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Malignant carcinoid tumor of the colon
Malignant
Carcinoid FRANCIS
Tumor
of the Colon
J. BURNS, M.D., St. Louis, :Missouri
CASE REPORT hf. hl., a sixty-four year old white woman, entered Firmin Desloge Hospital on March 24, 1953. She had had decreased frequency of bowel movement for about two months, with occasional cramping pains after eating. The day before hospital admission the cramps became more severe and more frequent. On admission the abdomen was distended and tympanitic, and bowel sounds were exaggerated. Barium enema showed an obstructive lesion of the left half of the transverse colon. The obstruction was relieved by intubation and on April 1st laparotomy was performed. A moderately large tumor of the mid-portion of the transverse colon was present and on gross examination was found to he malignant. Numerous small metastatic deposits were found on the peritoneal surfaces of the liver, pelvic colon, pelvic peritoneum and transverse mesocolon. No other abnormalities were noted on examination of the remainder of the abdominal contents. The tumor was excised and end-to-end anastomosis was performed. An epiploic appendage M:IS removed from the pelvic colon for biopsy. On April 7th wound disruption with evisceration occurred. The wound was promptly resuturecl, ancl the patient made an uneventful recovery. She \vas discharged from the hospital on April r-th and has remained clinically well to date.
N
1933 Raiford’ reported a series of twentycases of carcinoid tumors; all the I nine carcinoid tumors occurring in the stomach and coIon were malignant. Miller and Herrmann’ collected a series of sixty-eight metastasizing tumors of the gastrointestinal tract. The primary sites of these tumors were the stomach in one case, jejunum in two, ileum in thirtynine, small bowel (unspecified) in nine, appendix in fourteen, and the colon in three. Ritchie and Stafford3 reviewed the literature up to 1944 and found that in series of 332 cases of carcinoid tumors from all sites 126 (37.9 per cent) had shown metastases.4 Horn5 reported two cases of carcinoid tumor in the transverse colon, one without evident metastasis and one with metastasis to the liver. He noted that these were the only two cases of carcinoid of the transverse colon reported in the literature until that time (1949), and only two such cases of carcinoid of the sigmoid colon had been reported. Raphael” added a third case of carcinoid of the sigmoid colon, ancl in 1952 Ferguson7 reported tJlree cases of carcinoid tumor: one in the rectum, one in the transverse colon and one in the cecum. The tumor in the transverse colon was a malignant carcinoid. Therefore only twenty-eight cases of carcinoid tumor of the colon have been reported” in all, and of this number three were cases in \vhich the tumor was in the transverse colon. In two of these three cases the tumor had metastasized. Yletastasis from a carcinoitl tumor is more apt to be present if the tumor is located in the colon rather than in the rectum. KunkeI, Waugh and DockertyX reported a case of rectal carcinoid with metastasis, bringing to fifteen the number of rectal carcinoids with metastasis of a total of 104 cases of rectal carcinoid reported in the literature I,- 1953. Fourteen per cent of rectal carcinoids, therefore, metastasize. Reported herein is a fourth case of a carcinoid tumor of the transverse colon.
PATHOLOGY The following pathologic report is from the hospital record. Crossly, specimen A consisted of a firm, yellow and multinodular piece of tissue (epipJoic appendage) 2 by I by 0.3 cm. Specimen B consisted of 20 cm. of large bowel. Approximately in the middle of this specimen there was an externally visible stricture, otherwise the serosal surface appeared unchanged. On opening the bowel, the mucosal surface of the externally visible stricture 733
Anmiran
Journal
of Surperv.
Volume
yr, Jonuarv.
rui/i
Burns
FIG. I. (High and carcinoid
power.) Adenocarcinoma is seen in the photograph in the photograph on the right.
