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Smooth muscle tumors of the stomach
SMOOTH
MUSCLE TUMORS
JACK W.
COLE, M.D.
AND
OF THE STOMACH*
FRANK
M.
BARRY,
M.D.
Cleveland, Ohio
T
HE purpose of this paper is to present four cases of smooth muscIe tumors of the stomach seen on the surgical service of the University HospitaIs during the past eighteen months and to discuss brieffy the subject of smooth muscle tumors of the stomach in generaI. Two of our cases were benign Ieiomyomas and two were Ieiomyosarcomas and of particular interest in either their cIinica1 manifestations or probIem of therapeutic management. Inasmuch as the surgica1 prognosis is good in these cases even when sarcomatous degeneration is demonstrated histoIogicaIIy, it has become increasingly important for the surgeon to keep these Iesions in mind when there is evidence of occuIt or massive gastric hemorrhage or a paIpabIe upper abdomina1 mass. SeveraI authors have adequateIy reviewed the Iiterature1s3,4’6’14 and further eIaboration on this aspect of the probIem does not faI1 within the scope of this paper. UnquestionabIy the incidence of smooth muscle tumors of the stomach is quite high when we consider those cases which are recorded as incidenta findings at autopsy as we11 as Iaparotomy. A routine examination of fifty stomachs at autopsy picked at random by Meissner12 reveaIed Ieiomyomas occurring in twenty-three cases, 46 per cent. However, the patients who become symptomatic and present themseIves for diagnosis and treatment are stiI1 considered uncommon in most cIinics. Leiomyomas constitute 39.9 per cent of a11 benign gastric tumors according to CoIIins and CoIIins.4 Leiomyosarcomas comprise IO per cent of a11 gastric sarcomas according to Schind1er.l’ Smooth muscIe tumors of the stomach * From the Department
of Surgery, Western
with symptoms necessitating hospitalization occur most commonIy between the ages of forty and seventy. A review of 363 cases by Chaffin showed an age range of seven years to ninety years. The average age in our cases was forty-nine years and represents both benign and maIignant Iesions. Leiomyomas and Ieiomyosarcomas of the stomach have approximateIy equa1 incidence in maie and femaIe patients. Pathology. These tumors arise in the muscuIaris of the stomach. They may be divided for cIinica1 purposes into intragastric (submucosal) and extragastric (subserosal) depending on whether the tumor protrudes into the Iumen of the stomach or whether its growth is predominantly beneath the serosa and into the surrounding peritonea1 cavity. The submucosa1 type is most commonly associated with uIceration. The tumor generaIIy appears to be encapsuIated and cIearIy demarcated even with sarcomatous Iesions. In the absence of obvious metastases or invasion of surrounding organs by the tumor it is impossibIe to determine by the gross appearance whether or not the tumor is benign or malignant. The tumor may be quite vascuIar. HistoIogicaIIy they are composed of fusiform ceIIs with elongated and rounded basophiIic nucIei containing fine chromatin materia1. Evidence of sarcomatous degeneration is not always cIear-cut, depending on the appearance of mitotic figures, pIeomorphism and the degree of necrosis. MeInick’3 reported a case of metastasizing Ieiomyoma which appeared benign histoIogicaIIy but gross Iiver metastases were present. AIthough reports have differed as to the
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site from which these tumors most commonIy arise in the stomach, our experience indicates a predisposition for the cardia on the greater curvature. Laheys reports the highest incidence in the lower portion of the stomach with equa1 distribution between the greater and Iesser curvature. GoIden and Stout” reported that 60 per cent occur in the pyloric region, 20 per cent in the pars media and 15 per cent in the cardia. Symptoms. While these tumors may have a rather wide variety of clinical manifestations, a high percentage will present objective or subjective evidence of gastrointestinal hemorrhage. Hematemesis is common. Anemia is often profound giving rise to symptoms of paIpitation, weakness and exertional dyspnea. In a11 four of the cases presented in this communication frank hemorrhage or symptoms referabIe to marked anemia due to insensibIe blood Ioss were present. Five out of seven cases reported by Lahey 8 had hematemesis or tarry stools. A paIpable epigastric mass is frequentIy present occurring most commonIy in Ieiomyosarcomas. In three cases of Ieiomyosarcomas reported by HorsIey and Berger? a mass was noted on physica examination and “its size was out of proportion to patient’s weIIbeing.” We beIieve that this point shouId be emphasized in the differentia1 diagnosis of more mabgnant Iesions causing gastric hemorrhage and that not infrequentIy the patient’s nutritiona state is exceIIent with onIy sIight weight 10s~. The pain which frequentIy accompanies the Iesion is generaIly miId and characterized chiefly ‘as a duII, gnawing epigastric distress. It may be severe, however, and simuIate a peptic uIcer” and occasionaIIy responds to an uIcer diet aIthough the beneficia1 effect as wouId be expected is generaIIy transient. There are cases reported in the Iiterature of peduncuIated smooth muscIe tumors occluding the Iumen of the pyIorus, leading to signs and symptoms of high intestinal obstruction with gastric diIatation and
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persistent vomiting. 11p16Other cases, generalIy the Ieiomyosarcomas, may have necrosis of the tumor mass with contamination of the peritonea1 cavity and present the cIinica1 picture of peritonitis.6p1a These findings however are uncommon. Diagnosis. These tumors should aIways be considered in the differentia1 diagnosis of Iesions producing gastric hemorrhage or occuIt bIood in the stooIs. FIuoroscopic and x-ray examination of the stomach remains the single best method for demonstrating a tumor mass in the stomach and uIcer formation. Much has been written concerning the roentgenoIogic appearance of these Iesions and the criteria for differentiating these tumors from other gastric neopIasms.2’15 Perhaps the greatest pitfall is in overIooking Iesions high on the cardia (Case III) and specia1 technics have been advocated to obviate this source of error. Gastroscopic examination frequentIy can be heIpfu1 to the surgeon in estabIishing the preoperative diagnosis. In two of four cases of Ieiomyosarcoma reported by SchindIer” gastroscopy disclosed the presence of a gastric tumor overlooked on x-ray examination. Treatment. Our views are in accordance with those expressed by Laheys who advocates high subtota1 gastric resection. Because of the Iow grade maIignancy seen in Ieiomyosarcomas they offer a good prognosis when treated radicaIIy. Lemon9 reports a case in which the patient Iived for six years with gross Iiver metastases. In addition, the fact that these Iesions cannot be easiIy recognized in the gross as benign or maIignant Iends support to the necessity of performing gastric resection rather than IocaI excision. Microscopic study with frozen section technic is often inconcIusive in estabIishing of maIignancy in these the diagnosis Iesions. We wouId be extremeIy hesitant to perform a simpIe IocaI excision of a gastric tumor on the strength of a frozen section biopsy interpreted whiIe the operation was in progress. The surgeon shouId be prepared to remove any surrounding structures
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the abdomen and determine the presence of invasion of contiguous structures by the tumor. Complications. The postoperative compIications in these cases are essentiaIIy those incident to any major gastric procedure. It is we11 to bear in mind that these tumors may be quite vascuIar and hemostasis is Imperative. (Case IV.) In Case I the patient deveIoped a pIeura1 effusion and a Ieft subdiaphragmatic abscess as a resuIt of Ieakage from the anastomosis. Cases II and III had occasiona bouts of postprandia1 epigastric distress and infrequent vomiting attributed to diminished gastric capacity. These symptoms cIeared in both instances when the patient was pIaced on smaI1, frequent feedings. CASE FIG. I. Case I. L&myoma filling defect in the car&a
of the stomach showing with central ulceration.
