Leiomyoma of the Cecum Presenting as an Acute Surgical Abdomen: Report of a Case* DAVE B. SWERDLO~N,M.D., CONO PECORA, M.D., FRANK GRADONE, M . D .
Department of Surgery, Clara Maass Hospital, Belleville, New Jersey demonstrated throughout the mesentery. The liver appeared and felt smooth, with no clinical evidence of metastases. A right hemicolectomy was performed without incident. Postoperatively the patient had a slight fever that responded to antibiotic therapy. About ten days postoperatively, some mild congestive heart failure developed, but responded to diuretics. The patient was discharged about 2 89 weeks after admission. The pathologic specimen (Fig. 1) demonstrates the complete loss of the mucosal lining, with subsequent destruction of the layers of the outer wall by the infiltrating leiomyoma.
'THIS CASE PR~ESENTATION is t h a t of a ben i g n l e i o m y o m a of t h e c e c u m . T h e t u m o r g r e w a n d u l c e r a t e d t h r o u g h the f u l l thickness of the b o w e l wall, w i t h s u b s e q u e n t p e r f o r a t i o n . T h e p a t i e n t h a d an acute surgical a b d o m e n w h e n first seen. A b r i e f rev i e w of t h e l i t e r a t u r e is i n c l u d e d . Report of a Case An 86-year-old Caucasian man was admitted with the chief complaint of pain in the right lower quadrant of the abdomen on January 1, 1974. He had begun to experience vague abdominal pains on the day prior to admission. He complained of anorexia, but not nausea or vomiting. Stools had been normal. Some urinary frequency was reported. No history of melena, hematemesis, hemoptysis, jaundice, or weight loss was elicited. Past history revealed only a 1eft inguinal herniorrhaphy and a hemorrhoidectomy. On physical examination, the patient was alert, and in no acute distress. Hydration was clinically satisfactory. No general signs of toxicity were present. The blood pressure was 160/90 mm Hg, pulse rate 80/min, temperature 99 F, respiratory rate 20/ min. Auscultation of the chest revealed some fine tales in the right base. The abdomen was obese and soft. Tenderness was present in the right lower quadrant, but no rebound tenderness was present. No mass was palpated. A complete blood count revealed a hemoglobin of 14.6 g/100 ml and 7,600 leukocytes with 65 per cent neutrophils. The next morning the patient remained afebrile. The pain was more localized in the right lower quadrant. The leukocyte count had increased to 11,500, with 75 per cent neutrophils. With a more persistent specific location and the elevation of the leukocyte count, surgery was planned. Operation disclosed a large fungating lesion of the cecum with a small perforation. The area was surrounded with a thickened edematous vigorous inflammatory response. Palpable lymph nodes were
S m o o t h m u s c l e t u m o r s of t h e a l i m e n t a r y tract are i n f r e q u e n t . T h e i n c i d e n c e of ben i g n s m o o t h m u s c l e r u m o r s of the c o l o n is e x t r e m e l y low. T h e a d e n o m a t o u s p o l y p r e p r e s e n t s a b o u t 90 p e r c e n t of t h e b e n i g n lesions of t h e b o w e l . 2 S t o u t 9 f o u n d 20 l e i o m y o m a s in 200 b e n i g n t u m o r s i n his 50-year study. F e r g u s o n a n d H o u s t o n 2 rep o r t e d two l e i o m y o m a s in 67 b e n i g n t u m o r s in a 15-year study. K a p u r et al,3 i n 1971, q u o t e d M a c k e n z i e
el al., 5 w h o h a d c o l l e c t e d r e p o r t s of 19 cases f r o m t h e l i t e r a t u r e a n d a d d e d e i g h t of t h e i r o w n . K a p u r 3 also q u o t e s S k a n d a lakis et al.,S w h o r e p o r t e d a n d r e v i e w e d 59 cases of l e i o m y o m a . L e i o m y o m a s m a y o c c u r in all parts of the anus, r e c t u m , a n d colon. T h e s i g m o i d a n d t r a n s v e r s e c o l o n s e e m to be the m o s t c o m m o n sites. V e r y few h a v e b e e n f o u n d in t h e cecum. 4 T h e p a t i e n t s m a y be a s ) m p tomatic and have the tumors discovered f o r t u i t o u s l y . T h e y m a y also be first seen w h e n s y m p t o m s such as b l e e d i n g , 6 ulceration, i n t u s s u s c e p t i o n , a n d p e r f o r a t i o n neces-
* Received for publication November 27, 1974. Address reprint requests to Dr. Swerdlow, 44 Fairfield Street, Montclair, New Jersey 07042.
