CARCINOID TUMORS OF T H E ILEUM (ARGENTAFFINOMAS)
CHRISTIE E. McLEOD, M.D.
From the Department of Pathology, Middlesex Hospital, Middletown, Connecticut
There are approximately 283 reports in the literature on carcinoid tumors of
the small intestine. The appendix is the most common site of origin while the
terminal ileum is the second most common site. These tumors are frequently
found at necropsy, incidental to other major findings. Humphreys 1 concluded
from her study that the carcinoid tumor of the small intestine was a far from
harmless lesion. She summarized 152 cases, 36 or 24 per cent of which gave
symptoms of obstruction and 37 or 24.4 per cent had metastases. Cooke2 summarized 115 cases of argentaffinomas, reporting that 20 or 17.4 per cent had
produced symptoms of obstruction and 21 or 18.3 per cent had metastases.
Ariel3 reported 122 cases with 38 cases or 31 per cent which had produced clinical
symptoms and 33 or 27 per cent had metastases. Dangremond 4 summarized
46 cases, 24 or 52 per cent of which had metastases and 16 or 34.8 per cent were
known to have had clinical symptoms.
I t is not the purpose of this paper to discuss the theories of origin of these
tumors which have been discussed in detail by Oberndorfer5, Forbes 6 , and Masson 7 ' 8 .
The theory of Masson that these tumors have their prigin in the
Kultschitzky cells of the crypts of Lieberkiihn is generally accepted. These
cells contain granules which stain dark brown with the ammoniacal silver staining technic. The presence of these silver reducing granules gave rise to the term
argentaffinoma.
CASE REPORTS
Casel. E. Y. % 69121. A white female, age 66, entered Middlesex Hospital as a patient
of Dr. G. M. Craig on September 11,1941 with a complaint of diarrhea of six months duration.
She had been well until the onset of the diarrhea. She had moved about considerably
during that six months period and on returning to her home consulted her physician. Physical examination was essentially negative. She had lost 15 pounds in weight. She was
treated medically with no clinical improvement and was admitted to the hospital for
study.
Examination in the hospital presented the following positive findings: Obvious weight
loss, slight abdominal distention and slight tenderness throughout the abdomen.
Laboratory Examinations: Hemoglobin 15.3 grams per cent (Sahli). Erythrocytes 4.1
million per cu.mm. Leukocytes 4,200 per cu.mm.. segmented polymorphonuclears 70 per
cent, non-segmented polymorphonuclears 8 per cent, lymphocytes 15 per cent, monocytes
5 per cent, eosinophiles 2 per cent. Urinalysis: Specific gravity 1.021, albumen 1 plus;
Sediment: Numerous pus cells, rare red blood cells. Stool culture: Negative for typhoid,
paratyphoid and dysentery bacilli. X-ray studies: The colon was examined by barium
enema and no evidence of any organic lesion in the large bowel was found. There was no
evidence of any abnormality of the gall bladder or stomach. Marked hyperperistalsis of
the proximal portion of the small bowel was noted, the significance of which could not be
determined at that time.
The. patient was discharged September 20. The etiology of the diarrhea was not determined. The patient continued to have diarrhea and cramps at home during the next four
months when she suddenly had severe pain in right lower quadrant, distention and obstipa301
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CHRISTIE E. MCLEOD
tion. She expired at home on January 21,1942, 2 days after the acute symptoms developed
and ten and half months after the onset of the first symptoms.
The essential findings of the post-mortem examination were: The abdominal cavity
contained approximately 1000 cc. of cloudy fluid with a purulent exudate in the region of
the cecum and terminal ileum. There was dilatation of the small intestine, proximal to
the terminal ileum and the loops of small intestine were matted together by a fibrinopurulent exudate. Just at the ileo-cecal valve, in the region of the mesenteric attachment,
was a firm yellow nodule measuring 2.2 x 1.8 x 1.5 cm. This nodule extended into the lumen
of the bowel causing almost complete obstruction at this point. It also extended into the
mesentery. The mesentery was contracted and contined numerous yellow nodules averaging 1.3 cm. in diameter. The cecum was also contracted and the inner wall was drawn together. The entire wall was markedly congested, edematous and there was an area of perforation at the base covered over with a plastic exudate. The base of the cecum was drawn
up behind the terminal ileum into the mesenteric mass described above.
