V most often occur in the rectum and sigmoid

Transcription

1 VILLOUS ADENOMAS OF THE RIGHT COLON WALTER B. GOLDFARR, M.D. ILLOUS ADENOMAS ARE NEOPLASMS THAT V most often occur in the rectum and sigmoid colon.7.8,21 These tumors exhibit a high propensity for malignant transformation and are occasionally associated with large losses of electrolyte-rich colonic mucus.2. l9 They rarely have been reported in the more proximal colon. This study defines the clinical behavior of this tumor in the right side of the colon. At the Barnes Hospital, St. Louis, Mo., in the past 13 years 146 cases of villous or papillary adenomas of the colon have been seen. Of these, 11 (7.4%) have been located in the right colon; 7 (4.8%) of which were situated in the cecum. In the cases in the literature in which location of the tumor was specified, with the exception of Grinnell and Lane s series? the incidence in the cecum and ascend- From the Department of Surgery and the Division of Surgical Pathology, Barnes Hospital and Washington University School of Medicine, 600 S. Kingshighway, St. Louis 10, Mo. This investigation was supported in part by a Public Health Service traineeshi (CST-041) from the National Cancer Institute, OF the National Institutes of Health, Public Health Service. The microscopic sections have been reviewed by Malcolm H. McGavran, M.D., Division of Surgical Pathology, Washington University School of Medicine. Received for publication July 17, ing colon was low (Table 1). A few case reports of villous tumors of the right colon have appeared There have been several series of unusual tumors of the cecum; however, none of these mentioned villous adenoma.l8-l7 Villous adenomas are sessile, polypoid masses, poorly demarcated, consisting of projecting mucosal villi piled upon one another. The clefts between the villi give this tumor a characteristic irregular appearance. This gross appearance is the same regardless of location within the large intestine (Figs. 1 through 3). The histological pattern of villous adenomas has been well described by Sunderland and Binkley,22 Ewing,s and Wheat and Ackerman.25 The microscopic characteristics of villous tumors of the right colon are identical with those located in the rectum (Figs. 4 and 5). The roentgenological diagnosis of villous tumors of the colon is based upon the splotchy appearance of barium in the irregular clefts between the polypoid protrusions of this tumor Roentgenograms of a single tumor are often inconstant because of the movement of the villi and the variations in shape due to irregularity in the size and depth of the clefts. They have a broad base and a lacelike or reticulated surface pattern. The usual appearance is that of a nonobstructing filling defect TABLE 1 ANATOMIC LOCATIONS OF VILLOUS ADENOMAS OF THE COLON Location, no. cases Total - Yr. no. Desc. Splenic Trans. Hepatic Asc. Author publ. cases Rectum Sigmoid colon flexure colon flexure colon Cecum Grinnell & Lane SouthwoodZ Hanley et a Welch & Dockertv t... Enterline et al t... Harp et al Swinton et a Wheat & Ackerman Sunderland & Binkley2% Dreese et a f Junghannsla Bacon et al * There was, in addition, 1 adenoma of cecum seen after the series was completed. t Right colon. $ Twelve of the adenomas were said to be situated in the rectosigmoid area. 5 All situated in the rectosigmoid area. 264 *

2 No. 2 VILLOUS ADENOMAS OF RIGHT COLON Goldfarb 265 FIG. 1. Case 1. (WU ill ). Gross photograph of a villous adenoma of the cecum. The tumor is confined to the cecum. Microscopic sections of this tumor showed no adenocarcinoma. best seen in the postevacuation roentgenogram or by double contrast methods (Figs. 6 and 7). A constant rigid filling defect or a persistent constriction of the lumen is indicative of invasive carcinoma in addition to a villous adenoma (Fig. 8). However, the absence of invasive carcinoma in a villous adenoma cannot be excluded by roentgen examination. The roentgenological diagnosis was polypoid tumor in 4, filling defect in 3, and constncting lesion in 1 of the 11 patients examined at the Barnes Hospital. Despite the similarities of the pathological and mtgenographic appearances of villous adenomas in the left and the right sides of the colon, there are differences in the symp- FIG. 2. Case 1. (WU ill ). Cross section of the villous adenoma of the cecum seen in Fig. 1 showing the characteristic mucosal villi.

