DISCUSSION Careful review of the literature has failed to reveal an example of melanin staining of the duodenum on surgical, postmortem, or endoscopic evaluation. Pigment deposition in the rectum has been associated with the ingestion of cathartics of the anthracine type and is thought to be related to fecal stasis. The pa'tient herein described denied the use of cathartics or the ingestion of unusual foods or home remedies. The melanin pigment in the duodenal mucosa was clearly extracellular, collecting in clumps below the epithelial surface. The cause and clinical significance of this unusual finding remains obscure.
REFERENCES 1. CRUVEILHEIR j: Cancer avec melanose. In Anatomic Patho/ogique du Corps Humain, ). B. Bailliere (ed.), Paris, 1829. p. 6 2. WITIOESCH IH, JACKMAN RI, McDONALD jR: Melanosi coli: general
review and a study of 887 cases. J Dis Colon Rectum 1: 172, 1958 a pathological study. Its experimental production in monkeys. J Med Sci 6:654, 1940 4. WON KH, RAMCHAND 5: Melanosis of the ileum: case report and electron microscopic study. Am J Dig Dis 15:57, 1940 5. ANDREJAUKAS G: Rare cases of esophagitis with melanosis. Medicine 18:13, 1937
3. RODEN B: Melanosis coli -
~:
Adenocarcinoma occurring in a hyperplastic gastric polyp Removal by electrosurgical polypectomy
John P. Papp, MD* Department of Internal Medicine Michigan State University and Blodgett Memorial Hospital Grand Rapids, Michigan
Julian I. Joseph, MD Department of Pathology Mary's Hospital Grand Rapids, Michigan
Polyps of the stomach are rare.'-2 They may be benign or malignant tumors, hyperplastic (regenerative), or composed of ectopic tissue. Hyperplastic polyps occur from 3 to 8 times more commonly than adenomatous polyps. Although the frequency of associated malignancy has been reported to vary from 8% to 28%, malignancy occurring in a hyperplastic polyp is said not to occur. 3- 4 This report descri bes partial gastric outlet obstruction due to a hyperplastic polyp. After removal by endoscopic electrosurgery, it was found that the polyp was partially composed of an adenocarcinoma without invasion into the stalk. CASE REPORT An 8S-year-old woman had had midepigastric pain and vomiting for 4 weeks before admission. Emesis occurred 60 to 120 minutes after eating and relieved the midepigastric pain. Solid food increased her pain. She had lost 10 pounds. Physical examination revealed tenderness to palpation of the midepigastric area. A succussion splash was present. The extent of liver dullness was 11 cm. There were no abdominal masses. The hemoglobin was 12.S g, and the bematocrit was 40%. An electrocardiogram showed first degree A-V block. Upper gastrointestinal barium radiography revealed a polyp extending from the distal antrum through the pylorus into the duodenal bu Ib (Figure 1a). Gastroscopy with the Olympus GIF endoscope showed severe superficial gastritis throughout the stomach. A 1 cm stalk was seen to protrude into the duodenal bulb through the pylorus. The polyp stalk was grasped by biopsy forcep, and the polyp head was brought into the antrum. The polyp was snared, and the stalk was transected at setting 7 of the Cameron-Miller electrocoagulation unit. The polyp was resnared and withdrawn with the endoscope applying constant suction. The external appearance was lobulated (Figure 1b). The stalk was light yellow and measured 0.8 cm. The main portion of the polyp was light brown. On microscopic exam'Reprint requests: John P. Papp, MD, 2500 Oakwood Drive SE, Grand Rapids, Michigan 49506.
