Primary malignant disease of the small intestine

PRIMARY

MALIGNANT DISEASE OF THE SMALL INTESTINE * SHERMAN A. EGER, M.D. Assistant Surgeon,

THOMAS A. SHALLOW, M.D., Attending Surgeon,

Jefferson Medical CoIIege Hospital

Jefferson Medical College HospitaI

AND JAMES B. CARTY, M.D. FeIIowin Surgery, Jefferson Medical College Hospital PHILADELPHIA,

P

RIMARY

intestine surgery

PENNSYLVANIA CASE

mahgnancy of the smaI1 is a chaIIenge to modern because

of

its

rarity,

REPORT

This case is that of a primary adenocarcinoma of the mid-jejunum producing a coatact,

diffI-

B

FIG. I. A, roentgenograxn*ofsmaI1 intestine folIowing barium mea1; showing IistuIa between midjejunum and terminal ileum. B, roentgenogram folIowing barium enema showing the opaque material ascending from the termina1 ileum through the fistuIa to the jejunum.

fistuIous communication with the termina1 iIeum, requiring extensive surgery which was successfuIIY performed. A sixty-nine year oId white female was admitted to the Jefferson Medical CoIIege HospitaI on May 29, 1940, complaining of recurrent attacks of epigastric pain, vomiting and diarrhea during the past two years, accompanied by a gradua1 loss of thirty pounds

cuIty of earIy diagnosis, extensive technic required, high operative mortaIity and For this reason a study grave prognosis. was made of thirty-eight consecutive cases of histoIogicaIIy proven primary maIignancy of the smaI1 bowe1 encountered in the Jefferson MedicaI CoIIege HospitaI. One unusua1 case is described in detail :

* From the Samuel D. Gross SurgicaI Division of the Jefferson Medical CoIIege HospitaI. Presented before the PhiIadeIphia Academy

of Surgery,

372

November,

1942.

NEW SERIES VOL. LXIX,

No. 3

ShaIIow et aI.-MaIignancy

in weight. Increasing in frequency, these attacks finaIIy occurred once or twice a week and Iasted about two hours. The stools had been a putty color but never contained gross bIood or mucous. A gastrointestina1 .x-ray study, February, 1938, showed onIy hypermotiIity of the small intestine. Past history and family history were negative for malignancy. Positive findings were limited to the abdomen where there was a hard, moveable, orange-sized mass to the right of the umbilicus. There was no tenderness, distention or ascites. The blood count showed hemoglobin 48 per cent, red cells 2,~00,000, color index .98 and white cells 5,600. Repeated urine examinations were normaI. The non-protein nitrogen of the blood was 23 mg. The bromsulfalein test revealed a11 dye removed from the bIood serum in thirty minutes. The Van den Bergh reaction was negative direct. A quantitative Van den Bergh and icteris index were 0.6 mg. and 9 units, respectively. Plasma prothrombin time was 50 per cent of average normal. Stool examination was negative for gross and occult blood. Electrocardiographic study was normal. Roentgenographic examination following a barium meal revealed a hstulous communication between the mid-jejunum and the terminal ileum. (Fig. IA.) A barium enema revealed no abnormaIity in the large bowel but showed a considerable amount of opaque materia1 entering the smaII intestine, passing from the terminal iIeum through a fistula into the jejunum. (Fig. IB.) Preoperative treatment extended over a seven-day period and consisted of a high vitamin, high caloric, Iow residue diet, whole blood transfusions, vitamin K, biIe salts and intravenous glucose in saIine solution. On May 31, 1940, under spinal anesthesia, the abdomen was opened through a midright rectus incision. A tumor was found involving the mid-jejunum and terminal ileum about 15 cm. from the iIeoceca1 valve with the area of contact about 4 cm. in Iength in a sideto-side manner. (Fig. 2A.) This mass with involved bowe1 and regiona mesentery was resected (Fig. 2~) followed by an end-to-end end-to-side ileo-ascending jejunojejunostomy, coIostomy and inversion of the stump of the terminal ileum into the cecum. (Fig. 2c.) A temporary iIeostomy was made using a soft rubber catheter. The abdomen was closed without drainage. The total operating time was two hours and fifteen minutes.