which may be involved by direct spread of the tumor whenever feasible. A Iarge part of the excelIent results reported in recent years in the management of these cases can be attributed to the IiberaI use of whoIe bIood transfusions in correcting the patient’s anemia preoperativeIy. A probIem which may occasionaIIy confront the surgeon is the necessity of having to operate upon these patients as an emergency procedure because of severe intractabIe hemorrhage. In an aheady anemic patient this is extremeIy hazardous. Whenever possibIe surgery shouId be forestalIed unti1 adequate blood repIacement therapy has been instituted. In lesions such as those described in Case I and Case III situated high in the cardia it is necessary to mobihze the Iower end of the esophagus to effect a satisfactory esophagogastrostomy anastomosis foIIowing remova of the stomach. We have been able to accomplish this transabdominally but acknowIedge the merits of a transthoracic approach. In our opinion, however, the abdomina1 method affords a somewhat better opportunity to expIore
REPORTS
CASE I. A fifty-seven year oId white housewife was admitted to the University HospitaIs on May 5, 1948, with the chief compIaints of severe headaches which began three weeks prior to admission. These headaches were Iocalized in the fronta and occipital areas, present chiefly on arising in the morning and relieved by aspirin. For the same period of time the patient had noted duI1, constricting, substernal discomfort with associated dyspnea. These episodes lasted ten to sixty minutes and were relieved by rest. The patient had no symptoms referable to the gastrointestinal tract. There was no weight Ioss and no known bIood 10s~. Physical examination reveaIed a we11 deveIoped, slightly obese woman who did not appear acutely ill. The only significant hnding was a marked paIlor of the mucous membranes of her mouth, conjunctivas and nail beds. Abdominal and rectal examinations were negative. Her heart was not enIarged to percussion. II bIowing, precordial There was a Grade systolic murmur. Her lungs were clear to auscuItation. Laboratory studies revealed an erythrocyte count of 2,140,000 and a hemoglobin of 37 per cent. Plasma proteins, blood urea nitrogen, urine and white blood count were within normal limits. There was free acid on gastric anaIysis fohowing histamine. Stool examination was negative for occult bIood. GastrointestinaI x-ray studies found “a 4 cm. X 5 cm. tumor in the cardiac end of the American
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Frc. 2. Case I. Photomicrograph showing fusiform tumor cells with basophilic staining nuctei arranged in characteristic bundIes; Ieiomyoma of stomach. x 179.
stomach. The tumor may represent a benign or malignant leiomyoma with a smaI1 ulcer less than I cm. in size. A carcinoma might also have this appearance.” (Fig. I.) FolIowing severa days’ preparation with repeated whole blood transfusions the patient was taken to surgery and under cycIopropane anesthesia a high subtota1 gastric resection was performed with anastomosis of the Iower end of the esophagus to the smaI1 portion of remaining stomach. The pathoIogic diagnosis was Ieiomyoma of the stomach. (Fig. 2.) Postoperatively a left subdiaphragmatic abscess developed in the patient which was drained. A Ieak at the site of anastomosis, communicating with the abscess cavity, was demonstrated with barium swaIIow. The fistuIous tract cIosed eventuaIIy with conservative management and the patient is alive and we11 today. CASE II. A forty year oId coIored maid was admitted on December rg, 1947, compIaining of being weak and tired for two weeks. She had enjoyed exceIIent heaIth unti1 one month prior to admission at which time she began to have episodes of bIoating in her epigastrium following meaIs. Two weeks foIIowing onset of epigastric distress she became progressively weak and tired and anorexia developed. These symptoms became severe and in performing househoId chores the patient would .frequentIy have to lie down to avoid fainting. Because of the increasing severity of her symptoms the
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FIG. 3. Case II. GastrointestinaI x-ray demonstrating Wing defect on greater curvature of stomach in the pars media; Ieiomyoma of stomach.
patient became confined to her bed. Efforts to arise produced marked diaphoresis, paIpitation and a feeIing of faintness. She had noticed no weight Ioss, pain, nausea or vomiting. Hospitalization was advised by her physician at this time. Examination revealed a we11 deveIoped, we11 nourished, coIored female appearing weak and listless. All mucous membranes were pale. Physical examination of heart, Iungs and abdomen was negative. Recta1 examination was negative and reff exes physioIogic. Laboratory studies showed an erythrocyte count of 1,320,000 and hemoglobin of 3 gm. In the bIood smear there were three normobIasts per IOO white bIood ceIIs. The stoo1 examination was reported as guaiac positive. PIasma proteins and blood urea nitrogen were normal. FIuoroscopic and x-ray studies of the stomach revealed “a constant, rounded filling defect 2.5 cm. in diameter with a small fleck of retained barium at its center was present in the body of the stomach cIose to the fundus, high on the greater curvature. The rugal pattern of the Iesion is fairly well-maintained. ConcIusion: FiIIing defect of the stomach most IikeIy representing gastric poIyp or intramural tumor.” (Fig.
3.)
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CASE III. A thirty-seven year oId colored femaIe was admitted to the University Hospitals on December 18, 1947, with the compIaint
FIG. 4. Case II. Photomicrograph of tumor adjacent to ulcerated gastric mucosa showing uniform arrangement of tumor cells; leiomyoma of stomach. X 165.