38
FIGURE 1 (a) A polypoid lesion contrasted by barium is seen in the duodenal bulb. (b) A brown, lobulated polyp measuring 2.5 cmf x 2 cm is seen arising from a light yellow stalk. (c) Carcinomatous involvement ofa hyperplastic polyp is seen (H & Ex 55). (d) Invasion of the stroma of the hyperplastic polyp by signet cell carcinoma (H & Ex 430). GASTROINTESTINAL ENDOSCOPY
ination almost three-fourths of the cross-sectional area of the polyp head appeared carcinomatous (Figure Ic). Signet-like carcinoma cells were seen invading the stroma of the hyperplastic polyp (Figure Id). These cells stained with mucicarmine. The carcinoma did not invade into the stalk. There was intestinal ization ofthe mucosa of the hyperplastic polyp. After polypectomy, the patient had no further gastrointestinal complaints. She died following a cerebrovascular accident 8 months afterwards. Necropsy was not obtained. DISCUSSION The patient was referred for electrosurgical polypectomy because she was felt not to be a suitable surgical candidate by the referring surgeon by reason of digitalis intoxication, severe coronary artery disease, and debility. The endoscopic electrosurgical polypectomy was performed without difficulty. That carcinoma was present in the polyp was an unexpected finding. However, insofar as there was no invasion into the stalk of the polyp, no further therapy was pursued. No longer is it necessary to operate upon patients for symptomatic gastric polyps or to follow them radiographically when polyps can be removed endoscopically without apparent morbidity or mortality.s-B Superficial biopsy of gastric polyps has been shown to be misleading.' Therefore, accurate diagnosis can be obtained only by examination of the entire polyp removed by electrosurgical polypectomy. Gastric polyps larger than 2 cm have been shown to have approximately a 50% chance of malignancy.· Sagaidak reported a 77% occurrence of gastric carcinoma and death in polyps over 2 cm in diameter in a series of 227 patients. 9 There continues to be controversy whether adenomatous polyps degenerate into carcinoma or occurde nova. It appears that adenomatous polyps with intestinalization of gastric mucosa have a propensity to do SO.4,1O-12 No report of adenocarcinoma occurring in a hyperplastic gastric polyp published in English could be found.
REFERENCES 1. STEWART MJ: Observations on the relation of malignant disease to benign tumors of the gastrointestinaltracl. Br Med J 2:567, 1929 2. GRAFE W, THORBJARNARSON B, PEARCE JM, BEAL JM: Benign neoplasms of stomach. Am J Surg 100:561, 1960 3. TOMASULO J: Gastric polyps; histologic types and their relationship to gastric carcinoma. Cancer 27:1346, 1971 4. MING SC, GOLDMAN H: Gastric polyps; a histologic classification and its relation to carcinoma. Cancer 18:721, 1965 5. PAPP)P: Electrosurgical gastric polypectomy via the Olympus GIF endoscope: Gastrointestinal Endoscopy 20:70, 1973 6. ROLSCH W, KOCH H, FRUEHMORGEN P, CLASSEN M: Operative endoscopy of the upper gastrointestinaltracl. Gastrointestinal Endoscopy 20: 108, 1974 7. SEIFERT E, ELSTER K: Endoskopische Polypektomie am Magen; Inlikation, Technik, und Ergebnisse. Dtsch Med Wochenschr 97:1199,1972 8. HAY LH: Gastric polyps: a clinical study. Minn Med 34:362, 1951 9. SAGAIDAK VN: Gastric polypi. Orob On col 6:1155, 1960 10. BERG JW: Histologic aspects of relation between adenomatous polyps and gastric cancer. Cancer 11 :1149,1958 11. BOWDEN L: Adenocarcinoma in a small gastric polyp; a case report. Cancer 15:468, 1962 12. HOLMES EJ: Morphogenesis of gastric adenomatous polyps; transformation to invasive carcinoma of intestinal type. Cancer 19:794, 1966
VOLUME 23, NO.1, 1976
A cutaneous and pelvic lymphangioma with varices, lymphangiomas and capillary hemangiomas of the rectosigmoid colon Michael O. Blackstone, MD* B. H. Gerald Rogers, MD Alfred L. Baker, MD Section of Gastroenterology, Department of Medicine The University of Chicago Pritzker School of Medicine Chicago, Illinois
