BENIGN TUMORS OF THE STOMACH
JAMES F. MINNES, M.D.,
AND
CHARLES F. GESCHICKTER, M.D.
(From the Surgical Pathological Laboratory, Department oj Surgery Johns Hopkins Hospital)
Benign tumors of the stomach, though of more infrequent occurrence than
malignant growths of that organ, are sufficiently common to warrant attention. In recent years an extensive literature has accumulated on their incidence, pathological and clinical features, and roentgen diagnosis. They are
frequently confused clinically with malignant and inflammatory lesions, and
may give rise to complications which demand immediate surgical intervention.
It is the purpose of this paper to review briefly the literature and to present
the clinical and pathological features of 50 benign tumors of the stomach
recorded in the Johns Hopkins Hospital from 1889 to the present day.
TYPES AND INCIDENCE
Benign tumors may arise from any of the several coats of the stomach:
the mucosa, submucosa, muscularis, or serosa. According to the tissue of
origin they may be divided into two groups: epithelial and mesenchymal.
Among the epithelial tumors are adenomas, adenopapillomas, adenomyomas,
and fibro-adenomyomas. Chief among the mesenchymal tumors are the leiomyomas, fibromas, lipomas, neurofibromas, and the rare angiomas and osteomas. Finally there is a group of lesions which are not truly neoplastic but
are usually included with tumors. These include cysts-simple blood or
lymph cysts, dermoid and echinococcus cysts-and rarely embryonic rests
of the pancreas.
The absolute incidence of these benign tumors, as well as their relative
frequency as compared with malignant gastric tumors, is difficult to determine.
Eusterman and Senty reported a series of 27 benign tumors, which represented
1.3 per cent of all gastric neoplasms operated on at the Mayo Clinic between
1907 and 1921. In 1932 Lockwood stated that nearly 1,000 cases had been
reported; his series of 12 constituted 4.5 per cent of all gastric neoplasms
seen in a period of seven years. This is in accord with the findings at the
University of Minnesota, where it has been estimated that 5 per cent of all
gastric tumors are benign. In 1925 Eliason and Wright were able to collect
560 cases, to which they added 50 of their own, making a total of 610.
Because of the confusion of nomenclature in the literature it is even more
difficult to state the exact incidence of the individual types of benign tumor.
The term" polyp" has been employed frequently to describe any pedunculated tumor either actually or apparently arising from the mucous layer. It
refers only to the gross morphologic characteristics of the lesion rather than
to the more intimate histopathological structure. It is therefore suggested
that this term be rejected and the more accurately descriptive terms adenoma
and adenopapilloma be adopted.
136
137
BENIGN TUMORS OF THE STOMACH
In 1928 Szokoblow reported 182 gastric polyps of probable adenomatous
structure, to which 8 polypoid adenomas have been added. In 1925 Eliason
and Wright collected from the literature 44 adenopapillomas and 31 adenomas,
to which they added 16 and 5 cases respectively. In 1930 Ackman collected
88 cases of multiple papillomas from the literature and added one of his own.
Among the benign tumors of mesenchymal origin the leiomyomas are by
far the most common. Eliason and Wright found 321 cases, to which they
added 4 of their own. In 1927 Nigrisoli collected 211 cases. Since then
Balfour and Henderson have reported 23 tumors arising from connective tissue
and muscle, and 16 additional cases have been recorded by various authors.
Two fibromyomas have been reported.
TABLE
I; Incidence of Benign Tumors Gathered from the Literature
Epithelial
Polyps
182 (19.5%)
Papillomata. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 89 (9.5%)
Adenomata. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 42 (4.5%)
Polyposis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16 (1.7%)
Mesenchymal
Leiomyomata
Neurofibromata
Fibromata
Lipomata
Osteomata
Osteochondromata
Myomata
. 341 (36.6%)
. 102 00.9%)
. 42 (4.5%)
. 32 (3.4%)
.
1 (0.1 %)
.
1 (0.1%)
.
3 (0.3%)
Endothelial
Hemangiomata
Lymphadenomata
Endotheliomata
.
