Lymphosarcoma of the rectum

LYMPHOSARCOMA FIVE.YEAR FRANKLIN

I.

HARRIS,

CURE M.D.

OF THE RECTUM*

FOLLOWING AND

FRANCISCO,

T

HE purpose of this case report is to present a five-year cure of a recta1 Iymphosarcoma which was treated onIy by IocaI excision -and fuIguration rather than by more radica1 surgery. The generaIIy accepted treatment of recta1 Iymphosarcoma has been radica1 surgica1 excision of the rectum when possible, foIIowed by radiation, or radiation aIone in inoperabIe cases. Hayes, Burr, and Pruitt,’ in 1940, stated: “ . . . regarding Iymphosarcoma, a11 are agreed that metastases occur ea;Iy and that the onIy hope of a cure is earIy radica1 remova1, foIIowed by irradiation.” Rankin and ChumIey2 reported the resuIts of fifteen resections for Iymphosarcoma of the rectum and coIon with four operative deaths, five with known recurrence at the time of writing, and an average Iength of Iife of eIeven and a haIf months. One patient Iived one year and another four years without recurrence. Tuta and Rosi3 reported a case in 1942 in which the patient was treated with IocaI wide excision foIIowed by irradiation. There is no foIIowup report as yet. T. E. Smith,4 in 1943, reported a case simuIating an internal hemorrhoid which was removed and then treated with irradiation. In 1943, Rosser5 stated that there was no agreement at that time as to the proper management of Iymphoid tumors of the bowe1. N. D. Smith6 summarized the treatment of such tumors by stating that it can be divided into three types : symptomatic, surgica1 and that by radiation, and usuaIIy two or three types are combined. He adds that surgica1 treatment of the part has pro* From the Department

GERALD Adjunct

Chief of Division of Surgery, Mount Zion HospitaI SAN

LOCAL

REMOVAL MASON

FEIGEN,

M.D.

Surgeon, Anorectal Surgery, Mount Zion HospitaI

CALIFORNIA

duced some apparent cures, and radium and roentgen rays have produced some very striking resuIts. The foIIowing patient was treated by IocaI snare excision with fuIguration : CASE

REPORT

M. H., a thirty-five year old white female, began to have diarrhea in the Iatter part of November, 1940. It consisted of three to five soft stooIs daiIy with some sharp recta1 pain occurring momentariIy with each defecation. There were aIso severa episodes of tenesmus. This continued for eight days, and during the Iatter two days of this period she had two to three bowe1 movements daiIy with thick yeIIow mucus and some smaI1 dark red cIots, and one to two Iight brown stooIs. On November 30, 1940, she was examined and a smaI1 polyp, about I cm. in diameter with 3 mm. base, was seen on the posterior rectal waI1, just inside the interna sphincter. This was removed with the diathermy snare and compIeteIy fuIgurated at the base with diathermy. The tumor was examined by Dr. G. Y. Rusk, pathoIogist at Mt. Zion HospitaI at that time, who reported: “Microscopic examination of polypoid mass from rectum shows the epitheIium and mucous membrane normaI. In the submucosa and subjacent tissues are a number of variably sized cIusters of smaI1 mononuclear cells, Iymphocytic in type. Some of the ,ceIIs show less denseIy chromatic staining than typical lymphocytes. CeIIs in mitotic division are present in moderate numbers. The growth invades the deeper structures and through strands of connective tissue. DifferentiaI staining for reticuIum fails to discIose argyrophiIic fibriIs reIated to the tumor ceIIs. Diagnosis: Lymphosarcoma.” (Fig. I .) Examination of the operated area two weeks Iater reveaIed a smaI1 crater-Iike depression on

of Surgery, 277

Mt. Zion Hospital, San Francisco.

278

A me&an Journal of Surgery

Harris,

Feigen-Lymphosarcoma

the posterior walI, just inside the ana canal. HospitaIization was again recommended for more compIete study. PhysicaI examination

on admission

to the

hospita1 was not remarkabIe. Except for a few smaII paIpabIe anterior cervical lymph nodes and sIightIy enlarged biIatera1 inguina1 Iymph nodes, there was no Iymphadenopathy. BIood count: hemogIobin 12.7 Gm., 82.7 per cent; white bIood ceIIs 12,100; poIymorphonucIears 4, Iymphocytes 30; flamented 66; monocytes 79 per cent; coaguIation time 3; bIeeding time 3; urine--trace of aIbumin, seven to eight