of Intestine

A merican JournaI of Surgery

373

PathoIogicaIIy the specimen consisted of two pieces of smal1 intestine, jejunum and ileum, joined together in a side-to-side manner with

u

INVERTED

C

STUMP

OF ,LE”M

w*.,.v

4‘

FIG. 2. A, diagram showing tumor of mid-jejunum with contact carcinoma and fistuIa to terminal ileum. B, diagram showing cIamps in pIace prior to bowe1 resection. c, diagram showing intestinat anastomoses as we11 as inversion of terminal ileal stump completed.

an ostium 2 cm. in diameter connecting them. Both segments were IO cm. in Iength. On the jejunal side of the ostium, extending aIong the mucosa, was a Iarge cauIiflower mass 3 cm. in diameter. (Fig. 3A.) In histological section (Fig. 3~) the normal mucosa was suddenIy interrupted fly a change in character of both the glands and tfle ceIIs composing them. The glands were more numerous, arranged in disorderIy fashion and infiItrated the sub-

374

American JournaI of Surgery

ShaIIow et aI.-Malignancy

mucous tissue. The ceIIs had Iost their secretory power and contained hyperchromatic nucIei and many mitoses.

FIG.

3. A, opened

specimen

showing

of Intestine

SEPTEMBER, 1945

cc. of titrated bIood, intravenous fluids were continued for thirteen days maintaining a daiIy urine output of 1,500 cc. The iIeostomy

250

tumor of jejunum arising from margin tumor shown in Figure 3.4; IOO X.

of ostium.

B, microphotograph

of

FIG. 4. A, postoperative rzentgenogram one and one-half hours after bariumzeal. The outIine of the intestine shows no distention and a normal functioning jejunojejunostomy. B, postoperative roentgenogram four and one-haIf hours after barium meal. The outline of the terminal ileum and colon shows that the ileo-ascending colostomy is functioning.

The diagnosis was primary adenocarcinomn of the jejunum. PostoperativeIy in addition to 500 cc. of 8 per cent suIfaniIamide soIution parenteraIIy daiIy for five days and two transfusions of

tube was withdrawn on the eighth day. Following a satisfactory convalescence, the patient was discharged from the hospita1 on the thirty-third postoperative day, in exceIIent condition.

NEW SERIES VOL. LXIX,

No.

ShaIIow et aI.-Malignancy

3

TABLE FREQUENCY

OF

INTESTINAL

MALIGNANCY

AMONG

~

Author

I

MulIe?“.

FRO-M

Large Intestines

I

-

No. of

Year

375

LITERATURE

SmaII Intestines

Autopsies ~ No.

34.523 20,480

100

Vienna Gen. IHospital

187o 1881 1881 1893

21,358

243

Path.

I886

5,621

41

Inst. of Bernc

Journal of Surgery

COLLECTED

1870 1858 )

Vienna Gem HospitaI

Maydi”

AUTOPSIES

I

’ Vienna Gen. Hospital I

A m&can

I

GENERAL

I

I

Leichtenstern”.

of Intestine

)

j

770

Per Cent

No.

2.23

33

Per Cent

6

,488 1.13

II

9

,729

1891

Hospitals

I leiman”‘.

of Prussia

20,054

I895

1,708

8.50

20

~ 1896

Meyer

and Rosenberglo.

Nickerson and WilIiams2’. Christofferson and Jacobs”. Bowe and NeeIy2”.

I 0,876

569 ~

5.23

IO

I937

I I ,206

IO

10,309

343 163

3.05

I929

I,I9I

I81

I5.

I

8

1,456

918

63.04

22

Cook Co. Hosp. Mich’l. Reese HospitaI Boston City Hospital Cook Co. Hospital Bryan

‘933 I928

Mem. Lincoln

Gen.

‘93’

I937

Medinger’a.

New Eng. Mem.

( i

Total.

Deac.

Palmer

.._........

5.034

A roentgenographic study of the small intestine and colon, three and one-half months revealed no abnormality. after operation, TABLE FREQUENCY

OF

SMALL

GENERAL TABLE

MALIGNANCY

AMONG

MALIGNANCY--UPPER

CARCINOMA,

LOWER

TABLE

SARCOMA

1 Small Intestinal Intestinal -2rcinoma Carcinoma’ ( No.

Author Jefferson12. Meyer and Rosenberg’!‘. Aaron’. Ackman2. IIinzII.

Total..

..

_. .I

__._ _~~ ~_~~~~~~~ Crowtherb. Ullman and Abeshouse”’ StaemmIer2*. Liu’” . . . .._.........._.. Weeden”“. G ravesB. TotaI..