.
.
15 (1.6%)
14 (1.5%)
12 (1.2%)
Cysts
Simple
Dermoid
Echinococcus
.
.
.
29 (3.2%)
5 (0.5%)
4 (0.4%)
TOTAL ..•.••........•.......•.•.•.•••...•..••••.•
931
Eliason and Wright collected 28 lipomas from the literature and added one
case of their own. In 1926 Bianchi, in France, found only 11 reported cases
and added one more. Three additional cases have since been reported.
Neurofibromas are not infrequent. Harild reviewed the literature in 1931
and found 100 cases, to which he added one of his own. One other case has
been reported.
Hemangiomas are much rarer. Ten have been collected by Eliason and
Wright, to which 5 recent cases may be added. The same authors found 23
fibromas, and added 6 of their own. Thirteen cases have since been recorded.
In one case, reported by Nelson, the tumor had become partially ossified.
Twelve cases of " endothelioma" of the stomach were reported by Dahlgren
in 1934.
Cysts apart from simple cysts (29 cases have been reported) are extremely
rare. There are on record 5 dermoid cysts, one reported by Ruysch in 1732,
138
JAMES F. MINNES AND CHARLES F. GESCHICKTER
one by Love, and the remainder by Balfour and Henderson. Echinococcus
or hydatid cysts are reported by Oehlecker and by Bachlendorf, Castelvi, and
Pelares. There are reports of 3 pancreatic rests in the wall of the stomach.
The above review of the literature is summarized in Table I.
PATHOLOGY
In the present series of 50 cases the following types were found: neurofibroma, 1; fibroma, 1; hemangioma, 1; leiomyomas, 16; polyps, 31; adenomyomas, 9; adenopapillomas, 11; multiple papillomas (polyposis), 2; un-
FIG. 1.
PHOTOMICROGRAPH OF A LEIOMYOMA SHOWING !!'(TERLACING BUNDLES OF MUSCLE FIBERS
The cells are elongated and spindle-shaped, and have plump, oval nuclei. Autopsy No. 2247.
classified, 9. In over half of the cases, 26, the polypoid tumors were multiple,
2 instances of so-called polyposis being observed.
Benign tumors show no strong predilection for anyone part of the stomach,
but are slightly more common in the pyloric region than elsewhere. Nineteen
of the 50 cases in our series occurred in the pylorus, 12 at the cardia, 10 in the
fundus, and 1 in the posterior wall. In 5 instances where the tumors were multiple they were scattered diffusely throughout the mucosa. In 8 instances the
location was not accurately recorded. The majority of the lesions were small,
the size of a pea or smaller. Only two tumors were as large as a hen's egg,
one a neurofibroma occurring at the cardia and the other an adenoma located
in the pyloric region.
The mesenchymal tumors may be sessile or pedunculated. They lie within
the wall of the stomach, project into its lumen, or remain subserous and
FIG. 2.
LOW-POWER AXD HIGH-POWER PHOTOMICROGRAPHS OF AN ADENOMA OF THE STOMACH
The low-power shows a greatly thickened gastric mucosa and cystic dilatation' of the gastric
glands and crypts. The high-power shows greatly dilated glands lined by an orderly row of
gastric epithelium. The lumina of the glands are filled with mucus. Autopsy No. 9300.
139
140
JAMES F. MINNES AND CHARLES F. GESCHICKTER
project into the peritoneal cavity. They are usually small but sometimes
grow to a tremendous size. Scharapo and Pendl described fibromas of the
stomach weighing 5,500 grams and 3,600 grams respectively. Occasionally,
by virtue of their size and position, they cause embarrassment of the circulation to the supra-adjacent mucosa, resulting in necrosis and ulceration. Rarely
do they undergo hyaline, cystic, or malignant change. (Fig. 1.)