sitate c o m p l i c a t e d s u r g i c a l t r e a t m e n t o n a n e m e r g e n c y basis. Less d r a m a t i c s y m p t o m s , 438
Dis. Col. & Rect. July-Aug. 1975
Volume 18 Number 5
Volume 18 Number 5
439
LEIOMYOMA OF T H E CECUM
Fie.,, 1. Perineal biopsy showing endometriosis.
such as pain and a lump, are more usually found. Roentgenologic features depend upon whether the tumor is intramural, submucosal, subserosal, or dumbbell-shaped. 1 Discussion "A neoplasm is a new growth, comprising an abnormal collection of cells, the growth of which exceeds and is uncoordinated with that of normal tissues. ''7 It is not always possible to make an absolute distinction between benign and malignant tumor. T h e therapy of the lesion and prognosis of the patient depend on this distinction. T h e mode of growth is often used to dib ferentiate malignant from benign tumors. Malignant tumors almost never have true :apsules, and are characterized by infiltrative, erosive growth. In sharp contrast, nearly all benign tumors grow as localized expansile masses with obvious fibrous caproles. This encapsulation tends to contain the tumor and to maintain the lesion so that it can be surgically enucleated by dissection in the extracapsular plane. T h e
leiomyoma, although it tends to be discrete, localized and apparently contained, is not encapsulated. As the tumor is not encapsulated, it is not easily differentiated as benign or malignant. T h e t u m o r should be treated as a malignant minor, with wide resection. Summary T h i s is a case of a benign leiomyoma of the cecum that perforated the bowel wall and manifested as an acute surgical abdomen. T h e literature was reviewed and the lesion was found to be uncommon. Clinical pictures may vary, but a colonic mass of this nature should be treated as a cancer, as it is not usually possible to distinguish benign from malignant lesions preoperatively. References 1. Baker H L Jr, Good CA: Smooth-muscle tumors of the alimentary tract: T h e i r roentgen manifestations. Am J Roentgenol Radium T h e r Nucl Med 74: 246, 1955 2. Ferguson EF Jr, Houston CH: Benign and malignant tumors of the colon and rectum, South Med J 65: 1213, 1972
440
SWERDLOW, ET AL.
3. Kapur MM, Gulat SM, Basu RN: Leiomyoma of the colon: Report of a case. Dis Colon Rectum 14: 394, 1971. 4. Lookanoff VA, Tsapralis PC: Smooth-muscle tumors of the colon: Report of a case involving the cecum and ascending colon. JAMA 198: 88, 1966 5. MacKenzie DA, McDonald JR, Waugh JM: Leiomyoma and leiomyosarcoma of the colon. Ann Surg 139: 67, 1954 6. Murphy B: Leiomyoma of intestine. J Jr Med Assoc 66: 153, 1973
Dis. Col. &Reet. July-Aug. 1975
7. Robbins SL: Pathology. Ed. 3, Philadelphia, W. B. Saunders, 1967, volume 1, pp 89-93 8. Skandalakis JE, Gray SW, Shepard D, et al: Smooth muscle tumors of the colon and appendix, Smooth Muscle Tumors of the Alimentary Tract: Leiomyomas and Leiomyosarcomas--A Review of 2525 Cases. Springfield, II1., Charles C Thomas, 1962, chapter XI, p 155 9. Stout AP: Tumors of the colon and rectum (excluding carcinoma and adenoma). Surg Clin North Am 35:1283 (Oct) 1955
Selected Abstracts EUoENE A. GASTON, M.D., E d i t o r
Koren, E., A. Lazarovitch, M. Baratz, M. Loewenthal, and M. Solowiejczyk: Gardner's Syndrome: Report of a Family. Ann. Surg. 180: 198, 1974.
Lame, L. O., J. Larsson, and B. Nylen: Results of Different Types of Operation for Pilonidal Sinus. Acta Chir. Scand. 140: 321, 1974.
