1977, British Journal of Radiology, 50, 224-227
Case reports interstitial gastric emphysema, secondary to obstruction, is proposed.
enterocolitis with intramural bowel gas, four cases of which showed gas in the stomach wall. SUMMARY
DISCUSSION
The mechanism of production of gastric emphysema in this patient can be explained by a simple process. The stomach was chronically distended due to incomplete obstruction of the duodenum. There was sudden rise of intragastric pressure during the bouts of vomiting. At the height of raised intraluminal pressure, there was breach of the gastric mucosa and air escaped into the submucous layer. A similar process is described by Ward (1960) in an adult patient with pyloric stenosis due to gastric carcinoma. Fierst and his colleagues (1951) have postulated a similar mechanism in gastric emphysema following gastroscopy when the stomach is inflated and there is a rise in intragastric pressure. Interstitial gastric emphysema may also be produced by other instrumentations as in sigmoidoscopy, oesophagoscopy, retroperitoneal air insufflation and therefore a history of instrumentation must always be sought. It is also described as a rare extension of pneumoperitoneum. Vichi and his colleagues (1973) have described 18 cases of necrotizing
A case of interstitial gastric emphysema secondary to duodenal obstruction is reported here. Localized involvement of the stomach wall is extremely unlikely in necrotizing entercolitis. In the absence of signs of infection, or a history of instrumentation or immuno-suppressive therapy, a lesion producing gastric or duodenal obstruction should be suspected. The presence of intramural gas should in no way alter the management. A barium examination will usually demonstrate the site of obstruction. ACKNOWLEDGMENTS
I would like to thank Professor R. B. Zachary for permitting me to publish this case and also acknowledge the encouragement by Dr. R. K. Levick with his guidance and helpful suggestions. REFERENCES FIERST, S. M., ROBINSON, H. M., and LASAGNA L.,
1951.
Interstitial gastric emphysema following gastroscopy. Annals of Internal Medicine, 34, 1202-1212. VICHI, G. F., MAGGINI, M., MOGGI, P., GORI, F.,
and
PAOLI, F., 1973. Pneumatosis intestinalis, clinical, radiological and anatomo-pathological study on eighteen patients. Anales de Radiologie, 16, 153-161. WARD, R. P., 1960. Interstitial gastric emphysema. British Journal of Radiology, 33, 458-459.
Reactivation of radiation pneumonitis by adriamycin By D. P. Mclnerney, F.R.C.R., M.B., M.R.C.P. and J. Bullimore, M.B., B.S., D.M.R.T., F.R.C.R. Departments of Radiodiagnosis and Radiotherapy, United Bristol Hospitals {Received July, 1976)
The onset and severity of radiation pneumonitis depend on the total dosage, fractionation technique, the duration of treatment (Evans, 1960; Jennings and Arden, 1962) and concomitant chemotherapy (Littman et al, 1974). The ability of actinomycin D to potentiate and reactivate the effects of radiation in the skin (Liebner, 1962), mucosa (D'Angio et al, 1959) and in the lungs is well known (Wara et al., 1973) and a similar toxic effect has been ascribed recently to adriamycin (Donaldson et al., 1974; Cassady et al, 1975). We wish to report a case in which pneumonitis was activated by actinomycin D and reactivated by adriamycin, but in which empirical steroid therapy enabled the course of treatment to be continued. The important implications of these phenomena for current developments in treatment planning are discussed.
CASE REPORT
A female, aged four presented with a three week history of abdominal pain and haematuria. On examination there was a large mass in the left flank. Excretion urography showed delayed excretion of contrast medium in the lower part of the left kidney and an extensively disorganized pelvicalyceal system. A diagnosis of nephroblastoma was made. Chest radiograph showed multiple metastases (Fig. 1). Left nephrectomy was performed on 17/12/74. The diagnosis was confirmed histologically. On the day of operation treatment was started with vincristine 0.75 rag/m2 intravenously, and actinomycin D 0.0152 mg/kg daily for five consecutive days. Vincristine 1.5 mg/m was continued weekly for five weeks. On the 10th postoperative day abdominal irradiation was started but was interrupted after three days because the pulmonary metastases were enlarging. Therefore, on the 14th day irradiation of the whole of both lungs was begun and a dose of 1500 rad in6017 days in 10 fractions was given using opposed fields and Co radiation. On the 21st day post-operatively adriamycin 35 mg (50 mg/m2) was given. On the 30th day a chest radiograph showed complete radiological resolution of the metastases (Fig. 2).