The epithelial tumors may be divided into two groups, the adenomas and
the adenopapillomas. The adenomas arise from the mucosa as reddish,
friable, button-like or lobulated masses. Microscopically they represent
localized areas of hypertrophy and hyperplasia of the gastric epithelium resting upon a broad connective-tissue and smooth muscle base. The stroma is
extremely vascular and is seen to contain relatively large blood vessels stuffed
with red blood cells, and there is an extensive cellular infiltration of lymphocytes, mononuclears, eosinophils and plasma cells. The glands are enlarged,
usually dilated and cystic. They are lined by an orderly row of columnar or
cuboidal epithelium. In some instances several layers of cells are found to
line a single gland or crypt. When the connective-tissue or muscular elements predominate over the glandular structure, the tumor is designated
a fibro-adenoma or adenomyoma. Menetrier distinguished two varieties of
adenoma, depending upon whether the ducts or the fundus of the gland were
involved. In the former variety the tumor is distinctly lobulated and the
cysts are large and numerous. In the latter there is little or no lobulation
and the cysts are either few in number or entirely absent. Menetrier called
growths of the former type polyadenomes polypeux, and of the latter polyadenomes en nappe. (Fig. 2.)
The adenopapillomas form cauliflower-like projections of varying size
within the lumen of the stomach. They are friable and not infrequently ulcerated. It is this type of tumor that may cause pyloric obstruction.
The pedicle is generally quite slender and through it run delicate bands of
fibrous connective tissue which arborize frequently. Superimposed on this
fibrous connective-tissue stalk is an orderly row of tall columnar epithelium.
The normal peristalsis of the stomach probably acts as a contributing factor
to the pedunculated nature of these papillomas and continues to exaggerate
the deformity. (Fig. 3.)
The term" polyposis," although frequently used in the literature, is like
" polyp" a poor descriptive word. It is here used to signify multiple, minute
epithelial tumors either of an adenomatous or papillomatous character scattered diffusely throughout the gastric mucosa.
There is considerable evidence in the literature to show that benign adenomas and adenopapillomas may develop into cancer. In 1930 Miller et al
reported 8 cases out of 23, or 35 per cent, as showing carcinomatous changes;
to these they added 24 cases gathered from the literature. Ackman in 1930
stated that '15 per cent of reported cases of adenopapillomas had shown malignancy. Benedict and Allen in 1934, reviewing a series of 17 cases of adenomatous polyps in the Massachusetts General Hospital, found microscopic
evidence of malignancy in 7 cases, or 41.2 per cent. In the present series of
31 gastric adenomas and papillomas malignant change had occurred in 3.
Microscopically the malignant tissue shows epithelial cells lining the
FIG. 3.
LOW-POWER AND HIGH-POWER PHOTOMICROGRAPHS OF A PAPILLOMA OF THE STOMACH
The pedunculated character of the growth is seen in the- low-power picture. The high-power
photomicrograph shows columnar epithelial cells resting upon a delicate, arborizing, connectivetissue stalk which is infiltrated by numerous small round cells. Path. No. 45290.
141
FIG. 4.
PAPILLOMATOUS TUMOR
oz
TilE STOM,\CH WITH EARLY CARCINOMATOUS CHANGE
The gastric glands are dilated, the mucosa is greatly thickened, and the epithelium is migrating
down into the underlying submucosa and muscularis. The high-power photomicrograph shows
the area outlined in the low-power view. The malignant character of the tumor is indicated by
the hyperchromatic appearance of the nuclei and the invasion of the surrounding connective tissue
by the cells lining the gastric glands. Autopsy No. 5170.
142
BENIGN TUMORS OF THE STOMACH
143
gastric glands and crypts, breaking through the basement membrane, and
invading the submucosa and muscularis. The individual cells have lost their
polarity in relation to adjacent cells, and numerous mitotic figures are present.
(Fig. 4.)
CLINICAL OBSERVATIONS
In the present series of benign tumors 26 occurred in white and 23 in
colored patients. The 16 leiomyomas were equally distributed between the
two races. Since, however, the ratio of colored to white patients in Johns
Hopkins Hospital is 1:6, the incidence in the former is approximately six times
that in the latter. This is in harmony with the high incidence of other mesenchymal tumors in the colored race. The proportion of males to females was
39 to 11. The age distribution is given in Fig. 5, which shows the age of the
patients at the time of death. The youngest patient was twenty-one, the
oldest ninety-four; the majority of tumors occurred during the fifth and sixth
decades, with a maximum incidence between seventy-five and eighty years.