Per Cent

4,177 569 343 600 584

3. ’ ~ 130 I.7 I 10 4.9 ~ 17 7 1.0 ~ ~ 18 i 3.08

6,273

1

IntestinaI Sarcoma

Author

3.66

I34

(Figs. 4A and B.) At the present years after operation, the patient symptom free.

098

time, four is entirely

II

INTESTINAL

INTESTINAL

1927

~ ~

5

I. 50

191 126 394 12 12

I ,

249

1

984

182

1 2.9

SmaII Intestinal Sarcoma ____~ No.

Per Cent

166

61.2 61.9 55.3 75.” 83.3 67.3

1 598

1 60.7

117 78 218 9

10

INCIDENCE

Primary smaII intestina1 malignancy occurs in 0.1 per cent of a11 genera1 autopsies whiIe that of the IargL is found in 3.6 per cent, or thirty-six times as frequent. (TabIe I.) Among genera1 intestina1 carcinoma and sarcoma, the smaI1 bowe1 is invoIved in 3 and 60 per cent, respectiveIy. (TabIe II.) Table III shows that malignancy in genera1 occurs with about equa1 frequency in each of the three divisions of the smaI1 intestine, that carcinoma is found twice as often as sarcoma and that the iIeum ranks Iowest for carcinoma but highest for sarcoma. Of 305 coIIected primary duodena1 carcinomas, Eger’ found 62 per cent in the second portion, 24 per cent in the first, 12 per cent in the third portion and 2 per cent invoIved the entire duodenum. SmaII intestina1 carcinoids comprise 0.02 per cent of autopsy and surgica1