224
MARCH
1977
Case reports
FIG. 1. Multiple rounded opacities are seen throughout both lungs consistent with metastases.
FIG. 2. There is no radiological evidence of lung metastases.
Abdominal irradiation was recommenced on the 35th day and a total dose of 3186 rad was given in 60 days in 18 fractions with a gap of 24 days and another of 15 days during treatment. Opposed fields and Co60 were used and the remaining kidney was shielded throughout. The proposed long term chemotherapy was a 6 week cycle using actinomycin D 0.015 mg/kg on days 1 to 5 and adriamycin 50 mg/m2 on day 22 with vincristine 1.5 mg/m2 on days 1,8 and 22.
FIG. 3. Opacification of the left mid and lower zone and interstitial thickening in the right mid zone are present due to radiation pneumonitis.
On the 100th day the third course of actinomycin D was finished. Four days later the patient developed acute otitis media which was treated successfully with antibiotics. On the 111th day the patient became acutely short of breath with central cyanosis. The pulse rate was 140/min., the respiratory rate 40/min. and the temperature normal. The chest radiograph showed a large opacity in the left lung, obscuring the heart border and patchy opacification in the right mid zone (Fig. 3). These were regarded as features of radiation pneumonitis and because of the clinical urgency treatment with prednisolone 15 mg. daily was started at once, without lung biopsy. Symptoms were relieved within 24 hours on this treatment and no pathogens were cultured from sputum or blood. The dose was tapered off over three weeks and then stopped. The chest radiograph (Fig. 4) showed almost complete clearing of the pneumonitis. On the 133rd day the patient became acutely dyspnoeic, 24 hours after a planned dose of adriamycin. Prednisolone was restarted at 20 mg. daily with prompt relief of symptoms. The chest radiograph showed extensive opacification of the left lung (Fig. 5). The dose was gradually reduced over 3 weeks but when it was stopped cough and breathlessness rapidly returned and a maintenance dose of 5 mg. prednisolone daily was instituted. This dosage was continued in the form of enteric-coated capsules after a melaena on the 140th day. On the 190th day the chest radiograph showed a little diffuse opacification at the left base and left perihilar region (Fig. 6). Subsequent doses of actinomycin D and adriamycin were given with steroid cover without adverse effect. Adriamycin was discontinued after a total dose of 200 mg/m2 on the 200th postoperative day. A new regime of actinomycin D 1.4 mg/m2 on day 1 and vincristine 1.5 mg/m2 on days 1, 8 and 15 of a 6-week cycle was adopted. Enteric-coated prednisolone 2.5 mg. daily was given from days 1 to 22 of each cycle.
225
VOL.
50, No. 591 Case reports
FIG. 4. Almost complete clearing of the radiation pneumonitis has occurred.
FIG. 6. No lung lesion is shown on the final radiograph.
DISCUSSION
FIG. 5. Patchy opacification of the left mid zone due to recurrent radiation pneumonitis.
The child remains well apart from a slight cough. She attends full-time school and takes part in games. Her chest is radiologically clear at follow-up to 15 months.