FIG. 5.
CHART SHOWING AGE hCIDENCE IN
50 CASES OF BENIGN GASTRIC TUMORS
Symptomatology: As indicated by Table II, little reliance can be placed
upon the clinical features in arriving at a diagnosis. In 36 of the 50 cases the
tumors gave no indication of their presence. The complaints on admission and
the causes of death were quite independent of the gastric lesion. In 5 instances there was some concomitant lesion elsewhere in the gastro-intestinal
tract, as carcinoma of the rectum and esophagus. In these cases it was impossible to determine whether the gastric symptoms were primary in the
stomach or reflex from some other portion of the digestive tract. In 4 cases
there were associated lesions of the stomach: cancer in three instances and
a chronic gastritis accompanying pernicious anemia in the fourth. In only
four patients did it seem likely that the gastric tumors produced symptoms.
These cases are reported in detail below.
Symptoms when present are dependent upon the development of some
complication such as obstruction, ulceration, or hemorrhage. The size and
position of the tumor are important. A large tumor situated at the pyloric
144
JAMES F. MINNES AND CHARLES F. GESCHICKTER
TABLE
Path. No.
Lesion
Race,
Sex,
Age
II; Summary of Cases
Location
Clinical Features
Cause of Death
----- ------. ----- ----- ----------1------------
\V.M.78
Cardia
Asymptomatic
\V.F.42
\V.M.55
Fundus
Pylorus
A-11265
A-11706
Neurofibroma
Fibroma
Hemangioma
Leiomyoma
Leiomyoma
A-10227
"A-10404
Leiomyoma
Leiomyoma
\V.M.72
C.F. 80
Fundus
A-I0604
A-7205
Leiom yoma
Leiomyoma
\\i.M.60
W.F.44
Cardia
Pylorus
"A-7739
"tA-7799
A-5004
"A-4000
"A-2247
Leiomyoma
Leiomyoma
Leiomyoma
Leiomyoma
Leiomyoma
W.F.
C.M.
C.F.
C.M.
C.M.
Pylorus
Pylorus
Asymptomatic
Pyelonephritis
Pain, vomiting, mass, Gastric cancer
loss of weight
Asymptomatic
Tetanus
Pain, vomiting, consti- Sigmoid cancer
pation
Asymptomatic
Heart disease
Pain, filling defect, stool Gastric cancer
benzidine positive
Asymptomatic
Kidney cancer
Diarrhea, loss of weight, Pellagra
anorexia
Asymptomatic
Heart disease
Asymptomatic
Pneumonia
Asymptomatic
Heart disease
Asymptomatic
Uremia
Asymptomatic
Heart disease
"A-372R
Leiomyoma
C.M. 40
"A-927
Leiomyoma
C.M. 54
"A-930
"tA-969
Leiomyoma
Leiomyoma
W.M.63
W.M.46
Cardia
and
fundus
Pylorus
Pylorus
A-1931
"A-I 1584
A-11993
Leiomyoma
Polyposis
Papilloma
W.M.47
W.M.61
W.M.71
Cardia
Diffuse
Cardia
tA-10102
"A-9300
"A-R7R4
Adenoma
Adenoma
Papilloma
W.F. 75
C.M. 65
C.F. 5R
Pylorus
Diffuse
Fundus
"tA-7479
Adenoma
W.M.50
Pylorus
"A-7992
A-6072
"tA-5170
Papilloma
Papilloma
Papilloma
C.M. 63
W.M.79
C.M. 50
Fundus
A-4030
tA-4250
"tA-331O
A-3341
"tA-225t
Papilloma
Papilloma
Adenoma
Papilloma
Adenoma
C.M. 63
C.F. 49
C.M. 65
W.M.76
C.M. 52
Pylorus
Pylorus
Diffuse
Pylorus
Diffuse
"A-2575
Adenoma
C.M. 48
"tA-2619