376

American

~~~~~~~ of surgeryShafIow

et aI.-Malignancy

specimens, 8.3 per cent of all smal1 intestinal neopIasms and occur chieffy in the iIeum but occasionaIIy in the jejunum and duodenum (Arie13).

of Intestine

SEPTEMBER.

1945

contradistinction to carcinoma. Carcinoids are usually smaI1, firm, submucosal yellow noduIes which rarely produce obstruction, grow sIowIy and metastasize in 25 per

TABLE III INCIDENCE

AND

DISTRIBUTION

OF

CARCINOMA

AND

SARCOMA

AMONG

PRIMARY

SkfALL

INTESTINAL

MALIGNANCIES

Jejunum

Duodenum I

_~~~~-I Author

Raiford*s. Steinzg Doub and Jones.G Rowe and NeeIy.2”

Ragins and ShiveIv.z* Goldberg “8. Medinger.‘*

No. of Cases

SOWCl

Johns Hopkins Hosp. Edward Hines Jr. Hospital Henry Ford HospitaI Lancaster Co. Lab. Bryan MemoriaI Hosp. LincoIn Gen. Hosp. LincoIn CIinic Cook Count Hospital Presbyterian Hosp., Newark, N.J. IPath.Lab.ofNewEng, Iand DeaconessHosp. Palmer MemoriaI Hosp. Mayo CIinic

Carcinoma

I

Sarcoma

~

Ileum

~-~

I Car& ( noma

Sarcoma

Car& nvma

i

7

20.0’

1

2.9

3

7

2

28.51

o

14.51

2

up to

'3

9

69.3

1

1936 1928

8

up to 1931 ‘931

, Sarcoma

35

)

8.5' 19

28.5

o

1936

I 12.5

0

1 . . ..i

5

62.51

o

7937

'929 10x8

16.7 1939

Weber and KirkIand32 Swenson30.. Presbyterian Hosp. New York, N.Y. Authors’ : Jefferson Hospital series. 1

5.9 17.8 24.4

18.6

TotaI.. * Two cases of malignant Ieiomyoma of the jejunum previously reported by KIopp and Crawford,‘3 denal carcinoma previousIy reported by Lieber, Stewart and Morgan.ls PATHOLOGY

Primary carcinomas of the smaI1 intestine are divided by their gross morphology into three types which in order of frequency are the stenosing (Figs. 5~ and s), the infiltrating or ukerative and the polypoid. (Fig. 6.) Primary sarcoma usually extends toward the mesentery without producing obstruction (exception observed in Figs. 7~ and B) or hemorrhage, in

and I duo-

cent chiefly to the regional nodes and onIy occasionaIIy to the Iiver (Arie13). Thirty-one of the thirty-eight cases of primary smal1 intestina1 maIignancy in this series had evidence of extension or metastasis most frequentIy to the regionat nodes and Iiver. (Table IV.) Of the seven duodenal carcinomas, there was no metasnode involvement tasis in one, regiona in one and widespread metastasis in five. Parsons and MuIIinsz3 beIieve that am-

NEW

SERIES VOL. LXIX,

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ShaIIow et aI.-MaIignancy

puIIary maIignancies first extend aIong the common duct and into the pancreas. In our group of seven ampuIIary Iesions, a11 of

of Intestine

A me&an

Journal of Surgery

377

the onset of symptoms was usuaIIy insidious, aIthough occasionaIIy it was sudden with a perforation, a severe hemorrhage

FIG. 5. A, stenosing adenocarcinoma

of the jejunum. B, opened specimen of stenosing adenocarcinoma of the jejunum.

which were carcinoma, five showed metastasis, but the pancreas was onIy invoIved in one. Of the twenty-four jejuna1 and iIea1 maIignancies, four were without evidence of extension or metastasis, nine invoIved only the regiona modes and eIeven had widespread metastasis. There were no malignant carcinoids. DIAGNOSIS

The earIy diagnosis of primary malignancy of the smaI1 intestine is dependent upon careful evaIuation of the history, physica1, Iaboratory, and roentgen ray findings. Among these thirty-eight cases

or an acute intestinaI obstruction (Figs. 7~ and 7~) ; the duration of symptoms varied from five days to three years, with an average of seven months. Lesions of the ampuIIary portion produced biIiary obstruction before intestina1 obstruction in intermittency and a11 cases; occasiona variation in intensity of the jaundice may result from sIoughing of the tumor, increased intrabiIiary tension ,forcing biIe through the point of constriction and the subsidence of papillary edema. Over 74 per cent of the smaI1 intestina1 neoplasms in this series were palpabIe, usuaIIy fixed in the duodenum and mobiIe in the

378

American ~~~~~~~ surgery

ShaIIow et aI.-MaIignancy

jejunum and ileum. Laboratory studies not onIy aided in the diagnosis, but aIso in determining the severity of the disease

of Intestine

SEPTEMBER, ,945

Vater, two carcinomas and one sarcoma of the jejunum and two carcinomas and two sarcomas of the ileum, even though the

FIG. 6. MuItipIe poIypi of iIeum having undergone malignant change.