Gastroscopic examination reveaIed, “In the midportion of the stomach on the anterior waI1, near the greater curvature, there was seen a tumor which projected into the Iumen of the stomach on a broad base and which appeared to be about the size of a waInut. The surface of the tumor contained 3 ulcerated Iesions; these were not bIeeding and the mucosa over the tumor was otherwise normaI. The remainder of the stomach did not appear abnorma1. Impression : Gastric tumor-probabIy benign.” Following preoperative preparation with whoIe bIood transfusions, intravenous amigen and gIucose the patient was taken ,to surgery on her twenty-first hospita1 day. At the time of surgery the tumor was easiIy paIpabIe within the lumen of the stomach and had produced sIight dimpIing of the overIying serosa. A subtota gastric resection was performed with a wide margin of normal stomach being removed adjacent to the tumor. An anterior Polya gastro-enterostomy was carried out. The pathoIogic diagnosis was Ieiomyoma of the stomach. (Fig. 4.) The postoperative course was uneventfu1 except for symptoms referabIe to diminished gastric capacity and this was eventuaIIy controIIed with a diet of smaI1 frequent feedings. Comment. Cases I and II iIIustrate how the presenting complaint of the patient on admission to the hospita1 may be one referable to the profound anemia resuIting from insensibIe bIood Ioss in the cases of Ieiomyomas with uIceration.
of hematemesis. On the day of admission the patient had had a persistent sensation of abdomina1 fuIIness. ApproximateIy three hours before admission whiIe ironing she suddenly feIt warm and light-headed. She stopped her work and Iay down with some relief. On arising she fainted. After regaining consciousness she became nauseated and vomited approximateIy I pint of bright, red bIood containing a few cIots. She had had similar episodes of abdomina1 fullness during the few months prior to her present iIIness but gave no previous history of hematemesis or meIena. There had been no recent weight Ioss or change in bowe1 habits. Two years previousIy she underwent a panhysterectomy, Ieft saIpingo-oophorectomy and appendectomy for fibromyomas of the uterus and chronic saIpingitis. PhysicaI examination reveaIed a we11 developed, we11 nourished, coIored femaIe in no apparent distress and not vomiting. The remainder of the examination was negative with the exception of sIight epigastric tenderness on paIpation and a we11 heaIed midline suprapubic scar. Laboratory findings showed erythrocytc count 4, rgo,ooo, hemoglobin 12.2 gm. and hematocrit 38. StooI was guaiac positive. Urine and white blood ceI1 count were normaI. On gastric anaIysis there was free hydrochIoric acid following histamine. Blood urea nitrogen and serum proteins were within norma limits. During the patient’s hospita1 course the pain in her epigastrium became progressiveIy worse folIowing admission and slight atelectasis deveIoped at both Iung bases. The pain was somewhat relieved by the ingestion of aIuminum hydroxide and atropine. A gastrointestina1 x-ray series eight days folIowing admission was reported as no certain evidence of organic disease of the stomach or duodenum. A repeat examination ten days Iater showed retention of a ffeck of barium high on the lesser curvature of the stomach with fiIIing of a diverticulum-Iike structure and suggestion of a tumor mass. (Fig. 4.) Gastroscopic examination was performed and revealed a tumor high on the Iesser curvature projecting into the Iumen of the stomach which 3 cm. was irreguIar in shape and approximateIy in diameter. The surface was described as
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FIG. 6. Tumor invading adjacent fat and showing Ioss of uniform ceIluIar arrangement and pIeomorphic [nuclei; Ieiomyosarcoma of stomach. X 150.
FIG. 5. Case III. Leiomyosarcoma of the stomach with diverticulum-like ulceration into the tumor mass arising from the cardia.
smooth and pearly white. No ulceration was noted and no bleeding focus couId be seen with the gastroscope. The gastroscopist’s impression was that it was a maIignant Iesion but benignancy couId not be excluded. The patient was taken to surgery and under cycIopropane and curare anesthesia the abdomen was explored. A tumor mass arising high on the cardia near the Iesser curvature of the stomach was found. It extended aIong the gastrospIenic Iigament and had involved the spleen. A high subtota1 gastric resection and splenectomy were performed. The esophagus was anastomosed to the remaining portion of the stomach. There was no evidence of metastasis to other organs. The pathologic diagnosis was Ieiomyosarcoma of the stomach with uIceration. (Fig. 6.) The patient’s convaIescence was uneventfu1 with the exception of slight postprandia1 distress and occasiona vomiting folIowing a Iarge mea1. A recent gastric study foIIowing barium reveaIed no evidence of IocaI recurrence of the Iesion and she is enjoying good heaIth. CASE IV. A sixty-five year old maIe was of readmitted ApriI 20, 1948, compIaining peated episodes of severe gastric hemorrhage.
April, Igfo
The patient dated the onset of symptoms to December, 1946, at which time he had a sudden attack of extreme fatigue and syncope. He consuIted a physician at that time and a diagnosis of bIeeding uIcer was made. The patient was hospitaIized in an Akron hospita1 and received bIood transfusions as an emergency measure. Some time Iater a gastrointestina1 series was performed and reveaIed a posterior mid-abdomina1 mass suggestive of pancreatic cyst. (Fig. 7.) He was treated symptomatically at this time and discharged. During the foIIowing six months the patient experienced no obvious recurrence of gastric hemorrhage and no pain. He lost no weight during this period. In June, 1947, the patient was readmitted to the hospita1 and an abdomina1 Iaparotomy was performed. The surgeon described the foIIowing findings at the time of surgery, “There was a nodular, spherical tumor mass approximateIy 6 inches in diameter Iying on the Iesser curvature but apparentIy not directIy attached to the stomach. The mass was soft and cystic to paIpation and covered with a network of diIated veins. The Iiver was norma to inspection and paIpation. Inspection and paIpation of the remaining abdomina1 viscera was negative. The mass was adherent to a Iarge bIood vessel posteriorly, and attempts to remove the mass resulted in profuse hemorrhage. A biopsy was taken and hemorrhage controIIed with oxyce1 gauze and the abdomen was cIosed.” The
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FIG. 8. Case IV. Leiomyosarcoma of stomach; note increased vascularity and focal necrosis. NucIei are pIeomorphic and the celIuIar pattern irregutar. X 202.