Polyposis
W.M.75
Cardia
and
fundus
Diffuse
tA-3753
A-2159
A-1287
C.M. 20
W.M.77
51
94
43
57
39
Posterior
wall
Cardia
Cardia
and
pylorus
Pylorus
Indigestion, pain, anorexia
Asymptomatic
Asymptomatic
Pain, loss of weight,
weakness
Asymptomatic
Asymptomatic
Nausea, vomiting
Ruptured bladder
Prostatic disease
Heart disease
Tuberculosis
Pancreatic cancer
Bladder cancer
Pneumonia
Rectal cancer and
uremia
Cerebral hemorrhage
Cerebral hemorrhage
Gastric cancer
Asymptomatic
Asymptomatic
Anorexia, fatigue, pain,
tarry stools
Weakness, indigestion, Pernicious anemia
anemia
No free hydrochloric
acid
Asymptomatic
Pneumonia
Asymptomatic
Bronchial pneumonia
Nausea, vomiting, diarrhea, weakness, mass,
anemia, filling defect
Asymptomatic
Heart disease
Morning nausea
Syphilitic aortitis
Vomiting
Gastric cancer
Asymptomatic
Heart disease
Ascites
Syphilit ic cirrhosis of
liver
Asymptomatic
Tuberculosis
Asymptomatic
Obstruction of lower
ileum
145
BENIGN TUMORS OF THE STOMACH
TABLE
Path. No.
Lesion
Race,
Sex,
ARe
A-2622
*tA-2762
Adenoma
Adenoma
C.M. 57
C.M. 52
*A-2786
A-1162
tA-1180
*A-1206
tA-1275
*A-1348
*tA-1433
Adenoma
Papilloma
Polyp
Polyp
Polyp
Polyp
Polyp
W.M.39
\V.F. 60
M.
55
C.F. 65
W.F. 75
C.M. 39
W.M.54
A-1677
tA-2811
*A-515
*A-489
*tA-45290
Polyp
Polyp
Polyp
Polyp
Papilloma
C.M.55
W.M.57
\V.M.61
\V.M.
\Y.M.65
* = Multiple lesion.
II (Continued)
Location
Pylorus
cardia
Diffuse
Fundus
Cardia
Pylorus
Pylorus
Fundus
cardia
Cardia
Fundus
Pylorus
Pylorus
Pylorus
and
fundus
Clinical Features
Cause of Death
Asymptomatic
Asyrn ptomatic
Heart disease
Rectal cancer
Asymptomatic
Gastric symptoms
Asymptomatic
Asymptomatic
Asymptomatic
Asymptomatic
Asymptomatic
Heart disease
Heart disease
Heart disease
Heart disease
Gangrene of lung
Tuberculosis
Cirrhosis of liver
Asymptomatic
Asymptomatic
Asymptomatic
Asymptomatic
Indigestion, loss
Meningitis
Esophageal cancer
Cirrhosis of liver
Esophageal carcinoma
of Postop. pneumonia
weight
No free
acid
hydrochloric
t = Lesion greater than 1 em.
valve may prolapse through it and cause obstruction. Size alone, however, is
not a determining factor. Two of the largest tumors in this series, each about
the size of a hen's egg, were entirely symptomless. Scharapo describes a
fibroma weighing 5,500 grams excised from the stomach of a women who
had had no other symptoms than a feeling of weight in the abdomen, while
Pendl reports a fibroma of the stomach in a man who died of bronchial pneumonia, which weighed 3,600 grams and which had apparently been symptomless. Loss of weight, emaciation, epigastric pain, anorexia, nausea and vomiting, hematemesis, melena, and a severe secondary anemia are occasionally
observed, depending upon the location, size, and condition of the lesion.
Although these symptoms are suggestive, they are by no means diagnostic.