duration averaged

and served as a guide in the pre- and postoperative management. Of the twenty-nine cases with roentgenographic gastrointestina studies, the Iesion was demonstrated in seventeen and suggested in another; the examination was unsatisfactory in two duodena1 carcinomas and one extensive sarcoma of the iIeum because of vomiting. Eight neopIasms not demonstrated foIIowing a compIete gastrointestina1 examination were one carcinoma of the ampuIIa of

TREATMENT

AND

AND

RESULTS

OF METASTASES

- -

$ .‘.

TotaI............................../38,

_

1. i

1

::I::j:: 7

group

IV

SITE

c Duodenum-Carcinoma. AmpuIIa of Vater-Carcinoma.. . Jejunum-Carcmoma. Jejunum-Sarcoma. Ileunl-Carcinomn. Ileum-Sarcoma

this

In addition to decompression of the gastrointestina1 tract, it is essential that these patients be improved medically to a maximum degree before operation and supported after operation by correcting any fluid and eIectroIyte imbaIance,

TABLE INCIDENCE

of symptoms for fourteen months.

-

-

NEW Smras VOL. LXIX,

No.

3

ShaIIow

et aI.-MaIignancy

anemia, vitamin and pIasma protein deficiency and impaired function of the heart, Iiver and kidneys.

of Intestine

Ame&an Journal of Surgery

379

continuity of the bowe1 is the treatment of choice. In this series a variety of surgica1 pro-

FIG. 7. A, specimen of lymphosarcoma of the jejunum with intussusception producing obstruction. B, opening specimen of lymphosarcoma of the jejunum with intussusception.

The type of operative procedure depends upon the condition of the patient, the location and extent of the growth and the presence or absence of complications as jaundice or metastasis. EarIy and adequate resection of the growth and regiona mesentery with re-estabIishment of the

cedures was performed. (TabIe v.) The onIy duodenal malignancy resected was a carcinoma in the third portion. The third and fourth portions were resected foIIowed side-to-side duodenoby an antecoIic jejunostomy anastomosing the second portion of the duodenum, just dista1 to the

380

ShalIow et aI.-MaIignancy

A merican ~~~~~~~ of surgery

ampulla of Vater, to the jejunum IO inches from the Iigament of Treitz. The patient was we11 ten months Iater (ShaIIow, Eger, Cartyz7).

in two, without metastasis, had they survived the first stage. AI1 the jejuna1 lesions found at operation were resected folIowed by primary anasto-

TABLE OPERATIVE

PROCEDURES

! Duodenum

~Carcinoma

V

EMPLOYED

IN

AUTHORS’

SERIES

Jejunum

AmpuIIa of Vatcr (larcinoma

SEPTEMBER, ,945

of Intestine

I 1Carcinoma

Ileum

1

;---p,

I Sarcoma I’ Carcinoma

:I Sarcoma

I Total

I-

Resection; side-to-side duodenojejunostomy T-tube drainage of common duct. . Castro-enterostomy . ChoIecystogastrostomy choleGastro-enterostomy, cytojejunostomy Chosecysto-enterostomy, Ytype; gastro-enterostomy Cholecystogastrostomy, Iigation of common bile duct, gastro-enterostomy, enteroenterostomy _. . . Resection; end-to-end anastomosis. . Resection; three separate end-to-end anastomoses. Resection; end-to-end anas- I tomosis with proxima1 rnterostomy Resection; side-to-side anastomosis. Resection of jejunum and, portion of transverse colon, 1 end-to-end anastomoses of, each................... Resection of portion of jejunum foIlowed by end-toend anastomosis; resection of termina1 ileum foIIowed by end-to-side iIeo-ascending colostomy.. Resection; end-to-side anastomosis of iIeum to splenic flexure of colon. ileotransversc Resection; coIostomy, proximal ileostomy....................’ Exteriorization of tumor. Exploratory Iaparotomy

I

1 1

3 I

1

.

I

. 2

2

2

L

I

-1

Total

No. of operations.

4

ij

5

i In the ampullary group, the biIe was redirected to the gastrointestinal tract in al1 cases, but resection was contempIated

3

-I

moses. One, because of a contact carcinomatous fistuIa, aIso required a resection of the termina1 iIeum foIIowed by an

NEW

SERIES Var. LXIX.

ShaIIow et aI.-Malignancy

No. 3

end-to-side anastomosis of the ileum and ascending coIon (see case report). Another produced contact sarcoma to the transverse coIon which was aIso successfuIIy resected and anastomosed primarily. The patient is we11 twelve years Iater. Another died of sarcomatous metastasis after fifteen years (Klopp and Crawford’“).