Large cutaneous (cavernous) lymphangiomas are wellknown pediatric entities requiring surgical extirpation at an early age but with frequent recurrence. Occasionally these extensive cutaneous lesions are associated with visceral lymphangiomas.',2 We report a case of a recurring lower extremity cutaneous lymphangioma with pelvic extension in a patient with a lifelong history of rectal bleeding in whom colonoscopic and arteriographic findings strongly suggested varices, lymphangiomas, and capillary hemangiomas of the rectosigmoid colon. CASE REPORT An 18 year old white university student with a lifelong history of rectal bleeding was admitted to the hospital for evaluation. As a child he had had multiple surgical treatments of an extensive cutaneous lymphangioma involving the left buttock, medial aspect of the thigh, and popliteal area. At age 4, during a repair of a left inguinal hernia, a pelvic mass was discovered in continuity with the cutaneous lymphangioma, strongly suggesting that it also was a lymphangioma. At age 10, proctoscopy performed because of recurrent rectal bleeding showed blue, vascular mucosa with the site of bleeding located in the anal verge. A biopsy of this area the following year, with the same proctoscopic picture, was reported as consistent with lymphangioma with interstitial hemorrhage at the anal verge. From that time to the present, the patient had had no major episode of rectal hemorrhage althou'gh he passed 3 to 4 blood-containing stools weekly. His present admission was prompted by increasing shortness of breath and weakness for 2 months when he had discontinued his iron supplement. In addition, an alcoholic binge the week of admission was followed by the passage of a large bloody stool. Physical examination revealed pallor of the conjunctivae and nail beds and lymphedema of the left leg with several weeping areas in the popliteal space. A large cutaneous lymphangioma with obvious areas of surgical scarring extended from the popliteal space, to involve the inner aspect of the thigh, the left buttock, and the perianal area. The admission hematocrit was 16%, hemoglobin 4.4 g, WBC 2700, platelet count 168,000, serum iron 35 and total iron binding capacity 270. An abdominal radiograph disclosed a pelvic mass with discrete calcification. A barium enema showed irregular filling defects of the rectosigmoid (Figure I). Radiographic examination of the stomach and small bowel and peroral endoscopy were unremarkable. The patient was treated with multiple transfusions. The size and extent of the pelvic mass were considered to preclude surgical intervention. • Address requests for reprints to: Michael O. Blackstone, MD, Department of Medicine, The University of Chicago, Box 400,950 East 59th Street, Chicago, Illinois 60637.
39
REFERENCES 1. CRUVEILHEIR j: Cancer avec melanose. In Anatomic Patho/ogique du Corps Humain, ). B. Bailliere (ed.), Paris, 1829. p. 6 2. WITIOESCH IH, JACKMAN RI, McDONALD jR: Melanosi coli: general
review and a study of 887 cases. J Dis Colon Rectum 1: 172, 1958 a pathological study. Its experimental production in monkeys. J Med Sci 6:654, 1940 4. WON KH, RAMCHAND 5: Melanosis of the ileum: case report and electron microscopic study. Am J Dig Dis 15:57, 1940 5. ANDREJAUKAS G: Rare cases of esophagitis with melanosis. Medicine 18:13, 1937
3. RODEN B: Melanosis coli -
~:
Adenocarcinoma occurring in a hyperplastic gastric polyp Removal by electrosurgical polypectomy
John P. Papp, MD* Department of Internal Medicine Michigan State University and Blodgett Memorial Hospital Grand Rapids, Michigan
Julian I. Joseph, MD Department of Pathology Mary's Hospital Grand Rapids, Michigan