Radiation pneumonitis occurs in 5 per cent of cases receiving a nominal standard dose (Ellis, 1968) of 900 rets, or of 700 rets with actinomycin D (Phillips and Margolis, 1972); and for a given dose of radiation, pneumonitis develops more frequently in those also given actinomycin D (Margolis and Phillips 1969). Usually there is an interval of two to three months between conventional radiation dosage and the onset of pneumonitis. In this case the total radiation dosage to the lungs of 656 rets was unlikely alone to cause pneumonitis. A dose of adriamycin 35 mg was given on the 7th day of lung irradiation and appears to have lowered the lung tolerance to a similar degree to that expected if actinomycin D were given concurrently with radiation. It is likely that the radiation effect was potentiated by the chemotherapy. Pneumonitis occurred 11 days after a dose of actinomycin D, three months after the start of lung irradiation. It was recalled 24 hours after subsequent treatment with adriamycin. The empirical use of corticosteroids in treating radiation pneumonitis is supported by experimental studies in which their use increased the compliance of irradiated lungs in rats (Moss et al., 1966); and it is reported that clinical and radiographic evidence of pneumonitis may occur within days of steroid withdrawal in patients with malignant lymphomas
226
1977, British Journal of Radiology, 50, 227-228
MARCH 1977
Case reports receiving radiotherapy to the chest and cyclic chemotherapy (Castellino et al., 1973, 1974). Corticosteroid cover treatment may enable adriamycin and actinomycin D treatment to be completed despite the risk of reactivating radiation pneumonitis. The combined disciplinary approach of surgery, radiation and chemotherapy in the treatment of malignant disease is being applied to an increasing number of tumours. When radiation and chemotherapy are used concurrently, modification of radiation dosage will be necessary if excessive normal tissue damage is to be avoided. When adriamycin is administered concurrently with radiation, pneumonitis may occur at an N.S.D. level below 700 rets. Corticosteroid cover allows treatment with adriamycin and actinomycin D to be continued despite recall radiation pneumonitis. REFERENCES
D'ANGIO, G. J., FARBER, S., and MADDOCK, C. L., 1959.
Potentiation of X-ray effects by actinomycin D. Radiology, 73,175-177. DONALDSON, S., GLUCK, J., and WITHER, J., 1974. Adria-
mycin activating a recall phenomenon after radiation therapy. Annals of Internal Medicine, 81, 407-408. ELLIS, F., 1968. Relationship of biological effect to dosetime—fraction factors in radiotherapy. In Current Topics in Radiation Research, edited by Ebert and Howard, publishers North and Holland, Amsterdam, 1968. EVANS, J. C , 1960. Time-dose relationships of radiation fibrosis of the lung. Radiology, 74,104. JENNINGS, F. L., and ARDEN, A., 1962. Development of
radiation pneumonitis; time and dose. Archives of Pathology, 74, 351-360. LIEBNER, E. J., 1962. Actinomycin D and radiation therapy. American Journal of Roentgenology, 87, 94-105. LITTMAN, P., DAVIS, L. W., NASH, J., TEFFT, M., BORNS, P.,
LEPANTO, P., 1974. The hazard of acute radiation pneumonitis in children receiving mediastinal radiation. Cancer, 33, 1520-1525. MARGOLIS, L. W., and PHILLIPS, T. L., 1969. Whole lung
irradiation for metastatic tumour. Radiology, 93, 1173— 1179. Moss, W. T., HADDY, F. J., and SWEANY, S. K., 1966.
1975. Radiation-adriamycin interactions: preliminary clinical observations. Cancer, 36, 946-949.
Some factors altering the severity of acute radiation pneumonitis; variation with cortisone, heparin and antibiotics. Radiology, 75, 50-54.
CASTELLINO, R. A., GLATTSTEIN, E., and KAPLAN, H. S.,
PHILLIPS, T. L., and MARGOLIS, L. W., 1972. In Frontiers
CASSADY, J. R., RICHTER, M. P., PIRO, A. J., and JAFFE, N.,
1973. Radiation pneumonitis precipitated by exogenous steroid manipulation with emphasis on cyclic chemotherapy. Investigative Radiology, 8, 271-272. CASTELLINO, R. A., GLATTSTEIN, E., TURBOW, M. M.,
of Radiation Therapy and Oncology. Published by Kurger, Basel and University Park Press, Baltimore. Volume 6, 254-273. WARA, W. M., PHILLIPS, T. L., MARGOLIS, L. W., and
SMITH, V., 1973. Radiation pneumonitis: a new approach to the derivation of time-dose factors. Cancer, 32, 547552.
ROSENBERG, S., and KAPLAN, H. S., 1974. Latent radia-
tion injury of lungs or heart activated by steroid withdrawal. Annals of Internal Medicine, 80, 593-599.