FIG. 7. Case IV. Distortion of norma gastric confrguration by large tumor mass; x-ray taken one year prior to admission to University HospitaIs; Ieiomyosarcoma of stomach.
pathologic diagnosis at that time was neuriJemmoma. PostoperativeIy the patient did we11 1947, when he again had a unti1 November, sudden fainting speI1 and subsequent meIena. The patient was again hospitaIized and given a transfusion of whoIe bIood. Four months the patient was again Iater in March, I@, hospitaIized because of easy fatigability. A rather marked anemia was noted and the patient was given a transfusion and discharged. Another massive gastric hemorrhage occurred one week prior to admission to University Hospitals in ApriI, 1948. During the course of the patient’s iIIness he had had hematemesis on two occasions. His appetite remained good with only slight weight 10s~. He had noticed a progressive increase in abdomina1 girth since the onset of his iIIness in December, 1946. At no time was epigastric pain or distress a feature of his disease. Prior to the onset of his present iIIness the patient’s heaIth had been exceIIent. PhysicaI examination reveaIed a somewhat obese, we11 deveIoped male in no apparent pain or distress. The mucous membranes of his mouth and conjunctivas were paIe. His Iungs were cIear to auscuttation and percussion. His heart was normal. Abdominal examination
showed a we11 heaIed upper Ieft rectus incision. A poorIy defined mass was paIpabIe beneath the incision measuring approximately 8 cm. by I cm. and only sIightIy movable. No other masses or organs were feIt. Rectal examination was negative with the exception of tarry, bIack feces being noted on the examining glove. The remainder of the examination was not remarkable. Laboratory studies showed erythrocyte count 2,160,000 and hemogIobin 6.5 gm. Blood urea nitrogen was 8.3 mg. per I00 cc., stool guaiac positive and urine negative. During the day following admission the patient experienced an episode of faintness with a slight fall in bIood pressure, increased pulse rate and marked diaphoresis. Gastrointestinal series scheduIed for that day were canceIled and the patient was given a transfusion. In spite of the whoIe bIood transfusion the patient’s erythrocyte count had fallen the following day to I ,~OO,OOO. Gastric hemorrhage recurred the next day and it was decided to abandon any attempt to get x-rays of the stomach and to prepare the patient for surgery with repeated blood transfusions. This was done and on the patient’s ninth hospital day he was taken to surgery. Under satisfactory gasoxygen-ether anesthesia the abdomen was opened and the stomach identified. A Iarge ovoid tumor measuring approximateIy I o inches in its greatest diameter was presenting through the gastrohepatic ligament and firmIy attached to a11 adjacent structures. The Iesser omental American
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bursa was opened and the tumor was adherent on a broad transverse plane to the pancreas and IateralIy to the spIeen. A gastrostomy was performed to determine the site of hemorrhage and an uIcerated area in the mucosa contiguous with the tumor was seen just proxima1 to the esophagea1 opening in the cardia of the stomach on the lesser curvature. SeveraI vertical mattress sutures were used to cIose the defect and the gastrostomy was cIosed. The tumor had spread so extensiveIy that tota extirpation was impossible. An attempt was made to remove a Iarge part of the tumor but hemorrhage from the substance of the Iesion was severe and the patient went into a state of irreversibIe shock and expired shortIy following completion of the procedure. PathoIogic diagnosis of tumor tissue removed at the time of surgery was Ieiomyosarcoma. (Fig. 8.) At autopsy there was np evidence of metastatic foci eIsewhere in the body. Comment. Cases III and IV are exampIes of leiomyosarcomas. Case III demonstrates the importance of early recognition of these Iesions and radica1 surgica1 intervention. In these cases the resuIts are very gratifying in spite of a histoIogic evidence of maIignancy. Case IV makes evident the necessity for radica1 surgery when the patient first presents himseIf for treatment and IocaI spread of the tumor shouId not deter the surgeon from attempting tota extirpation of the Iesion. The Iow grade maIignancy and slow rate of growth of Ieiomyosarcomas invite a boId attack on these Iesions.
REFERENCES I. BEHRENDS, M.
stomach.
Ulcerative leiomyomas of the J. Internat. Co[l. Surgeons, 7: 436444,
‘944. 2. CARTER, R. A. and LAING, D. R. Non-carcinoma-
tous tumors of the stomach. 3. 4.
5. 6.
7.
8.
9.
IO.
I I.
12. 13. 14.
15. I.
April, I 950
of Stomach
3. Two cases of Ieiomyomas of the stomach and two cases of Ieiomyosarcoma of the stomach are presented.
SUMMARY
Leiomyomas and Ieiomyosarcomas of the stomach have been briefly reviewed. 2. Smooth muscle tumors of the stomach though uncommon are not rare and because of the Iow grade maIignancy in Ieiomyosarcomas they offer a good surgica1 prognosis.
Tumors
16. 17.
Radiology, 28: 3o1-
3’4. 1937. CHAFFIN, L. Smooth muscle tumors of the stomach. West. J. Surg., 46: 513-524, 1938. COLLINS, F. K. and COLLINS, D. C. SurgicaI significance of gastric Ieiomyomas. West. J. Surg., 46: 188-194, 1938. ECKHOFF, N. Leiomyoma of the stomach. Guy’s Hosp. Rep., 91: 153, 1942. GOLDEN, T. and STOUT, A. P. Smooth muscIe tumors of the gastrointestinal tract and retroperitonea1 tissue. Surg., G)nec. fY Obst., 73: 784-810, 1941. HORSLEY, G. W. and BERGER, R. A. Leiomyosarcoma of the stomach, a report of three cases. Ann. Surg., I 12: 22-30, 1940. LAHEY, F. H. and COLCOCK, B. P. Diagnosis and surgical management of leiomyomata and Ieiomyosarcomata of the stomach. Ann. Surg., I 12: 671-686, 1940. LEMON, R. G. and BRODERS, A. C. A cIinica1 and pathoIogica1 study of leiomyosarcoma, hemangioendotheIioma or angiosarcoma, and fibrosarcoma. Surg., Cynec. @ Obst., 74: 671-680, 1942. MASS. M. and KIRSCHBALM.J. D. Leiomvosarcoma of the fundus of the stomach with perforation. Am. J. Roentgenol., 44: 716-718, 1943. MATAS, R. PedicuIated poIypoid fibroadenoma of the stomach of the ball-valve type, causing unusuaI and complex syndrome. Surg., cyynec. ti Obst., 37: 723-731, 1923. MEISSNER, W. A. Leiomyoma of the stomach. Arch. Patb., 38: 207-209, 1944. MELNICK, P. J. Metastasizing leiomyoma of the stomach. Am. J. Cancer, 16: 890-902, 1932. MINNES, J. F. and GESCHICKTER, C. F. Benign tumors of the stomach. Am. J. Cancer, 28: 136149, 1936. MOORE, A. B. RoentgenoIogic study of benign tumors of stomach. Am. J. Roentgenol., I I : 61-66, 1924. MUIR, J. B. G. Notes on case of Ieiomyoma of stomach. M. J. Australia, 2: 87-88, 1943. SCHINDLER,R., BLOMQUIST,0. A., THOMPSON,H. L. and PETTLER, A. M. RoentgenoIogic and gastroscopic diagnosis and its possibIe reIation to pernicious anemia. Surg., Gynec. TV Obst., 82: 239252, 1946.
