necropsy for a perforated gastric carcinoma.
Summary A case of leiomyosarcoma of the stomach with perforation into the peritoneal cavity is described. Leiomyosarcoma of the stomach is diagnosed more often nowadays and may not be so uncommon as used to be supposed. Such cases repay diagnosis because the prognosis is good after surgical excision. I wish to thank Mr. Forrester-Wood for allowing me to report a case admitted under his care and for the interest he has shown in the preparation of this paper. REFERENCES
Baumgartner. C. J. (1939) West. J. Surg. 47, 27. Cowdell, R. H. (1950) Brit. J. Surg. 38, 3. Fritzsche, R. (1918) KorrespBl. scheiz. Az. 48, 1273. Golden, T., Stout, A. P. (1941) Surg. Gynec. Obstet. 73, 784. Lyons, C. G., Schneider, M. (1913) Amer. J. Roentgenol. 49, 393. Marshall, S. F., Meissner, W. A. (1950) Ann. Surg. 131, 824. Marvin, C. P.. Walters, W. (1948) Arch. Surg. 57, 62. Mass, M., Kirshbaum, J. D. (1940) Amer. J. Roentgenol. 44, 716. Shepherd, J. A. (1950) Brit. J. Surg. 37, 479. Watson, K. (1950) Ibid, p. 21.
Fig.
2-The
cut
surface of the tumour.
LEIOMYOMA OF THE STOMACH H. R. KER M.B. Lond., F.R.C.S. SURGICAL
CHARING CROSS REGISTRAR, WEMBLEY HOSPITAL
HOSPITAL
GROUP,
MYOMA of the stomach is not all exceptionally rare Aird (1949) states that it occurs once in every 2000 gastric neoplasms. It mayhe pedunculated and attached to the serous or mucous aspects of the stomach, ami usually presents hy causing pyloric obstruction, or ulceration of a submucous growth. The case here described is of interest because the only symptom was nocturnal dyspepsia, present for some years, and because of the unusual manner in which it finally became an emergency. tumour.
Case-report Case-report
patient was a fit retired Guards omcer of 77. On Feb. 18, slipped and teH on ice. and was brought to Wembley Hospital complaining oi pain in the let’t, hip. Clinical and The
19.).B he
examination showed an iniracapsular fracture of the neck of the left femur, and he was admitted for pinning. In the course of routme preoperative examination he stated that he was perfectly well exce])t for nocturnal dyspepsia, from which ltc had suffered for about seven years. There was
radiological
AN UNUSUAL CASE
slight feeling of fullness after meals during the day, but when he retired to bed he would get cohcky epigastric pain, and would vomit a small amount of bile-stained fluid almost every night. The house-surgeon vereda round, mobile, non-tender tumour, thesize of a grapefruit, situated in the epigastrium just to the rmln ot the miclline. The only other abnormahty was a hydrocele of t])e right tunica vaginalis. It was felt that the treatment of lus fracture was of more urgent importancethan his abdominal tumour, and as X-ray examination did not reveal any evidence of’ a secondary deposit, a Smith-Petersen pin was inserted by Mr. A. J. Cokkinis on Feb. 24. Postoperative progress was satisfactory, apart from his old feeling of epigastric discomfort, and bilious regurgitation on the first day. On Feb. 26 lie complamed of more pain, and the vomiting became more severe. A milk drip was tried, but this did not relieve him, and an mtravenous drip with gastric a
aspiration
was set up.