on the left
these sections. Numerous mitotic figures were seen among the atypica1 gIanduIar epitheIium. A nest of ceIIs simiIar to those seen in specimen A was noted in the muscuIaris. (Fig. I.) The sections of the polyp described in specimen B showed some sIight atypism with occasiona gIands “back-to-back,” aIso some hyperchromatism. However, no evidence of invasion in the stalk was noted. There was a Ioss of poIarity in the epitheIia1 ceIIs in some areas. MicroscopicaIIy one of the Iymph nodes was found to have its normal architecture completely repIaced by nests of ceIIs similar to those seen in specimen A. The other nodes appeared norma and were free of metastasis. Diagnosis was (I) adenocarcinoma of the coIon; (2) maIignant carcinoid-probabIy primary in the coIon: (a) metastasis to the transverse mesocoIon, (b) metastasis to one of five Iymph nodes examined; and (3) adenomatous poIyp of the coIon. This case is unusua1 in that two malignant tumors were present without metastasis from the obvious maIignancy (adenocarcinoma), but with metastasis from the usuaIIy benign carcinoid. The nest of carcinoid ceIIs in the waI1 of the coIon beneath the adenocarcinoma wouId indicate the primary site of the metastatic lesion to be the bowel waI1, aIthough this cannot be stated with certainty.
reveaIed a fungating, firm, pink growth compIeteIy invoIving the mucosa1 circumference for a distance of 3.5 cm. In this area the bowe1 Iumen was Iess than I cm. in diameter. GrossIy, the entire thickness of the bowe1 waI1 in this area had a firm, white appearance. At a distance of 5 cm. from one line of resection there was a peduncuIated tumor I by I by I cm. with a 3 cm. pedicle. It was soft in consistency and pink in coIor. Examination of the mesentery discIosed five firm, white Iymph nodes which varied in size from 0.5 to 1.0 cm. in diameter. The connective tissue surrounding the invoIved portion of intestine aIso appeared invoIved by hard, white tissue. MicroscopicalIy, specimen A, a we11 circumscribed noduIe of tissue surrounded by fat, was composed of nests of ceils divided by thin strands of connective tissue. These cells were basophiIic and had ovoid vesicular nuclei. An occasiona mitotic tigure was seen, and some of the ceIIs were hyperchromatic. These ceIIs had a very monotonous appearance and were dissimiIar from the mass of tumor described in specimen B. In specimen B normaI colonic mucosa could be seen bIending into areas in which the gIands were atypica1, being composed of Iarge hyperchromatic ceIIs. These gIands couId be seen deep in the muscularis near the serosa, but no actua1 serosa1 involvement couId be seen in ‘34
Malignant
Carcinoid
Tumor
of Colon REFERENCES
COMMENTS I. RAIFORD, T.
The obstruction was caused by the adenocarcinoma which apparentIy did not metastasize. Although multiple primary tumors of the bowe1 do occur in about 5 per cent of cases of malignancy of the coIon and rectum, the type of tumor is usually adenocarcinoma. Therefore, and a the finding of an adenocarcinoma malignant carcinoid in the same area of the bowel is quite unusual.
S. Carcinoid
tumors
of the
gastro-
intestinal tract (so-called argentaffine tumors). Am. J. Cancer, 18: 803, 1933. 2. ~ZILLER, E. K. and HERRMANN, \V. W. Argentaffinc tumors of the smal1 bowel, roentgen signs of malignant change. Radiology, 39: 214, 1942. 3. RITCHIE, G. and STAFFORD, W. T. Argentaffinc tumors of gastrointestina1 tract. Arch. Path., 38:
123-127, 1944. 4. TAVF.XXE.R, \I. C., BAWX,
II. E. and PEALE, A. R. Carcinoid tumors of the rectum. J. Internat. Cull. Surgeons, 16: 265 284, 1951. 5. HORK, R. C., JK. Carcinoid tumors of the &on and rectum. Cuncer, 2: 819, 1949.
SUMMARY
A case is presented in which an adenocarcinema and a mahgnant carcinoid tumor occurred in the same area of the transverse colon. Only three cases of carcinoid tumor of the transverse coTon have been reported in the literature and in two of these cases the tumor was malignant. The case reported herein is added to the literature.
6. RAPHAEL., S. S. Carcinoid of the sigmoid colon. Ant. J. Clin. Path., 22: 564-568, 1952. 7. FERGLISON,J. A. Carcinoid of the coion and rectum. J. .\/lichigan M. Sot., 5 I: 467-468, ,952. 8. KIYKEL, W. hi., JR., WAUCH, J. bI. and Do~:K!L.K.~Y, \I. B. Carcinoid of the rectum with metastasis. .4w. Surg., 139: 224-229, 1954.
