The Pyloric Sphincteric Cylinder in Health and Disease



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Chapter 34 (page 176)

At laparotomy two apparently separate mass lesions were found, one in the first part of the duodenum and the other in the distal stomach. Several enlarged perigastric lymph nodes were present. The liver and spleen appeared normal. Frozen sections suggested malignant lymphomatous disease, and a Billroth II partial gastrectomy was performed. Macroscopically the resection specimen showed several tumor nodules, varying in diameter from 1.5 cm to 4.0 cm, in the mucosa; some were ulcerated. The surrounding mucosa felt indurated. Microscopically the nodules consisted of mixed cellular infiltration; the majority of cells were of a lymphoid type while histiocytes, plasma cells and eosinophils were also present. Similar cells, as well as Reed Sternberg cells were seen in the lymph nodes. The condition was diagnosed as mixed cellularity Hodgkin's lymphoma.

Discussion

Although primary malignant lymphoma may occur anywhere in the stomach, several authors commented on the fact that the pyloric region is the site most commonly affected (Naqvi et al l969; Meyers et al. l975; Lim et al. l977). It usually develops from lymphoid tissue in the mucosa (Ming l973), submucosa (Hricak et al. l980) or lamina propria (Sandler l984). In the early stages peristalsis may be impaired (Ngan and James l973), but it is usually not completely absent (Zornoza and Dodd l980), as the muscular layer is not infiltrated till a late stage (Sandler l984). In Case 34.1 radiographic examination showed widespread infiltration of the proximal part of the stomach, extending as far as the commencement of the pyloric sphincteric cylinder, which was in a state of partial contraction with absent cyclical activity; this is an uncommon presentation of malignant gastric lymphoma. In Case 34.2 there was radiographic and operative evidence of widespread involvement of the distal stomach, including the pyloric sphincteric cylinder and the first part of the duodenum, with destruction of normal anatomical features. The failure of cyclical activity of the sphincteric cylinder may be expected to hamper propulsion and trituration of solids.

Malignant gastric lymphoma has a definite tendency to extend across the pylorus into the duodenum (Meyers et al. l975; Hricak et al. l980; Craig and Gregson l98l); the spread usually occurs submucosally (Meyers et al. l975; Hricak et al. l980; Sandler l984), although mucosal spread has also been mentioned (Craig and Gregson l98l). Spread of gastric adenocarcinoma into the duodenum, although not as rare as postulated some decades ago, is less likely to occur (Chap. 33).

In one of 7 cases of duodenal spread of malignant gastric lymphoma, Meyers et al. (l975) noted that Brunner's glands were surrounded, but not invaded, by lymphomatous cells. (A possible relationship between pyloric adenocarcinoma and Brunner's glands of the duodenum is discussed in Chap. 33).

Whether malignant gastric lymphoma affects cells of the APUD system in the stomach is not known.

References

  1. Craig O, Gregson R. Primary lymphoma of the gastrointestinal tract. Clin Rad l98l, 32, 63-71.
  2. Dawson IMP, Cornes JS, Morson BC. Primary malignant lymphoid tumors of the intestinal tract. Brit J Surg l96l, 49, 80-89.
  3. Fork FT, Haglund U, Hogstrom H, et al. Primary gastric lymphoma versus gastric cancer: an endoscopic and radiographic study of differential diagnostic possibilities. Endoscopy l985, l7, 5-7.
  4. Hricak H, Thoeni RF, Margulis AR, et al. Extension of gastric lymphoma into the esophagus and duodenum. Radiology l980, 135, 309-312.
  5. Katz S, Klein MG, Winawer SJ, et al. Disseminated lymphoma involving the stomach: correlation of endoscopy with directed cytology and biopsy. Amer J Dig Dis l973, l8, 370-374.
  6. Koehler RE, Hanelin LG, Laing FC, et al. Invasion of the duodenum by carcinoma of the stomach. Amer J Roentg Rad Ther Nucl Med l977, 128, 201-205.
  7. Lim FE, Hartman AS, Tan EGC, et al. Factors in the prognosis of gastric lymphoma. Cancer l977, 39, 1715-1720.
  8. Meyers MA, Katzen B, Alonso DR. Transpyloric extension to duodenal bulb in gastric lymphoma. Radiology l975, 115, 575-580.
  9. Ming SC. Tumors of the esophagus and stomach. In: Atlas of Tumor Pathology. 2nd Series, Fasc 7, Armed Forces Institute of Pathology, Wash. D.C. l973, pp 231-238.
  10. Naqvi MS, Burrows L, Kark AE. Lymphoma of the gastrointestinal tract: prognostic guides based on 162 cases. Ann Surg l969, 170, 221-231.
  11. Ngan H, James KW. Clinical Radiology of the Lymphomas. Butterworth Co, London l973, pp 105-131.
  12. Rappaport H. Tumors of the hematopoietic system. In: Atlas of Tumor Pathology, Sect 3, Fasc 8, Armed Forces Institute of Pathology, Wash. D.C. l966, pp 97-160.
  13. Sandler RS. Primary gastric lymphoma: a review. Amer J Gastroenterol l984, 79, 21-25.
  14. United States National Cancer Institute: Sponsored Study of Classifications of Non-Hodgkin's Lymphomas. Cancer l982, 49, 2112-2135.
  15. Zornoza J, Dodd GD. Lymphoma of the gastrointestinal tract. Sem Roentg l980, 15, 272-287.


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