MUSCLE TUMORS
JACK W.
COLE, M.D.
AND
OF THE STOMACH*
FRANK
M.
BARRY,
M.D.
Cleveland, Ohio
T
HE purpose of this paper is to present four cases of smooth muscIe tumors of the stomach seen on the surgical service of the University HospitaIs during the past eighteen months and to discuss brieffy the subject of smooth muscle tumors of the stomach in generaI. Two of our cases were benign Ieiomyomas and two were Ieiomyosarcomas and of particular interest in either their cIinica1 manifestations or probIem of therapeutic management. Inasmuch as the surgica1 prognosis is good in these cases even when sarcomatous degeneration is demonstrated histoIogicaIIy, it has become increasingly important for the surgeon to keep these Iesions in mind when there is evidence of occuIt or massive gastric hemorrhage or a paIpabIe upper abdomina1 mass. SeveraI authors have adequateIy reviewed the Iiterature1s3,4’6’14 and further eIaboration on this aspect of the probIem does not faI1 within the scope of this paper. UnquestionabIy the incidence of smooth muscle tumors of the stomach is quite high when we consider those cases which are recorded as incidenta findings at autopsy as we11 as Iaparotomy. A routine examination of fifty stomachs at autopsy picked at random by Meissner12 reveaIed Ieiomyomas occurring in twenty-three cases, 46 per cent. However, the patients who become symptomatic and present themseIves for diagnosis and treatment are stiI1 considered uncommon in most cIinics. Leiomyomas constitute 39.9 per cent of a11 benign gastric tumors according to CoIIins and CoIIins.4 Leiomyosarcomas comprise IO per cent of a11 gastric sarcomas according to Schind1er.l’ Smooth muscIe tumors of the stomach * From the Department
of Surgery, Western
with symptoms necessitating hospitalization occur most commonIy between the ages of forty and seventy. A review of 363 cases by Chaffin showed an age range of seven years to ninety years. The average age in our cases was forty-nine years and represents both benign and maIignant Iesions. Leiomyomas and Ieiomyosarcomas of the stomach have approximateIy equa1 incidence in maie and femaIe patients. Pathology. These tumors arise in the muscuIaris of the stomach. They may be divided for cIinica1 purposes into intragastric (submucosal) and extragastric (subserosal) depending on whether the tumor protrudes into the Iumen of the stomach or whether its growth is predominantly beneath the serosa and into the surrounding peritonea1 cavity. The submucosa1 type is most commonly associated with uIceration. The tumor generaIIy appears to be encapsuIated and cIearIy demarcated even with sarcomatous Iesions. In the absence of obvious metastases or invasion of surrounding organs by the tumor it is impossibIe to determine by the gross appearance whether or not the tumor is benign or malignant. The tumor may be quite vascuIar. HistoIogicaIIy they are composed of fusiform ceIIs with elongated and rounded basophiIic nucIei containing fine chromatin materia1. Evidence of sarcomatous degeneration is not always cIear-cut, depending on the appearance of mitotic figures, pIeomorphism and the degree of necrosis. MeInick’3 reported a case of metastasizing Ieiomyoma which appeared benign histoIogicaIIy but gross Iiver metastases were present. AIthough reports have differed as to the
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site from which these tumors most commonIy arise in the stomach, our experience indicates a predisposition for the cardia on the greater curvature. Laheys reports the highest incidence in the lower portion of the stomach with equa1 distribution between the greater and Iesser curvature. GoIden and Stout” reported that 60 per cent occur in the pyloric region, 20 per cent in the pars media and 15 per cent in the cardia. Symptoms. While these tumors may have a rather wide variety of clinical manifestations, a high percentage will present objective or subjective evidence of gastrointestinal hemorrhage. Hematemesis is common. Anemia is often profound giving rise to symptoms of paIpitation, weakness and exertional dyspnea. In a11 four of the cases presented in this communication frank hemorrhage or symptoms referabIe to marked anemia due to insensibIe blood Ioss were present. Five out of seven cases reported by Lahey 8 had hematemesis or tarry stools. A paIpable epigastric mass is frequentIy present occurring most commonIy in Ieiomyosarcomas. In three cases of Ieiomyosarcomas reported by HorsIey and Berger? a mass was noted on physica examination and “its size was out of proportion to patient’s weIIbeing.” We beIieve that this point shouId be emphasized in the differentia1 diagnosis of more mabgnant Iesions causing gastric hemorrhage and that not infrequentIy the patient’s nutritiona state is exceIIent with onIy sIight weight 10s~. The pain which frequentIy accompanies the Iesion is generaIly miId and characterized chiefly ‘as a duII, gnawing epigastric distress. It may be severe, however, and simuIate a peptic uIcer” and occasionaIIy responds to an uIcer diet aIthough the beneficia1 effect as wouId be expected is generaIIy transient. There are cases reported in the Iiterature of peduncuIated smooth muscIe tumors occluding the Iumen of the pyIorus, leading to signs and symptoms of high intestinal obstruction with gastric diIatation and
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persistent vomiting. 11p16Other cases, generalIy the Ieiomyosarcomas, may have necrosis of the tumor mass with contamination of the peritonea1 cavity and present the cIinica1 picture of peritonitis.6p1a These findings however are uncommon. Diagnosis. These tumors should aIways be considered in the differentia1 diagnosis of Iesions producing gastric hemorrhage or occuIt bIood in the stooIs. FIuoroscopic and x-ray examination of the stomach remains the single best method for demonstrating a tumor mass in the stomach and uIcer formation. Much has been written concerning the roentgenoIogic appearance of these Iesions and the criteria for differentiating these tumors from other gastric neopIasms.2’15 Perhaps the greatest pitfall is in overIooking Iesions high on the cardia (Case III) and specia1 technics have been advocated to obviate this source of error. Gastroscopic examination frequentIy can be heIpfu1 to the surgeon in estabIishing the preoperative diagnosis. In two of four cases of Ieiomyosarcoma reported by SchindIer” gastroscopy disclosed the presence of a gastric tumor overlooked on x-ray examination. Treatment. Our views are in accordance with those expressed by Laheys who advocates high subtota1 gastric resection. Because of the Iow grade maIignancy seen in Ieiomyosarcomas they offer a good prognosis when treated radicaIIy. Lemon9 reports a case in which the patient Iived for six years with gross Iiver metastases. In addition, the fact that these Iesions cannot be easiIy recognized in the gross as benign or maIignant Iends support to the necessity of performing gastric resection rather than IocaI excision. Microscopic study with frozen section technic is often inconcIusive in estabIishing of maIignancy in these the diagnosis Iesions. We wouId be extremeIy hesitant to perform a simpIe IocaI excision of a gastric tumor on the strength of a frozen section biopsy interpreted whiIe the operation was in progress. The surgeon shouId be prepared to remove any surrounding structures
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the abdomen and determine the presence of invasion of contiguous structures by the tumor. Complications. The postoperative compIications in these cases are essentiaIIy those incident to any major gastric procedure. It is we11 to bear in mind that these tumors may be quite vascuIar and hemostasis is Imperative. (Case IV.) In Case I the patient deveIoped a pIeura1 effusion and a Ieft subdiaphragmatic abscess as a resuIt of Ieakage from the anastomosis. Cases II and III had occasiona bouts of postprandia1 epigastric distress and infrequent vomiting attributed to diminished gastric capacity. These symptoms cIeared in both instances when the patient was pIaced on smaI1, frequent feedings. CASE FIG. I. Case I. L&myoma filling defect in the car&a
of the stomach showing with central ulceration.