‘34
Carcinoid FRANCIS
Tumor
of the Colon
J. BURNS, M.D., St. Louis, :Missouri
CASE REPORT hf. hl., a sixty-four year old white woman, entered Firmin Desloge Hospital on March 24, 1953. She had had decreased frequency of bowel movement for about two months, with occasional cramping pains after eating. The day before hospital admission the cramps became more severe and more frequent. On admission the abdomen was distended and tympanitic, and bowel sounds were exaggerated. Barium enema showed an obstructive lesion of the left half of the transverse colon. The obstruction was relieved by intubation and on April 1st laparotomy was performed. A moderately large tumor of the mid-portion of the transverse colon was present and on gross examination was found to he malignant. Numerous small metastatic deposits were found on the peritoneal surfaces of the liver, pelvic colon, pelvic peritoneum and transverse mesocolon. No other abnormalities were noted on examination of the remainder of the abdominal contents. The tumor was excised and end-to-end anastomosis was performed. An epiploic appendage M:IS removed from the pelvic colon for biopsy. On April 7th wound disruption with evisceration occurred. The wound was promptly resuturecl, ancl the patient made an uneventful recovery. She \vas discharged from the hospital on April r-th and has remained clinically well to date.
N
1933 Raiford’ reported a series of twentycases of carcinoid tumors; all the I nine carcinoid tumors occurring in the stomach and coIon were malignant. Miller and Herrmann’ collected a series of sixty-eight metastasizing tumors of the gastrointestinal tract. The primary sites of these tumors were the stomach in one case, jejunum in two, ileum in thirtynine, small bowel (unspecified) in nine, appendix in fourteen, and the colon in three. Ritchie and Stafford3 reviewed the literature up to 1944 and found that in series of 332 cases of carcinoid tumors from all sites 126 (37.9 per cent) had shown metastases.4 Horn5 reported two cases of carcinoid tumor in the transverse colon, one without evident metastasis and one with metastasis to the liver. He noted that these were the only two cases of carcinoid of the transverse colon reported in the literature until that time (1949), and only two such cases of carcinoid of the sigmoid colon had been reported. Raphael” added a third case of carcinoid of the sigmoid colon, ancl in 1952 Ferguson7 reported tJlree cases of carcinoid tumor: one in the rectum, one in the transverse colon and one in the cecum. The tumor in the transverse colon was a malignant carcinoid. Therefore only twenty-eight cases of carcinoid tumor of the colon have been reported” in all, and of this number three were cases in \vhich the tumor was in the transverse colon. In two of these three cases the tumor had metastasized. Yletastasis from a carcinoitl tumor is more apt to be present if the tumor is located in the colon rather than in the rectum. KunkeI, Waugh and DockertyX reported a case of rectal carcinoid with metastasis, bringing to fifteen the number of rectal carcinoids with metastasis of a total of 104 cases of rectal carcinoid reported in the literature I,- 1953. Fourteen per cent of rectal carcinoids, therefore, metastasize. Reported herein is a fourth case of a carcinoid tumor of the transverse colon.
PATHOLOGY The following pathologic report is from the hospital record. Crossly, specimen A consisted of a firm, yellow and multinodular piece of tissue (epipJoic appendage) 2 by I by 0.3 cm. Specimen B consisted of 20 cm. of large bowel. Approximately in the middle of this specimen there was an externally visible stricture, otherwise the serosal surface appeared unchanged. On opening the bowel, the mucosal surface of the externally visible stricture 733
Anmiran
Journal
of Surperv.
Volume
yr, Jonuarv.
rui/i
Burns
FIG. I. (High and carcinoid
power.) Adenocarcinoma is seen in the photograph in the photograph on the right.