3 266 CANCER February 1964 Vol. 17 TABLE 2 VILLOUS ADENOMAS OF THE RIGHT COLON Pt. Size Case age, Pt. Site tumor, Durat. Operation no. yr. sex tumor cm. Ca. symptoms Other colon problems performed 1 66 F Cecum & appendix 2 80 F Appendix 3 52 F Cecum 4 65 M Cecum 5 65 F Cecum 6 65 F Cecum 7 72 F Cecum 8 66 M Asc. colon 9 58 F Asc. colon M Cecum M Asc. colon 5x7. No 2-3 yr.... No 2-3 days 3. No 3mo. 4.X2. No 2 mo. 6.X6. Yes 1 yr. 5.X4. Yes 2 yr. 4.5 Yes 2 yr. 3.5 No 2 wk. 6. No 2 yr. 4.5 No Unknown 1.7 Yes 3 wk. Diverticulosis 19 yr.; pres. with acute appendicitis Hemorrhoidect. & excis. rectal adenomatous polyp 6 mo. prev. Died 9 mo. postop. metast. ca. Sigmoid colect for adenoca. Died postop. tot. gastrect. for ca.; villous adenoma cecum & rt. renal cell ca. found incident. at autopsy Dukes s grade B adenoca. cecum causing acute appendicitis; villous adenoca. asc. colon found incident. Rt. hemicolect. Cecotomy & pol y pect. Rt. hemicolect. Colotomy & polypect. Rt. hernicolect... toms and signs produced (as shown in Table 2). The average duration of symptoms in our cases was 12 months, the longest being 2 to 3 years. This is to be compared to the 2.5 years average duration of symptoms for the cases recorded by Sunderland and Binkley22 and Wheat and Ackerman,25 whose patients had distal colonic lesions. Although the duration of symptomatology in our cases appeared to be somewhat less, the average size of the right colon tumors was 4.5 cm. in greatest dimension. This is well within the range of size recorded in most series of villous adenomas and is smaller than that noted by some. FIG. 3. Case 6. (WU ill ). Photograph of a villous adenoma of the cecum involving the ileocecal valve. Ileum is at the right, colon at the left. This tumor contains invasive adenocarcinoma.

4 No. 2 VILLOUS ADENOMAS OF RIGHT COLON Goldfarb 267 The incidence of bleeding per rectum was 68y0 by Sunderland and Binkley.22 This varilower than that associated with the more dis- ation may be related to the inclusion with tal colonic villous adenomas. Three of 10 pa- invasive carcinoma of focal carcinoma limited tients were noted to have occult blood and to the mucosa only. Four of the 11 patients none had massive rectal bleeding. In Ewing s5 in this series (36y0) had invasive carcinoma series, 75% of the patients, and in Grinnell originating in a villous adenoma. Of these and Lane s,s 60% of the patients had rectal tumors, 3 were in the cecum and 1 in the as- FIG. 4. Case 6. (WU ill ). Low-power photomicrograph of villous adenoma shown in Fig. 3. The mucosal villous projections are readily apparent. (~12.) FIG. 5. (WU ill ). High-power photomicrograph of a villous adenoma showing the long villi lined by a single layer of cells around a central vascular stalk. ( ~85.) bleeding. Mucus discharge from the rectum, often the prominent symptom of this disease, was not present in any of our cases. Whether the mucus was absorbed distal to its secretion or the right colon tumors secrete less is not known. No cases of circulatory collapse or of electrolyte disturbances were noted. The reported cases with this syndrome have uniformly been in association with rectal or sigmoid tumors.2.18,19 The incidence of carcinoma in villous adenomas of the rectum and sigmoid has been reported as 32% by Grinnell and Lane7 and ceriding colon. In Grinnell and Lane s series,7 2 of 9 cecal and 4 of 9 ascending colon villous adenomas contained adenocarcinoma. In Enterline et al. s4 group of 6 right colon villous tumors only 1 contained carcinoma. Of the 4 patients with invasive adenocarcinoma in our series, only 1 had metastases to the regional lymph nodes. This patient (case 7) had hepatic metastases at the time of operation and died 9 months later. The other 3 patients with invasive carcinoma are well and without evidence of metastases 3v2 years (case 11) and 4 months (cases 5 and 6) postoperatively.