which may be involved by direct spread of the tumor whenever feasible. A Iarge part of the excelIent results reported in recent years in the management of these cases can be attributed to the IiberaI use of whoIe bIood transfusions in correcting the patient’s anemia preoperativeIy. A probIem which may occasionaIIy confront the surgeon is the necessity of having to operate upon these patients as an emergency procedure because of severe intractabIe hemorrhage. In an aheady anemic patient this is extremeIy hazardous. Whenever possibIe surgery shouId be forestalIed unti1 adequate blood repIacement therapy has been instituted. In lesions such as those described in Case I and Case III situated high in the cardia it is necessary to mobihze the Iower end of the esophagus to effect a satisfactory esophagogastrostomy anastomosis foIIowing remova of the stomach. We have been able to accomplish this transabdominally but acknowIedge the merits of a transthoracic approach. In our opinion, however, the abdomina1 method affords a somewhat better opportunity to expIore
REPORTS
CASE I. A fifty-seven year oId white housewife was admitted to the University HospitaIs on May 5, 1948, with the chief compIaints of severe headaches which began three weeks prior to admission. These headaches were Iocalized in the fronta and occipital areas, present chiefly on arising in the morning and relieved by aspirin. For the same period of time the patient had noted duI1, constricting, substernal discomfort with associated dyspnea. These episodes lasted ten to sixty minutes and were relieved by rest. The patient had no symptoms referable to the gastrointestinal tract. There was no weight Ioss and no known bIood 10s~. Physical examination reveaIed a we11 deveIoped, slightly obese woman who did not appear acutely ill. The only significant hnding was a marked paIlor of the mucous membranes of her mouth, conjunctivas and nail beds. Abdominal and rectal examinations were negative. Her heart was not enIarged to percussion. II bIowing, precordial There was a Grade systolic murmur. Her lungs were clear to auscuItation. Laboratory studies revealed an erythrocyte count of 2,140,000 and a hemoglobin of 37 per cent. Plasma proteins, blood urea nitrogen, urine and white blood count were within normal limits. There was free acid on gastric anaIysis fohowing histamine. Stool examination was negative for occult bIood. GastrointestinaI x-ray studies found “a 4 cm. X 5 cm. tumor in the cardiac end of the American
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Frc. 2. Case I. Photomicrograph showing fusiform tumor cells with basophilic staining nuctei arranged in characteristic bundIes; Ieiomyoma of stomach. x 179.
stomach. The tumor may represent a benign or malignant leiomyoma with a smaI1 ulcer less than I cm. in size. A carcinoma might also have this appearance.” (Fig. I.) FolIowing severa days’ preparation with repeated whole blood transfusions the patient was taken to surgery and under cycIopropane anesthesia a high subtota1 gastric resection was performed with anastomosis of the Iower end of the esophagus to the smaI1 portion of remaining stomach. The pathoIogic diagnosis was Ieiomyoma of the stomach. (Fig. 2.) Postoperatively a left subdiaphragmatic abscess developed in the patient which was drained. A Ieak at the site of anastomosis, communicating with the abscess cavity, was demonstrated with barium swaIIow. The fistuIous tract cIosed eventuaIIy with conservative management and the patient is alive and we11 today. CASE II. A forty year oId coIored maid was admitted on December rg, 1947, compIaining of being weak and tired for two weeks. She had enjoyed exceIIent heaIth unti1 one month prior to admission at which time she began to have episodes of bIoating in her epigastrium following meaIs. Two weeks foIIowing onset of epigastric distress she became progressively weak and tired and anorexia developed. These symptoms became severe and in performing househoId chores the patient would .frequentIy have to lie down to avoid fainting. Because of the increasing severity of her symptoms the
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FIG. 3. Case II. GastrointestinaI x-ray demonstrating Wing defect on greater curvature of stomach in the pars media; Ieiomyoma of stomach.
patient became confined to her bed. Efforts to arise produced marked diaphoresis, paIpitation and a feeIing of faintness. She had noticed no weight Ioss, pain, nausea or vomiting. Hospitalization was advised by her physician at this time. Examination revealed a we11 deveIoped, we11 nourished, coIored female appearing weak and listless. All mucous membranes were pale. Physical examination of heart, Iungs and abdomen was negative. Recta1 examination was negative and reff exes physioIogic. Laboratory studies showed an erythrocyte count of 1,320,000 and hemoglobin of 3 gm. In the bIood smear there were three normobIasts per IOO white bIood ceIIs. The stoo1 examination was reported as guaiac positive. PIasma proteins and blood urea nitrogen were normal. FIuoroscopic and x-ray studies of the stomach revealed “a constant, rounded filling defect 2.5 cm. in diameter with a small fleck of retained barium at its center was present in the body of the stomach cIose to the fundus, high on the greater curvature. The rugal pattern of the Iesion is fairly well-maintained. ConcIusion: FiIIing defect of the stomach most IikeIy representing gastric poIyp or intramural tumor.” (Fig.
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CASE III. A thirty-seven year oId colored femaIe was admitted to the University Hospitals on December 18, 1947, with the compIaint
FIG. 4. Case II. Photomicrograph of tumor adjacent to ulcerated gastric mucosa showing uniform arrangement of tumor cells; leiomyoma of stomach. X 165.