Gardner's syndrome consists of the triad of colonic polyposis, benign osseous tumors, and soft-tissue masses. T h e case histories of a father and daughter with Gardner's syndrome are presented. Both patients underwent abdominal colectomies with ileorectal anastomoses because of multiple colonic polyps. Both had subsequent excisions of desmoid tumors, and a tibial exostosis was found in the father. Gardner's syndrome is a hereditary disease which is transmitted as a mendelian dominant, probably arising as a gene mutation. While the number of polyps is less than usually found in familial polyposis, the malignant potential is high in both, and treatment is the same. The genes for these syndromes are probably different but located at the same genetic locus. Very few kindred members of families with Gardner's syndrome have all three abnormalities of the triad, the majority affected having only one or two. Rectal polyps in these patients have been observed to disappear after ileorectal anastomoses. It has been postulated that this might be due to: 1) direct contact of ileal contents with the polyps, 2) reduction of the blood supply to the rectum, or 3) the existence of an intrinsic factor which is excluded by the surgery. The rectum must be preserved when no carcinoma is found.--HAaRls S. GOLOMAN, M.D.
I n a series of 196 patients with pilonidal sinuses the three-year recurrence rates that followed a) excision and suture, b) excision only, and c) other types of operations are compared. The disease had occurred in the families of 13 per cent of the patients and had been present an average of 2t/2 years prior to surgery. The excision and suture technique was used in 93 patients with an average hospital stay of 10.5 days and a recurrence rate of 26 per cent. Excision alone was done in 60 patients, required an average of 7.1 hospital days, and had a 22 per cent recurrence rate. Other operations (marsupialization, etc.)was done in 43 patients, required an average of 23 hospital days and had a recurrence rate of 16 per cent. Further surgery was required in 18 per cent of the excision and suture group and in 15 per cent of each of the other two groups.--D,~vE B. SwEao•ow, M.D. e
Nivatvongs, S., and S. Goldbe~'g: Results of 100 Consecutive Polypectomies with the Fiberoptic Colonoscope. A New Mode of Treatment. Amer. J. Surg. 128: 347, 1974. Experiences with I00 consecutive polypectomies performed with the 100-cm Olympus fiberoptic colonoscope, using a specially designed holder to anchor the scope, are reviewed. The procedures were performed on 78 patients.
Department of Surgery, Clara Maass Hospital, Belleville, New Jersey demonstrated throughout the mesentery. The liver appeared and felt smooth, with no clinical evidence of metastases. A right hemicolectomy was performed without incident. Postoperatively the patient had a slight fever that responded to antibiotic therapy. About ten days postoperatively, some mild congestive heart failure developed, but responded to diuretics. The patient was discharged about 2 89 weeks after admission. The pathologic specimen (Fig. 1) demonstrates the complete loss of the mucosal lining, with subsequent destruction of the layers of the outer wall by the infiltrating leiomyoma.
'THIS CASE PR~ESENTATION is t h a t of a ben i g n l e i o m y o m a of t h e c e c u m . T h e t u m o r g r e w a n d u l c e r a t e d t h r o u g h the f u l l thickness of the b o w e l wall, w i t h s u b s e q u e n t p e r f o r a t i o n . T h e p a t i e n t h a d an acute surgical a b d o m e n w h e n first seen. A b r i e f rev i e w of t h e l i t e r a t u r e is i n c l u d e d . Report of a Case An 86-year-old Caucasian man was admitted with the chief complaint of pain in the right lower quadrant of the abdomen on January 1, 1974. He had begun to experience vague abdominal pains on the day prior to admission. He complained of anorexia, but not nausea or vomiting. Stools had been normal. Some urinary frequency was reported. No history of melena, hematemesis, hemoptysis, jaundice, or weight loss was elicited. Past history revealed only a 1eft inguinal herniorrhaphy and a hemorrhoidectomy. On physical examination, the patient was alert, and in no acute distress. Hydration was clinically satisfactory. No general signs of toxicity were present. The blood pressure was 160/90 mm Hg, pulse rate 80/min, temperature 99 F, respiratory rate 20/ min. Auscultation of the chest revealed some fine tales in the right base. The abdomen