The tumor is rarely large enough to be palpable through the anterior abdominal wall. Not infrequently tenderness and muscle spasm in the epigastrium are noted. The determination of the hydrochloric acid content of the
gastric juice is of equivocal value. Usually it is diminished or entirely absent,
but cases are reported in which it has been increased. There is one group of
patients who present themselves complaining only of breathlessness, weakness
and fatigue, arising from anemia and consequent to melena. In such exceptional cases the clinical picture may suggest a correct diagnosis.
Roentgen Findings: Although a few isolated cases of benign tumor have
been accurately diagnosed preoperatively by microscopic examination of a
fragment of the tumor found in the gastric contents (Semenza and others),
little reliance can be placed on the clinical findings in arriving at a correct
diagnosis. With expert radiological examination of the stomach a greater
number of correct diagnoses have been made. Pansdorf and Determann report 4 cases of benign tumor all of which were diagnosed correctly by x-ray
and confirmed at operation. Ackman diagnosed a case of multiple adeno-
146
JAMES F. MINNES AND CHARLES F. GESCHICKTER
papilloma and reports 3 similar cases that had been diagnosed by x-ray.
Moore asserts that benign tumors present certain roentgenologic signs which
differentiate them from malignant or inflammatory lesions. He says: "If
these signs are not characteristic they are at least suggestive:
" 1. They produce a filling defect that is circumscribed and punched-out
in appearance.
" 2. The filling defect is usually on the gastric walls, leaving the curvature
regular and pliant.
"3. While the rugae are obliterated in the immediate area of the tumor,
just as in inflammatory and malignant lesions, the rugae surrounding a benign
tumor are more nearly normal in their arrangement and distribution.
"4. They cause little or no disturbance in peristalsis, and retention is
uncommon except when the lesion is at, or very near, the pylorus.
" 5. They do not reveal a niche, nor is there any incisura or other evidence
of spasm.
" 6. They are rarely sufficiently large to be palpated.
" Probably the most essential feature in the examination is the close and
complete approximation of the walls of the barium-filled stomach. . . .
"Differentiation roentgenologically, of benign tumors and other gast.ric
lesions can seldom be absolute, but in many instances the roentgenologic signs
warrant an attempt at such a distinction."
CASE REPORTS
1. PAPILLOMA WITH MALIGNANT CHANGE (AUTOPSY No. 5170): H. H., a fiftv-vearold colored male, was admitted to the hospital May 8, 1917, complaining of sweliiIi'g of
both legs. His illness had begun ten months earlier, with nausea, vomiting, diarrhea, and
weakness. During the month before admission the diarrhea had become more severe.
The patient was emaciated, and considerable ascites was present. There was no blood
in the stool, but there was a severe secondary anemia. The red blood cell count was
2,774,000; the hemoglobin 28 per cent. On May 19 a firm, rounded mass was felt two
fingers breadth below the left costal margin. This was thought to be the spleen or the left
lobe of the liver. On May 24 there was a bulging over the 8th and 9th ribs in the left
axillary line, and a mass was discovered in the left flank. There was no distinct edge to
the mass. The percussion note over it was not flat. Abdominal pain and tenderness were
severe. The area of splenic dullness was not increased. The tumor was thought to be
connected with a hollow viscus rather than with the spleen or kidney, and because of the
anemia, asthenia, and diarrhea, a neoplasm of the stomach was suspected. The gastric test
meal showed a free hydrochloric acid of 14, total acidity 60. There was no blood and no
evidence of retention in the gastric contents. On repeating the examination a large blood
clot was removed. A roentgenogram showed a "fish-hook type" of stomach with a large
filling defect involving nearly the entire body of the organ except the pylorus. There was
no obstruction. The patient became progressively weaker and died on June 6.
At autopsy there was found a chronic hypertrophic gastritis with benign and malignant
polypi. Microscopically the section showed a greatly thickened mucous membrane with
enlarged glands. These were frequently cystic. In the region of the polyp the mucous
membrane suddenly became tremendously increased in thickness. The glands were greatly
dilated, frequently cystic, and were lined by high columnar epithelial cells. The epithelium
everywhere was benign in appearance. Sections through the large cauliflower-like polyp on
the greater curvature of the stomach showed a mucous membrane quite similar to that
described above, which suddenly passed over into smaller masses of epithelial cells arranged
in imperfect glandular fashion. A portion of the surface showed necrosis and ulceration.