group, one Iymphosarcoma is well seven years Iater, and the remaining two, which survived the operation, are Iost to foIIow-up. The results of surgery compare very unfavorably with those for maIignancy of the Iarge intestine. Since smaI1 intestinal malignancy metastasizes earIy and its diagnosis is diffkuIt, it is usuaIIy beyond the point of curative resectabiIity when operation is performed. The prognosis of sarcoma seems better than carcinoma. Primary malignancy is most favorabIe in the jejunum and Ieast in the duodenum. Of these thirty-eight cases, twenty-seven were treated surgicaIIy with an operative mortaIity of 44 per cent. (TabIe VI.) Four are Iiving and we11 tweIve, seven, and four years, and ten months, respectively, after operation; four others Iived fifteen, four, three and one year respectively; sixteen survived six months or less; three have been Iost to foIIow up and eIeven expired without surgery. (TabIe VII.) The most common causes of death were metastasis and circuIatory failure. (Table VIII.)

TABI.E VI OPEKATIVEMORTALITYAMONC.TWENTY-SEVEN PRlMARY MALIGNANCIES

OF

THE

SMALL

INTESTINE

Percentage Mortality

Location and Type of Neoplasm

Duodenum Carcinoma. Ampulla of Vater Carcinema. Jejunum Carcinoma, S arcoma. _, lIeurn Carcinoma. Sarcoma..............

4 i;

60

5

20

3

33

3 7

4

33 57

27

I2

44

A mericanJournal of Surgery38 I

of Intestine

SUMMARY

In the iIeum, six maIignant tumors were resected and primary anastomoses were performed, another was mereIy exteriorized and three, not resectabIe, were administered roentgen therapy. Of the resected

AND

CONCLUSIONS

Thirty-eight consecutive and verified cases of primary maIignancy of the small intestine are reviewed and an unusua1 case of jejuna1 carcinoma, producing a contact

TABLE VII END RESULTS

OF THIRTY-EIGHT

i Location and Type of Neoplasm

PRIMARY

I

MALIGNANCIES

I

Expired No. of without Cases Operation

Duration

OF THE

SMALL INTESTINE

of Life FolIowing Operation

I

I

Week MO

I _,-_I

_-

I

Duodenum Carcinoma

. Supra-amp.. Peri-amp.. Infra-amp . Ampulla of Vater Carcinoma. Jejunum Carcinoma.. Jejunum Sarcoma. Ileum Carcinoma.. Ileum Sarcoma.. Total.....

I

2

3 2

1 ’ I 1

!:

2

1

I:.

1 I ’ .’ ( I I I

3 I

I

i

I

-

-

,’

~-

I

..I

I (IO mo.)

~ 1 (4 yr.1

I 1

I

I

3

I

I

2

I

I

I

1’

4

3

382 A mericsn

CAUSES

Journal

OF

of SurgerySh a IIow et aI.-MaIignancy

DEATH

IN

THIRTY-FOVII

REFERENCES

CASES

I

Causes of Death

I

~O;z:on~$_zzn

2.

3.

8 I I

5

8 4.

’

2

2 5.

2

I I ,

. .j

6.

~

: 7.

TotaI..

23 I

of the duodenum. f’biludelpbia Med. J., 3: 280-283, 1899. ACK~IAN, F. D.: Carcinoma of small intestine. Canad. M. A. J., 32: 634-639, 1935. , ARIEL, I. M. Argentaffm (carcinoid) tumors of the smaII intestine. Arch. Path., 27: 25-52, 1939. CHRISTOFFERSON,E. A. and JACOBS,M. B. Primary adenocarcinoma of jejunum with perforation, case with some cIinicopathoIogic notations. J. A. M. A., 112: 1576-1579, 1939. CROWTHER, C. Studio dei sarcomi primitivi de11 intestino tenue con contributio di tre casi OriginaIi. C/in. cbir. Milano, 21: 2107-2144, 1913. DOUB, H. P. and JONES, H. C. The RoentgenoIogic diagnosis of tumors of the small bowel. Am. J. Digest Dis., 8: 149-154, 1941. EGER, S. A. Primary maIignant diseases of the duodenum. Arch. surg., 27: 1087-1108, 1933. GOLDBERG, S. A. UnusuaI neopIasms of smaI1 intestines. Am. J. Clin. Patb., 9: 516528, 1939. GRAVES, S. Primary Iymphoblastoma of the intestine. J. Med. Research, 40: 415-431, 1919-20. HEIMANN, G. Die Verbeitung der Krebserkrankung, die Haufigkeit ihres Vorkommens an den einzel. Arch. f.klin. Chit-., 57: 937, 1898. HINZ, R. Ueber den Primaren Dunndarmkrebs. Arch. f.klin. Cbir., 99: 305-362, 1912. JEFFERSON, G. Carcinoma of the suprapapillary duodenum casuaIIy associated with preexisting simple ulcer; report of a case, and an appendix of 30 coIIected cases. Brit. J. Surg., 4: 209-226, 1916. KLOPP, E. J. and CRAWFORD, B. J. Leiomyoma of the smaII intestine. Ann. .%rg., 101: 726733.

1. AAKON, C. D. Carcinoma

Metastasis.. Circulatory f&me. Acute intestinal obstruction due to metastasis. Pneumonia. . Peritonitis. Hepatorenal insufhciency Gastrointestinal hemorrhage.. Liver and pancreatic necrosis. Diabetic acidosis. Lost to foIIow-up..

of Intestine

II !