The solitary ulcer syndrome of the rectum: radiological features By F. W. Lewis, M.B., Ch.B., D.M.R.D., M. P. Mahoney, M.B., Ch.B., M.R.C.P., and C. K. Heffernan, M.R.C.P.(I), F.R.C.Path. Departments of Radiology, Medicine and Pathology, The Royal Infirmary, Blackburn, Lanes {Received July, 1976)
The solitary ulcer syndrome of the rectum is a well defined pathological entity. The name was coined by Lloyd Davies at St. Mark's Hospital, London, during the 1930s. The condition was first described by Cruveilhier (1870) as a chronic ulcer of the rectum. Allen (1966) called it a hamartomatous polyp of the rectum and others have called it colitis cystica profunda (Epstein et ah, 1966; Wayte and Helwig, 1967). Madigan and Morson (1969) reviewed 68 cases that had been collected at St. Mark's Hospital and the subject has been recently reviewed by Rutter and Riddell (1975). Despite its pathological and clinical recognition, however, the condition appears to be largely unknown to radiologists, with no reports in the radiological literature. The following case report shows, however, that it is of radiological significance.
CASE HISTORY
The patient, a 17-year-old girl, presented with a three year history of intermittent rectal bleeding which recently had become more frequent. She was otherwise fit. On clinical examination the only abnormality was a polypoidal mass in the rectum about 6 cm from the anal margin. Routine laboratory tests were normal. Sigmoidoscopy confirmed a mass at 6 cm involving two-thirds of the circumference of the rectal lumen. The mucosa above and below was normal. Biopsy of this area showed a large increase in fibrous tissue with abnormally sited deep glandular elements. A tentative diagnosis of an ulcerated granulomatous polyp was made. A barium enema showed non-distensible annular narrowing in the rectum (Fig. 1). An irregularity in the mucosa was thought to be due to the biopsy site. The barium enema was otherwise normal. Despite the young age of the patient, it was suggested that this lesion was probably malignant. Biopsy specimens taken at a sigmoidoscopy under G.A. showed similar histological appearances and because of the doubt raised by the deep glandular structure in the biopsy specimens, these were sent to Dr. Basil Morson at St. Mark's Hospital, London, for his opinion. Dr. Morson was in no doubt that the appearance was typical of
227
Case reports interstitial gastric emphysema, secondary to obstruction, is proposed.
enterocolitis with intramural bowel gas, four cases of which showed gas in the stomach wall. SUMMARY
DISCUSSION
The mechanism of production of gastric emphysema in this patient can be explained by a simple process. The stomach was chronically distended due to incomplete obstruction of the duodenum. There was sudden rise of intragastric pressure during the bouts of vomiting. At the height of raised intraluminal pressure, there was breach of the gastric mucosa and air escaped into the submucous layer. A similar process is described by Ward (1960) in an adult patient with pyloric stenosis due to gastric carcinoma. Fierst and his colleagues (1951) have postulated a similar mechanism in gastric emphysema following gastroscopy when the stomach is inflated and there is a rise in intragastric pressure. Interstitial gastric emphysema may also be produced by other instrumentations as in sigmoidoscopy, oesophagoscopy, retroperitoneal air insufflation and therefore a history of instrumentation must always be sought. It is also described as a rare extension of pneumoperitoneum. Vichi and his colleagues (1973) have described 18 cases of necrotizing
A case of interstitial gastric emphysema secondary to duodenal obstruction is reported here. Localized involvement of the stomach wall is extremely unlikely in necrotizing entercolitis. In the absence of signs of infection, or a history of instrumentation or immuno-suppressive therapy, a lesion producing gastric or duodenal obstruction should be suspected. The presence of intramural gas should in no way alter the management. A barium examination will usually demonstrate the site of obstruction. ACKNOWLEDGMENTS
I would like to thank Professor R. B. Zachary for permitting me to publish this case and also acknowledge the encouragement by Dr. R. K. Levick with his guidance and helpful suggestions. REFERENCES FIERST, S. M., ROBINSON, H. M., and LASAGNA L.,
1951.
Interstitial gastric emphysema following gastroscopy. Annals of Internal Medicine, 34, 1202-1212. VICHI, G. F., MAGGINI, M., MOGGI, P., GORI, F.,
and
PAOLI, F., 1973. Pneumatosis intestinalis, clinical, radiological and anatomo-pathological study on eighteen patients. Anales de Radiologie, 16, 153-161. WARD, R. P., 1960. Interstitial gastric emphysema. British Journal of Radiology, 33, 458-459.