Malignant epithelial cells invaded the musculature and extended into the surrounding tissue.
BENIGN TUMORS OF THE STOMACH
147
II. PAPILLOMA WITH MALIGNANT CHANGE (AUTOPSY No. 8i04): E. B., a colored
female aged fifty-eight, was admitted June 2, 1925, complaining of "stomach trouble."
Her past history was irrelevant apart from a loss of 50 pounds in weight during the ten
months prior to admission. Her illness had begun two months previously with anorexia,
fatigue, loss of energy, and an abrupt onset of pain in the right lower quadrant. The pain
had been steady and gnawing in character. One month before admission there had been
gaseous eructations, occasional vomiting, and tarry stools. Constipation had been slight.
On physical examination the abdomen was found to be tense and tender but there was
no muscular rigidity. The tenderness was most marked in the right lower quadrant. Examination of the blood showed 4,160,000 red cells; hemoglobin 52 per cent. The stool was
positive for blood. A barium meal showed the stomach to be actively irritable. There was
a probable defect of the pylorus. A diagnosis of carcinoma of the pylorus was made and a
Polya operation was performed July 27, 1925. The patient died Aug. 6 from pulmonary
embolus.
At autopsy there was found in the wall of the stomach, about 5 cm. above the point of
anastomosis, a small papillomatous tumor which on section appeared to be benign. Associated with this larger papillomatous mass were two or three small projecting masses of
mucosa about 1 em. from the larger one. The appearance of this papilloma suggested that
the primary tumor which was resected might have been of the malignant papillomatous
type. The tumor had a velvety and papillary surface. It had not extended through the
wall of the stomach. The peritoneal wall was smooth and uninvolved. The edges of the
tumor were not heaped up or undermined. When a section was made through the entire
mass numerous areas were seen where the tumor substance was thrown into folds. The
presence of other types of papillomatous tumors of benign character in the remaining
unresected portion of the stomach suggested that the primary growth was a malignant
papilloma. No metastases were found.
Microscopically the section showed a papillary growth with a characteristic adcnomatous
arrangement. The base, however, showed invasion of the submucosa by epithelial cells
which had broken through the basement membrane and were migrating downward.
III. DIFFUSE ADENOMAS WITH MALIGNANT CHANGE (AUTOPSY No. 3310): 1 T. N .. a
male mulatto sixty-five years old, was admitted Nov. 1'i , 1906, with swelling of the
abdomen. The past history was irrelevant except that the patient was a ship's cook and
up to two years before had been a steady drinker. When on shore he drank three to four
glasses of beer and a half pint of whiskey a day. He had no liquor at sea but went on a
" spree" whenever in port. Two years previously he had stopped drinking.
The patient had always had a good appetite, the bowels were regular. He had never
had any colic or pain in the abdomen. About twenty months before admission he began
to have occasional attacks of vomiting in the morning, and these had occurred once every
two or three weeks up to the time of admission. He had not noticed blood in the stools.
Physical examination showed the abdomen to be tense and swollen. Because of the
presence of ascites there was no palpable mass and no tenderness. Examination of the blood
showed moderate secondary anemia. The red cell count was 4,492,000; hemoglobin 82 per
cent. Three months later the red cell count was 4,000,000 and the hemoglobin 60 per cent.
The clinical diagnosis was cirrhosis of the liver. subcutaneous angiomatous nodules, ichthyosis simplex, and chronic gastritis and colitis. The patient died Dec. 15, 1909.