was obese and soft. Tenderness was present in the right lower quadrant, but no rebound tenderness was present. No mass was palpated. A complete blood count revealed a hemoglobin of 14.6 g/100 ml and 7,600 leukocytes with 65 per cent neutrophils. The next morning the patient remained afebrile. The pain was more localized in the right lower quadrant. The leukocyte count had increased to 11,500, with 75 per cent neutrophils. With a more persistent specific location and the elevation of the leukocyte count, surgery was planned. Operation disclosed a large fungating lesion of the cecum with a small perforation. The area was surrounded with a thickened edematous vigorous inflammatory response. Palpable lymph nodes were
S m o o t h m u s c l e t u m o r s of t h e a l i m e n t a r y tract are i n f r e q u e n t . T h e i n c i d e n c e of ben i g n s m o o t h m u s c l e r u m o r s of the c o l o n is e x t r e m e l y low. T h e a d e n o m a t o u s p o l y p r e p r e s e n t s a b o u t 90 p e r c e n t of t h e b e n i g n lesions of t h e b o w e l . 2 S t o u t 9 f o u n d 20 l e i o m y o m a s in 200 b e n i g n t u m o r s i n his 50-year study. F e r g u s o n a n d H o u s t o n 2 rep o r t e d two l e i o m y o m a s in 67 b e n i g n t u m o r s in a 15-year study. K a p u r et al,3 i n 1971, q u o t e d M a c k e n z i e
el al., 5 w h o h a d c o l l e c t e d r e p o r t s of 19 cases f r o m t h e l i t e r a t u r e a n d a d d e d e i g h t of t h e i r o w n . K a p u r 3 also q u o t e s S k a n d a lakis et al.,S w h o r e p o r t e d a n d r e v i e w e d 59 cases of l e i o m y o m a . L e i o m y o m a s m a y o c c u r in all parts of the anus, r e c t u m , a n d colon. T h e s i g m o i d a n d t r a n s v e r s e c o l o n s e e m to be the m o s t c o m m o n sites. V e r y few h a v e b e e n f o u n d in t h e cecum. 4 T h e p a t i e n t s m a y be a s ) m p tomatic and have the tumors discovered f o r t u i t o u s l y . T h e y m a y also be first seen w h e n s y m p t o m s such as b l e e d i n g , 6 ulceration, i n t u s s u s c e p t i o n , a n d p e r f o r a t i o n neces-
* Received for publication November 27, 1974. Address reprint requests to Dr. Swerdlow, 44 Fairfield Street, Montclair, New Jersey 07042.
sitate c o m p l i c a t e d s u r g i c a l t r e a t m e n t o n a n e m e r g e n c y basis. Less d r a m a t i c s y m p t o m s , 438
Dis. Col. & Rect. July-Aug. 1975
Volume 18 Number 5
Volume 18 Number 5
439
LEIOMYOMA OF T H E CECUM
Fie.,, 1. Perineal biopsy showing endometriosis.
such as pain and a lump, are more usually found. Roentgenologic features depend upon whether the tumor is intramural, submucosal, subserosal, or dumbbell-shaped. 1 Discussion "A neoplasm is a new growth, comprising an abnormal collection of cells, the growth of which exceeds and is uncoordinated with that of normal tissues. ''7 It is not always possible to make an absolute distinction between benign and malignant tumor. T h e therapy of the lesion and prognosis of the patient depend on this distinction. T h e mode of growth is often used to dib ferentiate malignant from benign tumors. Malignant tumors almost never have true :apsules, and are characterized by infiltrative, erosive growth. In sharp contrast, nearly all benign tumors grow as localized expansile masses with obvious fibrous caproles. This encapsulation tends to contain the tumor and to maintain the lesion so that it can be surgically enucleated by dissection in the extracapsular plane. T h e
leiomyoma, although it tends to be discrete, localized and apparently contained, is not encapsulated. As the tumor is not encapsulated, it is not easily differentiated as benign or malignant. T h e t u m o r should be treated as a malignant minor, with wide resection. Summary T h i s is a case of a benign leiomyoma of the cecum that perforated the bowel wall and manifested as an acute surgical abdomen. T h e literature was reviewed and the lesion was found to be uncommon. Clinical pictures may vary, but a colonic mass of this nature should be treated as a cancer, as it is not usually possible to distinguish benign from malignant lesions preoperatively. References 1. Baker H L Jr, Good CA: Smooth-muscle tumors of the alimentary tract: T h e i r roentgen manifestations. Am J Roentgenol Radium T h e r Nucl Med 74: 246, 1955 2. Ferguson EF Jr, Houston CH: Benign and malignant tumors of the colon and rectum, South Med J 65: 1213, 1972
440
SWERDLOW, ET AL.