Reactivation of radiation pneumonitis by adriamycin By D. P. Mclnerney, F.R.C.R., M.B., M.R.C.P. and J. Bullimore, M.B., B.S., D.M.R.T., F.R.C.R. Departments of Radiodiagnosis and Radiotherapy, United Bristol Hospitals {Received July, 1976)
The onset and severity of radiation pneumonitis depend on the total dosage, fractionation technique, the duration of treatment (Evans, 1960; Jennings and Arden, 1962) and concomitant chemotherapy (Littman et al, 1974). The ability of actinomycin D to potentiate and reactivate the effects of radiation in the skin (Liebner, 1962), mucosa (D'Angio et al, 1959) and in the lungs is well known (Wara et al., 1973) and a similar toxic effect has been ascribed recently to adriamycin (Donaldson et al., 1974; Cassady et al, 1975). We wish to report a case in which pneumonitis was activated by actinomycin D and reactivated by adriamycin, but in which empirical steroid therapy enabled the course of treatment to be continued. The important implications of these phenomena for current developments in treatment planning are discussed.
CASE REPORT
A female, aged four presented with a three week history of abdominal pain and haematuria. On examination there was a large mass in the left flank. Excretion urography showed delayed excretion of contrast medium in the lower part of the left kidney and an extensively disorganized pelvicalyceal system. A diagnosis of nephroblastoma was made. Chest radiograph showed multiple metastases (Fig. 1). Left nephrectomy was performed on 17/12/74. The diagnosis was confirmed histologically. On the day of operation treatment was started with vincristine 0.75 rag/m2 intravenously, and actinomycin D 0.0152 mg/kg daily for five consecutive days. Vincristine 1.5 mg/m was continued weekly for five weeks. On the 10th postoperative day abdominal irradiation was started but was interrupted after three days because the pulmonary metastases were enlarging. Therefore, on the 14th day irradiation of the whole of both lungs was begun and a dose of 1500 rad in6017 days in 10 fractions was given using opposed fields and Co radiation. On the 21st day post-operatively adriamycin 35 mg (50 mg/m2) was given. On the 30th day a chest radiograph showed complete radiological resolution of the metastases (Fig. 2).
224
MARCH
1977
Case reports
FIG. 1. Multiple rounded opacities are seen throughout both lungs consistent with metastases.
FIG. 2. There is no radiological evidence of lung metastases.
Abdominal irradiation was recommenced on the 35th day and a total dose of 3186 rad was given in 60 days in 18 fractions with a gap of 24 days and another of 15 days during treatment. Opposed fields and Co60 were used and the remaining kidney was shielded throughout. The proposed long term chemotherapy was a 6 week cycle using actinomycin D 0.015 mg/kg on days 1 to 5 and adriamycin 50 mg/m2 on day 22 with vincristine 1.5 mg/m2 on days 1,8 and 22.
FIG. 3. Opacification of the left mid and lower zone and interstitial thickening in the right mid zone are present due to radiation pneumonitis.
On the 100th day the third course of actinomycin D was finished. Four days later the patient developed acute otitis media which was treated successfully with antibiotics. On the 111th day the patient became acutely short of breath with central cyanosis. The pulse rate was 140/min., the respiratory rate 40/min. and the temperature normal. The chest radiograph showed a large opacity in the left lung, obscuring the heart border and patchy opacification in the right mid zone (Fig. 3). These were regarded as features of radiation pneumonitis and because of the clinical urgency treatment with prednisolone 15 mg. daily was started at once, without lung biopsy. Symptoms were relieved within 24 hours on this treatment and no pathogens were cultured from sputum or blood. The dose was tapered off over three weeks and then stopped. The chest radiograph (Fig. 4) showed almost complete clearing of the pneumonitis. On the 133rd day the patient became acutely dyspnoeic, 24 hours after a planned dose of adriamycin. Prednisolone was restarted at 20 mg. daily with prompt relief of symptoms. The chest radiograph showed extensive opacification of the left lung (Fig. 5). The dose was gradually reduced over 3 weeks but when it was stopped cough and breathlessness rapidly returned and a maintenance dose of 5 mg. prednisolone daily was instituted. This dosage was continued in the form of enteric-coated capsules after a melaena on the 140th day. On the 190th day the chest radiograph showed a little diffuse opacification at the left base and left perihilar region (Fig. 6). Subsequent doses of actinomycin D and adriamycin were given with steroid cover without adverse effect. Adriamycin was discontinued after a total dose of 200 mg/m2 on the 200th postoperative day. A new regime of actinomycin D 1.4 mg/m2 on day 1 and vincristine 1.5 mg/m2 on days 1, 8 and 15 of a 6-week cycle was adopted. Enteric-coated prednisolone 2.5 mg. daily was given from days 1 to 22 of each cycle.