Gastroscopic examination reveaIed, “In the midportion of the stomach on the anterior waI1, near the greater curvature, there was seen a tumor which projected into the Iumen of the stomach on a broad base and which appeared to be about the size of a waInut. The surface of the tumor contained 3 ulcerated Iesions; these were not bIeeding and the mucosa over the tumor was otherwise normaI. The remainder of the stomach did not appear abnorma1. Impression : Gastric tumor-probabIy benign.” Following preoperative preparation with whoIe bIood transfusions, intravenous amigen and gIucose the patient was taken ,to surgery on her twenty-first hospita1 day. At the time of surgery the tumor was easiIy paIpabIe within the lumen of the stomach and had produced sIight dimpIing of the overIying serosa. A subtota gastric resection was performed with a wide margin of normal stomach being removed adjacent to the tumor. An anterior Polya gastro-enterostomy was carried out. The pathoIogic diagnosis was Ieiomyoma of the stomach. (Fig. 4.) The postoperative course was uneventfu1 except for symptoms referabIe to diminished gastric capacity and this was eventuaIIy controIIed with a diet of smaI1 frequent feedings. Comment. Cases I and II iIIustrate how the presenting complaint of the patient on admission to the hospita1 may be one referable to the profound anemia resuIting from insensibIe bIood Ioss in the cases of Ieiomyomas with uIceration.
of hematemesis. On the day of admission the patient had had a persistent sensation of abdomina1 fuIIness. ApproximateIy three hours before admission whiIe ironing she suddenly feIt warm and light-headed. She stopped her work and Iay down with some relief. On arising she fainted. After regaining consciousness she became nauseated and vomited approximateIy I pint of bright, red bIood containing a few cIots. She had had similar episodes of abdomina1 fullness during the few months prior to her present iIIness but gave no previous history of hematemesis or meIena. There had been no recent weight Ioss or change in bowe1 habits. Two years previousIy she underwent a panhysterectomy, Ieft saIpingo-oophorectomy and appendectomy for fibromyomas of the uterus and chronic saIpingitis. PhysicaI examination reveaIed a we11 developed, we11 nourished, coIored femaIe in no apparent distress and not vomiting. The remainder of the examination was negative with the exception of sIight epigastric tenderness on paIpation and a we11 heaIed midline suprapubic scar. Laboratory findings showed erythrocytc count 4, rgo,ooo, hemoglobin 12.2 gm. and hematocrit 38. StooI was guaiac positive. Urine and white blood ceI1 count were normaI. On gastric anaIysis there was free hydrochIoric acid following histamine. Blood urea nitrogen and serum proteins were within norma limits. During the patient’s hospita1 course the pain in her epigastrium became progressiveIy worse folIowing admission and slight atelectasis deveIoped at both Iung bases. The pain was somewhat relieved by the ingestion of aIuminum hydroxide and atropine. A gastrointestina1 x-ray series eight days folIowing admission was reported as no certain evidence of organic disease of the stomach or duodenum. A repeat examination ten days Iater showed retention of a ffeck of barium high on the lesser curvature of the stomach with fiIIing of a diverticulum-Iike structure and suggestion of a tumor mass. (Fig. 4.) Gastroscopic examination was performed and revealed a tumor high on the Iesser curvature projecting into the Iumen of the stomach which 3 cm. was irreguIar in shape and approximateIy in diameter. The surface was described as
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FIG. 6. Tumor invading adjacent fat and showing Ioss of uniform ceIluIar arrangement and pIeomorphic [nuclei; Ieiomyosarcoma of stomach. X 150.
FIG. 5. Case III. Leiomyosarcoma of the stomach with diverticulum-like ulceration into the tumor mass arising from the cardia.
smooth and pearly white. No ulceration was noted and no bleeding focus couId be seen with the gastroscope. The gastroscopist’s impression was that it was a maIignant Iesion but benignancy couId not be excluded. The patient was taken to surgery and under cycIopropane and curare anesthesia the abdomen was explored. A tumor mass arising high on the cardia near the Iesser curvature of the stomach was found. It extended aIong the gastrospIenic Iigament and had involved the spleen. A high subtota1 gastric resection and splenectomy were performed. The esophagus was anastomosed to the remaining portion of the stomach. There was no evidence of metastasis to other organs. The pathologic diagnosis was Ieiomyosarcoma of the stomach with uIceration. (Fig. 6.) The patient’s convaIescence was uneventfu1 with the exception of slight postprandia1 distress and occasiona vomiting folIowing a Iarge mea1. A recent gastric study foIIowing barium reveaIed no evidence of IocaI recurrence of the Iesion and she is enjoying good heaIth. CASE IV. A sixty-five year old maIe was of readmitted ApriI 20, 1948, compIaining peated episodes of severe gastric hemorrhage.
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The patient dated the onset of symptoms to December, 1946, at which time he had a sudden attack of extreme fatigue and syncope. He consuIted a physician at that time and a diagnosis of bIeeding uIcer was made. The patient was hospitaIized in an Akron hospita1 and received bIood transfusions as an emergency measure. Some time Iater a gastrointestina1 series was performed and reveaIed a posterior mid-abdomina1 mass suggestive of pancreatic cyst. (Fig. 7.) He was treated symptomatically at this time and discharged. During the foIIowing six months the patient experienced no obvious recurrence of gastric hemorrhage and no pain. He lost no weight during this period. In June, 1947, the patient was readmitted to the hospita1 and an abdomina1 Iaparotomy was performed. The surgeon described the foIIowing findings at the time of surgery, “There was a nodular, spherical tumor mass approximateIy 6 inches in diameter Iying on the Iesser curvature but apparentIy not directIy attached to the stomach. The mass was soft and cystic to paIpation and covered with a network of diIated veins. The Iiver was norma to inspection and paIpation. Inspection and paIpation of the remaining abdomina1 viscera was negative. The mass was adherent to a Iarge bIood vessel posteriorly, and attempts to remove the mass resulted in profuse hemorrhage. A biopsy was taken and hemorrhage controIIed with oxyce1 gauze and the abdomen was cIosed.” The
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FIG. 8. Case IV. Leiomyosarcoma of stomach; note increased vascularity and focal necrosis. NucIei are pIeomorphic and the celIuIar pattern irregutar. X 202.