Polyps of the stomach are rare.'-2 They may be benign or malignant tumors, hyperplastic (regenerative), or composed of ectopic tissue. Hyperplastic polyps occur from 3 to 8 times more commonly than adenomatous polyps. Although the frequency of associated malignancy has been reported to vary from 8% to 28%, malignancy occurring in a hyperplastic polyp is said not to occur. 3- 4 This report descri bes partial gastric outlet obstruction due to a hyperplastic polyp. After removal by endoscopic electrosurgery, it was found that the polyp was partially composed of an adenocarcinoma without invasion into the stalk. CASE REPORT An 8S-year-old woman had had midepigastric pain and vomiting for 4 weeks before admission. Emesis occurred 60 to 120 minutes after eating and relieved the midepigastric pain. Solid food increased her pain. She had lost 10 pounds. Physical examination revealed tenderness to palpation of the midepigastric area. A succussion splash was present. The extent of liver dullness was 11 cm. There were no abdominal masses. The hemoglobin was 12.S g, and the bematocrit was 40%. An electrocardiogram showed first degree A-V block. Upper gastrointestinal barium radiography revealed a polyp extending from the distal antrum through the pylorus into the duodenal bu Ib (Figure 1a). Gastroscopy with the Olympus GIF endoscope showed severe superficial gastritis throughout the stomach. A 1 cm stalk was seen to protrude into the duodenal bulb through the pylorus. The polyp stalk was grasped by biopsy forcep, and the polyp head was brought into the antrum. The polyp was snared, and the stalk was transected at setting 7 of the Cameron-Miller electrocoagulation unit. The polyp was resnared and withdrawn with the endoscope applying constant suction. The external appearance was lobulated (Figure 1b). The stalk was light yellow and measured 0.8 cm. The main portion of the polyp was light brown. On microscopic exam'Reprint requests: John P. Papp, MD, 2500 Oakwood Drive SE, Grand Rapids, Michigan 49506.
38
FIGURE 1 (a) A polypoid lesion contrasted by barium is seen in the duodenal bulb. (b) A brown, lobulated polyp measuring 2.5 cmf x 2 cm is seen arising from a light yellow stalk. (c) Carcinomatous involvement ofa hyperplastic polyp is seen (H & Ex 55). (d) Invasion of the stroma of the hyperplastic polyp by signet cell carcinoma (H & Ex 430). GASTROINTESTINAL ENDOSCOPY
ination almost three-fourths of the cross-sectional area of the polyp head appeared carcinomatous (Figure Ic). Signet-like carcinoma cells were seen invading the stroma of the hyperplastic polyp (Figure Id). These cells stained with mucicarmine. The carcinoma did not invade into the stalk. There was intestinal ization ofthe mucosa of the hyperplastic polyp. After polypectomy, the patient had no further gastrointestinal complaints. She died following a cerebrovascular accident 8 months afterwards. Necropsy was not obtained. DISCUSSION The patient was referred for electrosurgical polypectomy because she was felt not to be a suitable surgical candidate by the referring surgeon by reason of digitalis intoxication, severe coronary artery disease, and debility. The endoscopic electrosurgical polypectomy was performed without difficulty. That carcinoma was present in the polyp was an unexpected finding. However, insofar as there was no invasion into the stalk of the polyp, no further therapy was pursued. No longer is it necessary to operate upon patients for symptomatic gastric polyps or to follow them radiographically when polyps can be removed endoscopically without apparent morbidity or mortality.s-B Superficial biopsy of gastric polyps has been shown to be misleading.' Therefore, accurate diagnosis can be obtained only by examination of the entire polyp removed by electrosurgical polypectomy. Gastric polyps larger than 2 cm have been shown to have approximately a 50% chance of malignancy.· Sagaidak reported a 77% occurrence of gastric carcinoma and death in polyps over 2 cm in diameter in a series of 227 patients. 9 There continues to be controversy whether adenomatous polyps degenerate into carcinoma or occurde nova. It appears that adenomatous polyps with intestinalization of gastric mucosa have a propensity to do SO.4,1O-12 No report of adenocarcinoma occurring in a hyperplastic gastric polyp published in English could be found.