225
VOL.
50, No. 591 Case reports
FIG. 4. Almost complete clearing of the radiation pneumonitis has occurred.
FIG. 6. No lung lesion is shown on the final radiograph.
DISCUSSION
FIG. 5. Patchy opacification of the left mid zone due to recurrent radiation pneumonitis.
The child remains well apart from a slight cough. She attends full-time school and takes part in games. Her chest is radiologically clear at follow-up to 15 months.
Radiation pneumonitis occurs in 5 per cent of cases receiving a nominal standard dose (Ellis, 1968) of 900 rets, or of 700 rets with actinomycin D (Phillips and Margolis, 1972); and for a given dose of radiation, pneumonitis develops more frequently in those also given actinomycin D (Margolis and Phillips 1969). Usually there is an interval of two to three months between conventional radiation dosage and the onset of pneumonitis. In this case the total radiation dosage to the lungs of 656 rets was unlikely alone to cause pneumonitis. A dose of adriamycin 35 mg was given on the 7th day of lung irradiation and appears to have lowered the lung tolerance to a similar degree to that expected if actinomycin D were given concurrently with radiation. It is likely that the radiation effect was potentiated by the chemotherapy. Pneumonitis occurred 11 days after a dose of actinomycin D, three months after the start of lung irradiation. It was recalled 24 hours after subsequent treatment with adriamycin. The empirical use of corticosteroids in treating radiation pneumonitis is supported by experimental studies in which their use increased the compliance of irradiated lungs in rats (Moss et al., 1966); and it is reported that clinical and radiographic evidence of pneumonitis may occur within days of steroid withdrawal in patients with malignant lymphomas
226
1977, British Journal of Radiology, 50, 227-228
MARCH 1977
Case reports receiving radiotherapy to the chest and cyclic chemotherapy (Castellino et al., 1973, 1974). Corticosteroid cover treatment may enable adriamycin and actinomycin D treatment to be completed despite the risk of reactivating radiation pneumonitis. The combined disciplinary approach of surgery, radiation and chemotherapy in the treatment of malignant disease is being applied to an increasing number of tumours. When radiation and chemotherapy are used concurrently, modification of radiation dosage will be necessary if excessive normal tissue damage is to be avoided. When adriamycin is administered concurrently with radiation, pneumonitis may occur at an N.S.D. level below 700 rets. Corticosteroid cover allows treatment with adriamycin and actinomycin D to be continued despite recall radiation pneumonitis. REFERENCES
D'ANGIO, G. J., FARBER, S., and MADDOCK, C. L., 1959.
Potentiation of X-ray effects by actinomycin D. Radiology, 73,175-177. DONALDSON, S., GLUCK, J., and WITHER, J., 1974. Adria-
mycin activating a recall phenomenon after radiation therapy. Annals of Internal Medicine, 81, 407-408. ELLIS, F., 1968. Relationship of biological effect to dosetime—fraction factors in radiotherapy. In Current Topics in Radiation Research, edited by Ebert and Howard, publishers North and Holland, Amsterdam, 1968. EVANS, J. C , 1960. Time-dose relationships of radiation fibrosis of the lung. Radiology, 74,104. JENNINGS, F. L., and ARDEN, A., 1962. Development of
radiation pneumonitis; time and dose. Archives of Pathology, 74, 351-360. LIEBNER, E. J., 1962. Actinomycin D and radiation therapy. American Journal of Roentgenology, 87, 94-105. LITTMAN, P., DAVIS, L. W., NASH, J., TEFFT, M., BORNS, P.,
LEPANTO, P., 1974. The hazard of acute radiation pneumonitis in children receiving mediastinal radiation. Cancer, 33, 1520-1525. MARGOLIS, L. W., and PHILLIPS, T. L., 1969. Whole lung
irradiation for metastatic tumour. Radiology, 93, 1173— 1179. Moss, W. T., HADDY, F. J., and SWEANY, S. K., 1966.
