CARCINOMA OF ESOPHAGUS PERFORATING THE AORTA*

Transcription

1 CARCINOMA OF ESOPHAGUS PERFORATING THE AORTA* HERBERT J. SCHATTENBERG AND JOSEPH ZISKIND From the Department of Pathology, Graduate School, Tulane University, and the Charity Hospital, New Orleans Perforation of a carcinomatous ulcer of the esophagus is not uncommon. Kaufman 1 found that it occurred in 45 per cent of his cases. The perforation may take place into the trachea and bronchi, the mediastinum, large blood vessels and pleural or pericardial cavities. Erosion of large blood vessels with fatal hemorrhage, is, however, quite rare. Kaufman 1 noted erosion into the aorta four times in 126 cases of carcinoma of the esophagus. Knaut 2 collected all reported cases up to 1896 which numbered 50, and since Knaut's study Carr and Hanford 3 in 1922 found 21 cases in the literature and added one of their own. Since 1922 occasional cases have been added to the literature. We have recently had a case of esophageal carcinoma which perforated into the aorta and caused fatal hemorrhage and because of the rarity of this condition and the long history of esophageal bleeding we believe this case is of sufficient interest to warrant reporting. REPORT OF CASE H. R., a colored male, 45 years of age was perfectly well until January 1937 when he suddenly became hoarse, and in spite of symptomatic treatment, this condition never improved. Since the onset of hoarseness he noticed some difficulty in swallowing food. On July 3, 1937, five hours before admission to the hospital, he suddenly experienced a severe pain in the chest and abdomen following which he bled from the oral cavity. The patient estimated that he lost approximately one quart of blood. Physical examination revealed a well developed and nourished colored male about 45 years of age, who was restless and perspiring. The B. P. was 110/70; * Received for publication April 4,

2 616 HERBERT J, SCHATTENBERG AND JOSEPH ZISKIND the temperature 100; the pulse 120 and the respiration 24. The pupils were equal, regular and reacted to light and accommodation. The nose, ears and throat were negative. The neck showed no abnormal or visible pulsations, masses or adenopathy. The lungs were clear. The heart was not enlarged, the rate was rapid and no murmurs were heard. The aortic transverse diameter '.'. ;'$& '.H. '... «;. : 'A.... t FIG. 1. VIEW OF DESCENDING AORTA WITH PROBE IN THE PERFORATION appeared to be widened. The abdomen was tender in the umbilical region. No masses or abdominal organs were palpable. The extremities were normal. Laryngoscopy revealed paralysis of the left vocal cord. The Blood Wassermann was negative. The hemoglobin was 70 per cent and the white cell count was 11,250. The urine examination was normal. X-ray examination of the chest showed no significant increase in the perihilar and peribronchial markings and

3 CARCINOMA OF ESOPHAGUS 617 no evident lesion in the lung parenchyma. There was some increase in width of the upper mediastinal shadow suggesting dilatation of the aorta. The patient was put to bed and treated with sedatives. His temperature, pulse and respiration gradually came down to normal and he left the hospital on July 12, The patient was readmitted on September 15, 1937, with the following FIG. 2. ULCERATING CARCINOMA OF ESOPHAGUS DEMARCATED BY DOTTED LINE. PROBE IN THE CENTRAL NECROTIC AREA history. He felt fairly well since his discharge until four days before this second admission when he developed persistent vomiting. Shortly before admission he had a severe oral hemorrhage, which continued while in the hospital and caused the patient's death three hours after arrival on the ward. Autopsy. The body was that of an emaciated, poorly developed colored

4 618 HERBERT J. SCHATTENBERG AND JOSEPH ZISKIND male, about 45 years of age, weighing approximately 130 pounds and measuring 165 cm. in length. The conjunctivae and sclerae were very pale. The oral cavity was filled with many blood clots. The rest of the external examination was normal. The pleural cavities were partially obliterated by adhesions. FIG. 3. VIEW SHOWING PATH OF PERFORATION AS INDICATED BY PROBE Dotted line demarcates aorta from esophagus. (A) indicates aorta and (B) esophagus. Esophageal wall markedly thickened by tumor. The lungs showed moderate emphysema and the bronchi were normal. The heart weighed 300 grams and the myocardium was flabby. The coronary arteries were patent. At the junction of the transverse and descending aorta a perforation was noted in the intima (fig. 1) which communicated with the lumen of the esophagus adjacent to it. The rest of the aorta showed a moderate