I first saw him on the 4th postoperative day, by which time he had been on intravenous fluids for three days. He had been taking fluids by mouth, but the aspirations had exceeded the intake by about 3 oz. per day. He wasa thin man, with a hard round mobile tumour iii the epigastrium to the left of the midline. This fact was pointed out to the houseman, who announced himself to be undismayed —the tumour had been on the right on admission, and if it chose to move, he could not hold himself responsible for n. At this stage it was found that a barium meal performedt the request of his own doctor in 1949 was available. This showed that the stomach and first part of the duodenum were pushed to the left apparently by some radiotranslucent body. These films had been taken with the patient standing. There had apparently been no clinical evidence of a tumour at that time. It was decided that since gastric obstruction was complete, laparotomy must 1w performed. The provisional diagnosis was carcinoma of the stomach, or pancreatic cyst. ,
’
Operation On March 1, after anæsthesia had been induced by Dr. R. J. the abdomen was palpated, and the tumour could not be felt at all in the epigastrium. The abdomen was opened through a loft, paramedian incision. A large tumour 15 cm. by 12 cm. (figs. 1 and 2) was found in front of the descending colon just, bolow the level of the umbilicus. When it was delivered into the wound, it was found to be
Clausen,
Fig. I-The
tumour
after removal.
LEIOMYOSARCOMA OF THE STOMACH WITH INTRAPERITONEAL PERFORATION
J. F. HORLEY M.B. Lond. PATHOLOGIST,
ROYAL
SUSSEX COUNTY SUSSEX
HOSPITAL, BRIGHTON,
REPORTS of leiomyosarcoma of the stomach are sufficiently uncommon for individual examples to deserve
this account alone. Moreover, because the with suitable treatment may be excellent, the prognosis importance of distinguishing this neoplasm from carcinoma of the stomach makes its recognition especially
attention
on
important. The incidence is difficult to compute accurately, for reports have been concerned with single examples. Watson (1950) states that most authorities accept an incidence of 1 case in every 1000 malignant gastric neoplasms. However, Marvin and Walters (1948) found, in the records of the Mayo Clinic for 1907-47, 16 cases among 10,000 surgically verified cases of gastric carcinoma, an incidence of 1 in 625 ; but 10 of these had Marshall and Meissner (1950) occurred in 1940-47. found 9 cases of leiomyosarcoma in 1171 operations for malignant growths of the stomach ; and Cowdell (1950) described 5 examples found among 370 gastric neoplasms. These figures suggest that the present incidence may be about 1 in every 100 gastric malignant growths. Whatever the true incidence may be, its importance can never be judged by weight of numbers alone ; for, if it is recognised, there may be a chance of cure in a patient who would be considered hopelessly inoperable had he a gastric carcinoma of similar extent. many
Case-report aged 49, was admitted to the Royal Sussex County Hospital complaining of severe pain on the left side of the abdomen of sudden onset; for the past 6 months he had had discomfort in his epigastrium. On examination he was restless, sweating, and in pain, with blood-pressure 105/70 mm. Hg. His abdomen was distended and tender, with guarding, and some rigidity of the left side. Bowel sounds were diminished. Clinically a perforated viscus was suspected. Laparotomy was done by Mr. W. R. Forrester-Wood. A large cystic swelling was found adherent to the stomach and transverse colon and had perforated into the lesser sac. It was considered impossible to remove the tumour at that A man,
time ; instead
it
was
incised and drained of
some
30
oz.