FIG. 7. Case IV. Distortion of norma gastric confrguration by large tumor mass; x-ray taken one year prior to admission to University HospitaIs; Ieiomyosarcoma of stomach.
pathologic diagnosis at that time was neuriJemmoma. PostoperativeIy the patient did we11 1947, when he again had a unti1 November, sudden fainting speI1 and subsequent meIena. The patient was again hospitaIized and given a transfusion of whoIe bIood. Four months the patient was again Iater in March, I@, hospitaIized because of easy fatigability. A rather marked anemia was noted and the patient was given a transfusion and discharged. Another massive gastric hemorrhage occurred one week prior to admission to University Hospitals in ApriI, 1948. During the course of the patient’s iIIness he had had hematemesis on two occasions. His appetite remained good with only slight weight 10s~. He had noticed a progressive increase in abdomina1 girth since the onset of his iIIness in December, 1946. At no time was epigastric pain or distress a feature of his disease. Prior to the onset of his present iIIness the patient’s heaIth had been exceIIent. PhysicaI examination reveaIed a somewhat obese, we11 deveIoped male in no apparent pain or distress. The mucous membranes of his mouth and conjunctivas were paIe. His Iungs were cIear to auscuttation and percussion. His heart was normal. Abdominal examination
showed a we11 heaIed upper Ieft rectus incision. A poorIy defined mass was paIpabIe beneath the incision measuring approximately 8 cm. by I cm. and only sIightIy movable. No other masses or organs were feIt. Rectal examination was negative with the exception of tarry, bIack feces being noted on the examining glove. The remainder of the examination was not remarkable. Laboratory studies showed erythrocyte count 2,160,000 and hemogIobin 6.5 gm. Blood urea nitrogen was 8.3 mg. per I00 cc., stool guaiac positive and urine negative. During the day following admission the patient experienced an episode of faintness with a slight fall in bIood pressure, increased pulse rate and marked diaphoresis. Gastrointestinal series scheduIed for that day were canceIled and the patient was given a transfusion. In spite of the whoIe bIood transfusion the patient’s erythrocyte count had fallen the following day to I ,~OO,OOO. Gastric hemorrhage recurred the next day and it was decided to abandon any attempt to get x-rays of the stomach and to prepare the patient for surgery with repeated blood transfusions. This was done and on the patient’s ninth hospital day he was taken to surgery. Under satisfactory gasoxygen-ether anesthesia the abdomen was opened and the stomach identified. A Iarge ovoid tumor measuring approximateIy I o inches in its greatest diameter was presenting through the gastrohepatic ligament and firmIy attached to a11 adjacent structures. The Iesser omental American
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bursa was opened and the tumor was adherent on a broad transverse plane to the pancreas and IateralIy to the spIeen. A gastrostomy was performed to determine the site of hemorrhage and an uIcerated area in the mucosa contiguous with the tumor was seen just proxima1 to the esophagea1 opening in the cardia of the stomach on the lesser curvature. SeveraI vertical mattress sutures were used to cIose the defect and the gastrostomy was cIosed. The tumor had spread so extensiveIy that tota extirpation was impossible. An attempt was made to remove a Iarge part of the tumor but hemorrhage from the substance of the Iesion was severe and the patient went into a state of irreversibIe shock and expired shortIy following completion of the procedure. PathoIogic diagnosis of tumor tissue removed at the time of surgery was Ieiomyosarcoma. (Fig. 8.) At autopsy there was np evidence of metastatic foci eIsewhere in the body. Comment. Cases III and IV are exampIes of leiomyosarcomas. Case III demonstrates the importance of early recognition of these Iesions and radica1 surgica1 intervention. In these cases the resuIts are very gratifying in spite of a histoIogic evidence of maIignancy. Case IV makes evident the necessity for radica1 surgery when the patient first presents himseIf for treatment and IocaI spread of the tumor shouId not deter the surgeon from attempting tota extirpation of the Iesion. The Iow grade maIignancy and slow rate of growth of Ieiomyosarcomas invite a boId attack on these Iesions.
REFERENCES I. BEHRENDS, M.
stomach.
Ulcerative leiomyomas of the J. Internat. Co[l. Surgeons, 7: 436444,
‘944. 2. CARTER, R. A. and LAING, D. R. Non-carcinoma-
tous tumors of the stomach. 3. 4.
5. 6.
7.
8.
9.
IO.
I I.
12. 13. 14.
15. I.
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of Stomach
3. Two cases of Ieiomyomas of the stomach and two cases of Ieiomyosarcoma of the stomach are presented.
SUMMARY
Leiomyomas and Ieiomyosarcomas of the stomach have been briefly reviewed. 2. Smooth muscle tumors of the stomach though uncommon are not rare and because of the Iow grade maIignancy in Ieiomyosarcomas they offer a good surgica1 prognosis.
Tumors
16. 17.
Radiology, 28: 3o1-
3’4. 1937. CHAFFIN, L. Smooth muscle tumors of the stomach. West. J. Surg., 46: 513-524, 1938. COLLINS, F. K. and COLLINS, D. C. SurgicaI significance of gastric Ieiomyomas. West. J. Surg., 46: 188-194, 1938. ECKHOFF, N. Leiomyoma of the stomach. Guy’s Hosp. Rep., 91: 153, 1942. GOLDEN, T. and STOUT, A. P. Smooth muscIe tumors of the gastrointestinal tract and retroperitonea1 tissue. Surg., G)nec. fY Obst., 73: 784-810, 1941. HORSLEY, G. W. and BERGER, R. A. Leiomyosarcoma of the stomach, a report of three cases. Ann. Surg., I 12: 22-30, 1940. LAHEY, F. H. and COLCOCK, B. P. Diagnosis and surgical management of leiomyomata and Ieiomyosarcomata of the stomach. Ann. Surg., I 12: 671-686, 1940. LEMON, R. G. and BRODERS, A. C. A cIinica1 and pathoIogica1 study of leiomyosarcoma, hemangioendotheIioma or angiosarcoma, and fibrosarcoma. Surg., Cynec. @ Obst., 74: 671-680, 1942. MASS. M. and KIRSCHBALM.J. D. Leiomvosarcoma of the fundus of the stomach with perforation. Am. J. Roentgenol., 44: 716-718, 1943. MATAS, R. PedicuIated poIypoid fibroadenoma of the stomach of the ball-valve type, causing unusuaI and complex syndrome. Surg., cyynec. ti Obst., 37: 723-731, 1923. MEISSNER, W. A. Leiomyoma of the stomach. Arch. Patb., 38: 207-209, 1944. MELNICK, P. J. Metastasizing leiomyoma of the stomach. Am. J. Cancer, 16: 890-902, 1932. MINNES, J. F. and GESCHICKTER, C. F. Benign tumors of the stomach. Am. J. Cancer, 28: 136149, 1936. MOORE, A. B. RoentgenoIogic study of benign tumors of stomach. Am. J. Roentgenol., I I : 61-66, 1924. MUIR, J. B. G. Notes on case of Ieiomyoma of stomach. M. J. Australia, 2: 87-88, 1943. SCHINDLER,R., BLOMQUIST,0. A., THOMPSON,H. L. and PETTLER, A. M. RoentgenoIogic and gastroscopic diagnosis and its possibIe reIation to pernicious anemia. Surg., Gynec. TV Obst., 82: 239252, 1946.