5 CARCINOMA OF ESOPHAGUS 619 amount of arteriosclerosis but none at or just surrounding the perforation. In the middle third of the esophagus in the region of the bifurcation of the trachea, a tumor mass (fig. 2) was noted which measured 8 cm. by 4 cm. by 0.5 cm. and almost completely occluded and surrounded the esophageal lumen. The wall FIG. 4. GROUPS OF SQUAMOUS CELLS NOT WELL DIFFERENTIATED of the esophagus was thickened by the tumor mass. Within the center of the tumor, an area was noted measuring 1.5 cm. in diameter which was very soft and necrotic and a probe could be passed through it directly into the aorta through the previously described perforation (fig. 3). The aorta and esophagus were adherent to each other at this level for a distance of about 4 cm. The

6 620 HERBERT J. SCHATTENBERG AND JOSEPH ZISKIND regional esophageal lymph nodes, the bronchial and the posterior mediastinal lymph nodes were all considerably enlarged, firm and involved with neoplastic tissue. The stomach was distended and filled with an enormous blood clot. The small and large intestines contained altered blood. The liver, lungs, kidney, spleen, gastro-intestinal tract, heart, adrenals, pancreas, and genital organs showed no evidence of any metastatic involvement. Microscopic findings. The tumor of the esophagus was composed of groups of squamous cells whose centers showed, in a few instances, some slight attempt at cornification. In general, it was considerably undifferentiated (fig. 4). Considerable necrosis and secondary infection was present. The regional lymph nodes were infiltrated with similar groups of neoplastic cells. The tumor was classified as a squamous cell carcinoma Grade III. DISCUSSION Carcinoma of the esophagus begins by an infiltration of the mucosal cancer cells into the deeper layers of the esophageal wall. The tumor grows between the muscle fibers to the adventitia and together with the reacting connective tissue causes thickening of the esophagus. The normal layers are forced apart and destroyed and the wall is then composed entirely of neoplastic and fibrous tissues. Perforation of the aorta with fatal hemorrhage is one of the rare terminal complications of this disease. In ulcerative carcinoma of the esophagus with associated infiltration of the aorta, perforation will usually occur as the tumor disintegrates before the advancing ulcerative process. In some cases perforation is direct because of suppuration of the tumor. The case herein reported shows a tumor of a high degree of malignancy with metastases to the regional lymph nodes. This is in line with the findings of Vinson 4 who studied and reported his findings in 1000 cases of malignant disease of the esophagus and concluded that metastases are frequent and undoubtedly occur early in many cases. He takes exception to the prevalent view that carcinoma of the esophagus is a slow growing tumor of low grade malignancy with very little tendency to metastasize. This observer noted in those 519 of his cases which had tissue removed for examination that many of these were of a grade 3 or 4 according to Broder's classification. Vinson concludes, further,

7 CARCINOMA OF ESOPHAGUS 621 that esophageal carcinoma is usually of a high degree of malignancy, with little cell differentiation and with frequent metastases. SUMMARY A case of carcinoma of the esophagus with perforation into the aorta is reported. Metastases to the regional lymph nodes were present and the tumor was of a high grade of malignancy. Perforation of the aorta from an esophageal carcinoma with fatal hemorrhage is a rare complication of this disease. REFERENCES (1) KAUFMAN, EDWARD: Pathology, 1: 644. Blakiston's Son and Co., (2) KNAUT, B.: Ueber die durch Speiserohrenkrebs bedingten Perforationen der benachbarten Blutbahnen, nebst einer Beobachtung von primarer Oesophagusdilatation und von Leukoplakia eosophagi. Berlin, (3) CARR, JAMES G., AND HANFORD, C. W.: Carcinoma of the Esophagus with Perforation of the Aorta; Observations on Radium Therapy. Am. Jour. Med. Sci., 164: 340,1922. (4) VINSON, PORTER P.: Malignant Disease of the Esophagus, Study of 1000 cases. Northwest. Med., 32: 320, llfio Tulane Ave. New Orleans, La.