white bIood ceIIs per high power, five to six red bIood ceIIs; serology-negative. Sigmoidoscopy disclosed posteriorIy, just inside the interna sphincter, a shaIIow granulating uIcer at the site of the removed poIyp. The base appeared healthy. Barium enema showed muItipIe diverticuIa of the descending coIon; otherwise it was normal. On December biopsy was taken from the 21, 1940, another fulgurated area. This showed no evidence of the tumor noted in the previous biopsy. She was discharged to the out-patient department 23, 1940, for foIIow-up. On on December January 7, 1941, it seemed that there was some change in the operated area, and it was decided to readmit her to the hospita1 for further consideration and possibIe radica1 surgery. Her case was discussed at Grand Surgical Rounds, where a variety of opinions were expressed by different surgeons as to how she shouId be treated. It was decided fin&IIy to give no other treatment and observe her carefuIIy in the out-patient department. On January 14, 1941, she was discharged and foIIowed in the outpatient department at intervaIs of three to four months until June 15, 1943. At that time she feIJ well, had no recta1 compIaints, and there was no paIpabIe or visibIe signs of recurrence. The patient has been seen at intervaIs since then, the Iast time in November, 1945, at which time the findings continued to remain negative and she was in good heaIth. There is some confusion among pathoJogists as to the exact nature of this disease. The Iymphocytic type of Iymphosarcoma is a true neopIasm, infXtrative and destructive. Kundrat’ beIieved that it originates in a singIe site and then extends aIong the Iymphatic system, forming diffuse infiItrations more or Iess distant from

FIG. I. Microphotograph ,of section of rectal lymphosarcoma. The tumor is composed of a soIid sheet of smaI1 Iymphocytes enmeshed by a tine tibrous stroma. Two mitotic figures are readily noted. The stroma does not contain argyrophilic fibrils. X 600.

the origina site. There is no question, however, as to whether every Iymphocytoma which appears to be invasive and to show mitotic figures is cIinicaIIy equaIIy maIignant. Whether the term “benign as mentioned by Boyd,8 is Iymphoma,” acceptabIe or not, there appear to be IocaIized Iymphocytic tumors which may be encountered in the bowe1 and which are not cIinicaIIy maIignant, aIthough in microscopic appearance they are identica1 in many respects with the cIinicaIIy maIignant type of Iymphosarcoma. Ewing9 caIIs Iymphosarcoma of the rectum a maIignant The question is raised: Iymphocytoma. Is there a benign Iymphocytoma of the rectum? Our case wouId seem to beIong in this category. The fact that this growth was smaI1, poIypoid, singIe and unassociated with any symptoms of systemic invoIvement, Ied to the decision to treat it conservativeIy and thus avoid the risk and consequences attending radicaI surgery. Continued, carefu1 observation for a period of five years has discIosed no evidence of recurrence. We beIieve we are justified in concIuding that an occasional recta1 poIyp which proves to be histoIogi-

Vcx.LXXII,

Harris,

No. 2

Feigen-Lymphosarcoma

caIIy Iymphocytoma may ako prove to be cIinicaIIy benign and can be treated successfuIIy by local conservative surgery.

local removal observation.

American Journal of Surgery

and

continued

279

carefu1

REFERENCES

I. HARES, BURR and PRUITT. Lymphoid tumors of the SUMMARY

A case of Iymphosarcoma in a rectal polyp is presented. Treatment consisted onIy of IocaI remova with the diathermy snare and fuIsuration of the base. There is no evidence if recurrence after five years. It is suggested that Iymphosarcoma of the Iymphocytic type, when occurring in a poIyp and unassociated with any evidence of invoIvement of the genera1 lymphatic system, may be cIinicaIIy not maIi&ant, or of such a Iow grade of maIignancy as to permit successful treatment by thorough

2.

coIon and rectum. Surgery, 7: 540, 1940. F. W. and CHUMLEY, C. L. Lymphosarcoma of the colon and rectum. Minnesota Med., I 2 : 247,

KANKIN,

1929. 3. TUSA, J. A. and ROSI, P. A. Lymphosarcoma

4. i;.

6. 7.

8. 9.

of the rectum. Arch. ._%rg., 44: 157, 1942. SWITH, T. E. Primary Ivmphoid tumors of the rectum resembling htekai hemorrhoids. J. A. M. A., 121: 495, 1943. ROSSER. A. In discussion of No. d above. SMITH, N. D. Lymphosarcoma of the rectum and sigmoid. .p. Am. hoc. Sot., 34: 160, 1933. KUNDRAT. Uber Lympho-Sarkomatosis. Wien. klin. Wcbnscbr.. 6: 21 I. 180x. BOYD, WM. i‘extbobk l