3. Kapur MM, Gulat SM, Basu RN: Leiomyoma of the colon: Report of a case. Dis Colon Rectum 14: 394, 1971. 4. Lookanoff VA, Tsapralis PC: Smooth-muscle tumors of the colon: Report of a case involving the cecum and ascending colon. JAMA 198: 88, 1966 5. MacKenzie DA, McDonald JR, Waugh JM: Leiomyoma and leiomyosarcoma of the colon. Ann Surg 139: 67, 1954 6. Murphy B: Leiomyoma of intestine. J Jr Med Assoc 66: 153, 1973
Dis. Col. &Reet. July-Aug. 1975
7. Robbins SL: Pathology. Ed. 3, Philadelphia, W. B. Saunders, 1967, volume 1, pp 89-93 8. Skandalakis JE, Gray SW, Shepard D, et al: Smooth muscle tumors of the colon and appendix, Smooth Muscle Tumors of the Alimentary Tract: Leiomyomas and Leiomyosarcomas--A Review of 2525 Cases. Springfield, II1., Charles C Thomas, 1962, chapter XI, p 155 9. Stout AP: Tumors of the colon and rectum (excluding carcinoma and adenoma). Surg Clin North Am 35:1283 (Oct) 1955
Selected Abstracts EUoENE A. GASTON, M.D., E d i t o r
Koren, E., A. Lazarovitch, M. Baratz, M. Loewenthal, and M. Solowiejczyk: Gardner's Syndrome: Report of a Family. Ann. Surg. 180: 198, 1974.
Lame, L. O., J. Larsson, and B. Nylen: Results of Different Types of Operation for Pilonidal Sinus. Acta Chir. Scand. 140: 321, 1974.
Gardner's syndrome consists of the triad of colonic polyposis, benign osseous tumors, and soft-tissue masses. T h e case histories of a father and daughter with Gardner's syndrome are presented. Both patients underwent abdominal colectomies with ileorectal anastomoses because of multiple colonic polyps. Both had subsequent excisions of desmoid tumors, and a tibial exostosis was found in the father. Gardner's syndrome is a hereditary disease which is transmitted as a mendelian dominant, probably arising as a gene mutation. While the number of polyps is less than usually found in familial polyposis, the malignant potential is high in both, and treatment is the same. The genes for these syndromes are probably different but located at the same genetic locus. Very few kindred members of families with Gardner's syndrome have all three abnormalities of the triad, the majority affected having only one or two. Rectal polyps in these patients have been observed to disappear after ileorectal anastomoses. It has been postulated that this might be due to: 1) direct contact of ileal contents with the polyps, 2) reduction of the blood supply to the rectum, or 3) the existence of an intrinsic factor which is excluded by the surgery. The rectum must be preserved when no carcinoma is found.--HAaRls S. GOLOMAN, M.D.
I n a series of 196 patients with pilonidal sinuses the three-year recurrence rates that followed a) excision and suture, b) excision only, and c) other types of operations are compared. The disease had occurred in the families of 13 per cent of the patients and had been present an average of 2t/2 years prior to surgery. The excision and suture technique was used in 93 patients with an average hospital stay of 10.5 days and a recurrence rate of 26 per cent. Excision alone was done in 60 patients, required an average of 7.1 hospital days, and had a 22 per cent recurrence rate. Other operations (marsupialization, etc.)was done in 43 patients, required an average of 23 hospital days and had a recurrence rate of 16 per cent. Further surgery was required in 18 per cent of the excision and suture group and in 15 per cent of each of the other two groups.--D,~vE B. SwEao•ow, M.D. e
Nivatvongs, S., and S. Goldbe~'g: Results of 100 Consecutive Polypectomies with the Fiberoptic Colonoscope. A New Mode of Treatment. Amer. J. Surg. 128: 347, 1974. Experiences with I00 consecutive polypectomies performed with the 100-cm Olympus fiberoptic colonoscope, using a specially designed holder to anchor the scope, are reviewed. The procedures were performed on 78 patients.