REFERENCES 1. STEWART MJ: Observations on the relation of malignant disease to benign tumors of the gastrointestinaltracl. Br Med J 2:567, 1929 2. GRAFE W, THORBJARNARSON B, PEARCE JM, BEAL JM: Benign neoplasms of stomach. Am J Surg 100:561, 1960 3. TOMASULO J: Gastric polyps; histologic types and their relationship to gastric carcinoma. Cancer 27:1346, 1971 4. MING SC, GOLDMAN H: Gastric polyps; a histologic classification and its relation to carcinoma. Cancer 18:721, 1965 5. PAPP)P: Electrosurgical gastric polypectomy via the Olympus GIF endoscope: Gastrointestinal Endoscopy 20:70, 1973 6. ROLSCH W, KOCH H, FRUEHMORGEN P, CLASSEN M: Operative endoscopy of the upper gastrointestinaltracl. Gastrointestinal Endoscopy 20: 108, 1974 7. SEIFERT E, ELSTER K: Endoskopische Polypektomie am Magen; Inlikation, Technik, und Ergebnisse. Dtsch Med Wochenschr 97:1199,1972 8. HAY LH: Gastric polyps: a clinical study. Minn Med 34:362, 1951 9. SAGAIDAK VN: Gastric polypi. Orob On col 6:1155, 1960 10. BERG JW: Histologic aspects of relation between adenomatous polyps and gastric cancer. Cancer 11 :1149,1958 11. BOWDEN L: Adenocarcinoma in a small gastric polyp; a case report. Cancer 15:468, 1962 12. HOLMES EJ: Morphogenesis of gastric adenomatous polyps; transformation to invasive carcinoma of intestinal type. Cancer 19:794, 1966
VOLUME 23, NO.1, 1976
A cutaneous and pelvic lymphangioma with varices, lymphangiomas and capillary hemangiomas of the rectosigmoid colon Michael O. Blackstone, MD* B. H. Gerald Rogers, MD Alfred L. Baker, MD Section of Gastroenterology, Department of Medicine The University of Chicago Pritzker School of Medicine Chicago, Illinois
Large cutaneous (cavernous) lymphangiomas are wellknown pediatric entities requiring surgical extirpation at an early age but with frequent recurrence. Occasionally these extensive cutaneous lesions are associated with visceral lymphangiomas.',2 We report a case of a recurring lower extremity cutaneous lymphangioma with pelvic extension in a patient with a lifelong history of rectal bleeding in whom colonoscopic and arteriographic findings strongly suggested varices, lymphangiomas, and capillary hemangiomas of the rectosigmoid colon. CASE REPORT An 18 year old white university student with a lifelong history of rectal bleeding was admitted to the hospital for evaluation. As a child he had had multiple surgical treatments of an extensive cutaneous lymphangioma involving the left buttock, medial aspect of the thigh, and popliteal area. At age 4, during a repair of a left inguinal hernia, a pelvic mass was discovered in continuity with the cutaneous lymphangioma, strongly suggesting that it also was a lymphangioma. At age 10, proctoscopy performed because of recurrent rectal bleeding showed blue, vascular mucosa with the site of bleeding located in the anal verge. A biopsy of this area the following year, with the same proctoscopic picture, was reported as consistent with lymphangioma with interstitial hemorrhage at the anal verge. From that time to the present, the patient had had no major episode of rectal hemorrhage althou'gh he passed 3 to 4 blood-containing stools weekly. His present admission was prompted by increasing shortness of breath and weakness for 2 months when he had discontinued his iron supplement. In addition, an alcoholic binge the week of admission was followed by the passage of a large bloody stool. Physical examination revealed pallor of the conjunctivae and nail beds and lymphedema of the left leg with several weeping areas in the popliteal space. A large cutaneous lymphangioma with obvious areas of surgical scarring extended from the popliteal space, to involve the inner aspect of the thigh, the left buttock, and the perianal area. The admission hematocrit was 16%, hemoglobin 4.4 g, WBC 2700, platelet count 168,000, serum iron 35 and total iron binding capacity 270. An abdominal radiograph disclosed a pelvic mass with discrete calcification. A barium enema showed irregular filling defects of the rectosigmoid (Figure I). Radiographic examination of the stomach and small bowel and peroral endoscopy were unremarkable. The patient was treated with multiple transfusions. The size and extent of the pelvic mass were considered to preclude surgical intervention. • Address requests for reprints to: Michael O. Blackstone, MD, Department of Medicine, The University of Chicago, Box 400,950 East 59th Street, Chicago, Illinois 60637.
39