fistuIa to the termina1 iIeum, is described in detai1. The incidence of smaI1 intestina1 malignancy among genera1 autopsies is found to be .I per cent or about 36 times less frequent than Iarge intestinal malignancy. Three per cent of intestina1 carcinomas and 60 per cent of intestina1 sarcomas occur in the smaI1 intestine. Carcinoma is twice as common as sarcoma. MaIignancy in genera1 occurs with about equa1 frequency in a11 three divisions of the smaI1 intestine; however, the iIeum ranks Iowest for carcinoma but highest for sarcoma. CarefuI roentgenographic study seems to be the best aid to diagnosis of these Iesions at the present time. AIthough the treatment of choice is earIy and adequate resection of the growth and regional mesentery with re-estabIishment of the continuity of the bowe1, the type of operative procedure depends upon the condition of the patient, the Iocation and extent of the growth and the presence or absence of compIications as jaundice or metastasis. The operative mortahty, 44 per cent for the entire series, is highest in the duodena group and Iowest in the jejuna1 group. The results of surgery in smaI1 intestina1 maIignancy compare unfavorabIy with those for maIignancy of the Iarge intestine.

8. 9. IO.

I I. 12.

13.

‘935. Handbuch d. 14. LEICHTENSTERN, 0. Ziemssen’s Spec. PathoIogie und Therapie. bd. 7, heft 2, 359-555. Leipzig, 1878. 15. LIEBER, M. M., STEWART, H. L. and MORGAN, D. R. Adenosquamous carcinoma of the peri-papiIIary portion of the duodenum. Arch. Surg., 40: 988996, 1940. 16. LIU, J. H. Tumors of the smaI1 intestine with special reference to the Iymphoid ceI1 tumors, twelve cases. Arch. Surg., I I: 602-618, 1925. 17. MAYDL, C. Ueber den Darmkrebs. Wien, 1883. BraumueIIer. 18. MEDINGER, F. G. MaIignant tumors of smaI1 intestine; study of their incidence and diagnostic characteristics. Surg., Gynec. # Ohst., 69: 299305. 1939.

IO. MEYER, J. and ROSENBERG, D. H. Primary carcinoma of the duodenum; report of 4 cases, with review of literature. Arch. Int. Med., 47: 917-941, 193’. 20. MULLER, M. Beitrage zur Kenntniss der Metastasenbildungen maligner Tumoren, nach statistischen Zusammenstellungen aus den SektionsprotokoIIen des Bernischen pathoIogischen Instituts. InauguraI Dissertation, Bern, 1892. 64 pp. 8” Bern, L. Scheim & Co., 1892. 21. NICKERSON, D. A. and WILLIAMS, R. H. Malignant tumors of small intestine. Am. J. Patb., 13: 53-64. ‘937.

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VOL..LXIX.

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ShalIow et aI.-MaIignancy

22. NOTHNAGEL,H. SpezieIIe PathoIogie und Therapie; Diseases of Intestines and Peritoneum. Edited by H. D. Rolleston. London 8: 1032, 1904. 23. PARSONS, W. B. and MULLINS, C. R. Carcinoma ot Papilla of Vnter. Ann. Surg., 102: I ION-I II I, 1935. 24. RAGINS, A. B. and SHIVELY, F. L., JR. Sarcoma of small intestine. Am. J. Surg., 47: 96-104, 1940. 25. RAIFORD, T. S. Tumors of small intestine. Arch. .%r,&, 25: 122, 1932. 26. ROWE, E. W. and NEELY, J. M. Primary malignancy of smaI1 intestine. Radiology, 28: 325-338, ‘937. 27. SHALLOW, T. A., EGER, S. A. and CARTY, J. B. Primary carcinoma of third portion of duod enum. Surgery, 16: 939946, 1944. 28. STAEMMLER, M. Neoplasms of the intestines; two

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of Intestine

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autopsy cases. Deutscbe Cbir., 46: 296-298, 1923. (Quoted by UlIman and Abeshouse.) STEIN, J. J. Tumors of smalI intestine; review of literature and report of 8 additiona cases. Am. J. Digest. Dis. Nutrition, 4: 517-522, 1937. SWENSON, P. C. X-ray diagnosis of the primary malignant tumors of the smal1 intestine. Rev. Gastroenterol., IO: 77-91, 1943. ULLMAN, A. and ABESHOUSE,B. S. Lymphosarcoma of smaI1 and large intestines. Ann. Surg., 95: 878-915, 1932. WEBER, H. M. and KIRKLIN, B. R. Roentgenologic manifestations of tumors of small intestine. Am. J. Roentgenol., 47: 243-253, 1942. WEEDEN, W. M. Lymphosarcoma of the gastrointestinal tract; with report of thirteen cases. Ann. SUrg., 90: 247-252. 1929.

CHRONIC intestinal stasis with possible absorption of toxic matter may resuIt from intestina1 atony, the presence of prenatal or acquired peritonea1 bands or sheets of membrane especiaIIy over the Iower ileum and colon, as Jackson’s membrane or vei1, Lane’s kink or Price’s elbow. Pa.yr’s disease is due to a kink at the spIenic ffexure of the colon. From “PrincipIes and Practice of Surgery” by W. Wayne Babcock (Lea & Febiger).