Post-mortem examination showed the pylorus to be thickened and the surface of the
stomach covered with blood-stained mucus. The entire surface of the mucosa was studded
with polyp-like masses of varying size, differing greatly in appearance and showing every
gradation from small sessile masses 0.5 em. in diameter to definitely stalked tumors, with
cauliflower-like extremity, and a diameter of 2 or 3 em. Some of the largest nodules had
no pedicles. Sections through the masses showed them to be quite superficial, involving
only the mucosa and submucosa. In two tumors the underlying muscularis was thickened
and firmer in consistency, with translucent or colloid strands invading and separating the
muscle bundles. This involvement of the muscularis extended only about 2.5 em. beyond
1 This case was reported in full by M. C. Winternitz and Thomas R. Boggs: A unique coincidence of multiple subcutaneous hemangio-endothelioma, multiple lymphangio-cndothelioma of the
intestinal tract and multiple polypi of the stomach undergoing malignant changes ; associated with
~cneralized vascular sclerosis and cirrhosis of the liver, Johns Hopkins Hosp. Bull. 21: 203, 1910.
148
JAMES F. MINNES AND CHARLES F. GESCHICKTER
the base of the polyp. These polypi were associated with the gastritis, simple hypertrophy,
benign and malignant adenoma, and cancer, with extensive invasion from multiple points
of origin.
IV. LEIOMYOMA WITH PARTIAL OBSTRUCTIO~ (AUTOPSV No. 3728): F. L., a colored
male aged forty, was admitted May 11, 1912, complaining of "misery in the stomach and
bladder." The principal lesion was prostatic, and to this death was due. Two weeks prior
to admission the patient began to complain of anorexia and pain in the stomach three to
four hours after meals. There was also a feeling of distention in the epigastrium.
On physical examination the abdomen was found to be slightly distended. The hemoglobin was 65 per cent.
At autopsy a small, rounded, elevated area about 0.5 em. in diameter was found on
the anterior surface of the stomach near the pyloric valve. On incision it was found to
be a grayish white structure with concentric whorls situated in the muscle coats. This
tumor had apparently caused partial obstruction of the pylorus.
PATHOGENESIS
The occurrence of benign gastric tumors has been ascribed to several
factors. Some authors believe that they are congenital in origin, arising
from some anlage separated during early fetal life. This theory would explain the familial tendency that is sometimes observed. Others maintain that
chronic irritation, either physical, chemical, or bacterial, gives rise to a lowgrade inflammatory disorder of the mucosa resulting in hypertrophy. This
initial process is followed by a drawing out and elongation of the hypertrophied tissue produced by peristalsis of the stomach and the mechanical
passage of food, thus giving rise to a pedunculated tumor. In this manner
the so-called polyps are supposedly formed. In support of this latter theory
Scaglia has produced typical cystic gastritis and polypoid adenomatous outgrowths of the mucosa in dogs by the injection of scharlach red into the
mucosa. Although it is maintained by many that a chronic gastritis is the
immediate underlying factor in the production of these tumors, microscopic
examination usually shows small localized tumors arising from areas of otherwise normal gastric mucosa which is entirely free from evidence of inflammation. Likewise there are many cases of chronic gastritis which show no
true neoplasia. We may therefore conclude that, although chronic irritation
and chronic inflammation may be contributing factors in the production of
gastric tumors, they are by no means essential etiological agents.
PROGNOSIS AND TREATMENT
Benign tumors are seldom fatal, but in rare instances the sudden development of a complication such as hemorrhage may cause death. Because
these tumors may at any time give rise to annoying and even dangerous
symptoms or complications, and because the tumors of the epithelial group
not infrequently become malignant, they should be removed as soon as recognized. If the tumor is single and circumscribed, simple excision with a
good margin of healthy tissue will suffice. If the tumors are multiple, however, and scattered diffusely over the gastric mucosa, as in polyposis, as much
stomach should be resected as is consistent with the complete removal of the
diseased area.
BENIGN TUMORS OF THE STOMACH
149
CONCLUSIONS
1. An attempt has been made to evaluate the absolute and relative incidence of benign tumors of the stomach.
2. The clinical and pathological features of SO cases have been reported.
3. Benign gastric tumors rarely give rise to symptoms, but when symptoms
do occur, they demand instant surgical attention.
4. The only chance of a correct preoperative diagnosis is provided by
radiological examination.
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