5 268 CANCER February 1964 Vol. 17 FIG. 6. Case 5. (WU ill ). Roentgenogram from a barium air-contrast enema showing the sessile filling defect in the cecum produced by a villous adenoma containing invasive adenocarcinoma. FIG. 7. (WU ill ). Roentgenogram from a barium enema demonstrating a large irregular cecal filling defect produced by the villous adenoma seen in Fig. 1. There is no obstruction to the flow of barium. FIG. 8. Case 7. (WU ill ). Roentgenogram from a barium enema showing the rigid annular constricting filling defect produced by a villous carcinoma of the cecum. Wheat and Ackermanzj have pointed out that the incidence of associated colonic lesions in patients with villous adenomas is high. Ten per cent of their 50 patients had separate adenocarcinomas of the colon. Southwood21 found primary unassociated colon adenocarcinoma in 12 of 180 patients with villous tumors. Mackie et al.14 cited an incidence of 20% associated carcinomas of the colon in their series and concluded that I... the bowel which gives rise to villous adenomas appears to have a greater propensity to give rise to other lesions. In the present series 2 of 11 pa- tients (18.2%) had separate colon adenocarcinornas. In 1 other patient (case 4) an adenomatous polyp of the rectum had previously been removed. Another patient (case 10) had carcinoma of the stomach from which he died. This was the oniy case in which a villous adenoma was found incidentally at autopsy. Thus, 4 of the 11 patients had associated neoplasms of the intestinal tract, 3 of which were adenocarcinamas. There were no instances of multiple villous adenomas in this series. Of the 7 cases of cecal villous tumors in this group, there were 4 in which the ileocecal

6 No. 2 VILLOUS ADENOMAS OF RIGHT COLON Goldfarb 269 valve was involved by the tumor. Two of these were villous adenomas with invasive adenocarcinoma. However, in only 1 patient (case 8) was there sufficient obstruction of the ileocecal valve to cause intestinal obstruction. The clinical picture presented by patients with villous adenomas of the cecum and ascending colon followed no distinct pattern. One patient (case 10) was entirely asymptomatic. The lesion was found on a barium enema examination 9 months after sigmoid colectomy for adenocarcinoma. Of interest are 2 patients who presented with signs and symptoms of acute appendicitis with perforation. In case 2, an 80-year-old woman had a %day history of severe right lower abdominal pain. She had no fever, nausea, or vomiting. The white blood cell count was 16,000 per cu. mm. On physical examination, a 5x5-m. tender mass was palpable in the right lower quadrant of the abdomen. A diagnosis of acute appendicitis was made. At operation, a perforated appendix was found, and there was marked induration of the cecum extending to the region of the ileocecal valve. An ileoright hemicolectomy was performed. The appendiceal lumen was filled with a mucussecreting villous adenoma (Fig. 9). We have been unable to find another case in the literature of a villous adenoma of the appendix or of acute appendicitis caused by this tumor. FIG. 9. Case 2. (WU ill ). Photomicrograph of the vermiform ap endix showing the typical long villous projections. TKe appendix was perforated secondary to acute appendicitis. ( ~5.) In case 11, a 53-year-old man had acute appendicitis with perforation secondary to an FIG. 10. Case 1. (WU ill ). Low-power photomicrograph ol the proximal vermiform appendix into which a cecal villous adenoma grew. ( ~15.)