1975. Radiation-adriamycin interactions: preliminary clinical observations. Cancer, 36, 946-949.
Some factors altering the severity of acute radiation pneumonitis; variation with cortisone, heparin and antibiotics. Radiology, 75, 50-54.
CASTELLINO, R. A., GLATTSTEIN, E., and KAPLAN, H. S.,
PHILLIPS, T. L., and MARGOLIS, L. W., 1972. In Frontiers
CASSADY, J. R., RICHTER, M. P., PIRO, A. J., and JAFFE, N.,
1973. Radiation pneumonitis precipitated by exogenous steroid manipulation with emphasis on cyclic chemotherapy. Investigative Radiology, 8, 271-272. CASTELLINO, R. A., GLATTSTEIN, E., TURBOW, M. M.,
of Radiation Therapy and Oncology. Published by Kurger, Basel and University Park Press, Baltimore. Volume 6, 254-273. WARA, W. M., PHILLIPS, T. L., MARGOLIS, L. W., and
SMITH, V., 1973. Radiation pneumonitis: a new approach to the derivation of time-dose factors. Cancer, 32, 547552.
ROSENBERG, S., and KAPLAN, H. S., 1974. Latent radia-
tion injury of lungs or heart activated by steroid withdrawal. Annals of Internal Medicine, 80, 593-599.
The solitary ulcer syndrome of the rectum: radiological features By F. W. Lewis, M.B., Ch.B., D.M.R.D., M. P. Mahoney, M.B., Ch.B., M.R.C.P., and C. K. Heffernan, M.R.C.P.(I), F.R.C.Path. Departments of Radiology, Medicine and Pathology, The Royal Infirmary, Blackburn, Lanes {Received July, 1976)
The solitary ulcer syndrome of the rectum is a well defined pathological entity. The name was coined by Lloyd Davies at St. Mark's Hospital, London, during the 1930s. The condition was first described by Cruveilhier (1870) as a chronic ulcer of the rectum. Allen (1966) called it a hamartomatous polyp of the rectum and others have called it colitis cystica profunda (Epstein et ah, 1966; Wayte and Helwig, 1967). Madigan and Morson (1969) reviewed 68 cases that had been collected at St. Mark's Hospital and the subject has been recently reviewed by Rutter and Riddell (1975). Despite its pathological and clinical recognition, however, the condition appears to be largely unknown to radiologists, with no reports in the radiological literature. The following case report shows, however, that it is of radiological significance.
CASE HISTORY
The patient, a 17-year-old girl, presented with a three year history of intermittent rectal bleeding which recently had become more frequent. She was otherwise fit. On clinical examination the only abnormality was a polypoidal mass in the rectum about 6 cm from the anal margin. Routine laboratory tests were normal. Sigmoidoscopy confirmed a mass at 6 cm involving two-thirds of the circumference of the rectal lumen. The mucosa above and below was normal. Biopsy of this area showed a large increase in fibrous tissue with abnormally sited deep glandular elements. A tentative diagnosis of an ulcerated granulomatous polyp was made. A barium enema showed non-distensible annular narrowing in the rectum (Fig. 1). An irregularity in the mucosa was thought to be due to the biopsy site. The barium enema was otherwise normal. Despite the young age of the patient, it was suggested that this lesion was probably malignant. Biopsy specimens taken at a sigmoidoscopy under G.A. showed similar histological appearances and because of the doubt raised by the deep glandular structure in the biopsy specimens, these were sent to Dr. Basil Morson at St. Mark's Hospital, London, for his opinion. Dr. Morson was in no doubt that the appearance was typical of
227