Microscopic: Ileum. There were nests and cords of small speroidal cells of uniform size
without any attempt at gland formation. There was an occasional pleomorphic, hyperchromatic cell and a few mitotic figures. These cells replaced the mucosa, invaded the
entire wall and extended into the mesentery. They could also be seen invading the wall of
the cecum. Nests of these cells could be seen invading the blood vessels and lymphatics.
Masson's silver staining method showed the granules to take a dark brown stain.
Case 2. O. O. %71694. A 74 year old white male entered the Middlesex Hospital
April 13, 1942, as a patient of Dr. Henry Sherwood and Dr. Harry Frank. His complaints
were abdominal pain, nausea and vomiting of six hours duration. For the past 5 years he
had been having attacks of alternating constipation and diarrhea associated with griping
and generalized abdominal pains. This was accompanied by some nausea but no vomiting
until the present attack. One year previous to admission the patient had a barium enema
which revealed no abnormalities. He refused an x-ray study of the upper intestine at
that time. There had been some weight loss.
He was found to have auricular fibrillation four years previous and had been treated
with digitalis since that time.
Summary of physical examination: Somewhat emaciated, elderly male who appeared acutely ill. B.P. 148/92, Pulse rate 62, irregular. There was moderate distention of the abdomen with tenderness on palpation over the entire abdomen. The prostate was moderately
enlarged, smooth. Laboratory findings: Hemoglobim 13.5 grams per cent (Sahli), Erythrocytes 4.1 million per cu.mm. Leukocytes 16,400 per cumm, segmented polymorphonuclears
82 per cent, non-segmented polynuclears 7 per cent, lymphocytes 10 per cent, eosinophiles
1 per cent. Urinalysis: Specific gravity: 1.025, albumen 1 plus, occasional pus cells. A
flat plate of the abdomen showed some distention of the loops of the small bowel in the region of the mid- and terminal portions of the ileum suggestive of an incomplete small bowel
obstruction.
Under medical regime his distention was relieved and his general condition improved.
A complete gastro-intestinal x-ray study showed the terminal ileum to be the site of extensive changes characterized by puddling of the barium and small intestinal hypomotility.
At no time could the terminal ileum be satisfactorily visualized. X-ray diagnosis: Incomplete small intestinal obstruction in the region of the terminal ileum, which could be due
either to granuloma or new growth, presumably the former. The patient was prepared for
operation. An obstructive lesion of the ileum was found about 20 cm. proximal to the ileocecal valve above which point the small bowel was moderately distended. This portion of
the ileum was resected. The surgeon's operative note stated that there was a "puckering
and scarring of the mesentery extending from the region of the tumor to the root of the
mesentery where a nodule about the size of a hazel nut was found. A small nodule about the
size of a marble was felt on the inner margin of the right lobe of the liver. This was also
visualized as a whitish area." The patient did poorly after the operation and expired on
the 21st post operative day, five years after the onset of symptoms. Permission for autopsy
was not obtained.
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A report of the examination of the operative specimen follows:
A kinked portion of ileum measured 13 cm. in length. In the center, at the angle of the
kink, and at the mesenteric attachment was a yellow tumor nodule measuring 2.5 X 2 X
1.3 cm. The nodule protruded into the lumen and through the wall into the attached
mesentery. The obstruction was almost complete due both to the protrusion of the mass
into the lumen and the kinking of the bowel. There were small areas of yellow infiltration
in the fat.
Microscopic: The mucosa was replaced by nests and cords of small cuboidal cells of
uniform size. These nests and cords of cells invaded the entire bowel wall. Sections taken
from the attached mesentery showed nests of tumor cells invading the lymphatics and one
of the larger blood vessels invaded by a large mass of tumor cells.
Discussion: The first x-ray examination of both patients failed to reveal the lesion.
This failure was probably due to the fact that a detailed study of the small intestine was not
done in either case. The clinical symptoms in each case were certainly suggestive of a
neoplasm in the intestinal tract. A review of the clinical aspects of these cases suggests
that further examinations should have been carried out in the hope that surgical interference at an earlier date might have met with more favorable results.
Note: The author is grateful to Drs. G. M. Craig, Henry S. Sherwood and Harry S. Frank
for their permission to report these cases.
SUMMARY
Two cases of carcinoid tumor of the ileum have been reported. Both cases
presented symptoms of intestinal obstruction. Regional lymph node metastases
were present in both and one had a node in the liver which the surgeon interpreted
as a metastasis. These cases illustrate the surgical importance of carcinoid
tumors of the small bowel.
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