7 ~~ 270 CANCER February 1964 Vol. 17 adenocarcinoma of the cecum. In the ascending colon, several centimeters distal to the cecal tumor, was another smaller invasive adenocarcinoma arising from a villous adenoma. An ileo-right hemicolectomy was performed. Twenty-four regional lymph nodes were free of metastases. This patient remains well 2 years later. In case 1, a 5x7-un. villous adenoma of the cecum was found to surround and invade the appendiceal orifice. However, there was no microscopic evidence of appendicitis (Fig. 10). The treatment of villous adenoma is a controversial subject. However, most discussions of therapy of this lesion are in relation to the rectal tumor and have little application to those adenomas situated in the right colon. The high rate of local recurrence following inadequate excision of these tumors is well known. The fact that the roentgenographic diagnosis is rarely made, coupled with the significant rate of carcinoma found in villous adenomas make right hemicolectomy the preferred treatment. SUMMARY In the past 13 years, 146 cases of villous adenoma of the colon have been seen at the Barnes Hospital, St. Louis, Mo. Of these, 11 (7.4%) were located in the right colon; 7 (4.8%) in the cecum. The pathological and roentgenographic features of villous tumors in this location are identical with those situated in the sigmoid colon and rectum. The incidence of bleeding per rectum was low and no cases of electrolyte disturbances were seen. Of the 11 villous adenomas 4 contained invasive carcinoma, and 2 patients had separate adenocarcinomas of the colon. Two patients had villous adenomas of the appendix, 1 with acute appendicitis. Right hemicolectomy is the proper treatment. REFERENCES 1. BACON, H. E.; LOWELL, E. J., JR., and TRIMPI, 11. HINES, M. 0.; HANLEY, P. H.; RAY, J. E., and H. D.: Villous papillomas of colon and rectum; study BRALLIAR, M.: Villous tumors of colon and rectum. of 28 cases with end results of treatment over 5-year Dis. Colon Q Rectum 1: , period. Surgery 35: 77-87, HINFS, M. 0.; HANLEY, P. H., and SCHRAMEL, R.: 2. DAVIS, J. E.; SEAVEY, P. W., and SESSIONS, J. T., JR.: Villous tumors of colon and rectum; clinical experi- Villous adenomas of rectum and sigmoid colon with ence with 37 cases. South. M. J. 48: , severe fluid and electrolyte depletion. Ann. Surg. 155: 13. JUNGHANNS, H.: Die Zottengeschwiilste des Dick , darms und Mastdarms (klinische Beobachtungen und 3. DREESE, W. C.; GRADINGER, B. C.; HELLWIG, C. A.; Datholoeisch-anatomische Untersuchunnen am Oma- WELCH, J. W., and MCCUSKER, E. N.: Villous tumors iionsmgeria1 der Schmiedenschen Kiinik). Ergebn. of rectum and sigmoid. Surg. Gynec. 6 Obst. 115: 182- Chir. U. Ortho$. 28: 1-71, , MACKIE, J. A., JR.; MILLER, L. D., and Frm, W. 4. ENTERLINE, H. T.; EVANS, G. W.; MERCUDO-LUGO, T., JR.: Polyps and polypoid lesions of large bowel; R.; MILLER, L., and FITTS, W. T., JR.: Malignant po- surgical considerations. S. CZin. North America 42: tential of adenomas of colon and rectum. J. A. M. A , : , MILLER, G. F.: Unusual lesions of right colon. 5. EWING. M. R.: Villous tumours of rectum: Hun- Am. J. SUrg. 99: ,1960. terian lecture. dnn. Roy. Coll. Surgeons England PHILLIPS, W. M.; REMINE, W. H.; BWHRS, 0. H., , and SCUDAMORE, H. H.: Benign lesions of cecum simu- 6. FISHER, E. R., and CASTRO, A. F.: Diffuse papil- lating carcinoma. J. A. M. A. 172: , lomatous polyps (villous tumors) of colon and rectum; 17. PUESTOW. C. B., and WHEELER, J. R.: Unusual pathologic and clinical observations. Am. J. Surg. 85: benign lesions of cecum. Am. J. Proctol. 6: , , GRINNELL, R. S., and LANE, N.: Benign and malig- 18. SCHNITKA, T. K.; FRIEDMAN, M. H.; KIDD, E. G., nant adenomatous polyps and papillary adenomas and MACKENZIE, W. C.: Villous tumors of rectum and of colon and rectum; analysis of 1,856 tumors in 1,335 colon characterized by severe fluid and electrolyte loss. patients. Internat. Abstr. Surg. 106: , Suig. Gynec. 6. Obst. 112: , HANLEY, P. H.; HINFS, M. 0.; RAY, J. E.; Mc- 19. SHAMBLIN, J. R., JR.: HUFF, J. F.; WAUGH, J. M., PHERSON, F., and HIBBERT, W. A.: Villous tumors: ex- and MOERTEL, C. G.: Villous adenocarcinoma of colon perience with 163 patients. South. M. J. 55: , with pronounced electrolyte disturbance. Ann. Surg : , HARP, R. A.: WAUGH, J. M., and DOCKERTY, M. B.: 20. SHATZ, B. A., and BRICKER, E.: Papillary adenoma Noninfiltrating villous colonic tumors; partial review of ascending colon. Cancer Seminar 1: , of literature and report of 63 cases. Dis. Colon Q Rec tum 5: , SOUTHWOOD, W. F.: Villous tumors of large 10. HENSHALL. G. K.: Villous tumors of larne bowel intestine: their pathogenesis, symptomatology, diagand presentation of unusual case. Am. J. Rohgenol. nosis and management. Ann. Roy. Coll. Surgeons Eng- 84: ,1960. land 30: 23-45, 1962.

8 No. 2 VILLOUS ADENOMAS OF RIGHT COLON Goldfurb SUNDERLAND, D. A., and BINKLEY, G. E.: Papillary adenomas of large intestine; clinical and morphological study of 48 cases. Cancer 1: , SWINTON, N. W.; MEISSNER, W. A., and SOLAND, W. A., JR.: Papillary adenomas of colon and rectum; clinical and pathological study. A. M. A. Arch. Ztat. Med. 96: , WELCH, J. S., and DOCKERTY, M. B.: Villous carcinoma of colon. Dis. Colon Q Rectum 1: , WHEAT, M. W., JR., and ACKERMAN, L. V.: Villous adenomas of large intestine; clinicopathologic evaluation of 50 cases of villous adenomas with emphasis on treatment. Ann. Surg. 147: , WOLF, B. S.: Roentgen diagnosis of villous tumors of colon. Am. J. Roentgenol. 84: , 1960.