on the left
these sections. Numerous mitotic figures were seen among the atypica1 gIanduIar epitheIium. A nest of ceIIs simiIar to those seen in specimen A was noted in the muscuIaris. (Fig. I.) The sections of the polyp described in specimen B showed some sIight atypism with occasiona gIands “back-to-back,” aIso some hyperchromatism. However, no evidence of invasion in the stalk was noted. There was a Ioss of poIarity in the epitheIia1 ceIIs in some areas. MicroscopicaIIy one of the Iymph nodes was found to have its normal architecture completely repIaced by nests of ceIIs similar to those seen in specimen A. The other nodes appeared norma and were free of metastasis. Diagnosis was (I) adenocarcinoma of the coIon; (2) maIignant carcinoid-probabIy primary in the coIon: (a) metastasis to the transverse mesocoIon, (b) metastasis to one of five Iymph nodes examined; and (3) adenomatous poIyp of the coIon. This case is unusua1 in that two malignant tumors were present without metastasis from the obvious maIignancy (adenocarcinoma), but with metastasis from the usuaIIy benign carcinoid. The nest of carcinoid ceIIs in the waI1 of the coIon beneath the adenocarcinoma wouId indicate the primary site of the metastatic lesion to be the bowel waI1, aIthough this cannot be stated with certainty.
reveaIed a fungating, firm, pink growth compIeteIy invoIving the mucosa1 circumference for a distance of 3.5 cm. In this area the bowe1 Iumen was Iess than I cm. in diameter. GrossIy, the entire thickness of the bowe1 waI1 in this area had a firm, white appearance. At a distance of 5 cm. from one line of resection there was a peduncuIated tumor I by I by I cm. with a 3 cm. pedicle. It was soft in consistency and pink in coIor. Examination of the mesentery discIosed five firm, white Iymph nodes which varied in size from 0.5 to 1.0 cm. in diameter. The connective tissue surrounding the invoIved portion of intestine aIso appeared invoIved by hard, white tissue. MicroscopicalIy, specimen A, a we11 circumscribed noduIe of tissue surrounded by fat, was composed of nests of ceils divided by thin strands of connective tissue. These cells were basophiIic and had ovoid vesicular nuclei. An occasiona mitotic tigure was seen, and some of the ceIIs were hyperchromatic. These ceIIs had a very monotonous appearance and were dissimiIar from the mass of tumor described in specimen B. In specimen B normaI colonic mucosa could be seen bIending into areas in which the gIands were atypica1, being composed of Iarge hyperchromatic ceIIs. These gIands couId be seen deep in the muscularis near the serosa, but no actua1 serosa1 involvement couId be seen in ‘34
Malignant
Carcinoid
Tumor
of Colon REFERENCES
COMMENTS I. RAIFORD, T.
The obstruction was caused by the adenocarcinoma which apparentIy did not metastasize. Although multiple primary tumors of the bowe1 do occur in about 5 per cent of cases of malignancy of the coIon and rectum, the type of tumor is usually adenocarcinoma. Therefore, and a the finding of an adenocarcinoma malignant carcinoid in the same area of the bowel is quite unusual.
S. Carcinoid
tumors
of the
gastro-
intestinal tract (so-called argentaffine tumors). Am. J. Cancer, 18: 803, 1933. 2. ~ZILLER, E. K. and HERRMANN, \V. W. Argentaffinc tumors of the smal1 bowel, roentgen signs of malignant change. Radiology, 39: 214, 1942. 3. RITCHIE, G. and STAFFORD, W. T. Argentaffinc tumors of gastrointestina1 tract. Arch. Path., 38:
123-127, 1944. 4. TAVF.XXE.R, \I. C., BAWX,
II. E. and PEALE, A. R. Carcinoid tumors of the rectum. J. Internat. Cull. Surgeons, 16: 265 284, 1951. 5. HORK, R. C., JK. Carcinoid tumors of the &on and rectum. Cuncer, 2: 819, 1949.
SUMMARY
A case is presented in which an adenocarcinema and a mahgnant carcinoid tumor occurred in the same area of the transverse colon. Only three cases of carcinoid tumor of the transverse coTon have been reported in the literature and in two of these cases the tumor was malignant. The case reported herein is added to the literature.
6. RAPHAEL., S. S. Carcinoid of the sigmoid colon. Ant. J. Clin. Path., 22: 564-568, 1952. 7. FERGLISON,J. A. Carcinoid of the coion and rectum. J. .\/lichigan M. Sot., 5 I: 467-468, ,952. 8. KIYKEL, W. hi., JR., WAUCH, J. bI. and Do~:K!L.K.~Y, \I. B. Carcinoid of the rectum with metastasis. .4w. Surg., 139: 224-229, 1954.
‘34