of
dark fluid. The abdomen was closed with drainage of the neoplasm and lesser sac. Postoperatively the haemoglobin was 92% ( 100 % = 14.8g.). Subsequently, in spite of intravenous therapy, the blood-urea level rose to 178 mg. per 100 ml. on the tenth postoperative day, and twenty-four hours later the patient died. Necropsy twenty-four hours later showed no evidence of recent loss of weight. In the abdomen was found a tumour with irregular contours but roughly spherical (see figure) and measuring 21 X 16 X 10 cm. Its centre had degenerated and been discharged, leaving a wall which varied in thickness from 3 cm. to paper thinness and was firm and rubbery in consistence. Two perforations of this cystic neoplasm led into the peritoneal cavity : one opened into the lesser sac, and the other was the aperture through which the tumour had been drained to the surface at operation. The neoplasm was adherent to the transverse colon and the spleen, but the adhesions could be broken down easily. It was blended intimately with the tail and body of the pancreas, and one segment of the growth formed part of the wall of the stomach. A perforation of the gastric mucosa, measuring 2 X1 cm., opened into the centre of the neoplasm and thus communicated with the two perforations already mentioned. All the remaining organs of the body were normal, in particular no metastasis was found. Microscopty.—Sections, taken from many parts of the neoplasm, were stained with hæmatoxylin and eosin, Van Gieson, phosphotungstic acid hsematoxylm, and Mallory’s trichrome stains. The tumour consisted chiefly of fusiform cells which stained like smooth muscle. The morphology and arrangement of the cells varied considerably in different parts of the neoplasm : in some there was a very regular pattern of interlacing fibres with few mitotic figures ; in others the cells were plumper and pleomorphic, with 2-3 mitotic figures per high-power field. The tumour had broken through the muscularis mucosa of the gastric wall and was nowhere completely encapsulated. It was growing well into the substance of the pancreas but, except in a few places, the growing edge was tipped with a layer of fibroblasts and round cells. The appearances were those of a leiomyosarcoma of the stomach. Discussion
Leiomyosarcoma of the stomach is described as endogastric when the main bulk of the tumour, usually sessile, lies within the lumen of the stomach, and
gastric when
exo-
expands outside it. According to Golden and Stout (1941) these tumours occur with equal frequency in either sex, and may be found at any age. To the naked eye the tumours are usually irregularly lobulated, and to the touch they are firm and rubbery, quite unlike stony hard and friable carcinoma. Pedunculation, with cyst formation from central degeneration of the neoplasm, is not uncommon in the exogastric type. Extension of growth takes place by slow expansion, and the tumour’s invasive powers are usually slight ; hence it
metastases are slow to develop and were seen in less than 20% of the reported examples. However, a few cases, such as that of Lyons and Schneider (1943), have been described in which widespread metastases were found in the presence of a relatively small primary growth. Microscopically, increased mitotic activity and invasion of neighbouring organs may be found, but parts of the tumour, especially in isolation, may be difficult to distinguish from simple leiomyomas. For this reason, and because the term leiomyosarcoma, although histologically correct, may suggest erroneously a highly malignant neoplasm, Golden and Stout (1941) prefer to describe them as malignant leiomyomas. Clinically, leiomyosarcoma of the stomach, especially the exogastric type, may be completely silent until somE
of stomach : be seen emerging from led into lesser sac.
Leiomyosarcoma can
complete specimen. Tail of pancreas right border. Uppermost perforation -
complication arises. Intestinal blood-loss from ulceration of the overlying gastric mucosa may lead to severe and progressive ansemia, and this, combined with the para doxical coupling of a large epigastric tumour with slight loss of weight, may enable the diagnosis to be mad( preoperatively. The present case is unusual in several ways. Anaemia was not a feature, and the tumour, although large, wa, not palpable, possibly because of cystic degeneration
1306 Perforation into the peritoneal cavity, causing an acute abdominal emergency, has been reported previously only 5 times: in 4 (Fritzsche 1918, Baumgartner 1939, Mass and Kirshbaum 1940, Golden and Stout 1941) it was fatal ; but in 1 (Shepherd 1950) resection was followed by recovery. lu 3 of these 5 cases the tumour was mistaken before necropsy for a perforated gastric carcinoma.
Summary A case of leiomyosarcoma of the stomach with perforation into the peritoneal cavity is described. Leiomyosarcoma of the stomach is diagnosed more often nowadays and may not be so uncommon as used to be supposed. Such cases repay diagnosis because the prognosis is good after surgical excision. I wish to thank Mr. Forrester-Wood for allowing me to report a case admitted under his care and for the interest he has shown in the preparation of this paper. REFERENCES
Baumgartner. C. J. (1939) West. J. Surg. 47, 27. Cowdell, R. H. (1950) Brit. J. Surg. 38, 3. Fritzsche, R. (1918) KorrespBl. scheiz. Az. 48, 1273. Golden, T., Stout, A. P. (1941) Surg. Gynec. Obstet. 73, 784. Lyons, C. G., Schneider, M. (1913) Amer. J. Roentgenol. 49, 393. Marshall, S. F., Meissner, W. A. (1950) Ann. Surg. 131, 824. Marvin, C. P.. Walters, W. (1948) Arch. Surg. 57, 62. Mass, M., Kirshbaum, J. D. (1940) Amer. J. Roentgenol. 44, 716. Shepherd, J. A. (1950) Brit. J. Surg. 37, 479. Watson, K. (1950) Ibid, p. 21.
