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The Korean Journal of Pathology 1973;7(1): 47-62.
한국인 소장 및 대장종양에 관한 임상 및 병리조직학적 연구
Clinical and Histopathological Studies on Tumors of the Small and Large Intestine among Koreans
ABSTRACT
The tumors of the small and large intestine have been investigated by many workers in both clinical and pathological aspects. It is of interest that although the small bowel comprises the longest portion of the alimentary canal primary tumors in the small bowel are rare (Botsford and Seibel, 1947 ; Darling and Welch, 1959). However, among the tumors of the small bowel, malignancy is more common than benign tumor, and the former consists of adenocarcinoma, lymphosarcoma, carcinoids, etc. The carcinoma of the large intestine in the most frequent malignant tumor throughout the gastrointestinal tract in the U.S.A. But the incidence of this tumor was preceded by the carcinoma of the stomach in Korea(Lee et al., 1965 ; Kim, et al., 1967). The incidence of carcinoma of the colon and rectum in the Asian and African countries is less high than that of the Europe and America(Burkitt, 1971). Carcinoma of the large bowel occures mostly in the 5th and 6th decade of life. In the right colon carcinoma grows as fungating mass, while the distal colon shows "napkin-ring" configuration. The prognosis of a patient with cancer of the large bowel is dependent upon the progess made by that lesion up to the time of operation. The spread may occur through the lymphatics, by direct extension and by the blood stream. Dukes (1932) devided his cases of carcinoma of the rectum into three groups : Type A ; limited to the rectal wall without nodal involvement Type B ; penetrating through bowel wall into adjacent tissue without nodal involvement. Type C ; penetrating through bowel wall with nodal involvement. This classification by Dukes has been adopted as a useful prognostic guide in dealing with carcinoma of the large bowel, and its modifications were also reported. The polypoid lesions of the large bowel can be identified to be adenomatous polyp, villous adenoma, etc. The adenomatous polyp is almost always benign, the incidence of malignancy being less than 1 per cent. Villous adenoma is premalignant, the incidence of malignancy varying from 5 to ,50 per cent, depending upon the series quoted. But some investigators suggested that these two lesions were growth variants of the same tumor (Hellurg, 1963 ; Hertz, et al., ; Ross and Ferrara) There are several reports on carcinoma of the colon and rectum in Korea, which based on clinical and statistical aspects. The present study is attempt to investigate mainly histopathological characteristics and to compare with reports of other countries, and extent to tumors of the small bowel as well as those of the large intestine. Material and Methods ; The material used in this study consists of 408 surgically resected or biopsied tissue from tumors of the large and small bowel for 12 years from 1960 to 1971. At first gross examination was made to observe size, location and growing characteristics of tumors. Regional lymphnodes were dissected and obtained as possible as we could. All specimens were fixed in 10% formalin. For histological examinations, paraffin embedded blocks were cut in 6 micron thickness and sections were stained by routine hematoxylin-eosin method. Histopathological studies on the cases available for microscopic examination are performed as follows : 1. histopathological grading of carcinoma of the large bowel according to the Broders grade (1925) except the mucoid carcinoma was made ; 2. The grades were compared with metastasis to regional lymphnodes of carcinoma of the large intestine and also with venous or lymphatic invasion by carcinoma of the large bowel. ; 3. The carcinoma of the large bowel were classified as the Dukes’classification and stagings by Smith’s method were also made, and then they were made a comparison in relation to each grade of carcinoma. ; 4. The influences of size of carcinoma of the colon and rectum on metastasis to the regional lymphnodes ; 5. The influences of the growing pattern of the tumor margin, infiltrating or pushing, on metastasis to the regional lymphnodes ; 6. The tumors of the small bowel devided into benign and malignant tumors with location of the tumor. At the duodenum carcinomas arising from the ampullar of Vater were included in this study ; 7. The benign tumors of the large bowel also were classified in histopathological findings and associated malignant change was considered in the polyp. For the all cases which clinical redords were available, sex, age, chief complaints, duration of symptom and value of the serum hemoglobin were reviewed. The duration of recurrent carcinoma, of the large bowel was studied in relation to the staging in which readmissions for the treatment of 5-F. U. were not included. Results and Summary ; Clinical and histopathological studies were made on 408 surgically removed cases of tumors of the small and large intestine that were submitted to the Department of Pathology, Yonsei University College of Medicine, during the period of 12 years from 1960 to 1971. 1. Among 41 cases of tumors of the small intestine, 37 cases were malignant tumors and the ratio of malignancy and benignancy was 9.5 : 1. 2. Peutz-Jeghers syndrome was found in benign tumors of the small bowel. The malignant tumors of the small intestine consisted of 11 cases of adenocarcinoma, 16 cases of lymphoma, 2 cases of carcinoid, 1 case of undifferentiated carcinoma and 7 cases of metastatic malignant tumors. 3. The lymphoma occurred at the ileum in total 10 cases. The carcinoids throughout the large and small intestine had its origin in extraappendiceal areas, and it showed difference from the reports of the foreign countries. 4. The ratio of the benign tumors and malignant tumors in the large intestine was 1 : 4.8. And also the ratio of the malignant tumors of the large bowel and those of the small bowel was 8.3 : 1. 5. The adenomatous polyps occupied 85.9% of the benign tumors of the large intestine and 93.7% of them occurred at the rectum. The 34 cases of the benign polypoid lesions of the large intestine were less than that of 1.5cm in its diameter. 6. The malignant tumors of the large intestine were 4.3% of the total malignancy of surgical specimens for the same period. 7. Carcinoma of the large intestine showed different clinical symptoms according to the location. 8. The size of carcinoma of the large bowel had no much influence on the metastasis of the regional lymphnodes. 9. The grade of carcinoma of the large intestine had much effects on the venous or lymphatic invasion by carcinoma and also metastasis of the regional lymphnodes. 10. Stage 0 was not identified in the cases examined and the higher the stage of carcinoma of the large intestine was, the higher the grade was. 11. The characteristics of local spread of carcinoma, infiltrating margin or pushing margin, gave much effects on the metastasis to the regional lymphnodes. 12. The tendency was seen that the recurrent period in less advanced stage of carcinoma was a little short, compared with more advanced atage. In conclusions. based on above findings it can be stated that it is important to observe venous or lymphatic invasion by carcinoma, metastasis of the regional lymphnodes and to make stage of the patient of carcinoma in the large bowel. In this study the carcinoma of the large bowel showed relatively advanced stage, and among the tumors of the small intestine the carcinoid had different location from that reported at foreign countries.