Fig.
2-The
cut
surface of the tumour.
LEIOMYOMA OF THE STOMACH H. R. KER M.B. Lond., F.R.C.S. SURGICAL
CHARING CROSS REGISTRAR, WEMBLEY HOSPITAL
HOSPITAL
GROUP,
MYOMA of the stomach is not all exceptionally rare Aird (1949) states that it occurs once in every 2000 gastric neoplasms. It mayhe pedunculated and attached to the serous or mucous aspects of the stomach, ami usually presents hy causing pyloric obstruction, or ulceration of a submucous growth. The case here described is of interest because the only symptom was nocturnal dyspepsia, present for some years, and because of the unusual manner in which it finally became an emergency. tumour.
Case-report Case-report
patient was a fit retired Guards omcer of 77. On Feb. 18, slipped and teH on ice. and was brought to Wembley Hospital complaining oi pain in the let’t, hip. Clinical and The
19.).B he
examination showed an iniracapsular fracture of the neck of the left femur, and he was admitted for pinning. In the course of routme preoperative examination he stated that he was perfectly well exce])t for nocturnal dyspepsia, from which ltc had suffered for about seven years. There was
radiological
AN UNUSUAL CASE
slight feeling of fullness after meals during the day, but when he retired to bed he would get cohcky epigastric pain, and would vomit a small amount of bile-stained fluid almost every night. The house-surgeon vereda round, mobile, non-tender tumour, thesize of a grapefruit, situated in the epigastrium just to the rmln ot the miclline. The only other abnormahty was a hydrocele of t])e right tunica vaginalis. It was felt that the treatment of lus fracture was of more urgent importancethan his abdominal tumour, and as X-ray examination did not reveal any evidence of’ a secondary deposit, a Smith-Petersen pin was inserted by Mr. A. J. Cokkinis on Feb. 24. Postoperative progress was satisfactory, apart from his old feeling of epigastric discomfort, and bilious regurgitation on the first day. On Feb. 26 lie complamed of more pain, and the vomiting became more severe. A milk drip was tried, but this did not relieve him, and an mtravenous drip with gastric a
aspiration
was set up.
I first saw him on the 4th postoperative day, by which time he had been on intravenous fluids for three days. He had been taking fluids by mouth, but the aspirations had exceeded the intake by about 3 oz. per day. He wasa thin man, with a hard round mobile tumour iii the epigastrium to the left of the midline. This fact was pointed out to the houseman, who announced himself to be undismayed —the tumour had been on the right on admission, and if it chose to move, he could not hold himself responsible for n. At this stage it was found that a barium meal performedt the request of his own doctor in 1949 was available. This showed that the stomach and first part of the duodenum were pushed to the left apparently by some radiotranslucent body. These films had been taken with the patient standing. There had apparently been no clinical evidence of a tumour at that time. It was decided that since gastric obstruction was complete, laparotomy must 1w performed. The provisional diagnosis was carcinoma of the stomach, or pancreatic cyst. ,
’
Operation On March 1, after anæsthesia had been induced by Dr. R. J. the abdomen was palpated, and the tumour could not be felt at all in the epigastrium. The abdomen was opened through a loft, paramedian incision. A large tumour 15 cm. by 12 cm. (figs. 1 and 2) was found in front of the descending colon just, bolow the level of the umbilicus. When it was delivered into the wound, it was found to be
Clausen,
Fig. I-The
tumour
after removal.